[Senate Hearing 110-795]
[From the U.S. Government Publishing Office]
S. Hrg. 110-795
OVERSIGHT HEARING ON SYSTEMIC INDIFFERENCE TO INVISIBLE WOUNDS
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JUNE 4, 2008
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Arlen Specter, Pennsylvania
Barack Obama, Illinois Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio Lindsey O. Graham, South Carolina
Jim Webb, Virginia Johnny Isakson, Georgia
Jon Tester, Montana Roger F. Wicker, Mississippi
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
----------
June 4, 2008
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 3
Letters...................................................... 39
Murray, Hon. Patty, U.S. Senator from Washington................. 4
Brown, Hon. Sherrod, U.S. Senator From Ohio...................... 6
Tester, Hon. Jon, U.S. Senator From Montana...................... 7
Sanders, Hon. Bernard, U.S. Senator From Vermont................. 8
WITNESSES
Perez, Norma J., Ph.D., Mental Health Integration Psychologist,
and Former Coordinator, PTSD Clinical Team, Temple, Texas VA
Medical Center................................................. 10
Prepared statement........................................... 12
Kussman, Michael J., M.D., Under Secretary for Health, Department
of Veterans Affairs; accompanied by Ira Katz, M.D., Deputy
Chief Patient Care Services Officer for Mental Health.......... 13
Prepared statement........................................... 16
Response to written questions submitted by:
Hon. Bernard Sanders....................................... 19
Hon. Roger F. Wicker....................................... 21
Dunne, Patrick W., Rear Admiral, USN (Ret.), Acting Under
Secretary for Benefits and Assistant Secretary for Policy and
Planning, Department of Veterans Affairs; accompanied by Brad
Mayes, Director of Compensation and Pension Service............ 23
Prepared statement........................................... 25
Response to written questions submitted by Hon. Bernard
Sanders.................................................... 28
Attachments.............................................. 31
APPENDIX
Obama, Hon. Barack, U.S. Senator from Illinois; prepared
statement...................................................... 59
OVERSIGHT HEARING ON SYSTEMIC INDIFFERENCE TO INVISIBLE WOUNDS
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WEDNESDAY, JUNE 4, 2008
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9.30 a.m., in
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Murray, Brown, Tester, Sanders,
and Burr.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. The hearing of the U.S. Senate Committee of
Veterans Affairs on Systemic Indifference to Invisible Wounds
will come to order.
Before we begin, I want to share with you what happened
yesterday. I want all of you to look up over the door and see
what is there. I want to describe a ceremony that took place
yesterday in our newly-renovated hearing room.
The room received a traditional Hawaiian blessing. I know
you--our guests and witnesses and specifically Dr. Kussman--
would have an idea about this.
You may notice the green lei that is draped over the top of
the room's entrance. It is called maile, and in Hawaii that is
a sacred lei that is made of a vine that is very symbolic
because it is used by what we call the ali'i, or the people
that are there in charge, and it connects the things that are
separated; so, the symbolism there is good.
This is a lei we tied and untied at entry through the door
during the blessing, and traditionally after the lei is used in
the ceremony, it remains hung along the door's outline as you
see it.
When the room was blessed, I was reminded of the Hawaiian
concept of Kuleana, or responsibility. While many come to this
room with different perspectives, all of us enter with the same
Kuleana, and that is to honor veterans. And we want to do the
best we can to honor veterans.
It is my hope that we will be mindful of Kuleana to the
veterans of this Nation, and our Nation as a whole.
This morning we meet to discuss VA's commitment to PTSD,
both in terms of treatment and compensation.
Recent events at the Temple VA Medical Center have raised
concerns about the Department's dedication to the mental health
needs of our returning servicemembers.
I stress, however, that this hearing is not simply about
one facility or one clinician. This hearing is a part of the
Committee's ongoing oversight of VA activities including VA
mental health care.
Last month we learned that a VA official sent an email that
appeared to deliberately conceal data on suicides. Now, we have
another VA employee who appears to have linked the increase in
veterans seeking compensation for PTSD with a desire to assign
a lesser diagnosis of adjustment disorder--an action that
alarmed many veterans and others.
One question that was raised repeatedly about this email
was, and I quote, ``why would a clinician be so concerned about
the compensation rolls?'' Unquote.
We must know whether the actions of these VA employees
point to a systemic indifference to invisible wounds.
The Committee must understand how VA is dealing with PTSD
and other mental health concerns relating to war-zone service.
We must ensure that veterans receive compensation for
conditions related to their military service, and we must
ensure they are getting appropriate care.
From the testimony submitted for today's hearing, it
appears that VA takes the position that adjustment disorder is
a rational differential diagnosis to give to a veteran while
clinicians take the time to determine if PTSD is involved.
VA indicates that at Temple, whether a veteran has PTSD or
not, the treatment is the same. This suggests to me that the
diagnosis is meaningless if everyone gets the same treatment.
It is my understanding that the reason a clinician makes a
diagnosis is to inform treatment.
To the extent that there are issues or problems that exist
regarding PTSD or other psychological issues related to
service, the Committee must know what it can do to help ensure
that veterans receive accurate diagnosis from VA, proper care
and appropriate benefits.
The number of troops suffering from PTSD continues to
mount. The numbers are staggering. With so many troops
returning from multiple tours with various mental health
issues, VA must have the credibility, resources and commitment
to ensure that veterans are properly treated and appropriately
compensated.
If anyone here is puzzled about the reason for this
hearing, let me answer by using a letter I received yesterday
from the brother of a young man with PTSD who committed suicide
last year.
The brother writes, ``For PTSD the stigma of the label must
be removed starting prior to a veteran's discharge from the
armed services and confidence in the Veterans Health
Administration's ability to adequately treat the condition must
be restored.'' This is why we are holding this hearing today.
Veterans and their families must be assured when they turn
to VA, the Department is capable of caring for the veteran.
I am working with the Inspector General as his
investigation related to Temple progresses; and we expect
something formal in the next couple of months. In the meantime,
it is imperative that the Committee understand what is
occurring.
In closing, I note that last night the Senate passed
critical legislation on mental health care named for yet
another young veteran who died tragically after returning home
from service. His name was Justin Bailey.
Senator Burr and I worked to make this bill as focused as
possible on PTSD and substance abuse. I look forward to seeing
this bill through to the President's desk.
Again, I want to thank the witnesses for being here today
and look forward to your testimony.
Now I would like to call on the Ranking Member, Senator
Burr, for his statement.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Aloha, Mr. Chairman.
As I look up and see the Hawaiian decorations that appeared
late yesterday and the ceremony--which I had the opportunity to
meet your son and to know a little bit about the impact of that
ceremony in this beautiful room where some of the most
important work of this Congress is done--I want to thank you
and your family for the personal commitment you have to make
sure that we are blessed in more ways than we can imagine, and
guided, as I was told last night, by the ceremony and what it
will do.
Mr. Chairman, you called this oversight hearing today to
address potential mental health issues in the VA. Last month we
learned about the email that was sent at the Temple, Texas, VA
Medical Center that caught the attention of the media and the
attention of this Committee.
The email message contained references to, quote,
``compensation-seeking veterans'' and suggested to five other
VA clinicians that they, quote, ``refrain from giving a
diagnosis of PTSD straight out.''
We will have an opportunity to understand that email from
its author and I think that that will be helpful and
informative to all of us.
Dr. Kussman is here. Admiral Dunne is here. They will have
an opportunity to explain, as well, if there is a larger
problem within the VA health care system and the benefits
system.
Last month I joined with you, Mr. Chairman, in asking the
Inspector General to look into this matter. We asked the IG to
look into whether the email is evidence of a bigger problem
with PTSD examinations at the Temple facility and whether any
disability compensation claims were affected by those
examinations.
My preference, to be totally honest, would have been to
wait until the Inspector General completed his investigation
before holding this hearing. I dare say that we do not hold a
hearing that mental health is not a part of the hearing. But
the decision was made and I am prepared to join you, Mr.
Chairman, and other Committee Members to address any findings
in the IG's report once it is completed.
We are moving toward today, quite frankly, without having
all the facts. The title of today's hearing, Systemic
Indifference to Invisible Wounds suggests that some have
already reached a conclusion. Based on the title, it appears
they are prepared to use this email and maybe other emails,
rightly or wrongly, as a springboard to launch into attacks on
the system of VA care, as a whole.
There may be some areas of legitimate criticism, but I do
hope that we can avoid impugning the professionalism of the
entire cadre of VA health care workers to score any political
points.
Let us be careful about damaging the confidence veterans
have in our VA health care to the point that they stop seeking
treatment. We ought to be encouraging veterans to seek mental
health care.
Treatment is so important to me that I introduced a bill
that would pay for their living expenses while participating in
an effective program. So let us not destroy the progress we are
hoping to make with the use of headline-seeking rhetoric.
If, however, it is the judgment of my colleagues that there
is systemic indifference in how VA cares for veterans, then be
prepared to give those veterans an option for their care. Let
them go wherever they want for their care. It would not make
much sense to continue funding a system that was indifferent to
their needs. No amount of money can cure indifference.
Mr. Chairman, political headlines will not solve problems
inside the VA. The Chair will decide whether policy or politics
wins and drives this Committee.
Mr. Chairman, I will stay engaged regardless of the
direction the Committee Members choose, focused on our
veterans, thinking outside the box for solutions to complex
health care issues, confident that a promise that we made in
this country trumps any political agenda.
Mr. Chairman, our troops ignored party affiliations when
they chose to serve. I believe that we have a responsibility to
display a similar courage in how we approach the policies that
fulfill that promise.
I thank the Chair. I yield the floor.
Chairman Akaka. Thank you very much, Senator Burr.
Senator Murray.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Chairman Akaka and
Senator Burr, for holding today's hearing to talk about the
Department of Veterans Affairs' efforts to address the critical
mental health care needs of our veterans.
Today's hearing, as we all know, is going to explore
whether a recent email sent by a VA manager, directing staff to
refrain from diagnosing PTSD in veterans, is an isolated case
or whether it is representative of greater problems within the
VA mental health care system.
Now, I know Secretary Peake has strongly condemned this
email and said that it was an isolated case by a single
practitioner in a single location, and I sincerely hope that
this email is the only one of its kind. But I just have to tell
this Committee I have reason to be skeptical.
It was just a few months ago that we learned about an email
that was sent by Dr. Ira Katz, the VA's top mental health
official, that started off by saying, ``shhh,'' and indicated
that the VA had downplayed the number of suicides and suicide
attempts by veterans in the past several years.
It was not that long ago that Secretary Nicholson sent a
letter to Congress saying that the VA had all the resources it
needed, only to tell us just a short time later that, indeed,
they were $3 billion short. So, with all due respect to the
witnesses, I have to take the VA's explanations with a grain of
salt.
Now, one of the most frustrating things about this latest
episode is that it furthers the perception, the perception that
the VA is shortchanging our veterans. Citing, quote,
``compensation-seeking veterans,'' the email in question
encourages VA practitioners to avoid diagnosing veterans with
PTSD in order to save time and money.
After years of trying to get the VA and the Administration
to be honest about the cost of caring for our veterans, it is
very frustrating to read this email and see that it clearly
indicates that resources are an issue in getting our veterans
both the proper diagnosis and the care they need.
So, to me this email is really a sad reminder that this
Administration's attempt to play down the cost of war or the
cost of taking care of our veterans has begun to actually
affect the way that VA employees view their own work. VA
officials should be more focused on providing a lifeline to our
veterans than on meeting a bottom line that this Administration
has put above all else.
And so, today it is our responsibility to find out what
else needs to be done to ensure that our veterans are not being
shortchanged due to a lack of resources. And we, on this
Committee, know the stakes have never been higher. According to
the RAND Corporation, one in five troops who have returned from
Iraq and Afghanistan have PTSD or severe depression.
Last week, the Pentagon released a report showing that PTSD
cases increased by 50 percent in 2007, and just a few days ago
the Army reported that the number of soldiers who committed
suicide in 2007 is the highest it has been in decades. It is
well past time that every VA official, particularly those
setting policy for their employees, take the psychological
wounds of war just as seriously as the physical injuries.
Now, despite my grave concerns about the candor of senior
VA officials and the shortcomings of the President's budget, I
continue to believe that the VA is the best and most
appropriate place for veterans to receive health care. The VA,
unlike any other health care organization in this country, is
uniquely prepared to care for the distinct wounds of war.
VA staff across this country work their hearts out to get
our veterans the care they need and deserve every day. They
have a very hard job.
The stigma in our society surrounding mental health care
deters a great number of veterans from seeking help. That is
why we need to be doing everything we can to encourage veterans
with psychological wounds to go to the VA to get the care they
need and that they have earned; but time and again we have seen
the VA undermine its own employees and make their jobs harder,
and the email from Dr. Perez is only the latest example, but it
is a striking one.
So, Mr. Chairman, it is appropriate that we take a look at
this today to find out the extent of the problem, to make sure
that the VA truly, from the top to the very bottom, is seeking
these veterans, getting them the help they need, and not just
saying we do not have the resources, we cannot take care of it.
It is our job, as Members of Congress, to make sure they
have the resources they need. Without the accurate information,
we are just incapable of doing that.
So thank you very much for holding this important hearing,
Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Brown.
STATEMENT OF HON. SHERROD BROWN,
U.S. SENATOR FROM OHIO
Senator Brown. Thank you, Mr. Chairman. Senator Burr, thank
you and Senator Murray for your comments always.
Dr. Kussman, thank you for your meeting with and talking
about mental health issues with the Dayton Development
Coalition. I appreciate that some time ago.
When President Bush was inaugurated, he pledged our Nation
this goal. He said, ``When we see that wounded traveler in the
road to Jericho, we will not pass on the other side.''
This hearing should be about how we are going to care for
those men and women who have traveled to the other side of the
world for us and back. We should be working together to openly
start filling the gaps, closing loopholes, improving the
benefits and services available to vets. Yet here we are again,
hearing testimony from an Administration on the defense.
Instead of following the example of the Good Samaritan, the
Bush Administration has been too often passing to the other
side of the road.
One news story after another has documented the proposed
scheme, as Senator Murray said, to obscure the true numbers of
soldiers with Post Traumatic Stress Disorder.
The Cleveland Plain Dealer writer, Elizabeth Sullivan, in
reaction to this discovery, wrote, ``The VA should not be
limiting care and tightening hatches on information leaks. It
should be adding to services for weary and traumatized
veterans.'' Ms. Sullivan was married for many years to a
Vietnam veteran, who is since deceased.
It is shameful the Administration would treat injured
veterans in such a cavalier manner. It is also incredibly
shortsighted. The men and women who serve in our military--as
we all know and we all talk about here, and you all talk
about--have proven themselves time and again. They enrich our
workforce when they return. They strengthen our communities
when they are back Stateside.
When we ignore veterans' injuries or deny a veteran care or
do not take care of veterans who want to go to school, we are
not only shortchanging them, we are shortchanging our economy
and our society.
Look at the flip side: what happened after World War II
when we really did take care of veterans in terms of health
care and education the way that we should.
In the last 15 months, I have held some 100 round tables
around my State--gatherings of 15 and 20 people whom I just
listen to talk about their concerns in some 60-plus counties in
my State--and I have heard from many veterans many of these
same concerns that we talk about ad nauseam on this Committee.
The answer is not for the VA to fail and then privatize the
VA. We have seen that in part with Medicare. We have seen it as
part of a political philosophy in town. The answer is to make
the VA work, to fund it as we should and to make it work. There
is simply no reason we cannot do that, and I look forward to
working with all of you.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Brown.
Senator Tester.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Chairman Akaka, Ranking Member
Burr. It is a pleasure to be here. Unfortunately, I wish we
were talking about something more pleasant.
It would be the easiest thing in the world for me or my
colleagues to sit up here and talk about how outrageous some of
the emails are that have come out of the VA recently. I will
just tell you, it is a baseline set of information without
honesty, without honesty of diagnosis, without honesty of care,
without honesty of a realization that there is a problem, a
systematic problem in the VA right now that is apparent to me.
I do not know that the VA culture will change.
There is a lack of urgency among many of the bureaucrats
and a continued unwillingness to let the needs of our veterans
drive the VA budget. Instead budgets have been bean counted and
seem to come before the actual needs of our veterans. I think
that is very unfortunate.
Even after we have renewed the focus on the plight of the
wounded warriors caused by the Walter Reed scandal, even after
18 months of what I think is some greater oversight by this
Committee, even after a much needed change in leadership at the
top of the VA, the problems still exist.
And to be blunt, I am frustrated by the fact that whether I
am asking about veterans suicides or construction of new
clinics, the answer from the middle layers of the VA
bureaucracy seems to be the same, we will deal with it when we
can; it is not a big deal. Well, it is a big deal. The good
news is when I talk to the Secretary himself, I get a much
better response and that is good news.
But, it should not have to be that we have to work this
hard to make the system work. It should not be a matter whether
the Congress is trying to get some information about how we are
going to help our veterans or whether an individual veteran is
trying to get the benefits that he or she has earned. So, we
need some answers today.
The witnesses, myself, and other Members of this Committee
are in this business for a reason. That reason is that we all
believe that getting benefits and better health care for our
veterans is not something we do to feel good about ourselves.
It is not something we do to spend taxpayers' money. It is
something we do because our Nation has made a promise to the
fighting folks in this country: that after they served our
country, our country will serve them. And the VA is the
organization that bears responsibility for the entire country
for a follow-through on that promise.
In many cases it is happening and good jobs are being done,
but it is not happening in a lot of cases, and I regret to say
that in the cases where it did not happen, everyone is falling
short of doing their job; and as a result, our country is
falling short of doing its job. And when we fail a single
veteran, it is unacceptable.
I, too, have spent a lot of time with doctors and nurses
and right on down the line to the maintenance staff in VA
facilities in the State of Montana. Almost every person out
these hundreds of employees understand this concept. But when
it comes to the managers, I am not sure that they understand
it.
So, I hope that the witnesses are prepared and are able to
talk a little bit about what each of them is doing to make sure
the VA culture is changing from ``business as usual.'' I would
very much like to hear your thoughts on this and I have a
number of other questions that we can do during the questioning
rounds.
You folks are here for a reason. You are the easiest folks
for us to talk to and you will get the brunt, and that is good,
but the truth is that I have talked to veterans, I have talked
to staff, and things need to change.
Now, I do not know if it is because we do not have enough
veterans working in the VA. Maybe that is the problem. Or if it
is because people do not understand the urgency, the special
urgency with what is going on with returning soldiers from Iraq
and Afghanistan. But I will tell you this, it has to change and
I have a tremendous amount of respect for Secretary Peake. I
think he is a good man, but he cannot do it alone. Things have
to change. And I can give you example after example where I
have talked to people within the VA and have not been told the
whole story; I have been told part of the story.
I will tell you guys the same thing I told the head of the
VA in Montana, I am not here to fight you. I am here to help
you. I am here to help you to make sure the promises we made to
our veterans become a reality, and that is it. That is all I
want to do.
So with that, thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Tester.
Senator Sanders.
STATEMENT OF HON. BERNARD SANDERS,
U.S. SENATOR FROM VERMONT
Senator Sanders. Thank you, Mr. Chairman. I apologize for
being here late. And thank you, guests, very much for being
here.
Thank you for calling this important hearing.
Very clearly, I think there is a reality taking place today
that is a new reality. I think, generally speaking, we
understand from an historical perspective that when soldiers
have been wounded in a conventional military sense, gunshot
wounds or amputation needs, the VA has done an extraordinarily
good job.
But, I think, increasingly, what we also understand is that
we have what we call invisible wounds. Maybe it was Gulf War
syndrome that I worked on very hard when I was in the House.
Maybe it is Post Traumatic Stress Disorder, maybe it is
Traumatic Brain Injury--something where somebody has not lost
an arm or a leg.
It appears that the VA has not been as effective as it
might, and I think it has something to do with the culture,
perhaps, of the military where if you lose an arm or you lose a
leg, you are wounded. But if you come home with PTSD or TBI and
you are walking or talking, well, maybe. Are you really wounded
or maybe you are a little bit wimpy, or whatever the case may
be.
And I think the thrust of what you are hearing and have
been hearing for a number of months is that the evidence is
overwhelming: that what we are seeing today in terms of PTSD,
what we are seeing in terms of TBI--which is what is called the
signature injury of this war--is that tens and tens and tens of
thousands of our soldiers are being impacted. And we need a
culture now within the VA that begins to understand and address
that reality.
In my State and in every State in this country, men and
women are coming home who are not getting their lives together.
They are drinking too much. They cannot do their jobs. They are
getting fired from their work. They are turning to drugs. Their
marriages are falling apart. And that is absolutely as
important as other types of injuries; and we need a culture in
the VA which appreciates that. We also understand that issues
like TBI are very difficult to diagnose as being issues
separate from PTSD. Often they go together, and how to pull
them apart is something that is not so easy and that requires a
lot of work.
But I think the most important thing that we need from the
VA is an absolute commitment to understand that these so-called
invisible injuries are wrecking havoc on tens of thousands not
only of soldiers, but of their families and of their children.
And we consider it as important an injury as any other. So, we
need a culture and an approach that effectively addresses those
issues.
I should mention, Mr. Chairman, that in my own State of
Vermont, one of the things that we did is recognize that no
matter what kind of treatment the VA may have, it is not going
to do anybody any good unless our families and our soldiers get
to that treatment, which speaks to the need for an effective
outreach program.
And then when you are dealing with outreach, you understand
that PTSD is a different type of injury. It is not something--
by definition, it is not an injury where some guy is going to
stand up and you say, ``I am in pain. I am drinking too much. I
am on drugs. My marriage is falling apart. Help me.'' That is
not necessarily what happens.
So you have got to figure out a way to connect with those
men and women and bring them into the system. Then you have to
figure out a way to create the kind of support systems that
they need and provide the individual treatment; none of which
is easy. A lot has been thrown on you. This war, among many
other things, has given you hundreds and hundreds of thousands
of soldiers from all walks of life who need help.
I come from a rural State. That means a lot of our guys are
coming home from the National Guard. They are living in small
towns. They do not have the infrastructure of the U.S. Army.
How do you address that? We need help on that as well.
But I think, Mr. Chairman, clearly we need a culture in the
VA that recognizes that these problems are quite as significant
in people's lives as other problems and we want the VA to step
up to the plate and address them.
Thank you very much, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Sanders.
I want to welcome today's panel of witnesses from VA.
First, I will welcome Dr. Norma Perez, Mental Health
Integration Specialist, Austin Outpatient Clinic and former
PTSD Clinical Team Coordinator at the Temple, Texas VA Medical
Center.
Next, I will welcome Dr. Michael Kussman, Under Secretary
for Health. He is accompanied by Dr. Ira Katz, Deputy Chief
Patient Care Services Officer for Mental Health.
Finally, I welcome Admiral Patrick Dunne, Acting Under
Secretary for Benefits and Assistant Secretary for Policy and
Planning. He is accompanied by Mr. Brad Mayes, Director of
Compensation and Pension Service.
I thank all of you for being here today. Your full
statements will appear in the record of the Committee.
Dr. Perez, will you please begin with your statement.
STATEMENT OF NORMA J. PEREZ, Ph.D., MENTAL HEALTH INTEGRATION
PSYCHOLOGIST, AND FORMER COORDINATOR, PTSD CLINICAL TEAM,
TEMPLE, TEXAS VA MEDICAL CENTER
Ms. Perez. Good morning, Mr. Chairman and Members of the
Committee. Thank you for inviting me here to discuss the
quality of mental health care Central Texas veterans are
receiving in the Temple PTSD Clinic.
As the daughter, niece, sister, and cousin of Army, Navy
and Marine veterans, I have a personal commitment to my work,
and I have been blessed with the gift of trust from many East
Coast and Central Texas veterans. They instill the passion for
my work.
I started working for the Central Texas Veterans Health
Care System in June 2007 as a psychologist and program
coordinator of the Post Traumatic Stress Disorder Clinical
Team.
I came to VA after completing a National Cancer Institute
Research Fellowship at the University of Texas, Health Science
Center at Houston, School of Public Health.
Prior to that, I completed a clinical postdoctoral
fellowship at Brown University. I earned my Ph.D. in clinical
psychology from the University of Rhode Island, and I completed
a clinical internship at the Edith Nourse VA Medical Center in
Bedford, Massachusetts.
I realize the Committee is interested in learning more
about an email I sent to my team on March 20th so I will
provide some context for that message and explain its purpose.
My written statement, which I asked to be submitted for the
record, discusses the approaches and treatment provided by the
Temple PTSD clinical team.
The Central Texas Veterans Health Care System offers
specialized mental health care through the Temple PTSD Clinical
Team, or the PCT. Although we are a PTSD clinic, we have been
able to offer treatment to any veteran displaying any symptoms
of combat stress.
Combat stress is a normal reaction to abnormal events. It
can occur immediately following an event or many years later,
but in either situation, we stand ready to assist the veteran.
Combat stress can manifest itself in different clinical
conditions, including PTSD and Adjustment Disorder. We know we
can improve the lives of veterans by teaching them coping
strategies and other skills to reduce their level of distress
and improve their quality-of-life, and this is exactly what we
do in Central Texas.
All of our clinicians are trained to use the guidelines
published within the Diagnostic Standards Manual-IV for
clinical diagnosis of mental health conditions, including PTSD.
Individual providers develop a rapport and trust with each
patient and it is through this that the veteran is able to
safely convey their experiences and symptoms.
Although PTSD is sometimes recognizable as early as the
first few sessions, veterans often need more time to fully
disclose their trauma and its impact on their lives.
Several veterans expressed to my staff their frustration
after receiving a diagnosis of PTSD from a team member during
an initial intake when they had not received that diagnosis
during their compensation and pension examination. This
situation was made all the more confusing and stressful when a
team psychiatrist correctly told them, they were displaying
symptoms of combat stress but did not meet criteria for the
diagnosis of PTSD.
Because veterans were receiving conflicting messages from
the team, I thought it was necessary to provide further
guidance. As an extension of ongoing discussions and to address
the frustrations of veterans, I sent an email to my staff on
March 20th emphasizing careful evaluation of a patient's
symptoms to ensure consistent and accurate diagnosis.
The Temple PCT fully supports the compensation process and
the Department's policy of erring in the best interest of the
veteran whenever there is any doubt.
In retrospect, I realize I did not adequately convey my
message appropriately, but my only intent was to improve the
quality of care our veterans received.
I would like to conclude by discussing what a diagnosis of
Adjustment Disorder with rule out for PTSD means.
When a clinician makes a diagnosis, he or she is
considering the patient's symptoms and conditions that would
explain them. Many conditions look very similar to one another
and sometimes it is important to identify the likely diagnosis
while noting in the patient's record to test for possible
alternatives.
For example, a patient with chest pains could have
indigestion or could be experiencing the early effects of a
heart attack. Based on initial information, a clinician would
determine the most likely diagnosis, heartburn, but note in the
record the need to rule out a heart attack and proceed with
further assessment. In clinical shorthand, that diagnosis would
be indigestion, rule out heart attack, which would prompt
further testing.
The diagnostic note actually means, ``do not forget this
diagnosis'' and serves as a reminder for further investigation
into multiple possible conditions.
In the context of mental health and my email, I believed
that it was important to remind the team clinicians of the
diagnosis of Adjustment Disorder, which is a clinically sound
diagnosis and will result in the appropriate treatment while
continuing the assessment process for a possible PTSD
diagnosis.
Mr. Chairman, I am happy to report Central Texas veterans
are receiving the care that honors our pledge to care for those
who have sacrificed in service to this Nation.
This concludes my prepared statement and I am ready to
address the Committee's questions.
[The prepared statement of Ms. Perez follows.]
Prepared Statement of Dr. Norma Perez, Mental Health Integration
Psychologist, Central Texas Veterans Health Care System
Good morning, Mr. Chairman and Members of the Committee. On behalf
of Bruce Gordon, Director of the Central Texas Veterans Health Care
System, and Timothy Shea, Director of the VA Heart of Texas Health Care
Network (VISN 17), thank you for inviting me here to discuss the
quality of mental health care Central Texas veterans are receiving in
the Temple PTSD Clinic. As the daughter, niece, sister, and cousin of
Army, Navy, and Marine veterans, I have a personal commitment to my
work, and I have been blessed with the gift of trust from many East
Coast and Central Texas veterans--they instill my passion for my work.
I started working for the Central Texas Veterans Health Care System
in June 2007 as a psychologist and program coordinator of the Post
Traumatic Stress Disorder (PTSD) Clinical Team. I came to VA after
completing a National Cancer Institute Research Fellowship at the
University of Texas Health Science Center at Houston, School of Public
Health. Prior to that, I completed a clinical postdoctoral fellowship
at Brown University. I earned my Ph.D. in clinical psychology from the
University of Rhode Island and completed a clinical internship at the
Edith Nourse VA Medical Center in Bedford, Massachusetts.
The Central Texas Veterans Health Care system offers specialized
mental health care through the Temple PTSD Clinical Team (PCT). This
Clinical Team provides treatment only. Although we are a PTSD Clinic,
we have been able to offer everyone treatment who displays any symptoms
of combat stress. Combat stress is a normal reaction to abnormal
events. It can occur immediately following an event or many years
later, but in either situation, we stand ready to assist the veteran.
Combat stress can manifest itself in different clinical conditions,
including PTSD and Adjustment Disorder. Simply reporting combat-related
stress is insufficient for an accurate diagnosis, in the same way that
chest pain would be inadequate for determining whether a patient was
suffering from heartburn or a heart attack. Regardless of how combat
stress appears, our staff can make an initial diagnosis of a combat-
stress related disorder and begin treatment immediately. We know we can
improve the lives of veterans by teaching them coping strategies and
other skills to reduce their level of distress and improve their
quality-of-life, and this is exactly what we have been doing for the
last year in Temple.
Many individuals with symptoms of combat stress are not ready to
discuss the details of their experiences, but they can describe their
symptoms and their levels of distress. An accurate diagnosis of PTSD,
however, would require a veteran fully disclose the details and
feelings associated with a traumatic event, and in my clinical
experience, many have been unwilling to do this without a strong sense
of safety and trust, which can only be developed over time. Rather than
deter veterans from seeking treatment by requiring them to provide more
information than they feel comfortable, we believe it is essential to
begin providing care and support immediately. The Temple PCT Team
invites individuals into treatment if they exhibit any symptoms of
combat stress and works with them to develop skills and strategies to
reduce or eliminate those symptoms. Based on follow up data, this
approach has proven effective in reducing the distress levels of
veterans.
Our phases of treatment are generally the same for all veterans,
regardless of their specific condition. We begin by teaching veterans
skills and strategies they can use to address the specific combat
stress symptoms they describe. This process usually lasts 8-9 sessions,
although we continue to measure the veteran's self-reported level of
distress throughout the course of treatment and we often notice
improvement after only a few appointments. The second phase of
treatment, for those willing to pursue it, involves exposure therapy.
In this phase, we explore the most distressing trauma and work with the
veteran through any of several different approaches to allow them to
reprocess the trauma. This helps our patients cope with their feelings
and memories in a safe and therapeutic environment. The final phase of
treatment is available to all veterans and involves episodic follow up
at the veteran's request. While the strategies and therapy we teach
veterans work very well for the initial trauma, future stressful
situations, such as the loss of a job or a family member, may trigger
additional anxiety and re-aggravate the veteran's condition. Our staff
is available to veterans any time they need it to help them cope with
these new problems.
All of our clinicians are trained to use the guidelines established
within the Diagnostic Standards Manual IV for clinical diagnosis of
mental health conditions, including PTSD. I sent an email to my staff
on March 20 to stress the importance of an accurate diagnosis. Many of
the veterans we treat in Temple have already undergone an examination
for Compensation and Pension benefits, and our sole mission at the
Temple PCT is to provide treatment to veterans in need. Although our
clinic is a treatment clinic, we all fully support the compensation
process and the Department's policy of erring in the best interest of
the veteran whenever there is any doubt.
Several veterans expressed to my staff their frustration after
receiving a diagnosis of PTSD from a team member at Temple when they
had not received that diagnosis during their Compensation and Pension
examination. This situation was made all the more confusing and
stressful when a team psychiatrist correctly told them they were
displaying symptoms of combat stress, but did not meet criteria for the
diagnosis of PTSD. Veterans were receiving conflicting messages from
the team and I believed it was important to resolve this situation by
providing further guidance while not blaming any specific clinical
approach. In retrospect, I realize I did not adequately convey my
message appropriately, but my intent was unequivocally to improve the
quality of care our veterans received.
In conclusion, Mr. Chairman, I am happy to report Central Texas
Veterans are receiving care that honors our pledge to care for those
who have sacrificed in service to this Nation. This concludes my
prepared statement and I am ready to address questions from the
Committee.
Chairman Akaka. Thank you very much, Dr. Perez.
Dr. Kussman.
STATEMENT OF THE HONORABLE MICHAEL J. KUSSMAN, M.D., UNDER
SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY IRA KATZ, M.D., DEPUTY CHIEF PATIENT CARE
SERVICES OFFICER FOR MENTAL HEALTH
Dr. Kussman. Mahalo, Mr. Chairman, and Members of the
Committee. Good morning.
Thank you for mentioning earlier my time in Hawaii and my
appreciation of the blessing of this room. And I hope the
blessing allows all of us together to do what we are here for,
which is to provide the best service for all of our veterans.
Thank you for the opportunity to discuss the VA's mental
health services with you today.
I realize that you are concerned by an email sent from the
program coordinator of the Post Traumatic Stress Disorder
clinical team in Temple, Dr. Perez.
The email, as characterized by others, does not reflect the
policies or conduct of our health care system.
Let me be very clear. Any suggestion that we would not
diagnose a condition, any condition, is unacceptable and I, as
a veteran and a retiree, would not tolerate such a position for
personal and professional reasons.
I will further state for the record that not only was there
no systemic effort to deny diagnosis, but there was not even an
individual effort to that end.
However, the perception remains. So, we welcomed the
opportunity to appear before you today to explain the VA's
commitment to an honest and accurate diagnoses for every
veteran for every diagnosis. That this perception continues is
very unfortunate and how it has unfairly damaged the reputation
of VA's dedicated health care employees.
I was going to mention that with me is Dr. Perez, but
obviously that has already taken place.
I am grateful to the Committee for giving her the
opportunity to speak for herself and I will, therefore, not say
anything further about her email or about the specific
situation in Temple.
Delivering world class mental health care to enrolled
veterans is a requirement that the VA and VHA take extremely
serious. VA plans to spend more than $3.5 billion for mental
health services in fiscal year 2008 and project $3.9 billion in
fiscal year 2009.
We are proud of our accomplishments in this area. Many
health care professionals have recognized the VA's leadership
in this area and I firmly believe no one receives better mental
health care in this Nation than veterans enrolled in the VA for
care.
This is particularly true for veterans with Post Traumatic
Stress Disorder, an area in which the VA is nationally and
internationally recognized, both for its research work and its
ability to deliver outstanding care.
Although the quality of VA health care has been found equal
to and often superior to that furnished anywhere, ``best care
anywhere'' has been mentioned in numerous publications, the
popular perception of the quality of VA care is something less
than favorable. It is unfortunate and undeserved.
Some continue to believe that health care services
furnished by a government system can never be as good as those
delivered by the private sector. In many cases we have not done
enough to educate the public about VA's many achievements and
outstanding programs and we could do more to ensure our own
health care employees are informed about the Department's
recognized awards and achievements outside their own area of
expertise.
VA and this country have much to be proud of in terms of
the health care provided to veterans by the very skilled and
talented cadre of VA clinicians--not to mention our
researchers--who continue to improve the clinical care veterans
receive.
Improving VA's mental health services has been an active
pursuant of the Department for many years.
In 2004 we developed a mental health strategic plan that
was both unprecedented and widely acclaimed within the mental
health community. Through that effort we began to address gaps
in the mental health services provided at the local level and
to initiate programs at the national level.
This plan was intended to serve as a guide for 4 or 5
years. During that time we have continually reassessed our
progress and amended the strategic plan based on new
information particularly concerning new evidence-based
standards of care and improvements in the delivery and mental
health services. We continue to periodically re-access the plan
as appropriate.
As I alluded to earlier, the strategic plan was designed to
incorporate evidence-based treatments wherever possible,
encourage system redesigned activities and move our system to a
recovery-based model as required by the President's New Freedom
Commission for Mental Health.
For these significant changes to be successful, they must
be accompanied by a major educational effort appropriately
targeted at our staff and clinicians and patients. I now
believe, in retrospect, that we have not done as good a job as
we should have to educate veterans and our staff.
As we have initiated new programs that emphasize recovery
models for our newest veterans, we have, in some places, not
adequately responded to the needs of those who use and have
benefited from our existing programs such as group therapy
sessions for combat theater Vietnam era veterans.
In addition, some of our own providers have not thoroughly
understood our new approach, unfortunately compounding the
confusion experienced by veterans at those sites.
In response, we have developed an aggressive communication
and education plan for both clinicians and veterans which will
be launched shortly. Be assured that despite these inadvertent
but significant educational or communication lapses, our
commitment to our veterans and to improving their health status
is unwavering. Their well being and their continued improvement
to fully functional status has always been the objective of the
strategic plan.
We will work even harder to ensure that all understand the
needs of different groups of veterans and will keep them
apprised of further changes based on newer evidence.
As we have always sought to do, we will do the right thing
for every veteran who has entrusted us with his or her care--
one veteran at a time. We will do more to make sure our
decisionmaking process for these clinical policy determinations
is open and transparent to veterans.
Moreover, we will work with Members of this Committee, with
other mental health professionals and with veterans themselves
to ensure veterans continue to receive the highest quality care
available.
In summary, Mr. Chairman, I am very proud of what the VA
does in the area of mental health. More than 200,000 people are
fully committed to helping veterans receive the health care
benefits they have earned through their service and their
sacrifices.
I hope we can continue to move forward from this episode
and help veterans and their families, Congress and the news
media, and others to better understand what the VA has done and
is doing to fulfill our Nation's commitment to those who have
worn the uniform of our armed services.
Mahalo nui loa.
[The prepared statement of Dr. Kussman follows.]
Prepared Statement of Michael J. Kussman, MD, Under Secretary for
Health, Department of Veterans Affairs
Mr. Chairman and Members of the Committee, good morning. Thank you
for the opportunity to discuss VHA's mental health services with you
today. I am aware that today's hearing had its origins in the situation
that recently arose in our Temple, Texas facility. On March 20, 2008, a
VA psychologist and program coordinator for the Post Traumatic Disorder
(PTSD) sent an internal email to the PTSD Clinical Treatment Team. The
email, as characterized by others, does not reflect the policies or
conduct of our health care system. The email has been taken out of
context, though we certainly agree that it could have been more
artfully drafted. This is an unfortunate situation, which has also
unfairly damaged the reputations of VA's dedicated and committed health
care employees. The erroneous characterization may also hurt veterans
and their families, as some of them may call into question the quality
of VA's health care. As a result, those individuals may not seek needed
medical care from the Department, leaving their health care needs
unaddressed.
At the witness table with me is Dr. Norma Perez, who wrote the
email in question. As I have stated, Dr. Perez' motives and actions
have been unfairly characterized by others. I am grateful to the
Committee for giving her the opportunity to speak for herself, and I
will therefore not say anything further about her email or about the
specific situation at Temple.
VA has been, and remains, absolutely committed to delivering world-
class mental health care to enrolled veterans. We are very proud of our
accomplishments in this area. VA will spend more than $3.5 billion for
mental health services in Fiscal Year 2008, and we are very proud of
our accomplishments in this area. Indeed, many mental health
professionals and organizations outside the Department have recognized
VA's leadership in this area, and I firmly believe that no one receives
better mental health care in this Nation than veterans enrolled in VA's
health care system. This is particularly true for veterans with Post
Traumatic Stress Disorder (PTSD). VA is nationally recognized for its
outstanding PTSD treatment and research programs. Although the quality
of VA health care has been found equal to, and often superior to, that
furnished elsewhere, the popular perception of the quality of VA care
is sometimes less favorable. This is unfortunate and undeserved. Some
continue to believe that health care services furnished by a government
system can never be as good as those delivered by the private sector.
In many cases, we have not done enough to educate the public about VA's
many achievements and outstanding programs. And we could do more to
ensure our own health care employees are informed about the
Department's recognized awards and achievements outside their own areas
of expertise. VA and this country have much to be proud of in terms of
the health care provided to veterans by the very skilled and talented
cadre of VA clinicians, not to mention our researchers who continue to
improve the clinical care veterans receive.
Improving VA's mental health services has been an active pursuit of
the Department for many years. In 2004, we developed a Mental Health
Strategic Plan that was both unprecedented and widely acclaimed within
the Mental Health Community. Through that effort, we began to address
gaps in the mental health services provided at the local level, and to
initiate programs at the national level. This plan was intended to
serve as a guide for four to five years. During that time, we have
continually reassessed our progress and amended the strategic plan
based on new information, particularly concerning new evidence-based
standards of care and improvements in the delivery of mental health
services. We continue to periodically re-assess the plan, as
appropriate.
As alluded to earlier, the strategic plan was designed to
incorporate evidence-based treatments wherever possible; encourage
system redesign activities; and move our system to a recovery-based
model as required by the President's New Freedom Commission for Mental
Health. For these significant changes to be successful, they must be
accompanied by a major educational effort appropriately targeted at our
staff and clinicians. I now believe, in retrospect, that we have not
done as good a job as we should have to educate veterans and our staff.
As we have initiated new programs that emphasize recovery models
for our newest veterans, we have, in some places, not adequately
responded to the needs of those who use, and have benefited from, our
existing programs, such as group therapy sessions for combat-theater
Vietnam era veterans. In addition, some of our own providers have not
fully understood our new approach, unfortunately compounding the
confusion experienced by veterans at those sites. In response, we have
developed an aggressive communication and education plan for both
clinicians and veterans, which will be launched in the coming weeks.
Be assured that despite these inadvertent, but significant,
educational and communication lapses on our part, our commitment to our
veterans and to improving their health status is unwavering. Their
well-being and their continued improvement to fully functional status
has always been the objective of the strategic plan. We will work even
harder to ensure we are fully sensitive to veterans' needs from this
point forward and will keep them apprised of further changes based on
newer evidence.
As we have always sought to do, we will do the right thing for
every veteran who has entrusted us with his or her care--one veteran at
a time. We will do more to make sure our decisionmaking process for
these clinical policy determinations is open and transparent to
veterans. Moreover, we will work with Members of this Committee, with
other mental health professionals, and with veterans themselves to
ensure veterans continue to receive the highest quality care available.
At this time, Mr. Chairman, let me talk more generally about the
status of mental health care in our Department. VA strongly believes
that fully addressing the physical and mental health needs of veterans
is essential to their successful re-integration into civilian life. As
evidence of that commitment, we plan to spend more than $3.5 billion in
Fiscal Year (FY) 2008 for mental health services and the President's
Budget has allocated $3.9 billion for that purpose in FY 2009.
Mental health care is being integrated into primary care clinics,
Community Based Outpatient Clinics, VA nursing homes, and residential
care facilities. Placing mental health providers in the context of
primary care for the veteran is essential; it recognizes the
interrelationships of mental and physical health, and also provides
mental health care at the most convenient and desirable location for
the veteran.
In contrast to the private sector, whenever a veteran is seen by a
VA provider, he or she is screened for PTSD, military sexual trauma,
depression, and problem drinking. Screening gives us an early
opportunity to assess and treat the veteran for any identified problem.
Our clinicians act on positive screens, and we will continue to monitor
their compliance with our national screening directives.
VA employs full and part time psychiatrists and 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. We have
steadily increased the number of these mental health professionals over
the last 3 years. We have hired more than 3,800 new mental health staff
in that time period, for a total mental health staff of over 16,500. VA
will continue expanding our mental health staff and also will continue
to expand hours of operation for mental health clinics beyond normal
business hours.
We have reduced wait times throughout our system. At Temple, for
example, 99.58 percent of all mental health appointments are within 30
days of the desired appointment date. Nationwide, the percentage is
99.34 percent--and for veterans with PTSD, the percentage rises to
99.66 percent. We've also set standards for timeliness in our
Compensation and Pension Examinations. Nationally, our average in March
is 28 days to process these exams; Network 17, in which Temple is
located, processed exams in 22 days.
Our Department will continue to aggressively follow up on patients
in mental health and substance abuse programs who miss appointments to
ensure they do not miss needed, additional care. VA will also continue
to monitor the standards the Veterans Health Administration has set for
itself: to provide initial evaluations of all patients with mental
health issues within 24 hours, to provide urgent care immediately when
that evaluation indicates it is needed, and to complete a full
evaluation and initiate a treatment plan within 14 days for those not
needing immediate crisis care. At present, 93.4 percent of all veterans
seeking mental health care receive full evaluations within 14 days.
VISN 17 has a percentage exactly equal to the national average.
On May 1, VA began contacting nearly 570,000 combat veterans of the
Global War on Terror to ensure they know about VA medical services and
other benefits. The Department will reach out to every veteran of the
war to let them know we are here for them. Last month, we completed
calls to more than 15,000 veterans who were sick or injured while
serving in Iraq or Afghanistan. If any of these 15,000 veterans do not
now have a care manager to work with them to ensure they receive
appropriate health care, VA offered to appoint one for them.
While the numbers of veterans seeking VA care for PTSD is
increasing, VA is monitoring parameters (such as time to first
appointment for new and established veterans of all service eras) to
ensure they receive prompt and efficient services for PTSD and other
mental disorders. In FY 2009, funding enhancements will close gaps in
services and allow us to implement a more comprehensive and uniform
package of clinical services for PTSD and other disorders.
The Mental Health Initiative provides for the implementation of the
Veterans Health Administration's Comprehensive Mental Health Strategic
Plan (MHSP). Funding has been allocated for the Comprehensive MHSP each
year since FY 2005 and has been committed through FY 2008.
Funds were specifically allocated last year to promote
dissemination and delivery of exposure-based psychotherapies for PTSD.
In addition, we are providing training and dissemination of evidence-
based psychotherapies for other mental disorders. VA has allocated
additional funds to implement evidence-based programs integrating
mental health with primary care, with particular emphasis on
depression. That program will be further expanded in FY 2008 and FY
2009.
Since the implementation of the Mental Health Strategic Plan, VHA
has dedicated more than $458 million to improve access and quality of
care for veterans who present with substance use disorder treatment
needs. We have authorized the establishment of 510 new substance use
counselor positions and plan to continue expanding our services
throughout FY 2008 and FY 2009. In FY 2008, for example, our mental
health enhancement budget includes over $37.5 million for expanded
services.
VA is developing plans to allocate medical care funds from the FY
2008 funding to hire even more new mental health professionals, develop
new programs, expand existing services, and create an appropriate
physical environment for care by upgrading the safety and physical
structure of inpatient psychiatry wards, as well as domiciliary and
residential rehabilitation programs.
Further, VA is taking significant steps to prevent suicide among
veterans. We have provided training to all VA employees to underscore
that even strong and normally resilient people can develop mental
health conditions making them susceptible to suicide; care for those
conditions is readily available and should be immediately provided; and
treatment typically works.
VA's suicide prevention program includes two centers that conduct
research and provide technical assistance in this area to all locations
of care. One is the Mental Health Center of Excellence in Canandaigua,
New York, which focuses on developing and testing clinical and public
health intervention related to suicide risk and prevention. The other
is the VISN 19 Mental Illness Research Education and Clinical Center in
Denver, which focuses on research in the clinical and neurobiological
sciences with special emphasis on issues related to suicide risk.
VA has opened a unique suicide prevention call center in
Canandaigua focused entirely on veterans. Suicide prevention
coordinators are located at each of VA's 153 hospitals. Altogether, VA
has more than 200 mental health providers whose jobs are specifically
devoted to preventing suicide among veterans.
In developing the suicide prevention call center, the Department
has partnered with the Lifeline Program of the Substance Abuse and
Mental Health Services Administration. Those who call 1-800-273-TALK
are asked to press ``1'' if they are a veteran, or are calling about a
veteran.
From its beginnings in July 2007 through the end of April, 16,414
calls have come to the hotline from veterans and 2,125 family members
or friends have called on behalf of a loved one. These calls have led
to 3,464 referrals to suicide prevention coordinators and 885 rescues
involving emergency services. Of note, 493 active duty servicemembers
have also called our suicide hotline.
Unlike other such hotlines, VA's hotline is staffed solely by
mental health professionals--24 hours a day, 7 days a week. Our hotline
staff is trained in both crisis intervention strategies, and in issues
relating specifically to veterans, such as Traumatic Brain Injury and
Post Traumatic Stress Disorder. In emergencies, the hotline staff
contacts local emergency resources, such as police or ambulance
services, to ensure an immediate response.
If the veteran is a VA patient and willing to identify him or
herself, the hotline staff is able to access the veteran's electronic
medical record during the call. These records provide information that
is invaluable during a crisis, including information on medications;
the patient's treatment plan; and names and numbers of persons to
contact during this emergency. VA hotline staff can also talk directly
to the facility that is treating the veteran. They can place consults
in the patient's medical record. For veterans not under VA care, staff
can refer them to an individual VA Medical Center or Community Based
Outpatient Clinic as appropriate, and see to all of the necessary
administrative requirements.
And our hotline staff follows up on these referrals. They also
check patients' records to see if consultations were completed and to
ensure follow-up actions were taken or are ongoing. If the record does
not show this information, the suicide prevention coordinator at the VA
facility is called and tasked with following up on the case to ensure
that no referral is lost in the process.
In addition to the care offered in Medical Centers and Community
Based Outpatient Clinics, VA's Vet Centers provide outreach and
readjustment counseling services to returning combat-theater veterans
of all eras. It is well-established that rehabilitation for war-related
PTSD, substance use disorder, 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 combat-theater veterans.
The Vet Centers' mission is to provide readjustment and related
mental health services, through 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 mental health care that
helps many combat-theater veterans overcome the stigma and fear related
to accessing professional assistance for military-related problems. Vet
Centers are staffed by interdisciplinary teams that include
psychologists, nurses and social workers, many of whom are veteran
peers.
Vet Centers provide professional readjustment counseling for war-
related psychological readjustment problems, including PTSD. Other
readjustment problems may include family relationship problems, lack of
adequate employment, lack of educational achievement, social alienation
and lack of career goals, homelessness and lack of adequate resources,
and other psychological problems such as depression and/or substance
use disorder. Vet Centers also provide military-related sexual trauma
counseling, bereavement counseling, employment counseling and job
referrals, preventive health care information, and referrals to other
VA and non-VA medical and benefits facilities.
VA is currently expanding the number of its Vet Centers. In
February 2007, VA announced plans to establish 23 new Vet Centers
increasing the number nationally from 209 to 232. This expansion began
in 2007 and is planned for completion in 2008. Eighteen of the new Vet
Centers have hired staff and are fully open. Five other Vet Centers
have hired staff and are providing client services, but are operating
out of temporary space while they finalize their lease contracts. They
will all be open by the end of the Fiscal Year.
To enhance access to care for veterans in underserved areas, 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
veterans' psychological and social readjustment problems in convenient,
easy-to-access community-based locations and generally support ongoing
enhancements under the VA Mental Health Strategic Plan.
In summary, Mr. Chairman, I am very proud of what VHA does in the
area of mental health care. More than 200,000 people are fully
committed to helping veterans receive the health care benefits they
have earned through their service and sacrifices. I hope we can
continue to move forward from this episode, and help veterans and their
families; Congress; the news media and others to better understand what
VA has done, and is doing, to fulfill our Nation's commitment to those
who have worn the uniform of our Armed Services.
______
Response to Written Questions from Hon. Bernard Sanders to Michael J.
Kussman, M.D., Under Secretary for Health, Department of Veterans
Affairs
Question 3(a). Under Secretary Kussman, a recent Rand report
estimates that the costs of treating brain injuries in 2007 ranged from
$26,000 for mild cases to $409,000 for severe ones. The report
estimates that the costs for treating Post Traumatic Stress Disorder
and depression in the first 2 years after deployment could be as high
as $6 billion. And that is only the cost for TBI and PTSD. It does not
include the cost of prosthetics, eye injuries, or other medical or
mental health care. An Associated Press (article attached below)
recently reported on VA documents it had obtained that said the
government expects to be spending $59 billion a year to compensate
injured servicemembers over the next 25 years, up from today's $29
billion. The AP story noted that some at the VA believe these are
conservative estimates. Given these high costs, and the increased
demand and use of VA services, I would like the VA to provide me with
the long-term, 40 year, trend for the number of veterans that VA
expects to serve and the amount the VA expects to expend for:
Inpatient medical care
Outpatient medical care
Vet Center readjustment counseling
Response. The Veterans Health Administration (VHA) develops
projections for 20 years to support strategic and capital planning
activities. Our estimates are revised annually to reflect the most
recent enrollment, demographic, and economic data available. Through
the VA enrollment health care model, VHA makes assumptions regarding
potential changes in health care practice, new technologies, medical
advances, and new generations of drugs such as biologics. Given the
dynamic nature of health care, VHA would have concerns projecting
health care and readjustment counseling demand 40 years into the
future.
Question 3(b). Please provide this number both as an aggregate
number for all of the benefits/services and broken down by each type.
Response. The following table is from page 1C-20 of the FY 2009
Budget Submission for medical program and information technology
programs.
[GRAPHIC] [TIFF OMITTED] 43231.05
Q02Question 3(c). Given these high costs, and the increased demand
and use of VA services, does the VA have a long term plan which
includes expanded facilities, staffing, and other relevant matters that
will meet the needs of this new generation of veterans as well as our
existing veterans?
Response. We are constantly planning and implementing new
initiatives to address the needs of all veterans, including the new
generation of veterans through the following initiatives:
VA recognizes that delivering health care closer to the
veteran's place of residence is one way to better achieve our mission
of being a patient-centered integrated health care organization. VHA
continues to seek opportunities in the coming fiscal years to deploy
community based outpatient clinics (CBOC) in areas where they will
improve veterans' access to health care, particularly in underserved
and rural areas.
VA recognizes the need for expanded mental health care and
is now providing mental health services in all VA medical centers and a
majority of CBOCs across the country.
VA recognizes the need to address the fact that many of
the injured OEF/OIF veterans return with multiple injuries. To meet
their needs, VA established four polytrauma centers across the country
(Palo Alto, California; Tampa, Florida; Richmond, Virginia; and,
Minneapolis, Minnesota), and will soon open a fifth center in San
Antonio, Texas.
To meet the needs of veterans, VA is developing,
monitoring, tracking, and trending performance measures in various
administrative and clinical categories. These include: quality
management, clinic waiting times, financial and human resource
management, employee and patient satisfaction, workload production,
capital and planning, and special populations/clinical cohorts.
To address the needs of this new, younger generation of
veterans, VA is changing the culture of care at its nursing homes, now
known as community living centers.
Primary care/specialty care hours of operations are being
extended and made available in many medical centers and CBOCs
nationwide.
VA continues its efforts to outreach to veterans by
conducting multiple and diverse activities through, for example,
dedication ceremonies, educational programs, clinical care, health
fairs, town hall meetings, news releases, and other publications,
special event programming, speeches, and homeless stand downs.
VHA has opened CBOCs to make services more readily
accessible to veterans, especially in rural areas. Videoconferencing
technologies and diagnostic equipment mean specialists from major
hospital centers can review veteran patients in a CBOC close to home
thus avoiding travel and offering easier access to specialist care.
Veterans with chronic diseases such as diabetes, heart failure and
chronic pulmonary disease can be monitored at home using home
telehealth technologies. This prevents or delays an elderly veteran
needing to leave their home and move into long-term institutional care
unnecessarily.
With the addition of the 23 Vet Centers initiated in 2007,
the Readjustment Counseling Service's (RCS) will administer 232 Vet
Centers across the country by the end of FY 2008. Vet Centers are
unique in VA providing community-based services that go beyond medical
care, and professional readjustment counseling for war-related
psychological trauma, including Post Traumatic Stress Disorder (PTSD),
to returning combat veterans of all eras. Vet Centers are staffed by
interdisciplinary teams, including psychologists, nurses, and social
workers, many of whom are veterans themselves.
Question 4. Dr. Katz and Under Secretary Kussman, can you tell me
what the VA is doing system-wide to coordinate the medications that our
veterans are taking, particularly our OEF/OIF veterans? This Committee
has heard a number of stories about veterans in VA care that are being
over-medicated and medicated with different drugs that when taken
together can have drastic consequences including increasing the risk of
suicide. What kind of a tracking system does the VA have in place and
does this include tracking prescriptions a veteran may be taking
outside of the VA, such as those prescribed by another physician or
those prescribed while a veteran was in a military hospital?
Response. VA has upgraded capabilities in its computerized patient
record system (CPRS) to ensure the prescribing of medications is
coordinated. Using VA's award-winning electronic health record, the
veterans health information system technology architecture (VistA) and
CPRS, providers are notified automatically regarding any potential
conflicts with other medications the patient is taking, as well as any
possible allergies a patient may have. CPRS gives the provider the
ability to document mediations a patient is taking from outside the VA
system. The automatic notification occurs with non-VA medications as
well as with medications provided by the VA.
In addition, VA has upgraded its systems to include remote data
interoperability, which provides medication and allergy order checks
between VA facilities. VA and the Department of Defense (DOD) have
created a bidirectional health information exchange system and clinical
health data repository, which makes available to DOD and VA providers
real time information on medications and allergies for shared patients.
VA has placed a high priority on medication reconciliation.
Medication reconciliation is a Joint Commission National Patient Safety
Goal and is the process for comparing the patient's current medications
with those new medications ordered for the patient; communicating this
information to the next provider of service, and providing a
comprehensive written list to the patient. As part of this process, VA
staff engages the patient as an active partner in developing the list
with every admission and discharge from an inpatient stay or outpatient
appointment.
______
Response to Written Questions from Hon. Roger F. Wicker to Michael J.
Kussman, M.D., Under Secretary for Health, Department of Veterans
Affairs
Question 1. Modern medicine has made such significant progress on
healing the physical wounds and saving lives on the battlefield, but
the impact of mental wounds is becoming increasingly apparent.
Traumatic Brain Injury is one of the signature injuries of the war on
terror. Under Secretary Kussman, please provide me with an overview of
the changes the Veterans' Administration has made in screening for TBI
over the last decade. How does VA currently diagnose brain injury?
Response. Beginning in April 2007, VA has had a policy to screen
all OEF/OIF veterans who come to VA for possible Traumatic Brain Injury
(TBI). VA established a task force to develop a TBI screening procedure
in December 2006; the task force completed its charge by developing a
TBI screening instrument and evaluation protocol. An automated TBI
clinical reminder was established in the clinical patient record
system, policy was established (VHA Directive 2007-013), and national
training was completed for over 50,000 VA practitioners. The national
clinical reminder TBI screening was implemented on April 14, 2007.
Those who screen positive are offered a comprehensive evaluation to
confirm a diagnosis and be provided treatment for symptoms associated
with their TBI.
VA's approach to diagnosing TBI is consistent with the American
Congress of Rehabilitation's Diagnostic Criteria for mild TBI, which is
the ``occurrence of a traumatically induced physiologic disruption of
brain function as indicated by one of the following:
Any period of loss of consciousness,
Any loss of memory for events immediately before or after
the accident,
Any alteration in mental state at the time of the
accident,
Focal neurologic deficits that may or may not be
transient.''
For those who screen positive for possible TBI, VA's standardized
evaluation protocol includes the origin or etiology of the patient's
injury, assessment for neurobehavioral symptoms (via the 22 question
neurobehavioral symptom inventory), a targeted physical examination,
and a follow-up treatment plan. When any symptom is positive, the
protocol provides recommendations on physical examination, diagnostic
testing, and recommendations for initial treatment interventions and
referral pathways for persistent symptoms.
Question 2. With the large number of servicemembers that have
served in combat and, in particular, those returning with injuries from
mortar, grenade, RPG, or IED attacks, does the VA have the capacity to
properly evaluate them for brain injury? Does VA currently employ, or
is VA investigating the use of, diagnostic software that can help
identify brain injury?
Response. VA is sufficiently resourced to respond to the needs of
OEF/OIF veterans with TBI. VA provided health care to 5.5 million
veterans in FY 2007. Since April 2007, VA has screened approximately
185,000 OEF/OIF veterans for possible TBI. Of those who have screened
positive for possible TBI and completed the second level evaluation,
7,561 have received a definitive diagnosis of TBI. Additionally, there
have been about 550 OEF/OIF active duty servicemembers and veterans who
have been treated in VA polytrauma rehabilitation centers for severe
TBI since March 2003.
VA is actively pursuing initiatives, both clinically and through
research, to investigate use of various diagnostic tools that can help
identify brain injury. Currently, several diagnostic tests are being
used to diagnose mild TBI: magnetic resonance imaging (MRI), single
photon emission computed tomography (SPECT) scans, positron emission
tomography (PET) scans, evoked response potentials, and a variety of
neuropsychological test batteries. Many of these procedures are
sensitive to any type of brain dysfunction such as trauma, congenital
disease (for example, multiple sclerosis or Alzheimer's disease), and
depending upon the procedure, may be affected by conditions such as
mood, mental state, fatigue, medication, and patient participation in
the test. While these tests are sensitive to any trauma of the head,
body or even vigorous physical activity, none is specific to mild TBI.
Currently, no diagnostic test, software or other, has been demonstrated
to differentiate and identify mild TBI from numerous other potential
causative conditions. Definitive diagnosis of mild TBI requires
evaluation that includes documenting the injury, status immediately
following the event, cognitive screening, neurobehavioral assessment,
and medical evaluation.
Question 3. Secretary Kussman, is there any coordination between
the VA and the Department of Defense to assess servicemembers prior to
deployment to determine a cognitive baseline that can later be tested
against to diagnosis a brain injury?
Response. We would refer you to DOD for further explanation of any
mandatory TBI tests conducted for members of the Armed Services, the
National Guard, or the Reserve prior to deployment.
Question 4. Dr. Kussman, are there any mandatory TBI tests for
soldiers returning from a combat zone or separating from the military?
If so, please describe them.
Response. DOD has added questions to its post-deployment health
assessment and post-deployment health reassessment to screen for
Traumatic Brain Injury. When a veteran enrolls in the VA health care
system, DOD shares that information with VA clinicians as part of an
effort to facilitate the continuity of care for the veteran or
servicemember.
Since April 2007, any OEF/OIF veteran seen by a VA health care
provider is automatically screened for possible TBI. Veterans are asked
four sequential questions regarding events that may increase the risk
of TBI, immediate symptoms following the event, new or worsening
symptoms following the event, and current symptoms. If a person
responds negatively to any of the sets of questions, the screen is
negative and the remainder is completed. If the patient responds
positively to one or more possible answers in all four sections, the
screen is positive and the veteran is referred for further evaluation
or the veteran's refusal is documented. Not all patients who screen
positive have TBI; it is possible to respond positively to all four
sections due to the presence of other conditions such as PTSD,
cervicocranial injury with headaches, or inner ear injury. Therefore,
it is critical that patients not be labeled with the diagnosis of TBI
on the basis of a positive screening test. Patients need to be referred
for a comprehensive evaluation by a specialized team to substantiate
the diagnosis. Since April 2007, VA has screened approximately 185,000
OEF/OIF veterans for possible TBI. Of those who have screened positive
for possible TBI and completed the second level evaluation, 7,561 have
received a definitive diagnosis of TBI.
For severely injured veterans and servicemembers, VA's polytrauma
system of care provides specialized rehabilitation and treatment and
develops an individualized recovery plan tailored to the specific needs
of the veteran or servicemember.
Chairman Akaka. Thank you very much, Dr. Kussman, for your
statement.
Admiral Dunne.
STATEMENT OF PATRICK W. DUNNE, ACTING UNDER SECRETARY FOR
BENEFITS AND ASSISTANT SECRETARY FOR POLICY AND PLANNING,
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY BRAD MAYES,
DIRECTOR OF COMPENSATION AND PENSION SERVICE
Mr. Dunne. Good morning, Mr. Chairman and Members of the
Committee.
Thank you for the opportunity to discuss the important
issue of Post Traumatic Stress Disorder. I am pleased to be
accompanied by Mr. Brad Mayes, the Veteran Benefits
Administration's Director of the Compensation and Pension
Service.
We all share the goal of preventing and minimizing the
impact of this disability on our veterans and providing those
who suffer from it with just compensation for their service.
Today I will review how VBA processes claims for service
connection of PTSD and the relationship between VBA and the
Veterans Health Administration.
The number of veterans submitting claims for PTSD has grown
dramatically. From fiscal year 1999 through May 2008, the
number of veterans receiving disability compensation who are
service-connected for PTSD increased from 120,000 to nearly
329,000.
24,087 of these veterans served in World War II; 12,229 in
the Korean Conflict; 222,191 in the Vietnam Era; 11,220 during
peace time; 59,196 in the Gulf War Era. The Gulf War Era number
includes 37,460 OEF and OIF veterans.
Service connection for PTSD requires medical evidence
diagnosing the condition, medical evidence of a link between
current symptoms and an in-service stressor, and credible
supporting evidence that the in-service stressor occurred.
VA regulations established three categories of in-service
stressors: first, combat or prisoner of war; second, personal
assault; and third, non-combat.
Combat status may be established through the receipt of
certain recognized military citations and other supportive
evidence. If the evidence establishes that a veteran engaged in
combat or was a POW and the stressor relates to that
experience, the veteran's lay testimony alone may establish an
in-service stressor for purpose of service-connecting PTSD.
If the stressful event is not linked to combat or POW
status, VA requests that the veteran submit information to help
substantiate that the incident occurred. Reasonable doubt is
always resolved in favor of the veteran.
A VA examination is requested once credible supporting
evidence establishes that the claimed in-service stressor
occurred. The VHA medical examination for PTSD or an equivalent
contract examination essentially serves three purposes.
First, it serves to establish whether the veteran has PTSD.
Second, it provides an opinion as to the existence of a
link between the current symptoms and the in-service stressor.
It is important to note that this is a medical determination
performed by the examining psychiatrist or psychologist, not by
the rating specialist.
Third, it serves to provide an assessment of the current
level of disability resulting from the veteran's symptoms so
that VA can provide a rating for the extent of that disability.
Although a veteran may have received a diagnosis of PTSD
from a private mental health provider before submitting a claim
to VBA, the VHA examination is still necessary to confirm the
diagnosis in accordance with the DSM-IV, and to provide the
proper diagnostic criteria and level of disability assessment
needed for rating purposes.
To ensure that a qualified professional is responsible for
the examination, VA requires the initial examination be
conducted or supervised by a board-certified psychiatrist or
licensed doctorate-level psychologist.
Additionally, all potential examiners now must undergo
specific training and become certified prior to performing PTSD
exams.
Ratings are based on the rating schedule for mental
disorders. VBA rating personnel must evaluate the examination
report and any other relevant evidence to determine the most
appropriate level of disability. The examination report must be
carefully reviewed to match the examiner's description of the
veteran's symptoms with the disability percentage most closely
representing the severity of those symptoms.
This is a complex process that involves an element of
judgment. However, when a conflict arises as to what level of
evaluation should be assigned, reasonable doubt is resolved in
favor of the veteran.
It is critical that our employees receive the essential
guidance, materials and tools to meet the increasingly complex
demands of their decisionmaking responsibilities. To accomplish
this goal, VBA has developed new training tools and centralized
training programs that support more accurate and consistent
decisionmaking. New employees receive comprehensive training
through the national centralized training program called
``Challenge.''
VBA has developed job aids and training sessions to provide
employees the skills and tools essential to render fair and
timely decisions on PTSD claims. All veteran service
representatives and rating veteran service representatives are
required to receive training on the proper development and
analysis of PTSD claims. The training materials include medical
and military references and prerecorded video broadcasts
pertaining to PTSD development and records research.
Mr. Chairman, this completes my statement. I will be happy
to answer any questions.
[The prepared statement of Mr. Dunne follows.]
Prepared Statement of Rear Admiral Patrick W. Dunne, USN (Ret.), Acting
Under Secretary for Benefits, Veterans Benefits Administration,
Department of Veterans Affairs
Mr. Chairman and Members of the Committee: Thank you for providing
me the opportunity to appear before you today to testify on the
important issue of Post Traumatic Stress Disorder (PTSD). I am pleased
to be accompanied by Mr. Brad Mayes, the Veterans Benefit
Administration's (VBA) Director of Compensation and Pension Service. We
all share the goal of preventing and minimizing the impact of this
disability on our veterans and providing those who suffer from it with
just compensation for their service to our country. Today I will
explain how VBA processes claims for service connection of PTSD and the
relationship between VBA and the Veterans Health Administration (VHA)
in processing these claims.
The number of veterans submitting claims for PTSD has grown
dramatically. From FY 1999 through May 2008, the number of veterans
receiving disability compensation who are service-connected for PTSD
increased from 120,000 to nearly 329,000 (328,923). These veterans
represent veterans of World War II (24,087), the Korean Conflict
(12,229), the Vietnam Era (222,191), Peacetime (11,220), and the Gulf
War Era (59,196). The Gulf War Era number includes 37,460 OEF/OIF
veterans.
When a VBA regional office receives an initial claim for service
connection of PTSD, a series of steps are followed which include: (1)
providing the veteran with notice of what evidence is required to
substantiate the claim, commonly referred to as a Veterans Claims
Assistance Act or VCAA notice, and providing assistance with gathering
that evidence; (2) researching the evidence needed to support the
claimed in-service stressor; (3) providing the veteran with a PTSD
examination; and (4) assigning a disability rating percentage for
compensation purposes. These steps will be explained in detail.
providing the veteran with notice of evidence required to substantiate
the claim and assistance with gathering that evidence
When an initial claim for PTSD is received, the regional office
will respond to the veteran with a letter outlining the information and
evidence needed to substantiate the claim and the actions VBA will take
to assist the veteran with developing for that evidence and the
veteran's responsibility for providing evidence. VBA will then obtain
the veteran's service medical and personnel records and any post-
service medical or hospital records identified by the veteran. These
procedures are the same for all claims, regardless of the disability.
However, in PTSD claims, the veteran will generally be asked to provide
a description of the in-service stressor that has caused the current
PTSD symptoms.
researching for evidence to support the claimed stressor
The processing of PTSD claims is governed by our regulation at 38
CFR Sec. 3.304(f). This regulation states that, in order for service
connection to be granted, there must be medical evidence diagnosing the
condition, there must be medical evidence establishing a link between
current symptoms and an in-service stressor, and there must be credible
supporting evidence that the claimed in-service stressor occurred. The
first two requirements involve medical assessments, while the third
requirement generally involves investigation by VBA personnel into the
nature of the stressor.
The steps required to establish service connection for PTSD can be
affected by the specific circumstances in the claim.
In cases where PTSD is diagnosed in service and the nature of the
stressful event is not apparent, VA will request that the examiner
detail the circumstances surrounding the development of PTSD. If those
circumstances are consistent with military service, evidence of the
stressful event will be accepted without further development.
Even if PTSD is not diagnosed in service, under certain conditions
established by sections 3.304(f)(1) and (2), the veteran's lay
testimony alone can establish the occurrence of the stressor. When
sufficient evidence shows that the veteran engaged in combat with the
enemy or was a prisoner of war (POW) and the claimed stressor is
related to that combat or POW status, the veteran's statement
describing the stressor will allow the claim to go forward without
corroborating evidence. VBA will accept certain military awards
received by the veteran that designate participation in combat, such as
a Combat Infantryman Badge, Combat Action Ribbon, Purple Heart Medal,
etc., as evidence of exposure to combat-related stressors.
When evidence for combat status is not readily apparent or where
the claimed stressor is not directly related to combat, VBA is
obligated to search for evidence to corroborate the combat status or
the non-combat stressor before the claim can go forward. Such evidence
can come from additional military records, from the ``buddy
statements'' of individuals who served with the veteran, or from on-
line documents available at official military or government Web sites.
In addition, VBA personnel have access to thousands of declassified
military unit reports and histories from all periods of war on the
Compensation and Pension Service Intranet Web site. These reports and
histories document unit combat actions and can serve to corroborate a
stressor when the veteran's records show assignment to a particular
unit at the time covered in the report or history.
When VBA personnel cannot find sufficient credible evidence to
support a claimed stressor, the stressor information is forwarded to
the Army's Joint Services Records Research Center (JSRRC). This DOD
activity with full time researchers has access to multiple sources of
military documents, not readily available to VBA personnel. If JSRRC is
able to find evidence supporting the claimed stressor, it will be
provided to VBA. In all cases where there is an approximate balance of
evidence for and against occurrence of the stressor, the veteran will
be given the benefit of doubt and VA will find that the stressor
occurred.
Where PTSD is due to military sexual trauma and evidence of the
trauma is not of record, VA has developed processes to develop this
extremely sensitive issue. These include a search for potential
``markers'' of sexual assault such as sudden degradation in
performance, seeking duty station changes, visits to clinics for
sexually transmitted disease testing, provost marshal records, and
seeking out of medical or spiritual assistance.
In general, VBA procedures require that a claimed stressor must be
corroborated by credible supporting evidence before an initial PTSD
examination is scheduled with VHA. Generally, neither the examination
report as such nor the examiner's opinion can serve as credible
evidence to support occurrence of the stressor. However, under section
3.304(f)(3), when an in-service personal assault is involved, evidence
that can corroborate the veteran's account of the stressor includes
records from rape crisis centers and mental health counseling services.
A VHA examination may be scheduled before there is sufficient evidence
to corroborate the assault, and the examiner may be asked for an
opinion as to whether the assault occurred based on the available
evidence and the examination results. Also, where the veteran was
diagnosed with PTSD in service, there is an assumption that the
diagnosis was made by a competent military medical authority with a
factual basis for recognizing the stressor. Therefore, VBA need not
seek further credible evidence for the causative stressor. In these
cases, a VHA examination can be scheduled immediately to evaluate the
level of disability.
providing the veteran with a ptsd examination
The VHA medical examination for PTSD, or an equivalent contract
examination, essentially serves three purposes. First, it serves to
establish whether the veteran has PTSD, or some other mental disorder
for the veteran's presenting symptoms. Second, it provides an opinion
as to the existence of a link between the current symptoms and the in-
service stressor. Third, it serves to provide an assessment of the
current level of disability resulting from the veteran's symptoms so
that VA can provide a rating for the extent of the disability.
VBA and VHA have jointly developed a project to improve the
delivery and oversight of medical examinations used for VBA disability
rating purposes, referred to as the Compensation and Pension
Examination Program (CPEP). This project involves monitoring the
accuracy of the examination requests sent from VBA to VHA, as well as
the quality of the examinations conducted by VHA examiners. Quality in
this sense refers to the sufficiency of the examination report for VBA
disability rating purposes. Examination worksheets have been developed
to assist the VHA examiners with providing medical information that
fits the disability criteria described in 38 CFR, Part 4, Schedule for
Rating Disabilities. Specific information about these criteria is
necessary for VBA adjudicators to provide accurate and fair disability
rating evaluations for compensation purposes. Oversight efforts similar
to those of CPEP are also in place to monitor the quality of contract
examinations.
PTSD examinations are subject to the requirements of 38 CFR
Sec. 4.125(a), which provides that the diagnosis must conform to the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV), published by the American Psychiatric Association and must be
supported by the findings on the examination report. Although a veteran
may have received a diagnosis of PTSD from a private mental health
provider before submitting a claim to VBA, the VHA examination is still
necessary to confirm the diagnosis in accordance with the DSM-IV and to
provide the proper diagnostic criteria and level-of-disability
assessment needed for rating purposes. To ensure that a qualified
professional is responsible for the examination, VBA requires that the
initial examination be conducted or supervised by a board-certified
psychiatrist or licensed doctorate-level psychologist. Additionally,
all potential examiners must now undergo specific training and become
certified prior to performing PTSD examinations.
assigning a disability rating percentage for compensation purposes
VBA personnel evaluate the examination reports and assign the
veteran a percentage disability rating when the evidence supports
initial service connection for PTSD. Rating personnel also evaluate
PTSD reexamination reports for service-connected veterans who are
claiming an increase in compensation due to a worsened condition.
Ratings are based on the rating schedule for mental disorders found at
38 CFR Sec. 4.130. The schedule is a general rating formula for all
mental disorders except eating disorders based on the level of
occupational and social impairment caused by the veteran's mental
disorder. It provides for disability percentages of 10, 30, 50, 70, and
100, with a description of symptoms associated with each percentage
level. VBA rating personnel must evaluate the examination report, and
any other relevant evidence, to determine the most appropriate level of
disability. The examination report must be carefully reviewed to match
the examiner's description of the veteran's symptoms with a disability
percentage most closely representing the severity of those symptoms.
This is a complex process that involves an element of judgment.
However, when a reasonable doubt arises as to which of two possible
percentages to assign, 38 CFR Sec. 4.3 dictates that reasonable doubt
will be resolved in favor of the veteran and the higher of the 2
percentages will be assigned.
In response to recommendations of the Veterans' Disability Benefits
Commission and the Institute of Medicine, VBA is reviewing the mental
disorders rating schedule with a particular focus on possibly providing
specific criteria for rating PTSD based on the symptoms described in
the DSM-IV.
ptsd training
As more veterans returning from Iraq and Afghanistan are turning to
VA for benefits and medical care, including care for PTSD, it is
critical that our employees receive the essential guidance, materials,
and tools to meet the increasingly complex demands of their
decisionmaking responsibilities. To accomplish this goal, VBA has
deployed new training tools and centralized training programs that
support accurate and consistent decisionmaking. New employees receive
comprehensive training through the national centralized training
program called ``Challenge.'' The current curriculum consists of full
lesson plans, handouts, student guides, instructor guides, and slides
for classroom instruction. Recognizing the importance of continuing
education, all Veterans Service Center employees are required to
complete a mandatory cycle of training, consisting of 80 hours of
annual coursework.
VBA has developed job aids and training sessions to provide
employees the skills and tools essential to render fair and timely
decisions on PTSD claims. All Veteran Service Representatives (VSRs)
and Rating Veteran Service Representatives (RVSRs) are required to
receive training on the proper development and analysis of PTSD claims.
The training materials include medical and military references and pre-
recorded video broadcasts pertaining to PTSD development and records
research. VBA published PTSD guidance includes ``Handling PTSD Claims
Based on Stressors Experienced During Service in the Marine Corps''
dated June 2005, ``Military Sexual Trauma Training Letter'' dated
November 2005, and ``JSRRC Stressor Verification Guide'' dated January
2006. Additionally, VBA introduced the PTSD Training and Performance
Support System (TPSS) module for VSRs and RVSRs in 2006. The TPSS
module is an interactive learning tool in which employees complete
self-guided lessons on PTSD development and verification of in-service
stressors. Due to the success of the TPSS learning system, a second
PTSD module titled, ``Rate a Claim for PTSD'' was released in July
2007.
The foregoing description of the PTSD claims process is a general
outline of the procedures followed by VBA. I would be happy to answer
any specific questions the Committee Members may have.
______
Response to Written Questions from Hon. Bernard Sanders to Rear Admiral
Patrick W. Dunne, USN (Ret.), Acting Under Secretary for Benefits,
Veterans Benefits Administration, Department of Veterans Affairs
Question 1. Under Secretary Dunne, can you 1) tell me the current
backlog of claims for OEF/OIF veterans, 2) the average time to process
their claims, and 3) the average waiting time OEF/OIF veterans
experience when having these claims processed? In addition, please
provide a breakdown of the data requested in items #2 and #3 into
percentages, i.e., 25% of OEF/OIF claims take 5 months to process, 15%
take 4 months, etc). Can you also provide these same numbers for OEF/
OIF veterans only from Vermont?
Response. Our inventory of pending claims from Operation Enduring
Freedom/ Operation Iraqi Freedom (OEF/OIF) veterans is 50,528 as of May
31, 2008. Of those, 42,944 are original claims and 7,584 are reopened
claims. This fiscal year through May 2008, we completed 102,318 OEF/OIF
cases with an average processing time of 154 days. Our White River
Junction Regional Office's inventory of OEF/OIF cases is 116 as of the
end of May. Through May, White River Junction completed 218 OEF/OIF
cases in an average of 170 days.
The table below summarizes completed OEF/OIF claims for the Nation
and Vermont.
[GRAPHIC] [TIFF OMITTED] 43231.01
Q02Question 2(a). Under Secretary Dunne, a recent Rand report
estimates that the costs of treating brain injuries in 2007 ranged from
$26,000 for mild cases to $409,000 for severe ones. The report
estimates that the costs for treating Post Traumatic Stress Disorder
and depression in the first 2 years after deployment could be as high
as $6 billion. And that is only the cost for TBI and PTSD. It does not
include the cost of prosthetics, eye injuries, or other medical or
mental health care. An Associated Press article (attached below)
recently reported on VA documents it had obtained that said the
government expects to be spending $59 billion a year to compensate
injured servicemembers over the next 25 years, up from today's $29
billion. The AP story noted that some at the VA believe these are
conservative estimates. Can you provide me with the documents that are
referenced in the Associated Press article included below?
Response. The Associated Press article written by Jennifer Kerr
reported that the government expects to be spending $59 billion a year
to compensate injured servicemembers over the next 25 years. This
figure was obtained from the Veterans Benefit Administration's (VBA)
contingent liability model, prepared by PricewaterhouseCoopers, used to
estimate VA's total liabilities on the Consolidated Financial Statement
Balance Sheet. The liability for future compensation payments is
reported on the balance sheet as the net present value of expected
future payments. Various assumptions in the actuarial model, such as
the number of veterans and dependents receiving payments, discount
rates, cost of living adjustments, and life expectancy, impact the
amount of the liability. Although the liability model forecasts future
beneficiaries of the compensation program, including some members of
the current active duty military who may receive benefits, it does not
project new military enlistments. This model is not used to estimate
future budgetary needs because not all future payments are captured.
Ms. Kerr obtained the Annual Benefits Reports for 1999 to 2006 from
the Department of Veterans Affairs' (VA) Web site (http://
www.vba.va.gov/reports/index.htm). Ms. Kerr contacted VA to obtain data
on benefits dating back to 1950. Since VBA does not have benefits
reports prior to 1999, we provided her with copies of the VA Annual
Reports from 1918 to 1998, which contain some benefits information, on
CDs. We are providing a copy of these CDs for your reference.
The following documents were also provided and are attached.
1. Compensation and pension programs--estimate of liability as of
September 30, 2007, prepared by PricewaterhouseCoopers
2. Estimated values underlying the estimate of veterans
compensation liability as of September 30, 2007, prepared by
PricewaterhouseCoopers
3. Statistics on Global War on Terror (GWOT) veterans
Question 2(b). What yearly funding does the VA estimate will be
needed to compensate injured servicemembers over the next 25 years?
Given these high costs, and the increased demand and use of VA
services, I would like the VA to provide me with the long-term, 40 year
trend for the number of veterans that VA expects to serve and the
amount the VA expects to expend for:
Compensation
Pension
Home loan guaranty, including defaults (foreclosures and
sales)
Vocational rehabilitation
Life insurance (for deaths), and Traumatic Insurance (for
major injuries)
Educational benefits
Burial benefits
Adaptive automobile and home benefits.
Please provide this number both as an aggregate number for all of
the benefits/services and broken down by each type.
Response. VBA's budgetary needs are projected using budget models
specific to each benefit program. For example, the compensation and
pensions budget estimation model forecasts both the number of
disability compensation beneficiaries as well as the average benefit
payment for veterans and survivors using a complex combination of
historical data, current experience, workload and performance
projections and assumptions.
The budget models forecast obligations and outlays for 10 years.
VBA does not forecast benefit payments beyond the 10-year projection.
Projecting future demand is extremely difficult, as caseload and
average payment assumptions may be impacted by military operations and
separation rates, legislative and regulatory changes, court decisions,
changing demographics of the population, outreach efforts, future
application trends, and trends in benefits usage, as well as economic
factors.
Shown below are the fiscal year (FY) 2009 and 2018 estimated
caseload and obligations for VBA mandatory programs from the 2009
President's Budget submission.
[GRAPHIC] [TIFF OMITTED] 43231.03
Q06Question 2(c). Given these high costs, and the increased demand
and use of VA services, does the VA have a long term plan which
includes expanded facilities, staffing, and other relevant matters that
will meet the needs of this new generation of veterans as well as our
existing veterans?
Response. We are aggressively working to meet the increased demand
and improve benefits delivery by employing enhanced technologies that
will support claims processing in a ``paperless'' environment. Our
strategy is to move to a business model less reliant on paper
documents. Enhanced workflow capabilities, rules-based engines,
enterprise content management, and correspondence services are
important elements of our strategic vision for meeting the needs of
this new generation as well as those of our existing veterans. We are
also working to incorporate the use of portal technology and identity
management/user authentication to provide veterans the capability for
online self service. The integration of these new technologies will
significantly increase our flexibility to expand and electronically
move work to where we have the supporting infrastructure and resources.
We have already consolidated the processing of all benefits delivery at
discharge (BDD) claims to two sites and are implementing paperless
processing at these sites. Our plans call for all BDD claims to be
processed using imaging technology by the end of this fiscal year. We
are also developing a strategy for expanding the types of claims to be
processed in a paperless environment.
______
Attachment 1 in Support of Response to Question 2(a) Above
Attachment 2 in Support of Response to Question 2(a) Above
Attachment 3 in Support of Response to Question 2(a) Above
Chairman Akaka. Thank you very much, Admiral.
Dr. Kussman, you mentioned the word ``perception'' and for
me this is part of the reason we are having this hearing and
that is to deal with the perceptions of our veterans about the
Veterans' Administration and its service.
We know that the quality of service is good. Accessibility
and problems that we have always had, but we are trying to
correct the perception if there is a wrong perception here. I
share your concern about veterans not seeking treatment because
of the public perception that VA may not be sympathetic toward
their needs.
My question to you is what are your thoughts on how VA can
better assure veterans that they are welcome and will receive
needed care? You mentioned some of that in your statement.
As Chairman of this Committee I can tell that even before
the story broke about this email, veterans were quite vocal
with their concerns about how their mental health care needs
are regarded. Indeed, many of the stories about the email
expressed the view that it was only the latest example of how
VA regards PTSD, and that was the perception.
So what I am asking for is your thoughts on how VA can
better show veterans that they are welcome and will receive
needed care.
Dr. Kussman. Thank you, Mr. Chairman, for the question, and
obviously that type of thing is on my mind almost on an hourly
basis.
We are a large organization, 230,000 people, and I would be
the first person to say we are not perfect in what we do. When
we know about areas where this clearly is not being
communicated, we put a great deal of effort into that.
But sometimes as I alluded to in my written statement is
that a lot of times in our effort to meet the needs of the
veterans, sometimes we do not do what they want. I mean our
effort is to be sure that they get the right care and get a
firm and appropriate assessment. Sometimes they do not like
what the assessment is, and so there is a constant concern
about whether they perceive that they did not get what they
want rather than that the appropriate and an honest evaluation
was done.
But we have gone to a large degree. We have hired more than
3800 mental health people over the last year and one-half to
provide services and expand services. We are trying to put
those services as far forward into our CBOCs as well as our
clinics, increase the number of Vet Centers to provide
services. So we are doing everything we can to provide services
that make it convenient and easier for the veteran to come in.
As we talked about, and it was mentioned in opening
statements, patients do not come to say, oh, I think I have
PTSD. They usually come--and we know this from the 300,000 or
so OEF/OIF veterans who have already come to us--is that they
generally come for some other thing. They may come for a
musculoskeletal thing.
As you know, we screen everybody for PTSD in an effort to
determine whether there is any possibility of a diagnosis of
PTSD. Then we realize also that people are reluctant to go to a
mental health clinic because there is stigma, again, related to
that. That is a societal thing. It may be more so in the group
of patients that we take care of.
And I speak from 35 years of experience in that. Perhaps
some people think I should have gone to the mental health
clinic. I do not know.
But the important point here, not to make light of it, is
that what we have done is had an innovative process of putting
mental health in the primary care clinic, putting mental health
people there, partnering with the primary care people so that
as much as possible we can provide mental health services in a
more friendly and less stigmatizing environment for patients,
because we are concerned that people will not follow up if we
send them to a mental health clinic. And that has been
eminently successful with our primary care and mental health
people and Dr. Katz.
The other thing that we are doing, as you know, is waiting
for people to come to us. We have seen about one-third or 35-37
percent of the total number of people who have served in the
theater. And so, at least we have an opportunity to interact
with PTSD, or any other thing for that group.
But what about the other 60 plus percent who have not come
to us? With the Secretary's leadership, we have embarked upon a
very aggressive campaign of calling all the people that we have
contact numbers on--over 500,000 who have not come to us--but
who already have received two letters from the Secretary saying
we are here for you, and for whatever reason have chosen not to
use us. Maybe they have their own health care insurance or
maybe they do not need any health care. However, that is not
the issue.
The issue is to try to get in touch with them, particularly
offering them mental health services and other things because
we know people are reluctant to come.
We have been suggesting and we are working now--you know,
we have talked about the 24-hour suicide hotline, and I think
you have been briefed on that previously--to develop a
different type of 24-hour hotline, really an extension of
rehabilitation services that Dr. Adonis Al-Botros gives to Vet
Centers.
So not only will we have the Vet Centers themselves that
people can go to, but they would be staffed by people hired by
Dr. Al-Botros in the Vet Centers to be eligible to take calls
24/7, to talk to people because, as you know, many of these
combat veterans appreciate talking to someone who has walked in
their shoes.
They have done a great job, as you know, over 25 years, and
we would like to extend that into a virtual clinic that would
be open so that people do not even have to go look or try to
get to a Vet Center or a facility. They would have the ability
to call and get counseling.
This is not meant to replace any other 800 number but
rather specifically talk about some of the readjustment issues,
PTSD and other things; not suicide. If suicide came up in the
context of this, they would be referred to the suicide hotline
because you do not want dueling hotlines.
So, these are some of the things that we are doing to
aggressively assist people. But it is a challenge, as
mentioned. Particularly mental health, people are reluctant to
come. And what we are trying to do is make it easy for them to
come. Again, not to belabor the word, but to de-stigmatize it
and make sure people feel comfortable about what we can do. We
cannot impact if they do not come and see us.
Chairman Akaka. Thank you, Dr. Kussman.
Dr. Perez, I do not feel as if this issue has been
adequately addressed. The first line of your email notes that
there are, and I am quoting, ``more and more compensation
seeking veterans,'' unquote.
What exactly did you mean by this? It appears to me and
many others that you were linking diagnosis of PTSD and
potential compensation together and thereby either
intentionally or unintentionally raising concerns about the
cost to VA.
Can you please clarify what you meant by this?
Ms. Perez. Yes, sir. What I was stating there was the fact
that there were those individuals--it is even more critical to
be sensitive to what they have already gone through with a C&P
interview and knowing that they have had another evaluation--so
we have to really be very very accurate in our diagnosis.
All of our clinicians strive to give the accurate
diagnosis. But when you have somebody who may have already seen
a professional, then you want to really make sure that you are
going to be consistent and accurate with your diagnosis so that
you do not add to any distress levels.
Chairman Akaka. I have other questions here. I am going to
defer to our Ranking Member for his questions at this time.
Senator Burr. Thank you, Mr. Chairman.
Dr. Kussman, I had the opportunity with the opening of a
CBOC in Hickory, North Carolina, to see the changes that you
are making relative to mental health that makes a tremendous
amount of sense.
Mr. Chairman, I would ask unanimous consent to enter three
letters into the record. Two to General Peake and one to Dr.
Kussman.
The first one is from the University of Pittsburgh Medical
Center, Western Psychiatric Institute Clinic where within the
body of that letter it states, ``I am writing on behalf of the
president-elect of the American Psychiatric Association to
support the VA in their efforts to care for veterans. A
substantial amount of effort has gone into revitalizing the
system.'' So that was to Secretary Peake.
The second one, Mr. Chairman, is from the Association of VA
Psychologist Leaders, and I will also read from the body.
``We are very appreciative of the enormous efforts by all
of you at the VA and especially the Office of Mental Health
Services in supporting the efforts of those in the field to
provide the best quality mental health care possible to our
veterans.'' That was to Dr. Kussman.
The last one is from the American Society for Suicide
Prevention on an email that went to Secretary Peake. And I will
also read from the body.
``Dr. Ira Katz is an outstanding leader for this work. He
is uniquely qualified to organize the best programs based on
the latest psychiatric research.''
I would ask that they all be in the record.
Chairman Akaka. Without objection.
[The three letters follow:]
Association of VA Psychologist Leaders,
May 1, 2008.
Michael Kussman, M.D.,
Under Secretary for Health,
Department of Veterans Affairs,
Washington, DC.
Dear Dr. Kussman, This last March you were very generous in
spending time with the Executive Committee of the Association of VA
Psychologist Leaders (AVAPL) during our recent trip to Washington, DC.
It was very useful to hear about the large array of policy issues that
have to be dealt with in order to provide resources to those of us in
the field.
AVAPL is an independent organization of VA psychologists in
leadership positions or psychologists aspiring to leadership positions.
As such, our membership directly benefits from the resources provided
by VHA and, more specifically, the Office of Mental Health Services. In
the past several years, we have experienced a very large and beneficial
increase in resources available to us to help meet the mental health
needs of veterans. Many new positions have been created and filled and
this has substantially increased the number of psychologists within VA.
It has allowed for the creation of new and innovative programs for the
treatment of traumatic brain Injury and Polytrauma, integrating mental
health and primary care services, expanding treatment options in areas
such as PTSD and substance abuse and residential treatment for
homelessness. The recent placement of Suicide Prevention Coordinators
at facilities and the creation of a national VA suicide hotline have
greatly enhanced our ability to assess for and respond to these
emergent mental health issues. We are very appreciative of the enormous
efforts by all of you in VHA and especially the Office of Mental Health
Services in supporting the efforts of those of us in the Field to
provide the best quality mental health care possible to our veterans.
AVAPL as an organization also remains dedicated to promoting this same
goal.
Sincerely,
Steven Lovett, Ph.D.,
President,
Association of VA Psychologist Leaders.
______
American Foundation for Suicide Prevention (AFSP),
New York, NY, May 04, 2008.
James B. Peake, M.D.,
Secretary
Department of Veterans Affairs
Dear Dr. Peake, As Medical Director of the AFSP I strongly
encourage the administration to continue to support the valiant efforts
of the current VA leadership. They face an enormous task because the
frequency of PTSD with depression and suicide is high and a suicide
outcome is very common. Their Hotline and hiring of suicide prevention
coordinators are the first steps in dealing with this unprecedented
problem. Many other things must follow, but this is a very appropriate
beginning. Dr. Ira Katz is an outstanding leader for this work. He is
uniquely qualified to organize the best program based on the latest
psychiatric research. Please don't do anything to interfere with the
progression of care that must be instituted.
Sincerely,
Paula J. Clayton, M.D.,
Medical Director.
Cc: Clayton Paula
______
University of Pittsburgh Medical Center,
Western Psychiatric Institute and Clinic,
Pittsburgh, PA, May 5, 2008.
Dr. James B. Peake,
Secretary of Veterans Affairs,
Office of Mental Health Services
Washington, DC.
Dear Dr. Peake: Serving the health care needs of our veterans is
one of the greatest honors a clinician can experience. The current war,
and the political attention to the war, has brought the health care of
our veterans to a national forum. We are fortunate that mental health
care has been recognized as a vital part of the health care system.
Indeed, the Department of Veteran Affairs may be the largest mental
health group in the country. I am writing on behalf of the President-
elect of the American Psychiatric Association to support the VA in
their efforts to care for veterans. A substantial amount of effort has
gone into revitalizing the system. These efforts should not go
unnoticed. In the last year alone, the VA has developed a suicide
hotline and placed a suicide prevention coordinator in every facility.
The system has accomplished true integration of behavioral health into
primary care. Moreover, the VA has established a minimum set of
requirement for all programs to follow in an effort to bring new
evidence based treatments to every facility and every veteran. These
efforts are unprecedented in our society. While there is more work to
be done, I want to applaud the Office of Mental Health Services for the
dedication and innovation that they have shown during the last two
years. I am committed to continue working with VA leadership in
accomplishing the goals of developing a truly national mental health
system for veterans.
Sincerely,
Charles F. Reynolds III, M.D.,
UPMC Endowed Professor of Geriatric Psychiatry,
Director, Advanced Center for Interventions and
Services Research for Late-Life Mood Disorders and
John A. Hartford Center of Excellence in Geriatric Psychiatry.
Senator Burr. What we see, and I say this to all our
witnesses, we have an oversight responsibility that cannot be
ignored. And when issues are raised, whether they are internal
or external--these happen to be external--it is appropriate for
this Committee to begin to look. Do we know the full breadth of
the problem? Is there a problem? If there is not, is there a
reasonable explanation?
Hopefully, at some point in the process we also remember to
ask whether we are making progress. Are we positively affecting
the lives of more veterans? Are we learning? Are we, as I read
from the piece on Dr. Katz, are we using the latest of what we
have learned to incorporate in the delivery of care for
patients?
It is certainly my hope that we are doing that and I have
every reason to believe that there is every effort made at
every level of the VA to incorporate that into a field that is
very difficult, and I think Dr. Perez has alluded to that.
Let me just ask two very pointed questions because they
were raised in opening statements.
Dr. Kussman, Senator Murray said that we did not have
enough resources to treat mental health. Do you have the
resources needed to provide mental health services to our
veterans?
Dr. Kussman. Mr. Ranking Member, yes. Again, if you talk to
any of our mental health people I believe you will be told that
frequently when we are challenged about providing services in
some geographic area, it is not the resources themselves but
the ability to buy those resources or provide those resources.
And so, I believe that there are adequate resources. As he
said, almost $4 billion, significant amounts targeted directly
to PTSD; 3800 new employees.
Actually we have been so successful that there was an
article in a mental health journal that sort of in a backhand
way criticized the VA for having scooped up so many mental
health people in the country that we are hurting the delivery
of care in the civil community. And I know my friends south of
the river at the Pentagon who we have been challenged to hire
more mental health people are a little frustrated with us
because we got ahead of them, and they are having challenges
hiring people because there is a shortage of mental health
services, psychiatrist and Ph.D. psychologist nationally.
Senator Burr. We see that in North Carolina.
Is there a culture in the VA that ignores or devalues
mental health needs?
Dr. Kussman. I do not believe that to be the case. If I was
aware of any kind of culture, I would be at the forefront of
trying to change that culture. I think that our people
understand the mission that we have and they are committed to
doing that.
I will respond to Senator Tester, if I might, where he had
talked about the culture. I do not think it was the culture, I
hope he was not mentioning the culture of not providing
services but responding to needs and things related to that.
Senator Tester. It was the response I am talking about, the
response to the needs.
Dr. Kussman. Of issues coming up with whether it was the
construction or hiring more people or whatever it was. This is
a huge organization. We are well aware of that. The Secretary
and I are working very hard to inculcate changes.
I have four primary things that I am pushing at. One is
patient care and the second one is leadership. We are working
hard to develop the appropriate leadership and the
understanding of everyone in the system to expeditiously look
at the problems that we have. If we cannot fix something, admit
it. Be transparent. Communicate with the congressional people
and the VSOs. We have a good new story to talk about. And when
it gets clouded by the perception or the reality of people not
responding, shame on us.
Senator Burr. Dr. Perez, two quick questions and really
going to what the Chairman raised and that was in your email,
compensation-seeking veterans specifically. What relationship
does your clinic have with the disability compensation process?
Ms. Perez. No relationship whatsoever.
Senator Burr. Were there veterans looking to your clinic to
improve their health through treatment or to provide diagnosis
of PTSD that could be used to substantiate their disability
claims that drove that phrase?
Ms. Perez. No, not at all. Our clinic is just a treatment
clinic. That is it. We are pretty clear with all our veterans
that this is why we are here, to offer the treatment.
Senator Burr. So, given the nature of your treatment
facility--even though I agree with you that this could have
been worded differently in your email--it cannot imply that
veterans were only there to try to enhance their disability
claims because you had no connection to disability process and
you are there not to do anything other than treat for mental
health illness?
Ms. Perez. Exactly. It is just a treatment clinic.
Senator Burr. I thank you for that.
I thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Burr.
Senator Murray.
Senator Murray. Thank you very much, Mr. Chairman.
Like a lot of my colleagues, I am very concerned not only
with the content of Dr. Perez's March 20th email but also with
its potential implications.
A lot of our veterans perceive the VA as an obstacle rather
than an ally today. I know everyone is working in an effort to
make that better. I am greatly concerned that this incident
only adds to that impression. I think that is part of why we
really need to get good strong answers from all of you.
I do have a lot of questions but I want to begin by asking
Dr. Perez today if her testimony was reviewed by the OMB today
before you gave it?
Ms. Perez. Pardon me. I am real new to the VA and
unfamiliar with the initials.
Senator Murray. With the Office of Management and Budget.
Ms. Perez. No, no, no. The reason I was so grateful to be
invited here was that I was given the opportunity to give my
entire story.
Senator Murray. Good. So you wrote it yourself.
Ms. Perez. Yes.
Senator Murray. It did not go to any other agency or get
reviewed by anybody before it came?
Ms. Perez. Correct.
Senator Murray. Great. OK.
Dr. Perez, your email raises a serious question about
whether or not veterans are receiving inadequate evaluations
for their mental health issues because the VA lacks the staff
or the money that they need.
Can you tell us how much time you think is needed to
properly evaluate a veteran to accurately diagnose PTSD?
Ms. Perez. It really is on an individual case basis,
because in order to diagnose anyone with PTSD, they have to be
at the point where they are ready to share their most traumatic
experience, and that takes time. So in order to compassionately
do that, it has to be at the veteran's own pace and on their
time table.
Senator Murray. So it may take some time to do that?
Ms. Perez. Right. It is very different for each one.
Senator Murray. How much time did VA staff spend with
veterans when they were evaluated for PTSD at Temple VA Medical
Center where you work?
Ms. Perez. When we do our intakes, they can range usually
anywhere from half an hour to an hour. It kind of depends on
the veteran and what time they get there and what materials
they have already answered for us. But usually at the intake
our goal really is to kind of gather information that will help
us identify the most significant symptoms that bring them there
that day and what are the strengths and the limitations that
they have in treatment so we can develop a treatment strategy.
Senator Murray. So it is a very complex process.
Ms. Perez. It is very complex, yes.
Senator Murray. You are on the ground. Do you think that
the VA has enough staff to properly evaluate the veterans you
are seeing with mental health care issues?
Ms. Perez. Well, I know in my clinic we did have an
opening. So, I think that they are, from what I see, intensely,
actively recruiting to try to get those positions filled,
specifically, in Central Texas.
Senator Murray. OK. I understand they are trying to be
filled. But do you think you have enough staff to evaluate
everybody in the complex procedures that you just talked about
a minute ago?
Ms. Perez. Like I said, for those that we have there and
the numbers that are coming in at this current time, we do have
that staff. But at any given day you really do not know the
numbers that are going to walk through the door.
Senator Murray. I think at least why I am confused is
because the actual language of your email is ``we really do not
have time to do the extensive testing that should be done to
determine PTSD.''
Ms. Perez. Right. If we were going to require--in our
clinic we would accept anybody with even one single combat
stress symptom. If we were to require a diagnosis of PTSD in
order to admit them into treatment, then you are going to want
to get that answer initially, right off the bat, and you really
should do the extensive testing because you do not have the
gift of time to let them go at their own pace. You have to kind
of push the issue and give them more assessments and kind of
push them to share their story before they are ready.
Dr. Kussman. Could I just add a comment, Senator? Is that
OK?
Senator Murray. Yes.
Dr. Kussman. I think what Dr. Perez was also talking about
is that they have a clinic that has no wait times. People can
walk in.
Senator Murray. I understand.
Dr. Kussman. If I could just finish please. So, most people
who are involved in the treatment of PTSD acknowledge that the
best way to evaluate and treat is developing a relationship
with a provider over time as this evolves.
Senator Murray. My question is do you have enough staff to
do that? Because your email implies that you do not have the
time to do that kind of extensive testing. I am asking you
because it is our responsibility to make sure we have enough
people out there that have the time, which should not be the
factor that stops people from being treated.
So, your email says we do not have enough time to evaluate
everybody. Does that mean you do not have enough people to do
that evaluation, or you do not have----
Ms. Perez. That was more at the initial 1-hour or half-to-
1-hour intake; that they were scheduled for that amount of time
in the initial intake. If we were going to require that, then
we would have to have scheduled probably a 3-hour window for
the intake.
Senator Murray. Right. OK. Let me ask Dr. Katz and Dr.
Perez a question. In the email that we have, Dr. Perez, you
suggest that they ``consider a diagnosis of Adjustment
Disorder, rule out PTSD.'' That was meant I understand to
suggest that the initial diagnosis would be Adjustment Disorder
while the clinician took the time to determine if a diagnosis
of PTSD was warranted.
Here is my question. It is my understanding that the
guidelines, the Adjustment Disorder guidelines, indicate that
an Adjustment Disorder diagnosis should be limited to a period
of 6 months after the event or stressor.
Now I suspect that most of our VA facilities do not see
very many veterans within the 6 months of their having actually
had that stressor or left a war zone. So, is Adjustment
Disorder the correct diagnosis to give to a veteran who
presents with serious behavioral or emotional symptoms?
Ms. Perez. Well, we actually are getting quite a few
veterans, that have not even completely discharged from DOD. So
we do get some active duty. As part of the out-processing, they
will sometimes come see us when they are still actually active
duty. Also we are doing redeployment counseling because we did
have quite a few veterans who were----
Senator Murray. In your email you suggest a diagnosis that
suggests that it is an Adjustment Disorder. But from what I am
looking at, that should be done within 6 months. So it is
curious to me that you suggest that diagnosis when it is
obvious that you are outside the 6-month timeframe.
Ms. Perez. Well, that is why it is just a suggestion
because each clinician needs to really look at the criteria of
what the veteran is presenting with--what symptoms are they
presenting with--and do an assessment based on that, on
whatever they are willing to----
Senator Murray. Dr. Katz, is that concurrent with what you
believe should be done in the field?
Dr. Katz. Thank you for asking. About the Adjustment
Disorder diagnosis, my read is actually close to yours. I would
disagree respectfully with my colleague about the diagnosis of
an Adjustment Disorder a year after an event relating it to the
event. I would have concerns about it.
There are questions, in general, about whether a diagnosis
matters and whether the specific diagnosis matters. And the
answer is probably, yes and no.
One thing that really does matter is making a diagnosis of
PTSD versus something else. PTSD versus depression, for
example. The best treatment--behavioral and cognitive--for PTSD
is trauma-focused, going back to the event. But, the best
treatment for depression is present-focused, dealing with
current problem-solving, beliefs and thoughts. So, diagnosis
matters to help someone plan treatment.
In another sense, however, diagnosis does not really matter
that much. There are a certain number of symptoms required for
PTSD. Many people have subclinical PTSD or partial PTSD where
they may be one symptom short of the number required for a
formal diagnosis. And my read is that the best treatment for
subclinical, subsyndromal partial PTSD is the same treatment as
PTSD.
So, if someone does not quite make the diagnosis for PTSD,
I would think if they are suffering, they should get exposure-
based treatments just like if they have PTSD.
Senator Murray. Thank you for your honesty on that which
goes really to my real concern, and our responsibility is that
this is a difficult diagnosis. Our job is to make sure that we
do have enough people on the ground who are capable of doing
that in a timely fashion and that we do not have a VA or a
system or anywhere isolated or not to say, ``do not make this
diagnosis because we do not have the resources.'' It rather
should be we need the resources so we can make the proper
diagnosis.
And I have a number of other questions but I know my time
is out so, Mr. Chairman, I will wait until the second round.
Thank you.
Chairman Akaka. Thank you, Senator Murray.
Senator Sanders.
Senator Sanders. Thank you, Mr. Chairman.
Let me begin with Dr. Katz. Dr. Katz, I am looking at the
email that you exchanged with Ev Chasen, Chief Communications
Director. In it you respond to Mr. Chasen and you say, ``Shhh.
Our suicide prevention coordinators are identifying about 1000
suicide attempts per month among the veterans we see in our
medical facilities. Is this something we should carefully
address ourselves in some sort of release before someone
stumbles on it?''
Media reports tell us the Army just reported that at least
115 soldiers killed themselves in 2007. Is this an epidemic? A
thousand attempted suicides--that sounds like a very large
number.
Dr. Katz. The ``is it an epidemic question'' comes up again
and again. Is a thousand a month too many? Of course, it is too
many. Are there too many suicides among veterans? Of course,
there are too many suicides among veterans.
Senator Sanders. That was not my question. One suicide
attempt, no matter where, is one too many; but 1000 a month
sounds like an extraordinary number. What is going on where
1000 guys who were in the military--people who were trained,
tough guys--are attempting suicide? Can you give me something?
Dr. Katz. Yes. Could I comment on the ``Shhh'' email first
for just a minute? I was very excited when I learned about this
finding and I wrote to a friend on the eighth floor, Mr.
Chasen, asking what should we do with this new knowledge?
Should we send it out to the field or should we use it to
improve care first? I was writing to someone who gets about 400
emails a day so I wanted to get his attention right away and I
was far too dramatic in trying to do that.
Senator Sanders. I am not here to talk--I just want to know
the numbers. Go back to this issue. Is it true that a thousand
soldiers a month are attempting suicide? Is that true?
Dr. Katz. Well, we still have to validate that number. We
expect so. We know from NIH data that the ratio of suicide
attempts to deaths from suicide is between 8- and 25-to-1.
Senator Sanders. Excuse me. I am just asking one simple
question. All right, to a lay person, the fact that you have a
thousand active-duty soldiers, a thousand soldiers----
Dr. Katz. A thousand veterans.
Senator Sanders. A thousand veterans--I am sorry--a month.
That sounds like a very high number. Is that not the case?
Dr. Katz. It is a thousand attempts. We do not yet know how
many multiple attempts there are. It is within the expected
range but it is too much.
Senator Sanders. OK. What about----
Dr. Katz. It does suggest something, through, if I may. We
know that the group at highest risk for suicide is those who
have previously attempted suicide. So this knowledge is an
important window into prevention.
Senator Sanders. What about 115 soldiers having killed
themselves in 2007 within the Army?
Dr. Katz. I have read that in the paper and in the Pentagon
report just as you have. That is very separate from the VA.
Dr. Kussman. Sir, if I could just add to that question.
Senator Sanders. Yes.
Dr. Kussman. I am obviously aware, and as Dr. Katz just
mentioned, that is the Department of Defense, not us. But as
far as my understanding of that number, even though it has gone
up, if you look at an age-adjusted population of the group that
are in the uniform that commit suicide, it is a lower rate than
it is in the civilian community for an age-adjusted population.
It is not to say that it is not going up, but suicide is a
great problem in our society, particularly in young people who
tend to be somewhat impulsive. So I think that the military is
well aware of that and so are we. And the question is why do
they do it? And we are looking at research and everything to
try to determine what etiologies would lend somebody to be more
susceptible to suicide than others.
Senator Sanders. 115 soldiers in the Army in 2007 killed
themselves. Again to a layman this seems like a very high
number. Is that not, in your judgment, a very high number?
Dr. Kussman. I am saying it is much higher than we would
like to see.
Senator Sanders. That goes without saying.
Dr. Kussman. But if you put it in perspective and I am not
trying to minimize it in any way, shape or form. But it is my
understanding that if you look at the same age group of people
who never put on a uniform, the amount of suicides per 100,000
is
higher.
Senator Sanders. If I could ask Mr. Dunne a question.
Mr. Dunne, the AP recently reported on VA documents it had
obtained that said that the government expects to be spending
$59 billion a year to compensate injured servicemembers of the
next 25 years, up from today's $29 billion. The AP story noted
that some at the VA believe that these are conservative
estimates.
Overall there are some people who think that the end result
of this war might be as high as some $3 trillion, and that one
of the reasons is that there will be a huge amount of money
spent over the lifetime of soldiers who served dealing with
their wounds, mental and physical.
What is your estimate in terms of how much we will be
spending per year to compensate injured servicemembers?
Mr. Dunne. Senator, I do not have numbers with me with that
calculation. I can make a projection and get back to you
afterwards.
Senator Sanders. I would appreciate that.
If the number is really what the AP says it is, $59 billion
a year, I mean that is for the next 25 years. That is just an
extraordinary sum of money. And I would like to know if that is
accurate. And it gets to the issue of what the cost of war is.
When we go to war, it is not just the guns and tanks of today;
it is the cost years into the future.
Last, if I could, Mr. Dunne, as I understand it, there are
some 400,000 outstanding claims for our veterans. I know that
this Committee and the Congress has put a lot more money into
the VA in recent years not only for health care but to
accelerate the processing of these claims.
Are we making any progress?
Mr. Dunne. Senator, I think we are making progress. We are
not happy with where we are right now. We are striving to do
better. As of the first of this month, we had an inventory of
390,034 claims which we were still working on. We have made
progress on our hiring initiative. We have hired since January
2007--2650 approximately of the 3100 that we intend to hire by
the end of this fiscal year.
They take about 2 years to become journeyman status when
they are most effective at handling claims, but probably within
the first year that they are onboard and complete their
training they can begin to have an impact.
We think that we are starting to see an impact on that but
we are continuing to look at other initiatives such as a
paperless environment. This week we have just instituted
electronic signatures for original applications for claims and
education and VR&E.
Senator Sanders. This is an issue that interests me very
much. I look forward to talking with you more in the future.
Thank you very much, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Sanders.
Senator Tester.
Senator Tester. Thank you, Mr. Chairman.
I want to thank you all for your service. I appreciate your
testimony today. I want to echo the Chairman's remarks. This
email is not why I am here exclusively. You hear a lot of
things on the ground that are going on from veterans and I
think this email contributes to that because it reaffirms what
you hear on the ground.
I am going to bring up two cases that reflect back to what
you said earlier. This has nothing to do with mental health. It
has to do with a clinic that is to be built in Billings where
Secretary Peake and I thought it was to be done, yet the people
down below had a different idea. We found out in the paper that
it was not going to be built until 2009, and that is what I am
talking about. That is what I am talking about being laid back.
We will get to it when we get to it attitude. That is
unacceptable.
The other thing that is unacceptable is when I was also
told by a veteran that when he talks to me, he was threatened
with his disability being reduced. That is unacceptable.
And I got in a bit of trouble through the papers because I
said I thought the person who did that, and I did not know who
it was, should be fired on the spot. But that is the way it
goes.
Senator Murray talks about getting through the door.
Getting through the door is proper diagnosis.
I have some questions for your, Dr. Perez. You are at the
Central Texas PTSD clinic. How long have you been in that
position?
Ms. Perez. Since June 10, 2007.
Senator Tester. June 10, 2007. So you are coming on a year?
Ms. Perez. Yes, sir.
Senator Tester. All right. Have you seen the PTSD diagnoses
going up over your tenure there or is it pretty static?
Ms. Perez. It is pretty static.
Senator Tester. OK. The diagnosis between Adjustment
Disorder and PTSD, are there different factors involved that
diagnosis?
Ms. Perez. Yes.
Senator Tester. They are clear?
Ms. Perez. They are clear.
Senator Tester. OK. Can you tell me, folks that come in
with, that are diagnosed with Adjustment Disorder, do they stay
at that level or is there a percentage that are moved up to
PTSD later on; or once they are diagnosed with Adjustment
Disorder, they are there for a while? What is the process?
Ms. Perez. No, no. Immediately a treatment plan is
developed and they are entered into treatment. And as their
provider works with them, again at their own pace of
disclosure, then that is adjusted by the provider that is
working with them.
Senator Tester. Adjusted to PTSD diagnosis?
Ms. Perez. It depends on whatever their symptoms are.
Senator Tester. Can you tell me what percentage of veterans
that are diagnosed with Adjustment Disorder are moved to a PTSD
category?
Ms. Perez. I do not have that information
Senator Tester. Can you get it for me?
Ms. Perez. I can take that for the record, yes, sir.
[The Department of Veterans Affairs was unable to provide
this information within the Committee's timeframe for
printing.]
Senator Tester. That would be great. Can you tell me what
percentage of claims where you make the diagnosis for PTSD and
you find out that that diagnosis was a mistake?
Ms. Perez. I am not sure I understand the question.
Senator Tester. A veteran comes in. A diagnosis is made
that they have PTSD. You find out later or you do not think
they have PTSD. What percentage of those that you diagnosis
with PTSD do you feel that the diagnosis was inadequate or the
person did not have PTSD?
Ms. Perez. There have actually been two cases where--
because we do not require a DD-214, we do not require them to
tell us, you know, everything at the initial interview--so
there has been twice where I have been told that.
Senator Tester. Out of how many cases?
Ms. Perez. That I do not know.
Senator Tester. Out of a hundred?
Ms. Perez. More than that.
Senator Tester. A thousand.
Ms. Perez. Well, probably close to a thousand.
Senator Tester. In your facility.
Ms. Perez. I am thinking just from what I have seen, my own
patients that I have evaluated.
Senator Tester. In the whole system?
Ms. Perez. I have no idea of the whole system.
Senator Tester. OK. I want to go to your email, because I
think it is quite instructive, and you know what it says
because you wrote it. It says that ``given that we are having
more and more compensation seeking veterans, I would like to
suggest that you refrain from giving the diagnosis of PTSD
straight out.''
So what that implies to me is that the diagnoses for PTSD
that were given--for you to send something like that out--
either they were not accurate at diagnosis or you want to deny
benefits. Tell me what it says if that does not say one of
those two things.
Ms. Perez. Again it was really to stress the accuracy of
diagnoses.
Senator Tester. But there is only two that have been
diagnosed wrong.
Ms. Perez. Right. But that was in my personal experience
with my patients. That email was triggered out of two other
ones who had become distressed and had verbalized that distress
with a psychiatrist. And so, that email was a result of trying
to remind everybody to be accurate in your diagnoses.
Senator Tester. But that is not what it says. It does not
say you need to be accurate in your PTSD diagnosis. It says
refrain from giving a diagnosis of PTSD.
Ms. Perez. Well, again, that email was written specifically
to my clinical staff there.
Senator Tester. There has to be a reason for this. So what
is the reason that you send this email out? I do not mean to
put you on the spot.
Ms. Perez. No, no. I understand. But I mean it was a real
significant issue when you have got two veterans that are
coming to you very distressed.
Senator Tester. Yes.
Ms. Perez. And it led to some----
Senator Tester. So what you are saying is those veterans
were diagnosed with Adjustment Disorder and they really had
PTSD?
Ms. Perez. Well, what I was told from the psychiatrist was
that they were given a diagnosis of Adjustment Disorder when
they had their compensation and pension examination. At intake
a clinician gave them a diagnosis of PTSD. They went for their
psychiatric consult, and that psychiatrist evaluated them and
showed, OK, you do have symptoms of combat stress but you do
not meet criteria for PTSD. At that time, in both instances the
veterans became very distressed, and in one case they charged
the psychiatrist, and so it became a safety issue.
Senator Tester. I am trying to track you here. What you are
saying is they were diagnosed with PTSD and then they came in
and they back off that diagnosis?
Ms. Perez. No, no.
Senator Tester. So you are saying they were diagnosed with
Adjustment Disorder and they went in they were kept at
Adjustment Disorder?
Ms. Perez. No, no, no.
Senator Tester. So the only third option left is they came
in with Adjustment Disorder and they were diagnosed with PTSD.
Ms. Perez. Right. Then another team member, a
psychiatrist--when they went to go have an evaluation to see if
they needed any kind of medication----
Senator Tester. Yes.
Ms. Perez [continuing]. Then that second team member stated
no, no, no, you do not have that. You do not meet criteria but
you do have combat trauma symptoms.
It is not unusual for someone to come in and have a
different rapport with a different provider so they may share
different information.
Dr. Kussman. Senator.
Senator Tester. Go ahead.
Dr. Kussman. I do not want to belabor it. I apologize. But
as Senator Murray mentioned, this is complex stuff sometimes
with things. I think what we are doing here is that the
individual may have been in the system before and may have
submitted a claim for PTSD.
Senator Tester. Sure.
Dr. Kussman. That went through the process, and on occasion
they do not get their diagnosis. Most people do, by the
statistics, but some do not.
Senator Tester. Yes.
Dr. Kussman. The person may then still have symptoms.
Senator Tester. Yes.
Dr. Kussman. No question. They are enrolled with us and
then they come to a treatment clinic like Dr. Perez is working
in. It has nothing to do with compensation. But they are still
pretty upset that they did not sometimes get a diagnosis of
PTSD when they went through the VBA process. So they come in,
and again, in the intake on the cases that I think Dr. Perez
was talking about somebody said I think you have PTSD----
Senator Sanders. What you are saying is you have two docs
that have a different opinion on what is going on, right?
Dr. Kussman. Right.
Senator Tester. OK. I know this is complicated stuff. I
know we are on grounds where we have got, what, 30 percent of
the folks coming back. There is a claim that there is PTSD
involved. I know that this is new ground. I know you are
hiring, what, 3800 new psychiatrists, psychologists. I know you
are doing this stuff.
But I can tell you what the veterans think because I just
talked to a bunch of them last week. They think that they are
given this Adjustment Disorder diagnosis so that it takes away
the government's liability in paying for anything that may be
more than that. That is what the veterans think. That is what
the people who put their lives on the line for this country
think that the VA is doing to them. That is what they think.
Perception is reality.
What I have to say is just I am not a doc. You guys are far
more educated than I am, probably. We have got to have definite
criteria for PTSD and you have got to have definite criteria
for Adjustment Disorder so that, quite frankly, you can sit
down and explain to the person why. That is what is really
important.
The other thing is that I am going to go back to the very
first statement. Make sure that people below you are doing what
you want them to do. That is critically important because you
can have the best, the best intentions, and if the folks on the
ground that are working with the vets are not doing what needs
to be done, you guys end up in front of a hearing, in front of
the VA Committee in Washington, DC.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Tester.
Dr. Perez, in your testimony you make two points about the
best way to provide a diagnosis for PTSD. One, that a
differential diagnosis is good medicine; and two, that trust
must be established before PTSD can be identified. I agree with
both of these points.
I am concerned, however, with how you appear to have made
these points in your email to your colleagues, your suggestion
to them. When you were preparing your email, did you believe
that the other clinicians of the PTSD treatment team, some of
whom have many years of experience with PTSD, whether they were
not aware of the treatment approach you set forth if your
testimony?
For example, did they know about providing a differential
diagnosis even one that Dr. Katz said was probably not the best
one?
Ms. Perez. Yes, they do know that. They are very familiar
with that and very--my thoughts are that they are probably very
accurate in that.
Chairman Akaka. Dr. Katz, you said that Adjustment Disorder
is probably not a good suggested diagnosis. What are you doing
to ensure that your providers understand your position on this?
Dr. Katz. Well, specifically after that 6 months or so
period, as Mrs. Murray mentioned, I would have concerns about
it. I think the issue comes to how doctors say, ``I do not
know'' or ``I do not know yet,'' and I think this is the issue
that Dr. Perez was probably addressing.
Sometimes after one-half hour or an hour or an hour and
one-half with the patient, you do not know enough to make a
diagnosis. We have to allow coding for that in an appropriate
way to be able to get credit for the visit but not to commit
ourselves prematurely to the presence or absence of any
diagnosis.
Chairman Akaka. Dr. Kussman and Admiral Dunne, do you agree
that there may be confusion for both veterans and clinicians
when a particular clinician may act as both care provider and
evaluator? Does this suggest that C and P exams, that is,
compensation and pension, should be conducted by non-VA
physicians; or at a minimum, that no VA physician who provides
direct care should be tasked to conduct a C and P exam?
Dr. Kussman. OK. I win. First of all, Mr. Chairman, there
are two ways that the exam is done, as you know, either through
the VHA personnel or under contract with QTC. And the
evaluation is very proscribed. There are templates and other
guidance that have to be followed.
We have set standards for that saying that only
psychiatrists and Ph.D. psychologists should do that. Although
the IOM did not put that level of proscription, we wanted to be
sure that that took place.
If you are asking specifically about whether a psychologist
or psychiatrist who was taking care of somebody in a clinical
setting be the one that does their Comp and Pen, I would have
to think about that. But, the fact that somebody is in a clinic
and does a Comp and Pen exam would not preclude them from doing
it, because we have lots of people who maybe Monday and
Wednesday they are in the treatment clinic, and maybe Tuesday
afternoon they are doing Comp and Pen exams.
So, I do not think they are mutually exclusive. But if, you
know, we want to separate the clinical treatment from the
assessment of how much compensation a person gets I think I
would--and again I do not know if anybody has done it on their
own patient--but that would, I think, not be the best way to do
it.
Do you have any comments?
Chairman Akaka. Admiral Dunne.
Mr. Dunne. Senator, I would agree that, as people have said
this morning, the process is very complex and what I have
learned over the past 2 months is a review of the template that
is used to conduct that examination, which is a very very
extensive and complex template. I have confidence in that. I
have confidence in the VA doctors to execute that template and
to provide us with a valid, medically correct evaluation of
every veteran who comes to see them.
Chairman Akaka. Thank you very much.
Senator Burr.
Senator Burr. Thank you, Mr. Chairman.
Admiral Dunne, your testimony noted that there has been 150
percent increase in the number of veterans receiving disability
compensation since 1999. In 2004, the Inspector General found
that veterans PTSD rating levels, and I quote, ``typically
increase over time indicating the veterans' PTSD condition had
worsened. Generally, once a PTSD rating was assigned, it was
increased over time until the veteran was paid at the 100
percent rate.''
Does your information square with the IG's findings--that
veterans with PTSD get worse over time?
Mr. Dunne. Senator, I do not have that information but
perhaps Mr. Mayes does.
Mr. Mayes. Yes, sir. What we know is that--or I guess what
the IG found was that--once veterans were service-connected for
PTSD that it was rare that service connection was stopped or
that the evaluations were reduced. So what we have done is, we
have begun to look at PTSD. We are looking at evaluations
across States and we are evaluating that as part of our quality
assurance program.
So, we are taking a look at that. That was also one of the
things that the Institute for Defense Analysis also
recommended, that you take a look at any possible variants and,
you know, any underlying causes for that.
So we are taking a look at it. But I cannot, other than
that--I guess the question was does it square with the IG
report. That is what we found. That's what the IG found.
Senator Burr. Let me go to the clinician if I can. The 2007
Institute of Medicine report found insufficient evidence to
support the effectiveness of most PTSD treatment therapies with
the exception of exposure therapy.
If, in fact, we see this trend of increasing PTSD claims, a
worsening of the disability over time, is that not a suggestion
to us that we either need to implement total exposure therapies
because it is the only one that has the evidence of success;
or, two, that we need to look outside of the therapies that we
are currently using to try to find something to turn this trend
around. Or would this Committee accept the fact that from the
standpoint of mental health treatment there is no cure, that we
are managing a continual progress of getting sicker? Somebody
help you with that.
Dr. Katz. I like to think about an analogy, and the medical
advance that came out of World War II was penicillin. It was
known that penicillin existed in a laboratory and could kill
bacteria there beforehand. But it was during the war that it
was translated into a drug that helps people.
There was information about exposure-based treatments
before but in the past year or year and one-half, the VA has
trained almost 1200 people--existing staff members--to deliver
cognitive processing therapy for PTSD.
That is a huge number--enough to make a public health
difference. We have similar programs underway for prolonged
exposure therapy. So, we are very seriously working to
disseminate these treatments. I hope these treatments can be
the ``penicillin'' that comes out of this war.
Senator Burr. Dr. Katz, is the intent to try to cure, to
try to delay any further disability?
Dr. Katz. I want to respond to that and then talk about
medications and research.
PTSD is probably like asthma. We want to treat events. We
want to treat exacerbations and deal with symptoms. But once
someone has had PTSD, I am afraid they may be increasingly
vulnerable throughout their lives to retraumatization or
stress-induced traumatic reactions.
So we hope the treatment does both to deal with the event,
to deal with the episode and to decrease the probability that
another one would occur with retraumatization.
Going back to other forms of treatment, the Food and Drug
Administration views certain anti-depressants as safe and
effective for the treatment of PTSD. So, they differ in some
ways with the Institute of Medicine.
What this calls for is a need for more knowledge; a need
for research. And VA has been and continues to be a real leader
in research.
Senator Burr. Dr. Kussman keeps us up-to-date on the
progress.
Dr. Kussman. Yes, sir. If I could add to it, I think that
it is clear that you want to aggressively try to intervene
early in the diagnosis because sometimes the long-term effects
of PTSD are not really PTSD itself. It is the second- or third-
level effects where people will try to treat themselves with
substances or get depressed.
They frequently are the more severe things, longitudinally,
rather than the PTSD itself. So that is why it is so important
to try to get people in early, get them to feel comfortable so
you can prevent or attenuate some of those long-term issues.
What the IOM said, I think, sir, is that when they looked
academically, critically at the literature that was available,
what they said was the only treatment--the exposure treatment--
was the only one that they could say unequivocally had effect
on the basis of the search that was available.
But they did not say that other therapies like medication
and psychotherapy and things were not effective. They just did
not think there was evidence to show it was as effective as
the----
Senator Burr. Yes. The key word is ``evidence.'' Let me
just summarize by making a statement, and I think this might
express why there are so many questions about this from this
Committee.
Since the year 2001, the mental health budget at the
Veterans' Administration has doubled. Staffing has increased 73
percent over the last 3 years and we are not where we are
targeting yet, but we have got an aggressive goal as to how we
are going to get there.
Yet, people are still asking for an explanation about why
our veterans are getting worse versus better, as it relates to
mental health services.
I am not going to take up my colleagues' time asking for an
answer. I am not sure that there is an answer. But I think that
is the focus of where we need to be.
If all agree that the resources are there, that the plan to
hire the people and to train the people, which was a very
important part of the statements that you need, and that we
understand to some degree, to quote Dr. Perez, how we need to
peel the onion back before we begin to realize the true problem
or the depth of the problem.
At some point I hope you will share with us what it is we
should use to gauge success versus a continued worsening of the
health of our veterans; an increase in their disability
ratings, which is an indication to me that the therapies that
we are using are not working. And my hope is that that will
turn around.
I thank the Chair.
Chairman Akaka. Thank you very much, Senator Burr.
Senator Murray.
Senator Murray. Thank you very much, Mr. Chairman.
I would hope that the gauge of our success is that after a
very complex, difficult war--10, 15, 20 years from now--we do
not have men and women who served in that war who came home and
who were not treated.
I guess, really, the bottom line here is Post Traumatic
Stress Disorder is not a new issue from just this war. It has
been from every war. In World War I and World War II, many of
our veterans came home and suffered from mental health issues
and may or may not have been treated.
Certainly, the ones that I know better--the Vietnam War
veterans--came home and because of a culture that was not ready
to accept them, many of them never tried to get treatment, and
did not get treatment. We did not have the term PTSD in our
vocabulary at the time. And as a result, decades later those
men and women are suffering.
I think what we want is to make sure that in this conflict
that our generation is responsible to make sure that we do not
have veterans 20 years from now who were not given treatment.
Hence, Dr. Perez, our deep concern with an email that
indicates that because of cost, because of time, because of
whatever reason, we are not going to give you a diagnosis. That
is the genesis of the concern that many of us have.
It is difficult, but we need to make sure that any veteran
who seeks care is not under the perception at anytime that they
will not get that care, that the VA or this country does not
have the time for them, or the resources to help them.
We have to make every effort to do that, and every message
coming from the VA has to be that--that if you are a veteran
and you need care, this country will be there for you. Period.
So, Dr. Kussman and Secretary Dunne, I want to ask you. The
Chief of Staff at Temple apologized to the veterans and to the
advocates about Dr. Perez's email. Both Secretary Peake and
Deputy Secretary Mansfield have repudiated the email and that
was good. It needed to be done. The message had to be clear.
I was sort of struck by both of your testimonies today,
that they did not appear to have any remorse, and I wondered if
you could explain that, both of you.
Dr. Kussman. Senator, I think I said that any perception or
real that we were not approaching veterans in an appropriate
way and gave any perception that we would not make the
diagnosis is something that I cannot accept.
There were some, as we discussed, some interpretation of
what took place in the email and I think that we have
adequately discussed this here. But I have just as much concern
about all the things that you mentioned.
But I think a lot of it is communication; and we do need to
be able to be sure that we are explaining what we are doing and
things do not get taken out of context.
Mr. Dunne. Senator, I would agree that the email was poorly
worded, and it is an unfortunate instance but it only makes me
want to work harder to ensure that veterans understand that we
are here for them, whether it be for PTSD compensation or for
education or for loans, VR&E, whatever it is; we are working
hard to make sure that they know we are here and we want to
hear from them when they need something.
Senator Murray. Let me just say I am confused about
something. Deputy Secretary Mansfield said that Dr. Perez's
suggestion should be disregarded. That came from Secretary
Mansfield.
And that the people working there had been instructed this
was not what we are going to do. We are going to follow
Secretary Peake's direction, which is to put out the full and
accurate word and make sure that we stick with that.
Yet your testimony does not in any way backpedal from Dr.
Perez's suggestion even though Dr. Katz said that he would not
agree with that.
Dr. Kussman, Secretary Dunne, can you tell us--inartfully
worded is one thing--can you tell us what direction is from the
VA in terms of the diagnosis on someone coming in, whether it
should be as was stated in an email, that it should be
considered a diagnosis of Adjustment Disorder or not?
Dr. Kussman. As we have discussed, I think on any given
case do not make the diagnosis of Adjustment Disorder if you
think that is inappropriate or that it should be PTSD. And do
not make any diagnosis that you think is inappropriate for
anything other than the true clinical assessment of what you
think.
It should have nothing to do with time or money or anything
else. It should just be an appropriate diagnosis. As I said, I
would agree with the Secretary and Deputy that we would
repudiate any suggestion that somebody would make a diagnosis
of Adjustment Disorder in lieu of PTSD if there was any
suggestion that that is not an appropriate thing to do.
Now you mentioned that Dr. Katz has mentioned that after 6
months or whatever, and I think that that is something that has
to be determined on a clinical basis.
Senator Murray. Would you agree that most vets do not come
in and see you within 6 months of when they were in the field?
Dr. Kussman. Most do not. Some do, and it depends on the
timing. So, if it is beyond the 6 months, I think that maybe
something else would be as combat stressful, rule out PTSD. I
do not know what the appropriate thing is, but the message is,
I think, that just like any diagnosis: be careful when you make
the diagnosis; do a thorough assessment of people.
Senator Murray. Do you agree with Deputy Secretary
Mansfield that said Dr. Perez's suggestion should be
disregarded?
Dr. Kussman. If you again did not have the opportunity to
discuss exactly what was going on, I would agree that it should
be disregarded if it was intended in any way to be that you
should not make the diagnosis.
Senator Murray. Admiral Dunne.
Mr. Dunne. Senator, I have no disagreement with the Deputy
Secretary, and as I mentioned before, the templates that are
used for a claims evaluation examination are very specific.
They are very detailed. They would require the doctor to answer
a number of questions, many of them to respond to the DSM-IV
criteria so that the rating representative could make a valid
understanding and evaluation of the disability.
If that template is not filled out correctly or completely,
the rating representative is trained to reject that and return
it until it is sufficient medical evidence so that all the
questions are answered, all the information is available.
Senator Murray. Secretary Dunne, I appreciate the
complexity of the answer that you just gave. But to a country
that is listening to the VA, to a soldier that has come home
from a very challenging war, can you please give us in plain
English what you would say to someone who is seeking help from
a very difficult diagnosis of mental health?
Mr. Dunne. Yes, Senator. I would say that if they were
aware and had read about that email, that it did not reflect
the guidance of VA and that they should feel confident and come
see us both for treatment and compensation.
Senator Murray. Thank you very much.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Tester.
Senator Tester. Yes. Thank you, Mr. Chairman.
Dr. Kussman, either in your opening remarks or the
questions you mentioned stigma surrounding mental health
issues, and it is a point that I appreciate and it is a good
one, and I appreciate your interest to address it from a
societal standpoint.
It has been a difficult problem in Montana--the perception
issue around mental illness--but the National Guard has done a
great job in Montana and I do not anticipate that you've been
in contact with them so let me ask this question as kind of a
comment, and that is, are you coordinating VA's efforts with
State guard units around the Nation?
Dr. Kussman. Yes, sir. I have not personally spoken to
anybody in Montana but we have an office of seamless transition
and DOD/VA coordination, and there are individuals who do
nothing else but work the Guard and Reserve issues.
Senator Tester. Good.
Dr. Kussman. We have tried to learn from some of the States
that have done a good job and tried to encourage States that
maybe are not as engaged as others to do things.
But, my sense is that since this war has been different
than any war we have had since World War II--with the use of
the National Guard and Reserve--this has presented us with
challenges that we have not dealt with for 60 years. And I can
just tell you that we are committed to doing everything we can
to do that.
Senator Tester. I appreciate that.
Going to Senator Murray's question, I think, Dr. Kussman,
what I heard you say was spot on, and that is, if somebody
comes in, diagnose them properly. Do not diagnose them on
additional workload or anything like that.
I just want to say that because I appreciate that, because
what Admiral Dunne said in a previous question--that the
template for PTSD was solid. That's good to know. Hopefully,
the template for Adjustment Disorder is solid or whatever
disorder they may have either below or above what a PTSD
diagnosis would be.
I appreciate Dr. Katz's point about proper treatment
depends upon proper diagnosis, dealing with past events or
current events.
This question is for both Dr. Kussman and Patrick Dunne
because you both had a part in why I am asking this question.
Admiral Dunne had said reasonable doubt goes to the
veteran. And in my previous round of questions, Dr. Kussman
said that there was a difference of opinion that really causes
this problem.
One guy diagnoses it. One guy come in and says, or gal,
says, no, this is not correct and there it becomes a difference
of opinion. So if the tie goes to the runner, the tie goes to
the veteran, why does not the tie go to the veteran? Or do you
see it as an issue?
Dr. Kussman. No. First of all, it is rare that that
actually happens because most people will come to a consensus
of what the individual has. I agree wholeheartedly using the
baseball analogy; the tie goes to the runner.
Our job is to provide services, the full gamut of health
care benefits, and not try to find ways of not doing it, and so
whenever it is an appropriate clinical thing, we should err on
the side of the veteran unequivocally.
Dr. Katz. Could I?
Senator Tester. I will get to you, Dr. Katz. Admiral Dunne
first. Then you.
Mr. Dunne. Senator, I would agree in that we do the same
thing within our process. Once we get a medical evaluation in,
we then have to take it into the rating table and decide on a
percentage disability.
When the information in the medical exam would cause the
rating specialist to have a concern as to whether it is one
disability percentage or another, then the higher disability
would be assigned.
Senator Tester. So, the rating happens after the diagnosis
and not before.
Mr. Dunne. Yes, sir, that is correct.
Senator Tester. That is good to know.
Dr. Katz.
Dr. Katz. When we are talking about treatment rather than
compensation, the whole issue of the tie going to one side or
the other does not count. The patient needs the most accurate
diagnosis to allow the most precise and predictive treatment
planning.
Sometimes you do not get it right the first time. Someone
may be treated for what looks like depression, and during the
course of treatment for depression, symptoms of PTSD may emerge
and we should then change the treatment.
Senator Tester. Right. That is why that template that
Admiral Dunne talked about is so critically important. If that
template is as good as we think it is it will help your
treatment be solid from the get-go. Now, I am not saying
mistakes cannot be made and there are not things that happened,
but ultimately, in the end, what we need is diagnosis of a
proper problem when that problem exists and not putting folks
off.
Thank you, Mr. Chairman.
Thank you folks, too.
Chairman Akaka. Thank you very much, Senator Tester.
Do you have any more questions?
Senator Murray. No, Mr. Chairman.
Chairman Akaka. I have more questions that I will submit
for the record.
In closing I again thank all of our witnesses for appearing
before the Committee today. We really appreciate hearing your
views on these important issues. Your testimony today will
hopefully ensure that we will be able to better serve those who
are suffering with invisible wounds.
While it is apparent that VA is trying to do all that it
can to help, there is still much room for improvement. Issues
of veterans' suicide and PTSD are topics that cannot be taken
lightly.
We all must be careful about what we say, and, of course,
how we say it. You are all representatives of VA both to
veterans and to the public as a whole. And when it is
discovered that emails such as these have been written, it
reflects not just on an individual but on the Department as a
whole.
VA, without question, has a very very important mission.
When charged with such a heavy mission, it is imperative that
VA remains the best health care system in the Nation for
veterans.
We must not lose focus on that and that mission. VA is here
to serve those who served us. I look forward to continuing to
work with you to improve services and care for veterans and
their families.
This hearing is now adjourned.
[Whereupon, at 11:41 a.m., the Committee was adjourned.]
A P P E N D I X
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Prepared Statement of Hon. Barack Obama, U.S. Senator from Illinois
Chairman Akaka, I want to thank you for holding this important
hearing today. We are a nation at war and every day our brave men and
women return home from battle with wounds both visible and unseen, and
tragically these wounds can often end in death. We must do everything
we can to prevent these tragedies, but unfortunately, we have been
forced to battle the Veterans Administration over the past seven years
to ensure that our veterans receive the best care possible.
I don't deny that the Veterans Administration can provide some of
the highest quality health care in this country. Many veterans have
been pleased with the care they have received at the VA. But recent
events indicate a practice and a culture at the VA that seems intent on
denying full care for our veterans. We have seen the deputy chief of
patient care services imply that the actual rates of suicide among
veterans be suppressed. We have a mental health care therapist
suggesting to her colleagues that veterans with PTSD be underdiagnosed.
It is too easy to suppress and ignore the invisible wounds of PTSD and
mental health problems, and we cannot allow that.
When I first heard of Ms. Perez's email to her colleagues
recommending an underdiagnosis of PTSD cases, I immediately called on
Secretary Peake to investigate these efforts to provide fraudulent
diagnosis in an effort to save money. To Secretary Peake's credit, I
received the swiftest response from any Federal agency--he responded
within the day--but I demanded answers to specific questions regarding
the quality of mental health care provided our veterans and I expect
those answers to be forthcoming.
I hear every day from Illinois veterans who are frustrated--
frustrated with the bureaucracy at the Veterans Administration,
frustrated with the denial of claims, frustrated with an apparent
indifference to their needs. Too many veterans see the Veterans
Administration as a bureaucracy with the sole goal of denying their
benefits. Mr. Chairman, I know you agree that this is unacceptable and
I look forward to working with you and my colleagues on the Committee
to ensure that the Veterans Administration lives up to its mission--
``to care for him who shall have borne the battle.''