2008 Appropriations for Mental Health Research and Services for Veterans (Written Testimony)
Subcommittee on Military Construction & Veterans Affairs, Committee on Appropriations, U.S. House of Representatives, On Fiscal Year 2008 Appropriations for the Department of Veterans Affairs
Christopher C. Colenda, MD
3/21/2007
Mr. Chairman and members of the Subcommittee, I am Christopher Colenda, MD, a geriatric psychiatrist and immediate past president of the American Association for Geriatric Psychiatry (AAGP). I thank you for this opportunity to present AAGP’s recommendations related to Fiscal Year (FY) 2008 appropriations for mental health research and services for veterans. AAGP is a professional organization dedicated to promoting the mental health and well being of older Americans and improving the care of those with late-life mental disorders. Our membership consists of approximately 2,000 geriatric psychiatrists as well as other health professionals who focus on the mental health problems faced by senior citizens.
Mr. Chairman, although we agree with others in the mental health community about the importance of Federal support for mental health research and treatment, AAGP brings a unique perspective to these issues because our members serve the older adult patient population.
We appreciate the Subcommittee’s support for the highest quality health care for our nation’s veterans and for the research necessary to advance the quality of their care. Our veterans put forth their lives for our nation, and they deserve access to quality health care.
The Challenge of Meeting the Mental Health Needs of the Aging Veteran Population -- Proposal for IOM Study on Mental Health Workforce Needs of Older Veterans
AAGP is extremely concerned that the mental health needs of our aging veteran population are not being adequately met by current resources and that the gap between needs and resources will widen unless Congress acts to increase support for veterans’ mental health care, with an emphasis on older veterans.
Of the nation’s 25.5 million veterans, nine million -- approximately 35 percent -- served in World War II or the Korean War. Another eight million Vietnam era veterans will soon join this cohort and will bring increased challenges to the VA, including increased cases of post-traumatic stress disorder (PTSD) and, perhaps, a higher burden of substance abuse. In this context, it is important to note actions relating to late life mental health addressed by the White House Conference on Aging, which was convened by President Bush in December 2005. Recognizing the current health and mental health needs of older Americans and the challenges awaiting as the Baby Boom generation ages, delegates placed mental health and geriatric health professional training issues at the forefront by voting them among their top ten resolutions. The VA must be able to provide the specialized mental health care that these older veterans will need.
Between the years 1990 and 2000, the number of veterans in the 45-54 year-old age group who received mental health services from the VA more than tripled. As the nation continues to pursue the wars in Iraq and Afghanistan, thousands of younger veterans will turn to the VA for the special care and services only it can provide. All of these individuals will swell the ranks of those who will ultimately require geriatric care.
However, the most rapid growth in demand during the last decade was among older veterans. During that time, there was a four-fold increase in the number of veterans aged 75-84 who received VA mental health services. This substantial increase in utilization is even more striking when one considers that research has revealed an ongoing problem with under-diagnosis of mental disorders in older age groups.
More than half a million veterans are 85 years of age or older, and the VA predicts that this oldest group will grow to 1.2 million by 2010. Historically, as many as one-third of all veterans seeking care at the VA have received treatment for mental disorders; and research indicates that serious mental illnesses affect at least one-fifth of the veterans who use the VA health care system. In addition, those who are older often suffer from co-existing medical conditions such as heart disease, hypertension, diabetes, lung disease, debilitating arthritis, or other conditions. For these patients, treatment of their medical illnesses is often complicated by psychiatric disorders. Conversely, their psychiatric care is more complex because of the co-occurrence of medical illness, which commonly requires treatment with multiple medications. Thus, for older veterans with mental health problems, psychiatric treatment must be integrated and coordinated with their general medical care needs.
Despite the increasing need for coordinated mental health and general health care services for rapidly growing numbers of older veterans, funding for VA mental health services, training, and research remains disproportionately low and is inadequate to meet the needs of the aging veteran population.
The Institute of Medicine (IOM) of the National Academy of Sciences is currently undertaking a study of the readiness of the nation’s healthcare workforce to meet the needs of its aging population. IOM has recommended in discussions with AAGP that, because this study will not delve deeply into the composition of the mental health workforce needed to meet future needs of the elderly, a complementary study be undertaken to consider specifically this vital area of concern. This complementary study will focus on the mental health professional workforce that will be needed to meet the demands of the aging population in this country, including the specific needs of our nation’s veterans. IOM is extremely supportive of this proposed study and feel that it would complement their current study on broad health needs of older adults. IOM has advised AAGP that $1 million would be needed to undertake this complementary mental health study.
In discussions with AAGP, the senior staff of IOM suggested the following language for inclusion in the Fiscal Year 2008 VA Appropriations bill:
The [Appropriations] Committee provides $1,000,000 for a study by the Institute of Medicine of the National Academy of Sciences to determine the multi-disciplinary mental health workforce needed to serve older adults, including the specific needs of veterans. The initiation of this study should not be later than 60 days after the date of enactment of this Act, whereby the Secretary of Veterans’ Affairs shall enter into a contract with the Institute of Medicine to conduct a thorough analysis of the forces that shape the mental health care workforce for older adults, including education, training, modes of practice, and reimbursement.
This proposal for funding for an IOM study on mental health workforce needs of older veterans is supported by the IOM, and AAGP strongly urges its inclusion in the FY 2008 VA Appropriations bill.
President’s Fiscal Year 2008 Budget Proposal
President Bush’s budget proposal for the Department of Veterans Affairs for FY 2008 recommends that approximately $36.6 billion of the $86.75 billion proposed for the Department would go to medical care programs, an increase of approximately $5.1 billion over the FY 2007 funding level of $31.5 billion. The Administration’s budget also proposes an increase of nearly $3 billion for mental health services, including treatment for PTSD. This additional funding is crucial and welcome, but it is only a step toward remedying the existing shortfalls in the provision of mental health care.
The President’s budget again includes a provision to charge an annual user fee to veterans with non-service connected disabilities and illnesses along with increased copayments for outpatient primary care and pharmaceutical drugs. Rather than charging fees to some veterans and cutting off services to others, AAGP believes that the VA health care budget needs to rely on appropriated dollars—not enrollment fees, copayments, and service charges—to fulfill obligations to veterans. All veterans should be eligible to receive care, regardless of income or the nature of their illness or injury.
A 2006 study in the New England Journal of Medicine documented the alarming numbers of soldiers returning from Iraq and Afghanistan who suffer from symptoms of post-traumatic stress disorder, major depression, generalized anxiety disorder, and other mental health disorders. The study pointed to the inability of those veterans to obtain the mental health services they desperately need. In its FY 2008 budget recommendation, the Administration has recognized this problem and has proposed an increase in funding for mental health services. This funding is crucial. As large numbers of soldiers return from Iraq and Afghanistan and enter the VA health care system, the increase in demand for mental health services will far exceed capacity, and many will have to be turned away unless the system receives a very substantial infusion of support.
Comprehensive, Integrated Mental Health and General Health Care for Aging Veterans
Mental health treatment must address the special needs of those older veterans with concurrent psychiatric disorders, medical illness, and substance use disorders, as well as those with severely debilitating psychotic disorders and post-traumatic stress disorder (PTSD). According to the Veterans Administration, of the 455,000 veterans suffering from a service-connected mental disorder, more than 130,000 have chronic, severe psychotic disorders such as schizophrenia, and approximately 130,000 have PTSD, conditions that often have emerged or were aggravated during time in the service. PTSD is often directly related to combat duty. Those veterans should be afforded services of the highest quality, with access to a comprehensive continuum of care that defines state-of-the-art mental health treatment. The Administration’s request of $3 billion more than in FY 2007 for mental health services is an important and crucial step, but there must be a serious commitment to providing appropriate mental health throughout the life span.
Older veterans with co-occurring medical and psychiatric disorders, often complicated by alcohol or drug abuse, require access to a well-integrated system of services. For those veterans with serious mental illness, state-of-the-art care for severe mental illness is recovery-oriented, rather than dependency-oriented, as documented in the U.S. Surgeon General’s Report on Mental Health (1999). Such recovery requires an array of services that includes care coordination for a majority of patients, and intensive case management for the most seriously ill; pharmacological treatment for mental disorders and access to substance abuse treatment; and psychosocial rehabilitation that includes housing and employment services, independent living and social skills training, and psychological support. Within this continuum of services, Readjustment Counseling Service Vet Centers are a community-based component that provides veterans with counseling for psychological war trauma, using an interdisciplinary team approach. With the growth of the aging veteran population, which includes Vietnam-era veterans, AAGP regards these Vet Centers as an important site for the provision of integrated geriatric psychiatric care over the next ten to fifteen years.
AAGP strongly recommends greater investment in Community Based Outpatient Clinics and the development of an outpatient continuum of care. AAGP applauds the VA leadership for pursuing more efficient models of care coordination, designed to promote effective case management for outpatients. AAGP believes that these models, including peer monitoring and other non-traditional support systems, can help to maintain elderly veterans in the community, including many of those veterans with cognitive impairment. While a majority of patients can benefit from these approaches to care coordination, AAGP also urges continued support of Mental Health Intensive Case Management programs in community and home settings for those veterans with the most serious mental illnesses and the most complex, demanding treatment needs. VA mental health professionals have identified these as needs “that should be the target of developmental efforts in the coming years” (Report of the Committee on Care of the Severely Chronically Mentally Ill Veterans, February 2000, page 64).
Despite the outstanding advocacy of VA mental health professionals, the Department is still struggling to furnish this comprehensive spectrum of services to veterans with severe mental illness. Unless the VA budget for mental health care is increased, barriers to providing the full spectrum of mental health services will continue to mount, and effective care coordination will remain an elusive goal.
Veterans and Long-term Care
The projected aging of the veteran population will require the VA to increase its capacity to provide long-term health care and to continue its efforts to expand non-institutional options while preserving and enlarging its network of nursing homes. Quality of care for elderly veterans with long-term care needs will require substantial attention to the epidemiology of mental illness in this population, and the provision of geriatric mental health services that are vertically integrated into both institutional and non-institutional programs and horizontally integrated with general medical care and mental health services. This is the only way to prevent aging veterans with medical-psychiatric co-morbidity from falling through the “service system” cracks.
An estimated 30 percent of the patients in veterans’ nursing home facilities currently suffer from Alzheimer’s disease or other types of dementia. As the elderly veteran population increases, the capability of the traditional veterans’ nursing home facilities to care for veterans with Alzheimer’s disease will be overwhelmed. The VA should encourage innovation in the methods utilized by VA health personnel in treating veterans with Alzheimer’s disease; and should also develop family and caregiver support programs to enable veterans to remain at home for an extended period, and receive necessary community based support services, before nursing home care becomes necessary. AAGP recommends the creation of a new line of mental health research funding earmarked for the development, testing, and dissemination of interventions to manage the psychiatric manifestations and complications of Alzheimer’s disease and related dementias. AAGP also is concerned about the problem of agitation and aggression, which are frequent and severe behavior problems confronted by caretakers in long-term care facilities. We propose that the VA undertake studies to address ways to manage agitation and aggressive behavior in older veterans in long-term care and domiciliary facilities.
Research
Although the VA has made genuine progress in psychiatric research in recent years, the level of research funding remains disproportionate to the utilization of mental health services by veterans. Despite the fact that veterans with mental illness account for approximately one-third of all veterans receiving treatment within the VA system, VA resources devoted to psychiatric and behavioral health research have lagged far behind those dedicated to research on other medical conditions. In fact, support for psychiatric research dedicated to chronic mental illness, substance abuse, and PTSD has remained relatively flat for the last 15 years, despite the growing numbers of patients in the VA system receiving treatment for mental illness. As the elderly veteran population expands, and the number with mental illness grows, strengthening the research base in geriatric psychiatry becomes increasingly urgent. VA sponsored research into mental disorders of aging benefits all Americans, not just our veterans. One area of research that must be addressed is the potential re-emergence of symptoms of PTSD in World War II, Korean War, and Vietnam War veterans. There are no studies of this phenomenon to date, yet clinicians are reporting these symptoms in VA hospitals and clinics among their elderly patients. Such re-emergence could become a significant problem, especially when the structure of life of these veterans is disrupted by events such as retirement, excessive unstructured time, and death of the spouse and other family members, which may lead to a decline in the social support network. These factors then lead to emergence of physical and mental health issues, which can exacerbate the re-emergence of PTSD symptoms. This area needs to be studied both from a clinical and from an epidemiological viewpoint, and it has obvious implications for the current generation of returning veterans as well. AAGP proposes that the Subcommittee allocate $750,000 for funding three studies at $250,000 each to survey veterans in a clinical epidemiology study.
A vitally important VA program for coordinating mental health research with education and clinical care are the Mental Illness Research, Education, and Clinical Centers (MIRECCs). Since 1996, Congress has authorized the VA to establish eight of these centers dedicated to mental illness research, education and clinical activities. AAGP believes the MIRECCs have successfully demonstrated that coordinated research and education projects can achieve rapid translation of new scientific knowledge into improved models for clinical services for veterans with mental illness. These programs should be continued. MIRECCs focus on problems highly relevant to veterans with schizophrenia, PTSD, and other serious mental illnesses, including those whose treatment is complicated by homelessness, substance abuse, or alcoholism. AAGP wishes to emphasize the value of those MIRECCs that focus on issues related to aging, including dementia, and psychiatric disorders in older veterans with concurrent medical illness and/or substance use disorders.
MIRECCs have encouraged research, increased our fundamental understanding of mental illnesses, and given VA healthcare professionals more and better tools to treat patients with mental disorders. Much more can be done in this area if the program is expanded. The MIRECCs are a tremendous resource for improving the quality of mental health services and improving the outcomes of veterans living with mental illnesses.
In addition, AAGP strongly supports the work of Geriatric Research, Education and Clinical Centers (GRECCs). The GRECCs are centers of geriatric excellence designed for the advancement and integration of research, education, and clinical achievements in geriatrics and gerontology. Mental health has played a central role in the entire GRECC program since its inception in the mid-1970’s. GRECCs focus on various aspects in the quality of life and care for the aging veteran and are at the forefront of leading edge research and education. Research results have influenced therapies for diseases affecting older veterans and have also been exported outside the veteran community, and AAGP urges continuation and strengthening of these most important research centers.
Conclusion
In conclusion, AAGP commends this Subcommittee for its continued support for VA mental health services. Representing physicians who are specialists in geriatric psychiatry, AAGP is concerned that reductions in mental health services will undermine the provision of proper treatment not only to elderly veterans, but also to those who are currently young and middle-aged, a course that will lead to more severe problems later in life as their mental disorders become complicated by medical problems that commonly occur with aging. While the VA is facing budget constraints, delivering quality health care for all veterans—for both physical and mental health—must be a top priority. We therefore urge the Subcommittee to increase support for mental health services, training, and research; and to commit the resources necessary to provide our nation’s veterans with access to quality, affordable, coordinated physical and mental health care. Funding must be provided to enable IOM to undertake the study it would like to conduct on the mental health workforce that will be needed to meet the future needs of older adults, with specific emphasis on the specific needs of veterans. The information provided through this study will help to ensure that a mental health workforce will be available to provide appropriate mental health services for older veterans.
I would like to thank the Subcommittee for the opportunity to testify here today. On behalf of the American Association for Geriatric Psychiatry, we look forward to working with you to ensure that all veterans have access to quality affordable mental health care.
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