STATEMENT OF
GERALD M. CROSS, MD, FAAFP
ACTING PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS’ AFFAIRS
U.S. SENATE
* * * * * * * *
MARCH 3, 2010

Mr. Chairman, Mr. Ranking Member, and Members of the Committee:  Thank you for the opportunity to appear today to discuss the Department of Veterans Affairs’ (VA) response to the mental health needs of America’s Veterans.  I am accompanied today by my colleagues, Dr. Antonette Zeiss, Deputy Chief Consultant and Chief Psychologist, Office of Mental Health Services, Office of Patient Care Services, Veterans Health Administration (VHA); Dr. Theresa Gleason, Mental Health Research Portfolio Manager, Office of Research and Development, VHA; Dr. Alfonso Batres, Chief Readjustment Counseling Officer; and Dr. Janet Kemp, VA National Suicide Prevention Coordinator.

VA has responded aggressively to address previously identified gaps in mental health care by expanding our mental health budgets significantly.  In fiscal year (FY) 2010, VA’s budget for mental health services reached $4.8 billion, while the amount included in the President’s budget for FY 2011 is $5.2 billion.  Both of these figures represent dramatic increases from the $2.0 billion obligated in FY 2001.  VA also has increased the number of mental health staff in its system by more than 5,000 over the last 3 years.  During the past 2 years, VA trained over 2,500 staff members to provide psychotherapies with the strongest evidence for successful outcomes for post-traumatic stress disorder (PTSD), depression, and other conditions.  Furthermore, we require that all facilities make these therapies available to any eligible Veteran who may benefit.  In FY 2010 and FY 2011, we will continue to expand inpatient, residential, and outpatient mental health programs with an emphasis on integrating mental health services with primary and specialty care.

VA is working closely with our colleagues at the Department of Defense (DoD) to improve the quality of care for Veterans and service members alike.  Since October 2009, VA and DoD have held two major conferences related to the mental health needs of Veterans and service members.

My testimony today will make three points:  first, it will describe VA’s approach to treating mental health conditions.  It is our belief that treatment options should be widely available and uniquely tailored to the individual needs of each Veteran.  Second, it will detail VA’s policy and guidance to the field, as specifically identified in the Uniform Mental Health Services in VA Medical Centers and Clinics Handbook.  This Handbook is being implemented across the VA health care system to expand access to necessary mental health services for Veterans.  Finally, my testimony will conclude by providing evidence VA has gathered that our programs are successful and based upon the best available scientific basis; it will also detail the research VA conducts in this area.  In sum, our programs are saving lives and improving the quality of life for Veterans with mental illness.

VA’s Approach to Mental Health Care
With its emphasis on providing care management  for depression and making evidence-based psychotherapy available for all Veterans who need it, VA is ensuring that planning for treatment of mental health conditions includes attention to the benefits as well as the risks of the full range of effective interventions.  Making these treatments available responds to the principle that when there is evidence for the effectiveness of a number of different treatment strategies that can be effective, the choice of treatment should be based on the Veteran’s values and preferences, as well as the clinical judgment of the provider.

VA has been making significant enhancements to its mental health services since 2005, through the VA Comprehensive Mental Health Strategic Plan and special purpose funds available through the Mental Health Enhancement Initiative. VA’s enhanced mental health activities include outreach to help those in need to access services, a comprehensive program of treatment and rehabilitation for those with mental health conditions, and programs established specifically to care for those at high risk of suicide. To reduce the stigma of seeking care and to improve access, VA has integrated mental health into primary care settings to provide much of the care that is needed for those with the most common mental health conditions. In parallel with the implementation of these programs, VA has been modifying its specialty mental health care services to emphasize psychosocial as well as pharmacological treatments and to focus on principles of rehabilitation and recovery.

The focus on recovery for those with serious mental illnesses reflects major scientific advances in treatment and rehabilitation.  Although it is still not possible to offer definitive cures for all patients with serious mental illness, it is realistic to offer the expectation of recovery.  Veterans, often with their families, should collaborate with their providers in planning treatments, where the goals are to help the Veteran live the kind of life he or she chooses, in spite of any residual signs or symptoms of mental illness.  To achieve this vision, VA has hired staff to provide peer support, trained clinicians in evidence-based strategies for treatment and rehabilitation, enhanced the care in residential treatment settings, and strengthened programs that involve families.

In addition to the care offered in medical facilities and clinics, VA’s Vet Centers provide outreach and readjustment counseling services to returning war Veterans of all eras.  By the end of the current fiscal year, we anticipate having 299 Vet Centers in operation.  It is well-established that rehabilitation for war-related PTSD, Substance Use Disorder, and other military-related readjustment problems, along with the treatment of the physical wounds of war, is central to VA’s continuum of health care programs specific to the needs of war Veterans.  The Vet Center service mission goes beyond medical care in providing a holistic mix of services designed to treat the Veteran as a whole person in his or her community setting.  Vet Centers provide an alternative to traditional mental health care that helps many combat Veterans overcome the stigma and fear related to accessing professional assistance for military-related problems.  Vet Centers are staffed by interdisciplinary teams that include psychologists, nurses and social workers, many of whom are Veteran peers. 

Vet Centers provide professional readjustment counseling for war-related psychological readjustment problems, including PTSD counseling.  Other readjustment problems may include family relationship problems, lack of adequate employment, lack of educational achievement, social alienation and lack of career goals, homelessness and lack of adequate resources, and other psychological problems such as Depression and/or Substance Use Disorder.  Vet Centers also provide military-related sexual trauma counseling, bereavement counseling, employment counseling and job referrals, preventive health care information, and referrals to other VA and non-VA medical and benefits facilities.

To promote suicide prevention, VA established a strong partnership with the Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) to operate a Veterans Call Center as part of the National Suicide Prevention Lifeline (1-800-273-TALK).  VA also has appointed suicide prevention coordinators and care managers at each VAMC and the largest community-based outpatient clinics.  Altogether, VA employs over 400 staff members who focus specifically on suicide prevention.  My colleague, Dr. Janet Kemp, discusses these programs in greater detail in her testimony.

VA Policy and Requirements
In 2009, VA approved the Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics to define what mental health services should be available to all enrolled Veterans who need them, no matter where they receive care, and to sustain the enhancements made in recent years.  One important set of requirements in the Handbook was to ensure that evidence-based psychotherapies are available for Veterans who could benefit from them and that meaningful choices between effective alternative treatments are available.

Also, based on its Comprehensive Mental Health Strategic Plan, VA has enhanced access to mental health services by requiring that mental health services must be integrated into primary care services.  To ensure Veterans are monitored appropriately while they are receiving mental health services, including treatment with psychotherapeutic medications, VA requires that these integrated care programs include evidence-based care management.

Care management for depression includes repeated contacts with patients to educate them about depression, medications, and other treatment, as well as to provide evaluations of both therapeutic outcomes and adverse effects.  The benefits of the frequent contact program relate to increased patient-engagement in care.  Also, information from patient monitoring is translated into decision-support for providers about when they should modify treatment.  Two programs that are used frequently in VA primary care settings are Translating Initiatives in Depression into Effective Solutions (TIDES) and the Behavioral Health Laboratory (BHL), both of which are evidence-based interventions supported by extensive research.  Studies on care management for depression in primary care settings have demonstrated that these interventions can decrease both depression and suicidal ideation in older adults.  This led to recognition of care management for late life depression as a best practice for suicide prevention.   

For several years, VA has provided training to clinical mental health staff to ensure that there are therapists in each facility who are able to provide evidence-based psychotherapies for the treatment of depression and PTSD as alternatives to pharmacological treatment or as a course of combined treatment.  The initiative to make these psychotherapies broadly available within VA is relevant to concerns about medication safety, but the program was not developed as a result of those concerns.  VA implemented the broad use of evidence-based psychotherapies in response to evidence that for many patients, specific forms of psychotherapy are the most effective and evidence-based of all treatments.  Specifically, the Institute of Medicine report on treatment for PTSD emphasized findings that exposure-based psychotherapies, including Prolonged Exposure Therapy and Cognitive Processing Therapy, were the best-established of all treatments for PTSD.  Other specific psychotherapies included in VA’s programs include Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for depression and Skills Training and Family Psycho-Education for schizophrenia.  VA is adding other treatments such as Problem Solving for Depression, Cognitive Behavioral Therapy and Contingency Management for Substance Use Disorder, and behavioral strategies for managing both pain and insomnia.   

VA’s Accomplishments
As stewards of the public interest and bearing the responsibility for caring for America’s Veterans, VA conducts ongoing analyses of its programs and continually asks itself how they can be improved.  VA’s mental health enhancements were designed to implement evidence-based practices.  Evidence led VA to adopt specific requirements for follow-up care after hospital discharge, and to require depression care management.  Most generally, the findings support the conclusion that high quality mental health care can prevent suicide.  The suicide rate for all Veterans who used VA health care declined significantly from FY 2001 to FY 2007, as the attached chart indicates.

Mental illnesses are among the most prevalent conditions affecting Veterans of all generations, wars or conflicts.  VA research continues its commitment to defining the most effective mental health treatments.  VA investigators have generated many major findings related to behavioral and psychiatric disorders such as schizophrenia, depression, substance use (including alcohol, illicit drugs, and nicotine), suicide prevention, and PTSD.  From conducting large clinical trials to supporting center-based research programs to improving care delivery, mental health research continues to be a major priority for the VA research program.

In one line of research, VA scientists are investigating factors related to improving adherence and compliance.  This includes studies on anti-depressant adherence among older Veterans, reducing the impact of drug side effects, and a patient-centered approach to improve screening for side effects of second-generation antipsychotics.  Efforts to improve the quality of care for persons with severe mental illness have focused on the inclusion of family members as active participants in the patient’s treatment. VA researchers are also evaluating how to best implement an integrated health care approach for Veterans with serious mental illness.  Combined with a number of other behavioral and psychological intervention studies, VA has been at the forefront of mental health research that seeks to improve treatment options for clinicians and patients dealing with mental health care needs.

VA research is also striving to identify critical risk factors for major mental health disorders.  One unique study is looking at Veterans who were deployed to Iraq as active duty Army, National Guard, or Reservists who had baseline physical and mental health assessments before deployment.  Planned follow up studies will determine the effect of the combat experience on mental health, emotions, reactions, and cognition – shortly after return from Iraq as well as over ensuing years.  Research is also changing how care is provided to individuals with less access to treatment facilities or providers.  VA investigators successfully adapted a collaborative/team care approach to treat depression in older Veterans using telemedicine to address rural health disparities.  Subsequently, this study provided the support for implementing telemedicine-based collaborative care in hundreds of small rural CBOCs that do not have on-site mental health specialists.

Moreover, VA is working to better understand risk factors associated with suicide and the optimal means to prevent suicide.  VA investigators focused on suicide prevention recently reported a correlation between chronic pain and suicide suggesting an important risk factor and highlighting a potentially at-risk group.  Additional research is ongoing to evaluate the effectiveness of suicide hotline interventions, firearm safety, and how to care for Veterans receiving treatment for substance use disorder and depression who express suicidal thoughts.

Conclusion
VA as a system is committed to improving the quality and availability of mental health care to Veterans.  VA’s mental health enhancements have included major initiatives – far too many to itemize completely, but including effective efforts to increase access to mental health care, increase the use of evidence-based psychotherapy for the treatment of PTSD and depression, enhance the safe use of psychotherapeutic medications, provide effective suicide prevention interventions, fully utilize psychosocial rehabilitation and recovery-oriented services, and ensure the appropriate level of trained staff are available to provide needed services.  VA firmly believes that each Veteran has earned an individual determination of the best treatment and routine follow up for his or her specific condition, and its clinical guidelines support this endeavor.  Thank you again for the opportunity to appear, and my colleagues and I are available to address any questions from the Committee.