Veterans and Mental Health Care, The Court Speaks

An honor guard from the 1st Special Forces Group transports the flag-draped coffin of Sgt. 1st Class Nathan R. Chapman just before midnight Jan. 8 at Seattle-Tacoma International Airport. More than 60 Green Berets joined the Chapman family at the airport to pay their respects to the first U.S. soldier killed by hostile fire in Afghanistan. Photo by Joe Barrentine, US Army

As Memorial Day comes to a close and we ready ourselves for a return to work and all that brings, let’s take a moment, after this single day dedicated to the ultimate sacrifices made by American military men and women, to consider our part of the bargain.

These are the opening paragraphs from an Associated Press article which ran two weeks ago:

Noting that an average of 18 veterans a day commit suicide, a federal appeals court on Tuesday ordered the Department of Veterans Affairs to dramatically overhaul its mental health care system.

In the strongly worded ruling, the 9th U.S. Circuit Court of Appeals said it takes the department an average of four years to fully provide the mental health benefits owed veterans.

The court also said it often takes weeks for a suicidal vet to get a first appointment.

The “unchecked incompetence” in handling the flood of post-traumatic stress disorder and other mental health claims is unconstitutional, the court said.

And, one might add, unconscionable. The AP notes that

The court said a 2007 report by the Office of the Inspector General found significant delays in timely referrals from VA doctors for treatment of PTSD and depression. Fewer than half of the patients received same-day mental evaluations while others had to wait as long as two months for a counseling session.

But wait, there’s more.  A questioning attempt at cover up in an email from a high ranking VA official–which begins with an imperative for quiet: The AP notes:

“Shhh!” began a Feb. 13, 2008, e-mail from Dr. Ira Katz, a VA deputy chief. “Our suicide prevention coordinators are identifying about 1,000 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?”

Katz wrote in another e-mail that 18 veterans kill themselves daily on average.

And then, an attempt to have VA counselors purposefully misdiagnose. AP reports

After the trial another e-mail surfaced that was written by VA psychologist Norma Perez suggesting that counselors in Texas make a point to diagnose fewer post-traumatic stress disorder cases. The veterans’ lawyers argued that e-mail showed the VA’s unwillingness to properly treat mental health issues.

Judge Stephen Reinhardt wrote for the court:

“No more veterans should be compelled to agonize or perish while the government fails to perform its obligations. Having chosen to honor and provide for our veterans by guaranteeing them the mental health care and other critical benefits to which they are entitled, the government may not deprive them of that support through unchallengeable and interminable delays.”

On Memorial Day we rightly honor our dead. But let’s not forget the sacrifices of the living– or our part of the bargain.

Lingering Questions about Mild Traumatic Brain Injury: A Medical Research Priority

For anyone who missed it, I highly recommend the eye opening series NPR has been running this week, reported by T. Christian Miller and Daniel Zwerdling, on the military’s failure to diagnose and treat soldiers with mild traumatic brain injury, defined by the Department of Defense as a blow or jolt to the head that results in a brief change in mental status or consciousness.

As Miller and Zwerdling explain, “[b]etter armor and battlefield medicine mean troops survive explosions that would have killed an earlier generation. But blast waves from roadside bombs, insurgents’ most common weapon, can still damage the brain.  The shockwaves can pass through helmets, skulls and through the brain, damaging its cells and circuits in ways that are still not fully understood. Then, secondary trauma can follow, such as sending a soldier tumbling inside a vehicle or hurling into a wall, shaking the brain against the skull.”  While most sufferers of mild traumatic brain injury make a full recovery, some — termed the “miserable minority” — experience a devastating array of chronic, disabling symptoms, including balance issues, dizziness, headaches, memory and reasoning deficits, and vertigo.  Among Miller and Zwerdling’s findings are that “[w]ithout diagnosis and official documentation [a distinct possibility given the weaknesses of the diagnostic tests used and the fact that handheld recordkeeping devices fail and paper records are burned] soldiers with head wounds have had to battle for appropriate treatment.”

Complicating matters is a lingering controversy over what the appropriate treatment is for mild traumatic brain injury.  In a 2009 opinion piece in the New England Journal of Medicine, Charles Hoge — a retired Army psychiatrist whom Miller and Zwerdling note is a high-level advisor to Lt. Gen. Eric Schoomaker, the Army’s most senior medical officer — argued that (1) there are no validated diagnostic criteria for clinicians to use in diagnosing mild traumatic brain injury, (2) the physical, neurocognitive, and behavioral symptoms believed to be associated with mild traumatic brain injury are more strongly associated with post-traumatic stress disorder and depression, and (3) that misattributing “postwar health conditions that have been described for centuries” to mild traumatic brain injury could result in “a failure to address underlying conditions (e.g., depression, PTSD, or substance abuse), the use of unproven rehabilitation procedures, and the prescribing of medications for nonapproved indications (e.g., an atypical antipsychotic for sleep).”  On the other hand, Miller and Zwerdling report that “[a]n increasing number of brain-injury specialists say the best way to treat patients with lasting symptoms is to get them into cognitive rehabilitation therapy as soon as possible. That was the consensus recommendation of 50 civilian and military experts gathered by the Pentagon in 2009 to discuss how to treat soldiers.”

Given the high number of veterans of the wars in Iraq and Afghanistan who are affected, resolving the debate over the diagnosis and treatment of mild traumatic brain injury is a medical research priority of the highest order.  Miller and Zwerdling quote Congressman Bill Pascrell (D-NJ) as follows: “We are not doing service to our bravest.  There needs to be a sense of urgency on this issue.”

Veterans, Health Care and the VA

Consider this a follow-up to my Memorial Day post on Veterans & Health Care. There’s an interesting article over at GoozNews regarding health care for veterans at the VA. Goozner writes:

Journalist Phil Longman at the New American Foundation recently updated his book “Best Care Anywhere,” which documents the 1990s rejuvenation of the Veterans Administration’s health care system. Between editions, the wars in Iraq and Afghanistan placed strains on the VA not seen since Vietnam. Here’s his thoughts on the current state of the system, and the lessons its transformation holds for other delivery systems in the U.S.

How does contact with the VA healthcare system compare in terms of
medical outcomes for its patients? How about in other measures of
quality?

In study after study published in peer‐reviewed journals, the VA beats other health care providers on virtually every measure of quality. These include patient safety, adherence to the protocols of evidence medicine, integration of care, cost‐effectiveness, and patient satisfaction. The VA is also on the leading edge of medical research, due to its close affiliation with the nation’s leading medical schools, where many VA doctors have faculty positions. The VA has its problems, but compared to those found elsewhere in the U.S. health care system, it offers “Best Care Anywhere.”

Read more

Veterans & Health Care

As we come upon Memorial Day, it is fitting that we take a moment to consider health care and veterans. We are, after all, a Nation at war. And we have been at war now for closing in on a decade; the casualties mount. As of May 28, 2010 the Department of Defense official number for American deaths is 5,480. My own research experience with official DoD representations in Seton Hall Law’s world renowned GTMO Reports leaves me somewhat skeptical as to the numbers (I cannot tell, for instance, whether post-service and/or inactive reserve veteran suicides are included in this number, but suspect they are not: “There is no epidemic in suicide in VA,” Dr. Ira Katz, the VA’s head of Mental Health told CBS News in November. “But in this e-mail to his top media adviser, written two months ago, Katz appears to be saying something very different, stating: ‘Our suicide prevention coordinators are identifying about 1,000 suicide attempts per month among veterans we see in our medical facilities’” ). Having said that, as in the GTMO reports, we’ll take the government at its word. Not counting civilian contractors, in addition to 5,480 deaths, 37,865 are said to have been wounded. The ratio of wounds to death is approximately 7 to 1.

Such a high ratio of wounded to deaths is a feature of advancing medical technology. More of the injured are kept alive. A quick look at the ratios of deaths to wounded in other American wars witnesses a trend capped off with a precipitous jump.

In modern warfare, through advances in medical technology, more lives are saved, more of the critically injured are kept alive; but it is also true that many of those lives saved have been affected by wartime trauma in often serious and debilitating ways. Many have lost limbs and sight and hearing, experienced traumatic brain injuries, and suffer from grave psychological harm. They do and will require care. We, as a Nation, committed to that care the moment we sent those men and women into harm’s way.

In his Memorial Day address, Secretary of Veterans Affairs, Edward K. Shineski, offered the following quote:

“Poor is the Nation that has no heroes, but beggared is the Nation that has and forgets them.”

This Memorial Day, as we honor those who gave their all in service of their country, let’s not forget our end of the bargain. The care for the families of the fallen and of disabled veterans is perhaps the most sacred contract of all. Men and women who risk their lives for their country have every right to expect that that country will help take care of them –and their families–to the utmost of its ability in the event that they are in some way hurt, disabled or deceased. We simply cannot ask of them to serve and risk if we are not there to help mend.

On May 5, 2005 President Barack Obama signed into law the Caregivers and Veterans Omnibus Health Services Act.

At signing the President said the following:

With this legislation, we’re expanding mental health counseling and services for our veterans from Afghanistan and Iraq, including our National Guardsmen and Reservists. We’re authorizing the VA to utilize hospitals and clinics outside the VA system to serve more wounded warriors like Ted with traumatic brain injury.

We’re increasing support to veterans in rural areas, with the transportation and housing they need to reach VA hospitals and clinics. We’re expanding and improving health care for our women’s veterans, to meet their unique needs, including maternity care for newborn children. And we’ll launch a pilot program to provide child care for veterans receiving intensive medical care.
We’re eliminating co-pays for veterans who are catastrophically disabled. And we’re expanding support to homeless veterans, because in the United States of America, no one who has served this nation in uniform should ever be living on the streets.

Finally, this legislation marks a major step forward in America’s commitment to families and caregivers who tend to our wounded warriors every day. They’re spouses like Sarah. They’re parents, once again caring for their sons and daughters. Sometimes they’re children helping to take care of their mom or dad.

These caregivers put their own lives on hold, their own careers and dreams aside, to care for a loved one. They do it every day, often around the clock. As Sarah can tell you, it’s hard physically and it’s hard emotionally. It’s certainly hard financially. And these tireless caregivers shouldn’t have to do it alone. As of today, they’ll be getting more of the help that they need.

If you’re like Sarah — and caring for a severely injured veteran from Afghanistan or Iraq — you’ll receive a stipend and other assistance, including lodging when you travel for your loved one’s treatment. If you need training to provide specialized services, you’ll get it. If you need counseling, you’ll receive it. If you don’t have health insurance, it will be provided. And if you need a break, it will be arranged — up to 30 days of respite care each year.

So today is a victory for all the veterans’ organizations who fought for this legislation. It’s a tribute to those who led the fight in Congress, including Senator and World War II vet Danny Akaka, and Senator Richard Burr; and in the House, Representatives Mike Michaud and Bob Filner. And I thank all the members of Congress who are joining us here today.

This law looks like a good step in the right direction. I’ve been highly critical in the past regarding the politics first agenda of a bickering and often, it seems, obstructionist Congress. Such was not the case here. As politics has absolutely no place in this discussion, I commend all involved for a job well done.

4/05/05 - Birgit Smith caresses the headstone of her late husband Army Sgt. 1st Class Paul Smith after it was unveiled at Arlington Cemetery on April 5, 2005. Sgt. Smith was posthumously awarded the Medal of Honor by President George W. Bush in ceremonies at the White House, Apr. 4, 2005. Sgt. Smith, a combat engineer, was killed defending his soldiers on April 4, 2003, in the Battle for the Baghdad Airport. Smith commandeered a .50-caliber machine gun and engaged the enemy force, continuing to fire until theenemy attack was repelled and he was mortally wounded. Smith is the first to receive the military's highest award for actions in support of Operation Iraqi Freedom. DoD photograph by Staff Sgt. Reeba Critser, U.S. Army. (Released)

But if this legislation fails to make available needed services to veterans and their families, and you have experienced such personally, please consider Health Reform Watch open to you as a forum to make systemic shortcomings known to a wider audience.  I can be reached at michael.ricciardelli@shu.edu and I will work with you to publish your thoughts and experience as an article.

May God bless our troops and the families of those who have served.