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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.