Saul Rosenberg, Ph.D.
Mr. Chairman, thank you for inviting me to this joint hearing of the Subcommittees on Health and Disability Assistance and Memorial Affairs to discuss the needs of women and minority veterans. My name is Dr. Saul Rosenberg. I have been engaged in assessing and treating veterans and civilians with Posttraumatic Stress Disorder (PTSD) for many years. As a clinical psychology intern at the Ann Arbor VAMC I learned that to be an effective therapist I had to understand the cultural experiences, preferences and values of the individual I was trying to help. The lessons I learned as a trainee I have taught to interns and psychiatry residents at the San Francisco VAMC. I am not employed by the VA nor do I represent the VA.
With my colleagues in the Dept. of Psychiatry at the University of California, San Francisco and the San Francisco VAMC I have participated in the development of diagnostic interviews and psychological tests to help counselors and therapists better understand the psychological problems that contribute to social isolation. Social support from families, friends, Vet Centers and veterans’ service organizations play a huge role in healing the body, mind and spirit.
My current professional interest is in the development of public-private partnerships, between University of California campuses, affiliated military hospitals and VAs, governmental agencies, foundations and the private sector to improve access to evidence-based, cost-effective mental health diagnostic and treatment services. I believe that public-private partnerships are essential to reduce the disparities in access to mental health services for racial and ethnic minorities, native Americans, rural populations, women, children, the elderly and all underserved and vulnerable populations.
My colleagues at UCSF and the SFVAMC recently published the first detailed report on the prevalence of mental health and psychosocial problems, with a breakdown by gender and race, for over 100,000 veterans first seen at VA health care facilities. The prevalence of mental disorders was high: over 30% had a diagnosed mental disorder or psychosocial problem. Posttraumatic Stress Disorder (PTSD) was the most common diagnosis, and more than half of those diagnosed with a mental disorder had two or more mental health diagnoses.
Women comprised 13% of the sample; 69% were White, 18% were Black, 11% were Hispanic and 2% came from other racial groups. The likelihood of receiving a diagnosis for PTSD or another mental disorder was the same for women and men and across all racial groups. The most striking finding in the study had to do with age and not with race or gender. The youngest veterans, between 18 and 24 years of age, had a significantly higher likelihood of being diagnosed with PTSD or another mental disorder, compared to veterans 40 years and older. The youngest men and women, Whites, Blacks and Hispanics, were more vulnerable to stress than those who were over 40 years of age. The results of this study point to the importance of funding programs that target the early identification and treatment of PTSD in the youngest servicemen and women.
In this study, most mental disorders were identified in primary care and non-mental health settings within a few days of the first visit to a VA clinic. The detection of PTSD, depression and substance abuse in primary care settings is crucial in order to initiate treatment which can prevent chronic mental disorders and disability. This study shows that the emphasis the VA is placing on the early detection of mental disorders in primary care settings has been effective.
Clinical research on the screening and psychological assessment of mental and substance abuse disorders and suicide risk in primary care deserves continued funding. Evidence-based clinical guidelines for the detection of PTSD, substance abuse and suicide risk should be continuously evaluated. The most effective protocols should be disseminated to all settings where veterans receive care, including the private sector.
For many years, The VA, DoD, National Institute of Health (NIH) and the National Institute of Mental Health (NIMH) have supported research on evidence-based diagnostic tools and treatments for PTSD, depression and substance abuse. I have been grateful to the NIMH for supporting my own research. Like most academics, I have published my research in peer reviewed journals. However I now believe that research that benefits patients needs to be delivered to health care providers when they need it -- at the point of care.
The VA – more than any other public or private institution – is in the best position to implement computer-aided decision support for mental disorders at the point of care. The VA is the largest integrated delivery system that provides mental and behavioral health care. In addition, the VA has VistA, the oldest and most robust Electronic Health Record (EHR). The delivery of clinical practice guidelines matched to a patient’s diagnosis and delivered directly into to a patient’s EHR at the point of care deserves the highest priority. In addition, efforts now underway to develop portable longitudinal Personal Health Records that injured veterans can take with them wherever they seek care deserve continued support.
Too much excellent research that could benefit veterans is buried in professional journals; we need one place to accumulate all the data from all the studies so that health care providers can learn from past experience and share knowledge about the best ways to treat and rehabilitate injured veterans. All researchers and contractors who receive federal funding for health related projects should be encouraged to deposit their data in a secure, private and confidential data base. Investigators and contractors should be encouraged to report results by gender and race to insure that treatments are available that are attuned to the experiences, culture, values and preferences of injured veterans and their families.
Many servicemen and women returning from Iraq have been exposed to roadside bombs and improvised explosive devices. Never before have so many soldiers received simultaneous injuries to their brain and mind. There is much that we have to learn about the diagnosis and cognitive rehabilitation of Traumatic Brain Injuries (TBI) from powerful bombs. These blast injuries are not the same as concussions resulting from a car accident or a sports injury. Thorough screening and comprehensive neurological and neuropsychological assessment is essential to characterize these injuries and to maximize the prospects for recovery, a good quality of life and the ability to work, contribute and participate in a community.
Most veterans receive their health care outside the VA system. I am especially concerned about the lack of coverage provided by private health insurance plans for neuropsychological assessment. Many private insurance companies will pay over $1,000 for neuroimaging studies but refuse to pay for the costs of comprehensive neuropsychological testing. Proper neuroimaging studies are essential but they cannot measure cognitive functioning, like the ability to sustain and focus attention or short-term memory – only neuropsychological tests can do that. Congressional hearings that investigate the treatment of veterans with TBI should invite neuropsychologists and representatives of professional neuropsychological associations to provide testimony on this issue. Before the DoD and VA outsource the treatment of military personnel and veterans with brain injuries to private facilities they should have the assurance that unwarranted restrictions on neuropsychological assessment are the exception rather than the rule.
The VBA has acknowledged a backlog of over 400,000 disability claims awaiting disability determination. The VBA has acknowledged that the waiting time to complete disability examinations is unacceptably long.
According to a 2007 Institute of Medicine (IOM) report regarding disability determination for veterans, the methodology the VBA uses for determining disability is outmoded and does not reflect current knowledge about the assessment of functional impairments. The IOM recommended development of pilot programs to immediately award partial disability to veterans who meet presumptive criteria for a disabling mental disorder. Implementing the IOM’s recommendations would assure that injured veterans received immediate help and financial support while waiting – sometimes for years – for their claims to be adjudicated.
The IOM also recommended funding demonstration projects to implement the International Classification of Functioning, Health and Disability published by the World Health Organization. The IOM pointed out that we need better description and quantification of functional capacities that promote involvement. Projects should be encouraged that map the full range of impairments and also the full range of functional capacities. A major goal of rehabilitation is to reengage the disabled veteran and promote social connections. Injured veterans need to be engaged in their communities, working, volunteering and connecting with friends and veterans.
Wide variability exists between military and VA disability ratings and across different regions of the U.S. I am especially concerned about the possibility of racial disparities in disability ratings for PTSD. In a presentation to the Institute of Medicine, Dr. Charles Engel, the Director of the Deployment Health Clinical Center, reported that African American veterans were about half as likely as other veterans to receive service connected disability for PTSD (Medical Care 2003;41(4):536-549). This issue deserves urgent attention. Culturally sensitive assessment tools need to be developed to insure that consistent and equitable procedures are implemented and that any racial disparities that exist are eliminated.
A 2007 Institute of Medicine (IOM) report, PTSD Compensation and Military Service, recommended that new methods should be developed to identify women who are victims of military sexual assault. Because PTSD from sexual assault is more difficult to prove than PTSD resulting from combat, the IOM recommended that more attention should be focused on the prompt identification and treatment of women who are victims of sexual assault and that better procedures be established for awarding disability compensation.
A 2007 report form the DoD Task Force on Mental Health has called for more attention to the prevention of mental disorders and the building of resilience and coping strategies to deal with the stress of deployment. The report stated:
“The mission of caring for the psychological health of the military has fundamentally changed…new programs are needed…to meet current and future demands for a full spectrum of services including: resilience-building, assessment, prevention, early intervention, and provision of an easily-accessible continuum of treatment for psychological health of service members and their families in both the Active and Reserve Components. There are not sufficient mechanisms in place to assure the use of evidence-based treatments or the monitoring of treatment effectiveness”
Currently, health information technology contracts and clinical research are conducted along parallel separate tracks. I recommend that contracts and research be funded for joint projects that integrate health services research and health information technology. Programs like the VA Special Fellowship Program in Medical Informatics provide a bridge for connecting patients, providers and researchers to health information technologies.
The next generation of providers will be increasingly sophisticated in utilizing cutting edge technologies for telemedicine such as those being developed by the Telemedicine and Advanced Technology Research Center (TATRC).
A recent study by Dr. Charles Marmar at the San Francisco VAMC and UCSF and his colleagues across the country, found predictors of PTSD for police and other first responders following a disaster or critical incident. This study measured personal characteristics prospectively -- prior to exposure to a stressful event. Factors that predicted chronic and severe PTSD symptoms and greater functional impairments included the use of maladaptive coping strategies, especially self-medication with alcohol. In contrast, police officers who had a strong social support network after exposure to a critical stressful incident, exhibited less symptoms and impairments in functioning and were more likely to return to duty. The National Institute of Mental Health has generously funded research on vulnerabilities and protective factors related to the development of PTSD; congress should continue to support these promising initiatives.
The Mental Illness Research, Education and Clinical Centers (MIRECC) were established by Congress to translate clinical research and best practices in mental health care into tangible benefits for patients of the VA. The MIRECCs are conducting research on post-deployment mental disorders, PTSD, substance abuse and suicide prevention. In addition, the MIRECCs produce clinical educational programs. These excellent programs deserve continued support and new programs should be funded, such as centers of excellence for the study of resilience – an idea promoted by the DoD Task Force on Mental Health.
The Telemedicine and Advanced Technology Research Center (TATRC) was established by congress to implement innovative telemedicine and technology projects to deliver medical expertise anywhere it is needed. Technologies developed by TATRC to help injured servicemen and women on the battlefield, and in remote rural communities, can be transferred to the private sector. Like many technology projects sponsored by the VA, the benefits accrue not only to veterans and their families but to the whole community. VistA, the VA’s EHR is being installed around the world; countries that cannot afford to spend millions of dollars to develop an EHR can install VistA for a tiny fraction of the cost of commercial EHR.
Thank you for your support for research and for the education and training of the clinicians who provide health care to injured veterans. I will be happy to answer any questions.
 Karen H. Seal, MD, MPH; Daniel Bertenthal, MPH; Christian R. Miner, PhD; Saunak Sen, PhD; Charles Marmar, MD, “Bringing the Ware Back Home: Mental Health Disorders Among 103 788 US Veterans Returning from Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities” Arch Intern Med. 1007, 167, 476-482.
 Charles R. Marmar; Shannon E. McCaslin; Thomas J. Metzler; Suzanne Best; Daniel S. Weiss; Jeffery Fagan; Akiva Liberman; Nnamdi Pole; Christian Otte; Rachel Yehuda; David Mohr; and Thomas Neylan, “Predictors of Posttraumatic Stress in Police and Other First Responders” Ann. N.Y. Acad. Sci. 1071: 1-18 (2006).