[Senate Hearing 111-716]
[From the U.S. Government Publishing Office]
S. Hrg. 111-716
HEARING ON MENTAL HEALTH CARE AND SUICIDE PREVENTION FOR VETERANS
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
MARCH 3, 2010
__________
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 Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Roger F. Wicker, Mississippi
Jim Webb, Virginia Mike Johanns, Nebraska
Jon Tester, Montana Scott P. Brown, Massachusetts\1\
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
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\1\ Hon. Scott P. Brown was recognized as a minority Member on March
24, 2010.
C O N T E N T S
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March 3, 2010
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Isakson, Hon. Johnny, U.S. Senator from Georgia.................. 2
Johanns, Hon. Mike, U.S. Senator from Nebraska................... 3
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 4
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 5
Prepared Statement........................................... 5
Begich, Hon. Mark, U.S. Senator from Alaska...................... 6
Murray, Hon. Patty, U.S. Senator from Washington................. 59
WITNESSES
Hanson, Daniel J., Operation Iraqi Freedom Veteran............... 7
Prepared statement........................................... 9
Response to post-hearing questions submitted by:
Hon. John D. Rockefeller IV................................ 10
Hon. Mark Begich........................................... 10
Rudd, M. David, Ph.D., ABPP, Dean, College of Social and
Behavioral Science, University of Utah......................... 11
Prepared statement........................................... 12
Response to post-hearing questions submitted by:
Hon. Daniel K. Akaka....................................... 14
Hon. John D. Rockefeller IV................................ 15
Jordan, Clarence, Member, National Board of Directors, National
Alliance on Mental Illness..................................... 16
Prepared statement........................................... 18
Attachment............................................... 22
Response to post-hearing questions submitted by:
Hon. Daniel K. Akaka....................................... 23
Hon. John D. Rockefeller IV................................ 25
Cross, Gerald, M.D., Acting Principal Deputy Under Secretary for
Health, U.S. Department of Veterans Affairs; accompanied by
Janet Kemp, R.N., Ph.D., VA National Suicide Prevention
Coordinator; Caitlin Thompson, Ph.D., Clinical Care
Coordinator; Antonette Zeiss, Ph.D., Associate Deputy Chief
Consultant and Chief Psychologist, Office of Mental Health
Services; Theresa Gleason, Ph.D., Deputy Chief, Mental Health
Services, Office of Research and Development; and Alfonso
Batres, Ph.D., MSSW, Director for Readjustment Counseling for
Vet Centers.................................................... 30
Prepared statement........................................... 32
Chart presented to the Committee............................. 36
Response to post-hearing questions to Dr. Cross submitted by:
Hon. Daniel K. Akaka....................................... 36
Hon. John D. Rockefeller IV................................ 37
Hon. Mark Begich........................................... 38
Response to post-hearing questions submitted by Hon. Daniel
K. Akaka to Caitlin Thompson, Ph.D......................... 45
Response to post-hearing questions submitted by Hon. Daniel
K. Akaka to Antonette Zeiss, Ph.D.......................... 45
Response to additional post-hearing questions............ 48
Response to post-hearing questions submitted by Hon. Daniel
K. Akaka to Theresa Gleason, Ph.D.......................... 49
Response to request arising during the hearing by Hon. Patty
Murray.....................................................60, 66
APPENDIX
Burris, Hon. Roland W., U.S. Senator from Illinois; prepared
statement...................................................... 69
Lautenberg, Frank R., U.S. Senator from New Jersey; prepared
statement...................................................... 69
Three Wire Systems, LLC and Health Net, Inc.; prepared statement. 70
HEARING ON MENTAL HEALTH CARE AND SUICIDE PREVENTION FOR VETERANS
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WEDNESDAY, MARCH 3, 2010
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:32 a.m., in
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Murray, Brown, Begich, Burris,
Burr, Isakson, and Johanns.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. The Senate Committee on Veterans' Affairs
will come to order.
I want to say aloha and welcome to our panelists as well as
other who are here and, of course, our Members and staff who
have been working hard to prepare for this hearing. Today, we
will address mental health issues confronting veterans with a
particular emphasis on the risk of suicide.
These are grave and troubling matters that I fear are
becoming more prevalent as we send servicemembers into combat
zones on repeated occasions. When we send men and women in
uniform into battle, we seek to provide them with equipment to
protect them from physical dangers. Too often, however, we do
not provide sufficient protection and preparation for the
equally serious mental dangers they will face.
Mental illness is prevalent among today's veterans, which
include PTSD, depression, and substance use disorders.
Unfortunately, many of those suffering from such disorders do
not seek proper help. The rising rate of suicide among these
men and women is especially heartbreaking.
The best information available suggests that about 18
veterans kill themselves every day. In December 2009, the Army
reported 17 suicides of active duty members. In January, the
Army reported 27 confirmed or suspected suicides. These are
very troubling and sobering numbers.
I mention these statistics to open a broader discourse on
mental health care issues affecting veterans and the need for
focused and increased attention to effectively address these
matters. As a Nation at war, it is our responsibility to fully
explore ways to help those suffering from mental health
disorders and to develop preventive measures to safeguard
against the risks of suicide.
We have made a promise to care for the invisible wounds of
veterans and we must be vigilant ensuring we keep that promise.
This obligation is not limited just to the time after a veteran
separates from service. We must ensure we prepare deploying
servicemembers for what they might experience and make sure
that resource are available during deployment to help them cope
with it.
We must ensure that returning servicemembers are screened
carefully, that those who need assistance are provided
appropriate mental health care, and that all those leaving the
military have a seamless transition to VA. It is also vitally
important that family members be involved throughout these same
stages.
As a Senior Member of the Armed Services Committee and as
Chairman of this Committee, I know that VA is a leader in
providing mental health care and suicide prevention services.
It is my strong hope that VA and DOD will work together to
provide the best care to those in need.
I continue to believe that it is very difficult to provide
effective mental health care to someone still in active
service. For that reason, I encourage VA and DOD to increase
cooperation so that resources are used to their fullest
potential and no veterans or servicemembers are overlooked or
ignored.
We had a productive hearing on mental health issues in
April 2007. That hearing contributed to the passage of mental
health care legislation dedicated to Justin Bailey, a veteran
who overdosed while receiving treatment from VA for PTSD and
substance use disorder. I hope to learn about how VA is
implementing the provisions of the Bailey bill.
VA has made great strides in improving the care and
services available to veterans, but there is always more that
can be done. I hope that our witnesses today can help us have a
constructive discussion on what VA is currently doing, what VA
can do better, and what VA needs to start doing. I look forward
to hearing more about what the latest research is telling us
and how we can implement these findings to keep VA on the
cutting edge of mental health care delivery. While it is never
possible to prevent all suicides in all cases, that must not
stop us from trying.
I thank the witnesses for being here this morning and look
forward to hearing your testimony.
May I now call on Senator Isakson for his statement.
STATEMENT OF HON. JOHNNY ISAKSON,
U.S. SENATOR FROM GEORGIA
Senator Isakson. Aloha, Mr. Chairman.
Chairman Akaka. Aloha.
Senator Isakson. Thank you very much for calling this
hearing today. I was there 2 years ago at our first hearing,
because we had a rapid spike in suicides in the First Blended
Air Force Wing stationed at Warner Robins, GA, where I will be
this coming Saturday. It was an alarming statistic. It was an
alarming occasion, and I took an interest in mental health in
all of our military personnel.
I think it should be noted that following that hearing in
2007, the implementation of the Warrior Transition Centers was
expedited. I have toured the one at Fort Stewart, GA, which is
the DOD's attempt to have these transition centers ready for
diagnosiswhen our soldiers are coming back, both for wounds
that you can see as well as those that you cannot see. I think
we are making progress, but there is a long way for us to go.
I also want to thank the Chairman for referencing the
seamless transition from DOD to Veterans health care. That is a
significant area where we need improvement. The Uptown VA in
Augusta and the Eisenhower Medical Center at Fort Gordon have
developed a great seamless transition where the veterans don't
end up falling in this black hole when they leave active duty
and go into veteran status. I think it is an example of what
can be done in our medical centers to see to it that our
veterans have that continuum of contact with mental health and
with physicians to help us reduce this problem of a high rate
of suicide.
So, your hearing 2 years ago has paid a dividend in a
higher level of attention, and from what I have been able to
see in my State, both at Fort Gordon as well as Fort Stewart,
the military is addressing it quickly and decisively.
Hopefully, with our continued pressure, we can get help to
those that need it and we can get diagnosis of those that have
not been diagnosed so they can get help before it is too late.
So I want to thank the Chairman for his calling of this
hearing today, but in particular note the success that has
taken place since the 2007 hearing. Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Isakson.
Senator Johanns, your statement, please.
STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEBRASKA
Senator Johanns. Mr. Chairman, let me just say thank you
for holding this hearing today on what all of us regard as an
enormously important topic.
I certainly know that mental health and suicide are
challenges that servicemembers and veterans are struggling with
very intensely. If my numbers are correct here, last year, the
active Army alone reported 160 actual and suspected suicides
for 2009, and it is my understanding that that is the worst
year on record. It is enormously troubling. I know that the DOD
and the VA are making an effort to stem this tide, but we all
hope that more can be done and sooner.
There are a couple of pieces of legislation that I just
want to mention that I was proud to be a part of, which I hope
will help. The first, with Senators Baucus and Tester,
increased PTSD screening before and after deployments. The
other, with Senator Shaheen, expanded Yellow Ribbon suicide
prevention efforts for Guard and Reserve servicemembers.
We do have a responsibility to care for our servicemembers
not only while they are in the military, but also when they
leave. That responsibility begins with oversight and making the
efforts that I hope will bear some fruit.
Now, I want to acknowledge that I am very aware that the VA
is working on a solution, as Dr. Cross notes in his testimony.
VA is allocating more financial and staff resources toward
mental health in fiscal year 2011. That is a good step. Solving
the problem probably, though, needs more than just additional
brute force, if you will. Some of the nongovernmental people
and organizations here today are doing groundbreaking work in
helping loved ones support veterans with mental health
disorders.
On Friday, I was here for a hearing on the budget. I was
very impressed by Secretary Shinseki's promotion of innovative
pilot projects to reduce the disability claims backlog. My hope
is that that kind of spirit of outside-the-box thinking will be
applied to dealing with mental health disorders.
So I look forward to the testimony today. I applaud the
efforts, but I think we all have to acknowledge it is just such
a heartbreaking problem. My hope is that we will continue to
find ways forward to deal with this very important issue.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Johanns.
Senator Brown?
STATEMENT OF HON. SHERROD BROWN,
U.S. SENATOR FROM OHIO
Senator Brown. Aloha, Mr. Chairman----
Chairman Akaka. Aloha.
Senator Brown [continuing]. And thank you for holding this
important hearing. I appreciate your leadership. And I want to
thank even more than normal the witnesses for coming in. These
are hard issues to discuss and thank you for joining us and
applaud your willingness to talk about this.
I am reminded that we have such a stigma attached to
suicide. The President historically--Presidents of both
parties, have typically not sent letters as they do when
servicemen and women are killed. They have not sent letters out
to families when someone commits suicide and that is a, if not
a policy, a practice that clearly needs to change.
Several veterans every day kill themselves. We know that.
The rate of young veterans committing suicide continues to rise
at alarming rates. We know that when young veterans return,
when young soldiers, marines, sailors, airmen and women return
from Iraq or Afghanistan or from the service and go back to
Coshocton, St. Clairesville, Finley, or Dayton, OH, that so
often the veterans service organization doesn't even know that
young returning soldier or airwoman is even in town and then is
less likely to get the counseling, the testing, the screening
for PTSD, the support groups from peers and all that so often
can save that young man or woman from continuing persistent and
worse behavior later in their lives. That is why it is so
important that we are here.
The VA's residential PTSD program at Cincinnati Medical
Center is an example of the extraordinary work VA is doing, not
only treating PTSD, but helping veterans suffering from all
kinds of mental illness and how important that is. My office is
inundated with casework-related PTSD claims by Vietnam-era
veterans. The question becomes, what can we do to help older
veterans? What can we do to help younger veterans just
returning?
The Cincinnati VA is leading the Nation in providing vital
and cutting-edge services in mental health, yet we have so much
more to do.
I am also concerned, Mr. Chairman, with veterans and
military personnel self-medicating with drugs or alcohol. I
hear from so many veterans' advocates who tell stories of
veterans seeking help, but since they were discharged from the
military on drug or alcohol abuse or some other manifestation
of mental illness, rather than for the service-connected mental
illness, they are essentially shut out of care from the VA.
That is inhumane. It is bad public policy. It is morally wrong.
I have introduced legislation and offered amendments to
previous Defense Authorization bills to put important
safeguards in place so that servicemembers can understand the
ramifications of accepting a discharge that could prohibit them
from receiving VA benefits later on.
And last, I want to commend Secretary Shinseki, who was at
the Vet Center, the Chillicothe Medical Center, 2 weeks ago.
They are a national leader in treatment and care for homeless
veterans. I want to commend him and the VA for their bold
homelessness initiative. We have much to do.
I want to thank those, again, who are testifying today.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator.
Now, we will receive the opening statement of our Ranking
Member, Senator Burr.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Aloha, Mr. Chairman. My apologies for my
tardiness. I am going to ask unanimous consent that my opening
statement be a part of the record, and I would like to
specifically welcome Mr. Hanson and Mr. Jordan. I thank both of
you for your willingness to share your experiences with us,
many of which I know are painful to recount. This country owes
both of you a debt of gratitude for your service and your
continued service.
Mr. Chairman, 3 years ago, this Committee held a hearing to
examine VA's efforts to address the mental health needs of our
veterans. At that hearing, we heard from family members of
veterans and servicemembers who had taken their own lives
following combat service. Only days after that hearing, a
National Guard unit headquartered in Boone, NC, returned home
from Iraq. Within 18 months of their return, four of the unit's
175 soldiers had taken their own lives. This problem is real.
With that said, Mr. Chairman, VA cannot be expected to do
this alone. The Department of Defense has a critical role to
play, but so do community organizations, veterans groups,
nonprofits, churches, and others. This has to be an effort
where we use every available source to help us end this quest.
And I thank the Chair.
[The prepared statement of Senator Burr follows:]
Prepared Statement of Hon. Richard Burr, Ranking Member,
U.S. Senator from North Carolina
Good morning, Mr. Chairman, and a warm welcome to our panelists
today, particularly you, Mr. Hanson and Mr. Jordan.
We are truly grateful for your willingness to share your
experiences with us, many of which are no doubt painful for you to
recount. This country owes you both a debt of gratitude for your
sacrifice and continued service to the Nation.
Three years ago, the Committee held a hearing to examine VA's
efforts to address the mental health needs of veterans. At that
hearing, we heard from family members of veterans and servicemembers
who had taken their own lives following combat service. They told us of
a mental health care system that was too reactive, often only making
services available when it was too late to be effective.
Only days after that hearing, a National Guard unit headquartered
in Boone, North Carolina, returned home from Iraq. Within 18 months of
their return, four of the unit's 175 soldiers had taken their own
lives.
I hope to hear today that we have, in fact, put more emphasis on
outreach, early intervention, and prevention. Legislation was enacted
out of this Committee giving VA the authority it needs to do this; I'm
anxious to hear about the progress being made, although the statistics
we do have remain sobering.
According to Congressional Quarterly, more American servicemembers
took their own lives in 2009 than were killed in the wars in
Afghanistan and Iraq combined. With that said, VA can't be expected to
do it alone. The Department of Defense has a critical role to play, but
so do community organizations, veterans' groups, non-profits, churches
and others.
The reasons which lead a young man or woman to contemplate ending
their life are complex. So, too, are the solutions to prevent that from
happening. We must continue to reach out on a general level to provide
help for veterans with PTSD, depression, anxiety disorder, and other
mental illness.
The goal is to be sure that those with mental illness can return to
live, work, learn, and participate fully in their communities.
That means we must identify unmet needs and barriers to services.
We must identify innovative treatments and services that are
demonstrably effective. We must improve coordination among case
managers and providers.
These are tough goals, and they require that we ask tough
questions. Questions such as whether our servicemembers are prepared to
manage the stresses of combat before they set foot on the battlefield,
and whether we are setting appropriate benchmarks to evaluate the
effectiveness of prescribed treatment.
As I said, these remain difficult questions. But the price of not
addressing them is too high.
Thank you, Mr. Chairman, and thank you to all of our witnesses.
Chairman Akaka. Thank you very much, Senator Burr. Your
full opening statement will be included in the record, without
objection.
The Senator from Alaska, Senator Begich.
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Thank you very much, Mr. Chairman. I will
be very brief. I have a meeting in Commerce at 10:15 for a
budget presentation, but I am going to first say I appreciate
you all being here. I am anxious for your comments.
I have a series of questions which I am going to submit for
the record to have you respond to of which some are very
parochial. Alaska is a very rural State and how we deliver
services and so forth; some commentary from that perspective
and your thoughts in that arena; how do we use telemedicine;
how do we use other avenues?
But again, for this panel as well as the second panel who
might be in the audience, I have a series of questions, Mr.
Chairman, that I will just submit to the Committee, if that is
OK, for response. I apologize for having to leave early, but I
do want to hear the first panel's commentary. Thank you.
Chairman Akaka. Thank you very much, Senator Begich.
I want to welcome the witnesses on our first panel, all of
whom bring a different perspective to this issue which will
help to broaden our dialog of mental health care and suicide
prevention for veterans. We have Daniel J. Hanson, an Operation
Iraqi Freedom veteran; David Rudd, Dr. David Rudd, Dean of the
College of Social and Behavioral Science at the University of
Utah; and last, Clarence Jordan, a member of the National Board
of Directors of the National Alliance on Mental Illness.
I thank you all for being here this morning. Your testimony
will appear in the record.
Mr. Hanson, will you please begin with your testimony.
STATEMENT OF DANIEL J. HANSON, VETERAN,
OPERATION IRAQI FREEDOM
Mr. Hanson. Good morning. My name is Daniel Hanson and I am
27 years old. I joined the U.S. Marine Corps in 2003. Shortly
after, I was assigned to Second Battalion, Fourth Marines, and
we were deployed to Ar-Ramadi, Iraq. It was a deployment that
started out with one of our Marines committing suicide. Shortly
after, the funerals seemed to become a regular thing. It was
pretty difficult to know that you had just talked to someone
the day before and now you are saluting a pair of empty boots
and an upside down M-16 and a set of dog tags. We lost 35
total.
After we got back from the deployment, we had a few classes
and then we went on leave and that was that. Shortly after, 6
months later, we deployed to Okinawa, Japan. After Okinawa, I
got out of the Marine Corps, and just before getting out, I had
a good friend, also a Marine, who went to the VA to get
services, but they were booked at the time and he ended up
hanging himself the next day, and that was hard for me. I was
trying to get things back--my life was getting a little out of
control--so I was trying to get things back in order.
Shortly after, I lost another friend. He was killed in
combat, buried at Arlington Cemetery here, and it kind of got
me sliding again, as well. On March 23, 2007, my best friend
and my brother was--he hung himself--he was also a Marine--in
the basement of his home. After that day, I pretty much lost
it. I was drinking every day, doing drugs, anything I could do
to get away from the pain.
I worked with the VA medical center. They were helpful. I
did therapy and things like that. Eventually, I started getting
DUIs and I went to the Dual Diagnosis Program at the St. Paul
VA medical center. I did 30 days of treatment. I got out, and
though it was informative, it wasn't something very applicable
to my life. I kind of felt like just a number going through a
revolving door. I have had doctors kind of deal, just do their
things.
About a month after I got out of the program, I attempted
suicide. I woke up at the St. Cloud VA medical center on a 72-
hour lock-up. After that, I was released back to work. I think
I got a phone call or two to make sure I was all right, to make
sure that I had my life together. I was pretty much a monster.
I was drinking all the time. I was lying all the time. I
thought about dying every day. I got a divorce. I also just
left my kids aside. I didn't want to live every day. I thought,
I have got to kill myself before my kids know what a loser
their dad is. I didn't know what to do.
Eventually, after my last DUI, I just gave up and I knew I
was either going to kill myself or I was going to do something
for myself, for my kids. So, finally I had enough--I don't know
what it was. I just gave up and I went to a program called
Minnesota Teen Challenge. It is a 13- to 15-month faith-based
rehabilitation program. I graduated a week ago, actually. For
once in my life, I have a purpose. I don't wake up every day
wanting to kill myself.
I know if I did a 3-month program, a 6-month program, a 9-
month program, I would still be in the same boat I was. But 13
to 15 months is what I needed to be able to get through, not
just scratch the surface, but get down to the deep, the root
issues that I was dealing with. And I know that going on an
outpatient or going on a 30-, 60-, 90-day inpatient program
wasn't going to do it. I needed much more, and I would be dead
or in prison right now if I hadn't gone to Minnesota Teen
Challenge. I mean, the problems I picked up over the years
weren't going to go away in just a matter of months.
I know a lot of veterans still that need it. They are kind
of going through the outpatient program. I have friends that
still just don't know what to do. Their everyday, once-a-week
counseling isn't doing anything for them. They are going out
drinking 10 minutes after they leave.
For me, if I could suggest anything, it would be that there
is more long-term care. I know in Minnesota the only thing that
they really offer is the Dual Diagnosis Program, and I believe
there is one at the Minneapolis VA, but it is outpatient only
and I believe it is 5 or 6 weeks. For someone like me who hated
myself, hated everything, wanted to die every day, I just
needed way more. I was sick and nothing else was going to do it
except for getting away from that environment for a long, long
period of time.
And the second, I would say there was really no
accountability. I mean, it wasn't too long after I attempted a
suicide and I was doing a once-a-week thing at the VA medical
center where it was, you know, like everything was all right,
but it wasn't all right. Sure, it was my part, too. I didn't
want to--I was embarrassed. I thought, what kind of loser would
kill himself? There is no reason for it. But there was never a
feeling that someone really cared for me, really cared what
happened to me when I left out that door. Maybe that hour we
were together, but after that, it was done. There was no
connection. There was no feeling that I needed--that they cared
about me, that there was something, that if I died that day,
that someone would care. And that is part of the reason why I
was angry for so long.
And then, also, I would suggest that--I think the VA has
great programs, but programs like Minnesota Teen Challenge that
can offer a 13- to 15-month stay and have been doing it for a
long time would be great organizations to have relationships
with, not just keep it internal in the VA, but be able to
branch out to some of the nonprofit organizations, branch out
to some of the non-government places to help these veterans so
nobody is left behind and so that nobody commits suicide,
because I have seen too many great men take their own life and
I just would do anything to prevent it--anything. Anything.
And that is all I have. Thank you very much for letting me
share.
[The prepared statement of Mr. Hanson follows:]
Prepared Statement of Daniel J. Hanson, Operation Iraq Freedom Veteran
My name is Daniel Joseph Hanson and I am 27 years old. I joined the
United States Marine Corps in January 2003. I was eventually was
assigned to 2d Battalion, 4th Marines and in February 2004 was deployed
to Ar-Ramadi Iraq. The deployment started with one of our Marines
shooting himself in the head and killing himself. It was not long
before we started losing men and funerals seemed to become a regular
thing. It was hard to know that you had just talked to someone the day
before and now you were saluting an empty pair of combat boots, an
upside down M-16 and a pair of dog tags. When it was all over in
October 2004 we lost a total of 35 Marines.
On our ``cool down'' period before returning we had a few classes
discussing what each person had seen and how they were dealing with it.
For me it was very difficult to talk about anything that bothered me
because I was not an infantryman and felt as if I did not have the
right to raise my hand because of it. I felt as if I was subpar because
the other people in my battalion had been through much worse and I was
weak if I couldn't handle the things that I went through. After a few
classes we all returned from the deployment and shortly after went on
leave. That is all that we went through in regards to post-deployment,
a few classes to make sure that if we had any traumatic events we made
sure we let somebody know.
I was deployed a second time to Okinawa Japan in 2005. At this
point I was married and had a child on the way. Upon returning from
Okinawa I had my son and began preparations to get out of the Marine
Corps. I was drinking almost every single day, getting in fights and
was very depressed. I got out of the Marine Corps in January 2007 and
decided I was out of control and needed to get help.
Before I was released from active duty a friend and fellow Marine
hanged himself in the basement of his home with an electrical wire. He
had gone to the Saint Cloud VA Medical center seeking help, but was
turned away. A couple weeks later (February 7th, 2007) my good friend
and father figure SgtMaj J.J. Ellis was killed in combat. His funeral
at Arlington National Cemetery got me to start drinking just a few
short weeks after I was trying to get things together again. Then on
March 23, 2007 my brother and best friend, who was also a Marine,
hanged himself in the basement of his home. Travis was working with the
VA Medical Center, but was not willing to open up to them about his
internal struggles.
At that point I really went off the deep end. I started working
with the VA Medical Center on an outpatient basis. I struggled with
anxiety and depression which eventually lead to a lot of destruction.
In August 2007 I separated from my wife and eventually got divorced,
after I got another woman pregnant while I was still married. I started
racking up DUI after DUI and spent some time in jail. I went to the
Saint Cloud VA Medical Center and went through the Dual Diagnosis
Program. There was good content and it was very informative. However,
it lacked any sort of discipline and there was a gentleman that was
smoking meth in the stairwell at one point in time. It seemed more like
something that would be to teach people about what drugs and alcohol
can do to a person, but there was not a whole lot of real life
application. Also, there was no aftercare so once I was cut loose I was
pretty much on my own. I still did follow up at the Minneapolis VA
Medical Center, but I was so far gone outpatient would not suffice.
About a month after I completed the Dual Diagnosis Program I am
attempted to kill myself by swallowing a large amount of prescribed
pills. I woke up in the Saint Cloud VA Medical Center and was put up in
the psych ward. I was put on a 72 hour hold and then released. There
was almost no follow up after my departure from my 72 hour hold and
then I was just thrown back into my life again. I continued to drink,
cheat, and live a life of anger. I started using drugs again because
the alcohol was not doing enough to help me cope during the day. I got
another DUI and found myself in jail yet again. A week after my last
DUI I found myself looking at a lot of jail time. I was scared, broken
and wanted to die yet again. One week later I checked myself into
Minnesota Teen Challenge, which is a 13-15 month faith based program.
The Minneapolis VA Medical Center does not offer anything close to
a 13-15 month long inpatient treatment program. I was walking around
wanting to die every single day, month after month, and no 30, 60, or
90 day program would have been able to get me to where I needed to be.
A year removed from the world that had just become too much for me and
that I hated seemed like way too much to commit to, but it has saved my
life. Minnesota Teen Challenge changed me more than I ever thought
possible. I have completely changed my thoughts, actions, and attitude
over the last year. It was a struggle and I considered leaving many
times, but that is because I have always been a person that always took
the easy way out. I now want to live and I want to live a successful
life free of any chemicals.
While at Minnesota Teen challenge one of the biggest struggles that
I dealt with was not having the funds to complete the program. I was
not able to get the VA to fund the program while I was attending so I
put in a claim to have my disability raised. I fell behind in child
support, bills and eventually my payments to MnTC. It made things very
difficult in the midst of me trying to get my life straightened out. I
finally got my claim completed one day after my graduation and up until
then I thought I was going to have to sleep in my car to come out to
Washington D.C. to testify.
In my working with the VA the three biggest things that I noticed
was through my experiences at the VA Medical Center. First, they do not
provide any long term care at all. The longest program that I know
about is the Dual Diagnosis Program at the Saint Cloud VA Medical
Center and I believe that it is only 90 days at the most. The problems
that I picked up over the years of bad living were not going to go away
in a matter of months. There are a lot of veterans I know that walk
around in constant pain and depression because they have never been
able to overcome the root of their problems. A program that lasts for a
year or more is much more likely to help a person, and help them not
just cope with their problems, but get rid of them all together.
Minnesota Teen Challenge has changed my life from wanting to die every
day to wanting to get up every day because I finally have a passion to
live. Second, there was never any accountability in my experiences with
the VA system. If I missed appointments or just stopped calling all
together it did not seem to really matter to anyone. I felt like I was
just another number going through the revolving door of head doctors
that had to talk to me. I had the opportunity to work with a lot of
great VA employees over my time there, but I never really felt
connected. Never thought anyone really cared. Third, there are a lot of
great organizations that are not connected to the Government, but are
not being utilized because it may be more expensive. The VA cannot
possibly take care of all the hurting veterans on their own and I
believe that being able to utilize the resources of organizations not
connected to the VA is necessary to help all of them.
I would not be where I am now without the help from the Department
of Veterans Affairs, but I could have gotten here a lot sooner. I have
watched my friends and family who are veterans suffer through many of
invisible wounds and there is no reason for it. Being able to get
outside programs funded, keeping accountability of veterans and opening
up to long term rehabilitation programs will save lives. I appreciate
your time and the opportunity to share my testimony.
______
Response to Post-Hearing Questions Submitted by Hon. John D.
Rockefeller IV to Daniel J. Hanson, Operation Iraqi Freedom Veteran
First, I want to thank you for your compelling testimony. Sharing
your difficulties has to be hard, but it is brave of you to speak out
about what you think needs to change to help other veterans. I
understand your points about the need for a longer program--over 90
days--and the importance of follow up.
Question. What do you think about a mandatory training course or
mental health program for all veterans as a way to eliminate the
stigma? Do you think this would be helpful? How long should such course
be?
Response. I think that is a great idea and the more training the
better, but I just feel it is of the utmost importance to have the
right people in charge of a program like that. I also think that it
would be a great idea for some of the non VA programs to get training
for how to handle veterans with problems. A program that would really
be able to help, in my opinion, would be a lot more beneficial if it
was at least a few months long.
______
Response to Post-Hearing Questions Submitted by Hon. Mark Begich to
Daniel Hanson, Operation Iraqi Freedom Veteran
Question 1. Long term care, was it available for you?
Response. None. The longest care that I was offered was the Dual
Diagnosis Program and that is 90 days at the most. I went through the
program in 30 days and was no better than the day I started. There is
not even an inpatient program offered in Minneapolis.
Question 2. What type of follow-up aftercare by the VA was
available for you?
Response. I did weekly 1 hour therapy sessions and the occasional
group therapy through the VA, but it was very hands off.
Question 3. Did the VA give you a choice of outside treatment
facilities and Faith-Based programs?
Response. No. I had to pay for Minnesota Teen Challenge out of my
own pocket and was told the VA would not pay for the program. That made
things much more difficult for me and for trying to support my
children.
Question 4. What type outreach and follow-up did you receive from
the VA?
Response. Weekly counseling sessions. The occasional phone call was
all I received even after I attempted suicide.
Chairman Akaka. Thank you very much, Mr. Hanson.
Dr. David Rudd?
STATEMENT OF M. DAVID RUDD, Ph.D., ABPP, DEAN, COLLEGE OF
SOCIAL AND BEHAVIORAL SCIENCE, UNIVERSITY OF UTAH
Mr. Rudd. Mr. Chairman, Mr. Ranking Member, and Members of
the Committee, as a veteran and a psychologist, I appreciate
the opportunity to appear today and discuss the Department of
Veterans Affairs efforts to address the mental health needs of
America's veterans. I would like to thank Mr. Hanson for his
testimony. It is the kind of strength and courage that he
demonstrates that is exactly what we need: for people to step
forward, talk about their experiences, and offer unique insight
and input into the process.
There is no disagreement that the mental health demands on
the VA will continue to grow over the course of the next
decade. Given the duration of Operation Enduring Freedom and
Operation Iraqi Freedom, current mental health demands are
unprecedented. In addition to grappling with anticipated
problems like depression, Post Traumatic Stress Disorder, and
substance abuse, the VA is struggling to address the tragic
loss of veterans to suicide. I have absolutely no hesitation to
endorse the recent efforts of the VA, but will certainly
encourage the VA to explore non-traditional approaches and
public-private partnerships in an effort to undermine the
devastating impact of stigma, an issue that oftentimes gets
very little discussion and debate.
As you will hear from other witnesses, the VA has
implemented a range of programs and initiatives all geared
toward meeting the growing mental health demands of today's
veterans. With respect to suicide, the VA has launched an
intensive suicide prevention program, one that includes an
innovative Suicide Prevention Hotline, an Internet chat line--
and let me say, these two programs are cutting edge. They are
unlike any that have ever been implemented and they are having
great success, and I would certainly applaud those efforts.
As you know, there are 18 deaths per day due to suicide
among American veterans with approximately five per day among
those in active treatment. The numbers are nothing short of
heartbreaking. These numbers reveal several challenges,
including the simple reality that the majority of veterans are
not accessing much-needed care during moments of crisis. I
think that is the critical point--that we are not reaching the
veterans that are at highest risk, and that is the primary
concern that I personally have.
Data is emerging to suggest that recent changes in the VA
delivery system are proving more effective with OEF and OIF
veterans, with a reduction in soldier risk for those in active
treatment. We have good treatments today for suicidality. There
are a number of treatments that are effective and can be
effective in a number of settings. They are not difficult to
implement. The problem is getting people to actually access the
treatment, and getting people to stay in treatment once they
start.
Scientifically, we know that there are a number of
treatments and inventions that prove effective. The effective
elements of these treatments are simple and straightforward,
they are very concrete, and they result in hope, which is what
we need to help overcome the issue of suicidality. Despite the
availability of effective treatments, it is important to
remember that not only will many of our veterans face acute
problems, but just as Mr. Hanson has demonstrated, they will
continue to face chronic problems. This is an issue that is not
going to go away. Part of my concern personally and
scientifically is that this is going to require long-term care,
far more than short-term care that we have conceptualized to
this point.
In addition to what the VA is currently doing, efforts that
certainly should be applauded, I would like to emphasize the
need for the VA to think outside of the box, to experiment with
non-traditional approaches and consider that the existing data
point to the undeniable truth that we simply are not reaching
the larger portion of veterans in need. This is a problem for
both the VA and the Department of Defense.
I would suggest to you that stigma and the nature of the
military culture are at the heart of the problem. The military
culture is one that appropriately is dedicated to developing
warriors, a culture that treasures strength, courage, and
sacrifice, all admirable qualities.
As OEF and OIF have demonstrated, psychiatric casualties
are much larger than originally anticipated. Prolonged and
repeated exposure to combat takes a considerable psychological
toll. Our soldiers and veterans struggle to understand their
health--they continue to struggle to understand the health
consequences of killing, the exposure to combat, what it means
to be in combat, and what the normal trajectory of response to
combat is. It is an issue that we need to think very seriously
about and we need to look beyond traditional mental health
approaches when we are doing that.
Traditional mental health approaches talk almost
exclusively in the language of illness, contrary to the very
core of what we know about a warrior mentality. For many of our
veterans, the notion of illness and disorder is synonymous with
personal failing and weakness, and it only serves to compound
the existing shame and guilt that they experience. We need to
move away from this traditional language of pathology and talk
about the issues of optimal performance and resilience. We need
to do this early in the experience of training soldiers. We
need to look at unique programs and alternatives for helping
soldiers understand early in the process about potential
problems in terms of adjustment to combat.
It is critical for the Department of Defense and the VA to
reach veterans by normalizing the combat experience and
subsequent adjustment. This can take a number of forms, but it
is essential that early in training, all soldiers be exposed to
training targeting the consequences of killing, talking in
specific terms about post-combat adjustment.
It is important for the VA to recognize that they fight a
longstanding image as an inflexible and unresponsive
bureaucracy. There is a need to stretch existing boundaries and
explore public-private partnerships that provide new experience
and alternatives for our veterans.
As an example, given an estimated 500,000 veterans will
transition to college campuses over the course of the next
decade, I would strongly encourage the VA to look at partnering
with university campuses. They need to go where the veterans
are, and a large portion of those veterans are going to be on
our college campuses. We need to look at partnering in very
specific ways. I can tell you, we would welcome the opportunity
to partner with the VA system in terms of providing care and
assessing and responding to veterans on campuses.
The problems experienced by today's veterans demonstrate an
undeniable truth. Traditional approaches do not reach those in
greatest need. We need to think outside of the box, experiment
with non-traditional approaches, set aside the language of
mental illness and pathology, and put our veterans first.
Thank you very much. I would welcome the opportunity to
answer questions.
[The prepared statement of Mr. Rudd follows:]
Prepared Statement of M. David Rudd, Ph.D., ABPP, Dean, College of
Social & Behavioral Science, University of Utah; Scientific Director,
National Center for Veterans Studies, University of Utah
Mr. Chairman, Mr. Ranking Member, and Members of the Committee, I
appreciate the opportunity to appear today to discuss the Department of
Veterans' Affairs (VA) efforts to address the mental health needs of
America's Veterans.
There is no disagreement that the mental health demands on the VA
will continue to grow over the course of the next decade. Given the
duration of Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF) current mental health demands are unprecedented. In
addition to grappling with anticipated problems like depression, Post
Traumatic Stress Disorder, and substance abuse, the VA is struggling to
address the tragic loss of veterans' to suicide. I have no hesitation
to endorse the recent efforts of the VA, but will offer encouragement
for the VA to explore non-traditional approaches and public-private
partnerships in an effort to undermine the devastating impact of
stigma.
As you will hear from other witnesses, the VA has implemented a
range of programs and initiatives, all geared toward meeting the
growing mental health demands of today's Veterans. With respect to
suicide, the VA has launched an intensive suicide prevention program,
one that includes an innovative suicide prevention hotline and Internet
chat line. As you know, there are eighteen deaths per day due to
suicide among America's Veterans, with approximately five per day among
those in active treatment with the VA. These numbers are nothing short
of heartbreaking.
These numbers reveal several challenges, including the simple
reality that the majority of Veterans' in need are not accessing much
needed services at moments of crisis. Data is emerging to suggest that
recent changes in the VA delivery system are proving more effective
with OEF and OIF Veterans', with a reduction in suicide risk for those
in active treatment. Scientifically we know that there are a number of
treatments and interventions proven effective for suicidality. The
effective elements of these treatments are simple and straightforward,
inspiring hope and recovery in concrete fashion. Despite the
availability of effective treatment, it is important to remember that
not only will many of our Veterans face acute problems a large
percentage will struggle for many years requiring intensive and
enduring care. This is not a short-term issue.
In addition to what the VA is currently doing, efforts that
certainly should be applauded, I would like to emphasize the need for
the VA to think outside of the box, to experiment with non-traditional
approaches and consider that the existing data point to one undeniable
truth, we simply are not reaching the larger portion of those in need.
This is a problem for both the VA and the Department of Defense. Stigma
and the military culture are at the heart of the problem.
The military culture is one appropriately dedicated to developing
warriors, one that treasures strength, courage and sacrifice. As OEF/
OIF have demonstrated, psychiatric casualties are much larger than
originally anticipated. Prolonged and repeated exposure to combat takes
a considerable psychological toll. Our soldiers and Veterans struggle
to understand their experiences and the consequences of killing.
Traditional mental health approaches are simply not effective at
reaching our soldiers and Veterans, an outcome that is not particularly
surprising. Traditional mental health approaches talk almost
exclusively in the language of illness, contrary to the very core of
military training. For many of our Veterans the notion of illness and
disorder is synonymous with personal failing and weakness, only serving
to compound existing shame and guilt. We need to move away from the
traditional language of pathology and talk about the issue of optimal
performance and resilience.
It is critical for both the Department of Defense (DOD) and VA to
reach Veterans by ``normalizing'' the combat experience and subsequent
adjustment. This can take many forms, but it is essential that early in
training all soldiers be exposed to training targeting the consequences
of killing, talking in specific terms about post-combat adjustment. Not
a single soldier comes out of combat the way that they went in; combat
is a life altering experience. We can do a better job of helping our
warriors understand the normal adjustment problems experienced
following combat, eliminating the possibility that subsequent
psychological problems will be attributed to personal failings and
weakness. As the Air Force Suicide Prevention Program demonstrated, the
impact of high-ranking leaders cannot be underestimated. Nothing is
more powerful to a struggling enlisted man or woman, hesitant to seek
care, than to see a commander talk openly and honestly about his or her
own difficulties following combat.
Similarly, it is important for the VA to recognize that they fight
a longstanding image as an inflexible and unresponsive bureaucracy.
There is a need to stretch existing boundaries and explore public-
private partnerships that provide new service alternatives for our
Veterans. As an example, given that an estimated 500,000 Veterans will
make their way to college and university campuses over the next decade,
the VA should consider the placement of providers on campuses around
the country. The VA will need to go to where the Veterans are in order
to reach the seventy percent hesitant to seek care. We would certainly
welcome such a partnership. Similarly, expansion of the existing VA
system may not be the most effective expenditure of available funds. As
is well known among suicide researchers, a large percentage of those
that take their own lives see primary care providers in the month prior
to their death. Although the VA has improved training for primary care
providers within their system, why not explore other potential
partnerships with private medical centers?
The problems experienced by today's Veterans demonstrate an
undeniable truth, traditional approaches do not reach those in greatest
need. We need to think outside of the box, experiment with non-
traditional approaches, set aside the language of mental illness and
pathology, and put our Veterans first.
______
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
M. David Rudd, Ph.D., ABPP, Dean, College of Social and Behavioral
Science, University of Utah
Question 1. Especially in terms of research and emerging opinions
on most effective treatment methods, what was not discussed in the
hearing that needs to be?
Response. It should be mentioned that, according to the empirical
literature, there are only two effective treatments for PTSD, including
cognitive processing therapy and prolonged exposure therapy. There
needs to be more effort to make sure that these are the
psychotherapeutic treatments offered to veterans, including the
necessary clinical training for VA providers.
With respect to suicidality, there are only a handful of effective
treatments. As with PTSD, it is important for the VA system to offer
these psychotherapeutic options and make sure their providers are
appropriately trained.
The VA system should also be making a concerted effort to implement
interventions in Emergency Departments that work to do two things: 1)
reduce the rates of ED presentations for suicide attempts and 2)
facilitate transition into treatment and improved compliance with
ongoing treatment.
Question 2. We recently heard from veterans in Hawaii that they do
not want to utilize tele-mental health options, whereas many younger
veterans like this form of care delivery. What studies have been done
to compare needs and preferences of the different generations with
respect to delivery or type of care? How should that be integrated into
VA's care delivery?
Response. There are a number of options for integrating online
treatment options. The majority view online options as adjunctive in
nature, i.e. used as a resource to traditional approaches. In net gain
is a reduction in demand for face-to-face sessions, something
particularly important for veterans in rural areas with limited access
to major medical centers and clinics. We are in the process of testing
an online ``toolkit'' for suicidal veterans with the goal of reducing
the need for face to face contact. The most effective tele-mental
health/online options utilize a combination of online and face to face
contact.
Question 3. In addition to veterans severely injured and those
returning from combat zones, do any of you have any recommendations for
identifying less obvious groups of veterans who might be at an
increased risk for suicide?
Response. The VA and DOD have both launched fairly extensive
efforts to identify high-risk veterans struggling with mental health
problems. I would suggest (and empirical data supports the idea) that
there is far greater need to identify at risk veterans in primary care
settings (i.e. family medicine, internal medicine). A considerable
number of high risk patients appear in primary care and refuse mental
health care. They can more effectively be identified, treated and
maintained in primary care settings.
Question 4. We know that the stigma associated with mental health
problems is a serious barrier to veterans seeking treatment. What else,
in addition to VA's current efforts to overcome stigma, would be
beneficial?
Response. Far greater coordination is needed between DOD and the
VA. The problem with stigma is generated while on active duty. If
greater steps are not taken by DOD the problem will persist. We need
those in the upper echelon of command (both officers and NCO's) to
openly discuss mental health problems and talk about the effectiveness
of their own treatment, all the while emphasizing that it has not
limited their careers. Additionally, more attention needs to be focused
on the transition from active duty status, particularly for National
Guard and Reserves. These two groups in particular need to be the
target of stigma reductions campaigns.
Question 5. Have male and female veterans differed much in their
treatment outcomes for various models of mental health services? If so,
how well do you believe VA has factored such differences into its
treatment programs?
Response. There are not particular differences in response rates to
care. However, there are differences in the types of trauma that
precipitate care. For example, sexual assault among female veterans has
not received the attention it deserves. The same can be said for
vicarious trauma, i.e. among health care providers (e.g. nurses) in
combat zones.
______
Response to Post-Hearing Questions Submitted by Hon. John D.
Rockefeller IV to M. David Rudd, Ph.D., ABPP, Dean, College of Social
and Behavioral Science, University of Utah
Question 1. In your testimony, you mention the need to change
traditional language about mental health for the military and veterans.
Can you explain that idea in more detail?
Response. DOD and the VA can do a better job ``normalizing'' post
traumatic stress by ``relabeling'' the problem. We need to talk about
how to effectively adjust to post combat environment. As long as we
continue to use diagnostic labels like depression, PTSD, and substance
abuse we'll see a large percentage of soldiers unwilling to receive
care. If we talk about building and maintaining ``resilience'' and
``optimal performance'', something that should be started in basic
training, we'll have more soldiers involved. We'll also have to go to
the soldiers and stop asking them to come to clinics and hospitals for
care. The facilities themselves stop soldiers from accessing care since
they don't want to be ``seen'' in those settings.
Question 2. You mention partnerships with other health providers,
but how would this work with your other idea of changing the
traditional language about mental health for the military?
Response. We should partner with primary care providers. The
integration of mental health professionals in primary care settings
carries far less stigma. Soldiers are willing to willing to be seen for
``medical'' problems and related injuries. Providing mental health care
in that context helps get around the traditional problem of going to a
specialty mental health clinic.
Question 3. How could we educate or make the entire private sector
sensitive to this issue?
Response. I believe we have to start talking in consistent fashion
about the emotional and psychological consequences of combat,
normalizing the experience. Not one single soldier goes to war and
returns home without having to address emotional or psychological
issues in some form or fashion, whether it's grieving the loss of
friends or more complex issues. The issue of the Purple Heart is a
great example. We honor those with physical wounds but not those with
psychological ones. Until we are willing to take on that problem,
psychological problems following combat will continue to be viewed as
``weakness'' and ``failure.''
Chairman Akaka. Thank you very much, Dr. Rudd.
Mr. Clarence Jordan, your statement, please.
STATEMENT OF CLARENCE JORDAN, MEMBER, NATIONAL BOARD OF
DIRECTORS, NATIONAL ALLIANCE ON MENTAL ILLNESS
Mr. Jordan. Thank you. Chairman Akaka, Ranking Member burr,
and Members of the Committee, on behalf of the National
Alliance on Mental Illness, NAMI, thank you for inviting me
today to share my views.
I am privileged to serve on the National Board of Directors
of NAMI, the Nation's largest grassroots mental health consumer
organization. We are dedicated to improving the lives of
individuals and families affected by mental health in adults
and in children.
Mr. Chairman, NAMI is deeply concerned about the newest
generation of repatriated war veterans, whether they remain on
active duty, serve in the Guard and Reserve, or return to
civilian life following service. We want to see the VA take a
more relating posture in coordinating both intergovernmental
and public-private arrangements that would do a better job at
outreach, screening, education, counseling, and care of
veterans who fought and are still fighting these wars and to
help their families recover from these experiences.
NAMI is very proud that the VA in 2008 recognized that we
can play an important role within the VA in helping families of
veterans cope with and recover from mental illness. NAMI's
signature program, Family-to-Family, is dedicated and designed
to meet the needs of family members who have questions relative
to whether or not their loved one, the veteran home from
deployment and war, is experiencing not only from the
standpoint of what the illness is, but the treatment, the
various medications, the prognosis, and what they can expect in
supporting and caring for those loved ones and gaining the
ultimate goal of recovery.
Mr. Chairman, I am a 15-year veteran of the world's finest
Navy. I know how combat situations and military life in general
put unique stresses on these individuals. In my case, while the
signs and symptoms of a problem were there and more than one
person tried to point them out to me, I completely denied the
problem at the time. I mean, after all, an individual with
mental illness isn't sent to the Naval War College or given a
scholarship to Naval Post-Graduate School in Monterey.
With the clarity of hindsight now, I can say that I
struggled for years with mental illness, and when I was on
active duty, I know that I was not alone. Following the Navy, I
wandered literally in the wilderness for nearly two decades.
This lifestyle ultimately led to getting me into deep kimchi. I
owe a debt of gratitude to the judge who gave me a choice of
going to treatment or going to jail. I chose treatment. It was
the push that I needed to start turning my life around.
I stayed in treatment at a local community mental health
center for 12 months and I continue to be a consumer today. I
believe I have achieved recovery to enable me to live a better
life. I am living proof that a mental illness does not mean
that one cannot live happy, productive lives. Since leaving
that initial treatment, I have not only held responsible jobs,
but I have become actively involved in NAMI, where I train
others to do advocacy work and to help others achieve their
ultimate goal of recovery.
It is important for people, veterans and non-veterans, to
realize that there are different types and levels of mental
illness and that, most importantly, the things they can do to
stop forward is to talk to mental health professionals to find
out the essence of their problems.
When I served in the Navy, I had no basis of experience or
knowledge about mental illness that would have led me to
believe I had a problem. Furthermore, my personal image of
someone with a mental illness when I was in the Navy was
definitely not me. I knew next to nothing about the VA and its
mental health programs. I believe I share this experience with
thousands of military servicemembers, veterans who could
benefit from VA services but may not be getting them. I believe
that the VA must do a better job of reaching out and making its
services known to larger shares of the veterans' population who
serve.
Given our experience to date in the wars in Afghanistan and
Iraq, plus the overlay of combat experience of prior
generations of veterans, more veterans need readjustment and
mental health counseling and other mental health services than
those who are appearing at the VA facilities to seek these
services. I believe much insight about veterans who do not use
VA health care should be obtained from serving those veterans
who have called 273-TALK, the National Suicide Prevention
Hotline, and I would urge this Committee to consider requiring
such a study to determine how much VA is aiding these callers.
Make no mistake, NAMI deeply appreciates the existence of
273-TALK. We have committed and commended to VA's Office of
Mental Health Services for having established this vital link
to VA counseling and who have saved the lives of thousands of
veterans, but we believe a large group of veterans still are in
need and are not being reached. We are proud that our members,
despite these problems, actively participate in consumer
counsels and our Family-to-Family education programs in VA
facilities.
The VA and NAMI executed an important Memorandum of
Understanding in 2007 formally committing to our signature
Family-to-Family education program within the VA facilities. At
100 VA medical centers, Family-to-Family is a formal 12-week
NAMI education program. It enables families living with mental
illness to learn how to cope and better understand it. Also,
Family-to-Family focuses on care for caregivers and how
caregivers can cope with worry, stress, and the emotional
overload that attends mental illness in families. Based on the
success of Family-to-Family, we have a goal of introducing more
NAMI signature programs, such as Peer-to-Peer and NAMI
Connection program within the VA mental health care.
Mr. Chairman, our Grade the States Report last year
revealed that very few States offered mental health or
readjustment programs for returning members of the National
Guard and Reserve from Iraq and Afghanistan. However, we
learned that States like Massachusetts and Vermont are good
models of programs that provide peer outreach and direct
delivery of services to their Guardsmen.
We call your attention also to similar efforts in
California, Connecticut, Maine, Maryland, New Hampshire, and
New Jersey, New Mexico, New York, and North and South Carolina.
Of special note, the State of Montana launched an ambitious
program of post-deployment screening and referrals for Montana
National Guardsmen home from Afghanistan and Iraq.
NAMI is committed to recovery. In the case of our
professional military service, we want to ensure that those
serving in these regular forces are well cared for by the DOD
when they return from active duty; by both DOD and the VA for
those in the National Guard and Reserve components when they
return to their garrisons. NAMI believes that many tailored
approaches need to be made for those new veterans, that all
civilian efforts should be led by VA in coordination with
agencies, including DOD, SAMHSA, the Public Health Services,
Indian Health Services, the National Guard Bureau, the State
Guard leadership, and leaders of State public mental health
agencies, as appropriate as needed. In some cases, private
mental health providers should be enlisted and coordinated by
VA to ensure they can provide the quality of care veterans may
need.
NAMI also urges this Committee to expand the establishment
of diversionary courts for veterans. I mentioned my personal
experience with that judge in Nashville who gave me an
opportunity to turn my life around, and I believe that many
military experiences like mine can be helped if provided an
opportunity.
NAMI urges the Committee to support the development of
diversionary courts for veterans, especially combat veterans,
to make sure that the VA reaches out and coordinates with
existing court systems in cities and States to ensure post-
deployment veterans receive the most timely and effective care
possible rather than allowing sick and disabled veterans
suffering with mental illnesses consequences to their war
service to be convicted and sent to jail.
Finally, NAMI endorses the organization of the Independent
Budget for fiscal year 2011. In that budget and policy
statement, AMVETS, Disabled Veterans, Paralyzed Veterans, and
American Veterans of Foreign Wars in the United States
recommend a series of good ideas that would further improve
VA's mental health programs. I ask the Committee to consider
these recommendations and to ensure, either through oversight
or legislation, the Department of Defense carries out these
intents and the spirits of these recommendations.
This concludes my testimony, Mr. Chairman.
[The prepared statement of Mr. Jordan follows:]
Prepared Statement of Clarence Jordan, Member, National Board of
Directors, National Alliance on Mental Illness (NAMI)
Chairman Akaka, Ranking Member Burr, and Members of the Committee:
On behalf of the National Alliance on Mental Illness (NAMI), please
accept NAMI's collective thanks for this opportunity to provide
testimony at today's oversight hearing to assess the Department of
Veterans Affairs' (VA) mental health programs.
I am privileged to serve on the national Board of Directors of
NAMI, the Nation's largest grassroots consumer organization dedicated
to improving the lives of individuals and families affected by mental
illness. Through NAMI's 1,100 chapters and affiliates in all 50 states
NAMI supports education, outreach, advocacy and research on behalf of
persons with schizophrenia, bipolar disorder, major depression, severe
anxiety disorders, Post Traumatic Stress Disorder (PTSD), and other
chronic mental illnesses that affect both adults and children. In my
opinion what NAMI does best as an organization is to advocate for,
train and educate family members of persons living with mental illness.
In recent years NAMI began to realize that the lives of our newest
veterans and the experiences that they've had while serving our country
in combat necessitate not only that they receive post-deployment
services essential to get well afterward, but also that their families
have needs that must be addressed to ensure that a family recovers from
the experience.
NAMI is very proud that the VA has recognized that NAMI can play an
important role within VA mental health in helping families of veterans
cope with, and recover from, mental illness, whether acute or chronic.
One NAMI signature program in particular, Family-to-Family, is designed
to meet the needs of family members who have questions relative to what
their loved one--the veteran home from deployment in war--is
experiencing, not only from the standpoint of what the illness is, but
the treatment protocol, the various medications and prognosis, and what
they can expect in supporting and caring for their loved one in gaining
the ultimate goal of recovery.
As a case in point, I am a 15-year veteran of U.S. Navy aviation. I
know how combat situations, as well as other more basic tenets of
military life, put unique stressors on those of us who have served, as
well as on our families. In my case, while the signs of a problem were
there, and more than one person tried to point them out to me, I
completely denied the problem at that time. With the clarity of
hindsight now, I can say that I struggled for years with mental illness
when I was on active duty in the United States Navy. I know now that I
was not alone.
My struggle with mental illness ultimately led me to leave military
service, and for nearly a decade afterward I bounced from one job to
another and from city to city. In 1998 I finally had to face the fact
that I had a problem. At the time, I was using alcohol and other drugs
to keep me from dealing with the realities of my life, and that
approach ultimately led me to trouble with the law. I owe a debt of
gratitude to a judge who gave me a choice of going to jail or going
into mental health treatment. It was the push I needed to start turning
things around. In my case I went to a local community mental health
center in Nashville, Tennessee, and met with several doctors who
evaluated my condition. I ultimately was diagnosed with major
depression.
I stayed in treatment at that health center for 12 months to work
through the issues I was experiencing. I believe I have achieved
recovery to enable me to live a better life. I believe I am living
proof that a mental illness does not mean that one cannot live a happy,
productive life. Since leaving that initial treatment, I have not only
held responsible jobs but I've become actively involved in NAMI, where
I now train others and do advocacy work to help those with these
problems achieve their potential.
It's important for people, veterans and non-veterans, to realize
that there are different types and levels of mental illness and that
the most important thing they can do if they think they have a problem
is to step forward and talk to a mental health professional to find
out.
When I served in the Navy, I personally had no base of experience
or knowledge about mental illness that would have led me to believe I
had a problem. Furthermore, my personal ``image'' of someone with a
mental illness when I was in the Navy was definitely not me. I knew
next-to-nothing about the VA and its mental health programs. I believe
I share this experience with thousands of military servicemembers and
veterans who could benefit from VA services but may not be getting
them.
I believe that the VA must do a better job of reaching out and
making its services known to a larger share of the veteran population
(both those recently discharged-demobilized and older generations), and
work more cooperatively with the military service branches, other
Federal agencies, state governments, and private mental health
providers. Today, we have over 23 million living veterans, yet VA sees
only a quarter of them in its health care programs, and even a smaller
fraction in its mental health services. Given our experience to date in
the wars in Afghanistan and Iraq, plus the overlay of combat
experiences of prior generations of veterans, it is obvious that more
veterans need readjustment and mental health counseling and other
mental health services than those who are appearing at VA facilities to
seek these services.
No one to my knowledge is studying what happens to veterans after
combat if they do not enroll in VA health care. VA participates in the
national suicide hotline program, 273-TALK, and recently reported that
over 60,000 veterans had contacted that resource since it was
established. I believe much insight about veterans who do not use VA
health care could be gleaned from surveying those veterans who have
called 273-TALK, and would urge this Committee to consider requiring
such a study by VA or the Substance Abuse and Mental Health Services
Administration (SAMHSA) to determine how much VA is aiding these
callers. Make no mistake: NAMI deeply appreciates the existence of 273-
TALK. We have commended VA's Office of Mental Health Services for
having established this vital link to VA counselors who have saved the
lives of thousands of veterans, but we believe a larger group of
veterans still is in need and is not being reached.
Despite our concerns about the need for broader outreach, not only
to prevent suicides but to ensure that more veterans can become aware
of VA services, NAMI has enjoyed a long-term interest and involvement
in mental health programs within the VA. For 30 years NAMI has served
as an advocate for veterans under care in VA programs, because VA is
caring for our family members. NAMI and its veteran members formally
established a Veterans Council in 2004 to assure close attention is
paid to mental health issues and policies in the VA, especially within
each Veterans Integrated Services Network (VISN) and programs at
individual VA facilities. Council membership includes veterans who live
with serious mental illness, family members of these veterans, and
other NAMI supporters with an involvement and interest in the issues
that affect veterans living with and recovering from mental illness.
The Council members serve as NAMI liaisons with their VISNs; provide
outreach to veterans through local and regional veterans service
organization chapters and posts; increase Congressional awareness of
the special circumstances and challenges of serious mental illness in
the veteran population; and work closely with NAMI's State and
affiliate offices on issues affecting veterans and their families.
Our members are directly involved in consumer councils at more than
one-third of VA medical centers and we advocate for even more councils
to be established throughout the VA system. Also, VA and NAMI executed
an important memorandum of understanding in 2007 formally promoting our
signature ``Family to Family'' education program within VA facilities.
As I mentioned above, Family to Family is a formal twelve-week NAMI
educational program that enables families living with mental illness to
learn how to cope with and better understand it. The program provides
current information about schizophrenia, major depression, bipolar
disorder (manic depressive illness), Post Traumatic Stress Disorder
(PTSD), panic disorder, obsessive-compulsive disorder, borderline
personality disorder, co-occurring brain disorders and addictive
disorders, to family members of veterans suffering from these
challenges. Family to Family supplies up-to-date information about
medications, side effects, and strategies for medication adherence.
During these sessions participants learn about current research related
to the biology of brain disorders and the evidence-based, and most
effective, treatments to promote recovery from them.
Family members of veterans living with mental illness gain empathy
by understanding the subjective, lived experience of a person with
mental illness. Our Family to Family volunteer teachers provide
learning in special workshops for problem solving, listening, and
communication techniques. They provide proven methods of acquiring
strategies for handling crises and relapse. Also, Family to Family
focuses on care for the caregiver, and how caregivers can cope with
worry, stress, and the emotional overload that attends mental illness
in families. We at NAMI are very proud of Family to Family, and we were
especially pleased that former VA Under Secretary Michael Kussman and
VA's Office of Mental Health Services saw the wisdom of formally
bringing NAMI resources like Family to Family into VA mental health
programs at the local level.
I believe I can fairly report that this effort has been a great
success to date, functioning in about 100 VA medical centers. We at
NAMI are hoping to continue building on that success, including
renewing the existing Family to Family memorandum of understanding with
VA, and to introduce more of NAMI's signature programs, such as our
Peer to Peer and NAMI Connections programs, into VA mental health care.
Mr. Chairman, in March of last year NAMI issued its biennial Grade
the States report, an effort to survey state mental health program
directors on the types and scope of mental health programs available
within their states for all residents.
I hope the Committee's professional staff will take the opportunity
to review the results. NAMI found that while 14 States had improved
their grades since NAMI's 2006 survey, 12 fell backwards, and that the
national average grade for state-sponsored public mental health
programs still remained unchanged, a grade of ``D.'' You can see the
full Grade the States report at www.nami.org/grades09.
For the first time ever, the Grade the States report last year
asked a series of questions about whether states offered any
readjustment or other mental health programs for servicemembers and
family members of the state National Guard units returning from
deployments in Afghanistan and Iraq. Very few states responded in the
affirmative, but we have learned that the states of Massachusetts and
Vermont are two good models of programs that effectively provide peer-
outreach and direct delivery of coordinated services to their returning
Guardsmen. These appear to be state-funded efforts, but in the case of
Vermont they are subsidized by a VA cooperative funding agreement. This
is good information that might encourage some States to look to
Massachusetts and Vermont for ideas. We call your attention also to
similar efforts in California, Connecticut, Maine, Maryland, New
Hampshire, New Jersey, New Mexico, New York, North Carolina and South
Carolina. Of special note, the State of Montana launched an ambitious
program of post-deployment screening and referrals for Montana National
Guard members home from Afghanistan and Iraq. NAMI commends Congress
for including Senator Tester's bill, modeled on the Montana program and
based on advocacy by NAMI Montana, in last year's National Defense
Authorization Act (NDAA). That new law requires the Department of
Defense (DOD) to conduct three face-to-face mental health screenings of
every servicemember returning from a contingency operation. NAMI is
also pleased that Congress included Senator Shaheen's legislation based
on a New Hampshire NAMI suicide prevention training initiative, the
``Yellow Ribbon Reintegration Program,'' also called ``Yellow Ribbon
Plus,'' in the NDAA. Unfortunately, while Congress authorized these two
new programs, it did not provide designated funding for them. We hope
directed funding to support these efforts will be provided in the next
DOD appropriations act, in Fiscal Year 2011.
Mr. Chairman, as you can see from some of these examples, NAMI is
deeply concerned about the newest generation of repatriated war
veterans, whether they remain on active duty, serve in the Guard or
Reserves, or return to civilian life following service. We want to see
the Department of Veterans Affairs take a more leading posture in
coordinating both inter-governmental and public-private arrangements
that would do a better job at outreach, screening, education,
counseling and care of the veterans who fought and are still fighting
these wars, and to help their families recover from these experiences.
NAMI is committed to recovery, whether from transitional readjustment
problems coming to a family that welcomes an Army or Marine infantryman
back from war, or one dealing with chronic schizophrenia in a young
adult who never served in the military. In the case of our professional
military services, we want to ensure that those serving in the regular
force are well cared for by DOD when they return to their duty stations
after combat deployments; by both DOD and VA for those in the National
Guard or Reserve components when they return to garrison in their
armories; and, by VA for those who become veterans on completion of
their military service obligations and return to their families--
whether in urban or rural areas.
NAMI believes many tailored approaches will need to be made for
these new veterans, but that all of the civilian efforts should be led
by VA, in coordination with other agencies (including DOD, SAMHSA, the
Public Health Service and the Indian Health Service), the National
Guard Bureau, State Guard leaderships, and the leaders of State public
mental health agencies, as appropriate to the need. In some cases,
private mental health providers should be enlisted and coordinated by
VA to ensure they can provide the quality of care veterans may need,
and are trained to do so in the case of Post Traumatic Stress Disorder
and other disorders consequent to combat exposure and military trauma,
including military sexual trauma. We realize that finding qualified
private mental health providers in highly rural areas is an extreme
challenge and will require VA and other public agencies to be creative.
Nevertheless, we believe these unmet needs can be dealt with if VA
establishes a firm will to do so.
NAMI also urges this Committee and other relevant groups in
Washington and in state capitals, to expand the establishment of
diversionary courts for veterans. I mentioned my personal experience
with a judge who gave me an opportunity to turn my life around, and I
believe that my military experience was part of that judge's
consideration in diverting me to treatment rather than sending me to
jail. In the few instances where veterans courts exist, they have
become effective tools to get veterans who are struggling with mental
illnesses the help that they need. NAMI urges the Committee to support
the development of diversionary courts for veterans, and especially
combat veterans, and to make sure that VA reaches out and coordinates
with the existing courts systems in cities and States to ensure post-
deployment veterans receive the most timely and effective care
possible, rather than allowing sick and disabled veterans suffering
with mental illnesses consequent to their war service to be convicted
and sent to jail or prison.
Mr. Chairman, the National Alliance on Mental Illness is committed
to supporting VA efforts to improve and expand mental health care
programs and services for veterans living with serious mental illness.
Until recently, forward motion had been stalled on VA's ``National
Mental Health Strategic Plan,'' to reform its mental health programs--a
plan that NAMI helped develop and fully endorses. NAMI wants to see VA
stay on track to provide improved access to mental health services to
veterans returning from Iraq and Afghanistan today, as well as to other
veterans diagnosed with serious mental illness--all important
initiatives within the VA strategic plan. In 2008 VA announced its
establishment of a ``Uniform Mental Health Service'' benefits package,
one that NAMI supports as beneficial to ensuring VA progress toward
full implementation, and will provide help to the newest war veteran
generation and all veterans who live with mental illness.
Finally, NAMI is an endorser organization of the Independent Budget
for Fiscal Year 2011. In that budget and policy statement, AMVETS,
Disabled American Veterans, Paralyzed Veterans of America and Veterans
of Foreign Wars of the United States recommend a series of good ideas
that, if implemented would further improve VA's mental health programs.
I ask the Committee to closely consider these recommendations and to
ensure, either with oversight or legislation that VA (and the
Department of Defense in some instances) carries out the intent and
spirit of these recommendations. For the benefit of the Committee, I am
attaching these Independent Budget recommendations to this testimony.
This concludes my testimony on behalf of NAMI, and I thank you for
the opportunity.
Attachment
______
Attachment to Testimony of Clarence Jordan
Recommendations in VA Mental Health
Fiscal Year 2011 Independent Budget
VA should provide frequent periodic reports that include facility-
level accounting of the use of mental health enhancement funds, and an
accounting of overall mental health staffing, the filling of vacancies
in core positions, and total mental health expenditures, to
Congressional staff, veterans service organizations, and to the VA
Advisory Committee on the Care of Veterans with Serious Mental Illness
and its Consumer Liaison Council.
Consistent with strong Congressional oversight, the Under Secretary
for Health should appoint a mental health management work group to
study the funding of VA mental health programs and make appropriate
recommendations to the Under Secretary to ensure that VHA's allocation
system sustains adequate funding for the full continuum of services
mandated by the Mental Health Enhancement Initiative and UMHS handbook
and remains in full commitment to recovery as the driving force of VA
mental health programs.
VA must increase access to veteran and family-centered mental
health-care programs, including family therapy and marriage counseling.
These programs should be available at all VA health-care facilities and
in sufficient numbers to meet the need.
Veterans and family consumer councils should become routine
standing committees at all VA medical centers. These councils should
include the active participation of VA providers, veteran health-care
consumers, their families, and their representatives.
VA and the DOD must ensure that veterans and servicemembers receive
adequate screening for their mental health needs. When problems are
identified through screening, providers should use nonstigmatizing
approaches to enroll them in early treatment in order to mitigate the
development of chronic illness and disability.
VA and the DOD should track and publicly report performance
measures relevant to their mental health and substance-use disorder
programs. VA should focus intensive efforts to improve and increase
early intervention and the prevention of substance-use disorder in the
veteran population.
VA should invest in research on effective stigma reduction,
readjustment, prevention, and treatment of acute Post Traumatic Stress
Disorder (PTSD) in combat veterans, increase its funding for evidence-
based PTSD treatment programs, and conduct translational research on
how best to disseminate this state-of-the-art care across the system.
VA should conduct an assessment of the current availability of
evidence-based care, including for PTSD, identify shortfalls by the
site of care, and allocate the resources necessary to provide universal
access to evidence-based care. VA should conduct a rigorous study of
the intensity of mental health care to determine if it has been reduced
for older generations of veterans in order to generate the capacity to
absorb newer arrivals (primarily veterans of Operations Enduring and
Iraqi Freedom) with more acute needs. If the study finds results in the
affirmative, VA should begin to address that trend.
A task force--composed of experts from the Veterans Benefits
Administration, Veterans Health Administration mental health staff,
veterans service organizations, and disabled veterans--should be
assembled to explore potential barriers and disincentives to recovery
from mental health disabilities that may be created or influenced by
VA's disability compensation system.
VA should immediately correct case management program deficiencies
and begin to treat psychological injury and mental illness in veterans
with the same intensity that it treats serious physical injuries. VA
and the DOD should move rapidly to develop health policy and research
inquiries that are responsive to the recommendations published in the
2007 IOM report, Gulf War and Health: Physiologic, Psychologic, and
Psychosocial Effects of Deployment-Related Stress.
VA needs to improve its succession planning in mental health to
address the professional field shortages, recruitment, and retention
challenges noted in this Independent Budget. VA should ensure that
qualified women mental health counselors with expertise in military
sexual trauma are available in all Vet Centers and that all
professional staff are provided training on the current roles of women
returning from combat theaters and their unique post-deployment mental
health challenges.
The VA Advisory Committee on the Care of Veterans with Serious
Mental Illness should be replaced by a secretarial-level committee on
mental health, armed with significant resources and independent
reporting responsibility to Congress.
Congress should ensure that the new mandatory, face-to-face mental
health screening process for post-deployed combat servicemembers
(including National Guard and Reserves) required by the National
Defense Authorization Act of 2010 is conducted by personnel who are
effectively trained to identify these hidden service-incurred wounds,
and to treat them when found. This responsibility should be jointly
embraced by both DOD and VA mental health-care programs in a shared
effort under the authority of Public Law 97-174, ``VA/DOD Health
Resources Sharing and Emergency Operations Act.''
______
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
Clarence Jordan, Member, National Board of Directors, National Alliance
on Mental Illness
Question 1. What are the members of NAMI's Veterans' Council
finding are the most serious roadblocks to veterans or family members
receiving the necessary care and services, and do you have any
recommendations to remove those roadblocks?
Response. Of primary concern is stigma, which continues to exert a
tremendous amount of force on those in need of care. Ignorance and
confusion over signs and symptoms are baffling resulting in prolonged
periods of rationalization and denial. The resulting effect is
individuals who present late in the disease state at which time any
number of co-morbid conditions become apparent. Another critical
roadblock for many is accessibility and an attending social and
cultural norm that results in the prospective recipient of care
isolating and resulting in self destructive behaviors.
There is any number of roadblocks and depending upon the resilient
nature of the veteran and/or family member, presenting lesser or
greater degree of difficulty in overcoming them to include:
Dual diagnosis of mental health and primary care have been
co-located but not with substance abuse.
Women's issues are still huge, with concerns over
inconsistencies in care and apparent confusion over a no-fault process
for obtaining gender preference therapists for military sexual trauma
treatment. In previous generations we did not talk about military
sexual trauma, and some women veterans going back as far as Vietnam and
Korea are just beginning to tell their stories. There are no verifying
records because there were no mechanisms to deal with the issue at that
time.
Treatment for PTSD claims for veterans who have either had
no symptoms for years and are experiencing symptoms re-emerging or that
were never addressed.
Cultural competency on the part of health care providers
is extremely problematic; veterans have expressed numerous concerns
over the lack of a shared set of values and beliefs with their VA
caregivers.
Outreach to families including children (of deployed,
returning troops) is still a great concern, despite recent reported
improvement in the numbers over the past several months.
Lack of a person-centered family first approach to care.
In VA there is this ``assembly line'' approach; get them in, and get
them out. Individual needs preference, hopes and aspirations are seldom
heard resulting in a feeling of not being heard. There is not a sense
of hope or expectation of recovery at the service level.
On the plus side of the equation the VA Secretary has listed both
substance abuse and homelessness as high priorities. As mentioned
previously there is more family involvement than a year ago, but not
enough. I do not think that the VA will go full bore on children's
services, but a family therapy approach that includes the children both
as a support system to a returning parent and for their own stability
is needed. Maybe this could be a contract issue with children's or
family services in the community.
Secretary Shinseki in my opinion is really doing a good job. His
T--21 Initiatives that include strategies to improve community
partnerships, outreach and education and addition to supportive
services, are strategies for the 21st century. His style as well as his
content are highly respected but he alone cannot do it all. A
collaborative approach with private and public service centers and
support facilities could go a long way to dealing with many of the
issues raised above. Employing the principles espoused in the SAMHSA
Consensus Statement on recovery combined with the Secretary's T-21
Initiative would help immensely. Borrowing from lessons learned in the
public sector VA should use more web-based resources to provide 24-hour
a day, seven days a week access to user information and connection to
others through social networking. Also VA should use trained consumer
experts in recovery to help shape and guide recovery services employed
at higher levels within the VA system for greater continuity and
oversight of recovery efforts and programs. Finally, the VA needs to
find an innovative solution to engage over time with this latest cohort
of returning veterans and family members that circumvents existing
stigma and is designed to assist those less likely to ask for
assistance in current traditional outreach ways. Mr. Chairman, a life
filled with hope, pride of service and support of a grateful nation and
community should be the end game for our returning warriors.
Question 2. During your 12-month inpatient treatment, what do you
believe was the most effective component of the program that motivated
you to become more proactive in your own treatment and adhere to your
program?
Response. In a word, CONTACT; the development of an interpersonal
relationship with a person who self disclosed they had a mental illness
just like me. Gentlemen, we should never underestimate the power that
stigma holds sway over the sufferer. In my case I was affected in three
ways: self stigma, label avoidance and public stigma. My sense of self
worth and self efficacy was all but eliminated. To avoid being labeled
as someone with a mental illness I would rather had been labeled as an
addict, alcoholic and yes, even as homeless, with all its connotations.
For decades I wore a mask, too afraid of what I might really see if
ever I took a good look in a mirror. Estranged from family and friends
and everything that ever meant anything to me, I existed in a world of
aberrant behavior whereas to hide my own bizarre behaviors. I paid
tithes to the church of shame and despair, attending every sermon
hoping and praying that one day I would be delivered from this hellish
no-man's land of the self-exiled. This once proud Naval Officer
willingly embraced all the negative stereotypes of what it meant to
live on the fringes of society.
Even after the diagnosis, or shall I say diagnoses, I believed that
one day I would just be over it like a common cold.
Like my descent, my rise from the depths of my despair took a slow,
often fatuous journey of having to re-learn the simplest of executive
functioning skills. I found the road of treatment to be fraught with
disempowering practices and low expectations.
Peer support for me was more than mentorship through a twelve-step
process; it was about vicariously learning how to deal with decisions
involving emotions and a fragile belief system. The weeks and months of
treatment that preceded the acquisition of peer services could only do
so much; I had learned that medication could have positive effects, I
had learned the importance of journaling as a means of mood check; I
had arrived at a state of enactive attainment. I was at a point
persuasion, still being seduced by my illness, and my peer specialist
provided the physical arousal needed to move beyond the symbiotic
nature of our relationship and posed for a renewed self-efficacy. It
was at this point that I appreciated all the more the values and
beliefs I had learned in the Navy.
______
Response to Post-Hearing Questions Submitted by Hon. John D.
Rockefeller IV to Clarence Jordan, Member, National Board of Directors,
National Alliance on Mental Illness
Thank you for your testimony and the commitment of NAMI to the
Family to Family program for education and support. I hope you will
continue to work on this until every VAMC has a group.
Question. Can you also share your thoughts on a mandatory training
course or mental health program for all veterans as a way to eliminate
the stigma? Do you think this would be helpful? How should such a
course be structured?
Response. Programs like the Illinois Warrior Assistance Program and
the Real Warriors Campaign are very valuable. The developer and staff
of these great efforts deserve to be commended; their scope is very
comprehensive, offering a full array of social networking, information
and referrals. They are packaged in very patriotic and eye popping web
designs, and unique and return visitor numbers are very impressive.
They, like our own NAMI web resources and so many other tremendous
resources, depend on a ``pull'' methodology; they are built to bring
those in who are seeking help and are willing to receive the much
needed support.
The real or more pressing question at hand is what programs exist
for the more than two thirds of those eligible who are in need but do
not seek help. And unless I miss my guess, there may be significant
underserved segments of our Veterans population that have not yet come
to rely upon the internet for their information.
The warrior ethos, good order and discipline along with a sense of
esprit-de corps goes to the heart of our military culture and structure
on which Army, Navy, Air Force, Marine Corps and Coast Guard depend.
Military culture is sometimes maligned as too rigid and involving too
much discipline that nevertheless colors the environment in which the
sailor, soldier, airman and marine must step forward and admit to an
illness that for some invokes feelings of weakness and perhaps laziness
or just being a plain slacker. Promoting and rewarding (at a minimum,
not penalizing) help-seeking behavior is at odds with the public stigma
both within military and civilian (for Guard and Reservists) worlds
these service personnel compete and live in, and that is the dilemma.
Some programs use a reverse logic approach depicting help-seeking
behavior as consistent with a sense of operational readiness; some use
an avoidance approach whereby mental illness and/or its many symptoms
are simply looked upon as a natural consequence of military life.
Research certainly suggests that education in and of itself, whether
conducted at the unit or brigade level, whether single or multiple
presenters, produces limited effects with most participants returning
to their base line within a week. Public stigma and negative
stereotypes return leaving those who responded to the affirmative
without much support and worse yet, they may encounter outright
discrimination.
An approach that is designed to resemble more of a push or
``mandatory approach,'' could speak to that. By its very nature a push
approach wherein everyone participates could go a long way in avoiding
personal stigma associated with help-seeking behaviors. Such an
approach would also have a higher probability of neutralizing public
stigma.
A combination push/pull approach could increase significantly the
number of veterans receiving care provided there is some incentive for
individuals to participate fully and with anonymity. The use of
technology that is not only personal but also employed to reach the
masses with simultaneous messaging could be used to produce the desired
push for participation. Innovative use of screening and incentives
could enhance more timely and effective interactive between military
servicemember and helpers. ValueOptions has designed an innovative
solution that, in my opinion, addresses these cultural challenges
inherent in asking for help and garnering access to care to existing
programs.
One other barrier exists that is directly associated with the
stigma of label avoidance. Personnel policies and procedures exist
which serve as a barrier to military servicemember participation in
operational readiness programs, and must be silent on matters of
servicemember's successful treatment. Stigma will be more difficult to
battle as long as policies remain that penalize or limit future options
or opportunities as a consequence of seeking behavioral health
assistance. While there has been progress in this area, there is much
work to be done before eliminating rational reasons for not seeking
care. Additionally, the Uniform Code of Military Justice (UCMJ) can, by
individual commanders, be misused to exorcise personnel deemed to be
``odd balls'' or different following deployments and exposure to war.
Such practices must be closely monitored.
Chairman Akaka. Thank you very much, Mr. Jordan.
My first question is to Mr. Hanson, and I want to thank you
for sharing your story with us. We heard from Dr. Rudd that a
large number of veterans will contend with mental health
difficulties over the long term and may require treatment for
years. Your experience seems to support that. Do you believe
the VA program you completed was helpful as a stepping stone to
your final recovery, or do we need to significantly revise the
VA program?
Mr. Hanson. Well, Mr. Chairman, I believe that the program
I did was beneficial and that I was able to see what the drugs
and alcohol were doing, that I did have a problem; but as far
as treating my issues, I believe that it was little to no
benefit for me. I mean, I drank the day after I got out of the
program and I pretty much wasn't changed. It was something that
I had to do because I knew I eventually had a court case coming
up and I thought that treatment might look good, because it was
a licensed program, to be honest with you, Mr. Chairman. As far
as changing me the way I needed change, it did absolutely
nothing, to be honest with you. Having no disrespect to the
Department of Veterans Affairs, but I felt like it wasn't
beneficial at all.
Chairman Akaka. Mr. Jordan, I believe that involving family
members in care is critical to a successful outcome and to
getting a veteran seen in the first place. What lessons should
VA take from NAMI's Family-to-Family program that would make
mental health care more successful?
Mr. Jordan. Thank you, Mr. Chairman. Several things. One,
that recovery is possible.
Number 2, that recovery is a process; it is not linear.
That setbacks, such as those described by Mr. Hanson, do occur,
and that love and support more than anything else is the key to
supporting that member's recovery.
Chairman Akaka. For all of our witnesses, significant
resources have been allocated through VA over the last couple
years for the purpose of improving mental health care. If you
were to rate VA's progress over the past 8 years on a scale of
one to ten, what score would you give VA's mental health
services? Mr. Hanson?
Mr. Hanson. I only have been really working with the VA for
the last 3 years, Mr. Chairman. I would have to give it around
a six, just because I feel, kind of like Mr. Jordan said, there
is not a feeling of a lot of care or love and I think that is
what I need. I understand that it is a professional
environment, but there are a lot of times I felt like I was
just another number and it left me feeling, you know, put off
by it, really, to be honest, Mr. Chairman. So I would say a
six. Thank you.
Chairman Akaka. Thank you very much.
Mr. Jordan?
Mr. Jordan. I would agree, a five or a six. I mentioned the
273-TALK. I think that is an excellent program. I think that
there is a lot of research regarding peer-to-peer-type
services, mutual support groups, that have not benefited the
vast majority of individuals in care. There seems to be an
absence of outreach and education that I think is very vital to
a member obtaining full recovery.
Chairman Akaka. Thank you.
Dr. Rudd?
Mr. Rudd. Well, I probably would rate it a little higher. I
would say a seven or an eight. I think that they have been
innovative, that they have tried some new things. There is
evidence that some of these new things are working. Certainly,
the hotline and Internet chat line are unique and there is
evidence of success there. They are having much greater success
in terms of reduction of suicide risk for those in active
treatment.
I think at the heart of the problem, though, that they face
and that many other clinicians face is the difficulty of
getting a certain portion of the high-risk population actually
in for care, and that is where you have to think outside of the
mental health scope, that perhaps there are other kinds of
partnerships within primary care and other alternatives that we
can look at to get that portion of the population to agree to
come in for treatment.
Chairman Akaka. Thank you. Thank you very much.
Let me call on our Ranking Member for his questions.
Senator Burr. Thank you, Mr. Chairman.
Dean Rudd, I am sorry I overlooked your military service.
Thank you for that.
Dean, let me ask you, you expressed the importance for the
VA to think outside the box to treat mental illness by
experimenting with non-traditional approaches. The Department
of Defense funds the Complementary and Alternative Medicine
Research for Military Operations and Health Care Program, which
does research non-traditional treatments, such as manipulation,
bio-electromagnetic devices, and acupuncture. Are these
examples of non-traditional approaches that you would recommend
the VA take a look at or use?
Mr. Rudd. Not necessarily. I think that when I talk about
non-traditional, I am thinking more about how we reach out to
veterans, and rather than identifying the presence or absence
of a mental illness, telling someone that they have a mental
illness is not necessarily a compelling reason for them to get
care when they have been raised in a culture in which that
mental illness is seen as a weakness. It is almost an
affirmation of their failure----
Senator Burr. Let me ask you----
Mr. Rudd [continuing]. To say, you have PTSD. You need
treatment.
Senator Burr. Let me ask you from the standpoint of your
professional experience, how important is it when we identify a
servicemember who has been discharged and we think there is a
likelihood of a mental health challenge there, that we
immediately get them in treatment and keep them in treatment
versus to wait a year for something to manifest itself to a
different point?
Mr. Rudd. I think, actually, Mr. Hanson's story kind of
tells the tale. I think we need to get them in treatment,
recognize and understand what the barriers are to keeping them
in treatment, and then facilitate ongoing care; because once
they step out of treatment, the problem becomes far more
complex. And as he demonstrated, it goes from a difficulty of
perhaps a post-traumatic stress problem to depression to
substance abuse, a lot of comorbidity, a lot of clinical
complexity, where it is very difficult to keep people in care
at that point.
I, frankly, think we need to do far more on the very front
end when we bring people into basic training and start to talk
to them about resilience and about how they can perform at
their best and recognize when they are having difficulty to
relabel, reframe that to a large degree to make it acceptable
and understandable.
I can tell you the most compelling thing I have ever seen,
I was on a panel on Veterans Day and there was a one-star
general, a Brigadier General. He spoke at that panel about his
difficulty with PTSD after his experience in Iraq. After that
panel, there was a cohort of young soldiers that came up to him
to talk about that experience because he essentially said it is
acceptable, it is OK, it is understandable that you are going
to have these difficulties.
I think we just--we need to think differently and not
necessarily in terms of the clinical end, because we know what
works clinically, but how do we convince people, how do we talk
to people about the problem.
Senator Burr. Mr. Hanson, as you know, the primary
screening tool for returning combat servicemembers is the
completion of a Post-Deployment Health Assessment, and then we
do a Post-Deployment Reassessment several months after the
separation. What is your view on the adequacy of those
screening procedures?
Mr. Hanson. Senator, kind of like what Dr. Rudd said, it
was something where it is considered a weakness. Essentially, I
recall ours was in a large setting. They said, if you have any
problems, raise your hand or something like that. And, I mean,
you know, no one is going to raise their hand. For me, it was a
weakness kind of deal, especially for me. My primary MOS was in
infantry, so I felt like, these guys aren't raising their hand.
I have got absolutely no right to raise my hand, whether I saw
something or not. So for me, it is just if it can be maybe on a
more one-on-one basis where it is more personal, it would
probably be a lot more effective, I would think.
Senator Burr. Had yours been one-on-one, would you have
raised your hand?
Mr. Hanson. I definitely would have opened up, Senator,
that is for sure. A little bit more, anyway. But it is hard to
say, because I definitely thought I was a big, bad Marine, so I
didn't really want to talk about anything.
Senator Burr. And had you opened up and had the VA set out
a treatment regime for you, would you have gone?
Mr. Hanson. I highly doubt it.
Senator Burr. So what would it take for you to have
participated? I am asking more about the challenges you had in
life that were competing with, should I take the time to go to
this treatment.
Mr. Hanson. I think for me, if they would have made it
clear that, essentially, I have to. I mean, if I said that I
had an issue and it had to be addressed, then maybe it would be
something with my veterans' benefits, with a disability check.
You are not going to get any--you have to go to this or there
is going to be stuff held back, essentially. You have an issue.
You need readjusting. You are not man enough to do it.
Senator Burr. Daniel, at what point after you got back did
the alcohol and drugs begin to play a role?
Mr. Hanson. As soon as I went on leave, pretty much,
Senator. Right away. I mean, the drinking was progressive,
where I was on leave and I was drinking, and then slowly it got
to where when I was happy I was drinking. Then when I was sad I
was drinking. When I was bored I was drinking. So essentially
it was to drink to celebrate and it was to drink when I was
depressed and it just kind of slowly evolved into an everyday
thing where I was abusing and I was neglecting my family and
friends.
Senator Burr. And the length of that time between your
disengagement with the military and finding the program in
Minnesota was what length of time?
Mr. Hanson. It was about 2 years.
Senator Burr. About 2 years? During that 2-year period, did
you visit a VA facility?
Mr. Hanson. Yes, sir, I did. I was doing outpatient therapy
for some time. Also, I did the Dual Diagnosis Program.
Senator Burr. So did you share with them your level of
alcohol consumption and drug consumption?
Mr. Hanson. Yes, I did.
Senator Burr. And what was their course of treatment
relative to that?
Mr. Hanson. I mean, they knew that I--they told me that I
had a problem, that I shouldn't be drinking, that I was
depressed, and I was put on medication, and a follow-up where
it was once-a-week therapy. Once I completed that program, I
was told to take the anti-depressant, come in once a week, and
keep your head up.
Senator Burr. From the start of your association with VA or
at any point while you exercised services from the VA, did you
understand the full scope of benefits that were offered?
Mr. Hanson. For me, I did. When I--a couple months after I
got out of the Marine Corps, I worked for the Veterans'
Benefits Administration, so I was familiar with what was
offered. So, I knew on the grand scale of things what was
offered, that is, as far as the benefits go. But as far as the
VA hospital, there were a lot of things I wasn't aware of as
part of----
Senator Burr. Well, my next question was, did you
understand the full array of services, as well.
Mr. Hanson. No, sir.
Senator Burr. At any point, did you look at the VA doctor
that was treating you and say, what else can we do? Or were you
just feeling OK that you had gone occasionally?
Mr. Hanson. I mean, I work with a lot of really good
doctors over there and they--I mean, there was definitely
benefit there, but yes, Senator, I--we had a lot of
conversations where I just said, I don't know what to do
anymore, you know. Well, maybe you should do this other
program. Well, do you feel like killing yourself? Yes, I kind
of do. Well, do you have a plan to do it? No, not right now, I
don't have a plan to do it. Well, you know, here is a card if
you need it. You call this number if you are going to do that.
OK, you know. And I said, I just can't get this thing right,
and they made a lot of good suggestions. You can do this
program and this program. But at 4, it was leaving time and,
you know, you want to look at somebody in the eye when they are
going to their vehicle kind of deal. So it was--I had some
great conversations, but in the long run, it was kind of--I
know they have got a lot of people, and I understand, but I
just kind of felt like----
Senator Burr. You needed the boot in the butt to get you in
it?
Mr. Hanson. Yes, sir. I did need the boot in the butt.
Senator Burr. Good. Good. Thank you.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Burr, for your
questions.
I want to thank the panel for your testimony and also your
responses to our questions. This is an issue and an area where
we want to spend time in trying to help as much as we can, and
you have been helpful this morning and you will be very helpful
in what we are planning to do. So I want to thank you very much
for coming and participating in this hearing. Thank you.
Let me now introduce the second panel. I would like to
welcome the witnesses of our second panel, Dr. Gerald Cross,
Acting Principal Deputy Under Secretary for Health. Dr. Cross,
welcome back to the Committee. He is accompanied by Dr. Janet
Kemp, VA National Suicide Prevention Coordinator; Dr. Caitlin
Thompson, Clinical Care Coordinator; Dr. Antonette Zeiss,
Associate Deputy Chief Consultant and Chief Psychologist of the
Office of Mental Health Services; Dr. Theresa Gleason, Deputy
Chief of Mental Health Services at the Office of Research and
Development; and Dr. Alfonso Batres, Director for Readjustment
Counseling for Vet Centers.
I want to thank you for being here. Your full testimony
will appear in the record. Dr. Cross, will you please begin. I
understand that Dr. Thompson will be making some remarks, as
well. Thank you.
STATEMENT OF GERALD CROSS, M.D., ACTING PRINCIPAL DEPUTY UNDER
SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JANET KEMP,
R.N., Ph.D., VA NATIONAL SUICIDE PREVENTION COORDINATOR;
CAITLIN THOMPSON, Ph.D., CLINICAL CARE COORDINATOR; ANTONETTE
ZEISS, Ph.D., ASSOCIATE DEPUTY CHIEF CONSULTANT AND CHIEF
PSYCHOLOGIST, OFFICE OF MENTAL HEALTH SERVICES; THERESA
GLEASON, Ph.D., DEPUTY CHIEF, MENTAL HEALTH SERVICES, OFFICE OF
RESEARCH AND DEVELOPMENT; AND ALFONSO BATRES, Ph.D., MSSW,
DIRECTOR FOR READJUSTMENT COUNSELING FOR VET CENTERS
Dr. Cross. Chairman Akaka, Ranking Member Burr, and
distinguished Members of the Committee, thank you for the
opportunity to appear here today to discuss VA's response to
the mental health care needs of America's veterans.
I want to digress for a moment and say thank you to the
previous panel. I listened closely and I found the stories
compelling. That means a great deal to us. Particularly, I was
compelled by the alternative court mechanism, an innovative
approach that we are very interested in, as well, and we can
talk more about that perhaps later.
Thank you for the introductions of my team. I want to
mention that Dr. Thompson, sitting next to me, is one of the
counselors at our Suicide Prevention Hotline. She is on the
front lines every day, and her work as well as that of Dr. Kemp
and the other counselors on the hotline have saved countless
lives of veterans and we deeply appreciate her time and thank
her for her service to America's veterans.
My written testimony provides greater detail about our
mental health programs and policies. Right now, I want to make
three points.
First, VA's clinical programs are improving the lives and
well-being of veterans with mental health conditions. I can
point to several objective outcome measurements that support
this claim. To begin with, the number of homeless veterans
continues to decline. These data are gathered annually and show
that those veterans most in need are receiving the care and
services necessary to reestablish their lives.
Another outcome measure is that veterans with serious
mental illness who use VA services do not have the more
challenging gap that is present elsewhere. In this and in other
countries, individuals with serious mental illness have an
average life expectancy of approximately 20 years less than
those without mental illness. However, in VA, that has
virtually disappeared. It is less than 2 years' difference.
That is an 18-year benefit, approximately, to the veterans
being treated for serious mental illness in VA.
Yet another outcome measure is the soldier rate among
veterans receiving VA care. It continues to drop. And as you
can see on the chart, there has been a decline since 2001
resulting in about 250 fewer suicides per year. This decrease
was especially observed in our youngest veterans, those age 18
to 24.
Data obtained from the CDC confirms that young veterans
receiving VA care are significantly less likely to commit
suicide than those not receiving VA care. And based on these
findings, we know that our programs are working and we will
continue to improve them because we believe that we have much
more that needs to be done. Any suicide of a veteran is an
absolute tragedy, in my belief.
To continue achieving these results, we need to bring more
veterans into our facilities to deliver the care they need. We
have a variety of outreach initiatives because we understand
not all veterans are the same and there is no such thing as too
much communication when it comes to letting veterans know that
we are there for them.
So my first main point was better mental health outcomes at
the VA. My second main point is that VA is committed to a
robust research program that identifies the causes and
effective treatments for mental health conditions. Our current
budget for this research portfolio is about $100 million, and
we are using these resources to determine biologic and genetic
factors that may increase a person's risk for developing mental
health problems.
We are also researching the best treatment protocols and we
are using these results to improve care. For example, VA
research has determined that it is imperative we closely
monitor patients immediately following their inpatient stay,
and so more and more we are requiring closer follow-up, weekly
follow-ups, more periodic follow-ups, as necessary, after
inpatient care is completed.
The National Academy of Sciences Institute of Medicine
found that VA-sponsored research provided sufficient evidence
for prolonged exposure and cognitive processing therapy as key
treatments for PTSD, and we have actively implemented those
findings, those research findings, to guide our care for
veterans with PTSD.
My third point is that our suicide prevention efforts are
having a real impact and saving lives every day. It is no
exaggeration, sir, to say that our Suicide Prevention Hotline
is one of the most successful programs we have ever
implemented. In 2009 alone, we intervened to save more than
3,300 veterans from suicide. Our hotline operators, like Dr.
Caitlin Thompson right next to me, and suicide prevention
coordinators have compelling stories to share with you about
those encounters with veterans and how they bring them back
from the very edge.
Mr. Chairman and Ranking Member, this is work we can all be
proud of and we thank you for your support of these initiatives
and helping to make them possible.
In conclusion, VA has aggressively increased the resources
available to address the mental health needs of our veterans.
We are working closely with our partners at DOD to improve the
quality of care for veterans and for servicemembers alike.
Since October, we have held two major conferences related to
mental health care needs of veterans and servicemembers with
DOD.
We were also able to provide direct support to our
colleagues at DOD within hours of the shootings at Fort Hood.
We deployed staff, including four Mobile Vet Centers, to the
Fort Hood community. They provided readjustment counseling
services to more than 6,600 veterans, active duty
servicemembers, and families.
This concludes, sir, my prepared statement. Thank you again
for the opportunity to appear, and sir, my colleagues and I are
prepared to answer any questions.
[The prepared statement of Dr. Cross follows:]
Prepared Statement of Gerald M. Cross, MD, FAAFP, Acting Principal
Deputy Under Secretary For Health Veterans Health Administration, U.S.
Department of Veterans Affairs
Mr. Chairman, Mr. Ranking Member, and Members of the Committee:
Thank you for the opportunity to appear today to discuss the Department
of Veterans Affairs' (VA) response to the mental health needs of
America's Veterans. I am accompanied today by my colleagues, Dr.
Antonette Zeiss, Deputy Chief Consultant and Chief Psychologist, Office
of Mental Health Services, Office of Patient Care Services, Veterans
Health Administration (VHA); Dr. Theresa Gleason, Mental Health
Research Portfolio Manager, Office of Research and Development, VHA;
Dr. Alfonso Batres, Chief Readjustment Counseling Officer; and Dr.
Janet Kemp, VA National Suicide Prevention Coordinator.
VA has responded aggressively to address previously identified gaps
in mental health care by expanding our mental health budgets
significantly. In fiscal year (FY) 2010, VA's budget for mental health
services reached $4.8 billion, while the amount included in the
President's budget for FY 2011 is $5.2 billion. Both of these figures
represent dramatic increases from the $2.0 billion obligated in FY
2001. VA also has increased the number of mental health staff in its
system by more than 5,000 over the last 3 years. During the past 2
years, VA trained over 2,500 staff members to provide psychotherapies
with the strongest evidence for successful outcomes for Post Traumatic
Stress Disorder (PTSD), depression, and other conditions. Furthermore,
we require that all facilities make these therapies available to any
eligible Veteran who may benefit. In FY 2010 and FY 2011, we will
continue to expand inpatient, residential, and outpatient mental health
programs with an emphasis on integrating mental health services with
primary and specialty care.
VA is working closely with our colleagues at the Department of
Defense (DOD) to improve the quality of care for Veterans and
servicemembers alike. Since October 2009, VA and DOD have held two
major conferences related to the mental health needs of Veterans and
servicemembers.
My testimony today will make three points: first, it will describe
VA's approach to treating mental health conditions. It is our belief
that treatment options should be widely available and uniquely tailored
to the individual needs of each Veteran. Second, it will detail VA's
policy and guidance to the field, as specifically identified in the
Uniform Mental Health Services in VA medical centers and Clinics
Handbook. This Handbook is being implemented across the VA health care
system to expand access to necessary mental health services for
Veterans. Finally, my testimony will conclude by providing evidence VA
has gathered that our programs are successful and based upon the best
available scientific basis; it will also detail the research VA
conducts in this area. In sum, our programs are saving lives and
improving the quality of life for Veterans with mental illness.
va's approach to mental health care
With its emphasis on providing care management for depression and
making evidence-based psychotherapy available for all Veterans who need
it, VA is ensuring that planning for treatment of mental health
conditions includes attention to the benefits as well as the risks of
the full range of effective interventions. Making these treatments
available responds to the principle that when there is evidence for the
effectiveness of a number of different treatment strategies that can be
effective, the choice of treatment should be based on the Veteran's
values and preferences, as well as the clinical judgment of the
provider.
VA has been making significant enhancements to its mental health
services since 2005, through the VA Comprehensive Mental Health
Strategic Plan and special purpose funds available through the Mental
Health Enhancement Initiative. VA's enhanced mental health activities
include outreach to help those in need to access services, a
comprehensive program of treatment and rehabilitation for those with
mental health conditions, and programs established specifically to care
for those at high risk of suicide. To reduce the stigma of seeking care
and to improve access, VA has integrated mental health into primary
care settings to provide much of the care that is needed for those with
the most common mental health conditions. In parallel with the
implementation of these programs, VA has been modifying its specialty
mental health care services to emphasize psychosocial as well as
pharmacological treatments and to focus on principles of rehabilitation
and recovery.
The focus on recovery for those with serious mental illnesses
reflects major scientific advances in treatment and rehabilitation.
Although it is still not possible to offer definitive cures for all
patients with serious mental illness, it is realistic to offer the
expectation of recovery. Veterans, often with their families, should
collaborate with their providers in planning treatments, where the
goals are to help the Veteran live the kind of life he or she chooses,
in spite of any residual signs or symptoms of mental illness. To
achieve this vision, VA has hired staff to provide peer support,
trained clinicians in evidence-based strategies for treatment and
rehabilitation, enhanced the care in residential treatment settings,
and strengthened programs that involve families.
In addition to the care offered in medical facilities and clinics,
VA's Vet Centers provide outreach and readjustment counseling services
to returning war Veterans of all eras. By the end of the current fiscal
year, we anticipate having 299 Vet Centers in operation. 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 war
Veterans. The Vet Center service mission goes beyond medical care in
providing a holistic mix of services designed to treat the Veteran as a
whole person in his or her community setting. Vet Centers provide an
alternative to traditional mental health care that helps many combat
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 counseling.
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.
To promote suicide prevention, VA established a strong partnership
with the Department of Health and Human Services Substance Abuse and
Mental Health Services Administration (SAMHSA) to operate a Veterans
Call Center as part of the National Suicide Prevention Lifeline (1-800-
273-TALK). VA also has appointed suicide prevention coordinators and
care managers at each VAMC and the largest community-based outpatient
clinics. Altogether, VA employs over 400 staff members who focus
specifically on suicide prevention. My colleague, Dr. Janet Kemp,
discusses these programs in greater detail in her testimony.
va policy and requirements
In 2009, VA approved the Handbook on Uniform Mental Health Services
in VA medical centers and Clinics to define what mental health services
should be available to all enrolled Veterans who need them, no matter
where they receive care, and to sustain the enhancements made in recent
years. One important set of requirements in the Handbook was to ensure
that evidence-based psychotherapies are available for Veterans who
could benefit from them and that meaningful choices between effective
alternative treatments are available.
Also, based on its Comprehensive Mental Health Strategic Plan, VA
has enhanced access to mental health services by requiring that mental
health services must be integrated into primary care services. To
ensure Veterans are monitored appropriately while they are receiving
mental health services, including treatment with psychotherapeutic
medications, VA requires that these integrated care programs include
evidence-based care management.
Care management for depression includes repeated contacts with
patients to educate them about depression, medications, and other
treatment, as well as to provide evaluations of both therapeutic
outcomes and adverse effects. The benefits of the frequent contact
program relate to increased patient-engagement in care. Also,
information from patient monitoring is translated into decision-support
for providers about when they should modify treatment. Two programs
that are used frequently in VA primary care settings are Translating
Initiatives in Depression into Effective Solutions (TIDES) and the
Behavioral Health Laboratory (BHL), both of which are evidence-based
interventions supported by extensive research. Studies on care
management for depression in primary care settings have demonstrated
that these interventions can decrease both depression and suicidal
ideation in older adults. This led to recognition of care management
for late life depression as a best practice for suicide prevention.
For several years, VA has provided training to clinical mental
health staff to ensure that there are therapists in each facility who
are able to provide evidence-based psychotherapies for the treatment of
depression and PTSD as alternatives to pharmacological treatment or as
a course of combined treatment. The initiative to make these
psychotherapies broadly available within VA is relevant to concerns
about medication safety, but the program was not developed as a result
of those concerns. VA implemented the broad use of evidence-based
psychotherapies in response to evidence that for many patients,
specific forms of psychotherapy are the most effective and evidence-
based of all treatments. Specifically, the Institute of Medicine report
on treatment for PTSD emphasized findings that exposure-based
psychotherapies, including Prolonged Exposure Therapy and Cognitive
Processing Therapy, were the best-established of all treatments for
PTSD. Other specific psychotherapies included in VA's programs include
Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for
depression and Skills Training and Family Psycho-Education for
schizophrenia. VA is adding other treatments such as Problem Solving
for Depression, Cognitive Behavioral Therapy and Contingency Management
for Substance Use Disorder, and behavioral strategies for managing both
pain and insomnia.
va's accomplishments
As stewards of the public interest and bearing the responsibility
for caring for America's Veterans, VA conducts ongoing analyses of its
programs and continually asks itself how they can be improved. VA's
mental health enhancements were designed to implement evidence-based
practices. Evidence led VA to adopt specific requirements for follow-up
care after hospital discharge, and to require depression care
management. Most generally, the findings support the conclusion that
high quality mental health care can prevent suicide. The suicide rate
for all Veterans who used VA health care declined significantly from FY
2001 to FY 2007, as the attached chart indicates.
Mental illnesses are among the most prevalent conditions affecting
Veterans of all generations, wars or conflicts. VA research continues
its commitment to defining the most effective mental health treatments.
VA investigators have generated many major findings related to
behavioral and psychiatric disorders such as schizophrenia, depression,
substance use (including alcohol, illicit drugs, and nicotine), suicide
prevention, and PTSD. From conducting large clinical trials to
supporting center-based research programs to improving care delivery,
mental health research continues to be a major priority for the VA
research program.
In one line of research, VA scientists are investigating factors
related to improving adherence and compliance. This includes studies on
anti-depressant adherence among older Veterans, reducing the impact of
drug side effects, and a patient-centered approach to improve screening
for side effects of second-generation antipsychotics. Efforts to
improve the quality of care for persons with severe mental illness have
focused on the inclusion of family members as active participants in
the patient's treatment. VA researchers are also evaluating how to best
implement an integrated health care approach for Veterans with serious
mental illness. Combined with a number of other behavioral and
psychological intervention studies, VA has been at the forefront of
mental health research that seeks to improve treatment options for
clinicians and patients dealing with mental health care needs.
VA research is also striving to identify critical risk factors for
major mental health disorders. One unique study is looking at Veterans
who were deployed to Iraq as active duty Army, National Guard, or
Reservists who had baseline physical and mental health assessments
before deployment. Planned follow up studies will determine the effect
of the combat experience on mental health, emotions, reactions, and
cognition--shortly after return from Iraq as well as over ensuing
years. Research is also changing how care is provided to individuals
with less access to treatment facilities or providers. VA investigators
successfully adapted a collaborative/team care approach to treat
depression in older Veterans using telemedicine to address rural health
disparities. Subsequently, this study provided the support for
implementing telemedicine-based collaborative care in hundreds of small
rural CBOCs that do not have on-site mental health specialists.
Moreover, VA is working to better understand risk factors
associated with suicide and the optimal means to prevent suicide. VA
investigators focused on suicide prevention recently reported a
correlation between chronic pain and suicide suggesting an important
risk factor and highlighting a potentially at-risk group. Additional
research is ongoing to evaluate the effectiveness of suicide hotline
interventions, firearm safety, and how to care for Veterans receiving
treatment for substance use disorder and depression who express
suicidal thoughts.
conclusion
VA as a system is committed to improving the quality and
availability of mental health care to Veterans. VA's mental health
enhancements have included major initiatives--far too many to itemize
completely, but including effective efforts to increase access to
mental health care, increase the use of evidence-based psychotherapy
for the treatment of PTSD and depression, enhance the safe use of
psychotherapeutic medications, provide effective suicide prevention
interventions, fully utilize psychosocial rehabilitation and recovery-
oriented services, and ensure the appropriate level of trained staff
are available to provide needed services. VA firmly believes that each
Veteran has earned an individual determination of the best treatment
and routine follow up for his or her specific condition, and its
clinical guidelines support this endeavor. Thank you again for the
opportunity to appear, and my colleagues and I are available to address
any questions from the Committee.
______
The Chart Referenced During the Hearing
______
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
Dr. Gerald Cross, Acting Principal Deputy Undersecretary for Health,
U.S. Department of Veterans Affairs
Question 1. How is implementation of the Uniform Mental Health
Services package progressing? Are mental health clinics with weekend
and evening hours widely available across the system? What are the
barriers to full implementation?
Response. We have surveyed the field twice about the status of
their efforts to implement the requirements of the Uniform Mental
Health Services Handbook. The most recently completed survey reflects
the status of implementation as of the end of December 2009. At that
time, facilities reported implementing approximately 90 percent of more
than 200 requirements. A recent draft Office of Inspector General (OIG)
study indicated the same conclusion.
The draft OIG report specifically looked at the availability of
weekend and evening hours. They reported that these hours were
available in 94 percent of 139 VA medical centers, and in 43 percent of
the 49 very large Community Based Outpatient Clinics (CBOCs).
Some barriers to full implementation include: space limitation for
new staff programs as well as difficulties recruiting and hiring the
needed staff. Additionally, there are barriers with some of the complex
programs, such as Residential Rehabilitation and Recovery Centers,
which require a cultural shift as well as establishing new staff and
programming. The ultimate requirement also includes receiving
Commission on Accreditation of Rehabilitation Facilities (CARF)
accreditation. The Office of Mental Health Services (OMHS) works
closely with the field to accomplish this innovative implementation and
sites are making excellent progress; however, full implementation will
take additional time.
Question 2. What type of coordination is occurring between DOD and
VA to transition a demobilizing or separating servicemember to VA care,
or to refer a currently serving servicemember to VA care? How
effectively is data, such as PDHRA information, being communicated
between the Departments?
Response. Of the 1,094,502 servicemembers eligible for VA care who
have served in Afghanistan or Iraq since FY 2002 through the fourth
quarter of FY 2009, 46 percent have come to VA for health care which is
a significantly large number compared to other service eras. This is
due in part to the efforts of both the Department of Defense (DOD) and
VA to inform separating servicemembers of their health care and other
benefits to which they are entitled by virtue of their service to our
Nation in time of war. VA's outreach efforts to separating
servicemembers are multiple. Every eligible Veteran receives a letter
from the Secretary of Veterans Affairs informing them of their health
care benefits and follow-up letters are sent to those who have not come
to VA for care. Staff from Vet Centers, VA Regional Offices, and
medical centers attend Post-Deployment Health Reassessment (PDHRA)
administrations, National Guard and Reserve Yellow Ribbon events and
welcome home events at VA medical centers (VAMCs). These events provide
opportunities to share information about VA health care and other
benefits such as those involving education and home loans.
Specifically, DOD provides PDHRA records to VA on those Veterans who
are referred to VA for care. VA tracks the clinical services provided
to Veterans referred from DOD for care. DOD has systems in place to
follow-up on referred Veterans.
The Federal Partners Work Group on Reintegration of Returning
Servicemembers and their Families is an interagency group co-chaired by
Dr. Antonette Zeiss, Deputy Chief Consultant for Mental Health of VA
and Brigadier General Loree Sutton, Director of the Defense Center of
Excellence on Psychological Health and Traumatic Brain Injury. The work
group promotes collaborative actions across agencies and with community
providers. It has subgroups that focus on strategic collaborations
between VA, DOD and other Federal and state entities, services for
families, tracking of Veterans, destigmatization approaches and Veteran
employment issues.
For servicemembers who are ill or injured, VA and DOD have
complementary and integrated team activities including:
DOD and VA Federal Recovery Coordinators (FRCs) are
assigned to severely injured servicemembers/Veterans and families. The
FRCs work to coordinate VA and community benefits and services and
provide an integrated approach to coordinate medical, social and
community resources;
VA Liaisons at military treatment facilities (MTFs) who
transition injured Veterans to VA;
Coordination of lodging in Fisher Houses for family
members of Veterans in extended rehabilitation for war injuries;
Transition Patient Advocates (TPAs) as navigators or
advocates for Veterans and family member at VAMCs;
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/
OIF) Care Management teams that serve as an initial point of contact
for Veterans and family members and Military Liaisons at VA medical
centers (e.g. Army Wounded Warrior (AW2) staff);
VA mental health clinicians support the mental health
needs of wounded Veterans being treated in Polytrauma rehabilitation
settings.
Also, based on the October 2009 VA/DOD Mental Health Summit, VA and
DOD are collaborating on projects designed to support separating
servicemembers. This includes the DOD-sponsored ``In Transition''
project that provides trained mental health coaches to support
continuity of care for servicemembers and Veterans who are
transitioning from mental health care in DOD to VA.
______
Response to Post-Hearing Questions Submitted by Hon. John D.
Rockefeller IV to Dr. Gerald Cross, Acting Principal Deputy
Undersecretary for Health, U.S. Department of Veterans Affairs
Question 1. Dr. Cross, while it is good news that VA's new efforts
are reducing suicide among veterans in active treatment. If the
statistics of 18 veterans committing suicide and only 5 are known to
VA, there are 13 veterans not in care. What are the VA's ideas for how
to find and reach more veterans that need this assistance?
Response. We will continue to reach out to these Veterans through
the Hotline, media campaigns and outreach events as well as continue to
develop relationships with community organizations and individuals who
may be in a position to make referrals and provide assistance to
Veterans needing help. We have partnered with organizations such as the
Student Veterans of America and the American Legion to assist us to
reach out to Veterans in crisis. We have developed collaborative
agreements with the IHS and the Department of Health and Human
Services' Substance Abuse and Health Services Administration (SAMHSA)
to assist us to reach Veterans in the community who are in crisis.
Question 2. Dr. Cross, given all the new GI bill students on
campuses, what is VA doing to help their readjustment from Iraq and
Afghanistan with combat and IEDs to the new life of a college campus?
Response. VA has created an Internet page that targets college and
university counseling center staff to provide them with information
about common adjustment and mental health issues faced by Veteran
students. A resource page for Veteran students is also included. The
page can be accessed at: http://www.mentalhealth.va .gov/College/
index.asp.
Information about this resource has been broadly disseminated
throughout VA, in partnership with Veteran Service Organizations, and
through the National Academic Advisors Association Military Interest
Subgroup.
Additionally, VA has established a working relationship with the
Student Veterans of America, to facilitate development of resources for
student Veterans. One shared project involves suicide prevention
efforts. Locally, Suicide Prevention Coordinators, based at each VA
medical center, include college campuses in their outreach efforts and
are providing Operation SAVE training to college students.
______
Response to Post-Hearing Questions Submitted by Hon. Mark Begich to Dr.
Gerald Cross, Acting Principal Deputy Undersecretary for Health, U.S.
Department of Veterans Affairs
Question 1. How are the Veterans' Affairs Regional offices
preparing for the surge of Veterans returning in 2010 and 2011 with
mental health, TBI and PTSD problems?
Response. By hiring and training additional employees, VA will have
a stronger and more productive workforce to offset the impact of the
expected workload increases over the next two fiscal years. We are
actively exploring process and policy simplification, short-term
technology enablers, as well as the traditional approach of hiring
additional employees to address the continued growth of all categories
of claims.
Question 2. Alaska's Veterans need additional mental health
services. The Alaska VA system's participation in the Alaska Psychiatry
Residency would improve access to mental health care for Alaska's
Veterans. What financial and political support is necessary for the
Alaska VA system to be able to participate in the Alaska Psychiatry
Residency?
Response. VA is eager to enhance mental health services for all
Veterans, including those in Alaska. Clinical education programs have
been shown to be an important source for producing a pipeline of health
care professionals in a particular geographic area, and should be
encouraged in under-served areas.
The Alaska VA Healthcare System (HCS) is actively exploring the
possibility of participating in a psychiatry residency program. In
general, the requirements for such participation are as follows:
An Accreditation Council for Graduate Medical Education
(ACGME) accredited psychiatry residency program is willing to associate
with the Alaska VA HCS.
The Alaska VA HCS is found to be a good learning site with
experienced psychiatrists who are willing to teach.
Educational resources for trainees are available; these
include space, technology, and information resources to support the
training program.
The Office of Academic Affiliations could support trainees in a
psychiatry training providing the above minimum standards are met. The
financial considerations should not be considered a major barrier in
this endeavor.
Recently, VA opened a Psychology Internship Program at the Alaska
VA HCS. This is currently the only psychology internship program in
Alaska, and is also a potential program for expansion to meet the
mental health needs of the Alaskan Veterans.
Question 3. Rural Veterans are a major concern in my state and
across the country. What are your plans to coordinate with the Indian
Health Service (IHS) and Community Health Centers in rural areas to
provide ``seamless'' services for rural vets? For example, the vet
should be able to go to the clinic in their village and not have to
worry about paperwork or denials or to travel over 500 miles for an
appointment.
Response. Since the signing of a Memorandum of Understanding (MOU)
between VA and IHS in 2003, there have been and continue to be a number
of cooperative arrangements and agreements. For example, tele-
psychiatry clinical demonstration pilots are currently serving Native
Americans on rural reservations in eight sites covering 13 tribes in
four western states. In Alaska, a similar initiative is located at the
Yukon-Kuskokwim Regional Hospital in Bethel. The same initiative is
under negotiation at the Kotzebue Regional Medical Center. The Care
Coordination Store and Forward (CCSF) project, in Kenai, Alaska
includes tele-retinal imaging to screen for diabetic retinopathy, tele-
dermatology and tele-pathology. VHA has also initiated a project to
expand fee-based authority for primary and mental health care serving
Native Alaskans in the highly rural areas, a project with potential
national implications.
VA and IHS are partnering to allow IHS staff to view (read-only)
VA's electronic medical record on the Rosebud Reservation in South
Dakota. A project at the VA Outreach Clinic in Saipan, Commonwealth of
the Northern Mariana Islands includes the use of contracted part-time
providers, with on-island tele-health capability, negating the need for
Veterans to travel to more distant locations for routine examinations.
In collaboration with VA, IHS has developed a patch for Bar Code
Medication Administration, which has been tested at Fort Defiance, AZ
and connectivity has been established with the Tucson VA Centralized
Mail Out Pharmacy (CMOP).
In addition to supporting one another in the shared delivery of
care to rural Veterans who are located on Native lands, VA and IHS have
embarked on an ambitious cooperative educational program. In FY 2009,
VA provided 133 training episodes to tribal health care and IHS
providers. In the first quarter of FY 2010, VA has already provided 80
training programs. These educational sessions are conducted through
satellite, video teleconferencing and web-based technologies
strengthening our shared use of technology, and are highly valued by
both tribal and IHS providers.
In closing, the Under Secretary for Health and the Chief Medical
Officer for IHS agreed in January 2010 to update the 2003 MOU between
VA and IHS.
Question 4. In states, such as Alaska, where Psychological Health,
TBI, and Suicide resources are low and the workforce is underdeveloped,
is there a mechanism to encourage VA to work with state/community
leaders that are working hard to develop the same care in the civilian
sector and having similar workforce, access, or outreach/identification
challenges. How will (or can) telemedicine be used to increase access
to Psychological Health, TBI and suicide services and supports?
Response. VA actively engages the public and private sector to
identify, coordinate, and utilize providers and facilities within the
catchment areas of VA facilities to provide services that meet the
needs of Veterans. Such collaborations have been successful in
complementing VA care. For example, in FY 2009, over 3,800 Veterans
with TBI received inpatient and outpatient hospital care and medical
services from public and private entities, with a total disbursement of
$21,375,168.
VA uses Telehealth to provide medical care services and support to
more than 260,000 Veteran patients, including Veterans in Alaska and in
rural locations in other states. VHA Telehealth has increased access to
VA medical center service and support to 500 CBOCs and to 41,000
Veteran patients at home. VHA plans to increase Telehealth activity by
30 percent in FY 2010.
Increasingly, tele-mental health provides a mechanism for
specialist care within VA to diagnose, treat and prevent depression
with expanded accessibility to patients locally using health
information and telecommunication technologies. There is good evidence
to show that these telehealth interventions are effective and
comparable to face-to-face delivery of services. Over 30 peer-reviewed
scientific articles have substantiated the role for tele-mental health
in expanding access to care.
Telehealth services are an important element of VA's Uniform Mental
Health Services. The most common clinical videoconferencing Telehealth
application in VHA is tele-mental health used to link Veteran patients
at the CBOC with their mental health provider at the VAMC. In FY 2009,
VHA provided tele-mental health services to almost 40,000 Veteran
patients during more than 128,000 encounters.
The Alaska VA HCS has established a Tribal Veterans Representative
Program that uses local community volunteers to help VA in reaching out
to Alaska native Veterans. Alaska VA HCS has made special efforts to
reach out to Alaska Native Tribal Health Consortium organizations. A
group of VA staff has traveled to rural areas to provide education on
PTSD, TBI, and suicide awareness and prevention. Further, Alaska VA HCS
has signed an MOU with Alaska's Department of Military and Veterans
Affairs that outlines a partnership to work together to meet the needs
of returning soldiers.
Alaska is served by four Vet Centers located in Anchorage,
Fairbanks, Kenai and Wasilla. An American Indian counselor on staff at
Anchorage provides outreach services to Veterans in remote American
Indian and Native Alaskan villages, many not accessible by roads. On a
biannual basis, remote villages are visited by the counselor traveling
via bush plane and/or the Alaska National Guard. Remote villages are
contacted by radio transmission beforehand to announce the date of
arrival. The visiting Vet Center counselor provides informational VA
brochures, briefings, and some counseling to Veterans and family
members.
Staff from VISN 20 in Alaska participate in the Alaska Brain Injury
Network, a non-profit organization created by the Alaska mental health
trust to provide resources to Alaska residents with TBI and integrate
and share services from different sectors (Federal, state, Native,
private) for individuals with TBI. Telehealth is used to provide
follow-up comprehensive TBI evaluations from a VA medical center
provider to Veteran patients at rural clinics. Such a Telehealth link
has been established with the CBOC in Fairbanks, with plans for the
Kenai and Juneau CBOCs. This practice, also used in the VHA Eastern
Colorado Health Care System, continues to expand.
VHA is also in the final acceptance testing phase of a Home
Telehealth Disease Management Protocol (DMP) for mild TBI that will be
deployed throughout VA to eligible Veteran patients on home Telehealth
devices.
Regarding suicide prevention efforts relevant to rural Veterans,
OMHS has established mechanisms for access to care for those Veterans
in crisis through the use of the Hotline and Chat Service. VA Suicide
Prevention Coordinators have been conducting outreach programs in all
communities included in their respective catchment areas to involve
community organizations in the referral process. There is a pilot
project in Oregon that educates community health care personnel to do
suicide prevention outreach to Veterans, and provide initial services
and facilitate on-going care with VA using tele-mental health.
Finally, the VHA Polytrauma Telehealth Network established in 2006,
links the four VA Polytrauma Rehabilitation Centers and 17 VA
Polytrauma Network Sites from across the Nation (including the San Juan
VAMC). All of these sites are part of VHA's larger Clinical
Videoconferencing Network that currently reaches 500 CBOCs. VHA is
defining patient criteria and clinical pathways to enable CBOCs to link
appropriate patients into care via the polytrauma Telehealth network.
Question 5. Are there telemedicine options for specialty therapies
for TBI, such as physical therapy, speech therapy, occupational therapy
or counseling?
Response. Yes, currently, there are 60 VA sites providing
rehabilitation using Telehealth with planned expansions in FY 2010 in
the areas of speech pathology, mild TBI home Telehealth, Spinal Cord
Injury (SCI), and post-amputation medical services and support.
In 2009, 17 of 21 VISNs provided some form of tele-rehabilitation
with an overall increase in workload of 31 percent from the previous
year. Speech therapy accounted for 72 percent of this workload, and
Telehealth was also used to provide physical therapy and occupational
therapy services. New initiatives are underway to utilize telehealth
for audiology services
Question 6. Will case management be utilized? Why?
Response. Polytrauma/TBI specialty case managers are part of the
interdisciplinary rehabilitation teams that care for Veterans and
servicemembers with polytrauma and TBI. They participate in the
development of the individualized rehabilitation and re-integration
care plans, and oversee the implementation of the plan, including
securing the necessary resources to assist Veterans, servicemembers and
families through recovery, rehabilitation, and re-integration into the
community.
The Polytrauma Telehealth Network is utilized by these specialty
case managers to assess the psychosocial needs of the patient and the
family, help coordinate the necessary services to address those needs,
and to coordinate rehabilitation care including outreach to community
resources.
Case management is a core component in the provision of care and
services to help OEF/OIF servicemembers and Veterans restore or
maintain their functioning within the context of their family
relationships and community re-integration post-deployment. Case
managers for patients with complex, multiple injuries, including TBI,
amputation and psychological trauma require specialized knowledge and
skills. Patients and families need long-term case management services
to ensure coordination of services, evaluation of ongoing
rehabilitation needs, and supportive services to assist with successful
community reintegration. In rural or underserved areas of the country,
case managers assist Veterans and their families to identify and access
community, state and local resources close to the Veteran's home.
Services are provided across a continuum of care that may include
inpatient and outpatient rehabilitation, long-term care, transitional
living, community re-integration programs, and vocational
rehabilitation and employment services.
Each VA medical center has a Case Management team consisting of
both a clinical component (registered nurses and social workers) that
includes the OEF/OIF Program Manager and OEF/OIF case managers and a
non-clinical component led by Transition Patient Advocates (many of
whom are OEF/OIF Veterans). The Program Manager coordinates clinical
care and oversees the transition and care for this population. OEF/OIF
case managers coordinate patient care activities and ensure that all
clinicians providing care to the patient are doing so in a cohesive and
integrated manner. Transition Patient Advocates help Veterans navigate
the VA system and Veterans Benefits Administration (VBA) team members
assist Veterans with the benefit application process and provide
education about VA benefits.
All severely ill and injured OEF/OIF servicemembers and Veterans
receiving care at VA are provided a case manager. All others are
screened for case management needs and, based upon the assessment a
case manager is assigned as indicated. The patient and family serve as
integral partners in the assessment and treatment care plan. Our case
managers maintain regular contact with Veterans and their families to
provide support and assistance to address any health care and
psychosocial needs that may arise.
Question 7. What are you doing to ensure that Veterans are being
provided the best possible psychiatric care? Statistics show that 40%
of those servicemembers who die by suicide had previously been seen at
Behavioral health. Are the treatments effective? Do we have
appropriate, timely, cultural and effective treatments available?
Response. We know that a little less than 50 percent of VHA
Veterans who died by suicide had a mental health diagnosis. We believe
this is due to VA's ongoing efforts to provide quality mental health
services to all Veterans. There is an ``enhanced care package'' for
Veterans who have been identified as high risk for suicide. It includes
suicide-specific interventions such as safety planning and engagement
into evidence-based psychotherapies. We will continue to enhance our
mental health services as more information on the effectiveness of our
programs becomes available.
Question 8. What are you doing to reach out to families, especially
parents, to provide education on emergency mental health issues, how to
identify them and what to do about it?
Response. VHA Handbook 1160.01 identifies family involvement and
family services, when appropriate and in connection with the treatment
of the Veteran, as an essential component of the mental health program.
To facilitate this patient--centered, family focused transformation in
services, the Handbook requires that the clinical provider discuss with
the Veteran the need and the benefits of family involvement in their
care annually and at the time of discharge if there has been an
inpatient stay. As part of this process, the provider must seek the
consent of Veterans to contact family as necessary in connection with
Veterans' treatment. Additionally, every medical center will provide a
continuum of family services within existing statutory and regulatory
authority either on site, by tele-mental health, with community
providers through sharing arrangements, contracting, or non-VA fee
basis care to the extent the Veteran is eligible. Providing education
on emergency mental health issues, including how to identify them and
what to do about them, are addressed in our graduated continuum of
services that meet the varying needs of Veterans and their families.
The continuum of family services includes:
Family Consultation. Family consultation involves the
family meeting with a trained mental health professional as needed to
resolve specific issues related to the Veteran's treatment or recovery,
which may include emergency mental health issues. The intervention is
brief, typically one to five sessions are scheduled for each
consultation. Consultations may be provided on an as needed or
intermittent basis; if more intensive ongoing effort is required, the
family can be referred for Family Psychoeducation.
Family Education. Family education is a set of techniques
to provide families with the factual information necessary to partner
with the treatment team to support a Veteran's recovery. Typical topics
include symptoms, likely treatments, recognizing relapse, identifying
and managing sources of stress, minimizing crises, and increasing
problem-solving skills. Family education may be offered through written
and video materials, one day workshops and/or regularly scheduled
meetings conducted over time by professionals (e.g. the Support and
Family Education (SAFE) program) or by trained family members (e.g. the
National Alliance on Mental Illness Family to Family Education Program
(NAMI FFEP)). The Veteran may or may not be present at family education
meetings.
In June 2008, VHA signed an MOU with NAMI to offer the NAMI FFEP in
at least one VHA facility in each state during a two year period
starting in June 2008. The selected VHA facility and local NAMI
affiliate serve as models to continue this partnership throughout all
VISNs.
Family Psychoeducation (FPE). Family psychoeducation is a
type of evidence-based family therapy that focuses on developing coping
skills for handling problems posed by mental illness in one member of
the family. The models of family psychoeducation share a number of
components, including careful assessment, provision of education,
problem-solving training, and an emphasis on improving current
functioning. Interventions can be offered in a single family format
(e.g. behavioral family therapy) or multi-family group format (e.g.
multiple family group therapy). Veterans are typically present during
the FPE sessions.
With regard specifically to emergency mental health issues, massive
outreach programs have been established by the Suicide Prevention
Coordinators at each facility. These include face-to-face presentations
about how to recognize when someone is in trouble and how to get help.
In addition, posters, mailings and mass media public service
announcements have been made available across the country. VA has
developed its own Veteran-specific ``gatekeeper'' training program for
communities and families called Operation S.A.V.E. (Signs Ask Validate
Encourage) which is provided in all communities. VA has developed
family and age-specific suicide and suicide attempt education materials
for distribution. VA will continue to seek out ways on local levels to
communicate with families and communities.
In addition, in FY 2009 VA produced Public Service Announcements
(PSAs) starring actor Gary Sinise and news personality Deborah
Norville. The PSAs aired from October 2008 to September 2009. The
company contracted for PSA distribution reported that the PSA aired
over 17,000 times across the country in 118 markets on 222 stations,
one national cable outlet, and one local cable outlet. Although no
longer airing, the PSAs are available on a number of Web sites: VA's
Mental Health Service; House Committee on Veterans' Affairs; the
official Web site for the US Air Force; and, the Web sites for the
Military Officers Association of America, Military Lawyer Blog,
American Legion, National Association of State Directors of Veterans
Affairs, YouTube, CBS News, etc. A Google search of ``Suicide
Prevention PSA Gary Sinise,'' displays 20 pages of citations. Mr.
Sinise has agreed to do another PSA for which funding is available in
FY 2010. Production of this new PSA is planned for the summer of 2010
with release over the 2010 holiday season.
Question 9. Is the VA utilizing peer-based support to help them
with their behavioral health issues? What are you doing to try to build
peer-based support for Veterans?
Response. Currently, peer services are provided at 33 percent of VA
facilities and the number of such services is growing; these are a
vital component of optimal Veteran-centered mental health care. VHA
Handbook 1160.01, Uniform Mental Health Services in VA medical centers
and Clinics, requires medical centers and very large CBOCs to provide
individual and group counseling for Veterans with serious mental
illness through the use of Peer Support Technicians. In addition,
Residential Rehabilitation Treatment Programs and Psychosocial
Rehabilitation and Recovery Centers require the inclusion of Peer
Support Technicians as part of their staffing.
OMHS has developed job-specific competencies for Peer Support
Technicians to ensure the high quality of the services provided by
peers. These competencies are based on the certification examinations
for peers as administered by some states and outside-VA mental health
organizations. Finally, OMHS is providing funding for currently-
employed Peer Support Technicians to become certified by an outside
agency.
Question 10. How does one diagnose, treat, and prevent depression
and mental health disturbances in remote areas, for Veterans or
civilians, this is a difficult task. The use of telepsychiatry and
methods of selecting high risk populations after discharge are
important, what methods are being used? Any evidence they are
successful?
Response. The diagnosis, treatment and prevention of depression in
both Veteran and non-Veteran populations in remote areas is based upon
the same clinical, legal, evidence and health care organizational
principles as for patients in non-remote areas. The challenges in
remote areas are the logistic ones of access for both patients and
practitioners. There are circumstances where there is an obvious need
for face-to-face service delivery in which case physical health care
access and associated travel provide the solution. Increasingly tele-
mental health provides a mechanism for specialist care within VA to
diagnose, treat and prevent depression with expanded accessibility to
patients locally using health information and telecommunication
technologies. There is good evidence to show that these Telehealth
interventions are effective and comparable to face-to-face delivery of
services. Over 30 peer-reviewed scientific articles have substantiated
the role for tele-mental health in expanding access to care.
Question 11. If a family member of a suicide victim requests an
Inspector General investigation, and their benefits have already been
approved, can they be denied due to a request for a further
investigation or the filing of an IG complaint?
Response. Following the death of a Veteran due to suicide, a
determination may be made that service connection for cause of death is
established, and Dependency and Indemnity Compensation benefits may be
awarded to surviving family members. The request by family members for
an Inspector General (IG) investigation or the filing of an IG
compliant would not affect the continued eligibility for those
benefits.
All decisions rendered by the Veterans Benefits Administration
regarding entitlement to or eligibility for benefits, are made based on
all the evidence of record. The results of an IG investigation would
only affect previously approved decisions if they provided new evidence
altering a prior VBA entitlement or eligibility decision.
Question 12. There are cases in which family members have been
encouraged to seek help for their spouse or child when they fear they
may be suicidal as a result of combat related PTSD. Is there a plan to
provide families with a safe place to call where they can access care
for their loved one?
Response. Family members are encouraged to call the VA Suicide
Hotline (and many do) to get help for their loved ones. The Hotline
works with all third party callers (families, friends, co-workers,
etc.) to get Veterans the help they need.
Question 13. What are the staffing levels in VA facilities and how
do you see that growing and sustaining?
Response. VA currently has over 20,000 ``Core Mental Health Staff''
(psychiatrists, psychologists, social workers, and nurses) who provide
care to Veterans with mental health conditions. This represents a 44
percent increase over the staffing levels in VA at the end of FY 2005,
when there were 13, 950 mental health providers. We anticipate
sustaining this staffing level, with some slight additional growth over
time, as facilities hire additional approved staff in hard-to-recruit
parts of the country.
Question 14. Do you have outside groups/evaluators to determine if
the VA programs are successful?
Response. VA has numerous outside groups that provide evaluation of
VA programs. Some key examples include:
The Joint Commission includes review of mental health
programs in all medical facility reviews.
VA's Suicide Hotline was recently reviewed by the American
Association of Suicidology Crisis Center Accreditation Team and
received the highest scores possible and a full accreditation. The
Hotline also has a full CARF accreditation.
VA requires that many rehabilitation programs receive CARF
accreditation, including Residential Rehabilitation Treatment Programs
(RRTPs) and Psychosocial Rehabilitation and Recovery Centers.
In addition, VHA contracts with Mathematica to conduct
evaluations of all RRTPs, including on-site visits.
VHA is currently in the process of a Government
Performance and Results Act (GPRA) evaluation project to evaluate
mental health programs; the study is contracted to the RAND
Corporation.
Question 15. Should the Mental Health professionals who are working
with DOD carryover to VA? For example, the professionals (case manager,
etc.) follow the person, rather than go from DOD to VA, continuity of
service provider?
Response. We do not believe that mental health professionals should
``carry over'' from DOD to VA, as this would involve significant
logistical concerns and would work geographically for a minority of
servicemembers. However, we do agree that efforts should be made to
provide continuity of transition from DOD to VA for mental health
patients transferred from one Department to the other, for either
inpatient or outpatient care. For this reason, the in-Transition
Program was developed in response to a DOD Mental Health Task Force
recommendation to ``maintain continuity of care across transitions''
(5.2.2). This new program went active within DOD on February 1, 2010.
The in Transition voluntary coaching and assistance program can provide
a bridge of support for servicemembers while they transition between
health care systems or providers. VA is enthusiastically partnering
with DOD to implement this program for those transitioning to VA mental
health care.
Question 16. What type of classes is the VA offering for education
and prevention of suicide and MH issues?
Response. All VA staff are required to take suicide prevention
training. There is a web-based clinical program that includes risk
assessment and treatment strategies for all providers and a general
awareness program for non-clinicians. In addition, a variety of
training regarding specific Veteran populations and providers has been
developed and is offered on a regular basis via national and regional
suicide prevention conferences and web-based training efforts. Monthly
calls are held with the Suicide Prevention Coordinators and programs
have been developed for them to share with their facility staff on
specific suicide prevention strategies such as safety planning.
Question 17. What are the non-traditional programs the VA is
providing?
Response:
Veterans Chat is an innovative way for Veterans to seek
help through VA. VA is exploring ways to provide patient information
and education through MyHealtheVet. Pilot sites now allow Veterans to
interact directly with their providers.
VA also offers care online through MyHealtheVet, as
covered in other questions.
VA's use of tele-mental health for direct care provision
is also innovative and unmatched in any other part of the health care
system in the United States.
VA's intensive training to ensure that Veterans can
receive evidence-based psychotherapy for a variety of mental health
problems is innovative.
VA has a work group to review Complementary and
Alternative Medicine (CAM) approaches to mental health care, as well as
for other medical problems. Currently no approaches reach a sufficient
level of evidence for VHA to endorse their use, but we remain open to
expansion as evidence supports such action.
Question 18. What are the faith-based programs the VA have or work
with?
Response. VA Center for Faith-based and Neighborhood Partnerships
(CFBNP) is a staff office in the Office of the Secretary of Veterans
Affairs.
The CFBNP develops partnerships, works collaboratively, and
provides relevant information to faith-based, non-profit, community and
non governmental organizations. Our goal is to assist these
organizations in working effectively with our Veterans and their
families.
Our purpose is to expand the participations of our external
partners in VA programs equipping them to better serve the needs of our
Veterans and their families. CFBNP is the only faith-based program at
the Department of Veterans Affairs.
In FY 2009 and 2010, VA CFBNP has worked with the organizations
listed below in the following ways: attendance at VA CFBNP roundtables,
forums, trainings and or conferences. We have also presented at various
events hosted by some of these organizations.
South Avenue United Methodist, Pittsburgh, PA
YWCA of Greater Pittsburgh, PA
Salvation Army of Pittsburgh, PA
Church under the Bridge, Waco, TX
Greater Vision Church, Houston, TX
Mission WACO, Waco, TX
Salvation Army of WACO, Waco, TX
Korean Churches For Community Development, Los Angeles, CA
Cassa Madad Community Development Corp., Woodworth, LA
Goodwill Industries International, Inc., Rockville, MD
Quad Area CAA, Inc., Hammond, LA
Catholic Charities, New Orleans, LA
First Baptist Church of New Orleans, New Orleans, LA
Mount Olive Baptist Church, Pensacola, FL
American Red Cross, Washington, DC
First Non-Denominational Church of Jesus Christ, Arcola,
TX
Abundant Life Church, Edgewater Park, New Jersey
Emmanuel House Recovery Community, Detroit, MI
Coming Home Project, San Francisco, CA
Volunteers of America Greater New Orleans, New Orleans, LA
Dare Mighty Things, Arlington, VA
Ministry on the Go!--Baton Rouge, LA
Eighth Episcopal District African Methodist Episcopal
Church, Jackson, MS
Non-profit for Utah, Provo, UT
Question 19. What is the outreach to Veterans from the VA to get
information to Vets?
Response. Numerous mechanisms exist to get information to Veterans.
There are formal mailings, calls and VA participation in DOD events as
well as informal mass public health messaging on buses and public
transportation vehicles. We have developed public service announcements
on suicide prevention and safe driving. We have developed a large
internet presence through web pages and social media sites.
______
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
Caitlin Thompson, Ph.D., Clinical Care Coordinator
Question 1. Are any resources needed to make the Suicide Hotline
program more successful?
Response. No additional monetary resources are needed at this time.
We need everyone to continue to urge Veterans and their families to
call the Hotline or use the Chat Service. Additionally, we need public
support to destigmatize the concept of getting help for emotional
issues.
______
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
Antonette Zeiss, Ph.D., Associate Deputy Chief Consultant and Chief
Psychologist, Office of Mental Health Services
Question 1. Do you believe VHA is conducting adequate ongoing
analysis of its suicide reduction programs to determine the most
effective strategies to reduce suicide?
Response. We believe that VHA is conducting extremely thorough
analyses of its suicide reduction programs. All of the following are
done:
We continually analyze available data to look at rates and
effectiveness.
We require a monthly report from each facility which is
reviewed to identify trends, not only in numbers but also risk factors
and care elements.
We do annual aggregate reviews on both suicides and
suicide attempts.
Our Evaluation Center in Ann Arbor, MI is continually
looking at VA information in regards to national data.
We have weekly meetings with the Suicide Prevention Staff
and the Evaluation Center to continue to look at the information we
have to provide the most current information to the field. Recently, we
have released two memorandums to field staff to ensure they are aware
of recent suicide risk findings. A direct result of these weekly
reviews has been a memo concerning the relationship between pain and
suicide and another memo concerning suicide risk in patients with
Traumatic Brain Injury (TBI).
Question 2. How effectively do you believe VHA monitors patient
adherence to treatment?
Response. Monitoring adherence to treatment is an essential
clinical function done by staff directly delivering care to Veterans.
VHA does not have a national program to monitor adherence to mental
health care, nor is this best handled at the national level. VHA does
have a policy that any patient receiving mental health care who misses
an appointment unexpectedly (i.e. not calling in or otherwise notifying
the provider of a need to change an appointment) must be contacted to
determine the reason for the missed appointment and to establish a new
return appointment (unless the Veteran refuses to do so). A minimum of
three follow-up attempts to contact the Veteran are required to ensure
the patient is linked back into care. If the patient is known to be at
high risk for suicide, follow-up attempts should include a visit to the
patient's home with the assistance of community based local crisis
response teams or law enforcement if the patient cannot otherwise be
contacted. This requirement for active follow-up also triggers an
opportunity for providers to discuss adherence and any concerns the
Veteran may have about their treatment regimen.
Question 3. How fully has VHA integrated the TIDES Project into
each of its outpatient facilities system-wide?
Response. Translating Initiatives for Depression into Effective
Solutions (TIDES) is an evidence-based care management model that VHA
has implemented in routine practice as part of the primary care-mental
health integration (PC-MHI) program. Consistent with the PC-MHI
program, it has expanded to include activities addressing anxiety
disorders, problem use of alcohol, other substance use disorders, and
Post Traumatic Stress Disorder (PTSD). TIDES is one of several care
management models that may serve as a component to a facility's PC-MHI
program. Presently, 24 VHA facilities across 12 VISNs have care
management programs based on the TIDES model. The Steering Committee
for Mental Health/Primary Care integration continues to conduct
training to assist additional sites in developing a TIDES component for
their care. Training on another model, the Behavioral Health Lab, also
is provided, and sites can select which of these care management
programs to institute.
Question 4. We know that the stigma associated with mental health
problems is a serious barrier to Veterans seeking treatment. What else,
in addition to VA's current efforts to overcome stigma, would be
beneficial?
Response. VA has been diligent in dealing with the stigma issues
associated with mental health problems and will continue to work on
them. In the area of suicide prevention specifically, VA has developed
a mass media campaign including posters, bus and train displays, public
service announcements and community education programs. VA has recently
increased the required number of outreach activities from three to five
per month for all of our local Suicide Prevention Coordinators and they
have been asked to focus on both local Veterans Service Organizations
(such as the American Legion, which has partnered with VA to promote
suicide prevention awareness) and college campuses. VA has increased
access to care mechanisms by developing the Suicide Hotline and VA Chat
Service which allows Veterans to access care anonymously initially. VA
has asked the suicide prevention coordinators, OEF/OIF coordinators,
and homeless coordinators to initially meet with Veterans outside of VA
to establish relationships. The Vet Centers offer services that are not
associated with the ``stigma'' of mental health in the form of
readjustment counseling.
It will take all of these approaches, and more, to break down these
barriers. VA needs community support and assistance to do this. VA
knows that leadership at all levels can be influential in breaking down
barriers and setting examples. Senior DOD leaders are providing this
support, which is very beneficial. Dr. Rudd spoke to this in his
testimony. VA is working with national and community leaders to provide
support and examples of effective actions. VA continues to work with
families to make them aware of the signs and symptoms of people in
trouble and provide them with ways to seek help. VA plans to work with
employers to recognize signs of difficulty and encourage them to assist
Veterans to get assistance. This is a national undertaking and VA will
continue to do its part.
Question 5. Do patient outcomes indicate that inpatient or
outpatient mental health programs are more cost effective when
considering the cost of the patient recidivism?
Response. A global statement cannot be made because some conditions
are better treated in an inpatient setting, and many others can be
treated very effectively in an outpatient setting. VA provides care in
a number of inpatient, residential rehabilitation, and outpatient
settings, and strives to provide care in the least restrictive setting
possible. The general trend in recent decades has been a substantial
transition to care predominantly in outpatient settings, with increased
utilization of residential rehabilitation care and decreased
utilization of inpatient care and length of stay in inpatient. Fewer
patients with mental health conditions are being treated in inpatient
settings, and their average length of stay on an inpatient unit has
also declined substantially, compared to 10 and 20 years ago. These
changes are driven primarily by the mandate to provide care in the
least restrictive setting, to sustain a Veteran's contact with and
identity with the community (i.e. avoid institutionalization), and to
promote a model of care that emphasizes psychosocial rehabilitation
with a recovery orientation. This model of care is well supported by
evidence and provides the greatest hope for quality of life to Veterans
being treated for mental health problems.
Question 6. How can VA better address the unique challenges of
providing mental health services in the rural setting in light of the
unique challenges that face rural communities?
Response. Availability of VA's CBOCs and use of tele-mental health
services have improved access to mental health care for rural Veterans.
Contracting with community providers is another vehicle for improving
access to mental health care. Each of these continues to be expanded to
make the full array of mental health services available and accessible
to Veterans living in rural areas. In addition, several innovative
strategies are underway:
Section 107, Pub. L. 110-387 authorized VA to conduct a
three year pilot program to assess the feasibility and advisability of
providing mental health services to OEF/OIF Veterans who reside in
rural areas and do not have ready access to VA mental health services.
VISNs 1, 19 and 20 (VA New England Healthcare System, Rocky Mountain
Network and Northwest Network) are participating in the pilot program
and are in the process of negotiating contracts with community
providers. It is anticipated that all the pilot programs will be
operating by October 2010 and be completed by the end of September
2012.
An expansion of the Mental Health Care Intensive Care
Management--Rural Access Network for Growth Enhancement (MHICM-RANGE)
initiative has been supported by VA's Office of Rural Health. This
initiative adds mental health staff to CBOCs, enhances tele-mental
health services and uses referrals to community mental health services
and other providers to increase access to mental health care in rural
areas. The expansion of MHICM-RANGE has also led to four research
studies initiated in VISN 16 (South Central VA Health Care Network) to
investigate clinical policies or programs that improve access, quality
and outcomes of mental health and substance abuse treatment services
for rural and underserved Veterans.
The Vet Centers provide a continuum of social and
psychological services including community outreach to special
populations, professional readjustment counseling to Veterans and
families, and brokering of services with community agencies that
provide a key access link between the Veteran and other needed VA and
non-VA services. A core value of the Vet Centers is to promote access
to care by helping Veterans and families overcome barriers that impede
the receipt of needed services. To extend the geographical reach of Vet
Center services, the Readjustment Counseling Service (RCS) has
implemented initiatives to ensure that new OEF/OIF combat Veterans
living at a distance from existing services have access to care.
Following the on-set of hostilities in Afghanistan and Iraq, the Vet
Center program hired 100 OEF/OIF Veteran Outreach Specialists to
proactively contact their fellow returning Veterans at military
demobilization sites, including National Guard and Reserve locations.
The RCS' Mobile Vet Center (MVC) program is another major initiative
for extending the geographical outreach and counseling services to OEF/
OIF combat Veterans and their families. To facilitate access to
services for Veterans in hard-to-reach outlying areas, RCS has deployed
50 Mobile Vet Centers to strategically selected Vet Centers across the
country. The placement of the vehicles is designed to cover a national
network of designated Veterans Service Areas (VSAs) that collectively
cover every county in the continental United States. The 50 MVCs are
used to provide early access to returning combat Veterans via outreach
to active military demobilization sites, including National Guard and
Reserve sites, and extending services to Veterans at PDHRAs. The
vehicles are also extending Vet Center outreach to more rural
communities distant from existing VA services.
OMHS has partnered with the My HealtheVet Program office
and Office of Information and Technology (OI&T) to develop online
resources designed to complement traditional mental health services,
and to expand access to these services to Veterans in rural areas. OMHS
is working closely with the Office of Health Information and OI&T to
develop My Recovery Plan--an online, interactive application designed
to support Veteran-centered, evidence-based mental health practices.
Sections of My Recovery Plan will be available for self-paced
independent work, while other areas will be made available to Veterans
in conjunction with work with a provider. Both approaches can
facilitate treatment for Veterans in rural areas.
Question 7. Access to care is a critical concern. Dr. Rudd's
testimony suggested putting providers on college campuses to reach OEF/
OIF Veterans. What else should VA be doing to make mental health care
more available?
Response. VHA is implementing the Uniform Mental Health Services
Handbook, designed to ensure consistent access to services for Veterans
in VAMCs and CBOCs. A recent survey of the field indicated that as of
December 31, 2009, the VAMC Handbook implementation rate for VAMCs and
CBOCs was 98 percent.
Among the initiatives that are in place to assist community and
rural health care providers is an Internet Web site with basic
information on assessment and treatment of PTSD designed for college
mental health counselors who, like many community providers, may not
have knowledge about military service or experience treating combat
related PTSD and other disorders associated with war. It can be
accessed on the Internet at www.mentalhealth.va.gov/College/index.asp.
Access to services is supported increasingly by Internet-based
resources such as the VA OEF/OIF web site at www.oefoif.va.gov and the
National Center for PTSD's web site at www.ptsd.va.gov, as well as a VA
presence on social media sites such as Facebook and Twitter.
Other initiatives from OMHS include implementation of Public Law
110-387 (Veterans' Mental Health and Other Care Improvements Act of
2008) Title I, Section 107. Three pilots will be implemented in VISNs
1, 19, 20 to assess the feasibility and advisability of providing
mental health services to OEF/OIF Veterans who reside in rural areas
and do not have ready access to mental health services through VA
facilities. The effort will focus on Veterans who served as members of
the National Guard or Reserves as well as those separated from active
duty. Services will be provided through collaboration with community-
based entities including community mental health centers, the Indian
Health Service (IHS), and other providers. The three VISNs are
negotiating contracts with community providers. It is anticipated that
all the pilot programs will be operating by October 2010 and be
completed by the end of September 2012.
Telehealth capability is being expanded in rural CBOCs and also for
home Telehealth approaches. tele-mental health brings expert clinical
care and consultation services as close as possible to the Veteran.
In addition, VA's RCS has deployed 50 Mobile Vet Centers across the
Nation specifically to meet the needs of rural Veterans and families.
The placement of the 50 Mobile Vet Centers was designed to cover a
national network of designated Veterans Service Areas, inclusive of
every county in the continental US and not to augment the services at
any particular Vet Center.
______
Response to Additional Post-Hearing Questions Submitted by Hon. Daniel
K. Akaka to Antonette Zeiss, Ph.D., Associate Deputy Chief Consultant
and Chief Psychologist, Office of Mental Health Services
Question 1. Please elaborate on the differences between inpatient
care for women veterans and residential care for women veterans.
Response. Inpatient care and residential care are significantly
different models of care The inpatient care model is a very short
length-of-stay (a few days to at most a couple of weeks) for those who
are most acutely ill, are a danger to themselves or others, and cannot
safely receive treatment in a less restrictive environment. The goal is
symptom stabilization. Inpatient care is typically in locked units,
with patients not able to come and go at will.
Residential care is rehabilitation-focused care, with lengths of
stay of many weeks or even months, with time for prolonged treatment.
Residential programs provide a strong emphasis on rehabilitation and
recovery services and offer this longer-term treatment to Veterans who
may have a wide range of problems, illnesses, or rehabilitative care
needs requiring more intensive treatment than can be provided in an
outpatient setting. Residential care programs are typically open units
that instill personal responsibility and support and strengthen the
patient's links to family and community.
Thus, the goals, structure, and personal experience of someone in
the inpatient level of care vs. the residential level of care would be
extremely different.
Question 2. How many ``women only'' residential care units are
there in the VA system? Where are they located? How many Veterans does
each of them accommodate? What condition are they treated for in these
facilities?
Response. Mental Health Residential Rehabilitation Treatment
Programs (MH RRTP) provide residential treatment in a 24-hour, 7 days
per week, supervised and therapeutic milieu for Veterans in need of
more intensive treatment of mental health conditions and addictive
disorders than can be provided in an out-patient setting. Women
Veterans comprised 5.2 percent (1,789) of the total episodes of care in
MH RRTP in FY 2009 (North East Program Evaluation Center--NEPEC). Most
MH RRTPs have the capacity to serve women Veterans. In FY 2009, there
were a total of 237 operational MH RRTP providing more than 8,440
treatment beds, which includes 252 beds dedicated to women Veterans in
35 of the programs (NEPEC). Of those, there are six MH RRTP that are
dedicated to serving women Veterans in a setting where no male patients
would be receiving care on the same unit at the same time:
Boston, MA: 8 beds
Brockton, MA: 8 beds
Batavia, IL: 6 beds
Lyons, NJ: 10 beds
Temple, TX: 8 beds
Palo Alto, CA: 10 beds
The most prevalent diagnoses of women Veterans receiving services
in MH RRTP are substance use disorder (SUD), PTSD, and depression.
Question 3. Of the women requiring inpatient care services at VA
facilities, how many of them are receiving care for Military Sexual
Trauma (MST)? What other conditions require inpatient care for women
Veterans? Do you receive many complaints from women veterans with
regard to the location of the inpatient care services for them within
the VA facilities?
Response. OMHS produces reports annually on the amount of
outpatient Military Sexual Trauma (MST) related care at each facility
and the proportion of all patients with a history of a positive MST
screen who have received MST-related care. MST-related care is
monitored using the MST encounter form checkbox in the Computerized
Patient Record System (CPRS) electronic medical record system. The
encounter form checkbox allows clinicians to specially designate VHA
encounters when they have provided MST-related care as part of the
check-out procedure for an outpatient visit. This designation is
available for any outpatient VHA encounter of a patient with a positive
MST screen. However, inpatient care does not have a parallel checkout
process that would allow providers to designate that an inpatient stay
was related to MST. Therefore at this time, OMHS is not able to track
the number of women receiving inpatient MST-related care.
Inpatient care is appropriate for women Veterans who are acutely
ill and are a danger to themselves or others and cannot safely receive
treatment in a less restrictive environment than the locked, controlled
inpatient unit.
OMHS does not receive many complaints from women Veterans regarding
the location of the inpatient care services for them within VA
facilities. However, OMHS understands that continued efforts to enhance
safety and security on inpatient units, and especially the
psychological experience of safety and security on inpatient units, is
a priority effort for mental health care settings as well as other
health care settings in VHA. Clear standards for such enhanced safety
and experience of psychological safety are laid out in the Uniform
Mental Health Services Handbook and OMHS continues to monitor toward
full implementation of those standards.
It is important to understand, however, that the majority of care
in a setting with bed capacity for women (and men) Veterans is provided
in the RRTPs. VHA also offers mental health care to women Veterans on
Residential Rehabilitation Treatment Program (RRTP) units.
Question 4. What is the percentage of women mental health providers
within VA?
Response. Among VHA employees at the start of FY 2010, 55.1 percent
of psychologists are female; 72.2 percent of social workers are female;
and 41.2 percent of psychiatrists are female.
Question 5. What is the percentage of women veterans receiving
health care services for MST? What other mental health conditions
require women veterans to receive care?
Response. Among women outpatients in FY 2009, 21.9 percent (53,295)
had a positive screen for MST. Among women with a positive MST screen
69.7 percent (37,132) had at least one MST-related outpatient encounter
during FY 2009.
MST is an experience, not a diagnosis. Women Veterans receive
mental health care, including MST-related mental health care, for a
variety of mental health conditions diagnosed by VA providers. In FY
2008, the top five primary diagnoses for women associated with MST-
related mental health encounters were PTSD (46.6 percent), major
depression (20.1 percent), mania or bipolar disorder (7.7 percent),
schizophrenia and psychoses (5.6 percent), and SUDs (4.0 percent).
Women Veterans receive care for all mental health conditions,
including depression, PTSD, SUDs, and various psychotic disorders.
______
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
Theresa Gleason, Ph.D., Deputy Chief Mental Health Services, Office of
Research and Development
Question 1. Can you describe how the Quality Enhancement Research
Initiatives (QUERI) have translated evidence-based practice into real-
world clinical care and how VA might use such findings to improve the
delivery and patient outcomes of its mental health and substance abuse
services?
Response. The QUERI program uses a systematic approach to translate
evidence-based practices in high-priority areas such as mental health.
QUERI identifies proven practices, examines where there are gaps in
delivering those practices and why, creates and tests interventions to
close those gaps, and finally demonstrates how these strategies can be
implemented on a larger scale within VHA. One of the most important
lessons from QUERI is the need to align multiple parts of the health
care system to make sure important practices are measured, prioritized,
rewarded and facilitated at multiple levels of the organization. The
QUERI program has participated in developing VA guidelines, performance
measures, training programs, education for Veterans and tools to help
facilities implement new practices.
The Mental Health QUERI, under a series of projects beginning ten
years ago with ``TIDES'' (Translating Initiatives for Depression into
Effective Solutions), developed interventions to address problems in
care for the large number of Veterans with depression. They used a
proven model of collaborative care where mental health nurse care
managers assist primary care providers in managing depressed patients
and facilitate collaboration between primary care and mental health
specialists. To facilitate the uptake of this, they developed
educational and training materials for providers and managers,
specialized software for care managers to monitor their patients, and
programs to help new sites implement this new model of care. QUERI
studies demonstrated that the intervention led to more patients
receiving effective treatments and to improvements in quality of life
and demonstrated that the program was cost-effective. This model has
been implemented in over 50 practices in VA as part of efforts to meet
Uniform Mental Health Services handbook requirements and improve care
of depressed patients in primary care. The model has also been extended
to patients being treated in Human Immunodeficiency Virus (HIV) care
settings and substance abuse clinics.
Investigators are also testing methods to disseminate telemedicine-
based collaborative care for depression to rural, community-based
outpatient clinics (CBOCs). Participating CBOCs have improved
performance on the national measure for antidepressant medication
continuity and 32 percent of Veterans completing the intervention
responded to treatment. This web-based clinical information system for
depression care management also is being used at some primary care
mental health integration (PCMHI) sites to support clinical activities.
As a result of QUERI Substance Use Disorder (SUD) projects, VA has
implemented national clinical reminders for alcohol screening and for
brief intervention which can prevent more serious alcohol-related
problems. As a result, over 95 percent of all Veterans are routinely
screened for problem drinking, and rates of documented brief alcohol
intervention have been increasing steadily since January 2008, when the
clinical reminder developed by the QUERI was disseminated. In the first
year, rates of brief intervention increased from 42 to 58 percent.
QUERI investigators have also developed a care model for patients
who do not respond to brief interventions, decline referral to
addictions specialty care, and are at high risk of having alcohol use
disorders. This care model provides brief interventions that reduce
problem drinking in over 50 percent of Veterans getting the
intervention and provides outpatient medical withdrawal and
pharmacotherapy for preventing relapse in those Veterans with alcohol
dependence. Prescribing these medications like naltrexone has
substantially increased over the past three years, although it remains
well below optimal utilization.
QUERI investigators have also developed a reminder for assessing
depressive symptomatology among persons in treatment for substance use
disorders. The reminder incorporates the PHQ-9 (the nine item
depression scale of the Patient Health Questionnaire) depression screen
with additional questions needed to discern if current symptoms are
likely non-substance-induced. The reminder provides the assessment
tool, scores it, and provides evidence-based treatment recommendations
based on the score.
QUERI SUD investigators have improved continuity of care and
treatment retention through Veteran engagement in self-help groups and
specific improvements and expansions in opiate maintenance treatment.
They have developed a Web site that provides clinicians with an
empirically-based ``3-Step Referral Method'' for engaging SUD patients
in 12-step and other self-help groups. Opiate maintenance treatment has
been substantially improved through three evidence-based QUERI
interventions: 1) extensive training and Drug Enforcement Agency (DEA)
certification of providers to prescribe buprenorphine for cost-
effective maintenance treatment in the over 120 VA facilities where
methadone maintenance is not available, 2) Doubled medication doses in
methadone and buprenorphine maintenance from sub-therapeutic levels to
national guideline levels, and 3) Implemented contingency management
therapies throughout SUD programs.
Question 2. What are the determinants of best practices that
optimize the cost-effectiveness of mental health and substance abuse
care?
Response. Standards for mental health care are driven primarily by
evidence regarding the evidence-base for interventions, with the
philosophy that the most effective care is also the most cost-effective
given VHA's life time commitment to the Veterans we serve. Short term
cost-benefit is not as important as knowing that care is provided that
will decrease current symptoms, increase psychosocial rehabilitation
and recovery, and that have been shown to have the greatest likelihood
of decreasing future relapses. VA and DOD develop Clinical Practice
Guidelines for major mental health conditions. These are developed and
regularly updated to incorporate all of the current evidence on
effective care and also contain information relevant to cost
effectiveness. VHA endorses utilization of these Clinical Practice
Guidelines and they have been incorporated into the Uniform Mental
Health Services Handbook to provide consistent guidance to mental
health providers in the field.
Question 3. With regard to the integration of mental health
services into primary care settings, have any studies measured the
success of these initiatives at various phases of the treatment and
recovery process? For instance, while the integration of mental health
services into the primary care setting may increase access to mental
health services by reducing the stigma for seeking help, has the
primary care setting been effective at retaining patients in need of
more extensive, ongoing mental health care?
Response. Implementation of PC-MHI into routine practice within VHA
is an evidence-based practice supported by prior VA and non-VA
research. PC-MHI implementation began during FY 2007 and expanded with
the requirements of the Uniform Mental Health Services Handbook in FY
2009. Studies presenting data on these implementation efforts have not
presently been published; however, there are several sources of
pertinent data to report:
a. First, significant improvements in screening for depression,
alcohol misuse and PTSD have occurred during the period of PC-MHI
implementation. Specifically, depression screening performance was 83
percent in FY 2008, 93 percent in FY 2009, and 96 percent in FY 2010
(first quarter); alcohol misuse screening was 87 percent in FY 2008, 95
percent in FY 2009, and 97 percent in FY 2010 (first quarter); and PTSD
screening was 79 percent in FY 2008, 94 percent in FY 2009, and 98
percent in FY 2010 (first quarter).
b. Second, a study presently undergoing peer review found that the
prevalence of diagnoses for depression, anxiety, PTSD, and alcohol
abuse increased more from FY 2007 to FY 2008 in facilities with PC-MHI
program encounters than those without such program activity. This
demonstrates PC-MHI program activity is building on screening to
achieve greater case identification.
c. Third, the average number of PC-MHI encounters per unique
Veteran was 2.38 in FY 2008 and 2.42 in FY 2009. This demonstrates
engagement beyond initial case identification within the primary care
setting.
d. Finally, another study presently under peer review found no
decrease in rates of mental health clinic encounters for new patients
by facility PC-MHI status during 2008-2009.
Together, the data above show improvements in screening, case
identification, overall uptake, and retention of Veterans in mental
health care across all care settings within the VHA system.
Question 4. Access to care is a critical concern. Dr. Rudd's
testimony suggested putting providers on college campuses to reach OEF/
OIF veterans. What else should VA be doing to make mental health care
more available?
Response. VHA is implementing the Uniform Mental Health Services
Handbook, designed to ensure consistent access to services for Veterans
in VAMCs and CBOCs. A recent survey of the field indicated that as of
December 31, 2009, the VAMC Handbook implementation rate for VAMCs and
CBOCs was 98 percent.
Among the initiatives that are in place to assist community and
rural health care providers is an Internet Web site with basic
information on assessment and treatment of PTSD designed for college
mental health counselors who, like many community providers, may not
have knowledge about military service or experience treating combat
related PTSD and other disorders associated with war. It can be
accessed on the Internet at www.mentalhealth.va.gov/College/index.asp.
Access to services is supported increasingly by Internet-based
resources such as the VA OEF/OIF web site at www.oefoif.va.gov and the
National Center for PTSD's web site at www.ptsd.va.gov, as well as a VA
presence on social media sites such as Facebook and Twitter.
Other initiatives from OMHS include implementation of Public Law
110-387 (Veterans' Mental Health and Other Care Improvements Act of
2008) Title I, Section 107. Three pilots will be implemented in VISNs
1, 19, 20 to assess the feasibility and advisability of providing
mental health services to OEF/OIF Veterans who reside in rural areas
and do not have ready access to mental health services through VA
facilities. The effort will focus on Veterans who served as members of
the National Guard or Reserves as well as those separated from active
duty. Services will be provided through collaboration with community-
based entities including community mental health centers, the Indian
Health Service (IHS), and other providers. The three VISNs are
negotiating contracts with community providers. It is anticipated that
all the pilot programs will be operating by October 2010 and be
completed by the end of September 2012.
Telehealth capability is being expanded in rural CBOCs and also for
home Telehealth approaches. tele-mental health brings expert clinical
care and consultation services as close as possible to the Veteran.
In addition, VA's RCS has deployed 50 Mobile Vet Centers across the
Nation specifically to meet the needs of rural Veterans and families.
The placement of the 50 Mobile Vet Centers was designed to cover a
national network of designated Veterans Service Areas, inclusive of
every county in the continental US and not to augment the services at
any particular Vet Center.
Question 5. How effectively is VHA utilizing an evidence-based
screening methodology for determining which treatment setting might be
more effective for certain patients with specific risk factors?
Response. VHA is effectively using evidence-based screening for
identifying cases of depression, alcohol misuse and PTSD; performance
for these respective screenings was 96 percent, 97 percent, and 98
percent in the first quarter of FY 2010. Furthermore, primary care-
mental health integration is an evidence-based program that enhances
subsequent evaluation and treatment planning, including identification
of the treatment setting most appropriate to a Veteran's clinical needs
and preferences.
Question 6. In addition to Veterans severely injured and those
returning from combat zones, do any of you have any recommendations for
identifying less obvious groups of veterans who might be at an
increased risk for suicide?
Response. We know the common risk factors for suicide and do screen
for depression and PTSD on a regular, recurring basis. If Veterans
screen positive for these they are then assessed for suicide risk.
Question 7. We know that the stigma associated with mental health
problems is a serious barrier to veterans seeking treatment. What else,
in addition to VA's current efforts to overcome stigma, would be
beneficial?
Response. VHA is implementing the Uniform Mental Health Services
Handbook, designed to ensure consistent access to services for Veterans
in VAMCs and CBOCs. A recent survey of the field indicated that as of
December 31, 2009, the VAMC Handbook implementation rate for VAMCs and
CBOCs was 98 percent.
Among the initiatives that are in place to assist community and
rural health care providers is an Internet Web site with basic
information on assessment and treatment of PTSD designed for college
mental health counselors who, like many community providers, may not
have knowledge about military service or experience treating combat
related PTSD and other disorders associated with war. It can be
accessed on the Internet at www.mentalhealth.va.gov/College/index.asp.
Access to services is supported increasingly by Internet-based
resources such as the VA OEF/OIF web site at www.oefoif.va.gov and the
National Center for PTSD's web site at www.ptsd.va.gov, as well as a VA
presence on social media sites such as Facebook and Twitter.
Other initiatives from OMHS include implementation of Public Law
110-387 (Veterans' Mental Health and Other Care Improvements Act of
2008) Title I, Section 107. Three pilots will be implemented in VISNs
1, 19, 20 to assess the feasibility and advisability of providing
mental health services to OEF/OIF Veterans who reside in rural areas
and do not have ready access to mental health services through VA
facilities. The effort will focus on Veterans who served as members of
the National Guard or Reserves as well as those separated from active
duty. Services will be provided through collaboration with community-
based entities including community mental health centers, the Indian
Health Service (IHS), and other providers. The three VISNs are
negotiating contracts with community providers. It is anticipated that
all the pilot programs will be operating by October 2010 and be
completed by the end of September 2012.
Telehealth capability is being expanded in rural CBOCs and also for
home Telehealth approaches. tele-mental health brings expert clinical
care and consultation services as close as possible to the Veteran.
In addition, VA's RCS has deployed 50 Mobile Vet Centers across the
Nation specifically to meet the needs of rural Veterans and families.
The placement of the 50 Mobile Vet Centers was designed to cover a
national network of designated Veterans Service Areas, inclusive of
every county in the continental US and not to augment the services at
any particular Vet Center.
Question 8. Have male and female veterans differed much in their
treatment outcomes for various models of mental health services? If so,
how well do you believe VA has factored such differences into its
treatment programs?
Response. VA utilizes evidence-based treatments that have been
shown to be effective for both men and women in numerous research
trials, and VA uses adaptations for women as needed and supported by
evidence. Analyzing the impact of gender on outcomes specifically among
Veterans is complicated, and somewhat time-consuming. Women make up
about 10% of our treated patient population, so there is a constant
imbalance in sample sizes that needs to be addressed. This is further
complicated by the fact that female Veterans are disproportionately
younger--a greater percentage of them are from the current OEF/OIF era,
while a greater percentage of male Veterans are from the older, Vietnam
era. The table below documents these trends, showing the numbers of
unique Veterans treated in recent years in Mental Health settings, and
in any VA treatment setting.
These factors skew direct comparisons between all males and
females, or the average male versus the average female. Nonetheless, we
do gather and analyze data on relative utilization, lengths of stay,
and similar variables for male versus female Veterans being served in
specific settings such as Residential Rehabilitation Treatment Programs
(RRTPs).
Within RRTPs, we have observed that:
Women have shorter lengths of stay (approx 2 days);
They are less likely to have an irregular discharge;
They are more likely to be discharged to a VA hospital;
They are less likely to be readmitted; and
They have more outpatient care after discharge than men.
See attached table on outcomes for RRTP programs.
Among patients with Alcohol Use Disorders or Substance Use
Disorders (AUD/SUD), we have observed that women tend to:
engage in specialty treatment at higher rates than men;
stay in treatment longer; and
have better long-term outcomes.
In short, women tend to be more comfortable seeking help for AUD/
SUD treatment as it is generally provided.
However, other studies, including some in VA, have found that women
with SUD may have more psychiatric comorbidities and additional
psychosocial challenges which may complicate treatment engagement and
recovery.
VA has been putting efforts into making specialty SUD treatment
more appealing and accessible for Veterans of both genders. Recognizing
that women Veterans may be more likely to reach specialty care, but
have special needs once engaged, VA has been developing a special mix
of services for female Veterans at its specialty SUD treatment
programs. In FY 2008, approximately one-third of VA specialty SUD
treatment clinics offered specific treatment services for women, and we
(who is WE?) VHA expects these services will continue to expand.
Among Veterans with Serious Mental Illness (SMI), a group of VA
researchers reported in 2008 a number of gender differences they
observed. They found that the females in their sample, as compared to
males, were:
younger;
more likely to be diagnosed as having bipolar disorder;
more likely to have completed a high school education;
more likely to be employed;
less likely to be married; and
more likely to live alone.
In addition, female respondents in the study reported greater use
of health services outside of the VA. In this study, the female
Veterans were found to have more severe symptoms on average, but rated
their own self-perceived health and mental health more positively.
Among Veterans with Post Traumatic Stress Disorder (PTSD), we have
observed that women treated in intensive PTSD programs had:
Significantly lower PTSD symptoms;
Significantly lower alcohol use scores (ASI);
No difference in drug use scores;
No difference in reports of violence;
No difference in days worked; and
No difference in satisfaction with care.
In short, there is a complex pattern of gender differences observed
among the Veterans treated in the VA. VA continues to recognize and
respond to gender-based differences and needs. Clinicians or officials
continue to monitor the impacts our programs have on men and women, and
continue to make adjustments in the delivery of services in response to
any patterns observed.
Question 9. Do you believe VHA is conducting adequate ongoing
analysis of its suicide reduction programs to determine the most
effective strategies to reduce suicide?
Response. We believe that VHA is conducting extremely thorough
analyses of its suicide reduction programs. All of the following are
done:
We continually analyze available data to look at rates and
effectiveness.
We require a monthly report from each facility which is
reviewed to identify trends, not only in numbers but also risk factors
and care elements.
We do annual aggregate reviews on both suicides and
suicide attempts.
Our Evaluation Center in Ann Arbor, MI is continually
looking at VA information in regards to national data.
We have weekly meetings with the Suicide Prevention Staff
and the Evaluation Center to continue to look at the information we
have to provide the most current information to the field. Recently, we
have released two memorandums to field staff to ensure they are aware
of recent suicide risk findings. A direct result of these weekly
reviews has been a memo concerning the relationship between pain and
suicide and another memo concerning suicide risk in patients with
Traumatic Brain Injury (TBI).
Chairman Akaka. Thank you very much, Dr. Cross.
Dr. Thompson, do you have any further comments for me?
Ms. Thompson. It is just such an honor to be here today and
especially to be representing the staff of 160 hotline
responders and their staff who are up in Little Canandaigua,
New York.
I do have a story that I would like to tell about one of
the rescues that we had. I am just going to tell it. This
happened in October. At about 1 p.m., one of my colleagues took
a call from a Vietnam veteran in his 60s who said that he was
on his way into a Wal-Mart to purchase razor blades for the
sole purpose of killing himself. As Bruce, my colleague, tried
to gather more information from the veteran, he hung up. He
tried to call back, but there was no answer, and the veteran
appeared to use a cell phone, which is sometimes really hard to
trace.
About a half-hour later, another colleague--her name is
Gloria--answered the call of a veteran who told her that he had
purchased razor blades and was going to kill himself. Again,
Gloria tried to keep him on the phone, trying to engage him,
asking about his location, but the veteran again hung up. Our
staff tried to pinpoint his location through his phone number,
but we couldn't. There wasn't enough information.
Finally, 20 minutes passed again and this time it was my
hotline phone that rang. An older man started to yell that he
was bleeding. He had slit open his wrists with broken razor
blades, he had told me. I tried to calm him down, asking him to
tell me where he was, but he initially refused. He didn't want
me to send help. He wanted to die, he told me. He was homeless,
lost contact with his family. He said that he really had
nothing to live for.
I tried to work through why he was actually calling. Just
that very act of picking up a telephone and dialing a number
for a suicide hotline usually signifies an ambivalence that
people really--whether or not they do or they don't want to
die. I was able to keep him on the line, and as we talked, he
would vacillate between saying that he wanted to die and he
wanted to live. And then the conversation was just punctuated
by these moments when he would panic and scream about his
bleeding and begging me to help him.
Of course, my first priority was to keep him engaged and
awake and also to gather as much information about his location
as possible so that rescue could be sent immediately. After a
while, he started to give clues. He said he was near a dumpster
in an Applebee's parking lot. He was wearing a green T-shirt
and jeans. He was in a small town in North Carolina. And
finally, he told me the intersection near the parking lot. With
that, he hung up the phone.
And with the help of other hotline staff and local North
Carolina authorities, we found him within 15 minutes. He was
still alive. He was taken to a local hospital and then had
continued care with his suicide prevention coordinator at his
local VA.
And I tell this story because it is so indicative of the
stories that happen every day. It illustrates so powerfully how
this immediate access to mental health professionals over the
phone can save lives. Even though this veteran wasn't able to
engage immediately and accept the help that he needed within
the first couple calls, he just continued to call back until he
was ready to engage and we were always ready for him. So I just
happened to be the responder who answered the phone when he was
ready.
Thank you for letting me tell this story.
Chairman Akaka. Thank you very much, Dr. Thompson.
Dr. Cross, thank you for sharing the chart on the reduction
in suicides for VA patients. It is good to see rates going down
for VA patients. Dr. Cross, does this chart represent suicides
for all patients or does this chart just represent suicides
that have occurred related to an inpatient stay?
Dr. Cross. Sir, these were folks who have engaged with any
part of our VA Health Care programs, inpatient, outpatient, and
we worked with the CDC to get the national death index data and
we bump up our enrollees, or the folks who are using our
services, against that data set. It is probably the best data
we have. That is the most current data, by the way, from the
CDC that is available. It takes--there is a little bit of lag
time.
Chairman Akaka. Dr. Thompson, at the outset, thank you for
what you do on behalf of veterans. I believe the suicide
prevention lifeline is one of the great successes in the fight
against suicide. Can you illustrate for us what one of the
calls you take might sound like?
Ms. Thompson. What it would sound like? Well, the person--
you mean what the veteran would sound like when he calls?
Chairman Akaka. Yes.
Ms. Thompson. It really--it varies so greatly. We have
calls from veterans who are just coming home, so from ages 18
to over 80. We have had World War II veterans who also call.
Many times, their calls are, I am not quite sure why I am
calling. I am not sure if this is the right place for me. Or if
there is an immediate crisis, then there is a serious panic. We
are also getting so many calls from family and friends who are
calling for their veterans who don't know what to do and this
is their first way to reach out. So it certainly varies quite a
bit.
Chairman Akaka. Thank you.
We will have a second round. Let me pass it on to Senator
Burr for his questions.
Senator Burr. Dr. Cross, welcome, and to your talented
team, I thank all of you for your commitment to our country's
veterans.
Dr. Thompson, let me ask you, I found it shocking, because
we have been focused on OEF and OIF--that seems to be the
immediacy that we are dealing with, and all of a sudden you
tell us a story about a Vietnam veteran. How do the counseling
techniques differ from a Vietnam veteran to a veteran that you
might get a call from today that is out of Iraq or Afghanistan;
or do they?
Ms. Thompson. They differ in the way that we have to manage
how raw the emotions are, particularly for the OEF/OIF veteran.
The memories are so fresh, so at times, we will have to talk
veterans down from flashbacks, for instance, in the middle of
the night if they are calling, and those tend to occur more
frequently with our newer veterans coming home.
I wouldn't say that the counseling techniques vary
dramatically. Our immediate assessment is of safety and of
their risk of suicide and whether or not they have means at
home. And then what goes on from there is just support and
attempting to get them as quickly as possible connected with
their local services and their local VA. So I wouldn't say that
it varies too dramatically.
Senator Burr. OK. And again, I want to reiterate what the
Chairman said. A great deal of congratulations on the direction
of the trend right now, that we are doing much better, and I
think we are learning. But let me go to Mr. Hanson's story
specifically. I would like to get an idea from you as to once
you take that phone call, and this was Daniel Hanson calling in
this case, and you have walked him back from the ledge, you
have referred him to a VA service, what follow-up happens, if
any, on the handoff of him to that local VA entity. Is there
any boot in the butt, to use the terminology he and I used,
that happens? Is there an offensive effort on the part of the
local VA with that individual, not waiting for Mr. Hanson to
call, that they call him?
And then I will go back to Dr. Cross just to address, is
there more we can do when you have got a clinician that is
working with somebody that has finally opened up to them and
said, you know, I do think about this. I do think about this.
Well, we have got this service, this service, and this service.
Do we need to do more to actively get them involved, enrolled,
treated?
Ms. Thompson. So the hotline has this wonderful
collaboration with each of the local VAs across the country and
the suicide prevention coordinators at each of those VAs. If
anybody calls and they are--if any of our veterans calls--if
Mr. Hanson had called and said, yes, I would like to be
connected with the suicide prevention coordinator, that suicide
prevention coordinator would have called him within 24 hours,
hands down. So that always happens. There is always a reaching
out. And then the hotline follows up to ensure that that
handoff happened.
From there, the Suicide Prevention Coordinators, and Dr.
Kemp may be able to speak more about this in terms of how much
they attempt to find the person. But there is always a real
effort to follow up with the veteran.
Senator Burr. So let me go to you, Dr. Cross. Is the red
flag that she gets different than the red flag that a clinician
might get when they have got the veteran in seeing them on a
regular treatment basis and the veteran says, you know, yes,
last night, I thought about suicide. Does the same red flag go
off?
Dr. Cross. You know, Senator Burr, your opening question
was, is there more that should be done, and my response is, I
think, in my view, there is always more to be done with any
situation, however complex it may be, and that situation
sounded pretty darn complex to me. We can always find more
somewhere within the system, some other route that we can
pursue, and we should do that.
One of those routes, by the way, is our Vet Centers. A
great program that we have, and I think we are going to have
about 299 of them by the end of the year. Dr. Al Batres is in
the audience and runs that program. Sometimes that provides an
alternative venue, a different kind of feel, maybe a little bit
less--a lot less bureaucratic, very focused on combat veterans
being treated by combat veterans themselves. Sometimes those
different venues work for the different situations and we have
those available. So that would have been a good resource in
that situation.
Senator Burr. Just one statement, and with the Chair's
indulgence, I will ask one last question. I know I have got
colleagues that are here. I can't stay for a second round, and
so I will be very quick.
I sense that if the call went to Dr. Thompson's area, that
it would initiate a very proactive effort on the part of the VA
entity to connect with this person and to pull them in. I am
not sure from Mr. Hanson's experience being inpatient when he
talked about suicide it initiated the same proactive effort. It
was more of a buffet presentation of services that he might
look at taking advantage of, and that may be an area we want to
look at. You may tell me the data shows everybody that walks in
at some point mentions this, so everybody would be in a
proactive state. I personally believe the earlier we can get
them into treatment, the longer we can keep them there, the
less likely we are to get a phone call to Dr. Thompson's area,
and I think the goal should be to make sure that we don't need
the functions that her area actually does. That is the best
data.
I want to go very quickly, though, to the treatment that
Mr. Hanson did find that worked for him. It is community-based,
and I think it is faith-based. How open are we at VA to look at
contract partnerships for efforts, not just exclusively rural
because we don't have a facility close enough or a treatment
plan, but say we have identified a program that has a proven
track record of working--and as we weed through and find we
need to look at other maybe non-traditional ways to do it, that
we are willing to insert people into those programs?
Dr. Cross. Senator, I am going to ask Dr. Zeiss to comment
just a bit more, but I was pleased to see the representative
from NAMI here today discuss the relationship that we have with
them out in the civilian community. You know, from a budgetary
point of view, we are spending about $4 billion a year on
various types of fee-based services out in the community. A
portion of that is related to mental health. But I would like
to ask Dr. Zeiss to comment.
Ms. Zeiss. Well, I am happy to do that. I think that Mr.
Hanson's case is very complex and it is important for us to
think through together what could VA do, what more should we be
thinking about doing, and what kind of partnerships would make
sense.
I think that there have been some changes since his time
with VA. We are constantly trying to improve. Some things we
have already done that might have made it different for him: we
now require that everyone receiving mental health care have a
principal mental health provider. A person who is receiving
multiple services, as he was, would be assigned someone who is
that core central person who he could feel cares about him,
would know him best, would be the person to turn to to get a
more clear sense of how to integrate different treatment
components. We think that can make a difference.
We also have instituted throughout the system far more
intensive outpatient programs. So instead of 1 hour a week,
which we agree for the complexity he is describing would not be
sufficient, these are at least 3 hours a day, at least 3 days a
week, with an interdisciplinary team working to deliver very
complex and intensive services.
There are other things. I could go on. We have been trying
to bolster many of the kinds of gaps that he describes and that
we also saw and have been very committed to filling.
In addition, we completely agree with statements that we
need to have partnerships, that we can't do it alone, which we
need to continue to explore. If there is a level of care that
VA is not able to provide in rural or in urban or suburban
settings, we should look for what are well-tested programs. We
do have the mechanisms for doing either fee-basis or contract
care, and the Uniformed Mental Health Services Handbook does
mandate that people should look at those if there is something
beyond what VA is able to provide.
Again, we need to keep looking at how well our advancements
might help cases like Mr. Hanson's that we weren't ready for a
few years ago. But we also need to continue to look at
partnerships.
Senator Burr. Thank you for that answer. More importantly,
thank you for the ever-changing treatment process that we go
through. It does prove that the VA is listening and learning
and making every effort to try to pass that on to the veterans.
Thank you, Mr. Chairman. Thank you.
Chairman Akaka. Thank you, Senator Burr.
Senator Murray, your questions.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Mr. Chairman. I really
appreciate your having this hearing. It is an extremely
important issue that affects so many people and their families
and their communities and everyone around them. How we deal
with this issue, I think, is really visible to our men and
women who serve, that we are going to be there for them when
they come home. So I really appreciate the focus on this.
I want to thank all the witnesses who are here today,
especially those who are sharing their personal stories. I know
how difficult it is and challenging to you, yet it helps us
understand what you go through so that we can make sure we have
got the right resources and are doing the right thing at the
VA. So, I really appreciate that, in particular.
Mr. Chairman, everything is exacerbated for a man or woman
coming home from service, particularly in this tough economic
time when they are struggling to get a job, when they are
dealing with PTSD issues, mental health issues, and coming home
in this current economic climate. Not being able to find a job
exacerbates it for a lot of our men and women who have served
us.
I have been looking at this issue of employment and
veterans and have been working on legislation that I hope to
introduce shortly to help our veterans when they come home to
get a job and to feel more secure as part of this piece of the
puzzle, to help them feel more stable and secure versus going
to the downward cycle that we have seen so many of our veterans
go. So I will be looking forward to sharing that with all of
you and getting your input on it.
One of the things that concerns me on this issue in
particular is that veterans who come home and have PTSD,
suicidal behavior, or mental health issues, require intensive
care for a very long time. It isn't just a matter of a few days
or a few weeks or a few months or even a few years. We know
that triggers for relapse--whether it is marital issues or
inability to find and hold a job, as I just talked about--exist
in everyday life for everyone, and we know that a lot of our
veterans self-medicate to deal with those issues which
contributes to this, as well.
I understand that the VA is working really hard now to deal
with PTSD and provide care for those who are affected, but how
are you working to transition them from their intensive care
regime that you are providing back into civilian life for the
long-term?
Dr. Cross. Senator, let me ask Dr. Zeiss and Dr. Kemp both
if they could comment on that.
Ms. Zeiss. Well, we agree with you very much about veterans
returning to work and to full roles in the community, at school
for many returning veterans, which we expect will ultimately
lead to work, but also being part of their families, their
places of worship, all those community roles that are
important. We are working with the Department of Labor. They
have a wonderful program called Heroes at Work that you are
probably aware of.
We also have within mental health a strong compensated work
therapy and supported employment program. So, if it is mental
health problems that are preventing people from being able to
find or keep a job, part of their mental health plan can be
utilizing these vocational rehabilitation programs. Those are
designed to get them back to work in the community.
The success of those programs is pretty great, and we are
happy to gather some information for you about that, given your
interest in employment.
[The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to
Antonette Zeiss, Ph.D., Associate Deputy Chief Consultant and Chief
Psychologist, Office of Mental Health Services, U.S. Department of
Veterans Affairs
Question. Senator Murray requested information on VA Office of
Mental Health Services (OMHS) efforts to assist Veterans with
employment issues.
Response. OMHS provides work restoration and employment services
for Veterans with mental health problems through its Compensated Work
Therapy (CWT) and vocational rehabilitation programs. These programs
are incorporated into the Veteran's treatment as part of VHA's
comprehensive efforts to improve community integration for Veterans.
CWT is authorized by 38 U.S.C. Section 1718 to provide work skills
training and career enhancement, job development and placement, and
post-employment support services. As a part of Patient Care Services,
Therapeutic and Supported Employment Services within OMHS, administers
the CWT programs. VA service connection is not required to receive
treatment in CWT, nor can VA benefits be reduced, denied, or
discontinued based on participation. Only individuals with Veteran
status who are eligible for VHA services can participate, and a VHA
clinical referral is required.
Per VHA Handbook 1160.01, Uniform Mental Health Services in VA
medical centers and Clinics, each medical center must offer Therapeutic
and Supported Employment Services to Veterans who are receiving care
through VA and who have a mental health diagnosis with associated
functional impairment and whose treatment plan includes a goal for the
Veteran to receive employment assistance. Therapeutic and Supported
Employment Services guide the CWT programs, which consist of both the
Transitional Work program and the Supported Employment program. CWT
partnerships for both Transitional Work and Supported Employment are
developed through Memoranda of Agreement with Federal Government
agencies, county and state entities, and local businesses.
Transitional Work for involved Veterans occurs in a variety of work
settings at all VA medical centers as well as in partnership with
community employers. Veterans work a specified number of hours per week
under the direct supervision of VHA staff or private company employees
in their Transitional Work assignment. Transitional Work placements are
generally time limited, and participants receive compensation at or
above the Federal or state minimum wage (whichever is greater).
Participants are paid at wages commensurate with comparable wages for
workers employed in the community. There is no employer-employee
relationship between VA, participating companies or organizations, and
Veterans for those in Transitional Work experiences.
Supported Employment is an evidence-based practice integrating
vocational services into treatment at the earliest possible time for
individuals with severe mental illness. The primary focus of Supported
Employment is to provide the on-going support services--including
workplace accommodations and on-the-job support--these Veterans need to
obtain and maintain employment. Supported Employment positions are
developed in both public and private sector businesses, and individuals
are not prevented from receiving Supported Employment services because
of the lack of prior work history or vocational goal.
In FY 2009, Transitional Work and Supported Employment served over
30,000 Veterans at 169 VHA locations, and Veterans earned in excess of
$50 million. The personnel expenditure for the CWT programs in
combination for FY 2009 was $26,000,000. Approximately 40% of Veterans
participating in any component of CWT secure competitive employment at
the time of discharge from the program (including approximately 70% of
Transitional Work Veterans and approximately 25% of Supported
Employment Veterans).
Ms. Zeiss. In addition, there is this kind of interesting
relationship between Mr. Hanson's situation and his need for
more long-term possibly inpatient care and evidence that, in
many ways, having care provided in an outpatient environment
that is intensive enough to meet the complexity and severity of
the problems and which keeps people connected with their
families and their communities and where the family can be a
part of the treatment is one of the things we also really want
to emphasize and make sure that we are thinking about--not just
treating the individual mental health problem of the veteran,
but treating that in the context of his home situation, his
family, and making sure that we are supporting re-entry and the
ability to recover and thrive in the community.
Senator Murray. I think that is really important, because
we can't just treat this like coming to the VA with a cold and
we are sending you home.
Ms. Zeiss. Absolutely.
Senator Murray. And the transition and long-term support of
this is extremely important and I will be exploring that more
as I put my legislation together, so I appreciate that.
Dr. Cross, I wanted to ask you, because I was deeply
disturbed, as I think everyone was, by the news in January that
the VA's preliminary data shows a dramatic increase in veteran
suicide between 2005 and 2007. The fact that our veterans are
serving and sacrificing only to return to spiral into this
depression and suicide is appalling, I think, to all of us.
The preliminary data did suggest that access to VA service
does make a difference in suicide prevention. That is good
news. But if we are truly going to make a difference, the VA
needs a more comprehensive effort. These numbers show that the
duty of providing mental health services and outreach to
returning veterans is still a challenge at the VA. The 2008
RAND study revealed that nearly 20 percent of military
servicemembers who have returned from Iraq and Afghanistan
reported symptoms of post traumatic stress or major depression,
but only half sought treatment.
So I wanted to ask--it has been 9 years for the post-9/11
war effort. What the VA is doing, is it a matter of resources?
Is it a matter of hiring people? Is it a matter of greater
attention? What is it we could be doing to dramatically turn
this around?
Dr. Cross. Senator Murray, I would like to ask Dr. Kemp,
sitting right next to me, who is the Director of the Suicide
Hotline, to talk in just a moment about the specific part on
the rates and so forth.
You know, I think the biggest challenge that we have is
getting folks to come in and getting them engaged in treatment.
We were concerned when looking at the numbers coming back from
OIF and OEF, the numbers of soldiers who had not yet come in
for any health care-related service. So we have a program
called Seven Touches, where through a variety of mechanisms
that we reach out to them.
One of those, by the way, was we called them all. We hired
a contractor to make 700,000 phone calls and called every one
of them. We made 500,000 contacts of them. We found that we got
wrong phone numbers, and sometimes they had left off--they had
changed their phone number when they went over for deployment,
shut down their phone line, shut down their address, and so the
information we had was incorrect. We then hired a detective
agency to go find the new phone numbers and feed them to the
contractor to make those calls. As a result of that, or
partially as a result of that, at least a couple hundred
thousand people are now in our health care system that might
not have been otherwise.
A key point for me is there is no one mechanism of outreach
that is going to work for everybody. Sending a letter out is
very nice. It probably doesn't work that well.
You know, the thing that really matters, ultimately, is
looking somebody in the eye, being there personally, being
onsite, and talking to them by saying, hey, I am from the VA. I
am available. So, we are doing that at the post-deployment
sessions. Our Vet Center staff and others, our medical services
staff, go out there and do that face-to-face.
Senator Murray. With the veteran.
Dr. Cross. With the veteran----
Senator Murray. Are you working with the families----
Dr. Cross [continuing]. With the servicemembers returning.
Senator Murray [continuing]. And the employers and the
schools and everywhere else the VA might touch so they know
that----
Dr. Cross. Part of the Yellow Ribbon effort is related to
families. But I am going to ask Dr. Kemp to talk about that.
And if I have a chance, I would really like to have Dr. Batres
talk about some of his work in outreach, as well.
Senator Murray. OK.
Ms. Kemp. Thank you, Senator, for your question. I think it
is incredibly important. In my written testimony, I do explain
a little bit more about how we got some of the rate information
that we are presenting.
One of the issues within the VA is when we look at what we
call the case mix of people that we care for. It is higher than
in the general population, which means that when we look at
veterans who come back and have taken the Post-Deployment
Health Screening, out of those who screen positive for PTSD and
depression, they are more likely to come to the VA for care,
which is, in essence, a good thing. They are the people who
really do need us immediately.
But it does give us a population that is somewhat different
than the rest of the country when we are working with people
with mental illness and who do show some evidence of suicide
risk. So we are dealing with a little different population to
begin with, and the fact that we have been able to decrease the
rates of suicide among veterans who get care at the VA, then it
is a really very positive----
Senator Murray. Yes, I know the chart, but that doesn't
show--that is only inpatient data, right? That is not clinics?
Ms. Kemp. It is all patients who receive care in any--who
touch the VA in any way.
Senator Murray. OK, but it doesn't include veterans who
have not----
Ms. Kemp. It does--right. Right. So I think we have--and
people have brought it up a couple of times today--there is
that group of people that we don't see and that we don't touch,
and while their rates are remaining constant or in general
probably they are at higher risk for suicide, we are obligated
morally and ethically to try to find them.
So we have done several new outreach programs with the
Suicide Prevention Coordinators. They are required at their
sites to do five programs a month now out in their communities,
and not just the communities where the medical centers are, but
the communities within their network of care; so communities
where all the community-based clinics are and surrounding
areas.
We have developed a program called Operation Save, which is
the VA version of a gatekeeper program which is veteran-
specific, and we have provided this thousands of times in
various communities over the past year across the country and
will continue to do so.
The Suicide Prevention Coordinators themselves go to the
Yellow Ribbon events and the post-deployment events to make
sure that people have the number, the information, know how to
get in touch with us. We have worked with the Department of
Defense to develop materials and programs that are similar to
theirs so that especially families are comfortable with the
materials that they get and they know what it means. It
provides our access information, like the ACE program for
suicide prevention which is now a program that goes through the
DOD and VA.
We have done a great deal of public media campaigning. We
have had posters on buses and mass transport situations across
the country. We have had Public Service Announcements--I don't
know if you have seen them--by Gary Sinise and Deborah
Norville, which have been immensely successful.
We just completed work with SAMHSA to do a series of focus
groups for younger veterans in rural areas to see if the
message that we are trying to get across is resonating with
them. And to be honest, we found out that it is not always,
that they are sometimes not relating to some of these posters
and the Public Service Announcements that we have done. So we
are reworking those quickly to provide a different message.
They like the flags. They like the patriotic message. We didn't
always get the symbols right. We didn't get the right uniforms
on the right people asking the right questions. So we are
quickly trying to work that out.
I think it is, as we talked about earlier, not just a VA
problem. This is a national issue and we all have to work
together to get that number out. We chose to use the National
Suicide Prevention number for a reason, so that people would
not have a different number than their spouses or their
families or their coworkers. And if people see other people
asking for help, it makes it a little easier for them to ask.
So the things that Dr. Rudd said about messaging are extremely
important, and we know we have to work hard to do that.
Senator Murray. And do you have the resources? Have we
given you enough----
Ms. Kemp. We do have the resources to do that, but we need
your continued help to do it outside the VA, too. You know, one
of the stigma issues is that this is not just a veteran
problem, either. This is a national problem and we are all in
this together. It is OK for everybody to get help, and veterans
deserve the help in very special ways. And we are here for
them.
Senator Murray. Mr. Chairman, I have gone way over my time.
Dr. Cross, did you have someone else you wanted to speak?
With the Chairman's permission, if we could----
Mr. Rudd. Dr. Batres runs the Vet Centers, one of our
highly successful programs, and I want him to talk about
outreach for a moment, as well.
Senator Murray. Mr. Chairman, if you wouldn't mind, if he
could respond to that.
Mr. Batres. Good morning, Senator Murray. A couple of
things. One is the increase in Vet Centers that I want to flag
out. We have gone from 232 to almost 300 by the end of this
fiscal year. So there has been an increase in our services in
that fashion.
Inherent in that is who we hire, and over 33 percent, more
than a third of all my employees have served in Iraq and
Afghanistan, and they are the ones who are staffing and they
tend to reflect the community. And that, to me, is an important
transformational change, that we need to hire the young folks
to balance the old folks, like myself, in terms of connecting
and doing the outreach, because that is a very important
component.
I believe I am free to talk about this, but we are going to
be hiring a trained family therapist at every Vet Center. And
so at every Vet Center, we will have the capacity to see
families, because that is an increasing need for the veterans
who are coming out, and be more integrated----
Senator Murray. What is your timeline for having that?
Mr. Batres. We are hoping to hire 70 by the end of this
fiscal year, but 180 by the end of next year, and we do have
the funding, because I am sure that will be the second
question. The Secretary has approved that and we are moving
forward in doing that.
We are also exploring and have committed part of our
outreach to OEF/OIF women veterans because of the increasing
number of them. So when we talk family therapy, sometimes the
recipient is not a male but a female who is married to a combat
veteran who is female, and we are embracing all of those
challenges and trying to do the best we can to address that.
The other element that Dr. Cross referred to was our 50
Mobile Vet Centers that are now canvassing areas, in particular
VMOBE sites, outreach, PDHRAs, which gives us a lot of capacity
to address those issues more directly; and our partnerships
with some other organizations like the Wounded Warrior Project
and other groups where we are recruiting returning troops early
on with their family members and providing activities for them
together so that we can engage the family more in educating
them about the returning needs of veterans.
I hope my response is helpful.
Senator Murray. OK, that is, and Mr. Chairman, if you
wouldn't mind, he brought up women veterans. I just wanted to
ask about inpatient facility care for women veterans. They have
very few options, and of the $218 million in the President's
budget geared toward women veterans, are there funds to expand
that capability?
Dr. Cross. Yes, Senator, and I would like Dr. Zeiss to give
you some more details on what we are going to do.
Ms. Zeiss. Well, first of all, we make a distinction within
VA that I think is an important one between inpatient and
residential rehabilitation and we need to make efforts in both
those arenas. They offer different levels and types of care.
Currently, in terms of classic acute inpatient--that would
be a very short length of stay for someone at risk of harm to
themselves or others--we have not tried to establish separate
women's inpatient units but to create in our current units
areas that are separated, where the woman has the opportunity
to lock her door, although staff can access it certainly since
there might be suicide risk; to create greater safety and
security, emotionally, and psychologically for women veterans;
and to increase our staff with providers who are sensitive to
women's issues and who can then provide care in those settings.
We do track the percent of women mental health staff that
we have since one of the requirements is that women can request
a mental health provider of the same gender, or opposite gender
if they prefer, and we do have sufficient staff to do that.
Senator Murray. Can I interrupt you? So you are saying that
you are establishing a room for women in the facilities----
Ms. Zeiss. A section.
Senator Murray. Anecdotally, most women tell me that
military sexual trauma is a part of their experience. So
putting them into a facility with men is really intimidating.
Ms. Zeiss. Right. Well, and that is why I wanted to make
the distinction to the residential rehabilitation facilities,
which are a longer stay, deal with not that immediate urgent
need but with the needs of women who may have mental health
disorders after military sexual trauma or for other reasons,
you know, after a combat experience.
We do have an increasing number of women-only units for the
residential rehabilitation for treatment of PTSD and other
mental health problems. They have staff that are very sensitive
to the needs of women veterans. We have been gradually growing
those and follow closely how fully they are utilized and how we
need to keep expanding such units as the number of women
veterans continues to grow and they continue to enter VA at a
very high rate. So we will be expanding those programs.
Senator Murray. All right. Well, my time is way over, so if
I could explore with you outside the Committee hearing where
those are and where the numbers are----
Ms. Zeiss. Sure.
Senator Murray [continuing]. Because I am hearing a lot
there is not enough mental health----
Ms. Zeiss. We would be happy to.
[The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to
Antonette Zeiss, Ph.D., Associate Deputy Chief Consultant and Chief
Psychologist, Office of Mental Health Services, U.S. Department of
Veterans Affairs
Question. Are there Mental Health Residential Rehabilitation and
Treatment Programs (MH RRTP) that provide separate physical areas for
women Veterans?
Response. MH RRTPs provide residential treatment in a 24-hour,
seven days per week, supervised and therapeutic milieu for Veterans in
need of more intensive treatment of mental health conditions and/or
addictive disorders. All MH RRTPs have the capacity to serve women
Veterans. In Fiscal Year (FY) 2009, there were a total of 237
operational MH RRTPs providing more than 8440 treatment beds which
includes 252 beds dedicated to women Veterans in 35 of the programs
(North East Program Evaluation Center, NEPEC). Women Veterans comprised
5.2% (1,789) of the total episodes of care in MH RRTP in FY 2009
(NEPEC).
VA has initiated numerous enhancements to ensure the privacy,
safety and security of women Veterans. In January 2008, all MH RRTP
were mandated and funded to provide 24/7 on-site supervision, keyless
entry and locks for all female bedrooms and bathrooms as well as closed
circuit monitoring of all public areas. By January 2009, all programs
reported 100% compliance to VA Central Office. Further, the MH RRTP
Handbook released in May 2009, addresses the unique needs of women
Veterans by requiring that all MH RRTP must maintain environments that
support women Veterans' dignity, respect and safety; separate and
secure sleeping and bathroom arrangements must be provided for women
Veterans; that gender-specific treatment and rehabilitation services be
available and that services provided to women Veterans must be on par
with services for male Veterans.
Senator Murray. Thank you. Thank you, Mr. Chairman. I
apologize.
Chairman Akaka. Thank you very much, Senator Murray.
Dr. Thompson, at the outset, again, I want to thank you on
behalf of our veterans. I believe that your work has made a
difference and we want to continue to move in the areas where
we can kind of get the help.
Dr. Zeiss, the veterans outreach is one of my primary
concerns. VA certainly has a number of excellent VA initiatives
in this regard. A compelling op-ed in today's Washington Post
on suicides makes the point that when someone at risk of
suicide makes a decision to take their own life, it becomes
difficult to change their mind. Everything they see and do
reinforces their decision.
Dr. Zeiss, with that in mind, what else can VA do to reach
out to more veterans and bring them into the VA health care
system?
Ms. Zeiss. Well, I am happy to answer that, but I think
there are others here on the panel who also can address that.
In the Office of Mental Health Services, our suicide
prevention plan begins with the notion that the best suicide
prevention is good mental health care that will address needs
before people get to the point of being in suicidal crisis. So
we have developed very effective mechanisms to help people who
are in suicidal crisis that Dr. Kemp and Dr. Thompson can talk
about, and they do guide many outreach efforts.
In addition, we have bolstered our basic mental health
services and we have tried very much to get the word out about
that so that veterans who may have thought that if they came to
VA, we really did not have the staffing or the programs or the
commitment to serve their needs, can hear that, in fact, we
have hired over 5,000 new mental health staff in the last few
years, we have new programs, we have the capacity and, very
strongly, the commitment to help them.
Our office does outreach primarily through the Suicide
Prevention Coordinator program, so I would want Dr. Kemp to
speak to that. We also try to collaborate and support the
excellent efforts of the Vet Centers, who are very committed to
outreach efforts.
I think what our office has tried to do and will continue
to try to do in terms of outreach is to support the Post-
Deployment Health Reassessments by joining the Vet Center staff
who are always there. They have staff who can meet with the
veteran face-to-face, help him get enrolled in VA right at the
Post-Deployment Health Reassessment if they are Reserve, Guard,
or other separated veterans, and make sure that they get linked
to primary care and to any mental health appointments that they
should need.
We also work with SAMHSA to try to get out destigmatizing
messages and to try to let the country know what is available
for veterans and the importance of coming in to receive mental
health care.
We certainly agree there is always more we can do, so we
are open to other ideas.
Chairman Akaka. Are there any further comments on this from
the panel? Dr. Kemp?
Ms. Kemp. You know, again, thank you for the question.
Monday, I had the opportunity to speak here in Washington to a
convention of American Legion commanders who were here wanting
to know--what they wanted to know from me is what they could do
to make a difference. One of the things that we talked about
was setting an example for both our newer veterans and their
friends, a lot of older veterans across America, and just
letting them know that it is OK to get help. We discussed ways
that we could provide all of the Legionnaires across the
country with Operation Safe Training so that they would know
the signs and symptoms of someone having difficulty and how to
get them services.
At this point, one of our biggest outreach needs, I
believe, is for the community to be aware of what we do and
what we offer, and help each other get our services. That is
our goal.
The American Legion, by the way, has really pledged their
support to this effort, so it is an exciting opportunity for
us.
I think, also, leadership at all levels needs to set
examples and people need to know, again, that it is OK to ask
for services and to tell us that they are in trouble. When
community leaders, political leaders, their military leaders
set those examples, it is our obligation to be there to provide
those services that people are seeking. We can help them with
those messages, but we need everybody's help in this effort.
Chairman Akaka. Are there any further comments on that
question?
Otherwise, Dr. Cross and Dr. Kemp, we have two different
answers with regard to what this important chart shows. For the
record, is this all points of care, clinics included, or only
inpatient settings?
Ms. Kemp. My understanding is that this chart represents
all points of care, and the numbers that I have worked with and
that are in my written testimony deal with veterans who utilize
any point of care within the VA system.
Chairman Akaka. Dr. Cross, do you have any further comments
on that?
Dr. Cross. No, sir. That is my understanding, as well.
Chairman Akaka. Yes. Well, in closing, again, I want to
thank all of you for appearing today. Your contribution is
important as this Committee moves forward on improving VA's
mental health care and suicide prevention efforts. With rising
suicide rates, these issues are all too pressing for all of us.
For me and for this Committee, our focus is ensuring that VA
fully implements all the mental health programs that have been
authorized in recent years. VA now has resources and the tools
with which to help veterans in need. We still are searching for
at what point we can determine who needs the help and to try to
get them into the services that are available, and we need to
also work with the active service side before they become
veterans.
So, this is something we will continue to work on. We look
forward to partnering with you in doing this and also with the
community and, of course, the families. So all of us working
together, we think we can help the cause of preventing
suicides.
So with this, thank you very much again. This hearing is
now adjourned.
[Whereupon, at 11:25 a.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Roland W. Burris,
U.S. Senator from Illinois
Thank you Mr. Chairman, and thank you to our witnesses for being
here today. Every time a veteran commits suicide in our country, the VA
has failed in its responsibilities. It is the charge of VA, and this
Committee, to continue working until no veteran falls through the
cracks and every veteran gets the mental health services that he or she
needs.
The 2004 VA Mental Health Strategic Plan was a good start, and
Senator Akaka's 2008 mental health improvement bill took further
strides in addressing substance abuse and co-morbid disorders. These
efforts have led to some great successes, and likely saved thousands of
lives. However, clearly, we are not doing enough, in either the VA OR
Department of Defense. Suicide rates continue to climb, and suicide now
claims more lives from our Armed Forces than war efforts in the Middle
East.
I am anxious to hear the expertise and experience of our esteemed
panel. Their testimony will no doubt bring needed attention to this
issue and help us as we move forward in our efforts to fully meet the
mental health needs of our veterans.
______
Prepared Statement of Hon. Frank R. Lautenberg,
U.S. Senator from New Jersey
As a young man, I answered the call to service and wore our
Nation's uniform with pride. I was not a hero, but I did my duty for
the country I love. And one principle I have always insisted on is
this: we can't just stand by our military on the battlefield--we have
to stand by them when they return home, too.
Right now, military personnel are committing suicide at disturbing
rates, and the trend is getting worse. Last year, more U.S. military
personnel took their own lives than were killed in combat in Iraq. And
for our veterans, the picture is just as bleak: the Veterans
Administration estimates that 18 veterans take their own lives every
day.
The need to improve mental health care for our servicemembers and
veterans is clear and demands a new sense of urgency.
We must do better, and we can do better.
In my home state of New Jersey, there's a model of success for
confronting this problem.
Along with our state's Department of Military and Veterans Affairs,
the University of Medicine and Dentistry of New Jersey has created an
innovative program called Vet2Vet. This program, which works with
members of the New Jersey National Guard, has kept thousands of
military personnel, veterans and their loved ones from suffering in
silence.
While suicide rates are rising at a startling pace nationally,
there has not been a single suicide among the New Jersey National Guard
during Vet2Vet's first four years of operation.
Instead of waiting until they return from combat, Vet2Vet starts
its work with servicemembers pre-deployment and then helps them
readjust when they return from service.
Central to the program is the veteran-operated helpline that
provides servicemembers, veterans and their families access to all
types of support services, not just mental health support. Vet2Vet
closes gaps in the system by working in coordination with state and
community-based programs to take advantage of existing resources.
One of the reasons Vet2Vet has worked is that it relies on the
skills and know-how of veterans. These trained vets counsel fellow
veterans and their families--getting them the resources they need and
doing regular, comprehensive follow-ups.
Putting veterans on the frontlines of the phone lines helps
eliminate the stigma that discourages servicemembers and veterans from
reaching out for help. It also gives veterans good-paying jobs doing
what they do best: serving and protecting.
We are fortunate that our state has taken the lead on this critical
issue, but there's no reason the rest of the country's military
shouldn't have access to the same quality care that's being offered in
New Jersey.
New Jersey's success should not be an anomaly--it should be the
norm.
That is why I have urged Secretary Erick Shinseki to take UMDNJ's
model and make it available to every military member and every veteran
in every state.
We have a responsibility to serve our military and their families
as well as they've served us. Until military suicides are a thing of
the past, we cannot rest.
Thank you.
______
Prepared Statement of Three Wire Systems, LLC and Health Net, Inc.
Mr. Chairman and distinguished Members of the Committee, we
appreciate the offer from Ranking Minority Member Burr to submit
testimony for the record. Our statement will provide an overview and
results to date of the VetAdvisor Support Program (VetAdvisor), an
innovative evidence-based program designed to provide mental health
outreach and health coaching services to Operation Enduring Freedom and
Operation Iraqi Freedom (OEF/OIF) Veterans and their families,
regardless of their geographical location. VetAdvisor uses non-
traditional telehealth/virtual health delivery platforms to improve
Veteran awareness of, and access to, the mental health support to which
they are entitled.
VetAdvisor is an ongoing Veterans Integrated Service Network (VISN)
12 program, augmenting and supporting existing VA behavioral health
care services, and assisting Veterans with challenges they face during
reintegration into civilian life. Working in partnership with VA,
VetAdvisor assists Veterans and their families on a continuous basis,
providing complementary, non-clinical support to Veterans identified
and referred to the program by VA. VetAdvisor provides telephonic
screening and referral to a VA medical facility, when necessary, and
also offers an internet-based or telephonic health coaching component
to assist these Veterans with the challenges they face as they work to
reintegrate into their communities and families. The program focuses on
identifying and working with Veterans who have, or are at risk for,
PTSD, substance abuse, suicide and homelessness. This telephonic and
virtual approach to screening and coaching helps eliminate the stigma
Veterans often associate with seeking mental health services.
We thank the Committee for its leadership and appreciate its
interest in this important issue. We believe VetAdvisor has the
potential to assist veterans not only in VISN 12, but in VISNs across
the country, especially in rural areas. It provides a cost-effective,
appropriate and popular expansion of VA's reach to allow for convenient
follow-up with Veterans VA identifies as at risk. Without this program,
many of these Veterans might not return to VA to get the help they need
to successfully return to their jobs, school and families.
VetAdvisor was initiated in 2007 by VISN 12, in partnership with
Three Wire Systems, LLC (Three Wire), a Service Disabled Veteran Owned
Small Business, and MHN, a Health Net company. VetAdvisor targets
veterans who are already enrolled at VA medical facilities using
primary health care services, but are not participating in mental
health care.
Veterans who sign up with VA after returning home do not always
seek help until their mental health needs are critical. This may be due
to a lack of understanding of symptoms, denial that a problem exists,
lack of awareness of available mental health support, or stigma.
VetAdvisor addresses these barriers through its telephonic/virtual
approach to behavioral health care. VetAdvisor contacts those Veterans
who may not take the initiative to get involved in mental health care
before a tragedy or problems occur. VetAdvisor does this by using a
proactive outreach approach:
Using Computerized Patient Records provided by VA, Client
Service Representatives call Veterans to thank them for their service.
When appropriate, the representative offers immediate access to a
licensed, trained and experienced behavioral health clinician (e.g.,
Licensed Clinical Social Worker) called a Health Coach.
The Health Coach telephonically assesses the Veteran
through a series of VA-approved screenings. The screenings cover both
medical and behavioral health conditions associated with serving in
combat to include: Post Traumatic Stress Disorder (PTSD), Traumatic
Brain Injury (TBI), suicidal ideation, substance abuse, depression and
common medical screenings.
The VA medical facility is provided with the results of
these screenings. The results are used for follow-up and further
evaluation. Once Veterans with behavioral issues are identified, they
are encouraged to enroll in the Health Coaching Program.
The Health Coaching Program facilitates and supports
Veteran involvement in existing VA services. A Health Coach is assigned
to the Veteran for regular contact, advocacy and support.
Coordination continues with the Veteran, Health Coach, and
Primary Care Physician for as long as necessary.
In addition to telephonic communication, VetAdvisor provides Health
Coaching through virtual collaboration technology--the VetAdvisor
Virtual Room (VVR). In the VVR, the Veteran and the Coach interact as
avatars. This highly immersive virtual environment provides strong
feedback that enhances collaboration and communication. Virtual
technology assists Veterans in their reintegration efforts in a number
of ways. One of the major advantages is that it allows for the Veteran
to discuss personal issues from the privacy of his or her own home.
Second, it saves the Veteran time and travel costs associated with
office visits. For today's Internet savvy generation of Veterans and
their families, this form of communication feels more natural than
traditional communication methods.
The initial VetAdvisor pilot in VISN 12 covered an 18-month period
and a population of over 10,000 Veterans. Through this pilot, over
1,100 Veterans were directed to VA medical facilities for follow-up on
positive screening results. The statistics support the program's
success: when a Veteran was successfully contacted, there was a 95
percent acceptance for Health Coach screening appointments.
The types of issues discussed in Health Coaching sessions cover a
wide range. The top issues are anxiety, occupational, PTSD and
depression. The figure below illustrates the range of issues addressed
in the sessions.
VetAdvisor's proactive outreach and screening for behavioral issues
has proven to be an effective tool in helping Veterans access services
to treat or prevent potential issues such PTSD, depression, substance
abuse, suicide and homelessness. It is designed to provide support when
and where the Veteran chooses, and to help motivate those who realize
they may benefit from help to seek help. It augments existing VA
services by being pro-active rather than just waiting for the Veteran
to seek care. The VetAdvisor program would be a way to immediately
improve the VA's involvement and assistance to OEF/OIF Veterans in all
VISNs, and would ensure that these Veterans do not fall through the
cracks following their initial visit to and enrollment in VA.
On behalf of Three Wire Systems and Health Net, we would like to
thank you again for your interest in the VetAdvisor program and for
your commitment to ensuring that our veterans and their families
receive the care and services they may need.