Statement of the
American Psychiatric Association
July 26, 2005
The American Psychiatric Association (APA) consists of over 36,000
psychiatric physicians nationwide who specialize in the diagnosis and
treatment of mental and emotional illnesses and substance use disorders.
The APA thanks Chairman Buyer, Ranking Member Evans, members of
Committee and your House colleagues for your commitment to providing the
highest quality medical care for our nation's veterans and today’s
hearing on Post Traumatic Stress Disorder.
POSTTRAUMATIC STRESS DISORDER
Posttraumatic Stress Disorder, or PTSD, is a psychiatric disorder that
can occur following the experience or witnessing of life-threatening
events such as military combat, natural disasters, terrorist incidents,
serious accidents, or violent personal assaults like rape. People who
suffer from PTSD often relive the experience through nightmares and
flashbacks, have difficulty sleeping, and feel detached or estranged and
these symptoms can be severe enough and last long enough to
significantly impair the person's daily life. PTSD is complicated by the
fact that it frequently occurs in conjunction with related disorders
such as depression, substance abuse (often beginning with pain
medication prescribed because of combat wounds), problems of memory and
cognition, and other problems of physical and mental health. The
disorder is also associated with impairment of the person's ability to
function in social or family life, including occupational instability,
marital problems and divorces, family discord, homelessness and
incarceration.
Four months ago, an article in the New England Journal of Medicine
indicated that 10% of eligible ex-soldiers seeking medical treatment
between October 2003 and February 2005 presented with PTSD and that 9%
were struggling with drug and alcohol abuse. Further, 7% had been
diagnosed with depression and 6% had anxiety or phobia disorders. Many
ex-soldiers had multiple disorders.
One of the common misconceptions about PTSD is that it is highly
subjective and not readily apparent to the trained professional, In
fact, PTSD is marked by clear biological changes as well as emotional
symptoms. PTSD is an illness that is related to structural and chemical
changed in the brain. Using positron emission tomography (PET) and
single photon emission computed tomography (SPECT) studies, researchers
have found that the hippocampus—a part of the brain critical to memory
and emotion—appears to be different in cases of PTSD. Scientists are
investigating whether this is related to short-term memory problems.
Changes in the hippocampus are thought to be responsible for intrusive
memories and flashbacks that occur in people with this disorder.
Other studies demonstrate that people with PTSD tend to have abnormal
levels of key hormones involved in response to stress. Some studies have
shown that cortisol levels are lower than normal and epinephrine and
norepinephrine are higher than normal. Current research at the National
Institutes of Mental Health to understand the neurotransmitter systems
involved in memories of emotionally charged events may lead to discovery
of medications or psychosocial interventions that, if given early, could
block the development of PTSD symptoms.
CURRENT TREATMENT RESOUCRES ARE INADEQUATE
VA patients with severe PTSD increased 42% from 1998 to 2003, while
expenditures increased only 22% during that same time. Veterans who are
service-connected for PTSD use VA mental health services at a rate at
least 50% higher than other mental health user groups. It is essential
that identified PTSD programs be maintained consistent with the
provision of P.L. 104-262, so that veterans may reap the benefits of
specialized treatment delivered by clinicians who are experts in
addressing the unique needs of veterans with PTSD and its associated
co-morbid conditions.
Section 1706 of P.L. 104-262 states: “The Secretary shall ensure that
the Department maintains its capacity to provide for the specialized
treatment and rehabilitative needs of disabled veterans (including
veterans with…mental illness)…in a manner that affords those veterans
reasonable access to care and services for the specialized needs, and
ensures that overall capacity of the Department to provide those
services as of the date of enactment.”
The APA is concerned about significant inequalities in access and
quality of care of specialized services across the 22 relatively
autonomous Veterans Integrated Service Networks (VISNs). We understand
that some VISNs have been reluctant to make needed improvement in mental
health treatment and have made little progress in establishing
community-based programs for the mentally ill veteran. This lack of
action seems to re-enforce continuing biases and discrimination
regarding mental and substance use disorders, and thus runs contrary to
policy and direction from the VA in Washington, D.C. It is very
important for Congress to monitor local variations in service delivery
to insure that the same high quality of care be maintained across all
facilities and at all VISNs.
Fifteen years ago, the VA Special Committee on PTSD urged that there be
a PTSD Clinical Team (PCT) at every VA medical center. At the present
time only about half of all VA medical centers have PCTs, and many of
the staff originally dedicated to PTSD services at those sites have long
since been drawn off to other duties or lost to attrition. The Office of
the Inspector General recently questioned whether 39 of the existing 84
PCTs have any staff still assigned to those duties.
Additionally, a formidable challenge exists in addressing the needs of
the majority of troops serving in Iraq and Afghanistan as they return
home by way of demobilization sites across the country. Many of them
will remain in active service and are not triaged to VA health care
system. This is especially problematic for Guard and Reserve members who
have less access to DoD mental health services and who abruptly find
themselves back in their communities rather than on military bases where
they might receive more knowledgeable community support.
PTSD treatment programs for women veterans exist to some extent in Vet
Centers with far fewer specialized resources in VA medical facilities.
The need for treating combat stress, war zone stress, sexual harassment,
and sexual assault are increasing in this component of the VA
population. Recent studies of assault and harassment in Reservists and
National Guard troops underscore the growing needs of these veterans for
specialized treatment.
MENTAL HEALTH CARE OF VETERANS
• Since 1996, VA mental health spending has declined by 25% in real
dollars.
• Over 470,000 veterans are service-connected for mental disorders.
• More than 185,000 are service-connected for PTSD, a disorder most
often directly
related to combat duty.
• In 2003 alone more than 77,800 veterans received specialized care for
PTSD with tens of thousands more receiving some type of care through
their primary care clinic.
MENTAL HEALTH SERVICES FOR VETERANS
Over the past ten years, there has been an increase in the number of
veterans with serious mental illnesses being treated by the VA. This is
partially attributable to other avenues of care becoming closed (e.g.,
when private insurance coverage for mental illness becomes exhausted or
Medicaid systems are stretched to the breaking point). Over 90% of the
veterans being treated for psychosis are so ill that they cannot
maintain a significant income and therefore become indigent and heavily
reliant on the VA for their care.
For too long, mental health care has not been a priority for VA.
Virtually every entity with oversight of VA mental healthcare programs –
including Congressional oversight committees, the GAO, VA’s Committee on
Care of Veterans with Serious Mental Illness, and The Independent Budget
– have documented both the extensive closures of specialized inpatient
mental health programs and VA’s failure in many locations to replace
those services with accessible community-based programs. The resultant
dearth of specialized inpatient care capacity and the failure of many
networks to establish or provide appropriate specialized programs
effectively deny many veterans access to needed care. These gaps
highlight VA’s ongoing problems in meeting statutory requirements to
maintain a benchmark capacity to provide needed care and rehabilitation
through distinct specialized treatment programs and a comprehensive
array of services.
Congress has directed the VA to substantially expand the number and
scope of specialized mental health and substance abuse programs to
improve veterans’ access to needed specialized care and services (P.L.
107-135). The law details the VA’s obligation to make systemic changes
network-by-network to reverse the erosion of that specialized capacity.
Congress has made clear that the criteria by which the “maintain
capacity” obligation is to be met are hard, measurable indicators that
are to be followed by all Veterans Integrated Service Networks (VISNs).
Veterans with substance use disorders are drastically underserved. The
dramatic decline in VA substance use treatment beds has reduced
physicians’ ability to provide veterans a full continuum of care, often
needed for those with chronic, severe problems. Funding for programs
targeted to homeless veterans who have mental illnesses or co-occurring
substance use problems does not now meet of the demand for care in that
population. Additionally, despite the needs of an aging veteran
population, relatively few VA facilities have specialized
geropsychiatric programs.
The APA supports the calls of the VA Special Committee on PTSD for a
fully operational PCT at every medical center and the implementation of
defined standards for those teams. Filling vacancies in high priority
areas such as combat related PTSD treatment should be a priority. The
APA urges that VA prioritize the staffing of PCTs at VA's adjacent to
major military sites and in locations where mobilized Guard and Reserve
units are based.
Congressional support for developing innovative rehabilitative methods
for war injured veterans through MIRECC’s, Medical Research, Academic
Affairs, and the National Center for PTSD will assure that VA will
continue to attract top clinicians, teachers, and researchers into its
next generation of healthcare providers. This is an important priority.
The APA is pleased that VA will allocate additional resources, as
authorized by P.L. 108-170, for enhancement of PTSD and mental health
program capacity. However, given the scope of current and growing needs
as well as the unfortunate cultural intransigence of some VISNs towards
providing mental health services, the APA requests additional funding in
FY06 for VA PTSD and severe mental health and substance abuse programs.
The Department of Defense and the Veterans Administration have a unique
opportunity to intervene now, while the majority of new combatants are
still in uniform. The proactive education of staff and preparation of
programs can help providers take action before PTSD takes root. We can
employ the new joint VA/DoD guideline on traumatic stress to follow
these service men and women through the remainder of their DoD careers
and throughout their VA care. Further, we can create a comprehensive
database on response to treatment and use it to develop still better
treatments.
WORKFORCE SHORTAGE
The shortage of physicians and other mental health professionals has
compromised the services VA provides and has endangered patient safety.
Many veterans with mental illnesses are medically fragile – with
diabetes, liver or kidney failure, or cardiac disease, for example.
Their care requires a specially trained physician. A revision of salary
schedules, recognition of the contributions of International Medical
Graduates and minority American Medical Graduates, and the availability
of Continuing Medical Education (CME) courses and other professional
opportunities for advancement need to be addressed. We understand there
is a significant shortage of nursing staff, especially psychiatric
nurses, and we request that the VA address this shortage area.
RECOMMENDATIONS
The APA is deeply concerned about veterans with mental illness.
We recommend:
• Additional and specifically allocated funding for outreach, diagnosis
and treatment;
• Immediate implementation of clinical programs mandated within the
system;
• Compliance with legislation aimed at maintaining capacity; and
• Enhanced recruitment and retention of specialty personnel who will
improve the care and lives of veterans with mental illnesses and
substance abuse disorders.
Above all, a profound respect for the dignity of patients with mental
and substance use disorders and their families must be duly reflected in
serving the needs of veterans in the VA system and those attached to the
National Guard.
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