Are Veterans Receiving Adequate Mental Health Care?

Questions concerning the adequacy of mental health care for returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans continue to capture congressional attention. The latest reminder was a Government Accounting Office (GAO) report issued in May stating that of the 5% of returning veterans between 2001 and 2004 who tested as being at risk for posttraumatic stress disorder (PTSD), only 2% were referred by Department of Defense (DOD) health care providers for further mental health or combat/operational stress reaction evaluations.

“DOD cannot provide reasonable assurance that OEF/OIF service members who need referrals for further mental health or combat/operational stress reaction evaluations receive them,” the report said.

Any mental health care would normally be provided by the DOD for up to 180 days after discharge and then by the Department of Veterans Affairs (VA) after that. Senator Barbara Boxer (D-Calif) called the GAO finding “inexcusable” in a letter to Lt Gen Kevin Kiley, MD, Surgeon General, US Army, who is the highest ranking military officer appointed to the new DOD Mental Health Task Force. Congress ordered the Pentagon to establish that task force by April 7, 2006, but that deadline was missed.

VA and DOD care for returning veterans at risk for PTSD and other mental disorders is very much a hotbutton issue these days. That explains why William Winkenwerder, Jr, assistant secretary of defense for health affairs, was quick to dispute the GAO study in an interview with the American Forces Press Service. He stated: “The level of our effort and our outreach is unprecedented. We have broken new ground.”

Whatever new efforts the DOD has made-and critics like Boxer dispute the extent of any improvements--will probably be expanded on after the Mental Health Task Force submits a report to Secretary of Defense Donald Rumsfeld in May 2007. The task force's first meeting was in July. “High on the list will be steps for improving the awareness of the potential mental health conditions among service personnel and ways to improve the access and efficacy of our existing programs,” Winkenwerder said.

VA expands mental health efforts

The VA is also expanding its efforts. When he appeared before the Senate Veterans Affairs Committee last February, R. James Nicholson, secretary of the VA, said, “The department will continue to place particular emphasis on providing care to those suffering, as a result of their service in Operation Enduring Freedom and Operation Iraqi Freedom, from a spectrum of combat stress reactions, ranging from readjustment issues to . . . PTSD.”

Ira Katz, MD, PhD, deputy chief patient care services officer for mental health at the VA, said in an interview that the VA is working hard to expand mental health services for both veterans with PTSD and those with other psychiatric diagnoses. Reflective of that effort is a request for proposals recently issued by the VA. The 21 Veterans Integrated Service Networks (VISNs), which are regional arms of the VA, were asked to submit proposals for better integrating mental health care into primary care settings. Laurie Tranter, a VA spokeswoman, said there is no dedicated funding stream attached to this initiative. The first set of winning proposals will be funded in fiscal year 2006 and will have their funding continued in fiscal year 2007, when additional VISNs may be added to this new program.

Katz explained that of the 555,500 veterans who have returned home since the Iraq and Afghanistan war fronts opened, 168,500 as of February 2006 have elected to seek care from VA health centers for a psychiatric diagnosis (the second most common diagnosis after musculoskeletal conditions) and 15% of the latter group sought treatment for PTSD.

In addition, the VA is slowly setting up 3 new centers of excellence for mental health that were mandated by Congress. Legislation for these centers was established by Congress in 2005 and sponsored by Sen Kay Bailey Hutchison (R-Tex). Nicholson designated the 3 centers on December 5, 2005, to the VA hospitals in Waco, Texas; San Diego; and Canandaigua, NY.

VA officials in the 3 cities are currently searching for directors for those centers. They could be psychiatrists, psychologists, doctoral social workers, or doctoral nurses. “We are very pleased the centers will give us opportunity to focus on PTSD and other mental health conditions, including the stress and resiliency veterans experience throughout their life span, from the point they leave the military and as they age,” Katz stated.

Meanwhile, Congress is likely to increase VA mental health funding for those centers and for support of initiatives such as better mental health care at primary care clinics. The appropriations bill for the VA, passed by the House a few days after the GAO report on PTSD came out, contains $2.8 billion for specialty mental health care for fiscal year 2007, which starts on October 1, 2006. That would be an increase over the $2.2 billion budgeted for fiscal year 2006, according to Tim Peterson, a staffer on the House Appropriations Subcommittee on Military Quality of Life and Veteran's Affairs. Treatment for PTSD and funding for the 3 centers of excellence is included within the $2.8 billion. The Senate has not acted yet.

Dan Gage, spokesman for Rep James Walsh (R-NY), chairman of the House appropriations subcommittee in charge of VA and DOD mental health funding, said it is not surprising that the VA is taking its time setting up those 3 centers. “It is a new step for the VA and we don't want to rush to do it just to say we did it,” explained Gage.

The VA is also expanding its efforts. When he appeared before the Senate Veterans Affairs Committee last February, R. James Nicholson, secretary of the VA, said, “The department will continue to place particular emphasis on providing care to those suffering, as a result of their service in Operation Enduring Freedom and Operation Iraqi Freedom, from a spectrum of combat stress reactions, ranging from readjustment issues to . . . PTSD.”

Ira Katz, MD, PhD, deputy chief patient care services officer for mental health at the VA, said in an interview that the VA is working hard to expand mental health services for both veterans with PTSD and those with other psychiatric diagnoses. Reflective of that effort is a request for proposals recently issued by the VA. The 21 Veterans Integrated Service Networks (VISNs), which are regional arms of the VA, were asked to submit proposals for better integrating mental health care into primary care settings. Laurie Tranter, a VA spokeswoman, said there is no dedicated funding stream attached to this initiative. The first set of winning proposals will be funded in fiscal year 2006 and will have their funding continued in fiscal year 2007, when additional VISNs may be added to this new program.

Katz explained that of the 555,500 veterans who have returned home since the Iraq and Afghanistan war fronts opened, 168,500 as of February 2006 have elected to seek care from VA health centers for a psychiatric diagnosis (the second most common diagnosis after musculoskeletal conditions) and 15% of the latter group sought treatment for PTSD.

In addition, the VA is slowly setting up 3 new centers of excellence for mental health that were mandated by Congress. Legislation for these centers was established by Congress in 2005 and sponsored by Sen Kay Bailey Hutchison (R-Tex). Nicholson designated the 3 centers on December 5, 2005, to the VA hospitals in Waco, Texas; San Diego; and Canandaigua, NY.

VA officials in the 3 cities are currently searching for directors for those centers. They could be psychiatrists, psychologists, doctoral social workers, or doctoral nurses. “We are very pleased the centers will give us opportunity to focus on PTSD and other mental health conditions, including the stress and resiliency veterans experience throughout their life span, from the point they leave the military and as they age,” Katz stated.

Meanwhile, Congress is likely to increase VA mental health funding for those centers and for support of initiatives such as better mental health care at primary care clinics. The appropriations bill for the VA, passed by the House a few days after the GAO report on PTSD came out, contains $2.8 billion for specialty mental health care for fiscal year 2007, which starts on October 1, 2006. That would be an increase over the $2.2 billion budgeted for fiscal year 2006, according to Tim Peterson, a staffer on the House Appropriations Subcommittee on Military Quality of Life and Veteran's Affairs. Treatment for PTSD and funding for the 3 centers of excellence is included within the $2.8 billion. The Senate has not acted yet.

Dan Gage, spokesman for Rep James Walsh (R-NY), chairman of the House appropriations subcommittee in charge of VA and DOD mental health funding, said it is not surprising that the VA is taking its time setting up those 3 centers. “It is a new step for the VA and we don't want to rush to do it just to say we did it,” explained Gage.