GAO Questions VA's Ability To Provide More PTSD Care

Will veterans returning home from Iraq receive prompt and effective treatment for their war-related mental health disorders?

Neither the Department of Veterans Affairs (VA) nor the Department of Defense (DoD) can provide a definitive answer, according to a recent report from the Government Accountability Office (GAO).

The report, released September 20, offered recommendations that would lead to improved data collection and coordination between the two governmental agencies.

The VA is working to implement the recommendations that call for the agency to combine data about veterans receiving treatment for PTSD at VA medical centers with data about those receiving treatment for PTSD at its veterans centers (Vet Centers).

(Vet Centers were established as entities separate from the medical centers because Vietnam veterans were reluctant to receive medical care for their war-related mental health disorders in a federal building.)

The combination of the data sets will give VA officials a better assessment of the current availability of treatment for PTSD and improved ability to project need for more services.

Officials at six of the seven VA medical facilities visited by GAO researchers reported that although “they are now able to keep up with the current number of veterans seeking PTSD services, they may not be able to meet an increase in demand for these services.”

They also expressed concern because the VA had directed them to give priority for PTSD care to veterans returning from Iraq and Afghanistan. Follow-up care for veterans now receiving PTSD treatment could be delayed as much as 90 days, they fear.

Congress has appropriated $10 million for additional PTSD programs and outreach to returning veterans.

In July the New England Journal of Medicine published a study reporting the results of a survey administered to soldiers before deployment to Iraq and three to four months after return from combat duty in Iraq and Afghanistan (Psychiatric News, August 6).

According to lead author Charles Hoge, M.D., “The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (approximately 17 percent higher) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent).”

Hoge went on to report data that suggested the importance of outreach to veterans who need mental health services.

“Of those whose responses were positive for a mental disorder, only 23 percent to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.”

Miklos Losonczy, M.D., Ph.D., co-chair of the Committee on Care of Veterans With Serious Mental Illness (SMI Committee), told Psychiatric News that the committee is concerned that military personnel might be reluctant to seek mental health care because of the potential impact on their careers and because of stigma.

The SMI Committee has recommended a memorandum of understanding between the DoD and the VA that would provide all returning military personnel with a“ face-to-face discussion about possible reactions to stress....” This discussion would educate returning veterans about PTSD and other mental health problems and would also offer an opportunity for early intervention when treatment appears necessary.

Losonczy said that the “increased likelihood of surviving direct hits and nearby explosions... has ramifications for the provision of mental health services.”

It is likely there will be increased need for the provision of acute and chronic traumatic brain injury (TBI) rehabilitation. TBI, he added, is“ associated with substantial behavioral changes,” which require treatment.

Veterans surviving significant physical trauma will be at increased risk of depression, anxiety, and PTSD, Losonczy said.

Another problem is the “significant variability in access to services for veterans with all kinds of health care needs, including PTSD,” he said.

The VA has acknowledged the problem of variability. In fact,“ Achieving the Promise: Transforming Mental Health in the VA,” a report released by the VA in December 2003, found, “Consistent access to mental health care in Community Based Outpatient Clinics (CBOCs) had not yet been achieved. Of 616 CBOCs in FY 2001, 258 had no mental health visits, and an additional 78 report that mental health care accounts for under 5 percent of their workload” (Psychiatric News, November 5).

Losonczy noted that during the past year there has been “substantial emphasis” on developing a mental health strategic plan that would identify areas “requiring enhanced services.”

In his response to the GAO, VA Secretary Anthony Principi said that the VA had developed such a plan to “project demand by major diagnoses and provide capability for gap analysis.”

He estimated that the plan would be completed by November 30.

Robert Rosenheck, M.D., director of the VA's Northeast Program Evaluation Center, told Psychiatric News that it is important to consider the current challenges in the context of the progress that the VA has made in its capability to treat war-related mental illness.

He said, “This is clearly a moment of uncertainty and apprehension. On one hand, research has demonstrated serious postdeployment mental health problems among some combat troops. On the other hand, the VA has more than 200 community-based readjustment counseling centers and more than 150 programs specializing in the treatment of PTSD at medical centers. The National Center for PTSD will conduct further research on problems of returning troops and provide educational support as new knowledge becomes available.”

The report, “VA and Defense Health Care: More Information Needed to Determine if VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder Services” (GAO-04-1069), can be accessed online at<www.gao.gov/new.items/d041069.pdf>.▪