Col. Elspeth Cameron Ritchie, M.C.: "A soldier also can seek help
from an Army behavioral health professional or a chaplain."
Gerald Cross, M.D., the VA's acting principal deputy undersecretary for
health, comments on the extended time service members and veterans need for
rehabilitation from PTSD and traumatic brain injury. At right is Barbara
Sigford, M.D., M.P.H., the VA's national program director for physical
medicine and rehabilitation. Photos courtesy of House Veterans Affairs
More than 1,500 veterans of Iraq and Afghanistan have traumatic brain
injuries (TBIs), and 20 percent of all frontline troops return home with
concussions, but plans for their treatment and further research are
inadequate, Rep. Bill Pascrell Jr. (D-N.J.) told the health subcommittee of
the House Committee on Veterans Affairs last month in Washington, D.C.
Pascrell is a founder and co-chair of the Congressional Brain Injury Task
Force, which has sponsored bills supporting enhanced public awareness of
traumatic brain injury.
"The departments of Defense and Veterans Affairs must screen and
identify veterans with traumatic brain injuries, set up a TBI registry, and
improve care for these veterans," said Pascrell.
"Care for veterans with TBI from the Iraq war will cost the
government $14 billion over the next 20 years," he said, citing a
National Bureau of Economic Research working paper by Linda Bilmes of Harvard
and Joseph Stiglitz of Columbia University.
That paper used a Department of Defense estimate of 3,213 people with head
or brain injuries requiring lifetime care. However, a spokesperson for the
Defense and Veterans Brain Injury Center said it treated 1,360 troops with
mild to severe head injuries from January 2003, to July 2006.
Pascrell said he would support an additional $12 million in funding for the
2008 fiscal year.
He noted that a recent report on veterans with brain injuries from the VA
inspector general found a lack of consistency in case management within the
"The inspector general's report identifies areas where we can
improve, but patients now have outcomes similar to the general population with
TBI," replied Gerald Cross, M.D., acting principal deputy undersecretary
for health in the VA. "That demonstrates that we're doing an outstanding
job in treating TBI patients. Our attempt is to restore to every patient the
greatest possible level of functioning."
The Va now has a brain research and TBI center in Gainesville, Fla., and
four polytrauma level 1 sites in Richmond, Va., Tampa, Fla., Minneapolis, and
Palo Alto, Calif. Twenty-one polytrauma level 2 sites will open this fall as
part of the department's strategic plan, said cross. The Va will offer primary
care clinicians in its system supplemental training to recognize and treat
mild to moderate TBI, said Cross.
Asked why the VA did not use the Department of Defense TBI screen, which
has a sensitivity of 85 percent, Cross replied that the VA "wanted to be
sure that any screen was evidence-based" and would continue research to
find one it could accept.
Subcommittee chair henry E. Brown, Jr. (R-S.C.) queried the Va and Army
psychiatrists on how well the military and VA health systems coordinated
transitions when soldiers completed active service. The Post-Deployment Health
Assessment (PDHA), completed when troops leave Iraq or Afghanistan, is used to
screen for all health conditions, including mental health. However, some
troops won't check off mental health issues on their form, fearing stigma, the
psychiatrists acknowledged. Others worry that their return home will be
delayed for evaluation or counseling if they screen positive.
"If you answer `yes,' you'll be held over," Iraq War veteran
Patrick Campbell, a former Army medic and now congressional liaison for the
Iraq and Afghanistan Veterans of America, told Psychiatric News after
the hearing. "Soldiers just want to know what they need to put down to
let them go home."
Troops have other ways to access the Army's mental health services besides
the PDHA, said Col. Elspeth Cameron Ritchie, M.C., psychiatry consultant to
the U.S. Army Surgeon General. "A soldier also can seek help from an
Army behavioral health professional or a chaplain."
Chaplains have traditionally been an important source of counseling for
troops, and they are trained to refer individual soldiers to counseling or
medical services, if needed.
The VA is also trying to make it easier for veterans to get the care they
need, said psychiatrist Ira Katz, M.D., Ph.D., deputy chief patient care
services officer for mental health. "Our goal is to get people into
treatment," said Katz. "Our first step is to overcome barriers to
access, but we also need to improve outreach to reserve and National Guard
units and educate veterans and their families."
More active outreach may also be needed to attach returning vets to the VA
in the first place. About 69 percent of veterans who served in Iraq and
Afgahnistan and who have left active duty have not enrolled in VA health care,
even though they are eligible, according to a subcommittee staff report.
Reliance on passive systems, such as Web sites, to provide information and
respond to problems is not the answer, said Campbell. The services and the VA
must engage soldiers and their families actively.
"I got lots of mail from the Army telling me what I couldn't do, but
they never told me to sign up for the VA," he said.
Coincidentally, the General Accountability Office (GAO) issued a report the
morning of the hearing saying that not all of the $100 million intended for
mental health strategic plan initiatives had been used as intended in Fiscal
Va headquarters officials allotted $53 million to its medical centers for
targeted plan initiatives. However, the VA also sent $35 million through its
general resource allocation system to its 21 health care networks months after
other funding had gone out. "[The] VA did not notify network and medical
center officials that these funds were to be used for plan initiatives,"
said the GAO report. "As a result, it is likely that some of these funds
were not used for plan initiatives."
Furthermore, another $12 million was not allocated because the VA ran out
of time in the fiscal year, said the GAO.
The report also noted irregularities in the 2006 allocation for mental
health strategic plan initiatives. Ten days before the end of the fiscal year
(October 1), the VA had not allocated $42 million of the $200 million
Implementing the strategic plan will take more than money, said Katz."
it will require a cultural change to reorient the specialty mental
health sector to provide recovery-based treatment."
Rep. Michael Michaud (D-Maine) asked the Army and VA psychiatrists whether
they had enough money, space, and personnel to care for active-duty soldiers
"I don't have to get my statements approved, so I can say that
veterans are not getting the help they need," said Michaud, when the
witnesses hesitated in responding.
"The administration says `Support our troops' but won't provide the
resources to do it," he continued. "Men and women are coming back
from Iraq and Afghanistan with PTSD, and instead of providing treatment, the
VA is investigating why we have so many cases of PTSD. I implore each of you
to pressure your superiors to do what's right to tackle the care of