VA straining to treat post-traumatic stress
Seattle Times staff reporter
Definition: Post-traumatic stress disorder, or PTSD, is a psychiatric disorder that can occur after the experience or witnessing of life-threatening events such as military combat.
Symptoms: May include sleeplessness, nightmares, emotional numbness, irritability, avoidance of situations that trigger memories of a stressful experience, feelings of jumpiness or superalertness.
Physical changes: Dr. Thomas Horvath, a VA psychiatrist at the agency's Houston Medical Center, said PTSD can be "a persistent dangerous biological condition that maims the body as well the mind, the brain as well as social relationship." Horvath said that VA and university research indicates that it can trigger biochemical changes that persist for decades and result in higher rates of cardiovascular disease.
How to get help
Places for veterans to visit or call:
VA Puget Sound Health Care System: 800-329-8387
Deployment clinic for returning veterans: 206-764-2636
1660 S. Columbian Way
American Lake Division
9600 Veterans Drive, Tacoma
Seattle Vet Center
2030 9th Ave., Suite 210, Seattle
King County Veteran's Program
123 Third Ave. S., Suite 300, Seattle
Washington State Department of Veterans Affairs hotline: 800-562-2308
Web sites to visit:
Washington Department of Veterans Affairs PTSD programs: www.dva.wa.gov/Benefits/PTSD.htm
National Center for PTSD: www.ncptsd.va.gov/
ABERDEEN — During counseling, Vietnam veteran Rod Chenoweth always sits in the same place — a blue fabric couch carefully positioned in a corner to give his body the protective cover of a side and rear wall as he talks about his life.
He recounts an argument that left him seething in anger. He talks about an evening flashback to the grenade that wounded him in the leg and killed his 19-year-old buddy.
Chenoweth says the therapy, paid for by the Department of Veterans Affairs (VA), has helped pull him back from thoughts of suicide and other self-destructive acts in a life scarred by post-traumatic stress disorder (PTSD) — a war injury that ranks among the most common and the most difficult to heal.
Starting in July, Chenoweth's sessions with Aberdeen therapist Jack Dutro have been reduced from twice to once a month, a cut that comes as thousands of Iraq war veterans join those of previous wars in seeking treatment from the strained VA.
"I can understand that the new veterans need to be dealt with," said Chenoweth, 56. "But it's going to be tough. Jack has been a lifesaver."
The agency is required by law to take care of the war wounds of all combat veterans.
But the agency's PTSD experts, in a report delivered last fall to Congress, warned that the VA "does not have sufficient capacity to meet the needs of new combat veterans while still providing for the veterans of past wars."
Internal reports show the VA's mental-health network has been frayed by years of staffing cuts and budgets that failed to keep pace with the growth in patients.
According to an internal review of the agency's budget, delivered to Congress in September, problems have been years in the making:
• Between 1996 and 2003, annual spending for treatment of the serious mentally ill increased from $2.16 billion to $2.4 billion. But when those budgets were adjusted for inflation in medical costs — the increased costs of salaries and services — spending in 2003 was actually $630 million below the 1996 level. Meanwhile, the number of veterans seeking those services climbed by 11 percent.
• During the same period, overall mental-health staffing for the seriously ill declined by 31 percent.
• Drug and alcohol treatment for the seriously mentally ill, often a critical part of the program for those seeking PTSD therapy, has been the hardest hit. Annual funding, adjusted for inflation, dropped by 54 percent nationwide between 1996 and 2003.
"It's been a perfect storm of rising needs and tight resources," said Tom Schumacher, who directs a Washington state effort to assist PTSD veterans.
The Northwest VA network has fared better than most of the nation, avoiding many of the staff cuts that hit other regions.
But the four-state region that includes Washington, Oregon, Idaho and Alaska also is one of the busiest hubs of treatment. The PTSD patient load alone has increased from 3,194 in 1996 to 4,671 in 2004.
To help manage the crunch, the VA Puget Sound Health Care System earlier this year imposed new restrictions on PTSD therapy for veterans who already have undergone at least six months of treatment.
The VA guidelines now call for no more than once-a-month individual therapy, or twice-a-month group therapy. Those apply to Puget Sound-area clinics and a network of VA-funded private therapists who work around the state.
Dr. Miles McFall, director of PTSD programs at the VA Puget Sound, said that more frequent therapy does not necessarily help, and those in trouble are welcome to check into an inpatient VA hospital clinic.
"Even if money was not an issue, this is what we should be doing," he said. "We care about our Vietnam vets. We're not going to turn our backs on them."
Other therapists say while some veterans can handle less treatment, the more unstable ones may suffer setbacks.
"Some of them are devastated and feel like they have been abandoned one more time," said Jim Shoop, a Mount Vernon counselor. He said his office is reducing service to more than 50 vets with PTSD.
A lifetime of trouble
Soldiers have always suffered from the mental wounds of war.
But the diagnosis of post-traumatic stress disorder only emerged in 1979 in the aftermath of the Vietnam War as tens of thousands of distraught veterans, suffering from flashbacks, sleeplessness, anger and other symptoms, poured into VA hospitals.
By 1988, the VA estimated that 479,000 vets suffered PTSD symptoms.
For many of these vets, PTSD has meant a lifetime of trouble.
Chenoweth served with the Marines in Vietnam from 1968 to 1969, when the U.S. sustained some of its heaviest casualties. He turned 18 just before boarding the plane to Asia and soon found himself fighting in villages where anybody could be the enemy.
Chenoweth ended his tour of duty in a psychiatric hospital in Oakland. But it wasn't until the late '80s — after more than a dozen failed jobs, several more hospital stays and two broken marriages — that he was diagnosed with PTSD.
"The killing doesn't stop," Chenoweth said. "You taste it. You smell it. And you feel it. It uses all your senses."
The numbers of older veterans seeking mental-health treatment surged again in recent years, as new wars unfolding on television in Iraq and Afghanistan added to their stress.
That, coupled with the influx of soldiers returning from Iraq, has ratcheted up pressure on the VA system.
More become eligible
In the '90s, the VA went through a dramatic overhaul, moving away from a centralized hospital system as hundreds of new clinics opened up around the country. Congress also loosened eligibility requirements, so that more vets qualified for services, and increased the agency's overall health-care budget from $17 billion to more than $28 billion.
The transformation was lauded as a great success in an Annals of Internal Medicine article last year.
But mental-health services often lost out as regional administrators juggled budgets to pay for soaring caseloads, new services and pricey new drugs.
Managers also sometimes balked at pouring money into treatment for illnesses of the mind when compared with physical illnesses that are often easier to measure and cure.
"I regret to report that there are stigmas in the VA about the mentally ill," Thomas Horvath, a psychiatrist who serves as chief of staff at the agency's Houston medical center, told Congress in 2004.
"In this, we may be no worse than the rest of health care. VA needs to do better."
Sen. Patty Murray, who worked as a college intern in the Seattle VA psychiatric ward, has helped lead the congressional effort to boost funding for VA programs, including mental health.
"I have talked to soldiers who are returning, and a number of them say 'my marriage is much more difficult ... I am having trouble getting my head back in to work,'" said Murray, "It's the beginning of trouble. And the fallout from this 10, 15, 20 years from now is tremendous."
The issue of VA funding has been rife with partisan politics recently.
Murray, a Democrat, initially was rebuffed by the Republican majority in an effort to gain emergency funding for VA medical services.
VA administrators in June acknowledged a roughly $1 billion budget shortfall, prompting Senate Republicans to do an about-face and work with Murray to boost funding.
Congress is expected to approve an additional $975 million to $1.5 billion to help dig the agency out of the hole for this fiscal year.
If this money is equally divided within the agency, mental health would receive less than $300 million.
This emergency cash would fall short of shoring up the system.
To fully meet the needs of the seriously mentally ill, the VA would require an infusion of as much as $1.6 billion, according to a draft of the agency's strategic plan.
That estimate didn't assess the added costs of treating new Iraq veterans.
"Just good-enough care"
There is no fixed formula for treating PTSD.
Instead, the VA offers general guidelines for addressing the illness. This treatment may involve drugs that aid sleep and reduce anxiety or help fight depression. It may include classes in anger management and other coping skills.
Finally, there is therapy, which often enables the vet to recount and come to terms with combat experiences.
Some patients may benefit from just a few classes and counseling sessions. Others with chronic PTSD attend sessions for months or years. Some patients do fine in group; others do much better with individual therapy. But as budgets have shrunk, some VA mental-health workers say, they have been pressured to treat more people in less time.
In Portland, the VA mental-health clinic staff by January had shrunk by 25 percent due to budget freezes, according to an internal staff newsletter. The newsletter described the Portland program as "unquestionably underfunded."
Therapists in Portland earlier this year were asked to consider cutting individual sessions from 50 minutes to 30 minutes, and lengthen the time between visits, according to an internal VA memorandum.
They say they were also asked to consider dropping some patients altogether, after refilling their prescriptions and referring them back to primary-care physicians.
Megan Streight, a VA spokeswoman, said the Portland VA does not expect staff to cut back services for patients who need therapy. She also said that some jobs have been filled. "We are confident that veterans continue to receive high-quality mental-health care," Streight said.
But several Portland VA therapists expressed worries that expanding caseloads combined with a smaller staff threaten the quality of some care. All requested anonymity, concerned that speaking publicly could cost them their jobs.
These therapists say they have been asked to try to complete treatment of new patients in 10 or fewer counseling sessions, even those recently returned from Iraq. Some of these vets arrive at the VA with marriages already in turmoil or broken. Others have isolated themselves at home, and balked at returning to work. One, who came in after beating his wife, had penned a suicide note.
One therapist said she has been reluctant to stick several troubled Iraq vets in first-step classes of 20 or more that teach coping skills. But her own caseload already runs to several hundred patients, so she has no openings for more one-on-one counseling. To make room for the Iraq veterans, she asks some of her older veterans to come less often.
"But what kind of message is that — that you're not as important as the new guys coming in," she said.
The therapist says she needed to get used to the short-staffed conditions.
"I was told that there needed to be some changes made at the hospital due to the lack of resources, and I was going to have to adjust my thinking," said the therapist. "You need to give 'just good-enough care.' "
The Puget Sound VA's mental-health programs also have been caught in the regionwide budget crunch, which included a partial hiring freeze that replaces only one worker for every five who leave their jobs.
"We have to make the best use of resources that we can," said John Park, Puget Sound VA's director of health-care planning, at an April 30 community meeting on mental health sponsored by U.S. Rep. Jim McDermott, D-Seattle. "You can only cut so much of the budget before things get dicey."
Sharing hopes and fears
Most PTSD patients in Puget Sound are seen in a specialized program that includes clinics and in-patient care. The program has a national reputation for research and treatment.
McFall, who heads that program, says he was able to snag a special grant that allows him to add several more positions to the 21-person clinic staff in the months ahead.
"I want to say that the sky isn't falling. We can get every Iraq veteran an appointment within a week," he said.
But the local VA policy to limit treatment for patients who have had six months of therapy has caused a backlash. The loudest protests have come from the state network of private-practice therapists who are paid by the VA to treat vets with chronic PTSD.
"I believe that in order to do long-term recovery, I have to do a lot of work," said Steve Akers, a Vietnam vet who is an Everett therapist. Akers offers weekly group sessions, as well as individual counseling.
At the group sessions, the vets spend 90 minutes sharing hopes, fears and a few laughs before ending with a healing circle where they all grasp hands on a wooden staff known as a "talking stick."
One veteran of both the Vietnam and Gulf wars still lives on a razor's edge. At his house, he has installed a perimeter trip wire that sounds an alarm to warn of intruders, and outside lights that can turn midnight into day along a 400-foot driveway. The house is full of loaded guns, weapons his wife fears might be inadvertently used in a combat flashback.
"She doesn't want the one under the bed, and in every room," the vet said during the session. "But I've got to live with myself. I don't feel secure."
Akers opted to take things one step at a time, focusing on a pistol in a bedroom drawer.
"So, at one point, would you be willing to put the pistol in one drawer, and the ammo in another? You'll still have your safety factor but have to think to react."
"I could do that," the vet responded. "But it will be really hard for me. When they break in that door, they're only going to do it once."
Under the new VA policy, the group's weekly meetings will be reduced from twice a month to once a month.
Among the vets, that's the subject of much bitter debate.
"I try not to take it personally," said the veteran with the loaded gun. "There is an intimacy here that is incredible. I want to save it. And the fear, you know, is that it's not going to last."
Hal Bernton: or firstname.lastname@example.org
Seattle Times researcher David Turim contributed to this story.
Copyright © 2005 The Seattle Times Company