Are Brain-Injured Vets Getting Adequate Care?

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 agency.

“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 Year 2005.

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 budgeted.

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 and veterans.

“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 veterans.”

More information on the hearing is posted at<http://brown.house.gov/News/DocumentSingle.aspx?DocumentID=51019>.▪