In September 2004, the General Accountability Office (GAO) replied" maybe" when asked whether the Department of Veterans Affairs (VA) is prepared to meet the needs of returning vets for treatment of posttraumatic stress disorder (PTSD).

Officials at six of the seven VA medical facilities visited by the GAO researchers reported that although they are 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 those services.

A report of the VA Undersecretary for Health's Special Committee on Posttraumatic Stress Disorder in October 2004 identified major gaps in service capacity.

Committee members, all of whom are VA employees, alleged, "VA must meet the needs of new combat veterans while still providing for veterans of past wars. Unfortunately, VA does not have sufficient capacity to do this. VA PTSD services had been steadily losing capacity even before [the wars in Iraq and Afghanistan] began."

The committee noted that during the 1980s the first Special Committee on PTSD urged development of a PTSD Clinical Team (PCT) at every VA medical center.

Currently, only 86 of the 163 VA medical centers have PCTs. Many of the staff originally dedicated to PCTs have long since been drawn off to other duties or lost to attrition.

In fact, the agency's Office of the Inspector General has questioned whether 39 of the existing PCTs have any staff assigned to them.

In April 2004, APA Medical Director James H. Scully Jr., M.D., testified before the House Appropriations Subcommittee on VA, HUD, and Independent Agencies about erosion in access to mental health services, particularly treatment for PTSD.

He said that the number of patients diagnosed with severe PTSD had increased 42 percent from 1996 to 2001, but expenditures to treat the disorder had increased by only 22 percent.

In its official response, the VA "concurred in concept" with the recommendations of the special committee that a PCT be established at every VA medical center.

Mark Shelhorse, M.D., acting chief consultant for the VA's Mental Health Strategic Healthcare Group, responded in writing to questions submitted through the VA's Press Office from Psychiatric News about PTSD treatment capacity and other mental health issues.

In October the agency made $5 million in new money available for expanded PTSD services. Responses to a request for proposal could be for new PCT teams, but "the field was also encouraged to apply for new, innovative ways of addressing PTSD treatment."

Shelhorse wrote, "As to how long it would take to get new PCT teams or programs up and running, that completely depends on how quickly recruitment begins and how qualified the applicants are."

The VA's responsiveness will also be affected by the fate of a strategic-planning process that began in January 2004.

Former VA Secretary Anthony Principi charged the Mental Health Strategic Plan Group with development of a comprehensive plan for mental health services that would incorporate recommendations of previous reports, including the VA's response to the report of the New Freedom Commission on Mental Health.

In his response to the GAO report (GAO-04-1069), Principi wrote that the VA had developed a plan that would "project demand by major diagnoses and provide capability for gap analysis."

He predicted that the plan would be released by October 31, 2004. As of press time, however, the plan was still being reviewed by the Office of Management and Budget, according to Shelhorse. He said that the delay came from a need for a new data run with Fiscal 2003 data.

The plan, according to mental health advocates, acknowledges substantial weaknesses in the VA's provision of mental health and substance abuse services.

The VA has acknowledged a key and expensive problem: geographic variability in access to services.

"Achieving the Promise: Transforming Mental Health in the VA," released in December 2003, found, "Consistent access to mental health care in Community Based Outpatient Clinics (CBOCs) had not been achieved. Of 616 CBOCs in FY 2001, 258 had no mental health visits, and an additional 78 reported that mental health care accounts for under 5 percent of their workload."

Shelhorse wrote that the VA is establishing a performance standard requiring that CBOCs serving more than 1,500 veterans be able to show that at least 10 percent of the health care visits are for mental health purposes.

The VA will also require that all existing CBOCs offer mental health services in some fashion and that proposals for new CBOCs "address mental health services" in the application.

Principi is recognized within and without the VA as a strong advocate for quality mental health services. In 2002 he received the APA's Speaker's Award and was praised particularly for support of services for veterans with PTSD and for homeless veterans with serious mental illness.

There was concern, therefore, among mental health advocates that the Mental Health Strategic Plan was still "embargoed" at the time Principi submitted his resignation to the newly re-elected President Bush.

The mood now is of "cautious optimism," according to a member of the Committee on Care of Veterans With Serious Mental Illness (SMI Committee). That legislatively mandated committee plays a key role in monitoring the VA's capacity to serve veterans with serious mental illness.

According to minutes of its January meeting, Principi told the group that VA Undersecretary for Health Jonathan Perlin, M.D., is committed to implementation of the Mental Health Strategic Plan in 2005 and 2006 despite the budgetary challenges facing the VA.

Perlin described the strategic plan as a "working document" to the SMI Committee and announced a commitment of $100 million for new mental health initiatives from the Fiscal 2005 budget.

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>.▪