Combat Stress Takes Its Toll, But VA's Response Falls Short

February 11th, 2007  
Team Infidel

Topic: Combat Stress Takes Its Toll, But VA's Response Falls Short

Miami Herald
February 11, 2007
Pg. 1

Soldiers are coming home to a veterans' health system ill-equipped to treat the mental anguish of war.
By Chris Adams
FORRESTON, Ill. - A year ago on Thanksgiving morning, in the corrugated metal pole barn that housed his family's electrical business, Timothy Bowman put a handgun to his head and pulled the trigger. The bullet only grazed his forehead. So he put the gun in his mouth and pulled the trigger again.
He had been home from the Iraq War for only eight months.
Once a fun-loving, life-of-the-party type, Bowman had slipped into an abyss, tormented by things he had been ordered to do in war while patrolling in Iraq with the Illinois Army National Guard.
''I'm OK. I can deal with it,'' he would say whenever his father, Mike, urged him to get counseling.
The Department of Veterans Affairs is facing a wave of returning soldiers like Bowman who are struggling with memories of a war where it's hard to distinguish innocent civilians from enemy fighters and where the threat of suicide attacks and roadside bombs haunts the most routine mission. Since 2001, 1.4 million Americans have served in Iraq, Afghanistan or other locations in the global war on terrorism.
The VA counts post-traumatic stress disorder, or PTSD, as the most prevalent mental health malady -- and one of the top illnesses overall -- to emerge from the wars in Iraq and Afghanistan.
VA Secretary James Nicholson and other top administration officials have said that the agency is well-equipped to handle any onslaught of veterans with mental health issues and that it plans to continue to beef up mental healthcare and access, funded under the administration's proposed budget released last week.
But an investigation by McClatchy Newspapers has found that even by its own measures, the VA isn't prepared to give these returning soldiers the care that could best help them overcome destructive, and sometimes fatal, mental health ailments.
McClatchy relied on the VA's own reports, as well as an analysis of VA data released under the federal Freedom of Information Act. McClatchy analyzed 200 million records, including every medical appointment in the system in 2005, accessed VA documents and spoke with mental health experts, veterans and their families from around the country.
Among the findings:
*Despite a decadelong effort to treat veterans at all VA locations, nearly 100 local VA clinics provided virtually no mental healthcare in 2005. Beyond that, the intensity of treatment has diminished. Today, the average veteran with psychiatric troubles gets almost one-third fewer visits with specialists than he would have received a decade ago.
*Mental healthcare is wildly inconsistent from state to state. In some places, veterans get individual psychotherapy sessions. In others, they meet mostly for group therapy. Some veterans are cared for by psychiatrists; others see social workers.
And in some of its medical centers, the VA spends as much as $2,000 for outpatient psychiatric treatment for each veteran; in others, the outlay is only $500.
*The lack of adequate psychiatric care strikes hard in the western and rural states that have supplied a disproportionate share of the soldiers in the wars in Iraq and Afghanistan -- often because of their large contingents of National Guard and Army Reserves. More often than not, mental health services in those states rank near the bottom in a key VA measure of access. Montana, for example, ranks fourth in sending troops to war, but last in the percentage of VA visits for mental healthcare in 2005.
Moreover, the return of so many veterans from Iraq and Afghanistan is squeezing the VA's ability to treat yesterday's soldiers from Vietnam, Korea and World War II. And the competition for attention has intensified as the vivid sights of urban warfare in Iraq trigger PTSD symptoms anew in older veterans.
''We can't do both jobs at once within current resources,'' a committee of VA experts wrote in a 2006 report, saying it was concerned about the absence of specialized PTSD care in many areas and the decline in the number of PTSD visits that veterans receive.
''There are VA facilities that were fine in peacetime but are now finding themselves overwhelmed,'' said Steve Robinson, government relations director of the Washington-based advocacy group Veterans for America. ``So they're pitting the needs of the veterans of previous wars against the needs of Iraq veterans.''
While the debate in the VA about the level of its psychiatric care is often frank, the public assurances of top officials are oddly optimistic.
''Mental health is a very high priority of ours,'' VA Secretary Nicholson said last March. ``The VA possesses -- this will sound boastful, but . . . as we used to say back home, it ain't bragging if it's true -- but we have the best expertise in post-traumatic stress disorder in the world. . . . So we are ramped upward, and we have a terrific cadre of experts in that area, and we are adequately funded to deal with it.''
''We feel very well poised to meet the needs,'' said Antonette Zeiss, a VA health official who is helping to oversee the mental health system, in a November interview with McClatchy Newspapers.
A changed system
Soldiers coming home today walk into a VA health system that is nothing like it was when veterans returned from World War II, Korea, Vietnam or even the first Gulf War. The change began more than a decade ago, when the agency decided to shift its focus from high-cost inpatient hospital care to outpatient clinics that could tend to veterans' primary-care needs.
In addition, the VA scrapped its organizational structure and created about 20 networks, more than 150 hospitals and -- as of today -- more than 800 outpatient clinics. The new system would provide ''easier access to care and greater consistency in the quality of care,'' the VA said in a 1995 report.
Its committee of experts, however, said that specialized mental health services were declining and that the VA's use of unadjusted dollars in an era of high inflation in medical costs rendered its annual reports ``meaningless.''
At the same time, the VA began to treat many more people for mental health ailments, so the amount spent has plummeted from $3,560 per veteran in 1995 to $2,581 per veteran in 2004 -- even before correcting for inflation. (Overall, mental health spending during that period rose from $2.01 billion to $2.19 billion.)
In the past two years, the VA has committed more money to mental healthcare and brought services to previously underserved areas. But it has also changed its accounting system, so it's difficult to compare spending after 2005 with that of prior years.
What does all of this mean for veterans?
It means that veterans have fewer visits with mental health professionals, on average, than they did before. Between 1995 and the first half of fiscal 2006, for example, general psychiatry visits for those in the mental health system dropped, according to VA data.
VA experts said the system already was straining to provide veterans with what they needed before the United States attacked Afghanistan in October 2001.
''Even before the war in Afghanistan,'' Matthew Friedman, a top VA mental health official, told Congress in 2004, ``VA PTSD treatment capacity had been overtaxed.''
The VA outpatient clinic nearest to Tim Bowman's hometown is part of the Madison, Wis., network. Like a third of all the VA medical centers in 2005, Madison didn't have a specialized PTSD clinical team, according to VA records.
That's the case despite two decades of urging by VA experts that each medical center should have such a team. ''Such specialization has long been recognized as an essential feature in treatment of military-related PTSD,'' a 2006 VA report said. ``Treatment of PTSD requires specific familiarity with the kinds of trauma veterans encountered while in military service.''
Wide disparities
Its absence in many centers exemplifies a significant -- and growing -- problem in the VA: the wide disparities in mental health services.
The VA's mental health experts started to push for specialized PTSD programs in all medical centers in the 1980s. Top VA officials agreed ''in concept'' that it would be a good idea.
But in 2005 and 2006, despite telling Congress that it was setting aside an additional $300 million for expanding mental health services, such as PTSD programs, the VA didn't get around to spending $54 million of that, according to the Government Accountability Office.
At medical centers with no specialized PTSD teams, veterans still get PTSD treatment, but not from the specialists whom the VA considers to be most essential.
February 11th, 2007  
Team Infidel
In all, only 27 percent of veterans receiving PTSD care received it in one of the VA's specialized programs, VA data show. And that varies widely. In the region that includes Wisconsin, 13 percent of veterans with PTSD received care from specialized teams. In Ohio, 45 percent did.
The uneven mental health treatment of veterans across the country can be traced to the VA's health system reorganization, which gave a lot of leeway to local managers.
McClatchy reviewed two dozen mental health measures, based in part on an analysis of every inpatient and outpatient visit in the VA health system. The 200 million records were contained in two fiscal 2005 databases.
Among the findings:
*Some veterans get in for visits far more than others. The average number of visits per veteran with PTSD ranged from 22 in the Hudson Valley, N.Y., medical center and clinics to a low of 3.1 in Fargo, N.D. The national average was 8.1.
*Some VA medical centers spend far more on mental healthcare than others. In Connecticut, it was an average of $2,317 for each veteran's outpatient psychiatric care. In Saginaw, Mich., it was $468.
*Some veterans get in quickly. Others wait. At the Loma Linda, Calif., VA network, only 39 percent of new mental health patients were able to get appointments within 30 days, the VA's standard. In other networks, 90 percent or more did.
*Once they are in the door, some veterans get visits of 75 to 80 minutes, while others get 20- to 30-minute appointments, the shortest psychotherapy appointments listed in the system. Of all the individual sessions for veterans with PTSD, those in the Amarillo, Texas, network got the shortest possible visits 87 percent of the time, while those in Butler, Pa., were given those short visits 6 percent of the time.
Asked about the disparities, the VA's Zeiss said: ``It's true there are disparities. . . . Disparity is a part of healthcare. . . . I can tell you that the data you're looking at we're looking at, too, and we're using it to make decisions about how to close the gap and ensure a standard of care nationally.''
The VA's top mental health services official, Dr. Ira Katz, added in a separate interview that variation in a host of mental health measures wasn't necessarily good or bad. It could reflect different strategies being tried in different states so that ''our system can better learn what works and what doesn't work,'' he said.
Through such trial and error, variations likely would decrease over time, as, for example, expensive medical centers become more efficient and underserved medical centers are given more resources, he said.
Different outcome
So far, that hasn't happened, McClatchy found.
For starters, the variations in many mental health measures are growing, not shrinking, according to a McClatchy analysis of key measures back to the time of the reorganization. A 2005 study by two VA mental health experts came to the same conclusion, noting that ``system reforms did not lead to decreases in regional variation.''
In addition, the variation in mental health spending is far wider than it is in primary and hospital spending, indicating that the system is having more trouble ensuring consistency in mental healthcare.
As for the wide variation in spending per veteran on mental healthcare, Katz said it could be explained by the presence of special programs in various medical centers. There's a national PTSD research center at the Connecticut VA, for example, that inflates spending figures there.
When asked how many of 128 medical centers ranked by that measure had special programs that might distort spending figures, Katz said he didn't know if it was a half dozen or if it was 50.
He added that ``the VA is involved in a very active process of identifying and filling gaps in care.''
Among other things, the VA has begun to pump more money into local clinics to ensure that they begin to provide mental health treatment. ''We have invested more personnel and more money in this in 2006, and are investing still more in 2007,'' Katz said. The 2008 budget released last week will continue those efforts, the VA said.
February 15th, 2007  
it takes LOTS of guts to go into COMBAT...

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