thedrifter
07-25-05, 06:00 AM
VA straining to treat post-traumatic stress
By Hal Bernton
Seattle Times staff reporter
ABERDEEN During counseling, Vietnam veteran Rod Chenoweth always sits in the same place a blue fabric couch carefully positioned in a corner to give his body the protective cover of a side and rear wall as he talks about his life.
He recounts an argument that left him seething in anger. He talks about an evening flashback to the grenade that wounded him in the leg and killed his 19-year-old buddy.
Chenoweth says the therapy, paid for by the Department of Veterans Affairs (VA), has helped pull him back from thoughts of suicide and other self-destructive acts in a life scarred by post-traumatic stress disorder (PTSD) a war injury that ranks among the most common and the most difficult to heal.
Starting in July, Chenoweth's sessions with Aberdeen therapist Jack Dutro have been reduced from twice to once a month, a cut that comes as thousands of Iraq war veterans join those of previous wars in seeking treatment from the strained VA.
"I can understand that the new veterans need to be dealt with," said Chenoweth, 56. "But it's going to be tough. Jack has been a lifesaver."
The agency is required by law to take care of the war wounds of all combat veterans.
But the agency's PTSD experts, in a report delivered last fall to Congress, warned that the VA "does not have sufficient capacity to meet the needs of new combat veterans while still providing for the veterans of past wars."
Internal reports show the VA's mental-health network has been frayed by years of staffing cuts and budgets that failed to keep pace with the growth in patients.
According to an internal review of the agency's budget, delivered to Congress in September, problems have been years in the making:
Between 1996 and 2003, annual spending for treatment of the serious mentally ill increased from $2.16 billion to $2.4 billion. But when those budgets were adjusted for inflation in medical costs the increased costs of salaries and services spending in 2003 was actually $630 million below the 1996 level. Meanwhile, the number of veterans seeking those services climbed by 11 percent.
During the same period, overall mental-health staffing for the seriously ill declined by 31 percent.
Drug and alcohol treatment for the seriously mentally ill, often a critical part of the program for those seeking PTSD therapy, has been the hardest hit. Annual funding, adjusted for inflation, dropped by 54 percent nationwide between 1996 and 2003.
"It's been a perfect storm of rising needs and tight resources," said Tom Schumacher, who directs a Washington state effort to assist PTSD veterans.
The Northwest VA network has fared better than most of the nation, avoiding many of the staff cuts that hit other regions.
But the four-state region that includes Washington, Oregon, Idaho and Alaska also is one of the busiest hubs of treatment. The PTSD patient load alone has increased from 3,194 in 1996 to 4,671 in 2004.
To help manage the crunch, the VA Puget Sound Health Care System earlier this year imposed new restrictions on PTSD therapy for veterans who already have undergone at least six months of treatment.
The VA guidelines now call for no more than once-a-month individual therapy, or twice-a-month group therapy. Those apply to Puget Sound-area clinics and a network of VA-funded private therapists who work around the state.
Dr. Miles McFall, director of PTSD programs at the VA Puget Sound, said that more frequent therapy does not necessarily help, and those in trouble are welcome to check into an inpatient VA hospital clinic.
"Even if money was not an issue, this is what we should be doing," he said. "We care about our Vietnam vets. We're not going to turn our backs on them."
Other therapists say while some veterans can handle less treatment, the more unstable ones may suffer setbacks.
"Some of them are devastated and feel like they have been abandoned one more time," said Jim Shoop, a Mount Vernon counselor. He said his office is reducing service to more than 50 vets with PTSD.
A lifetime of trouble
Soldiers have always suffered from the mental wounds of war.
But the diagnosis of post-traumatic stress disorder only emerged in 1979 in the aftermath of the Vietnam War as tens of thousands of distraught veterans, suffering from flashbacks, sleeplessness, anger and other symptoms, poured into VA hospitals.
By 1988, the VA estimated that 479,000 vets suffered PTSD symptoms.
For many of these vets, PTSD has meant a lifetime of trouble.
Chenoweth served with the Marines in Vietnam from 1968 to 1969, when the U.S. sustained some of its heaviest casualties. He turned 18 just before boarding the plane to Asia and soon found himself fighting in villages where anybody could be the enemy.
Chenoweth ended his tour of duty in a psychiatric hospital in Oakland. But it wasn't until the late '80s after more than a dozen failed jobs, several more hospital stays and two broken marriages that he was diagnosed with PTSD.
"The killing doesn't stop," Chenoweth said. "You taste it. You smell it. And you feel it. It uses all your senses."
The numbers of older veterans seeking mental-health treatment surged again in recent years, as new wars unfolding on television in Iraq and Afghanistan added to their stress.
That, coupled with the influx of soldiers returning from Iraq, has ratcheted up pressure on the VA system.
More become eligible
In the '90s, the VA went through a dramatic overhaul, moving away from a centralized hospital system as hundreds of new clinics opened up around the country. Congress also loosened eligibility requirements, so that more vets qualified for services, and increased the agency's overall health-care budget from $17 billion to more than $28 billion.
The transformation was lauded as a great success in an Annals of Internal Medicine article last year.
But mental-health services often lost out as regional administrators juggled budgets to pay for soaring caseloads, new services and pricey new drugs.
Managers also sometimes balked at pouring money into treatment for illnesses of the mind when compared with physical illnesses that are often easier to measure and cure.
"I regret to report that there are stigmas in the VA about the mentally ill," Thomas Horvath, a psychiatrist who serves as chief of staff at the agency's Houston medical center, told Congress in 2004.
"In this, we may be no worse than the rest of health care. VA needs to do better."
Sen. Patty Murray, who worked as a college intern in the Seattle VA psychiatric ward, has helped lead the congressional effort to boost funding for VA programs, including mental health.
"I have talked to soldiers who are returning, and a number of them say 'my marriage is much more difficult ... I am having trouble getting my head back in to work,'" said Murray, "It's the beginning of trouble. And the fallout from this 10, 15, 20 years from now is tremendous."
The issue of VA funding has been rife with partisan politics recently.
Murray, a Democrat, initially was rebuffed by the Republican majority in an effort to gain emergency funding for VA medical services.
VA administrators in June acknowledged a roughly $1 billion budget shortfall, prompting Senate Republicans to do an about-face and work with Murray to boost funding.
Congress is expected to approve an additional $975 million to $1.5 billion to help dig the agency out of the hole for this fiscal year.
If this money is equally divided within the agency, mental health would receive less than $300 million.
This emergency cash would fall short of shoring up the system.
To fully meet the needs of the seriously mentally ill, the VA would require an infusion of as much as $1.6 billion, according to a draft of the agency's strategic plan.
That estimate didn't assess the added costs of treating new Iraq veterans.
"Just good-enough care"
There is no fixed formula for treating PTSD.
Instead, the VA offers general guidelines for addressing the illness. This treatment may involve drugs that aid sleep and reduce anxiety or help fight depression. It may include classes in anger management and other coping skills.
Finally, there is therapy, which often enables the vet to recount and come to terms with combat experiences.
Some patients may benefit from just a few classes and counseling sessions. Others with chronic PTSD attend sessions for months or years. Some patients do fine in group; others do much better with individual therapy. But as budgets have shrunk, some VA mental-health workers say, they have been pressured to treat more people in less time.
In Portland, the VA mental-health clinic staff by January had shrunk by 25 percent due to budget freezes, according to an internal staff newsletter. The newsletter described the Portland program as "unquestionably underfunded."
continued.....
By Hal Bernton
Seattle Times staff reporter
ABERDEEN During counseling, Vietnam veteran Rod Chenoweth always sits in the same place a blue fabric couch carefully positioned in a corner to give his body the protective cover of a side and rear wall as he talks about his life.
He recounts an argument that left him seething in anger. He talks about an evening flashback to the grenade that wounded him in the leg and killed his 19-year-old buddy.
Chenoweth says the therapy, paid for by the Department of Veterans Affairs (VA), has helped pull him back from thoughts of suicide and other self-destructive acts in a life scarred by post-traumatic stress disorder (PTSD) a war injury that ranks among the most common and the most difficult to heal.
Starting in July, Chenoweth's sessions with Aberdeen therapist Jack Dutro have been reduced from twice to once a month, a cut that comes as thousands of Iraq war veterans join those of previous wars in seeking treatment from the strained VA.
"I can understand that the new veterans need to be dealt with," said Chenoweth, 56. "But it's going to be tough. Jack has been a lifesaver."
The agency is required by law to take care of the war wounds of all combat veterans.
But the agency's PTSD experts, in a report delivered last fall to Congress, warned that the VA "does not have sufficient capacity to meet the needs of new combat veterans while still providing for the veterans of past wars."
Internal reports show the VA's mental-health network has been frayed by years of staffing cuts and budgets that failed to keep pace with the growth in patients.
According to an internal review of the agency's budget, delivered to Congress in September, problems have been years in the making:
Between 1996 and 2003, annual spending for treatment of the serious mentally ill increased from $2.16 billion to $2.4 billion. But when those budgets were adjusted for inflation in medical costs the increased costs of salaries and services spending in 2003 was actually $630 million below the 1996 level. Meanwhile, the number of veterans seeking those services climbed by 11 percent.
During the same period, overall mental-health staffing for the seriously ill declined by 31 percent.
Drug and alcohol treatment for the seriously mentally ill, often a critical part of the program for those seeking PTSD therapy, has been the hardest hit. Annual funding, adjusted for inflation, dropped by 54 percent nationwide between 1996 and 2003.
"It's been a perfect storm of rising needs and tight resources," said Tom Schumacher, who directs a Washington state effort to assist PTSD veterans.
The Northwest VA network has fared better than most of the nation, avoiding many of the staff cuts that hit other regions.
But the four-state region that includes Washington, Oregon, Idaho and Alaska also is one of the busiest hubs of treatment. The PTSD patient load alone has increased from 3,194 in 1996 to 4,671 in 2004.
To help manage the crunch, the VA Puget Sound Health Care System earlier this year imposed new restrictions on PTSD therapy for veterans who already have undergone at least six months of treatment.
The VA guidelines now call for no more than once-a-month individual therapy, or twice-a-month group therapy. Those apply to Puget Sound-area clinics and a network of VA-funded private therapists who work around the state.
Dr. Miles McFall, director of PTSD programs at the VA Puget Sound, said that more frequent therapy does not necessarily help, and those in trouble are welcome to check into an inpatient VA hospital clinic.
"Even if money was not an issue, this is what we should be doing," he said. "We care about our Vietnam vets. We're not going to turn our backs on them."
Other therapists say while some veterans can handle less treatment, the more unstable ones may suffer setbacks.
"Some of them are devastated and feel like they have been abandoned one more time," said Jim Shoop, a Mount Vernon counselor. He said his office is reducing service to more than 50 vets with PTSD.
A lifetime of trouble
Soldiers have always suffered from the mental wounds of war.
But the diagnosis of post-traumatic stress disorder only emerged in 1979 in the aftermath of the Vietnam War as tens of thousands of distraught veterans, suffering from flashbacks, sleeplessness, anger and other symptoms, poured into VA hospitals.
By 1988, the VA estimated that 479,000 vets suffered PTSD symptoms.
For many of these vets, PTSD has meant a lifetime of trouble.
Chenoweth served with the Marines in Vietnam from 1968 to 1969, when the U.S. sustained some of its heaviest casualties. He turned 18 just before boarding the plane to Asia and soon found himself fighting in villages where anybody could be the enemy.
Chenoweth ended his tour of duty in a psychiatric hospital in Oakland. But it wasn't until the late '80s after more than a dozen failed jobs, several more hospital stays and two broken marriages that he was diagnosed with PTSD.
"The killing doesn't stop," Chenoweth said. "You taste it. You smell it. And you feel it. It uses all your senses."
The numbers of older veterans seeking mental-health treatment surged again in recent years, as new wars unfolding on television in Iraq and Afghanistan added to their stress.
That, coupled with the influx of soldiers returning from Iraq, has ratcheted up pressure on the VA system.
More become eligible
In the '90s, the VA went through a dramatic overhaul, moving away from a centralized hospital system as hundreds of new clinics opened up around the country. Congress also loosened eligibility requirements, so that more vets qualified for services, and increased the agency's overall health-care budget from $17 billion to more than $28 billion.
The transformation was lauded as a great success in an Annals of Internal Medicine article last year.
But mental-health services often lost out as regional administrators juggled budgets to pay for soaring caseloads, new services and pricey new drugs.
Managers also sometimes balked at pouring money into treatment for illnesses of the mind when compared with physical illnesses that are often easier to measure and cure.
"I regret to report that there are stigmas in the VA about the mentally ill," Thomas Horvath, a psychiatrist who serves as chief of staff at the agency's Houston medical center, told Congress in 2004.
"In this, we may be no worse than the rest of health care. VA needs to do better."
Sen. Patty Murray, who worked as a college intern in the Seattle VA psychiatric ward, has helped lead the congressional effort to boost funding for VA programs, including mental health.
"I have talked to soldiers who are returning, and a number of them say 'my marriage is much more difficult ... I am having trouble getting my head back in to work,'" said Murray, "It's the beginning of trouble. And the fallout from this 10, 15, 20 years from now is tremendous."
The issue of VA funding has been rife with partisan politics recently.
Murray, a Democrat, initially was rebuffed by the Republican majority in an effort to gain emergency funding for VA medical services.
VA administrators in June acknowledged a roughly $1 billion budget shortfall, prompting Senate Republicans to do an about-face and work with Murray to boost funding.
Congress is expected to approve an additional $975 million to $1.5 billion to help dig the agency out of the hole for this fiscal year.
If this money is equally divided within the agency, mental health would receive less than $300 million.
This emergency cash would fall short of shoring up the system.
To fully meet the needs of the seriously mentally ill, the VA would require an infusion of as much as $1.6 billion, according to a draft of the agency's strategic plan.
That estimate didn't assess the added costs of treating new Iraq veterans.
"Just good-enough care"
There is no fixed formula for treating PTSD.
Instead, the VA offers general guidelines for addressing the illness. This treatment may involve drugs that aid sleep and reduce anxiety or help fight depression. It may include classes in anger management and other coping skills.
Finally, there is therapy, which often enables the vet to recount and come to terms with combat experiences.
Some patients may benefit from just a few classes and counseling sessions. Others with chronic PTSD attend sessions for months or years. Some patients do fine in group; others do much better with individual therapy. But as budgets have shrunk, some VA mental-health workers say, they have been pressured to treat more people in less time.
In Portland, the VA mental-health clinic staff by January had shrunk by 25 percent due to budget freezes, according to an internal staff newsletter. The newsletter described the Portland program as "unquestionably underfunded."
continued.....