VA Boasts of Major PTSD Strides but Critics Want More Progress

Government efforts to identify and treat veterans with posttraumatic stress disorder (PTSD) appear to have succeeded in reaching the vast majority of returning combat troops affected by the condition, according to a leader in the veterans mental health care system.

The revelation by psychiatrist Ira Katz, M.D, Ph.D., deputy chief for patient care services at the Department of Veterans Affairs, that up to 80 percent of veterans with PTSD have been identified and received treatment came during a congressional hearing before the House Veterans Affairs Health Subcommittee on April 30.

A 2008 Rand Corporation report stated that an estimated 14 percent (or 132,359 service members, according to Katz) who returned from Iraq and Afghanistan suffer from PTSD. If that figure is accurate—and some dispute it as either inflating or underreporting the extent of PTSD—then veterans health officials have reached a significant number of affected service members. Records from the VA indicate that through the end of Fiscal 2008, 105,465 veterans had received PTSD care in VA medical centers, clinics, or Vet Centers, which is about 80 percent of former combatants diagnosed with PTSD.

“We can be happy about [the high treatment rate], but we're not satisfied,” Katz told Psychiatric News after the hearing about the need to reach more affected veterans.

Katz said that the apparently large percentage of PTSD sufferers who seek care indicates that the veterans who really need care are more likely to seek treatment through the VA system. However, others who follow veterans health issues have emphasized that many who need psychiatric care have gone untreated.

For instance, Rep. Michael Michaud (D-Maine), chair of the House Veterans Affairs Health Subcommittee, emphasized at the April hearing a key finding on mental illness from the Rand study, which was that more than half of service members affected by mental illnesses are not seeking or receiving the care they need.

Michaud and others have expressed some optimism that the VA will further improve its mental health care, in part, through the dedicated $3.8 billion approved for mental health care in Fiscal 2009 and a new Uniform Mental Health Service handbook, which defines standard and minimal mental health care for VA facilities nationwide.

Adrian Atizado, assistant national legislative director for the group Disabled American Veterans, praised many VA efforts and the addition of dedicated funding to improve the care of veterans with mental illness, but noted that much more work remains. For example, the VA has no way of tracking the availability throughout its system of labor-intensive, evidence-based treatments for PTSD. A March report on veterans facilities in Montana by the VA Office of Inspector General, for example, found “limited availability” of evidence-based PTSD therapies for veterans in that state.

Inspector-general reports in Montana and elsewhere “raise concern that [the amount of labor-intensive, evidence-based treatments] have been falling, even in the face of evidence that effective services for PTSD require much greater intensity of services,” Atizado told the panel.

Many veterans groups are concerned that inadequate treatment for PTSD and other serious mental illnesses will continue to be common, despite promises to treat psychiatric problems among returning warriors aggressively.

Ralph Ibson, a senior fellow for health policy with the Wounded Warriors veterans group, said that the directors of veterans health care programs nationwide are facing the end to supplemental funding provided through the Mental Health Initiative. Funds for this initiative have been approved every year since Fiscal 2005 to implement the Mental Health Strategic Plan, which directed the overhaul of the VA's approach to mental health care.

The Obama administration plans to phase out this program beginning in Fiscal 2010, according to veterans' advocates.

The end to such dedicated mental health funds will likely impact the quality and availability of care for veterans with PTSD or other conditions that require time-intensive care, he said.

Although President Obama's proposed Fiscal 2010 budget document, released in May (see Federal MH Agencies Win Small Funding Boost), did not directly address the status of Mental Health Initiative funding, it increased overall VA mental health funding by 7 percent, to $4.5 billion. Funding for treatment of traumatic brain injuries increased even more sharply, 16 percent, to $298 million.

The focus on the VA's approach to mental health care and increasing the percentage of veterans who seek care through that system may, however, leave some veterans out of the equation. Katz said that the VA's extensive experience in studying and treating PTSD and other psychiatric problems should encourage psychiatrists and other mental health clinicians who encounter patients with service-related psychiatric conditions to refer them to the VA for treatment.

“Veterans really should come to us” for care, Katz said.

However, veterans' advocates said many returning combatants are not going to the VA for a variety of reasons, such as lack of accessibility in rural areas or their preference for using providers identified through an employer's private insurance plan.

A report in the May Health Affairs concluded that national efforts are needed to better prepare community health care providers to treat service-related psychiatric conditions because many veterans rely on private practitioners rather than the VA for treatment of those disorders.

Information and testimony on VA treatment for PTSD is posted at<http://veterans.house.gov/hearings/hearing.aspx?NewsID=366>. The Rand study “Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery” is posted at<www.rand.org/pubs/monographs/MG720/>.▪