STATEMENT OF
FRED FRESE, PH.D.
NATIONAL ALLIANCE ON MENTAL ILLNESS

SUBMITTED TO
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE

ON THE NOMINATION OF MICHAEL J. KUSSMAN, M.D., TO BE
UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

MAY 16, 2007
 
Chairman Akaka, Ranking Member Craig, and Members of the Senate Committee on Veterans' Affairs -

The National Alliance on Mental Illness (NAMI) appreciates your invitation to provide testimony regarding the President's nomination of Michael J. Kussman, MD, to be Under Secretary for Health of the Department of Veterans Affairs (VA).  My statement today constitutes a joint effort by our NAMI Veterans Council, ably chaired by Mrs. Mary Gibson of Waco, Texas, as well as our full national NAMI Board of Directors, on which I serve as a member and also as Chairman of its Veterans Subcommittee. 

At the outset, lest there be any doubt, I want the Committee and Dr. Kussman to know that NAMI supports his nomination to be Under Secretary for Health, albeit with some reservations that I will discuss in more detail in this statement. 

With 210,000 members, NAMI is the nation's largest organization representing and advocating on behalf of persons with serious brain disorders that manifest in chronic mental health challenges.  Through our 1,200 chapters and affiliates in all 50 states, NAMI supports education, outreach, advocacy and biomedical research on behalf of persons with serious brain disorders such as schizophrenia, manic depressive illness, bipolar disorder, major depression, severe anxiety disorders and other major mental illnesses affecting children and adults.

In addition to serving on the NAMI Board, I have a very personal connection to these issues.  I am a veteran.  In 1966 while serving in the U.S. Marine Corps, I was selected for promotion to the rank of Captain. During that period I was first diagnosed as having the brain disorder schizophrenia -- perhaps the most severe and disabling mental illness diagnosis. Over the years since my original diagnosis, I have been treated within the VA health care system, both as an inpatient at the VA hospital in Chillicothe, Ohio, and as an outpatient.  I believe I am an example of someone with a serious mental illness who can still contribute positively to American society.  During the past three decades I have functioned as a clinical psychologist and an administrator, served as Director of Psychology at Western Reserve Psychiatric Hospital for a 15-year period, and coordinated the Summit County Recovery Project to assist persons in recovery from mental illness to integrate into the vocational and social framework of greater Akron.

I hold degrees from Tulane University, the American Graduate School of International Management, and masters and doctoral degrees in psychology from Ohio University.  I am currently an Assistant Professor of Psychology in Clinical Psychiatry in the psychiatry departments at both Case Western Reserve University and the Northeastern Ohio Universities College of Medicine.  At the latter facility I lecture psychology interns and third year medical students, as well as third and fourth year psychiatry residents.  Additionally during the past several years I have been invited to deliver annual lectures at the Uniformed Services University of the Health Sciences and the George Mason University Law School.  I am providing the Committee this personal history not to boast, but to validate that mentally ill citizens like me can still serve in useful capacities and need not be shunted aside or locked in institutions.

Mr. Chairman, our veteran members established the NAMI Veterans Council and Veterans Subcommittee to assure that closer attention is paid to mental health issues in the Department of Veterans Affairs (VA), not only at the national level, but also within each Veterans Integrated Service Network (VISN).  The NAMI Veterans Council includes members from each of VA's 21 VISNs, and in that capacity we advocate for an improved VA continuum of care for veterans with severe and persistent mental illnesses.  The council is composed of persons with mental illnesses, relatives of persons with mental illnesses, or friends with mental illnesses who have an involvement and interest in issues affecting veterans who suffer from severe and persistent mental illness.  Some of the roles that Veterans Council members play include serving in liaison to VISNs; providing outreach to national veterans service organizations; educating Congress on the special circumstances and challenges of severe mental illness in the veteran population; and, working closely with NAMI state and affiliate offices on issues affecting veterans.  Also our Veterans Council Executive Committee holds regular monthly conference calls where featured speakers present new information on developments in treatment, research, service delivery and service initiatives for veterans and active military service members or dependents with severe and persistent mental illness.  We also use these opportunities to stay informed of national developments in Congress and the Executive Branch that affect veterans struggling to recover from mental illnesses.

Much has been reported in the news in the past few months about conditions at the Walter Reed Army Medical Center.  Our organization -- dedicated to advancing health care, research and improving social understanding on matters that deal with dysfunction of the human mind -- was deeply disturbed as were you at hearing how combat veterans recovering from serious disabilities, including mental and emotional problems, were being maltreated and mistreated by the system then in place at Walter Reed.  Adjusting to and recovering from, disability, whether it is physical or mental, is a challenge in itself that can rival the crossing of a mighty river against the current.  But when that challenge is made more difficult by a layering of mindless but "official" bureaucracy, delay, confusion, lost records, intimidation, threats, hazing and other inexcusable behaviors displayed in multiple reports of the media, this is doubly disturbing to us.  These veterans should be treated more decently, with compassion and with care, assured that their needs are going to be met by a grateful government, not one that is bent on minimizing the cost of war by reducing or hiding the liability for their injuries and illnesses.  One of the bittersweet lessons that may be learned from this war is that the ultimate cost to the human beings who had to actually fight it cannot be hidden from public view.  We hope that this shameful episode in the facility's history has been laid to rest with renewed intentions and actions to improve our care of American military heroes.  No veteran should be treated this way. 

NAMI members are deeply involved in the care of veterans in VA's mental health programs nationwide because many are family members of those veterans.  Some of us are those veterans.  On the ground every day we see the effects of what the national veterans service organizations have reported through the Independent Budget for years: chronic under-funding of veterans' health care.  Funding shortages and emergency supplemental appropriations, combined with the regular employment of Continuing Resolutions as stopgap measures to provide financial resources for VA health care, have caused deterioration in many VA programs, including those about which we are concerned. 

We are particularly concerned that VA's "National Mental Health Strategic Plan" to reform its mental health programs, has been stalled by VA's over-arching financial problems.  The General Accountability Office (GAO) issued a startling report last year to your House counterpart Committee documenting VA's failure to spend several millions of available dollars in pursuit of important initiatives that would continue moving VA in the right direction to reform its mental health programs.  The Veterans Council Executive Committee met a few months ago with Dr. Ira Katz, Deputy Chief Patient Care Services Officer for Mental Health, to discuss his plans to improve the allocation of funds dedicated to the initiatives under the new strategic plan.  We hope Congress will closely monitor VA's implementation of the new strategic plan to ensure it meets that promise.

Mr. Chairman, we ask today: Is Michael Kussman qualified to be Under Secretary for Health?  Speaking for NAMI, I must say that, while we have observed his presence in VA health care for several years, and are generally aware of his distinguished military career, it is fair to say that we at NAMI really do not know Dr. Kussman as well as we desire to know him.  While serving as Chief Patient Care Services Officer, Dr. Kussman supervised the mental health programs of the Department.  In that capacity and also during his term as Deputy Under Secretary, Dr. Kussman contributed positively to VA's corporate decision to engage and adopt concepts from the President's New Freedom Commission on Mental Health.  He is to be commended for this stance.  More recently as Acting Under Secretary, Dr. Kussman distinguished himself by making a number of comments in the media concerning the state of mental health of our fighting force in Iraq and Afghanistan.  This statement is illustrative:

"Readjustment and reintegration issues are very common among servicemen returning from any combat.  A large portion of people have this temporary reaction.  These are normal reactions to abnormal situations and are not considered mental illnesses." (Washington Post, March 1, 2006) 

NAMI commends Dr. Kussman's view that we should not stigmatize veterans who need care for adjustment disorders that may be temporary in nature following a period of combat exposure.  We strongly believe no one with a mental illness should be stigmatized, whatever the cause.  However, some veterans of war come home with serious problems, including deep-seated mental health problems.  We trust Dr. Kussman believes these veterans' needs must be addressed by a caring VA. 

As an organization concerned about the mental health of hundreds of thousands of Dr. Kussman's patients, NAMI desires to have a closer relationship with Dr. Kussman and those who work with him in mental health policy in Washington.  A number of issues have emerged to make those relationships problematic, but should you confirm him we hope to work with Dr. Kussman to relieve them.  Let me give you some pertinent examples.

NAMI is represented on the consumer affairs council associated with VA's Committee on Care of Severely and Chronically Mentally Ill Veterans, also known as the "SMI Committee," authorized in Section 7321, Title 38, United States Code.  This independent committee has played an active and vital role in determining policy and shaping programs in VA mental health care.  I am privileged to have been a regular participant on this consumer affairs council.  The SMI Committee was a driving force in VA's shift toward the "New Freedom" philosophy. To paraphrase the law, the committee has a clear mandate to assess, and carry out a continuing assessment of, the capability of the VA to meet effectively the treatment and rehabilitation needs of mentally ill veterans whose mental illness is severe and chronic. The law requires the committee to identify system-wide problems in caring for such veterans; identify specific facilities at which program enrichment is needed to improve treatment and rehabilitation; and identify model programs that should be implemented more widely in or through facilities of the VA.  The committee is required to advise the Under Secretary regarding the development of policies for the care and rehabilitation of severely chronically mentally ill veterans, and to make recommendations to the Under Secretary for improving programs of care of such veterans; for establishing special programs of education and training relevant to their care; regarding research needs and priorities relevant to the care of such veterans; and regarding the appropriate allocation of resources for all such activities.  The Secretary is required by law to submit a variety of reports to Congress on the work of the SMI Committee and VA's responses to the committee's recommendations.

Historically the SMI Committee met four times each year to carry out its responsibilities, held regular conference call meetings, reported at regular intervals, and provided VA and Congress an important and independent voice in evaluating VA's mental health programs, especially those that deal with veterans with psychoses and other very serious problems.  Several years ago, VA Central Office (VACO) determined the SMI Committee would be afforded only two meetings annually.  VA re-chartered the Committee in 2006 and populated it with new membership, some of whom were unfamiliar with the Committee's history or role.  The Consumer Affairs Council's participation since that time has been severely restricted.  The SMI Committee now seems moribund.  To NAMI and other participating organizations, this is a very large matter in terms of muffling a source that has provided VA and Congress an independent means of evaluating a very important VA program.  We hope your Committee will determine whether VA's justification for restricting and suspending the activities of this key committee was warranted, and to examine Dr. Kussman's role and reasons for those decisions.

Another issue of concern to NAMI bears discussion today.  In the past several fiscal years, VA's expenditures in mental health have unquestionably risen, and we deeply appreciate this Committee's insistence that VA mental health spending be maintained.  Nevertheless, in the final compromise on Public Law 110-5, the "Revised Continuing Appropriations Resolution, 2007," Congress removed a recurring requirement that VA spend at least $2.2 billion in programs of mental health care this year.  The following text carried out that decision:
 
"Sec. 20810. Notwithstanding any other provision of this division, the following provisions included in the Military Quality of Life, Military Construction, and Veterans Affairs Appropriations Act, 2006 (Public Law 109-114) shall not apply to funds appropriated by this division: the first, second, and last provisos, and the set-aside of $2,200,000,000, under the heading `Veterans Health Administration, Medical Services'; the set-aside of $15,000,000 under the heading `Veterans Health Administration, Medical and Prosthetic Research'; the set-aside of $532,010,000 under the heading `Departmental Administration, Construction, Major Projects'; and the set-aside of $155,000,000 under the heading `Departmental Administration, Construction, Minor Projects'." (emphasis added)

While we appreciate the need to give the VA flexibility in its spending decisions under the Medical Services account, NAMI comes from a perspective of observing, and hopefully protecting, a number of programs important to our members and to the veterans under VA care about whom we are most concerned.  The set-asides in prior appropriations acts gave us assurance of dependability of funding sources for VA programs that provide our loved ones the care they need.  Without that protection, some in VA may believe they are free to shift resources from these programs to the detriment of veterans with serious mental illnesses.  We ask that your Committee closely examine Dr. Kussman's commitment to spend appropriate sums on mental health programs to ensure this commitment is kept.

Mr. Chairman, the current overseas wars in Iraq and Afghanistan are producing a very heavy burden in follow-on mental health treatment and counseling requirements.  While we very much want to agree with the sentiments of Dr. Kussman, that the vast majority of our soldiers, sailors, marines, airmen and Coast Guardsmen are repatriating whole and healthy, with temporary adjustment problems, some reports are not encouraging.  About two of every ten serving members are experiencing problems of a magnitude about which we all should be concerned.  About 70,000 individuals have so far touched VA with some kind of mental or emotional challenge in post-service life.  The military departments are rotating active, reserve and Guard forces through these wars in multiple deployments of individuals and units.  The press has reported a number of cases of individuals having been deployed who may not be in ready condition to serve, some with worrisome mental states.  Given the drag of this war, it is not surprising that military recruiters are beginning to fail to meet their quotas or are meeting them by enlisting marginal candidates whose mental status might be of serious concern to domestic employers.  Another outcome of these wars is the unknown degree to which "mild" and "moderate" traumatic brain injury (TBI) is going to manifest into behavioral, medical and psychosocial problems later.   Thousands of our troops have been exposed to massive explosions in Iraq and Afghanistan but have come away apparently "unharmed" according to our current technology to measure harm.  We believe the complete story of those exposures is yet to be told.

Dr. Charles Hoge of the Walter Reed Army Institute of Research reported the following findings last year in a study he published in the New England Journal of Medicine: 

"This study has shown that overall 15-17% of Soldiers from combat units screen positive for PTSD when surveyed 3-12 months after returning from deployment to Iraq. When we added one additional question related to functional impairment at the end of the 17 question PTSD scale, we found that 10% of Soldiers surveyed 12 months after deployment reported that PTSD symptoms have made it very difficult to do their work, take care of things at home, or get along with other people. The inclusion of screens for major depression and generalized anxiety raise the rates of screening positive to approximately 20%; 16% of Soldiers surveyed 12 months after returning from Iraq screened positive for PTSD, depression, or anxiety and reported that there was functional impairment at the "very difficult" level."

Mr. Chairman, while many say that TBI is the "signature injury" of these wars, we believe the picture is more mixed, with a large burden of the war legacy expressing itself in mental and emotional damage from both TBI, post-traumatic stress disorder (PTSD), depression, substance abuse and other problems.  We hope the Committee as well as the VA will remain vigilant and sensitive to the needs of this new generation as time goes by, because their needs are going to exist long after cessation of deployment of our forces into Southwest Asia.  In this instance both Congress and NAMI need to depend on Dr. Kussman's judgment to ensure these needs are addressed with sensitivity and care.

The Secretary of Veterans Affairs James Nicholson has testified on VA's intentions with respect to funding mental health services in fiscal year 2008.  On February 8, 2007, and again on February 13, 2007, he stated "The President's request includes nearly $3 billion to continue our effort to improve access to mental health services across the country.  These funds will help ensure VA provides standardized and equitable access throughout the Nation to a full continuum of care for veterans with mental health disorders.  The resources will support both inpatient and outpatient psychiatric treatment programs as well as psychiatric residential rehabilitation treatment services.  We estimate that about 80 percent of the funding for mental health will be for the treatment of seriously mentally ill veterans, including those suffering from post-traumatic stress disorder (PTSD).  An example of our firm commitment to provide the best treatment available to help veterans recover from these mental health conditions is our ongoing outreach to veterans of Operation Iraqi Freedom and Operation Enduring Freedom, as well as increased readjustment and PTSD services." (emphasis added)

Without guidance from your Committee, Mr. Chairman, and strong oversight by other committees of jurisdiction, it is challenging at best for NAMI to measure whether, indeed, Secretary Nicholson's commitment, and presumably one to which Dr. Kussman agrees, will be fulfilled next year.  As consumers and monitors, we know the VA programs that treat mentally ill veterans certainly need more funding--for professional and support staff, administrative help, program development, technology, equipment, furnishings, infrastructure, family caregiver respite and other supports.  Our veterans in need of care for serious mental health conditions, whether new veterans from current wars or veterans from previous military service periods, depend on the good will of such promises.  We ask your Committee to monitor VA's investments and programs in mental health care to guarantee funding will remain available and will be used for the purpose for which it is intended.

In summary, holding in abeyance our stated reservations and looking optimistically to the future, NAMI believes Dr. Kussman is fully qualified to serve as VA Under Secretary for Health.  We recommend you report this nomination and that the Senate confirm him to serve as Under Secretary for Health.  Should the Senate in its wisdom confirm him for this position, we hope to gain a better working relationship with Under Secretary Kussman as time goes along.  NAMI wants to be a partner with VA as the New Freedom reforms are put into place, and as more veterans of the current wars come to VA for aid.  We want to work with Dr. Kussman, Dr. Katz and other key VA officials in Washington and across the VA system to ensure VA meets its responsibilities for the care of veterans with serious and chronic mental illnesses, whether from this war or previous military engagements.

Chairman Akaka, Ranking Member Craig and other distinguished Members of the Committee, NAMI appreciates your invitation to testify, and we thank you for giving consideration to our views.