[Senate Hearing 110-795]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 110-795
 
     OVERSIGHT HEARING ON SYSTEMIC INDIFFERENCE TO INVISIBLE WOUNDS

=======================================================================


                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                              JUNE 4, 2008

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont         Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Johnny Isakson, Georgia
Jon Tester, Montana                  Roger F. Wicker, Mississippi
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                              June 4, 2008
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     3
    Letters......................................................    39
Murray, Hon. Patty, U.S. Senator from Washington.................     4
Brown, Hon. Sherrod, U.S. Senator From Ohio......................     6
Tester, Hon. Jon, U.S. Senator From Montana......................     7
Sanders, Hon. Bernard, U.S. Senator From Vermont.................     8

                               WITNESSES

Perez, Norma J., Ph.D., Mental Health Integration Psychologist, 
  and Former Coordinator, PTSD Clinical Team, Temple, Texas VA 
  Medical Center.................................................    10
    Prepared statement...........................................    12
Kussman, Michael J., M.D., Under Secretary for Health, Department 
  of Veterans Affairs; accompanied by Ira Katz, M.D., Deputy 
  Chief Patient Care Services Officer for Mental Health..........    13
    Prepared statement...........................................    16
    Response to written questions submitted by:
      Hon. Bernard Sanders.......................................    19
      Hon. Roger F. Wicker.......................................    21
Dunne, Patrick W., Rear Admiral, USN (Ret.), Acting Under 
  Secretary for Benefits and Assistant Secretary for Policy and 
  Planning, Department of Veterans Affairs; accompanied by Brad 
  Mayes, Director of Compensation and Pension Service............    23
    Prepared statement...........................................    25
    Response to written questions submitted by Hon. Bernard 
      Sanders....................................................    28
        Attachments..............................................    31

                                APPENDIX

Obama, Hon. Barack, U.S. Senator from Illinois; prepared 
  statement......................................................    59


     OVERSIGHT HEARING ON SYSTEMIC INDIFFERENCE TO INVISIBLE WOUNDS

                              ----------                              


                        WEDNESDAY, JUNE 4, 2008

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9.30 a.m., in 
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Brown, Tester, Sanders, 
and Burr.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. The hearing of the U.S. Senate Committee of 
Veterans Affairs on Systemic Indifference to Invisible Wounds 
will come to order.
    Before we begin, I want to share with you what happened 
yesterday. I want all of you to look up over the door and see 
what is there. I want to describe a ceremony that took place 
yesterday in our newly-renovated hearing room.
    The room received a traditional Hawaiian blessing. I know 
you--our guests and witnesses and specifically Dr. Kussman--
would have an idea about this.
    You may notice the green lei that is draped over the top of 
the room's entrance. It is called maile, and in Hawaii that is 
a sacred lei that is made of a vine that is very symbolic 
because it is used by what we call the ali'i, or the people 
that are there in charge, and it connects the things that are 
separated; so, the symbolism there is good.
    This is a lei we tied and untied at entry through the door 
during the blessing, and traditionally after the lei is used in 
the ceremony, it remains hung along the door's outline as you 
see it.
    When the room was blessed, I was reminded of the Hawaiian 
concept of Kuleana, or responsibility. While many come to this 
room with different perspectives, all of us enter with the same 
Kuleana, and that is to honor veterans. And we want to do the 
best we can to honor veterans.
    It is my hope that we will be mindful of Kuleana to the 
veterans of this Nation, and our Nation as a whole.
    This morning we meet to discuss VA's commitment to PTSD, 
both in terms of treatment and compensation.
    Recent events at the Temple VA Medical Center have raised 
concerns about the Department's dedication to the mental health 
needs of our returning servicemembers.
    I stress, however, that this hearing is not simply about 
one facility or one clinician. This hearing is a part of the 
Committee's ongoing oversight of VA activities including VA 
mental health care.
    Last month we learned that a VA official sent an email that 
appeared to deliberately conceal data on suicides. Now, we have 
another VA employee who appears to have linked the increase in 
veterans seeking compensation for PTSD with a desire to assign 
a lesser diagnosis of adjustment disorder--an action that 
alarmed many veterans and others.
    One question that was raised repeatedly about this email 
was, and I quote, ``why would a clinician be so concerned about 
the compensation rolls?'' Unquote.
    We must know whether the actions of these VA employees 
point to a systemic indifference to invisible wounds.
    The Committee must understand how VA is dealing with PTSD 
and other mental health concerns relating to war-zone service.
    We must ensure that veterans receive compensation for 
conditions related to their military service, and we must 
ensure they are getting appropriate care.
    From the testimony submitted for today's hearing, it 
appears that VA takes the position that adjustment disorder is 
a rational differential diagnosis to give to a veteran while 
clinicians take the time to determine if PTSD is involved.
    VA indicates that at Temple, whether a veteran has PTSD or 
not, the treatment is the same. This suggests to me that the 
diagnosis is meaningless if everyone gets the same treatment. 
It is my understanding that the reason a clinician makes a 
diagnosis is to inform treatment.
    To the extent that there are issues or problems that exist 
regarding PTSD or other psychological issues related to 
service, the Committee must know what it can do to help ensure 
that veterans receive accurate diagnosis from VA, proper care 
and appropriate benefits.
    The number of troops suffering from PTSD continues to 
mount. The numbers are staggering. With so many troops 
returning from multiple tours with various mental health 
issues, VA must have the credibility, resources and commitment 
to ensure that veterans are properly treated and appropriately 
compensated.
    If anyone here is puzzled about the reason for this 
hearing, let me answer by using a letter I received yesterday 
from the brother of a young man with PTSD who committed suicide 
last year.
    The brother writes, ``For PTSD the stigma of the label must 
be removed starting prior to a veteran's discharge from the 
armed services and confidence in the Veterans Health 
Administration's ability to adequately treat the condition must 
be restored.'' This is why we are holding this hearing today.
    Veterans and their families must be assured when they turn 
to VA, the Department is capable of caring for the veteran.
    I am working with the Inspector General as his 
investigation related to Temple progresses; and we expect 
something formal in the next couple of months. In the meantime, 
it is imperative that the Committee understand what is 
occurring.
    In closing, I note that last night the Senate passed 
critical legislation on mental health care named for yet 
another young veteran who died tragically after returning home 
from service. His name was Justin Bailey.
    Senator Burr and I worked to make this bill as focused as 
possible on PTSD and substance abuse. I look forward to seeing 
this bill through to the President's desk.
    Again, I want to thank the witnesses for being here today 
and look forward to your testimony.
    Now I would like to call on the Ranking Member, Senator 
Burr, for his statement.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Aloha, Mr. Chairman.
    As I look up and see the Hawaiian decorations that appeared 
late yesterday and the ceremony--which I had the opportunity to 
meet your son and to know a little bit about the impact of that 
ceremony in this beautiful room where some of the most 
important work of this Congress is done--I want to thank you 
and your family for the personal commitment you have to make 
sure that we are blessed in more ways than we can imagine, and 
guided, as I was told last night, by the ceremony and what it 
will do.
    Mr. Chairman, you called this oversight hearing today to 
address potential mental health issues in the VA. Last month we 
learned about the email that was sent at the Temple, Texas, VA 
Medical Center that caught the attention of the media and the 
attention of this Committee.
    The email message contained references to, quote, 
``compensation-seeking veterans'' and suggested to five other 
VA clinicians that they, quote, ``refrain from giving a 
diagnosis of PTSD straight out.''
    We will have an opportunity to understand that email from 
its author and I think that that will be helpful and 
informative to all of us.
    Dr. Kussman is here. Admiral Dunne is here. They will have 
an opportunity to explain, as well, if there is a larger 
problem within the VA health care system and the benefits 
system.
    Last month I joined with you, Mr. Chairman, in asking the 
Inspector General to look into this matter. We asked the IG to 
look into whether the email is evidence of a bigger problem 
with PTSD examinations at the Temple facility and whether any 
disability compensation claims were affected by those 
examinations.
    My preference, to be totally honest, would have been to 
wait until the Inspector General completed his investigation 
before holding this hearing. I dare say that we do not hold a 
hearing that mental health is not a part of the hearing. But 
the decision was made and I am prepared to join you, Mr. 
Chairman, and other Committee Members to address any findings 
in the IG's report once it is completed.
    We are moving toward today, quite frankly, without having 
all the facts. The title of today's hearing, Systemic 
Indifference to Invisible Wounds suggests that some have 
already reached a conclusion. Based on the title, it appears 
they are prepared to use this email and maybe other emails, 
rightly or wrongly, as a springboard to launch into attacks on 
the system of VA care, as a whole.
    There may be some areas of legitimate criticism, but I do 
hope that we can avoid impugning the professionalism of the 
entire cadre of VA health care workers to score any political 
points.
    Let us be careful about damaging the confidence veterans 
have in our VA health care to the point that they stop seeking 
treatment. We ought to be encouraging veterans to seek mental 
health care.
    Treatment is so important to me that I introduced a bill 
that would pay for their living expenses while participating in 
an effective program. So let us not destroy the progress we are 
hoping to make with the use of headline-seeking rhetoric.
    If, however, it is the judgment of my colleagues that there 
is systemic indifference in how VA cares for veterans, then be 
prepared to give those veterans an option for their care. Let 
them go wherever they want for their care. It would not make 
much sense to continue funding a system that was indifferent to 
their needs. No amount of money can cure indifference.
    Mr. Chairman, political headlines will not solve problems 
inside the VA. The Chair will decide whether policy or politics 
wins and drives this Committee.
    Mr. Chairman, I will stay engaged regardless of the 
direction the Committee Members choose, focused on our 
veterans, thinking outside the box for solutions to complex 
health care issues, confident that a promise that we made in 
this country trumps any political agenda.
    Mr. Chairman, our troops ignored party affiliations when 
they chose to serve. I believe that we have a responsibility to 
display a similar courage in how we approach the policies that 
fulfill that promise.
    I thank the Chair. I yield the floor.
    Chairman Akaka. Thank you very much, Senator Burr.
    Senator Murray.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you very much, Chairman Akaka and 
Senator Burr, for holding today's hearing to talk about the 
Department of Veterans Affairs' efforts to address the critical 
mental health care needs of our veterans.
    Today's hearing, as we all know, is going to explore 
whether a recent email sent by a VA manager, directing staff to 
refrain from diagnosing PTSD in veterans, is an isolated case 
or whether it is representative of greater problems within the 
VA mental health care system.
    Now, I know Secretary Peake has strongly condemned this 
email and said that it was an isolated case by a single 
practitioner in a single location, and I sincerely hope that 
this email is the only one of its kind. But I just have to tell 
this Committee I have reason to be skeptical.
    It was just a few months ago that we learned about an email 
that was sent by Dr. Ira Katz, the VA's top mental health 
official, that started off by saying, ``shhh,'' and indicated 
that the VA had downplayed the number of suicides and suicide 
attempts by veterans in the past several years.
    It was not that long ago that Secretary Nicholson sent a 
letter to Congress saying that the VA had all the resources it 
needed, only to tell us just a short time later that, indeed, 
they were $3 billion short. So, with all due respect to the 
witnesses, I have to take the VA's explanations with a grain of 
salt.
    Now, one of the most frustrating things about this latest 
episode is that it furthers the perception, the perception that 
the VA is shortchanging our veterans. Citing, quote, 
``compensation-seeking veterans,'' the email in question 
encourages VA practitioners to avoid diagnosing veterans with 
PTSD in order to save time and money.
    After years of trying to get the VA and the Administration 
to be honest about the cost of caring for our veterans, it is 
very frustrating to read this email and see that it clearly 
indicates that resources are an issue in getting our veterans 
both the proper diagnosis and the care they need.
    So, to me this email is really a sad reminder that this 
Administration's attempt to play down the cost of war or the 
cost of taking care of our veterans has begun to actually 
affect the way that VA employees view their own work. VA 
officials should be more focused on providing a lifeline to our 
veterans than on meeting a bottom line that this Administration 
has put above all else.
    And so, today it is our responsibility to find out what 
else needs to be done to ensure that our veterans are not being 
shortchanged due to a lack of resources. And we, on this 
Committee, know the stakes have never been higher. According to 
the RAND Corporation, one in five troops who have returned from 
Iraq and Afghanistan have PTSD or severe depression.
    Last week, the Pentagon released a report showing that PTSD 
cases increased by 50 percent in 2007, and just a few days ago 
the Army reported that the number of soldiers who committed 
suicide in 2007 is the highest it has been in decades. It is 
well past time that every VA official, particularly those 
setting policy for their employees, take the psychological 
wounds of war just as seriously as the physical injuries.
    Now, despite my grave concerns about the candor of senior 
VA officials and the shortcomings of the President's budget, I 
continue to believe that the VA is the best and most 
appropriate place for veterans to receive health care. The VA, 
unlike any other health care organization in this country, is 
uniquely prepared to care for the distinct wounds of war.
    VA staff across this country work their hearts out to get 
our veterans the care they need and deserve every day. They 
have a very hard job.
    The stigma in our society surrounding mental health care 
deters a great number of veterans from seeking help. That is 
why we need to be doing everything we can to encourage veterans 
with psychological wounds to go to the VA to get the care they 
need and that they have earned; but time and again we have seen 
the VA undermine its own employees and make their jobs harder, 
and the email from Dr. Perez is only the latest example, but it 
is a striking one.
    So, Mr. Chairman, it is appropriate that we take a look at 
this today to find out the extent of the problem, to make sure 
that the VA truly, from the top to the very bottom, is seeking 
these veterans, getting them the help they need, and not just 
saying we do not have the resources, we cannot take care of it.
    It is our job, as Members of Congress, to make sure they 
have the resources they need. Without the accurate information, 
we are just incapable of doing that.
    So thank you very much for holding this important hearing, 
Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Brown.

               STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, Mr. Chairman. Senator Burr, thank 
you and Senator Murray for your comments always.
    Dr. Kussman, thank you for your meeting with and talking 
about mental health issues with the Dayton Development 
Coalition. I appreciate that some time ago.
    When President Bush was inaugurated, he pledged our Nation 
this goal. He said, ``When we see that wounded traveler in the 
road to Jericho, we will not pass on the other side.''
    This hearing should be about how we are going to care for 
those men and women who have traveled to the other side of the 
world for us and back. We should be working together to openly 
start filling the gaps, closing loopholes, improving the 
benefits and services available to vets. Yet here we are again, 
hearing testimony from an Administration on the defense. 
Instead of following the example of the Good Samaritan, the 
Bush Administration has been too often passing to the other 
side of the road.
    One news story after another has documented the proposed 
scheme, as Senator Murray said, to obscure the true numbers of 
soldiers with Post Traumatic Stress Disorder.
    The Cleveland Plain Dealer writer, Elizabeth Sullivan, in 
reaction to this discovery, wrote, ``The VA should not be 
limiting care and tightening hatches on information leaks. It 
should be adding to services for weary and traumatized 
veterans.'' Ms. Sullivan was married for many years to a 
Vietnam veteran, who is since deceased.
    It is shameful the Administration would treat injured 
veterans in such a cavalier manner. It is also incredibly 
shortsighted. The men and women who serve in our military--as 
we all know and we all talk about here, and you all talk 
about--have proven themselves time and again. They enrich our 
workforce when they return. They strengthen our communities 
when they are back Stateside.
    When we ignore veterans' injuries or deny a veteran care or 
do not take care of veterans who want to go to school, we are 
not only shortchanging them, we are shortchanging our economy 
and our society.
    Look at the flip side: what happened after World War II 
when we really did take care of veterans in terms of health 
care and education the way that we should.
    In the last 15 months, I have held some 100 round tables 
around my State--gatherings of 15 and 20 people whom I just 
listen to talk about their concerns in some 60-plus counties in 
my State--and I have heard from many veterans many of these 
same concerns that we talk about ad nauseam on this Committee.
    The answer is not for the VA to fail and then privatize the 
VA. We have seen that in part with Medicare. We have seen it as 
part of a political philosophy in town. The answer is to make 
the VA work, to fund it as we should and to make it work. There 
is simply no reason we cannot do that, and I look forward to 
working with all of you.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Brown.
    Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Chairman Akaka, Ranking Member 
Burr. It is a pleasure to be here. Unfortunately, I wish we 
were talking about something more pleasant.
    It would be the easiest thing in the world for me or my 
colleagues to sit up here and talk about how outrageous some of 
the emails are that have come out of the VA recently. I will 
just tell you, it is a baseline set of information without 
honesty, without honesty of diagnosis, without honesty of care, 
without honesty of a realization that there is a problem, a 
systematic problem in the VA right now that is apparent to me. 
I do not know that the VA culture will change.
    There is a lack of urgency among many of the bureaucrats 
and a continued unwillingness to let the needs of our veterans 
drive the VA budget. Instead budgets have been bean counted and 
seem to come before the actual needs of our veterans. I think 
that is very unfortunate.
    Even after we have renewed the focus on the plight of the 
wounded warriors caused by the Walter Reed scandal, even after 
18 months of what I think is some greater oversight by this 
Committee, even after a much needed change in leadership at the 
top of the VA, the problems still exist.
    And to be blunt, I am frustrated by the fact that whether I 
am asking about veterans suicides or construction of new 
clinics, the answer from the middle layers of the VA 
bureaucracy seems to be the same, we will deal with it when we 
can; it is not a big deal. Well, it is a big deal. The good 
news is when I talk to the Secretary himself, I get a much 
better response and that is good news.
    But, it should not have to be that we have to work this 
hard to make the system work. It should not be a matter whether 
the Congress is trying to get some information about how we are 
going to help our veterans or whether an individual veteran is 
trying to get the benefits that he or she has earned. So, we 
need some answers today.
    The witnesses, myself, and other Members of this Committee 
are in this business for a reason. That reason is that we all 
believe that getting benefits and better health care for our 
veterans is not something we do to feel good about ourselves. 
It is not something we do to spend taxpayers' money. It is 
something we do because our Nation has made a promise to the 
fighting folks in this country: that after they served our 
country, our country will serve them. And the VA is the 
organization that bears responsibility for the entire country 
for a follow-through on that promise.
    In many cases it is happening and good jobs are being done, 
but it is not happening in a lot of cases, and I regret to say 
that in the cases where it did not happen, everyone is falling 
short of doing their job; and as a result, our country is 
falling short of doing its job. And when we fail a single 
veteran, it is unacceptable.
    I, too, have spent a lot of time with doctors and nurses 
and right on down the line to the maintenance staff in VA 
facilities in the State of Montana. Almost every person out 
these hundreds of employees understand this concept. But when 
it comes to the managers, I am not sure that they understand 
it.
    So, I hope that the witnesses are prepared and are able to 
talk a little bit about what each of them is doing to make sure 
the VA culture is changing from ``business as usual.'' I would 
very much like to hear your thoughts on this and I have a 
number of other questions that we can do during the questioning 
rounds.
    You folks are here for a reason. You are the easiest folks 
for us to talk to and you will get the brunt, and that is good, 
but the truth is that I have talked to veterans, I have talked 
to staff, and things need to change.
    Now, I do not know if it is because we do not have enough 
veterans working in the VA. Maybe that is the problem. Or if it 
is because people do not understand the urgency, the special 
urgency with what is going on with returning soldiers from Iraq 
and Afghanistan. But I will tell you this, it has to change and 
I have a tremendous amount of respect for Secretary Peake. I 
think he is a good man, but he cannot do it alone. Things have 
to change. And I can give you example after example where I 
have talked to people within the VA and have not been told the 
whole story; I have been told part of the story.
    I will tell you guys the same thing I told the head of the 
VA in Montana, I am not here to fight you. I am here to help 
you. I am here to help you to make sure the promises we made to 
our veterans become a reality, and that is it. That is all I 
want to do.
    So with that, thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Tester.
    Senator Sanders.

              STATEMENT OF HON. BERNARD SANDERS, 
                   U.S. SENATOR FROM VERMONT

    Senator Sanders. Thank you, Mr. Chairman. I apologize for 
being here late. And thank you, guests, very much for being 
here.
    Thank you for calling this important hearing.
    Very clearly, I think there is a reality taking place today 
that is a new reality. I think, generally speaking, we 
understand from an historical perspective that when soldiers 
have been wounded in a conventional military sense, gunshot 
wounds or amputation needs, the VA has done an extraordinarily 
good job.
    But, I think, increasingly, what we also understand is that 
we have what we call invisible wounds. Maybe it was Gulf War 
syndrome that I worked on very hard when I was in the House. 
Maybe it is Post Traumatic Stress Disorder, maybe it is 
Traumatic Brain Injury--something where somebody has not lost 
an arm or a leg.
    It appears that the VA has not been as effective as it 
might, and I think it has something to do with the culture, 
perhaps, of the military where if you lose an arm or you lose a 
leg, you are wounded. But if you come home with PTSD or TBI and 
you are walking or talking, well, maybe. Are you really wounded 
or maybe you are a little bit wimpy, or whatever the case may 
be.
    And I think the thrust of what you are hearing and have 
been hearing for a number of months is that the evidence is 
overwhelming: that what we are seeing today in terms of PTSD, 
what we are seeing in terms of TBI--which is what is called the 
signature injury of this war--is that tens and tens and tens of 
thousands of our soldiers are being impacted. And we need a 
culture now within the VA that begins to understand and address 
that reality.
    In my State and in every State in this country, men and 
women are coming home who are not getting their lives together. 
They are drinking too much. They cannot do their jobs. They are 
getting fired from their work. They are turning to drugs. Their 
marriages are falling apart. And that is absolutely as 
important as other types of injuries; and we need a culture in 
the VA which appreciates that. We also understand that issues 
like TBI are very difficult to diagnose as being issues 
separate from PTSD. Often they go together, and how to pull 
them apart is something that is not so easy and that requires a 
lot of work.
    But I think the most important thing that we need from the 
VA is an absolute commitment to understand that these so-called 
invisible injuries are wrecking havoc on tens of thousands not 
only of soldiers, but of their families and of their children. 
And we consider it as important an injury as any other. So, we 
need a culture and an approach that effectively addresses those 
issues.
    I should mention, Mr. Chairman, that in my own State of 
Vermont, one of the things that we did is recognize that no 
matter what kind of treatment the VA may have, it is not going 
to do anybody any good unless our families and our soldiers get 
to that treatment, which speaks to the need for an effective 
outreach program.
    And then when you are dealing with outreach, you understand 
that PTSD is a different type of injury. It is not something--
by definition, it is not an injury where some guy is going to 
stand up and you say, ``I am in pain. I am drinking too much. I 
am on drugs. My marriage is falling apart. Help me.'' That is 
not necessarily what happens.
    So you have got to figure out a way to connect with those 
men and women and bring them into the system. Then you have to 
figure out a way to create the kind of support systems that 
they need and provide the individual treatment; none of which 
is easy. A lot has been thrown on you. This war, among many 
other things, has given you hundreds and hundreds of thousands 
of soldiers from all walks of life who need help.
    I come from a rural State. That means a lot of our guys are 
coming home from the National Guard. They are living in small 
towns. They do not have the infrastructure of the U.S. Army. 
How do you address that? We need help on that as well.
    But I think, Mr. Chairman, clearly we need a culture in the 
VA that recognizes that these problems are quite as significant 
in people's lives as other problems and we want the VA to step 
up to the plate and address them.
    Thank you very much, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Sanders.
    I want to welcome today's panel of witnesses from VA.
    First, I will welcome Dr. Norma Perez, Mental Health 
Integration Specialist, Austin Outpatient Clinic and former 
PTSD Clinical Team Coordinator at the Temple, Texas VA Medical 
Center.
    Next, I will welcome Dr. Michael Kussman, Under Secretary 
for Health. He is accompanied by Dr. Ira Katz, Deputy Chief 
Patient Care Services Officer for Mental Health.
    Finally, I welcome Admiral Patrick Dunne, Acting Under 
Secretary for Benefits and Assistant Secretary for Policy and 
Planning. He is accompanied by Mr. Brad Mayes, Director of 
Compensation and Pension Service.
    I thank all of you for being here today. Your full 
statements will appear in the record of the Committee.
    Dr. Perez, will you please begin with your statement.

 STATEMENT OF NORMA J. PEREZ, Ph.D., MENTAL HEALTH INTEGRATION 
   PSYCHOLOGIST, AND FORMER COORDINATOR, PTSD CLINICAL TEAM, 
                TEMPLE, TEXAS VA MEDICAL CENTER

    Ms. Perez. Good morning, Mr. Chairman and Members of the 
Committee. Thank you for inviting me here to discuss the 
quality of mental health care Central Texas veterans are 
receiving in the Temple PTSD Clinic.
    As the daughter, niece, sister, and cousin of Army, Navy 
and Marine veterans, I have a personal commitment to my work, 
and I have been blessed with the gift of trust from many East 
Coast and Central Texas veterans. They instill the passion for 
my work.
    I started working for the Central Texas Veterans Health 
Care System in June 2007 as a psychologist and program 
coordinator of the Post Traumatic Stress Disorder Clinical 
Team.
    I came to VA after completing a National Cancer Institute 
Research Fellowship at the University of Texas, Health Science 
Center at Houston, School of Public Health.
    Prior to that, I completed a clinical postdoctoral 
fellowship at Brown University. I earned my Ph.D. in clinical 
psychology from the University of Rhode Island, and I completed 
a clinical internship at the Edith Nourse VA Medical Center in 
Bedford, Massachusetts.
    I realize the Committee is interested in learning more 
about an email I sent to my team on March 20th so I will 
provide some context for that message and explain its purpose.
    My written statement, which I asked to be submitted for the 
record, discusses the approaches and treatment provided by the 
Temple PTSD clinical team.
    The Central Texas Veterans Health Care System offers 
specialized mental health care through the Temple PTSD Clinical 
Team, or the PCT. Although we are a PTSD clinic, we have been 
able to offer treatment to any veteran displaying any symptoms 
of combat stress.
    Combat stress is a normal reaction to abnormal events. It 
can occur immediately following an event or many years later, 
but in either situation, we stand ready to assist the veteran.
    Combat stress can manifest itself in different clinical 
conditions, including PTSD and Adjustment Disorder. We know we 
can improve the lives of veterans by teaching them coping 
strategies and other skills to reduce their level of distress 
and improve their quality-of-life, and this is exactly what we 
do in Central Texas.
    All of our clinicians are trained to use the guidelines 
published within the Diagnostic Standards Manual-IV for 
clinical diagnosis of mental health conditions, including PTSD.
    Individual providers develop a rapport and trust with each 
patient and it is through this that the veteran is able to 
safely convey their experiences and symptoms.
    Although PTSD is sometimes recognizable as early as the 
first few sessions, veterans often need more time to fully 
disclose their trauma and its impact on their lives.
    Several veterans expressed to my staff their frustration 
after receiving a diagnosis of PTSD from a team member during 
an initial intake when they had not received that diagnosis 
during their compensation and pension examination. This 
situation was made all the more confusing and stressful when a 
team psychiatrist correctly told them, they were displaying 
symptoms of combat stress but did not meet criteria for the 
diagnosis of PTSD.
    Because veterans were receiving conflicting messages from 
the team, I thought it was necessary to provide further 
guidance. As an extension of ongoing discussions and to address 
the frustrations of veterans, I sent an email to my staff on 
March 20th emphasizing careful evaluation of a patient's 
symptoms to ensure consistent and accurate diagnosis.
    The Temple PCT fully supports the compensation process and 
the Department's policy of erring in the best interest of the 
veteran whenever there is any doubt.
    In retrospect, I realize I did not adequately convey my 
message appropriately, but my only intent was to improve the 
quality of care our veterans received.
    I would like to conclude by discussing what a diagnosis of 
Adjustment Disorder with rule out for PTSD means.
    When a clinician makes a diagnosis, he or she is 
considering the patient's symptoms and conditions that would 
explain them. Many conditions look very similar to one another 
and sometimes it is important to identify the likely diagnosis 
while noting in the patient's record to test for possible 
alternatives.
    For example, a patient with chest pains could have 
indigestion or could be experiencing the early effects of a 
heart attack. Based on initial information, a clinician would 
determine the most likely diagnosis, heartburn, but note in the 
record the need to rule out a heart attack and proceed with 
further assessment. In clinical shorthand, that diagnosis would 
be indigestion, rule out heart attack, which would prompt 
further testing.
    The diagnostic note actually means, ``do not forget this 
diagnosis'' and serves as a reminder for further investigation 
into multiple possible conditions.
    In the context of mental health and my email, I believed 
that it was important to remind the team clinicians of the 
diagnosis of Adjustment Disorder, which is a clinically sound 
diagnosis and will result in the appropriate treatment while 
continuing the assessment process for a possible PTSD 
diagnosis.
    Mr. Chairman, I am happy to report Central Texas veterans 
are receiving the care that honors our pledge to care for those 
who have sacrificed in service to this Nation.
    This concludes my prepared statement and I am ready to 
address the Committee's questions.
    [The prepared statement of Ms. Perez follows.]
   Prepared Statement of Dr. Norma Perez, Mental Health Integration 
        Psychologist, Central Texas Veterans Health Care System
    Good morning, Mr. Chairman and Members of the Committee. On behalf 
of Bruce Gordon, Director of the Central Texas Veterans Health Care 
System, and Timothy Shea, Director of the VA Heart of Texas Health Care 
Network (VISN 17), thank you for inviting me here to discuss the 
quality of mental health care Central Texas veterans are receiving in 
the Temple PTSD Clinic. As the daughter, niece, sister, and cousin of 
Army, Navy, and Marine veterans, I have a personal commitment to my 
work, and I have been blessed with the gift of trust from many East 
Coast and Central Texas veterans--they instill my passion for my work.
    I started working for the Central Texas Veterans Health Care System 
in June 2007 as a psychologist and program coordinator of the Post 
Traumatic Stress Disorder (PTSD) Clinical Team. I came to VA after 
completing a National Cancer Institute Research Fellowship at the 
University of Texas Health Science Center at Houston, School of Public 
Health. Prior to that, I completed a clinical postdoctoral fellowship 
at Brown University. I earned my Ph.D. in clinical psychology from the 
University of Rhode Island and completed a clinical internship at the 
Edith Nourse VA Medical Center in Bedford, Massachusetts.
    The Central Texas Veterans Health Care system offers specialized 
mental health care through the Temple PTSD Clinical Team (PCT). This 
Clinical Team provides treatment only. Although we are a PTSD Clinic, 
we have been able to offer everyone treatment who displays any symptoms 
of combat stress. Combat stress is a normal reaction to abnormal 
events. It can occur immediately following an event or many years 
later, but in either situation, we stand ready to assist the veteran. 
Combat stress can manifest itself in different clinical conditions, 
including PTSD and Adjustment Disorder. Simply reporting combat-related 
stress is insufficient for an accurate diagnosis, in the same way that 
chest pain would be inadequate for determining whether a patient was 
suffering from heartburn or a heart attack. Regardless of how combat 
stress appears, our staff can make an initial diagnosis of a combat-
stress related disorder and begin treatment immediately. We know we can 
improve the lives of veterans by teaching them coping strategies and 
other skills to reduce their level of distress and improve their 
quality-of-life, and this is exactly what we have been doing for the 
last year in Temple.
    Many individuals with symptoms of combat stress are not ready to 
discuss the details of their experiences, but they can describe their 
symptoms and their levels of distress. An accurate diagnosis of PTSD, 
however, would require a veteran fully disclose the details and 
feelings associated with a traumatic event, and in my clinical 
experience, many have been unwilling to do this without a strong sense 
of safety and trust, which can only be developed over time. Rather than 
deter veterans from seeking treatment by requiring them to provide more 
information than they feel comfortable, we believe it is essential to 
begin providing care and support immediately. The Temple PCT Team 
invites individuals into treatment if they exhibit any symptoms of 
combat stress and works with them to develop skills and strategies to 
reduce or eliminate those symptoms. Based on follow up data, this 
approach has proven effective in reducing the distress levels of 
veterans.
    Our phases of treatment are generally the same for all veterans, 
regardless of their specific condition. We begin by teaching veterans 
skills and strategies they can use to address the specific combat 
stress symptoms they describe. This process usually lasts 8-9 sessions, 
although we continue to measure the veteran's self-reported level of 
distress throughout the course of treatment and we often notice 
improvement after only a few appointments. The second phase of 
treatment, for those willing to pursue it, involves exposure therapy. 
In this phase, we explore the most distressing trauma and work with the 
veteran through any of several different approaches to allow them to 
reprocess the trauma. This helps our patients cope with their feelings 
and memories in a safe and therapeutic environment. The final phase of 
treatment is available to all veterans and involves episodic follow up 
at the veteran's request. While the strategies and therapy we teach 
veterans work very well for the initial trauma, future stressful 
situations, such as the loss of a job or a family member, may trigger 
additional anxiety and re-aggravate the veteran's condition. Our staff 
is available to veterans any time they need it to help them cope with 
these new problems.
    All of our clinicians are trained to use the guidelines established 
within the Diagnostic Standards Manual IV for clinical diagnosis of 
mental health conditions, including PTSD. I sent an email to my staff 
on March 20 to stress the importance of an accurate diagnosis. Many of 
the veterans we treat in Temple have already undergone an examination 
for Compensation and Pension benefits, and our sole mission at the 
Temple PCT is to provide treatment to veterans in need. Although our 
clinic is a treatment clinic, we all fully support the compensation 
process and the Department's policy of erring in the best interest of 
the veteran whenever there is any doubt.
    Several veterans expressed to my staff their frustration after 
receiving a diagnosis of PTSD from a team member at Temple when they 
had not received that diagnosis during their Compensation and Pension 
examination. This situation was made all the more confusing and 
stressful when a team psychiatrist correctly told them they were 
displaying symptoms of combat stress, but did not meet criteria for the 
diagnosis of PTSD. Veterans were receiving conflicting messages from 
the team and I believed it was important to resolve this situation by 
providing further guidance while not blaming any specific clinical 
approach. In retrospect, I realize I did not adequately convey my 
message appropriately, but my intent was unequivocally to improve the 
quality of care our veterans received.

    In conclusion, Mr. Chairman, I am happy to report Central Texas 
Veterans are receiving care that honors our pledge to care for those 
who have sacrificed in service to this Nation. This concludes my 
prepared statement and I am ready to address questions from the 
Committee.

    Chairman Akaka. Thank you very much, Dr. Perez.
    Dr. Kussman.

  STATEMENT OF THE HONORABLE MICHAEL J. KUSSMAN, M.D., UNDER 
     SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS; 
   ACCOMPANIED BY IRA KATZ, M.D., DEPUTY CHIEF PATIENT CARE 
               SERVICES OFFICER FOR MENTAL HEALTH

    Dr. Kussman. Mahalo, Mr. Chairman, and Members of the 
Committee. Good morning.
    Thank you for mentioning earlier my time in Hawaii and my 
appreciation of the blessing of this room. And I hope the 
blessing allows all of us together to do what we are here for, 
which is to provide the best service for all of our veterans.
    Thank you for the opportunity to discuss the VA's mental 
health services with you today.
    I realize that you are concerned by an email sent from the 
program coordinator of the Post Traumatic Stress Disorder 
clinical team in Temple, Dr. Perez.
    The email, as characterized by others, does not reflect the 
policies or conduct of our health care system.
    Let me be very clear. Any suggestion that we would not 
diagnose a condition, any condition, is unacceptable and I, as 
a veteran and a retiree, would not tolerate such a position for 
personal and professional reasons.
    I will further state for the record that not only was there 
no systemic effort to deny diagnosis, but there was not even an 
individual effort to that end.
    However, the perception remains. So, we welcomed the 
opportunity to appear before you today to explain the VA's 
commitment to an honest and accurate diagnoses for every 
veteran for every diagnosis. That this perception continues is 
very unfortunate and how it has unfairly damaged the reputation 
of VA's dedicated health care employees.
    I was going to mention that with me is Dr. Perez, but 
obviously that has already taken place.
    I am grateful to the Committee for giving her the 
opportunity to speak for herself and I will, therefore, not say 
anything further about her email or about the specific 
situation in Temple.
    Delivering world class mental health care to enrolled 
veterans is a requirement that the VA and VHA take extremely 
serious. VA plans to spend more than $3.5 billion for mental 
health services in fiscal year 2008 and project $3.9 billion in 
fiscal year 2009.
    We are proud of our accomplishments in this area. Many 
health care professionals have recognized the VA's leadership 
in this area and I firmly believe no one receives better mental 
health care in this Nation than veterans enrolled in the VA for 
care.
    This is particularly true for veterans with Post Traumatic 
Stress Disorder, an area in which the VA is nationally and 
internationally recognized, both for its research work and its 
ability to deliver outstanding care.
    Although the quality of VA health care has been found equal 
to and often superior to that furnished anywhere, ``best care 
anywhere'' has been mentioned in numerous publications, the 
popular perception of the quality of VA care is something less 
than favorable. It is unfortunate and undeserved.
    Some continue to believe that health care services 
furnished by a government system can never be as good as those 
delivered by the private sector. In many cases we have not done 
enough to educate the public about VA's many achievements and 
outstanding programs and we could do more to ensure our own 
health care employees are informed about the Department's 
recognized awards and achievements outside their own area of 
expertise.
    VA and this country have much to be proud of in terms of 
the health care provided to veterans by the very skilled and 
talented cadre of VA clinicians--not to mention our 
researchers--who continue to improve the clinical care veterans 
receive.
    Improving VA's mental health services has been an active 
pursuant of the Department for many years.
    In 2004 we developed a mental health strategic plan that 
was both unprecedented and widely acclaimed within the mental 
health community. Through that effort we began to address gaps 
in the mental health services provided at the local level and 
to initiate programs at the national level.
    This plan was intended to serve as a guide for 4 or 5 
years. During that time we have continually reassessed our 
progress and amended the strategic plan based on new 
information particularly concerning new evidence-based 
standards of care and improvements in the delivery and mental 
health services. We continue to periodically re-access the plan 
as appropriate.
    As I alluded to earlier, the strategic plan was designed to 
incorporate evidence-based treatments wherever possible, 
encourage system redesigned activities and move our system to a 
recovery-based model as required by the President's New Freedom 
Commission for Mental Health.
    For these significant changes to be successful, they must 
be accompanied by a major educational effort appropriately 
targeted at our staff and clinicians and patients. I now 
believe, in retrospect, that we have not done as good a job as 
we should have to educate veterans and our staff.
    As we have initiated new programs that emphasize recovery 
models for our newest veterans, we have, in some places, not 
adequately responded to the needs of those who use and have 
benefited from our existing programs such as group therapy 
sessions for combat theater Vietnam era veterans.
    In addition, some of our own providers have not thoroughly 
understood our new approach, unfortunately compounding the 
confusion experienced by veterans at those sites.
    In response, we have developed an aggressive communication 
and education plan for both clinicians and veterans which will 
be launched shortly. Be assured that despite these inadvertent 
but significant educational or communication lapses, our 
commitment to our veterans and to improving their health status 
is unwavering. Their well being and their continued improvement 
to fully functional status has always been the objective of the 
strategic plan.
    We will work even harder to ensure that all understand the 
needs of different groups of veterans and will keep them 
apprised of further changes based on newer evidence.
    As we have always sought to do, we will do the right thing 
for every veteran who has entrusted us with his or her care--
one veteran at a time. We will do more to make sure our 
decisionmaking process for these clinical policy determinations 
is open and transparent to veterans.
    Moreover, we will work with Members of this Committee, with 
other mental health professionals and with veterans themselves 
to ensure veterans continue to receive the highest quality care 
available.
    In summary, Mr. Chairman, I am very proud of what the VA 
does in the area of mental health. More than 200,000 people are 
fully committed to helping veterans receive the health care 
benefits they have earned through their service and their 
sacrifices.
    I hope we can continue to move forward from this episode 
and help veterans and their families, Congress and the news 
media, and others to better understand what the VA has done and 
is doing to fulfill our Nation's commitment to those who have 
worn the uniform of our armed services.
    Mahalo nui loa.
    [The prepared statement of Dr. Kussman follows.]
   Prepared Statement of Michael J. Kussman, MD, Under Secretary for 
                 Health, Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, good morning. Thank you 
for the opportunity to discuss VHA's mental health services with you 
today. I am aware that today's hearing had its origins in the situation 
that recently arose in our Temple, Texas facility. On March 20, 2008, a 
VA psychologist and program coordinator for the Post Traumatic Disorder 
(PTSD) sent an internal email to the PTSD Clinical Treatment Team. The 
email, as characterized by others, does not reflect the policies or 
conduct of our health care system. The email has been taken out of 
context, though we certainly agree that it could have been more 
artfully drafted. This is an unfortunate situation, which has also 
unfairly damaged the reputations of VA's dedicated and committed health 
care employees. The erroneous characterization may also hurt veterans 
and their families, as some of them may call into question the quality 
of VA's health care. As a result, those individuals may not seek needed 
medical care from the Department, leaving their health care needs 
unaddressed.
    At the witness table with me is Dr. Norma Perez, who wrote the 
email in question. As I have stated, Dr. Perez' motives and actions 
have been unfairly characterized by others. I am grateful to the 
Committee for giving her the opportunity to speak for herself, and I 
will therefore not say anything further about her email or about the 
specific situation at Temple.
    VA has been, and remains, absolutely committed to delivering world-
class mental health care to enrolled veterans. We are very proud of our 
accomplishments in this area. VA will spend more than $3.5 billion for 
mental health services in Fiscal Year 2008, and we are very proud of 
our accomplishments in this area. Indeed, many mental health 
professionals and organizations outside the Department have recognized 
VA's leadership in this area, and I firmly believe that no one receives 
better mental health care in this Nation than veterans enrolled in VA's 
health care system. This is particularly true for veterans with Post 
Traumatic Stress Disorder (PTSD). VA is nationally recognized for its 
outstanding PTSD treatment and research programs. Although the quality 
of VA health care has been found equal to, and often superior to, that 
furnished elsewhere, the popular perception of the quality of VA care 
is sometimes less favorable. This is unfortunate and undeserved. Some 
continue to believe that health care services furnished by a government 
system can never be as good as those delivered by the private sector. 
In many cases, we have not done enough to educate the public about VA's 
many achievements and outstanding programs. And we could do more to 
ensure our own health care employees are informed about the 
Department's recognized awards and achievements outside their own areas 
of expertise. VA and this country have much to be proud of in terms of 
the health care provided to veterans by the very skilled and talented 
cadre of VA clinicians, not to mention our researchers who continue to 
improve the clinical care veterans receive.
    Improving VA's mental health services has been an active pursuit of 
the Department for many years. In 2004, we developed a Mental Health 
Strategic Plan that was both unprecedented and widely acclaimed within 
the Mental Health Community. Through that effort, we began to address 
gaps in the mental health services provided at the local level, and to 
initiate programs at the national level. This plan was intended to 
serve as a guide for four to five years. During that time, we have 
continually reassessed our progress and amended the strategic plan 
based on new information, particularly concerning new evidence-based 
standards of care and improvements in the delivery of mental health 
services. We continue to periodically re-assess the plan, as 
appropriate.
    As alluded to earlier, the strategic plan was designed to 
incorporate evidence-based treatments wherever possible; encourage 
system redesign activities; and move our system to a recovery-based 
model as required by the President's New Freedom Commission for Mental 
Health. For these significant changes to be successful, they must be 
accompanied by a major educational effort appropriately targeted at our 
staff and clinicians. I now believe, in retrospect, that we have not 
done as good a job as we should have to educate veterans and our staff.
    As we have initiated new programs that emphasize recovery models 
for our newest veterans, we have, in some places, not adequately 
responded to the needs of those who use, and have benefited from, our 
existing programs, such as group therapy sessions for combat-theater 
Vietnam era veterans. In addition, some of our own providers have not 
fully understood our new approach, unfortunately compounding the 
confusion experienced by veterans at those sites. In response, we have 
developed an aggressive communication and education plan for both 
clinicians and veterans, which will be launched in the coming weeks.
    Be assured that despite these inadvertent, but significant, 
educational and communication lapses on our part, our commitment to our 
veterans and to improving their health status is unwavering. Their 
well-being and their continued improvement to fully functional status 
has always been the objective of the strategic plan. We will work even 
harder to ensure we are fully sensitive to veterans' needs from this 
point forward and will keep them apprised of further changes based on 
newer evidence.
    As we have always sought to do, we will do the right thing for 
every veteran who has entrusted us with his or her care--one veteran at 
a time. We will do more to make sure our decisionmaking process for 
these clinical policy determinations is open and transparent to 
veterans. Moreover, we will work with Members of this Committee, with 
other mental health professionals, and with veterans themselves to 
ensure veterans continue to receive the highest quality care available.
    At this time, Mr. Chairman, let me talk more generally about the 
status of mental health care in our Department. VA strongly believes 
that fully addressing the physical and mental health needs of veterans 
is essential to their successful re-integration into civilian life. As 
evidence of that commitment, we plan to spend more than $3.5 billion in 
Fiscal Year (FY) 2008 for mental health services and the President's 
Budget has allocated $3.9 billion for that purpose in FY 2009.
    Mental health care is being integrated into primary care clinics, 
Community Based Outpatient Clinics, VA nursing homes, and residential 
care facilities. Placing mental health providers in the context of 
primary care for the veteran is essential; it recognizes the 
interrelationships of mental and physical health, and also provides 
mental health care at the most convenient and desirable location for 
the veteran.
    In contrast to the private sector, whenever a veteran is seen by a 
VA provider, he or she is screened for PTSD, military sexual trauma, 
depression, and problem drinking. Screening gives us an early 
opportunity to assess and treat the veteran for any identified problem. 
Our clinicians act on positive screens, and we will continue to monitor 
their compliance with our national screening directives.
    VA employs full and part time psychiatrists and psychologists who 
work in collaboration with social workers, mental health nurses, 
counselors, rehabilitation specialists, and other clinicians to provide 
a full continuum of mental health services for veterans. We have 
steadily increased the number of these mental health professionals over 
the last 3 years. We have hired more than 3,800 new mental health staff 
in that time period, for a total mental health staff of over 16,500. VA 
will continue expanding our mental health staff and also will continue 
to expand hours of operation for mental health clinics beyond normal 
business hours.
    We have reduced wait times throughout our system. At Temple, for 
example, 99.58 percent of all mental health appointments are within 30 
days of the desired appointment date. Nationwide, the percentage is 
99.34 percent--and for veterans with PTSD, the percentage rises to 
99.66 percent. We've also set standards for timeliness in our 
Compensation and Pension Examinations. Nationally, our average in March 
is 28 days to process these exams; Network 17, in which Temple is 
located, processed exams in 22 days.
    Our Department will continue to aggressively follow up on patients 
in mental health and substance abuse programs who miss appointments to 
ensure they do not miss needed, additional care. VA will also continue 
to monitor the standards the Veterans Health Administration has set for 
itself: to provide initial evaluations of all patients with mental 
health issues within 24 hours, to provide urgent care immediately when 
that evaluation indicates it is needed, and to complete a full 
evaluation and initiate a treatment plan within 14 days for those not 
needing immediate crisis care. At present, 93.4 percent of all veterans 
seeking mental health care receive full evaluations within 14 days. 
VISN 17 has a percentage exactly equal to the national average.
    On May 1, VA began contacting nearly 570,000 combat veterans of the 
Global War on Terror to ensure they know about VA medical services and 
other benefits. The Department will reach out to every veteran of the 
war to let them know we are here for them. Last month, we completed 
calls to more than 15,000 veterans who were sick or injured while 
serving in Iraq or Afghanistan. If any of these 15,000 veterans do not 
now have a care manager to work with them to ensure they receive 
appropriate health care, VA offered to appoint one for them.
    While the numbers of veterans seeking VA care for PTSD is 
increasing, VA is monitoring parameters (such as time to first 
appointment for new and established veterans of all service eras) to 
ensure they receive prompt and efficient services for PTSD and other 
mental disorders. In FY 2009, funding enhancements will close gaps in 
services and allow us to implement a more comprehensive and uniform 
package of clinical services for PTSD and other disorders.
    The Mental Health Initiative provides for the implementation of the 
Veterans Health Administration's Comprehensive Mental Health Strategic 
Plan (MHSP). Funding has been allocated for the Comprehensive MHSP each 
year since FY 2005 and has been committed through FY 2008.
    Funds were specifically allocated last year to promote 
dissemination and delivery of exposure-based psychotherapies for PTSD. 
In addition, we are providing training and dissemination of evidence-
based psychotherapies for other mental disorders. VA has allocated 
additional funds to implement evidence-based programs integrating 
mental health with primary care, with particular emphasis on 
depression. That program will be further expanded in FY 2008 and FY 
2009.
    Since the implementation of the Mental Health Strategic Plan, VHA 
has dedicated more than $458 million to improve access and quality of 
care for veterans who present with substance use disorder treatment 
needs. We have authorized the establishment of 510 new substance use 
counselor positions and plan to continue expanding our services 
throughout FY 2008 and FY 2009. In FY 2008, for example, our mental 
health enhancement budget includes over $37.5 million for expanded 
services.
    VA is developing plans to allocate medical care funds from the FY 
2008 funding to hire even more new mental health professionals, develop 
new programs, expand existing services, and create an appropriate 
physical environment for care by upgrading the safety and physical 
structure of inpatient psychiatry wards, as well as domiciliary and 
residential rehabilitation programs.
    Further, VA is taking significant steps to prevent suicide among 
veterans. We have provided training to all VA employees to underscore 
that even strong and normally resilient people can develop mental 
health conditions making them susceptible to suicide; care for those 
conditions is readily available and should be immediately provided; and 
treatment typically works.
    VA's suicide prevention program includes two centers that conduct 
research and provide technical assistance in this area to all locations 
of care. One is the Mental Health Center of Excellence in Canandaigua, 
New York, which focuses on developing and testing clinical and public 
health intervention related to suicide risk and prevention. The other 
is the VISN 19 Mental Illness Research Education and Clinical Center in 
Denver, which focuses on research in the clinical and neurobiological 
sciences with special emphasis on issues related to suicide risk.
    VA has opened a unique suicide prevention call center in 
Canandaigua focused entirely on veterans. Suicide prevention 
coordinators are located at each of VA's 153 hospitals. Altogether, VA 
has more than 200 mental health providers whose jobs are specifically 
devoted to preventing suicide among veterans.
    In developing the suicide prevention call center, the Department 
has partnered with the Lifeline Program of the Substance Abuse and 
Mental Health Services Administration. Those who call 1-800-273-TALK 
are asked to press ``1'' if they are a veteran, or are calling about a 
veteran.
    From its beginnings in July 2007 through the end of April, 16,414 
calls have come to the hotline from veterans and 2,125 family members 
or friends have called on behalf of a loved one. These calls have led 
to 3,464 referrals to suicide prevention coordinators and 885 rescues 
involving emergency services. Of note, 493 active duty servicemembers 
have also called our suicide hotline.
    Unlike other such hotlines, VA's hotline is staffed solely by 
mental health professionals--24 hours a day, 7 days a week. Our hotline 
staff is trained in both crisis intervention strategies, and in issues 
relating specifically to veterans, such as Traumatic Brain Injury and 
Post Traumatic Stress Disorder. In emergencies, the hotline staff 
contacts local emergency resources, such as police or ambulance 
services, to ensure an immediate response.
    If the veteran is a VA patient and willing to identify him or 
herself, the hotline staff is able to access the veteran's electronic 
medical record during the call. These records provide information that 
is invaluable during a crisis, including information on medications; 
the patient's treatment plan; and names and numbers of persons to 
contact during this emergency. VA hotline staff can also talk directly 
to the facility that is treating the veteran. They can place consults 
in the patient's medical record. For veterans not under VA care, staff 
can refer them to an individual VA Medical Center or Community Based 
Outpatient Clinic as appropriate, and see to all of the necessary 
administrative requirements.
    And our hotline staff follows up on these referrals. They also 
check patients' records to see if consultations were completed and to 
ensure follow-up actions were taken or are ongoing. If the record does 
not show this information, the suicide prevention coordinator at the VA 
facility is called and tasked with following up on the case to ensure 
that no referral is lost in the process.
    In addition to the care offered in Medical Centers and Community 
Based Outpatient Clinics, VA's Vet Centers provide outreach and 
readjustment counseling services to returning combat-theater veterans 
of all eras. It is well-established that rehabilitation for war-related 
PTSD, substance use disorder, and other military-related readjustment 
problems, along with the treatment of the physical wounds of war, is 
central to VA's continuum of health care programs specific to the needs 
of combat-theater veterans.
    The Vet Centers' mission is to provide readjustment and related 
mental health services, through a holistic mix of services designed to 
treat the veteran as a whole person in his/her community setting. Vet 
Centers provide an alternative to traditional mental health care that 
helps many combat-theater veterans overcome the stigma and fear related 
to accessing professional assistance for military-related problems. Vet 
Centers are staffed by interdisciplinary teams that include 
psychologists, nurses and social workers, many of whom are veteran 
peers.
    Vet Centers provide professional readjustment counseling for war-
related psychological readjustment problems, including PTSD. Other 
readjustment problems may include family relationship problems, lack of 
adequate employment, lack of educational achievement, social alienation 
and lack of career goals, homelessness and lack of adequate resources, 
and other psychological problems such as depression and/or substance 
use disorder. Vet Centers also provide military-related sexual trauma 
counseling, bereavement counseling, employment counseling and job 
referrals, preventive health care information, and referrals to other 
VA and non-VA medical and benefits facilities.
    VA is currently expanding the number of its Vet Centers. In 
February 2007, VA announced plans to establish 23 new Vet Centers 
increasing the number nationally from 209 to 232. This expansion began 
in 2007 and is planned for completion in 2008. Eighteen of the new Vet 
Centers have hired staff and are fully open. Five other Vet Centers 
have hired staff and are providing client services, but are operating 
out of temporary space while they finalize their lease contracts. They 
will all be open by the end of the Fiscal Year.
    To enhance access to care for veterans in underserved areas, some 
Vet Centers have established telehealth linkages with VA medical 
centers that extend VA mental health service delivery to remote areas 
to underserved veteran populations, including Native Americans on 
reservations at some sites. Vet Centers also offer telehealth services 
to expand the reach to an even broader audience. Vet Centers address 
veterans' psychological and social readjustment problems in convenient, 
easy-to-access community-based locations and generally support ongoing 
enhancements under the VA Mental Health Strategic Plan.
    In summary, Mr. Chairman, I am very proud of what VHA does in the 
area of mental health care. More than 200,000 people are fully 
committed to helping veterans receive the health care benefits they 
have earned through their service and sacrifices. I hope we can 
continue to move forward from this episode, and help veterans and their 
families; Congress; the news media and others to better understand what 
VA has done, and is doing, to fulfill our Nation's commitment to those 
who have worn the uniform of our Armed Services.
                                 ______
                                 
 Response to Written Questions from Hon. Bernard Sanders to Michael J. 
   Kussman, M.D., Under Secretary for Health, Department of Veterans 
                                Affairs
    Question 3(a). Under Secretary Kussman, a recent Rand report 
estimates that the costs of treating brain injuries in 2007 ranged from 
$26,000 for mild cases to $409,000 for severe ones. The report 
estimates that the costs for treating Post Traumatic Stress Disorder 
and depression in the first 2 years after deployment could be as high 
as $6 billion. And that is only the cost for TBI and PTSD. It does not 
include the cost of prosthetics, eye injuries, or other medical or 
mental health care. An Associated Press (article attached below) 
recently reported on VA documents it had obtained that said the 
government expects to be spending $59 billion a year to compensate 
injured servicemembers over the next 25 years, up from today's $29 
billion. The AP story noted that some at the VA believe these are 
conservative estimates. Given these high costs, and the increased 
demand and use of VA services, I would like the VA to provide me with 
the long-term, 40 year, trend for the number of veterans that VA 
expects to serve and the amount the VA expects to expend for:

     Inpatient medical care
     Outpatient medical care
     Vet Center readjustment counseling

    Response. The Veterans Health Administration (VHA) develops 
projections for 20 years to support strategic and capital planning 
activities. Our estimates are revised annually to reflect the most 
recent enrollment, demographic, and economic data available. Through 
the VA enrollment health care model, VHA makes assumptions regarding 
potential changes in health care practice, new technologies, medical 
advances, and new generations of drugs such as biologics. Given the 
dynamic nature of health care, VHA would have concerns projecting 
health care and readjustment counseling demand 40 years into the 
future.

    Question 3(b). Please provide this number both as an aggregate 
number for all of the benefits/services and broken down by each type.
    Response. The following table is from page 1C-20 of the FY 2009 
Budget Submission for medical program and information technology 
programs.
[GRAPHIC] [TIFF OMITTED] 43231.05

    Q02Question 3(c). Given these high costs, and the increased demand 
and use of VA services, does the VA have a long term plan which 
includes expanded facilities, staffing, and other relevant matters that 
will meet the needs of this new generation of veterans as well as our 
existing veterans?
    Response. We are constantly planning and implementing new 
initiatives to address the needs of all veterans, including the new 
generation of veterans through the following initiatives:

     VA recognizes that delivering health care closer to the 
veteran's place of residence is one way to better achieve our mission 
of being a patient-centered integrated health care organization. VHA 
continues to seek opportunities in the coming fiscal years to deploy 
community based outpatient clinics (CBOC) in areas where they will 
improve veterans' access to health care, particularly in underserved 
and rural areas.
     VA recognizes the need for expanded mental health care and 
is now providing mental health services in all VA medical centers and a 
majority of CBOCs across the country.
     VA recognizes the need to address the fact that many of 
the injured OEF/OIF veterans return with multiple injuries. To meet 
their needs, VA established four polytrauma centers across the country 
(Palo Alto, California; Tampa, Florida; Richmond, Virginia; and, 
Minneapolis, Minnesota), and will soon open a fifth center in San 
Antonio, Texas.
     To meet the needs of veterans, VA is developing, 
monitoring, tracking, and trending performance measures in various 
administrative and clinical categories. These include: quality 
management, clinic waiting times, financial and human resource 
management, employee and patient satisfaction, workload production, 
capital and planning, and special populations/clinical cohorts.
     To address the needs of this new, younger generation of 
veterans, VA is changing the culture of care at its nursing homes, now 
known as community living centers.
     Primary care/specialty care hours of operations are being 
extended and made available in many medical centers and CBOCs 
nationwide.
     VA continues its efforts to outreach to veterans by 
conducting multiple and diverse activities through, for example, 
dedication ceremonies, educational programs, clinical care, health 
fairs, town hall meetings, news releases, and other publications, 
special event programming, speeches, and homeless stand downs.
     VHA has opened CBOCs to make services more readily 
accessible to veterans, especially in rural areas. Videoconferencing 
technologies and diagnostic equipment mean specialists from major 
hospital centers can review veteran patients in a CBOC close to home 
thus avoiding travel and offering easier access to specialist care. 
Veterans with chronic diseases such as diabetes, heart failure and 
chronic pulmonary disease can be monitored at home using home 
telehealth technologies. This prevents or delays an elderly veteran 
needing to leave their home and move into long-term institutional care 
unnecessarily.
     With the addition of the 23 Vet Centers initiated in 2007, 
the Readjustment Counseling Service's (RCS) will administer 232 Vet 
Centers across the country by the end of FY 2008. Vet Centers are 
unique in VA providing community-based services that go beyond medical 
care, and professional readjustment counseling for war-related 
psychological trauma, including Post Traumatic Stress Disorder (PTSD), 
to returning combat veterans of all eras. Vet Centers are staffed by 
interdisciplinary teams, including psychologists, nurses, and social 
workers, many of whom are veterans themselves.

    Question 4. Dr. Katz and Under Secretary Kussman, can you tell me 
what the VA is doing system-wide to coordinate the medications that our 
veterans are taking, particularly our OEF/OIF veterans? This Committee 
has heard a number of stories about veterans in VA care that are being 
over-medicated and medicated with different drugs that when taken 
together can have drastic consequences including increasing the risk of 
suicide. What kind of a tracking system does the VA have in place and 
does this include tracking prescriptions a veteran may be taking 
outside of the VA, such as those prescribed by another physician or 
those prescribed while a veteran was in a military hospital?
    Response. VA has upgraded capabilities in its computerized patient 
record system (CPRS) to ensure the prescribing of medications is 
coordinated. Using VA's award-winning electronic health record, the 
veterans health information system technology architecture (VistA) and 
CPRS, providers are notified automatically regarding any potential 
conflicts with other medications the patient is taking, as well as any 
possible allergies a patient may have. CPRS gives the provider the 
ability to document mediations a patient is taking from outside the VA 
system. The automatic notification occurs with non-VA medications as 
well as with medications provided by the VA.
    In addition, VA has upgraded its systems to include remote data 
interoperability, which provides medication and allergy order checks 
between VA facilities. VA and the Department of Defense (DOD) have 
created a bidirectional health information exchange system and clinical 
health data repository, which makes available to DOD and VA providers 
real time information on medications and allergies for shared patients.
    VA has placed a high priority on medication reconciliation. 
Medication reconciliation is a Joint Commission National Patient Safety 
Goal and is the process for comparing the patient's current medications 
with those new medications ordered for the patient; communicating this 
information to the next provider of service, and providing a 
comprehensive written list to the patient. As part of this process, VA 
staff engages the patient as an active partner in developing the list 
with every admission and discharge from an inpatient stay or outpatient 
appointment.
                                 ______
                                 
 Response to Written Questions from Hon. Roger F. Wicker to Michael J. 
   Kussman, M.D., Under Secretary for Health, Department of Veterans 
                                Affairs
    Question 1. Modern medicine has made such significant progress on 
healing the physical wounds and saving lives on the battlefield, but 
the impact of mental wounds is becoming increasingly apparent. 
Traumatic Brain Injury is one of the signature injuries of the war on 
terror. Under Secretary Kussman, please provide me with an overview of 
the changes the Veterans' Administration has made in screening for TBI 
over the last decade. How does VA currently diagnose brain injury?
    Response. Beginning in April 2007, VA has had a policy to screen 
all OEF/OIF veterans who come to VA for possible Traumatic Brain Injury 
(TBI). VA established a task force to develop a TBI screening procedure 
in December 2006; the task force completed its charge by developing a 
TBI screening instrument and evaluation protocol. An automated TBI 
clinical reminder was established in the clinical patient record 
system, policy was established (VHA Directive 2007-013), and national 
training was completed for over 50,000 VA practitioners. The national 
clinical reminder TBI screening was implemented on April 14, 2007. 
Those who screen positive are offered a comprehensive evaluation to 
confirm a diagnosis and be provided treatment for symptoms associated 
with their TBI.
    VA's approach to diagnosing TBI is consistent with the American 
Congress of Rehabilitation's Diagnostic Criteria for mild TBI, which is 
the ``occurrence of a traumatically induced physiologic disruption of 
brain function as indicated by one of the following:

     Any period of loss of consciousness,
     Any loss of memory for events immediately before or after 
the accident,
     Any alteration in mental state at the time of the 
accident,
     Focal neurologic deficits that may or may not be 
transient.''

    For those who screen positive for possible TBI, VA's standardized 
evaluation protocol includes the origin or etiology of the patient's 
injury, assessment for neurobehavioral symptoms (via the 22 question 
neurobehavioral symptom inventory), a targeted physical examination, 
and a follow-up treatment plan. When any symptom is positive, the 
protocol provides recommendations on physical examination, diagnostic 
testing, and recommendations for initial treatment interventions and 
referral pathways for persistent symptoms.

    Question 2. With the large number of servicemembers that have 
served in combat and, in particular, those returning with injuries from 
mortar, grenade, RPG, or IED attacks, does the VA have the capacity to 
properly evaluate them for brain injury? Does VA currently employ, or 
is VA investigating the use of, diagnostic software that can help 
identify brain injury?
    Response. VA is sufficiently resourced to respond to the needs of 
OEF/OIF veterans with TBI. VA provided health care to 5.5 million 
veterans in FY 2007. Since April 2007, VA has screened approximately 
185,000 OEF/OIF veterans for possible TBI. Of those who have screened 
positive for possible TBI and completed the second level evaluation, 
7,561 have received a definitive diagnosis of TBI. Additionally, there 
have been about 550 OEF/OIF active duty servicemembers and veterans who 
have been treated in VA polytrauma rehabilitation centers for severe 
TBI since March 2003.
    VA is actively pursuing initiatives, both clinically and through 
research, to investigate use of various diagnostic tools that can help 
identify brain injury. Currently, several diagnostic tests are being 
used to diagnose mild TBI: magnetic resonance imaging (MRI), single 
photon emission computed tomography (SPECT) scans, positron emission 
tomography (PET) scans, evoked response potentials, and a variety of 
neuropsychological test batteries. Many of these procedures are 
sensitive to any type of brain dysfunction such as trauma, congenital 
disease (for example, multiple sclerosis or Alzheimer's disease), and 
depending upon the procedure, may be affected by conditions such as 
mood, mental state, fatigue, medication, and patient participation in 
the test. While these tests are sensitive to any trauma of the head, 
body or even vigorous physical activity, none is specific to mild TBI. 
Currently, no diagnostic test, software or other, has been demonstrated 
to differentiate and identify mild TBI from numerous other potential 
causative conditions. Definitive diagnosis of mild TBI requires 
evaluation that includes documenting the injury, status immediately 
following the event, cognitive screening, neurobehavioral assessment, 
and medical evaluation.

    Question 3. Secretary Kussman, is there any coordination between 
the VA and the Department of Defense to assess servicemembers prior to 
deployment to determine a cognitive baseline that can later be tested 
against to diagnosis a brain injury?
    Response. We would refer you to DOD for further explanation of any 
mandatory TBI tests conducted for members of the Armed Services, the 
National Guard, or the Reserve prior to deployment.

    Question 4. Dr. Kussman, are there any mandatory TBI tests for 
soldiers returning from a combat zone or separating from the military? 
If so, please describe them.
    Response. DOD has added questions to its post-deployment health 
assessment and post-deployment health reassessment to screen for 
Traumatic Brain Injury. When a veteran enrolls in the VA health care 
system, DOD shares that information with VA clinicians as part of an 
effort to facilitate the continuity of care for the veteran or 
servicemember.
    Since April 2007, any OEF/OIF veteran seen by a VA health care 
provider is automatically screened for possible TBI. Veterans are asked 
four sequential questions regarding events that may increase the risk 
of TBI, immediate symptoms following the event, new or worsening 
symptoms following the event, and current symptoms. If a person 
responds negatively to any of the sets of questions, the screen is 
negative and the remainder is completed. If the patient responds 
positively to one or more possible answers in all four sections, the 
screen is positive and the veteran is referred for further evaluation 
or the veteran's refusal is documented. Not all patients who screen 
positive have TBI; it is possible to respond positively to all four 
sections due to the presence of other conditions such as PTSD, 
cervicocranial injury with headaches, or inner ear injury. Therefore, 
it is critical that patients not be labeled with the diagnosis of TBI 
on the basis of a positive screening test. Patients need to be referred 
for a comprehensive evaluation by a specialized team to substantiate 
the diagnosis. Since April 2007, VA has screened approximately 185,000 
OEF/OIF veterans for possible TBI. Of those who have screened positive 
for possible TBI and completed the second level evaluation, 7,561 have 
received a definitive diagnosis of TBI.
    For severely injured veterans and servicemembers, VA's polytrauma 
system of care provides specialized rehabilitation and treatment and 
develops an individualized recovery plan tailored to the specific needs 
of the veteran or servicemember.

    Chairman Akaka. Thank you very much, Dr. Kussman, for your 
statement.
    Admiral Dunne.

   STATEMENT OF PATRICK W. DUNNE, ACTING UNDER SECRETARY FOR 
   BENEFITS AND ASSISTANT SECRETARY FOR POLICY AND PLANNING, 
  DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY BRAD MAYES, 
          DIRECTOR OF COMPENSATION AND PENSION SERVICE

    Mr. Dunne. Good morning, Mr. Chairman and Members of the 
Committee.
    Thank you for the opportunity to discuss the important 
issue of Post Traumatic Stress Disorder. I am pleased to be 
accompanied by Mr. Brad Mayes, the Veteran Benefits 
Administration's Director of the Compensation and Pension 
Service.
    We all share the goal of preventing and minimizing the 
impact of this disability on our veterans and providing those 
who suffer from it with just compensation for their service.
    Today I will review how VBA processes claims for service 
connection of PTSD and the relationship between VBA and the 
Veterans Health Administration.
    The number of veterans submitting claims for PTSD has grown 
dramatically. From fiscal year 1999 through May 2008, the 
number of veterans receiving disability compensation who are 
service-connected for PTSD increased from 120,000 to nearly 
329,000.
    24,087 of these veterans served in World War II; 12,229 in 
the Korean Conflict; 222,191 in the Vietnam Era; 11,220 during 
peace time; 59,196 in the Gulf War Era. The Gulf War Era number 
includes 37,460 OEF and OIF veterans.
    Service connection for PTSD requires medical evidence 
diagnosing the condition, medical evidence of a link between 
current symptoms and an in-service stressor, and credible 
supporting evidence that the in-service stressor occurred.
    VA regulations established three categories of in-service 
stressors: first, combat or prisoner of war; second, personal 
assault; and third, non-combat.
    Combat status may be established through the receipt of 
certain recognized military citations and other supportive 
evidence. If the evidence establishes that a veteran engaged in 
combat or was a POW and the stressor relates to that 
experience, the veteran's lay testimony alone may establish an 
in-service stressor for purpose of service-connecting PTSD.
    If the stressful event is not linked to combat or POW 
status, VA requests that the veteran submit information to help 
substantiate that the incident occurred. Reasonable doubt is 
always resolved in favor of the veteran.
    A VA examination is requested once credible supporting 
evidence establishes that the claimed in-service stressor 
occurred. The VHA medical examination for PTSD or an equivalent 
contract examination essentially serves three purposes.
    First, it serves to establish whether the veteran has PTSD.
    Second, it provides an opinion as to the existence of a 
link between the current symptoms and the in-service stressor. 
It is important to note that this is a medical determination 
performed by the examining psychiatrist or psychologist, not by 
the rating specialist.
    Third, it serves to provide an assessment of the current 
level of disability resulting from the veteran's symptoms so 
that VA can provide a rating for the extent of that disability.
    Although a veteran may have received a diagnosis of PTSD 
from a private mental health provider before submitting a claim 
to VBA, the VHA examination is still necessary to confirm the 
diagnosis in accordance with the DSM-IV, and to provide the 
proper diagnostic criteria and level of disability assessment 
needed for rating purposes.
    To ensure that a qualified professional is responsible for 
the examination, VA requires the initial examination be 
conducted or supervised by a board-certified psychiatrist or 
licensed doctorate-level psychologist.
    Additionally, all potential examiners now must undergo 
specific training and become certified prior to performing PTSD 
exams.
    Ratings are based on the rating schedule for mental 
disorders. VBA rating personnel must evaluate the examination 
report and any other relevant evidence to determine the most 
appropriate level of disability. The examination report must be 
carefully reviewed to match the examiner's description of the 
veteran's symptoms with the disability percentage most closely 
representing the severity of those symptoms.
    This is a complex process that involves an element of 
judgment. However, when a conflict arises as to what level of 
evaluation should be assigned, reasonable doubt is resolved in 
favor of the veteran.
    It is critical that our employees receive the essential 
guidance, materials and tools to meet the increasingly complex 
demands of their decisionmaking responsibilities. To accomplish 
this goal, VBA has developed new training tools and centralized 
training programs that support more accurate and consistent 
decisionmaking. New employees receive comprehensive training 
through the national centralized training program called 
``Challenge.''
    VBA has developed job aids and training sessions to provide 
employees the skills and tools essential to render fair and 
timely decisions on PTSD claims. All veteran service 
representatives and rating veteran service representatives are 
required to receive training on the proper development and 
analysis of PTSD claims. The training materials include medical 
and military references and prerecorded video broadcasts 
pertaining to PTSD development and records research.
    Mr. Chairman, this completes my statement. I will be happy 
to answer any questions.
    [The prepared statement of Mr. Dunne follows.]
Prepared Statement of Rear Admiral Patrick W. Dunne, USN (Ret.), Acting 
    Under Secretary for Benefits, Veterans Benefits Administration, 
                     Department of Veterans Affairs
    Mr. Chairman and Members of the Committee: Thank you for providing 
me the opportunity to appear before you today to testify on the 
important issue of Post Traumatic Stress Disorder (PTSD). I am pleased 
to be accompanied by Mr. Brad Mayes, the Veterans Benefit 
Administration's (VBA) Director of Compensation and Pension Service. We 
all share the goal of preventing and minimizing the impact of this 
disability on our veterans and providing those who suffer from it with 
just compensation for their service to our country. Today I will 
explain how VBA processes claims for service connection of PTSD and the 
relationship between VBA and the Veterans Health Administration (VHA) 
in processing these claims.
    The number of veterans submitting claims for PTSD has grown 
dramatically. From FY 1999 through May 2008, the number of veterans 
receiving disability compensation who are service-connected for PTSD 
increased from 120,000 to nearly 329,000 (328,923). These veterans 
represent veterans of World War II (24,087), the Korean Conflict 
(12,229), the Vietnam Era (222,191), Peacetime (11,220), and the Gulf 
War Era (59,196). The Gulf War Era number includes 37,460 OEF/OIF 
veterans.
    When a VBA regional office receives an initial claim for service 
connection of PTSD, a series of steps are followed which include: (1) 
providing the veteran with notice of what evidence is required to 
substantiate the claim, commonly referred to as a Veterans Claims 
Assistance Act or VCAA notice, and providing assistance with gathering 
that evidence; (2) researching the evidence needed to support the 
claimed in-service stressor; (3) providing the veteran with a PTSD 
examination; and (4) assigning a disability rating percentage for 
compensation purposes. These steps will be explained in detail.
providing the veteran with notice of evidence required to substantiate 
         the claim and assistance with gathering that evidence
    When an initial claim for PTSD is received, the regional office 
will respond to the veteran with a letter outlining the information and 
evidence needed to substantiate the claim and the actions VBA will take 
to assist the veteran with developing for that evidence and the 
veteran's responsibility for providing evidence. VBA will then obtain 
the veteran's service medical and personnel records and any post-
service medical or hospital records identified by the veteran. These 
procedures are the same for all claims, regardless of the disability. 
However, in PTSD claims, the veteran will generally be asked to provide 
a description of the in-service stressor that has caused the current 
PTSD symptoms.
        researching for evidence to support the claimed stressor
    The processing of PTSD claims is governed by our regulation at 38 
CFR Sec. 3.304(f). This regulation states that, in order for service 
connection to be granted, there must be medical evidence diagnosing the 
condition, there must be medical evidence establishing a link between 
current symptoms and an in-service stressor, and there must be credible 
supporting evidence that the claimed in-service stressor occurred. The 
first two requirements involve medical assessments, while the third 
requirement generally involves investigation by VBA personnel into the 
nature of the stressor.
    The steps required to establish service connection for PTSD can be 
affected by the specific circumstances in the claim.
    In cases where PTSD is diagnosed in service and the nature of the 
stressful event is not apparent, VA will request that the examiner 
detail the circumstances surrounding the development of PTSD. If those 
circumstances are consistent with military service, evidence of the 
stressful event will be accepted without further development.
    Even if PTSD is not diagnosed in service, under certain conditions 
established by sections 3.304(f)(1) and (2), the veteran's lay 
testimony alone can establish the occurrence of the stressor. When 
sufficient evidence shows that the veteran engaged in combat with the 
enemy or was a prisoner of war (POW) and the claimed stressor is 
related to that combat or POW status, the veteran's statement 
describing the stressor will allow the claim to go forward without 
corroborating evidence. VBA will accept certain military awards 
received by the veteran that designate participation in combat, such as 
a Combat Infantryman Badge, Combat Action Ribbon, Purple Heart Medal, 
etc., as evidence of exposure to combat-related stressors.
    When evidence for combat status is not readily apparent or where 
the claimed stressor is not directly related to combat, VBA is 
obligated to search for evidence to corroborate the combat status or 
the non-combat stressor before the claim can go forward. Such evidence 
can come from additional military records, from the ``buddy 
statements'' of individuals who served with the veteran, or from on-
line documents available at official military or government Web sites. 
In addition, VBA personnel have access to thousands of declassified 
military unit reports and histories from all periods of war on the 
Compensation and Pension Service Intranet Web site. These reports and 
histories document unit combat actions and can serve to corroborate a 
stressor when the veteran's records show assignment to a particular 
unit at the time covered in the report or history.
    When VBA personnel cannot find sufficient credible evidence to 
support a claimed stressor, the stressor information is forwarded to 
the Army's Joint Services Records Research Center (JSRRC). This DOD 
activity with full time researchers has access to multiple sources of 
military documents, not readily available to VBA personnel. If JSRRC is 
able to find evidence supporting the claimed stressor, it will be 
provided to VBA. In all cases where there is an approximate balance of 
evidence for and against occurrence of the stressor, the veteran will 
be given the benefit of doubt and VA will find that the stressor 
occurred.
    Where PTSD is due to military sexual trauma and evidence of the 
trauma is not of record, VA has developed processes to develop this 
extremely sensitive issue. These include a search for potential 
``markers'' of sexual assault such as sudden degradation in 
performance, seeking duty station changes, visits to clinics for 
sexually transmitted disease testing, provost marshal records, and 
seeking out of medical or spiritual assistance.
    In general, VBA procedures require that a claimed stressor must be 
corroborated by credible supporting evidence before an initial PTSD 
examination is scheduled with VHA. Generally, neither the examination 
report as such nor the examiner's opinion can serve as credible 
evidence to support occurrence of the stressor. However, under section 
3.304(f)(3), when an in-service personal assault is involved, evidence 
that can corroborate the veteran's account of the stressor includes 
records from rape crisis centers and mental health counseling services. 
A VHA examination may be scheduled before there is sufficient evidence 
to corroborate the assault, and the examiner may be asked for an 
opinion as to whether the assault occurred based on the available 
evidence and the examination results. Also, where the veteran was 
diagnosed with PTSD in service, there is an assumption that the 
diagnosis was made by a competent military medical authority with a 
factual basis for recognizing the stressor. Therefore, VBA need not 
seek further credible evidence for the causative stressor. In these 
cases, a VHA examination can be scheduled immediately to evaluate the 
level of disability.
             providing the veteran with a ptsd examination
    The VHA medical examination for PTSD, or an equivalent contract 
examination, essentially serves three purposes. First, it serves to 
establish whether the veteran has PTSD, or some other mental disorder 
for the veteran's presenting symptoms. Second, it provides an opinion 
as to the existence of a link between the current symptoms and the in-
service stressor. Third, it serves to provide an assessment of the 
current level of disability resulting from the veteran's symptoms so 
that VA can provide a rating for the extent of the disability.
    VBA and VHA have jointly developed a project to improve the 
delivery and oversight of medical examinations used for VBA disability 
rating purposes, referred to as the Compensation and Pension 
Examination Program (CPEP). This project involves monitoring the 
accuracy of the examination requests sent from VBA to VHA, as well as 
the quality of the examinations conducted by VHA examiners. Quality in 
this sense refers to the sufficiency of the examination report for VBA 
disability rating purposes. Examination worksheets have been developed 
to assist the VHA examiners with providing medical information that 
fits the disability criteria described in 38 CFR, Part 4, Schedule for 
Rating Disabilities. Specific information about these criteria is 
necessary for VBA adjudicators to provide accurate and fair disability 
rating evaluations for compensation purposes. Oversight efforts similar 
to those of CPEP are also in place to monitor the quality of contract 
examinations.
    PTSD examinations are subject to the requirements of 38 CFR 
Sec. 4.125(a), which provides that the diagnosis must conform to the 
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition 
(DSM-IV), published by the American Psychiatric Association and must be 
supported by the findings on the examination report. Although a veteran 
may have received a diagnosis of PTSD from a private mental health 
provider before submitting a claim to VBA, the VHA examination is still 
necessary to confirm the diagnosis in accordance with the DSM-IV and to 
provide the proper diagnostic criteria and level-of-disability 
assessment needed for rating purposes. To ensure that a qualified 
professional is responsible for the examination, VBA requires that the 
initial examination be conducted or supervised by a board-certified 
psychiatrist or licensed doctorate-level psychologist. Additionally, 
all potential examiners must now undergo specific training and become 
certified prior to performing PTSD examinations.
   assigning a disability rating percentage for compensation purposes
    VBA personnel evaluate the examination reports and assign the 
veteran a percentage disability rating when the evidence supports 
initial service connection for PTSD. Rating personnel also evaluate 
PTSD reexamination reports for service-connected veterans who are 
claiming an increase in compensation due to a worsened condition. 
Ratings are based on the rating schedule for mental disorders found at 
38 CFR Sec. 4.130. The schedule is a general rating formula for all 
mental disorders except eating disorders based on the level of 
occupational and social impairment caused by the veteran's mental 
disorder. It provides for disability percentages of 10, 30, 50, 70, and 
100, with a description of symptoms associated with each percentage 
level. VBA rating personnel must evaluate the examination report, and 
any other relevant evidence, to determine the most appropriate level of 
disability. The examination report must be carefully reviewed to match 
the examiner's description of the veteran's symptoms with a disability 
percentage most closely representing the severity of those symptoms. 
This is a complex process that involves an element of judgment. 
However, when a reasonable doubt arises as to which of two possible 
percentages to assign, 38 CFR Sec. 4.3 dictates that reasonable doubt 
will be resolved in favor of the veteran and the higher of the 2 
percentages will be assigned.
    In response to recommendations of the Veterans' Disability Benefits 
Commission and the Institute of Medicine, VBA is reviewing the mental 
disorders rating schedule with a particular focus on possibly providing 
specific criteria for rating PTSD based on the symptoms described in 
the DSM-IV.
                             ptsd training
    As more veterans returning from Iraq and Afghanistan are turning to 
VA for benefits and medical care, including care for PTSD, it is 
critical that our employees receive the essential guidance, materials, 
and tools to meet the increasingly complex demands of their 
decisionmaking responsibilities. To accomplish this goal, VBA has 
deployed new training tools and centralized training programs that 
support accurate and consistent decisionmaking. New employees receive 
comprehensive training through the national centralized training 
program called ``Challenge.'' The current curriculum consists of full 
lesson plans, handouts, student guides, instructor guides, and slides 
for classroom instruction. Recognizing the importance of continuing 
education, all Veterans Service Center employees are required to 
complete a mandatory cycle of training, consisting of 80 hours of 
annual coursework.
    VBA has developed job aids and training sessions to provide 
employees the skills and tools essential to render fair and timely 
decisions on PTSD claims. All Veteran Service Representatives (VSRs) 
and Rating Veteran Service Representatives (RVSRs) are required to 
receive training on the proper development and analysis of PTSD claims. 
The training materials include medical and military references and pre-
recorded video broadcasts pertaining to PTSD development and records 
research. VBA published PTSD guidance includes ``Handling PTSD Claims 
Based on Stressors Experienced During Service in the Marine Corps'' 
dated June 2005, ``Military Sexual Trauma Training Letter'' dated 
November 2005, and ``JSRRC Stressor Verification Guide'' dated January 
2006. Additionally, VBA introduced the PTSD Training and Performance 
Support System (TPSS) module for VSRs and RVSRs in 2006. The TPSS 
module is an interactive learning tool in which employees complete 
self-guided lessons on PTSD development and verification of in-service 
stressors. Due to the success of the TPSS learning system, a second 
PTSD module titled, ``Rate a Claim for PTSD'' was released in July 
2007.

    The foregoing description of the PTSD claims process is a general 
outline of the procedures followed by VBA. I would be happy to answer 
any specific questions the Committee Members may have.
                                 ______
                                 
Response to Written Questions from Hon. Bernard Sanders to Rear Admiral 
  Patrick W. Dunne, USN (Ret.), Acting Under Secretary for Benefits, 
    Veterans Benefits Administration, Department of Veterans Affairs
    Question 1. Under Secretary Dunne, can you 1) tell me the current 
backlog of claims for OEF/OIF veterans, 2) the average time to process 
their claims, and 3) the average waiting time OEF/OIF veterans 
experience when having these claims processed? In addition, please 
provide a breakdown of the data requested in items #2 and #3 into 
percentages, i.e., 25% of OEF/OIF claims take 5 months to process, 15% 
take 4 months, etc). Can you also provide these same numbers for OEF/
OIF veterans only from Vermont?
    Response. Our inventory of pending claims from Operation Enduring 
Freedom/ Operation Iraqi Freedom (OEF/OIF) veterans is 50,528 as of May 
31, 2008. Of those, 42,944 are original claims and 7,584 are reopened 
claims. This fiscal year through May 2008, we completed 102,318 OEF/OIF 
cases with an average processing time of 154 days. Our White River 
Junction Regional Office's inventory of OEF/OIF cases is 116 as of the 
end of May. Through May, White River Junction completed 218 OEF/OIF 
cases in an average of 170 days.
    The table below summarizes completed OEF/OIF claims for the Nation 
and Vermont.
[GRAPHIC] [TIFF OMITTED] 43231.01

    Q02Question 2(a). Under Secretary Dunne, a recent Rand report 
estimates that the costs of treating brain injuries in 2007 ranged from 
$26,000 for mild cases to $409,000 for severe ones. The report 
estimates that the costs for treating Post Traumatic Stress Disorder 
and depression in the first 2 years after deployment could be as high 
as $6 billion. And that is only the cost for TBI and PTSD. It does not 
include the cost of prosthetics, eye injuries, or other medical or 
mental health care. An Associated Press article (attached below) 
recently reported on VA documents it had obtained that said the 
government expects to be spending $59 billion a year to compensate 
injured servicemembers over the next 25 years, up from today's $29 
billion. The AP story noted that some at the VA believe these are 
conservative estimates. Can you provide me with the documents that are 
referenced in the Associated Press article included below?
    Response. The Associated Press article written by Jennifer Kerr 
reported that the government expects to be spending $59 billion a year 
to compensate injured servicemembers over the next 25 years. This 
figure was obtained from the Veterans Benefit Administration's (VBA) 
contingent liability model, prepared by PricewaterhouseCoopers, used to 
estimate VA's total liabilities on the Consolidated Financial Statement 
Balance Sheet. The liability for future compensation payments is 
reported on the balance sheet as the net present value of expected 
future payments. Various assumptions in the actuarial model, such as 
the number of veterans and dependents receiving payments, discount 
rates, cost of living adjustments, and life expectancy, impact the 
amount of the liability. Although the liability model forecasts future 
beneficiaries of the compensation program, including some members of 
the current active duty military who may receive benefits, it does not 
project new military enlistments. This model is not used to estimate 
future budgetary needs because not all future payments are captured.
    Ms. Kerr obtained the Annual Benefits Reports for 1999 to 2006 from 
the Department of Veterans Affairs' (VA) Web site (http://
www.vba.va.gov/reports/index.htm). Ms. Kerr contacted VA to obtain data 
on benefits dating back to 1950. Since VBA does not have benefits 
reports prior to 1999, we provided her with copies of the VA Annual 
Reports from 1918 to 1998, which contain some benefits information, on 
CDs. We are providing a copy of these CDs for your reference.
    The following documents were also provided and are attached.

    1. Compensation and pension programs--estimate of liability as of 
September 30, 2007, prepared by PricewaterhouseCoopers
    2. Estimated values underlying the estimate of veterans 
compensation liability as of September 30, 2007, prepared by 
PricewaterhouseCoopers
    3. Statistics on Global War on Terror (GWOT) veterans


    Question 2(b). What yearly funding does the VA estimate will be 
needed to compensate injured servicemembers over the next 25 years? 
Given these high costs, and the increased demand and use of VA 
services, I would like the VA to provide me with the long-term, 40 year 
trend for the number of veterans that VA expects to serve and the 
amount the VA expects to expend for:

     Compensation
     Pension
     Home loan guaranty, including defaults (foreclosures and 
sales)
     Vocational rehabilitation
     Life insurance (for deaths), and Traumatic Insurance (for 
major injuries)
     Educational benefits
     Burial benefits
     Adaptive automobile and home benefits.

    Please provide this number both as an aggregate number for all of 
the benefits/services and broken down by each type.
    Response. VBA's budgetary needs are projected using budget models 
specific to each benefit program. For example, the compensation and 
pensions budget estimation model forecasts both the number of 
disability compensation beneficiaries as well as the average benefit 
payment for veterans and survivors using a complex combination of 
historical data, current experience, workload and performance 
projections and assumptions.
    The budget models forecast obligations and outlays for 10 years. 
VBA does not forecast benefit payments beyond the 10-year projection. 
Projecting future demand is extremely difficult, as caseload and 
average payment assumptions may be impacted by military operations and 
separation rates, legislative and regulatory changes, court decisions, 
changing demographics of the population, outreach efforts, future 
application trends, and trends in benefits usage, as well as economic 
factors.
    Shown below are the fiscal year (FY) 2009 and 2018 estimated 
caseload and obligations for VBA mandatory programs from the 2009 
President's Budget submission.
[GRAPHIC] [TIFF OMITTED] 43231.03

    Q06Question 2(c). Given these high costs, and the increased demand 
and use of VA services, does the VA have a long term plan which 
includes expanded facilities, staffing, and other relevant matters that 
will meet the needs of this new generation of veterans as well as our 
existing veterans?
    Response. We are aggressively working to meet the increased demand 
and improve benefits delivery by employing enhanced technologies that 
will support claims processing in a ``paperless'' environment. Our 
strategy is to move to a business model less reliant on paper 
documents. Enhanced workflow capabilities, rules-based engines, 
enterprise content management, and correspondence services are 
important elements of our strategic vision for meeting the needs of 
this new generation as well as those of our existing veterans. We are 
also working to incorporate the use of portal technology and identity 
management/user authentication to provide veterans the capability for 
online self service. The integration of these new technologies will 
significantly increase our flexibility to expand and electronically 
move work to where we have the supporting infrastructure and resources. 
We have already consolidated the processing of all benefits delivery at 
discharge (BDD) claims to two sites and are implementing paperless 
processing at these sites. Our plans call for all BDD claims to be 
processed using imaging technology by the end of this fiscal year. We 
are also developing a strategy for expanding the types of claims to be 
processed in a paperless environment.
                                 ______
                                 
       Attachment 1 in Support of Response to Question 2(a) Above




       Attachment 2 in Support of Response to Question 2(a) Above


       Attachment 3 in Support of Response to Question 2(a) Above




    Chairman Akaka. Thank you very much, Admiral.
    Dr. Kussman, you mentioned the word ``perception'' and for 
me this is part of the reason we are having this hearing and 
that is to deal with the perceptions of our veterans about the 
Veterans' Administration and its service.
    We know that the quality of service is good. Accessibility 
and problems that we have always had, but we are trying to 
correct the perception if there is a wrong perception here. I 
share your concern about veterans not seeking treatment because 
of the public perception that VA may not be sympathetic toward 
their needs.
    My question to you is what are your thoughts on how VA can 
better assure veterans that they are welcome and will receive 
needed care? You mentioned some of that in your statement.
    As Chairman of this Committee I can tell that even before 
the story broke about this email, veterans were quite vocal 
with their concerns about how their mental health care needs 
are regarded. Indeed, many of the stories about the email 
expressed the view that it was only the latest example of how 
VA regards PTSD, and that was the perception.
    So what I am asking for is your thoughts on how VA can 
better show veterans that they are welcome and will receive 
needed care.
    Dr. Kussman. Thank you, Mr. Chairman, for the question, and 
obviously that type of thing is on my mind almost on an hourly 
basis.
    We are a large organization, 230,000 people, and I would be 
the first person to say we are not perfect in what we do. When 
we know about areas where this clearly is not being 
communicated, we put a great deal of effort into that.
    But sometimes as I alluded to in my written statement is 
that a lot of times in our effort to meet the needs of the 
veterans, sometimes we do not do what they want. I mean our 
effort is to be sure that they get the right care and get a 
firm and appropriate assessment. Sometimes they do not like 
what the assessment is, and so there is a constant concern 
about whether they perceive that they did not get what they 
want rather than that the appropriate and an honest evaluation 
was done.
    But we have gone to a large degree. We have hired more than 
3800 mental health people over the last year and one-half to 
provide services and expand services. We are trying to put 
those services as far forward into our CBOCs as well as our 
clinics, increase the number of Vet Centers to provide 
services. So we are doing everything we can to provide services 
that make it convenient and easier for the veteran to come in.
    As we talked about, and it was mentioned in opening 
statements, patients do not come to say, oh, I think I have 
PTSD. They usually come--and we know this from the 300,000 or 
so OEF/OIF veterans who have already come to us--is that they 
generally come for some other thing. They may come for a 
musculoskeletal thing.
    As you know, we screen everybody for PTSD in an effort to 
determine whether there is any possibility of a diagnosis of 
PTSD. Then we realize also that people are reluctant to go to a 
mental health clinic because there is stigma, again, related to 
that. That is a societal thing. It may be more so in the group 
of patients that we take care of.
    And I speak from 35 years of experience in that. Perhaps 
some people think I should have gone to the mental health 
clinic. I do not know.
    But the important point here, not to make light of it, is 
that what we have done is had an innovative process of putting 
mental health in the primary care clinic, putting mental health 
people there, partnering with the primary care people so that 
as much as possible we can provide mental health services in a 
more friendly and less stigmatizing environment for patients, 
because we are concerned that people will not follow up if we 
send them to a mental health clinic. And that has been 
eminently successful with our primary care and mental health 
people and Dr. Katz.
    The other thing that we are doing, as you know, is waiting 
for people to come to us. We have seen about one-third or 35-37 
percent of the total number of people who have served in the 
theater. And so, at least we have an opportunity to interact 
with PTSD, or any other thing for that group.
    But what about the other 60 plus percent who have not come 
to us? With the Secretary's leadership, we have embarked upon a 
very aggressive campaign of calling all the people that we have 
contact numbers on--over 500,000 who have not come to us--but 
who already have received two letters from the Secretary saying 
we are here for you, and for whatever reason have chosen not to 
use us. Maybe they have their own health care insurance or 
maybe they do not need any health care. However, that is not 
the issue.
    The issue is to try to get in touch with them, particularly 
offering them mental health services and other things because 
we know people are reluctant to come.
    We have been suggesting and we are working now--you know, 
we have talked about the 24-hour suicide hotline, and I think 
you have been briefed on that previously--to develop a 
different type of 24-hour hotline, really an extension of 
rehabilitation services that Dr. Adonis Al-Botros gives to Vet 
Centers.
    So not only will we have the Vet Centers themselves that 
people can go to, but they would be staffed by people hired by 
Dr. Al-Botros in the Vet Centers to be eligible to take calls 
24/7, to talk to people because, as you know, many of these 
combat veterans appreciate talking to someone who has walked in 
their shoes.
    They have done a great job, as you know, over 25 years, and 
we would like to extend that into a virtual clinic that would 
be open so that people do not even have to go look or try to 
get to a Vet Center or a facility. They would have the ability 
to call and get counseling.
    This is not meant to replace any other 800 number but 
rather specifically talk about some of the readjustment issues, 
PTSD and other things; not suicide. If suicide came up in the 
context of this, they would be referred to the suicide hotline 
because you do not want dueling hotlines.
    So, these are some of the things that we are doing to 
aggressively assist people. But it is a challenge, as 
mentioned. Particularly mental health, people are reluctant to 
come. And what we are trying to do is make it easy for them to 
come. Again, not to belabor the word, but to de-stigmatize it 
and make sure people feel comfortable about what we can do. We 
cannot impact if they do not come and see us.
    Chairman Akaka. Thank you, Dr. Kussman.
    Dr. Perez, I do not feel as if this issue has been 
adequately addressed. The first line of your email notes that 
there are, and I am quoting, ``more and more compensation 
seeking veterans,'' unquote.
    What exactly did you mean by this? It appears to me and 
many others that you were linking diagnosis of PTSD and 
potential compensation together and thereby either 
intentionally or unintentionally raising concerns about the 
cost to VA.
    Can you please clarify what you meant by this?
    Ms. Perez. Yes, sir. What I was stating there was the fact 
that there were those individuals--it is even more critical to 
be sensitive to what they have already gone through with a C&P 
interview and knowing that they have had another evaluation--so 
we have to really be very very accurate in our diagnosis.
    All of our clinicians strive to give the accurate 
diagnosis. But when you have somebody who may have already seen 
a professional, then you want to really make sure that you are 
going to be consistent and accurate with your diagnosis so that 
you do not add to any distress levels.
    Chairman Akaka. I have other questions here. I am going to 
defer to our Ranking Member for his questions at this time.
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Kussman, I had the opportunity with the opening of a 
CBOC in Hickory, North Carolina, to see the changes that you 
are making relative to mental health that makes a tremendous 
amount of sense.
    Mr. Chairman, I would ask unanimous consent to enter three 
letters into the record. Two to General Peake and one to Dr. 
Kussman.
    The first one is from the University of Pittsburgh Medical 
Center, Western Psychiatric Institute Clinic where within the 
body of that letter it states, ``I am writing on behalf of the 
president-elect of the American Psychiatric Association to 
support the VA in their efforts to care for veterans. A 
substantial amount of effort has gone into revitalizing the 
system.'' So that was to Secretary Peake.
    The second one, Mr. Chairman, is from the Association of VA 
Psychologist Leaders, and I will also read from the body.
    ``We are very appreciative of the enormous efforts by all 
of you at the VA and especially the Office of Mental Health 
Services in supporting the efforts of those in the field to 
provide the best quality mental health care possible to our 
veterans.'' That was to Dr. Kussman.
    The last one is from the American Society for Suicide 
Prevention on an email that went to Secretary Peake. And I will 
also read from the body.
    ``Dr. Ira Katz is an outstanding leader for this work. He 
is uniquely qualified to organize the best programs based on 
the latest psychiatric research.''
    I would ask that they all be in the record.
    Chairman Akaka. Without objection.
    [The three letters follow:]
                    Association of VA Psychologist Leaders,
                                                       May 1, 2008.
Michael Kussman, M.D.,
Under Secretary for Health,
Department of Veterans Affairs,
Washington, DC.
    Dear Dr. Kussman, This last March you were very generous in 
spending time with the Executive Committee of the Association of VA 
Psychologist Leaders (AVAPL) during our recent trip to Washington, DC. 
It was very useful to hear about the large array of policy issues that 
have to be dealt with in order to provide resources to those of us in 
the field.
    AVAPL is an independent organization of VA psychologists in 
leadership positions or psychologists aspiring to leadership positions. 
As such, our membership directly benefits from the resources provided 
by VHA and, more specifically, the Office of Mental Health Services. In 
the past several years, we have experienced a very large and beneficial 
increase in resources available to us to help meet the mental health 
needs of veterans. Many new positions have been created and filled and 
this has substantially increased the number of psychologists within VA. 
It has allowed for the creation of new and innovative programs for the 
treatment of traumatic brain Injury and Polytrauma, integrating mental 
health and primary care services, expanding treatment options in areas 
such as PTSD and substance abuse and residential treatment for 
homelessness. The recent placement of Suicide Prevention Coordinators 
at facilities and the creation of a national VA suicide hotline have 
greatly enhanced our ability to assess for and respond to these 
emergent mental health issues. We are very appreciative of the enormous 
efforts by all of you in VHA and especially the Office of Mental Health 
Services in supporting the efforts of those of us in the Field to 
provide the best quality mental health care possible to our veterans. 
AVAPL as an organization also remains dedicated to promoting this same 
goal.
            Sincerely,
                              Steven Lovett, Ph.D.,
                                                 President,
                            Association of VA Psychologist Leaders.
                                 ______
                                 
         American Foundation for Suicide Prevention (AFSP),
                                        New York, NY, May 04, 2008.
James B. Peake, M.D.,
Secretary
Department of Veterans Affairs
    Dear Dr. Peake, As Medical Director of the AFSP I strongly 
encourage the administration to continue to support the valiant efforts 
of the current VA leadership. They face an enormous task because the 
frequency of PTSD with depression and suicide is high and a suicide 
outcome is very common. Their Hotline and hiring of suicide prevention 
coordinators are the first steps in dealing with this unprecedented 
problem. Many other things must follow, but this is a very appropriate 
beginning. Dr. Ira Katz is an outstanding leader for this work. He is 
uniquely qualified to organize the best program based on the latest 
psychiatric research. Please don't do anything to interfere with the 
progression of care that must be instituted.
            Sincerely,
                                    Paula J. Clayton, M.D.,
                                                  Medical Director.
    Cc: Clayton Paula
                                 ______
                                 
           University of Pittsburgh Medical Center,
                  Western Psychiatric Institute and Clinic,
                                       Pittsburgh, PA, May 5, 2008.
Dr. James B. Peake,
Secretary of Veterans Affairs,
Office of Mental Health Services
Washington, DC.
    Dear Dr. Peake: Serving the health care needs of our veterans is 
one of the greatest honors a clinician can experience. The current war, 
and the political attention to the war, has brought the health care of 
our veterans to a national forum. We are fortunate that mental health 
care has been recognized as a vital part of the health care system. 
Indeed, the Department of Veteran Affairs may be the largest mental 
health group in the country. I am writing on behalf of the President-
elect of the American Psychiatric Association to support the VA in 
their efforts to care for veterans. A substantial amount of effort has 
gone into revitalizing the system. These efforts should not go 
unnoticed. In the last year alone, the VA has developed a suicide 
hotline and placed a suicide prevention coordinator in every facility. 
The system has accomplished true integration of behavioral health into 
primary care. Moreover, the VA has established a minimum set of 
requirement for all programs to follow in an effort to bring new 
evidence based treatments to every facility and every veteran. These 
efforts are unprecedented in our society. While there is more work to 
be done, I want to applaud the Office of Mental Health Services for the 
dedication and innovation that they have shown during the last two 
years. I am committed to continue working with VA leadership in 
accomplishing the goals of developing a truly national mental health 
system for veterans.
            Sincerely,
                     Charles F. Reynolds III, M.D.,
            UPMC Endowed Professor of Geriatric Psychiatry,
           Director, Advanced Center for Interventions and 
         Services Research for Late-Life Mood Disorders and
     John A. Hartford Center of Excellence in Geriatric Psychiatry.

    Senator Burr. What we see, and I say this to all our 
witnesses, we have an oversight responsibility that cannot be 
ignored. And when issues are raised, whether they are internal 
or external--these happen to be external--it is appropriate for 
this Committee to begin to look. Do we know the full breadth of 
the problem? Is there a problem? If there is not, is there a 
reasonable explanation?
    Hopefully, at some point in the process we also remember to 
ask whether we are making progress. Are we positively affecting 
the lives of more veterans? Are we learning? Are we, as I read 
from the piece on Dr. Katz, are we using the latest of what we 
have learned to incorporate in the delivery of care for 
patients?
    It is certainly my hope that we are doing that and I have 
every reason to believe that there is every effort made at 
every level of the VA to incorporate that into a field that is 
very difficult, and I think Dr. Perez has alluded to that.
    Let me just ask two very pointed questions because they 
were raised in opening statements.
    Dr. Kussman, Senator Murray said that we did not have 
enough resources to treat mental health. Do you have the 
resources needed to provide mental health services to our 
veterans?
    Dr. Kussman. Mr. Ranking Member, yes. Again, if you talk to 
any of our mental health people I believe you will be told that 
frequently when we are challenged about providing services in 
some geographic area, it is not the resources themselves but 
the ability to buy those resources or provide those resources.
    And so, I believe that there are adequate resources. As he 
said, almost $4 billion, significant amounts targeted directly 
to PTSD; 3800 new employees.
    Actually we have been so successful that there was an 
article in a mental health journal that sort of in a backhand 
way criticized the VA for having scooped up so many mental 
health people in the country that we are hurting the delivery 
of care in the civil community. And I know my friends south of 
the river at the Pentagon who we have been challenged to hire 
more mental health people are a little frustrated with us 
because we got ahead of them, and they are having challenges 
hiring people because there is a shortage of mental health 
services, psychiatrist and Ph.D. psychologist nationally.
    Senator Burr. We see that in North Carolina.
    Is there a culture in the VA that ignores or devalues 
mental health needs?
    Dr. Kussman. I do not believe that to be the case. If I was 
aware of any kind of culture, I would be at the forefront of 
trying to change that culture. I think that our people 
understand the mission that we have and they are committed to 
doing that.
    I will respond to Senator Tester, if I might, where he had 
talked about the culture. I do not think it was the culture, I 
hope he was not mentioning the culture of not providing 
services but responding to needs and things related to that.
    Senator Tester. It was the response I am talking about, the 
response to the needs.
    Dr. Kussman. Of issues coming up with whether it was the 
construction or hiring more people or whatever it was. This is 
a huge organization. We are well aware of that. The Secretary 
and I are working very hard to inculcate changes.
    I have four primary things that I am pushing at. One is 
patient care and the second one is leadership. We are working 
hard to develop the appropriate leadership and the 
understanding of everyone in the system to expeditiously look 
at the problems that we have. If we cannot fix something, admit 
it. Be transparent. Communicate with the congressional people 
and the VSOs. We have a good new story to talk about. And when 
it gets clouded by the perception or the reality of people not 
responding, shame on us.
    Senator Burr. Dr. Perez, two quick questions and really 
going to what the Chairman raised and that was in your email, 
compensation-seeking veterans specifically. What relationship 
does your clinic have with the disability compensation process?
    Ms. Perez. No relationship whatsoever.
    Senator Burr. Were there veterans looking to your clinic to 
improve their health through treatment or to provide diagnosis 
of PTSD that could be used to substantiate their disability 
claims that drove that phrase?
    Ms. Perez. No, not at all. Our clinic is just a treatment 
clinic. That is it. We are pretty clear with all our veterans 
that this is why we are here, to offer the treatment.
    Senator Burr. So, given the nature of your treatment 
facility--even though I agree with you that this could have 
been worded differently in your email--it cannot imply that 
veterans were only there to try to enhance their disability 
claims because you had no connection to disability process and 
you are there not to do anything other than treat for mental 
health illness?
    Ms. Perez. Exactly. It is just a treatment clinic.
    Senator Burr. I thank you for that.
    I thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Burr.
    Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman.
    Like a lot of my colleagues, I am very concerned not only 
with the content of Dr. Perez's March 20th email but also with 
its potential implications.
    A lot of our veterans perceive the VA as an obstacle rather 
than an ally today. I know everyone is working in an effort to 
make that better. I am greatly concerned that this incident 
only adds to that impression. I think that is part of why we 
really need to get good strong answers from all of you.
    I do have a lot of questions but I want to begin by asking 
Dr. Perez today if her testimony was reviewed by the OMB today 
before you gave it?
    Ms. Perez. Pardon me. I am real new to the VA and 
unfamiliar with the initials.
    Senator Murray. With the Office of Management and Budget.
    Ms. Perez. No, no, no. The reason I was so grateful to be 
invited here was that I was given the opportunity to give my 
entire story.
    Senator Murray. Good. So you wrote it yourself.
    Ms. Perez. Yes.
    Senator Murray. It did not go to any other agency or get 
reviewed by anybody before it came?
    Ms. Perez. Correct.
    Senator Murray. Great. OK.
    Dr. Perez, your email raises a serious question about 
whether or not veterans are receiving inadequate evaluations 
for their mental health issues because the VA lacks the staff 
or the money that they need.
    Can you tell us how much time you think is needed to 
properly evaluate a veteran to accurately diagnose PTSD?
    Ms. Perez. It really is on an individual case basis, 
because in order to diagnose anyone with PTSD, they have to be 
at the point where they are ready to share their most traumatic 
experience, and that takes time. So in order to compassionately 
do that, it has to be at the veteran's own pace and on their 
time table.
    Senator Murray. So it may take some time to do that?
    Ms. Perez. Right. It is very different for each one.
    Senator Murray. How much time did VA staff spend with 
veterans when they were evaluated for PTSD at Temple VA Medical 
Center where you work?
    Ms. Perez. When we do our intakes, they can range usually 
anywhere from half an hour to an hour. It kind of depends on 
the veteran and what time they get there and what materials 
they have already answered for us. But usually at the intake 
our goal really is to kind of gather information that will help 
us identify the most significant symptoms that bring them there 
that day and what are the strengths and the limitations that 
they have in treatment so we can develop a treatment strategy.
    Senator Murray. So it is a very complex process.
    Ms. Perez. It is very complex, yes.
    Senator Murray. You are on the ground. Do you think that 
the VA has enough staff to properly evaluate the veterans you 
are seeing with mental health care issues?
    Ms. Perez. Well, I know in my clinic we did have an 
opening. So, I think that they are, from what I see, intensely, 
actively recruiting to try to get those positions filled, 
specifically, in Central Texas.
    Senator Murray. OK. I understand they are trying to be 
filled. But do you think you have enough staff to evaluate 
everybody in the complex procedures that you just talked about 
a minute ago?
    Ms. Perez. Like I said, for those that we have there and 
the numbers that are coming in at this current time, we do have 
that staff. But at any given day you really do not know the 
numbers that are going to walk through the door.
    Senator Murray. I think at least why I am confused is 
because the actual language of your email is ``we really do not 
have time to do the extensive testing that should be done to 
determine PTSD.''
    Ms. Perez. Right. If we were going to require--in our 
clinic we would accept anybody with even one single combat 
stress symptom. If we were to require a diagnosis of PTSD in 
order to admit them into treatment, then you are going to want 
to get that answer initially, right off the bat, and you really 
should do the extensive testing because you do not have the 
gift of time to let them go at their own pace. You have to kind 
of push the issue and give them more assessments and kind of 
push them to share their story before they are ready.
    Dr. Kussman. Could I just add a comment, Senator? Is that 
OK?
    Senator Murray. Yes.
    Dr. Kussman. I think what Dr. Perez was also talking about 
is that they have a clinic that has no wait times. People can 
walk in.
    Senator Murray. I understand.
    Dr. Kussman. If I could just finish please. So, most people 
who are involved in the treatment of PTSD acknowledge that the 
best way to evaluate and treat is developing a relationship 
with a provider over time as this evolves.
    Senator Murray. My question is do you have enough staff to 
do that? Because your email implies that you do not have the 
time to do that kind of extensive testing. I am asking you 
because it is our responsibility to make sure we have enough 
people out there that have the time, which should not be the 
factor that stops people from being treated.
    So, your email says we do not have enough time to evaluate 
everybody. Does that mean you do not have enough people to do 
that evaluation, or you do not have----
    Ms. Perez. That was more at the initial 1-hour or half-to-
1-hour intake; that they were scheduled for that amount of time 
in the initial intake. If we were going to require that, then 
we would have to have scheduled probably a 3-hour window for 
the intake.
    Senator Murray. Right. OK. Let me ask Dr. Katz and Dr. 
Perez a question. In the email that we have, Dr. Perez, you 
suggest that they ``consider a diagnosis of Adjustment 
Disorder, rule out PTSD.'' That was meant I understand to 
suggest that the initial diagnosis would be Adjustment Disorder 
while the clinician took the time to determine if a diagnosis 
of PTSD was warranted.
    Here is my question. It is my understanding that the 
guidelines, the Adjustment Disorder guidelines, indicate that 
an Adjustment Disorder diagnosis should be limited to a period 
of 6 months after the event or stressor.
    Now I suspect that most of our VA facilities do not see 
very many veterans within the 6 months of their having actually 
had that stressor or left a war zone. So, is Adjustment 
Disorder the correct diagnosis to give to a veteran who 
presents with serious behavioral or emotional symptoms?
    Ms. Perez. Well, we actually are getting quite a few 
veterans, that have not even completely discharged from DOD. So 
we do get some active duty. As part of the out-processing, they 
will sometimes come see us when they are still actually active 
duty. Also we are doing redeployment counseling because we did 
have quite a few veterans who were----
    Senator Murray. In your email you suggest a diagnosis that 
suggests that it is an Adjustment Disorder. But from what I am 
looking at, that should be done within 6 months. So it is 
curious to me that you suggest that diagnosis when it is 
obvious that you are outside the 6-month timeframe.
    Ms. Perez. Well, that is why it is just a suggestion 
because each clinician needs to really look at the criteria of 
what the veteran is presenting with--what symptoms are they 
presenting with--and do an assessment based on that, on 
whatever they are willing to----
    Senator Murray. Dr. Katz, is that concurrent with what you 
believe should be done in the field?
    Dr. Katz. Thank you for asking. About the Adjustment 
Disorder diagnosis, my read is actually close to yours. I would 
disagree respectfully with my colleague about the diagnosis of 
an Adjustment Disorder a year after an event relating it to the 
event. I would have concerns about it.
    There are questions, in general, about whether a diagnosis 
matters and whether the specific diagnosis matters. And the 
answer is probably, yes and no.
    One thing that really does matter is making a diagnosis of 
PTSD versus something else. PTSD versus depression, for 
example. The best treatment--behavioral and cognitive--for PTSD 
is trauma-focused, going back to the event. But, the best 
treatment for depression is present-focused, dealing with 
current problem-solving, beliefs and thoughts. So, diagnosis 
matters to help someone plan treatment.
    In another sense, however, diagnosis does not really matter 
that much. There are a certain number of symptoms required for 
PTSD. Many people have subclinical PTSD or partial PTSD where 
they may be one symptom short of the number required for a 
formal diagnosis. And my read is that the best treatment for 
subclinical, subsyndromal partial PTSD is the same treatment as 
PTSD.
    So, if someone does not quite make the diagnosis for PTSD, 
I would think if they are suffering, they should get exposure-
based treatments just like if they have PTSD.
    Senator Murray. Thank you for your honesty on that which 
goes really to my real concern, and our responsibility is that 
this is a difficult diagnosis. Our job is to make sure that we 
do have enough people on the ground who are capable of doing 
that in a timely fashion and that we do not have a VA or a 
system or anywhere isolated or not to say, ``do not make this 
diagnosis because we do not have the resources.'' It rather 
should be we need the resources so we can make the proper 
diagnosis.
    And I have a number of other questions but I know my time 
is out so, Mr. Chairman, I will wait until the second round. 
Thank you.
    Chairman Akaka. Thank you, Senator Murray.
    Senator Sanders.
    Senator Sanders. Thank you, Mr. Chairman.
    Let me begin with Dr. Katz. Dr. Katz, I am looking at the 
email that you exchanged with Ev Chasen, Chief Communications 
Director. In it you respond to Mr. Chasen and you say, ``Shhh. 
Our suicide prevention coordinators are identifying about 1000 
suicide attempts per month among the veterans we see in our 
medical facilities. Is this something we should carefully 
address ourselves in some sort of release before someone 
stumbles on it?''
    Media reports tell us the Army just reported that at least 
115 soldiers killed themselves in 2007. Is this an epidemic? A 
thousand attempted suicides--that sounds like a very large 
number.
    Dr. Katz. The ``is it an epidemic question'' comes up again 
and again. Is a thousand a month too many? Of course, it is too 
many. Are there too many suicides among veterans? Of course, 
there are too many suicides among veterans.
    Senator Sanders. That was not my question. One suicide 
attempt, no matter where, is one too many; but 1000 a month 
sounds like an extraordinary number. What is going on where 
1000 guys who were in the military--people who were trained, 
tough guys--are attempting suicide? Can you give me something?
    Dr. Katz. Yes. Could I comment on the ``Shhh'' email first 
for just a minute? I was very excited when I learned about this 
finding and I wrote to a friend on the eighth floor, Mr. 
Chasen, asking what should we do with this new knowledge? 
Should we send it out to the field or should we use it to 
improve care first? I was writing to someone who gets about 400 
emails a day so I wanted to get his attention right away and I 
was far too dramatic in trying to do that.
    Senator Sanders. I am not here to talk--I just want to know 
the numbers. Go back to this issue. Is it true that a thousand 
soldiers a month are attempting suicide? Is that true?
    Dr. Katz. Well, we still have to validate that number. We 
expect so. We know from NIH data that the ratio of suicide 
attempts to deaths from suicide is between 8- and 25-to-1.
    Senator Sanders. Excuse me. I am just asking one simple 
question. All right, to a lay person, the fact that you have a 
thousand active-duty soldiers, a thousand soldiers----
    Dr. Katz. A thousand veterans.
    Senator Sanders. A thousand veterans--I am sorry--a month. 
That sounds like a very high number. Is that not the case?
    Dr. Katz. It is a thousand attempts. We do not yet know how 
many multiple attempts there are. It is within the expected 
range but it is too much.
    Senator Sanders. OK. What about----
    Dr. Katz. It does suggest something, through, if I may. We 
know that the group at highest risk for suicide is those who 
have previously attempted suicide. So this knowledge is an 
important window into prevention.
    Senator Sanders. What about 115 soldiers having killed 
themselves in 2007 within the Army?
    Dr. Katz. I have read that in the paper and in the Pentagon 
report just as you have. That is very separate from the VA.
    Dr. Kussman. Sir, if I could just add to that question.
    Senator Sanders. Yes.
    Dr. Kussman. I am obviously aware, and as Dr. Katz just 
mentioned, that is the Department of Defense, not us. But as 
far as my understanding of that number, even though it has gone 
up, if you look at an age-adjusted population of the group that 
are in the uniform that commit suicide, it is a lower rate than 
it is in the civilian community for an age-adjusted population.
    It is not to say that it is not going up, but suicide is a 
great problem in our society, particularly in young people who 
tend to be somewhat impulsive. So I think that the military is 
well aware of that and so are we. And the question is why do 
they do it? And we are looking at research and everything to 
try to determine what etiologies would lend somebody to be more 
susceptible to suicide than others.
    Senator Sanders. 115 soldiers in the Army in 2007 killed 
themselves. Again to a layman this seems like a very high 
number. Is that not, in your judgment, a very high number?
    Dr. Kussman. I am saying it is much higher than we would 
like to see.
    Senator Sanders. That goes without saying.
    Dr. Kussman. But if you put it in perspective and I am not 
trying to minimize it in any way, shape or form. But it is my 
understanding that if you look at the same age group of people 
who never put on a uniform, the amount of suicides per 100,000 
is 
higher.
    Senator Sanders. If I could ask Mr. Dunne a question.
    Mr. Dunne, the AP recently reported on VA documents it had 
obtained that said that the government expects to be spending 
$59 billion a year to compensate injured servicemembers of the 
next 25 years, up from today's $29 billion. The AP story noted 
that some at the VA believe that these are conservative 
estimates.
    Overall there are some people who think that the end result 
of this war might be as high as some $3 trillion, and that one 
of the reasons is that there will be a huge amount of money 
spent over the lifetime of soldiers who served dealing with 
their wounds, mental and physical.
    What is your estimate in terms of how much we will be 
spending per year to compensate injured servicemembers?
    Mr. Dunne. Senator, I do not have numbers with me with that 
calculation. I can make a projection and get back to you 
afterwards.
    Senator Sanders. I would appreciate that.
    If the number is really what the AP says it is, $59 billion 
a year, I mean that is for the next 25 years. That is just an 
extraordinary sum of money. And I would like to know if that is 
accurate. And it gets to the issue of what the cost of war is. 
When we go to war, it is not just the guns and tanks of today; 
it is the cost years into the future.
    Last, if I could, Mr. Dunne, as I understand it, there are 
some 400,000 outstanding claims for our veterans. I know that 
this Committee and the Congress has put a lot more money into 
the VA in recent years not only for health care but to 
accelerate the processing of these claims.
    Are we making any progress?
    Mr. Dunne. Senator, I think we are making progress. We are 
not happy with where we are right now. We are striving to do 
better. As of the first of this month, we had an inventory of 
390,034 claims which we were still working on. We have made 
progress on our hiring initiative. We have hired since January 
2007--2650 approximately of the 3100 that we intend to hire by 
the end of this fiscal year.
    They take about 2 years to become journeyman status when 
they are most effective at handling claims, but probably within 
the first year that they are onboard and complete their 
training they can begin to have an impact.
    We think that we are starting to see an impact on that but 
we are continuing to look at other initiatives such as a 
paperless environment. This week we have just instituted 
electronic signatures for original applications for claims and 
education and VR&E.
    Senator Sanders. This is an issue that interests me very 
much. I look forward to talking with you more in the future.
    Thank you very much, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Sanders.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    I want to thank you all for your service. I appreciate your 
testimony today. I want to echo the Chairman's remarks. This 
email is not why I am here exclusively. You hear a lot of 
things on the ground that are going on from veterans and I 
think this email contributes to that because it reaffirms what 
you hear on the ground.
    I am going to bring up two cases that reflect back to what 
you said earlier. This has nothing to do with mental health. It 
has to do with a clinic that is to be built in Billings where 
Secretary Peake and I thought it was to be done, yet the people 
down below had a different idea. We found out in the paper that 
it was not going to be built until 2009, and that is what I am 
talking about. That is what I am talking about being laid back. 
We will get to it when we get to it attitude. That is 
unacceptable.
    The other thing that is unacceptable is when I was also 
told by a veteran that when he talks to me, he was threatened 
with his disability being reduced. That is unacceptable.
    And I got in a bit of trouble through the papers because I 
said I thought the person who did that, and I did not know who 
it was, should be fired on the spot. But that is the way it 
goes.
    Senator Murray talks about getting through the door. 
Getting through the door is proper diagnosis.
    I have some questions for your, Dr. Perez. You are at the 
Central Texas PTSD clinic. How long have you been in that 
position?
    Ms. Perez. Since June 10, 2007.
    Senator Tester. June 10, 2007. So you are coming on a year?
    Ms. Perez. Yes, sir.
    Senator Tester. All right. Have you seen the PTSD diagnoses 
going up over your tenure there or is it pretty static?
    Ms. Perez. It is pretty static.
    Senator Tester. OK. The diagnosis between Adjustment 
Disorder and PTSD, are there different factors involved that 
diagnosis?
    Ms. Perez. Yes.
    Senator Tester. They are clear?
    Ms. Perez. They are clear.
    Senator Tester. OK. Can you tell me, folks that come in 
with, that are diagnosed with Adjustment Disorder, do they stay 
at that level or is there a percentage that are moved up to 
PTSD later on; or once they are diagnosed with Adjustment 
Disorder, they are there for a while? What is the process?
    Ms. Perez. No, no. Immediately a treatment plan is 
developed and they are entered into treatment. And as their 
provider works with them, again at their own pace of 
disclosure, then that is adjusted by the provider that is 
working with them.
    Senator Tester. Adjusted to PTSD diagnosis?
    Ms. Perez. It depends on whatever their symptoms are.
    Senator Tester. Can you tell me what percentage of veterans 
that are diagnosed with Adjustment Disorder are moved to a PTSD 
category?
    Ms. Perez. I do not have that information
    Senator Tester. Can you get it for me?
    Ms. Perez. I can take that for the record, yes, sir.
    [The Department of Veterans Affairs was unable to provide 
this information within the Committee's timeframe for 
printing.]
    Senator Tester. That would be great. Can you tell me what 
percentage of claims where you make the diagnosis for PTSD and 
you find out that that diagnosis was a mistake?
    Ms. Perez. I am not sure I understand the question.
    Senator Tester. A veteran comes in. A diagnosis is made 
that they have PTSD. You find out later or you do not think 
they have PTSD. What percentage of those that you diagnosis 
with PTSD do you feel that the diagnosis was inadequate or the 
person did not have PTSD?
    Ms. Perez. There have actually been two cases where--
because we do not require a DD-214, we do not require them to 
tell us, you know, everything at the initial interview--so 
there has been twice where I have been told that.
    Senator Tester. Out of how many cases?
    Ms. Perez. That I do not know.
    Senator Tester. Out of a hundred?
    Ms. Perez. More than that.
    Senator Tester. A thousand.
    Ms. Perez. Well, probably close to a thousand.
    Senator Tester. In your facility.
    Ms. Perez. I am thinking just from what I have seen, my own 
patients that I have evaluated.
    Senator Tester. In the whole system?
    Ms. Perez. I have no idea of the whole system.
    Senator Tester. OK. I want to go to your email, because I 
think it is quite instructive, and you know what it says 
because you wrote it. It says that ``given that we are having 
more and more compensation seeking veterans, I would like to 
suggest that you refrain from giving the diagnosis of PTSD 
straight out.''
    So what that implies to me is that the diagnoses for PTSD 
that were given--for you to send something like that out--
either they were not accurate at diagnosis or you want to deny 
benefits. Tell me what it says if that does not say one of 
those two things.
    Ms. Perez. Again it was really to stress the accuracy of 
diagnoses.
    Senator Tester. But there is only two that have been 
diagnosed wrong.
    Ms. Perez. Right. But that was in my personal experience 
with my patients. That email was triggered out of two other 
ones who had become distressed and had verbalized that distress 
with a psychiatrist. And so, that email was a result of trying 
to remind everybody to be accurate in your diagnoses.
    Senator Tester. But that is not what it says. It does not 
say you need to be accurate in your PTSD diagnosis. It says 
refrain from giving a diagnosis of PTSD.
    Ms. Perez. Well, again, that email was written specifically 
to my clinical staff there.
    Senator Tester. There has to be a reason for this. So what 
is the reason that you send this email out? I do not mean to 
put you on the spot.
    Ms. Perez. No, no. I understand. But I mean it was a real 
significant issue when you have got two veterans that are 
coming to you very distressed.
    Senator Tester. Yes.
    Ms. Perez. And it led to some----
    Senator Tester. So what you are saying is those veterans 
were diagnosed with Adjustment Disorder and they really had 
PTSD?
    Ms. Perez. Well, what I was told from the psychiatrist was 
that they were given a diagnosis of Adjustment Disorder when 
they had their compensation and pension examination. At intake 
a clinician gave them a diagnosis of PTSD. They went for their 
psychiatric consult, and that psychiatrist evaluated them and 
showed, OK, you do have symptoms of combat stress but you do 
not meet criteria for PTSD. At that time, in both instances the 
veterans became very distressed, and in one case they charged 
the psychiatrist, and so it became a safety issue.
    Senator Tester. I am trying to track you here. What you are 
saying is they were diagnosed with PTSD and then they came in 
and they back off that diagnosis?
    Ms. Perez. No, no.
    Senator Tester. So you are saying they were diagnosed with 
Adjustment Disorder and they went in they were kept at 
Adjustment Disorder?
    Ms. Perez. No, no, no.
    Senator Tester. So the only third option left is they came 
in with Adjustment Disorder and they were diagnosed with PTSD.
    Ms. Perez. Right. Then another team member, a 
psychiatrist--when they went to go have an evaluation to see if 
they needed any kind of medication----
    Senator Tester. Yes.
    Ms. Perez [continuing]. Then that second team member stated 
no, no, no, you do not have that. You do not meet criteria but 
you do have combat trauma symptoms.
    It is not unusual for someone to come in and have a 
different rapport with a different provider so they may share 
different information.
    Dr. Kussman. Senator.
    Senator Tester. Go ahead.
    Dr. Kussman. I do not want to belabor it. I apologize. But 
as Senator Murray mentioned, this is complex stuff sometimes 
with things. I think what we are doing here is that the 
individual may have been in the system before and may have 
submitted a claim for PTSD.
    Senator Tester. Sure.
    Dr. Kussman. That went through the process, and on occasion 
they do not get their diagnosis. Most people do, by the 
statistics, but some do not.
    Senator Tester. Yes.
    Dr. Kussman. The person may then still have symptoms.
    Senator Tester. Yes.
    Dr. Kussman. No question. They are enrolled with us and 
then they come to a treatment clinic like Dr. Perez is working 
in. It has nothing to do with compensation. But they are still 
pretty upset that they did not sometimes get a diagnosis of 
PTSD when they went through the VBA process. So they come in, 
and again, in the intake on the cases that I think Dr. Perez 
was talking about somebody said I think you have PTSD----
    Senator Sanders. What you are saying is you have two docs 
that have a different opinion on what is going on, right?
    Dr. Kussman. Right.
    Senator Tester. OK. I know this is complicated stuff. I 
know we are on grounds where we have got, what, 30 percent of 
the folks coming back. There is a claim that there is PTSD 
involved. I know that this is new ground. I know you are 
hiring, what, 3800 new psychiatrists, psychologists. I know you 
are doing this stuff.
    But I can tell you what the veterans think because I just 
talked to a bunch of them last week. They think that they are 
given this Adjustment Disorder diagnosis so that it takes away 
the government's liability in paying for anything that may be 
more than that. That is what the veterans think. That is what 
the people who put their lives on the line for this country 
think that the VA is doing to them. That is what they think. 
Perception is reality.
    What I have to say is just I am not a doc. You guys are far 
more educated than I am, probably. We have got to have definite 
criteria for PTSD and you have got to have definite criteria 
for Adjustment Disorder so that, quite frankly, you can sit 
down and explain to the person why. That is what is really 
important.
    The other thing is that I am going to go back to the very 
first statement. Make sure that people below you are doing what 
you want them to do. That is critically important because you 
can have the best, the best intentions, and if the folks on the 
ground that are working with the vets are not doing what needs 
to be done, you guys end up in front of a hearing, in front of 
the VA Committee in Washington, DC.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Tester.
    Dr. Perez, in your testimony you make two points about the 
best way to provide a diagnosis for PTSD. One, that a 
differential diagnosis is good medicine; and two, that trust 
must be established before PTSD can be identified. I agree with 
both of these points.
    I am concerned, however, with how you appear to have made 
these points in your email to your colleagues, your suggestion 
to them. When you were preparing your email, did you believe 
that the other clinicians of the PTSD treatment team, some of 
whom have many years of experience with PTSD, whether they were 
not aware of the treatment approach you set forth if your 
testimony?
    For example, did they know about providing a differential 
diagnosis even one that Dr. Katz said was probably not the best 
one?
    Ms. Perez. Yes, they do know that. They are very familiar 
with that and very--my thoughts are that they are probably very 
accurate in that.
    Chairman Akaka. Dr. Katz, you said that Adjustment Disorder 
is probably not a good suggested diagnosis. What are you doing 
to ensure that your providers understand your position on this?
    Dr. Katz. Well, specifically after that 6 months or so 
period, as Mrs. Murray mentioned, I would have concerns about 
it. I think the issue comes to how doctors say, ``I do not 
know'' or ``I do not know yet,'' and I think this is the issue 
that Dr. Perez was probably addressing.
    Sometimes after one-half hour or an hour or an hour and 
one-half with the patient, you do not know enough to make a 
diagnosis. We have to allow coding for that in an appropriate 
way to be able to get credit for the visit but not to commit 
ourselves prematurely to the presence or absence of any 
diagnosis.
    Chairman Akaka. Dr. Kussman and Admiral Dunne, do you agree 
that there may be confusion for both veterans and clinicians 
when a particular clinician may act as both care provider and 
evaluator? Does this suggest that C and P exams, that is, 
compensation and pension, should be conducted by non-VA 
physicians; or at a minimum, that no VA physician who provides 
direct care should be tasked to conduct a C and P exam?
    Dr. Kussman. OK. I win. First of all, Mr. Chairman, there 
are two ways that the exam is done, as you know, either through 
the VHA personnel or under contract with QTC. And the 
evaluation is very proscribed. There are templates and other 
guidance that have to be followed.
    We have set standards for that saying that only 
psychiatrists and Ph.D. psychologists should do that. Although 
the IOM did not put that level of proscription, we wanted to be 
sure that that took place.
    If you are asking specifically about whether a psychologist 
or psychiatrist who was taking care of somebody in a clinical 
setting be the one that does their Comp and Pen, I would have 
to think about that. But, the fact that somebody is in a clinic 
and does a Comp and Pen exam would not preclude them from doing 
it, because we have lots of people who maybe Monday and 
Wednesday they are in the treatment clinic, and maybe Tuesday 
afternoon they are doing Comp and Pen exams.
    So, I do not think they are mutually exclusive. But if, you 
know, we want to separate the clinical treatment from the 
assessment of how much compensation a person gets I think I 
would--and again I do not know if anybody has done it on their 
own patient--but that would, I think, not be the best way to do 
it.
    Do you have any comments?
    Chairman Akaka. Admiral Dunne.
    Mr. Dunne. Senator, I would agree that, as people have said 
this morning, the process is very complex and what I have 
learned over the past 2 months is a review of the template that 
is used to conduct that examination, which is a very very 
extensive and complex template. I have confidence in that. I 
have confidence in the VA doctors to execute that template and 
to provide us with a valid, medically correct evaluation of 
every veteran who comes to see them.
    Chairman Akaka. Thank you very much.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Admiral Dunne, your testimony noted that there has been 150 
percent increase in the number of veterans receiving disability 
compensation since 1999. In 2004, the Inspector General found 
that veterans PTSD rating levels, and I quote, ``typically 
increase over time indicating the veterans' PTSD condition had 
worsened. Generally, once a PTSD rating was assigned, it was 
increased over time until the veteran was paid at the 100 
percent rate.''
    Does your information square with the IG's findings--that 
veterans with PTSD get worse over time?
    Mr. Dunne. Senator, I do not have that information but 
perhaps Mr. Mayes does.
    Mr. Mayes. Yes, sir. What we know is that--or I guess what 
the IG found was that--once veterans were service-connected for 
PTSD that it was rare that service connection was stopped or 
that the evaluations were reduced. So what we have done is, we 
have begun to look at PTSD. We are looking at evaluations 
across States and we are evaluating that as part of our quality 
assurance program.
    So, we are taking a look at that. That was also one of the 
things that the Institute for Defense Analysis also 
recommended, that you take a look at any possible variants and, 
you know, any underlying causes for that.
    So we are taking a look at it. But I cannot, other than 
that--I guess the question was does it square with the IG 
report. That is what we found. That's what the IG found.
    Senator Burr. Let me go to the clinician if I can. The 2007 
Institute of Medicine report found insufficient evidence to 
support the effectiveness of most PTSD treatment therapies with 
the exception of exposure therapy.
    If, in fact, we see this trend of increasing PTSD claims, a 
worsening of the disability over time, is that not a suggestion 
to us that we either need to implement total exposure therapies 
because it is the only one that has the evidence of success; 
or, two, that we need to look outside of the therapies that we 
are currently using to try to find something to turn this trend 
around. Or would this Committee accept the fact that from the 
standpoint of mental health treatment there is no cure, that we 
are managing a continual progress of getting sicker? Somebody 
help you with that.
    Dr. Katz. I like to think about an analogy, and the medical 
advance that came out of World War II was penicillin. It was 
known that penicillin existed in a laboratory and could kill 
bacteria there beforehand. But it was during the war that it 
was translated into a drug that helps people.
    There was information about exposure-based treatments 
before but in the past year or year and one-half, the VA has 
trained almost 1200 people--existing staff members--to deliver 
cognitive processing therapy for PTSD.
    That is a huge number--enough to make a public health 
difference. We have similar programs underway for prolonged 
exposure therapy. So, we are very seriously working to 
disseminate these treatments. I hope these treatments can be 
the ``penicillin'' that comes out of this war.
    Senator Burr. Dr. Katz, is the intent to try to cure, to 
try to delay any further disability?
    Dr. Katz. I want to respond to that and then talk about 
medications and research.
    PTSD is probably like asthma. We want to treat events. We 
want to treat exacerbations and deal with symptoms. But once 
someone has had PTSD, I am afraid they may be increasingly 
vulnerable throughout their lives to retraumatization or 
stress-induced traumatic reactions.
    So we hope the treatment does both to deal with the event, 
to deal with the episode and to decrease the probability that 
another one would occur with retraumatization.
    Going back to other forms of treatment, the Food and Drug 
Administration views certain anti-depressants as safe and 
effective for the treatment of PTSD. So, they differ in some 
ways with the Institute of Medicine.
    What this calls for is a need for more knowledge; a need 
for research. And VA has been and continues to be a real leader 
in research.
    Senator Burr. Dr. Kussman keeps us up-to-date on the 
progress.
    Dr. Kussman. Yes, sir. If I could add to it, I think that 
it is clear that you want to aggressively try to intervene 
early in the diagnosis because sometimes the long-term effects 
of PTSD are not really PTSD itself. It is the second- or third-
level effects where people will try to treat themselves with 
substances or get depressed.
    They frequently are the more severe things, longitudinally, 
rather than the PTSD itself. So that is why it is so important 
to try to get people in early, get them to feel comfortable so 
you can prevent or attenuate some of those long-term issues.
    What the IOM said, I think, sir, is that when they looked 
academically, critically at the literature that was available, 
what they said was the only treatment--the exposure treatment--
was the only one that they could say unequivocally had effect 
on the basis of the search that was available.
    But they did not say that other therapies like medication 
and psychotherapy and things were not effective. They just did 
not think there was evidence to show it was as effective as 
the----
    Senator Burr. Yes. The key word is ``evidence.'' Let me 
just summarize by making a statement, and I think this might 
express why there are so many questions about this from this 
Committee.
    Since the year 2001, the mental health budget at the 
Veterans' Administration has doubled. Staffing has increased 73 
percent over the last 3 years and we are not where we are 
targeting yet, but we have got an aggressive goal as to how we 
are going to get there.
    Yet, people are still asking for an explanation about why 
our veterans are getting worse versus better, as it relates to 
mental health services.
    I am not going to take up my colleagues' time asking for an 
answer. I am not sure that there is an answer. But I think that 
is the focus of where we need to be.
    If all agree that the resources are there, that the plan to 
hire the people and to train the people, which was a very 
important part of the statements that you need, and that we 
understand to some degree, to quote Dr. Perez, how we need to 
peel the onion back before we begin to realize the true problem 
or the depth of the problem.
    At some point I hope you will share with us what it is we 
should use to gauge success versus a continued worsening of the 
health of our veterans; an increase in their disability 
ratings, which is an indication to me that the therapies that 
we are using are not working. And my hope is that that will 
turn around.
    I thank the Chair.
    Chairman Akaka. Thank you very much, Senator Burr.
    Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman.
    I would hope that the gauge of our success is that after a 
very complex, difficult war--10, 15, 20 years from now--we do 
not have men and women who served in that war who came home and 
who were not treated.
    I guess, really, the bottom line here is Post Traumatic 
Stress Disorder is not a new issue from just this war. It has 
been from every war. In World War I and World War II, many of 
our veterans came home and suffered from mental health issues 
and may or may not have been treated.
    Certainly, the ones that I know better--the Vietnam War 
veterans--came home and because of a culture that was not ready 
to accept them, many of them never tried to get treatment, and 
did not get treatment. We did not have the term PTSD in our 
vocabulary at the time. And as a result, decades later those 
men and women are suffering.
    I think what we want is to make sure that in this conflict 
that our generation is responsible to make sure that we do not 
have veterans 20 years from now who were not given treatment.
    Hence, Dr. Perez, our deep concern with an email that 
indicates that because of cost, because of time, because of 
whatever reason, we are not going to give you a diagnosis. That 
is the genesis of the concern that many of us have.
    It is difficult, but we need to make sure that any veteran 
who seeks care is not under the perception at anytime that they 
will not get that care, that the VA or this country does not 
have the time for them, or the resources to help them.
    We have to make every effort to do that, and every message 
coming from the VA has to be that--that if you are a veteran 
and you need care, this country will be there for you. Period.
    So, Dr. Kussman and Secretary Dunne, I want to ask you. The 
Chief of Staff at Temple apologized to the veterans and to the 
advocates about Dr. Perez's email. Both Secretary Peake and 
Deputy Secretary Mansfield have repudiated the email and that 
was good. It needed to be done. The message had to be clear.
    I was sort of struck by both of your testimonies today, 
that they did not appear to have any remorse, and I wondered if 
you could explain that, both of you.
    Dr. Kussman. Senator, I think I said that any perception or 
real that we were not approaching veterans in an appropriate 
way and gave any perception that we would not make the 
diagnosis is something that I cannot accept.
    There were some, as we discussed, some interpretation of 
what took place in the email and I think that we have 
adequately discussed this here. But I have just as much concern 
about all the things that you mentioned.
    But I think a lot of it is communication; and we do need to 
be able to be sure that we are explaining what we are doing and 
things do not get taken out of context.
    Mr. Dunne. Senator, I would agree that the email was poorly 
worded, and it is an unfortunate instance but it only makes me 
want to work harder to ensure that veterans understand that we 
are here for them, whether it be for PTSD compensation or for 
education or for loans, VR&E, whatever it is; we are working 
hard to make sure that they know we are here and we want to 
hear from them when they need something.
    Senator Murray. Let me just say I am confused about 
something. Deputy Secretary Mansfield said that Dr. Perez's 
suggestion should be disregarded. That came from Secretary 
Mansfield.
    And that the people working there had been instructed this 
was not what we are going to do. We are going to follow 
Secretary Peake's direction, which is to put out the full and 
accurate word and make sure that we stick with that.
    Yet your testimony does not in any way backpedal from Dr. 
Perez's suggestion even though Dr. Katz said that he would not 
agree with that.
    Dr. Kussman, Secretary Dunne, can you tell us--inartfully 
worded is one thing--can you tell us what direction is from the 
VA in terms of the diagnosis on someone coming in, whether it 
should be as was stated in an email, that it should be 
considered a diagnosis of Adjustment Disorder or not?
    Dr. Kussman. As we have discussed, I think on any given 
case do not make the diagnosis of Adjustment Disorder if you 
think that is inappropriate or that it should be PTSD. And do 
not make any diagnosis that you think is inappropriate for 
anything other than the true clinical assessment of what you 
think.
    It should have nothing to do with time or money or anything 
else. It should just be an appropriate diagnosis. As I said, I 
would agree with the Secretary and Deputy that we would 
repudiate any suggestion that somebody would make a diagnosis 
of Adjustment Disorder in lieu of PTSD if there was any 
suggestion that that is not an appropriate thing to do.
    Now you mentioned that Dr. Katz has mentioned that after 6 
months or whatever, and I think that that is something that has 
to be determined on a clinical basis.
    Senator Murray. Would you agree that most vets do not come 
in and see you within 6 months of when they were in the field?
    Dr. Kussman. Most do not. Some do, and it depends on the 
timing. So, if it is beyond the 6 months, I think that maybe 
something else would be as combat stressful, rule out PTSD. I 
do not know what the appropriate thing is, but the message is, 
I think, that just like any diagnosis: be careful when you make 
the diagnosis; do a thorough assessment of people.
    Senator Murray. Do you agree with Deputy Secretary 
Mansfield that said Dr. Perez's suggestion should be 
disregarded?
    Dr. Kussman. If you again did not have the opportunity to 
discuss exactly what was going on, I would agree that it should 
be disregarded if it was intended in any way to be that you 
should not make the diagnosis.
    Senator Murray. Admiral Dunne.
    Mr. Dunne. Senator, I have no disagreement with the Deputy 
Secretary, and as I mentioned before, the templates that are 
used for a claims evaluation examination are very specific. 
They are very detailed. They would require the doctor to answer 
a number of questions, many of them to respond to the DSM-IV 
criteria so that the rating representative could make a valid 
understanding and evaluation of the disability.
    If that template is not filled out correctly or completely, 
the rating representative is trained to reject that and return 
it until it is sufficient medical evidence so that all the 
questions are answered, all the information is available.
    Senator Murray. Secretary Dunne, I appreciate the 
complexity of the answer that you just gave. But to a country 
that is listening to the VA, to a soldier that has come home 
from a very challenging war, can you please give us in plain 
English what you would say to someone who is seeking help from 
a very difficult diagnosis of mental health?
    Mr. Dunne. Yes, Senator. I would say that if they were 
aware and had read about that email, that it did not reflect 
the guidance of VA and that they should feel confident and come 
see us both for treatment and compensation.
    Senator Murray. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Tester.
    Senator Tester. Yes. Thank you, Mr. Chairman.
    Dr. Kussman, either in your opening remarks or the 
questions you mentioned stigma surrounding mental health 
issues, and it is a point that I appreciate and it is a good 
one, and I appreciate your interest to address it from a 
societal standpoint.
    It has been a difficult problem in Montana--the perception 
issue around mental illness--but the National Guard has done a 
great job in Montana and I do not anticipate that you've been 
in contact with them so let me ask this question as kind of a 
comment, and that is, are you coordinating VA's efforts with 
State guard units around the Nation?
    Dr. Kussman. Yes, sir. I have not personally spoken to 
anybody in Montana but we have an office of seamless transition 
and DOD/VA coordination, and there are individuals who do 
nothing else but work the Guard and Reserve issues.
    Senator Tester. Good.
    Dr. Kussman. We have tried to learn from some of the States 
that have done a good job and tried to encourage States that 
maybe are not as engaged as others to do things.
    But, my sense is that since this war has been different 
than any war we have had since World War II--with the use of 
the National Guard and Reserve--this has presented us with 
challenges that we have not dealt with for 60 years. And I can 
just tell you that we are committed to doing everything we can 
to do that.
    Senator Tester. I appreciate that.
    Going to Senator Murray's question, I think, Dr. Kussman, 
what I heard you say was spot on, and that is, if somebody 
comes in, diagnose them properly. Do not diagnose them on 
additional workload or anything like that.
    I just want to say that because I appreciate that, because 
what Admiral Dunne said in a previous question--that the 
template for PTSD was solid. That's good to know. Hopefully, 
the template for Adjustment Disorder is solid or whatever 
disorder they may have either below or above what a PTSD 
diagnosis would be.
    I appreciate Dr. Katz's point about proper treatment 
depends upon proper diagnosis, dealing with past events or 
current events.
    This question is for both Dr. Kussman and Patrick Dunne 
because you both had a part in why I am asking this question.
    Admiral Dunne had said reasonable doubt goes to the 
veteran. And in my previous round of questions, Dr. Kussman 
said that there was a difference of opinion that really causes 
this problem.
    One guy diagnoses it. One guy come in and says, or gal, 
says, no, this is not correct and there it becomes a difference 
of opinion. So if the tie goes to the runner, the tie goes to 
the veteran, why does not the tie go to the veteran? Or do you 
see it as an issue?
    Dr. Kussman. No. First of all, it is rare that that 
actually happens because most people will come to a consensus 
of what the individual has. I agree wholeheartedly using the 
baseball analogy; the tie goes to the runner.
    Our job is to provide services, the full gamut of health 
care benefits, and not try to find ways of not doing it, and so 
whenever it is an appropriate clinical thing, we should err on 
the side of the veteran unequivocally.
    Dr. Katz. Could I?
    Senator Tester. I will get to you, Dr. Katz. Admiral Dunne 
first. Then you.
    Mr. Dunne. Senator, I would agree in that we do the same 
thing within our process. Once we get a medical evaluation in, 
we then have to take it into the rating table and decide on a 
percentage disability.
    When the information in the medical exam would cause the 
rating specialist to have a concern as to whether it is one 
disability percentage or another, then the higher disability 
would be assigned.
    Senator Tester. So, the rating happens after the diagnosis 
and not before.
    Mr. Dunne. Yes, sir, that is correct.
    Senator Tester. That is good to know.
    Dr. Katz.
    Dr. Katz. When we are talking about treatment rather than 
compensation, the whole issue of the tie going to one side or 
the other does not count. The patient needs the most accurate 
diagnosis to allow the most precise and predictive treatment 
planning.
    Sometimes you do not get it right the first time. Someone 
may be treated for what looks like depression, and during the 
course of treatment for depression, symptoms of PTSD may emerge 
and we should then change the treatment.
    Senator Tester. Right. That is why that template that 
Admiral Dunne talked about is so critically important. If that 
template is as good as we think it is it will help your 
treatment be solid from the get-go. Now, I am not saying 
mistakes cannot be made and there are not things that happened, 
but ultimately, in the end, what we need is diagnosis of a 
proper problem when that problem exists and not putting folks 
off.
    Thank you, Mr. Chairman.
    Thank you folks, too.
    Chairman Akaka. Thank you very much, Senator Tester.
    Do you have any more questions?
    Senator Murray. No, Mr. Chairman.
    Chairman Akaka. I have more questions that I will submit 
for the record.
    In closing I again thank all of our witnesses for appearing 
before the Committee today. We really appreciate hearing your 
views on these important issues. Your testimony today will 
hopefully ensure that we will be able to better serve those who 
are suffering with invisible wounds.
    While it is apparent that VA is trying to do all that it 
can to help, there is still much room for improvement. Issues 
of veterans' suicide and PTSD are topics that cannot be taken 
lightly.
    We all must be careful about what we say, and, of course, 
how we say it. You are all representatives of VA both to 
veterans and to the public as a whole. And when it is 
discovered that emails such as these have been written, it 
reflects not just on an individual but on the Department as a 
whole.
    VA, without question, has a very very important mission. 
When charged with such a heavy mission, it is imperative that 
VA remains the best health care system in the Nation for 
veterans.
    We must not lose focus on that and that mission. VA is here 
to serve those who served us. I look forward to continuing to 
work with you to improve services and care for veterans and 
their families.
    This hearing is now adjourned.
    [Whereupon, at 11:41 a.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


  Prepared Statement of Hon. Barack Obama, U.S. Senator from Illinois
    Chairman Akaka, I want to thank you for holding this important 
hearing today. We are a nation at war and every day our brave men and 
women return home from battle with wounds both visible and unseen, and 
tragically these wounds can often end in death. We must do everything 
we can to prevent these tragedies, but unfortunately, we have been 
forced to battle the Veterans Administration over the past seven years 
to ensure that our veterans receive the best care possible.
    I don't deny that the Veterans Administration can provide some of 
the highest quality health care in this country. Many veterans have 
been pleased with the care they have received at the VA. But recent 
events indicate a practice and a culture at the VA that seems intent on 
denying full care for our veterans. We have seen the deputy chief of 
patient care services imply that the actual rates of suicide among 
veterans be suppressed. We have a mental health care therapist 
suggesting to her colleagues that veterans with PTSD be underdiagnosed. 
It is too easy to suppress and ignore the invisible wounds of PTSD and 
mental health problems, and we cannot allow that.
    When I first heard of Ms. Perez's email to her colleagues 
recommending an underdiagnosis of PTSD cases, I immediately called on 
Secretary Peake to investigate these efforts to provide fraudulent 
diagnosis in an effort to save money. To Secretary Peake's credit, I 
received the swiftest response from any Federal agency--he responded 
within the day--but I demanded answers to specific questions regarding 
the quality of mental health care provided our veterans and I expect 
those answers to be forthcoming.
    I hear every day from Illinois veterans who are frustrated--
frustrated with the bureaucracy at the Veterans Administration, 
frustrated with the denial of claims, frustrated with an apparent 
indifference to their needs. Too many veterans see the Veterans 
Administration as a bureaucracy with the sole goal of denying their 
benefits. Mr. Chairman, I know you agree that this is unacceptable and 
I look forward to working with you and my colleagues on the Committee 
to ensure that the Veterans Administration lives up to its mission--
``to care for him who shall have borne the battle.''
  

                                  
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