Overcoming PTSD: Assessing VA's Effort to Promote Wellness

The United States military fosters a mission-first culture that prioritizes selflessness and teamwork, where most servicemembers feel a sense of higher purpose in the defense of our Constitution and the people of the United States of America. When active duty members transition from this environment of camaraderie to the civilian world, many feel confused, isolated, and misunderstood. Today, around eight percent[1] of the U.S. population has served, and while the public generally holds the military in high regard, many do not understand its culture or the values of the people who serve. With less than one-half of one percent of the American population currently serving on active duty, a shrinking minority of citizens shoulder the physical and psychological burdens of war. To visualize the cost of 16 years of continuous combat, it is important to recall that nearly 60,000 servicemembers have been killed or wounded in action since September 11, 2001 – enough people to fill Chicago’s Soldier Field to capacity. A new generation of America’s best young men and women now carry these scars and memories of war.

Chairman Roe, Ranking Member Walz, distinguished members of the House Veterans’ Affairs Committee; The American Legion works every day to ensure our 2.2 million members, and veterans everywhere, receive the expert care they have earned while serving in defense of this nation. We appreciate the opportunity to share our research and offer this testimony for the record before this committee.

After a decade and a half of conflict around the globe, post-traumatic stress disorder (PTSD) along with traumatic brain injury (TBI) are now recognized as the “signature wounds” of this war. The latest studies estimate that anywhere between 11 and 20 percent of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans are experiencing or have experienced PTSD. By comparison, Gulf War veterans experienced PTSD at a 12 percent rate and Vietnam veterans around 30 percent[2]. This variance can be explained by comorbidities, or symptoms belonging to multiple diagnoses, which are a frequent barrier to accurate assessment and diagnosis[3]. PTSD is a clear and present threat to our nation's veterans.  For many, the war continues well after they return to American soil and attempt to reintegrate into civilian life.

American Legion Leadership and Activism

In 2010, The American Legion commissioned a TBI and PTSD Ad Hoc Committee to “investigate the existing science and procedures, and to study alternative methods for treating TBI and PTSD.”[4]  The American Legion’s PTSD/TBI Ad Hoc Committee has carefully and compassionately studied these conditions and the way in which our government is responding to them. During the three-year study, the Committee held meetings and met with leading authorities in the Department of Defense (DoD) and the Department of Veterans Affairs (VA) while simultaneously interviewing veterans within our organization. In 2013, the Committee published the first iteration of “The War Within”[5], which identified obstacles to care, and made recommendations to improve mental health services at VA for PTSD. We concluded there was an urgent need to pursue research and urged the VA to use complementary and alternative medicines (CAM), such as hyperbaric oxygen chambers, animal-assisted intervention, and more. The Committee determined that CAM treatments could assist in reducing substance abuse and death resulting from opioid overuse for pain management and PTSD symptoms.

Following the publication of The War Within, the TBI/PTSD Committee launched a 30-day web survey with more than three-thousand veterans - approximately 10 percent female and 90 percent male - opting in. The Committee presented the findings at a two-day “Advancing the Care and Treatment of Veterans with TBI and PTSD” symposium in Washington, D.C. Subject matter experts from VA, DoD, relevant nonprofits, and the private sector discussed gaps in care, proposed best practices, and advocated for innovative treatments.

The TBI/PTSD Committee continues to expand its expertise and influence in the veteran mental health community through its work in evaluating diagnostic procedures, treatments, and prevention efforts. For the past seven years, our “System Worth Saving” (SWS) site-visits have collected data on the preparedness of VA facilities to handle mental health issues, and the Committee has published a series of resolutions in support of veterans struggling with PTSD.  These resolutions included the establishment of a Suicide Prevention Program as well as support for a number of diverse programs that have helped a great number of veterans we have worked with.

The American Legion’s TBI/PTSD Committee has advocated for a peer-to-peer and more holistic approach in treatment of PTSD. In 2016 The American Legion Departments of Alabama and Michigan held Veteran Retreats, taking over 60 veterans currently utilizing VA facilities, and showcasing a variety of CAM treatments and peer-to-peer activities and therapy.      

A Navy veteran who receives care at the Birmingham VA Medical Center for PTSD told us “Here I am sharing things with people who know what I am talking about. In civilian life, they want to say, ‘I know how you feel.’ But they really don’t. Here, they know how you feel. It’s been fabulous.”

Another attendee amplified this sentiment saying, “I suffer from PTSD. This camp has done more for me than any counseling or medication.”

The VA has recently taken several positive steps to care for veterans struggling with mental health issues. VA Secretary Dr. David Shulkin has named veteran suicide his highest clinical priority, launched the Center for Compassionate Innovation, and expanded access to mental health services for veterans with other-than-honorable (OTH) discharges; many of whom were wrongfully separated administratively due to mental health issues[6]. The American Legion applauds these efforts and looks forward to working with this committee and the administration to improve treatment options even further, and we call on VA to maintain their commitment to exploring more CAM treatments for PTSD through the newly created Center for Compassionate Innovation.

In 2011, Marine veteran Clay Hunt committed suicide. Before taking his life, Hunt was actively seeking to help other veterans with their mental health issues but often remarked to a friend that, “[PTSD] is like a bad movie on rewind. It plays, it rewinds, plays, rewinds”. Hunt had complained of extremely long wait times for mental health counseling appointments at VA[7], and in an attempt to immortalize his struggle, Congress passed the Clay Hunt Suicide Prevention Act in 2015, which took good steps to increase access to mental health care by creating peer support and community outreach pilot programs to assist transitioning servicemembers, as well as a one-stop, interactive website of available resources[8]. But VA’s most comprehensive suicide prevention report to date, published in 2016 concluded that 20 veterans a day are still committing suicide[9]. According to the report, the majority of suicides are committed by Vietnam veterans, and that OIF/OEF veterans commit suicide at a higher rate than their non-veteran peers. The report also found that 14 out of the 20 suicides that end veterans’ lives every day do not receive treatment at VA healthcare facilities. In an attempt to increase awareness of resources and connect with the 70 percent of veterans at risk of suicide, the report states:

Veterans’ Health Administration requires that facilities complete five outreach activities each month for community organizations, [mental health] groups, and/or other community advocacy groups. Outreach activities have direct effects on suicide hotline call volume and VHA’s ability to get help to veterans in need.” Reasons SPCs (suicide Prevention Coordinator) gave VAOIG for not providing outreach activities included lack of leadership approval or support to attend events or activities.”

The report explains further that employee training for primary care and mental health providers on suicide risk assessments were mandated to occur by VHA during orientation, and that clinicians complete a separate risk management training within 90 days of hire, however:

“45.7 percent of the time clinicians did not complete suicide risk management training within 90 days of hire. Reasons clinical managers gave VAOIG for not training clinicians included lack of allocated time to complete training, lack of leadership support, and not understanding that it was required.”[10]

Clinical and administrative leadership must improve cooperation, and the VA Central Office leadership must implement the IG’s incomplete recommendations for improvement to seizethese opportunities. VHA will continue to have challenges in their essential mission of providing mental health resource access to veteran populations living in rural areas, or those who feel a strong stigma asking for help through in-person resources.

An American Legion survey of over 3,000 veterans found that 14 percent were prescribed 10 or more medications for PTSD symptoms. 52 percent of all respondents reported no change or worsening symptoms after medication by a mental health professional, and 30 percent terminated treatment before completion. Reasons for termination consisted mainly of two categories: “Stigma/Solve By Myself” comprised 25 percent of early treatment termination and “Side Effect/Lack of Improvement” comprised 44 percent[11]. These concerns mirror the most frequently cited barriers to good care for PTSD in the general veteran population[12][13].

The Path Forward: Suggestions in Wellness and Healing for Veterans with PTSD

Leadership Sense of Urgency, Outreach, and Accountability

The American Legion applauds the passage of H.R. 1259, “VA Accountability First Act of 2017”, and thanks Chairman Roe for his leadership on this issue. The recent VAOIG report indicating negligence at VA facilities in mental health training and outreach are a perfect example of why the Secretary needs authority to hold employees accountable. The American Legion and its TBI/PTSD Committee applauds Secretary Shulkin for his focus on PTSD and encourages him to ensure all VA facilities promote a greater sense of urgency in outreach.

Public-private partnerships (PPPs) and more aggressive engagement are crucial in expanding access to high-quality mental health services for veterans who may not qualify or do not wish to use VA or DoD medical care for PTSD treatment. VA must ensure partnered organizations provide military cultural training to their counselors.

The American Legion recommends VA medical facility leaders and suicide prevention coordinators research grassroots resources for veterans who desire a sense of camaraderie or community outside of VA care.  The VA should then provide a list of these resources to primary care physicians, mental health providers, and veteran patients[14]. VA leadership should also ensure full compliance in suicide risk management training and suicide prevention outreach activities.

Complementary and Alternative Medicines

Cannabis

After 16 years of war in Afghanistan and Iraq, many Americans view post-traumatic stress disorder, or PTSD, and traumatic brain injury, or TBI, as the “signature” wounds of these conflicts. The Department of Veterans Affairs has spent billions of dollars to better understand the symptoms, effects, and treatments for these injuries. But despite advances in diagnostics and interventions in a complex constellation of physical, emotional, behavioral and cognitive defects, TBI and PTSD remain leading causes of death and disability within the veteran community.

There is something else the U.S. can do for suffering veterans: research medical marijuana.

Many Afghanistan and Iraq veterans have contacted The American Legion to relay their personal stories about the efficacy of cannabis in significantly improving their quality of life by enabling sleep, decreasing the prevalence of night terrors, mitigating hyper-alertness, reducing chronic pain, and more. This is why the 2.2 million members of the American Legion are calling on the Trump administration to instruct the Drug Enforcement Agency to change how it classifies cannabis, release the monopoly on cultivation for research purposes, and immediately allow highly regulated privately-funded medical marijuana production operations in the United States to enable safe and efficient cannabis drug development research.

The opioid epidemic that continues to grip veterans is yet another reason to ease the federal government’s outdated attitude toward America’s marijuana supply. The Trump administration should lead a new effort to combat opioid abuse, and it should include the elimination of barriers to medical research on cannabis. The result, potentially, could provide a non-addictive solution to the most common debilitating conditions our veterans— and others in society— face, including chronic pain, PTSD, and TBI.  

The American Legion is asking Congress to amend legislation to remove marijuana from Schedule I and reclassify it in a category that, at a minimum, will recognize cannabis as a drug with potential medical value.

A recent comprehensive study by the Committee on the Health Effects of Marijuana at the National Academies of Sciences, Engineering and Medicine found that there is, “conclusive or substantial evidence that cannabis or cannabinoids are effective for the treatment” of chronic pain, reducing nausea and vomiting during chemotherapy, and lowering spasticity in multiple sclerosis sufferers, that there is “moderate evidence” that cannabis is effective in treating sleep apnea, fibromyalgia, and chronic pain, and “limited evidence” that cannabis improves symptoms of posttraumatic stress disorder and creates better outcomes after traumatic brain injury.

We need to know more. With 20 veterans committing suicide every day, we cannot afford to delay research into this promising potential solution.

Service Dogs

In 2009, Congress mandated in the National Defense Authorization Act that the VA study whether service dogs have therapeutic benefits, reduce the cost of hospital stays, or help prevent suicides.

Unfortunately, eight years later, the study has not been completed. Other recently published studies show service dog assisted interventions, “may provide unique elements to address several PTSD symptoms,” [15] and the National Center for Complementary and Integrative Health recently authorized funding for a practical trial with service dogs. On March 7, 2017, Secretary Shulkin testified at a Congressional hearing on the use of service dogs for veterans with PTSD or psychological disorders, stating, “[I] think it’s common sense that service dogs help. We hear it every day from veterans. I’m not willing to wait [on congressional authority to implement what I can through my existing authority] because there are people out there today suffering.” The American Legion calls on Congress to pass responsible legislation providing service dogs to veterans with PTSD and to clearly define regulations for certification of service dogs for mental health and mobility issues.[16]

Reducing Stigma and Prescription Drug Abuse

The American Legion applauds this Committee, Congress, VA, DoD, the National Center for PTSD, and many of the VA Medical Centers for their efforts to reduce the stigma of asking for mental health treatment. Public awareness campaigns like PTSD Awareness Month, “Make The Connection,” and “Use Your Voice” save lives. The PTSD Treatment Decision Aid and Veterans’ Crisis Line increase access and greatly reduce the stigma of asking for help by enabling veterans to seek treatment anonymously.

Improve Services for Female Veterans

Women comprise 11 percent of the veteran population and are the fastest-growing demographic in the military.[17]

More than 20 percent of female veterans report disproportionally higher rates of military sexual trauma (MST) when compared to their male peers[18], and women have unique challenges when seeking treatment for PTSD[19].

Recent studies show that both sexes who report MST demonstrate an increased risk of PTSD and suicide, and MST remains an independent risk factor even after adjusting for mental health conditions, demographics, and medical conditions.[20] [21] 

The American Legion calls on VBA to provide sensitivity training to claims processors, analyze MST claim volume, assess adjudication consistency, and determine the need for training and testing on processing these claims,[22] and finally The American Legion urges the VA to work with DoD and the Department of Labor (DoL) to create a customized healthcare track for the Transition Goals, Plans and Success program facilitated by female clinicians.[23]

Conclusion

The Department of Veterans Affairs has made real progress in mental health awareness, outreach, and treatment through telehealth, digital media, and in-person care, but there is much work yet to be done. The last 16 years of continuous war has taken its toll on our active-duty and veteran communities. With 20 veterans committing suicide every day, all of us need to act quickly to mitigate the impact of PTSD, provide veterans the best possible care, and aggressively pursue all therapies that show promise in improving the lives of those who have given so much in the defense of our Nation.

To adequately care for those who have “borne the battle,” the VA must reinvigorate a sense of urgency within leaders at the facility level to include more holistic CAM treatments for PTSD, aggressively reach out to grassroots peer-to-peer organizations, and create new PPPs in expanding culturally competent access to care.

Together, we can help veterans suffering from PTSD (and comorbid psychological conditions) mitigate their symptoms, and work toward helping them regain their sense of community and identity.

The American Legion thanks this committee for its leadership and looks forward to working together to improve the lives of America’s veterans.

For additional information regarding this testimony, please contact Mr. Derek Fronabarger, Deputy Director of The American Legion Legislative Division, at (202) 861-2700 or dfronabarger@legion.org.