Welcome to www.vietnamvets.com
ENTER THE CHATROOM
VA system ill-equipped to treat mental anguish of war
By Chris Adams
McClatchy Newspapers
FORRESTON, Ill. - A year ago on Thanksgiving morning, in the corrugated
metal pole barn that housed his family's electrical business, Timothy Bowman
put a handgun to his head and pulled the trigger. The bullet only grazed his
forehead. So he put the gun in his mouth and pulled the trigger again.
He had been home from the Iraq war for only eight months. Once a fun-loving,
life-of-the-party type, Bowman had slipped into an abyss, tormented by
things he'd been ordered to do in war.
"I'm OK. I can deal with it," he would say whenever his father, Mike, urged
him to get counseling.
The Department of Veterans Affairs is facing a wave of returning veterans
like Bowman who are struggling with memories of a war where it's hard to
distinguish innocent civilians from enemy fighters and where the threat of
suicide attacks and roadside bombs haunts the most routine mission. Since
2001, about 1.4 million Americans have served in Iraq, Afghanistan or other
locations in the global war on terror.
The VA counts post-traumatic stress disorder, or PTSD, as the most prevalent
mental health malady - and one of the top illnesses overall - to emerge from
the wars in Iraq and Afghanistan.
VA Secretary James Nicholson and other top administration officials have
said that the agency is well-equipped to handle any onslaught of mental
health issues and that it plans to continue beefing up mental health care
and access under the administration budget proposal released this week.
But an investigation by McClatchy Newspapers has found that even by its own
measures, the VA isn't prepared to give returning veterans the care that
could best help them overcome destructive, and sometimes fatal, mental
health ailments.
McClatchy relied on the VA's own reports, as well as an analysis of VA data
released under the federal Freedom of Information Act. McClatchy analyzed
200 million records, including every medical appointment in the system in
2005, accessed VA documents and spoke with mental health experts, veterans
and their families from around the country.
Among the findings:
Despite a decade-long effort to treat veterans at all VA locations, nearly
100 local VA clinics provided virtually no mental health care in 2005.
Beyond that, the intensity of treatment has worsened. Today, the average
veteran with psychiatric troubles gets about one-third fewer visits with
specialists than he would have received a decade ago.
Mental health care is wildly inconsistent from state to state. In some
places, veterans get individual psychotherapy sessions. In others, they meet
mostly for group therapy. Some veterans are cared for by psychiatrists;
others see social workers.
And in some of its medical centers, the VA spends as much as $2,000 for
outpatient psychiatric treatment for each veteran; in others, the outlay is
only $500.
The lack of adequate psychiatric care strikes hard in the western and rural
states that have supplied a disproportionate share of the soldiers in the
wars in Iraq and Afghanistan - often because of their large contingents of
National Guard and Army Reserve troops. More often than not, mental health
services in those states rank near the bottom in a key VA measure of access.
Montana, for example, ranks fourth in sending troops to war, but last in the
percentage of VA visits provided in 2005 for mental health care.
Moreover, the return of so many veterans from Iraq and Afghanistan is
squeezing the VA's ability to treat yesterday's soldiers from Vietnam, Korea
and World War II. And the competition for attention has intensified as the
vivid sights of urban warfare in Iraq trigger new PTSD symptoms in older
veterans.
"We can't do both jobs at once within current resources," a committee of VA
experts wrote in a 2006 report, saying it was concerned about the absence of
specialized PTSD care in many areas and the decline in the number of PTSD
visits veterans receive.
"There are VA facilities that were fine in peacetime but are now finding
themselves overwhelmed," said Steve Robinson, government relations director
of the Washington-based advocacy group Veterans for America. "So they're
pitting the needs of the veterans of previous wars against the needs of Iraq
veterans."
While the debate in the VA about the level of its psychiatric care is often
frank, the public assurances of top officials are oddly optimistic.
"Mental health is a very high priority of ours," VA Secretary Nicholson said
last March. "The VA possesses - this will sound boastful, but ... as we used
to say back home, it ain't bragging if it's true - but we have the best
expertise in post-traumatic stress disorder in the world. ... So we are
ramped upward, and we have a terrific cadre of experts in that area, and we
are adequately funded to deal with it."
"We feel very well poised to meet the needs," said Antonette Zeiss, a VA
health official who's helping to oversee the mental health system, in a
November interview with McClatchy Newspapers.
McClatchy's investigation found otherwise, and it found that the
government's failings are felt acutely by families such as the Bowmans,
whose son Tim was a member of the Illinois Army National Guard.
A young warrior who spent months patrolling the treacherous highway that
runs between the Baghdad airport and the city's fortified Green Zone, Tim
received several medals and is set to be posthumously awarded the Purple
Heart.
"Tim always referred to the National Guard soldiers as the Army's disposable
soldiers," his father, Mike Bowman, said. "Six months of training to kill,
12 months of the nastiest duty in Iraq and then two weeks that the Army gave
them to be re-educated back to civilian life.
"It's not humanly possible to readjust to civilian life with that type of
treatment," he said.
A CHANGING VA, A DEAD SOLDIER
Soldiers coming home today walk into a VA health system that's nothing like
it was when veterans returned from World War II, Korea, Vietnam or even the
first Gulf War.
The change began more than a decade ago, when the agency decided to move
away from focusing on high-cost inpatient hospital care and toward
outpatient clinics that could tend to veterans' primary care needs.
In addition, the VA scrapped its organizational structure and created about
20 networks, more than 150 hospitals and - as of today - more than 800
outpatient clinics. The new system would provide "easier access to care and
greater consistency in the quality of care," the VA said in a March 1995
report.
At the same time, Congress passed legislation to make sure that the VA
didn't skimp on mental health care, with a key committee saying it was
concerned that mental health and other specialized treatment "may be
particularly vulnerable and disproportionately subject to budget cutting."
The reason? The "newly decentralized organization, under budget pressures
and focused heavily on instituting new primary care programs" might cut the
very programs on which "the Department's most vulnerable beneficiaries
depend," a congressional report said.
Congress ordered the VA to maintain the "capacity" of its mental health care
programs.
Over the next several years, however, VA management and a committee of its
mental health experts bickered over what "capacity" meant.
The expert committee said that "capacity" meant the number of people served
in special mental health programs and the amount of money spent, adjusted
for inflation. The VA administration didn't adjust for inflation.
Because specialized mental health spending inched up after 1996, the VA
could report to Congress every year that it was maintaining the capacity of
its mental health services.
Its committee of experts, however, said that specialized mental health
services were declining and that the VA's use of unadjusted dollars in an
era of high inflation in medical costs rendered its annual reports
"meaningless."
At the same time, the VA began treating many more people for mental health
ailments, so the amount spent has plummeted from $3,560 per veteran in 1995
to $2,581 per veteran in 2004 - even before correcting for inflation.
(Overall, mental health spending during that period went from $2.01 billion
to $2.19 billion.)
In the past two years, the VA has committed more money to mental health care
and brought services to previously underserved areas. But it's also changed
its accounting system, so it's difficult to compare spending after 2005 with
that of prior years.
What does this all mean for veterans?
It means that veterans receive fewer visits to mental health professionals,
on average, than they did before. Between 1995 and the first half of fiscal
2006, for example, general psychiatry visits for those in the mental health
system dropped from an average of 11.7 a year to 8.1 a year per veteran,
according to VA data.
VA experts said the system already was straining to provide veterans with
what they needed before the United States attacked Afghanistan in October
2001. "Even before the war in Afghanistan," Matthew Friedman, a top VA
mental health official, told Congress in 2004, "VA PTSD treatment capacity
had been overtaxed."
In 2003, a committee of VA insiders said that "it is unfortunate that the
decentralization ... was accompanied by substantial erosion of mental health
services."
In 2006, a separate committee of VA experts declared that the "VA cannot
meet the ongoing needs of veterans of past deployments while also reaching
out to new combat veterans ... and their families by employing older models
of care. We have a new job and we need to do it in a new way."
Veterans and their families are often caught completely unprepared.
In the small town of Grundy Center, Iowa, Randy and Ellen Omvig keep a large
plastic freezer bag. Inside is a piece of torn paper with "Mom & Dad"
written at the top.
When she first saw it in December 2005, Ellen thought it was a Christmas
list from her son Josh, who had just walked out the front door.
Then she read the words:
"Don't think this is because of you," it said. "You did the best you could
with me. The faces and the voices just won't go away."
The note indicated Josh's imminent suicide and went on to apologize for the
pain he would cause. He said he had just received a
driving-while-intoxicated charge - a surprise since he rarely drank. "This
kills all hope of becoming a police officer that I ever had," he wrote.
By the time Ellen realized what the note was about, she ran outside. Josh
was getting in his truck. She grabbed the side mirror, yelling hysterically
that he would have to run her over before driving away. He yelled back,
about a friend who had been killed in Iraq.
"Your battle buddy would not want you to die," she screamed.
"Mom, you don't understand," he said. "I've been dead ever since I left
Iraq."
Josh shot himself in the head a few seconds later, as a police officer - and
close friend - pulled up. His case made local headlines and has since become
the inspiration for legislation in Congress to better prevent veteran
suicides.
Josh Omvig had been a happy kid who signed up for the Army Reserve the day
after he turned 18. He spent an intense 10 months in Iraq and then suddenly
was home again. In the space of six days, he went from serving in Iraq to
sitting at his family's Thanksgiving dinner table.
In the 13 months that followed, it was clear that Josh had changed. His
parents urged him to get help. But he was convinced that showing up at the
VA would go on his record, costing him a career in the military and law
enforcement.
The Omvigs believe the nation faces a cascade of mental health problems.
"There are so many Joshes coming back now," Randy Omvig said.
THE TORMENT OF WAR
In many respects, the Omvigs' story is remarkably similar to that of the
Bowmans', whose son Tim killed himself on Thanksgiving Day in 2005.
It's impossible to know what goes through the mind of any suicidal veteran,
or whether VA care would have made a difference. But as he tries to rebuild
his life without his son, Mike Bowman is convinced that even a little care
would have been better than none.
Tim Bowman joined the National Guard after Sept. 11 but before the Iraq war.
He was a charming jokester, a small-town kid who played musical instruments
in high school, attended some junior college and then went to work in his
family's electrical business in Polo, Ill.
He left for the war on March 4, 2004, his 22nd birthday.
Over the next 12 months, his assignments varied, but among them was helping
patrol Route Irish, the treacherous airport highway. He told his father
about having to bag body parts.
In his communications back home, Tim became an expert at withholding the
details of his reality. He did open up once, however. Home for a short
leave, Tim and his father stopped for a beer after a softball game. They got
into their deepest conversation about the war and even talked about an
episode in which Tim, as the last line of defense, said he was forced to
shoot at a car - with a family inside - that had failed to stop at a
checkpoint.
"He was really quiet as he told me - not at all the normal Tim," his father
said. (His commander at the time said he is unaware of any incident like Tim
described. Tim's father said Tim may have been involved in a shooting and
"assumed the worst in his state of mind.")
At the end of his leave, Tim didn't want to go back to Iraq, but he didn't
not want to go back, either. More than anything, he couldn't stand being
away from his unit.
He returned home for good in March 2005. His deployment had included some
mental health screening, but he told his father that it was "a joke."
Soldiers coming off months of active duty would say anything during the
screenings. "All they wanted to do was get home," his father said.
That was a feeling shared by Tim's commander in Iraq, Maj. Mike Kessel of
Mahomet, Ill., who recently retired after 21 years in the Army National
Guard. Two months before his unit returned home to Illinois, Kessel urged
his bosses to change the demobilization process by letting the soldiers go
home briefly before returning for health screening.
"I knew we were going to have problems," Kessel said. But his proposal was
rejected.
"We got off the bus, we had a five-minute ceremony, and, boom, we were
released," he said. "We didn't come back to drill for 110 days. Suddenly,
your support system is gone. We had 120 people in 70 communities spread
across five states."
In a 2004 study, nearly two-thirds of soldiers and Marines who met the
criteria for mental health problems felt that seeking help would harm their
careers, that they would been seen as weak, that superiors might treat them
differently. One VA report from 2006 said that "any effort to reach out to
these veterans and their families will face enormous obstacles"; it also
said that the current system "follows an attitude of `ask, but don't tell.'"
While every returning soldier is asked four important PTSD-related
questions, "no one seems to expect them to answer truthfully."
Tim came home and tried to dive back into his life, working his electrical
job and volunteering at the fire department. He'd be pleasant one minute and
flip out over mild annoyances the next.
"I don't feel right here," Tim admitted during a rare candid conversation
with his sister Michelle. "I'm spending too much time in the bar," he added.
Tim took a six-week National Guard assignment to help with the Hurricane
Katrina recovery. His family said he relished the structure of the unit. He
even began talking about the possibility of going back to Iraq.
"What better place for a soldier to die," he told his father one night.
In November, Tim scheduled an appointment with the VA. His father wasn't
sure what it was for - mental issues, or perhaps follow-up for a hand injury
that Tim had suffered in Iraq.
The night before Thanksgiving, Tim had a great conversation with his father
and his sister. He seemed his old, jovial self. His family now believes that
by then he already knew what he was about to do.
The next day, Tim didn't show up for an extended-family Thanksgiving dinner.
They called and called. Finally, Mike Bowman decided to see if Tim was at
the family business. He found him on the floor, shot but still breathing.
Tim died two hours later.
At Tim's funeral, Kessel, his commanding officer, found that several other
soldiers were having mental troubles, too - and having trouble getting into
the VA.
"They were told, `We can't get you in for six months,'" Kessel said. "We
started pulling a bunch of strings and making lots of noise, and then people
started listening.
"But it was one soldier too late."
PSYCHIATRIC TREATMENT VARIES
The nearest VA outpatient clinic to Tim Bowman's hometown is part of the
Madison, Wis., network. Like a third of all the VA medical centers in 2005,
Madison didn't have a specialized PTSD clinical team, according to VA
records.
That's the case despite two decades of urging by VA experts that each
medical center should have such a team. "Such specialization has long been
recognized as an essential feature in treatment of military-related PTSD," a
2006 VA report said. "Treatment of PTSD requires specific familiarity with
the kinds of trauma veterans encountered while in military service."
Its absence in many centers exemplifies a significant - and growing -
problem in the VA: the wide disparities in mental health services.
The VA's mental health experts started pushing for specialized PTSD programs
in all medical centers in the 1980s. Top VA officials agreed "in concept"
that it would be a good idea. But in 2005 and 2006, despite telling Congress
that it was setting aside an additional $300 million for expanding mental
health services, such as PTSD programs, the VA didn't get around to spending
$54 million of that, according to the Government Accountability Office.
At medical centers with no specialized PTSD teams, veterans still get PTSD
treatment, but not from the specialists whom the VA considers to be most
essential.
In all, only 27 percent of veterans receiving PTSD care received it in one
of the VA's specialized programs, VA data show. And that varies widely: In
the region that includes Wisconsin, 13 percent of veterans with PTSD got
care from specialized teams. In Ohio, 45 percent did.
The amount of specialized care came up at a Senate committee last February,
in which VA Secretary Nicholson assured lawmakers that PTSD funding wasn't a
problem. "We're certainly getting the resources" to deal with the issue, he
testified. "In every one of our 154 major medical centers, we have a
certified expert on PTSD."
But that doesn't come close to meeting the goals of the VA's own committee
of PTSD experts, which for years had urged a full PTSD clinical team in
every VA medical center - not just an expert. By 2006, there were full PTSD
clinical teams in 104 of 163 medical centers; in the past, the department's
inspector general has questioned whether people are really working in some
of those units.
In the same month as Nicholson's testimony, the VA's PTSD expert panel
sounded a different note from the secretary's. "Just having a team or a PTSD
expert does not solve the problem," the committee concluded. It added:
"Specialized PTSD programs are not ready to meet the ongoing needs of
veterans of past deployments while also reaching out to new combat
veterans."
The uneven mental health treatment of veterans across the country can be
traced to the VA's health system reorganization, which gave a lot of leeway
to local managers.
"Some networks did an entirely fine job in maintaining capacity for the
treatment of mental illness," Thomas Horvath, a VA health official based in
Houston, told Congress in 2004. "Others did a terrible job."
"There appears to be little or no rationale for the size or distribution of
these programs nationally," a 2003 VA report concluded.
For the average veteran seeking care, this means that getting the best care
depends on geography and luck.
Consider what the VA considers a "crucial ingredient" for measuring the
comprehensiveness and consistency of its mental health treatment. Called the
"continuity of care index," it shows whether veterans are getting consistent
care rather than being bounced from doctor to doctor.
That continuity is absent in many parts of the country.
According to VA data, the "continuity of care index" for PTSD patients
varies widely across the country, even after adjusting for patient
characteristics and different diagnoses. In fact, more than a third of VA
medical centers had an index rating that was "significantly different" from
the national median "in the undesired direction," a 2006 VA report said.
McClatchy reviewed two dozen mental health measures, based in part on an
analysis of every inpatient and outpatient visit in the VA health system.
The 200 million records were contained in two fiscal 2005 databases.
Among the findings:
Some veterans get in for visits far more than others. The average number of
visits per veteran with PTSD ranged from 22 in the Hudson Valley, N.Y.,
medical center and clinics to a low of 3.1 in Fargo, N.D. The national
average was 8.1.
Some VA medical centers spend far more on mental health care than others. In
Connecticut, it was an average of $2,317 for each veteran's outpatient
psychiatric care. In Saginaw, Mich., it was $468.
Some veterans get in quickly. Others wait. At the Loma Linda, Calif., VA
network, only 39 percent of new mental health patients were able to get
appointments within 30 days, the VA's standard. In other networks, 90
percent or more did.
Once they're in the door, some veterans get visits of 75 to 80 minutes,
while others get 20- to 30-minute appointments, the shortest psychotherapy
appointments listed in the system. Of all the individual sessions for
veterans with PTSD, those in the Amarillo, Texas, network got the shortest
possible visits 87 percent of the time, while those in Butler, Pa., were
given those short visits 6 percent of the time.
The VA's mental health system is nonexistent for many veterans it's supposed
to serve.
One key measure is the number of veterans with mental illnesses who get all
their treatment outside the VA mental health system - that is, typically
from the VA's general primary care doctors. Nationwide, 22 percent of
veterans got all of their mental health care outside the mental health
system.
But there was a big range: In Beckley, W.Va., 10 percent got their care that
way. In Montana, 52 percent did, data from 2005 show.
Asked about the disparities, the VA's Zeiss said: "It's true there are
disparities. ... Disparity is a part of health care. ... I can tell you that
the data you're looking at we're looking at too, and we're using it to make
decisions about how to close the gap and ensure a standard of care
nationally."
The VA's top mental health services official, Dr. Ira Katz, added in a
separate interview that variation in a host of mental health measures wasn't
necessarily good or bad. It could reflect different strategies being tried
in different states so that "our system can better learn what works and what
doesn't work," he said.
Through such trial and error, variations likely would decrease over time as,
for example, expensive medical centers become more efficient and underserved
medical centers were given more resources, he said.
So far, that hasn't happened, McClatchy found.
For starters, the variations in many mental health measures are growing, not
shrinking, according to a McClatchy analysis of key measures back to the
time of the reorganization. A 2005 study by two VA mental health experts
found the same, noting that "system reforms did not lead to decreases in
regional variation."
In addition, the variation in mental health spending is far wider than it is
in primary and hospital spending, indicating that the system is having more
trouble ensuring mental health consistency.
As for the wide variation in spending per veteran on mental health care,
Katz said it could be explained by the presence of special programs in
various medical centers. There's a national PTSD research center at the
Connecticut VA, for example, that inflates spending figures there.
When asked how many of 128 medical centers ranked b
