Table Of ContentS. Hrg. 103-314
VA MENTAL HEALTH PROGRAMS
Y 4. V 64/4: S. HRG. 103-314
UA Hental Health Prograns> S. Hrg....
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED THIRD CONGRESS
FIRST SESSION
AUGUST 3, 1993
Printed for the use of the Committee on Veterans' Affairs
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U.S. GOVERNMENT PRINTING OFFICE
74-782CC WASHINGTON : 1993
ForsalebytheU.S.GovernmentPrintingOffice
SuperintendentofDocuments,CongressionalSalesOffice,Washington,DC 20402
ISBN 0-16-043320-7
S. Hrg. 103-314
VA MENTAL HEALTH PROGRAMS
Y 4, V 64/4: S, HRG. 103-314
UA Hental Health Prograns/ S. Hrg....
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED THIRD CONGRESS
FIRST SESSION
AUGUST 3, 1993
Printed for the use of the Committee on Veterans' Affairs
"''
^j:.
U.S. GOVERNMENTT PRINTING OFFICE
74-782CC WASHINGTON : 1993
ForsalebytheU.S.GovernmentPrintingOffice
SuperintendentofDocuments,CongressionalSalesOffice,Washington,DC 20402
ISBN 0-16-043320-7
COMMITTEE ON VETERANS' AFFAIRS
JOHN D. ROCKEFELLER IV, West Virginia, Chairman
DENNIS DeCONCINI, Arizona FRANK H. MURKOWSKI. Alaska
GEORGE J. MITCHELL, Maine STROM THURMOND, South Carolina
BOB GRAHAM, Florida ALAN K. SIMPSON, Wyoming
DANIEL K. AKAKA, Hawaii ARLEN SPECTER, Pennsylvania
THOMAS A. DASCHLE, South Dakota JAMES M. JEFFORDS, Vermont
BEN NIGHTHORSE CAMPBELL, Colorado
JlM GOTTUEB, ChiefCounsel/StaffDirector
John H. Moseman, Minority ChiefCounsel/StaffDirector
(II)
^V«
CONTENTS
AUGUST 3, 1993
Page
VAMentalHealth Programs 1
STATEMENTS BY COMMITTEE MEMBERS
ChairmanJohn D. RockefellerIV 1
Senator Daniel K. Akaka 31
SenatorAlan K. Simpson 18
Prepared statement ofSenatorSimpson 81
WITNESSES
Angell, Dr. Susan A., Regional Manager, Readjustment Counseling Service,
PacificWestRegion, San Francisco 49
Prepared statementofDr. Angell 119
Balenquah, Clifford, Counselor, Readjustment Counseling Service, Hopi Res-
ervation, Prescott, ArizonaVet Center 64
Prepared statementofMr. Balenquah 121
Batres, Dr. Alfonso R., Regional Manager, Readjustment Counseling Service,
Western—Mountain Region 4A, Denver Vet Center, and ChiefClinical Field
Manager West 46
Prepared statementofDr. Batres 117
Chamey, Dr. Dennis, Chief of Psychiatry, West Haven VA Medical Center
andiT^fessorofPsychiatry andAssociate Chairman forResearch in Psychi-
atry,Yale University School ofMedicine 3
Prepared statement ofDr. Chamey 84
Doyle, Dr. Daniel G., Team Leader, Richmond, VirginiaVet Center 67
Prepared statementofDr. Doyle 122
Friedman, Dr. Matthew J., Executive Director, National Center for Post-
TraumaticStress Disorder, White RiverJunction, Vermont 4
Prepared statement ofDr. Friedman 84
Gelsomino, Dr. Joe, Regional Manager, Southeast Region, Readjustment
CounselingService, Bay Pines, F'lorida 48
Prepared statement ofDr. Gelsomino 118
Gober, Hon. Hershel, Deputy Secretary of Veterans Affairs, accompanied
by Mary Lou Keener, General Counsel; C. Wayne Hawkins, Deputy Chief
Medical Director; Dr. ArthurS. Blank, Jr., Director, Readjustment Counsel-
ing Service; and Dr. Paul Errera, Director, Mental Health and Behavioral
Sciences Service 24
Prepared statementofMr. Gober 99
Gorman, David W., Assistant National Legislative Director for Medical Af-
fairs, DisabledAmerican Veterans 40
Prepared statement ofMr. Gorman 109
Grandison, Terry, Associate Legislative Director, ParalyzedVeterans ofAmer-
ica 42
Prepared statement ofMr. Grandison 112
Greer, Richard T., Member, Science Review Committee, National Alliance
fortheMentally 111 11
Prepared statement ofMr. Greer 92
Lipkin, Dr. John O., Clinical ProfessorofPsychiatry, University ofMaryland,
and ChiefofStaff, Perry Point VA Medical Center, on behalfofthe Amer-
icanPsychiatricAssociation 5
Prepared statementofDr. Lipkin 85
(III)
IV
Page
Loy, Michael, MSW, Team Leader, Reno, Nevada Vet Center 66
Prepared statement ofMr. Loy .—• 122
Magill, James N., Director, National Legislative Service, Veterans ofForeign
Wars ofthe UnitedStates 43
Prepared statementofMr. Magill 115
Molnar, Stephen T., Team Leader, Honolulu, Hawaii Vet Center 63
Prepared statementofMr. Molnar 120
O'Brien, Dr. Charles P., ChiefofPsychiatry, PhiladelphiaVAMedical Center 8
Prepared statementofDr. O'Brien 92
Poa^Clyde, Team Leader, GrandRapids, MichiganVet Center 68
Prepared statementofMr. Poag 123
Sutker, Dr. Patricia B., Chief, Psychology Service, New Orleans VA Medical
Center 7
Prepared statement ofDr. Sutker 91
Vitikacs, John R., Assistant Director, National Veterans Afiairs andRehabili-
tation Commission, TheAmerican Legion 39
Prepared statementofMr. Vitikacs 105
Weitz, Dr. William A., Team Leader, Readjustment Counseling Service, Palm
Beach, Florida Vet Center 49
Prepared statementofDr. Weitz 119
APPENDDC
Statements:
Brinck, Michael, National Legislative Director,AMVETS 123
Crandell, William F., LegislativeAdvocate, VietnamVeterans ofAmerica 125
Kaptur, Congresswoman Marcy 82
Written questions andthe responses:
Chairman Rockefellerto:
Friedman, Dr. MatthewJ 130
Gober, Hon. Hershel 148
Greer, RichardT 156
Lipkin, Dr. John O 159
O'Brien, Dr. Charles P 165
ParalyzedVeterans ofAmerica 153
Sutker, Dr. Patricia.B 169
The American Legion 173
SenatorAkaka to:
Angell, Dr. Susan A 176
Gelsomino, Dr. Joe 182
Gober, Hon. Hershel 186
Molnar, Stephen T 190
Weitz, Dr. WilliamA 194
SenatorMurkowski to:
DepartmentofVeteransAffairs 200
VA MENTAL HEALTH PROGRAMS
TUESDAY, AUGUST 3, 1993
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 11:05 a.m., in room
SR-418, Russell Senate Office Building, Hon. John D. Rockefeller
IV (Chairman ofthe Committee) presiding.
Present: Senators Rockefeller, Akaka, and Simpson.
OPENING STATEMENT OF CHAIRMAN ROCKEFELLER
Chairman Rockefeller. Good morning, everyone. I want to
apologize again. For those who don't know, we just had four or five
consecutive votes, which caused us to be late, one of which, of
course, was for Ruth Bader Ginsberg, and others. So I apologize,
particularly to those who have come from out oftown.
There are a lot of our veterans who continue to carry the burden
of post-traumatic stress disorder and other mental illnesses; one
could characterize them as our forgotten veterans. These are war-
riors who have not participated in welcoming ceremonies at home.
Rather, they are our brothers and sisters who have come home to
lives that are broken and fragmented. Today's hearing will focus on
what the VA does to meet the mental health needs of these forgot-
ten heroes and what we can do to make these efforts more effec-
tive.
At this very moment, there are more than 5,000 mentally ill vet-
erans who have been in VA hospitals for more than 1 year; more
than 30,000 who have been hospitalized for more than 45 days
within the past 2 years; and more than one-half million who have
been hospitalized for shorter periods of time or treated as out-
patients. They need and deserve our help to get good treatment
that will minimize their problems and enable them to lead as pro-
ductive lives as possible.
These veterans often lack the power to press for the services they
need. There is no massive lobbying effort on their behalf; indeed,
among those who work for health across our country, whether it be
in the Department of Veterans Affairs or in our national health
care reform process, mental health is often brushed aside. They are
wrong. While there are some very dedicated professionals and fam-
ily members and friends who have worked hard to help these veter-
ans, individual efforts on their own don't do enough. All too often
our Nation, in my judgment, has failed to address their complex
needs and provide the comprehensive services that they require
(1)
and, indeed, that they have earned. VA can and must take a lead-
ership role in all ofthis.
It is endlessly important for people to understand that the De-
partment of Veterans Affairs is the largest provider of mental
health services in the United States of America. As such, it pro-
vides a perfect setting for large-scale, multisite research studies
that can yield significant and valid results that will help people.
This has enormous implications for the entire Nation. However,
while more than 40 percent ofVA patients suffer with some degree
ofmental illness, less than 12 percent ofVA's research budget goes
to improving VA mental health services. More funds must be de-
voted to mental health research to remedy this clear imbalance.
As the veterans' population ages, older veterans constitute an in-
creasing proportion of the mentally ill veterans. VA has an oppor-
tunity here to become a leader in geriatric psychiatry, but to date,
VA officials have done little to foster and encourage research and
clinical care in this area. By missing the opportunity to actively en-
gage in research, VA is also shirking its duty to its veterans' popu-
lation.
Today we will examine two proposed bills. One would create so-
called centers of excellence for mental health research. The goal of
these centers would be to increase the basic knowledge of mental
illness and improve the quality ofcare for the mentally ill.
The second bill we will review, S. 1226, is legislation introduced
by my good friend. Senator Akaka, who will be here shortly. His
legislation is a very thoughtful attempt to improve the services of-
fered to veterans through the Department's Readjustment Counsel-
ing Service, more commonly known as Vet Centers. I know that
Senator Akaka has spent a lot of time working on this legislation,
and I intend for the Committee to act on his legislation, hopefully
very soon.
Our witness—es include Deputy Secret—ary of Veterans Affairs,
Hershel Gober we are honored by that and other VA officials,
VA mental health professionals, and representatives of veterans'
service organizations and other organizations concerned about VA
mental health services. I'm very pleased that they are all with us
today.
I was going to yield to other Senators for comments, but that
would be awkward. [Laughter.]
Originally, we had hoped to have Representative Marcy Kaptur
from Ohio with us here this morning, but she was not able to at-
tend. However, because she cares about this subject, we will make
her written statement a matter ofthe record.
[The prepared statement ofMs. Kaptur appears on p. 82.]
Chairman Rockefeller. Now, we have an extraordinary first
panel. We have an extraordinary second panel, too, Hershel, but
VA
the first panel is great. It consists of medical center personnel
and representatives from two associations. We have Dr. Dennis
Charney, Chief of the National Schizophrenia Biological Research
Center at West Haven VA Medical Center; Dr. Matt Friedman, Ex-
ecutive Director o—f the National Center for PTSD, White River
Junction, Vermont that is called coming some distance; Dr. John
Lipkin, Chief of Staff at the Perry Point VA Medical Center, rep-
resenting the American Psychiatric Association; Dr. Chuck O'Brien,
VA
Director of Psychiatric Services, Philadelphia Medical Center;
Dr. Pat Sutker, ChiefPs—ychologist, PTSD Clinical Team, New Orle-
ans VA Medical Center that's called distance; and Dick Greer, Di-
rector, National Alliance for the Mentally 111.
Let me remind each of our witness that we have your written
statements, that they are part of the record, and that I am going
to limit your oral remarks to 5 minutes. Some ofyou will be accus-
tomed to this and some of you will not. If you're not, it's difficult,
but please adjust to it, because I will abide by it.
Dr. Charney, maybe we can begin with you, sir.
STATEMENT OF DR. DENNIS CHARNEY, CHIEF OF PSYCHIA-
TRY, WEST HAVEN VA MEDICAL CENTER, AND PROFESSOR
OF PSYCHIATRY AND ASSOCIATE CHAIRMAN FOR RE-
SEARCH IN PSYCHIATRY, YALE UNIVERSITY SCHOOL OF
MEDICINE
Dr. Charney. Thank you very much. Currently, I am Chief of
Psychiatry at the VA Medical Center in West Haven, Connecticut.
I'm also Professor of Psychiatry and Associate Chairman for Re-
search in Psychiatry at the Yale University School ofMedicine.
The psychiatry service which I direct at West Haven is a large
and complex one, and, in fact, it raises many of the issues that
you've begun to address here today. We have 188 psychiatric inpa-
tient beds, outpatient clinics with a workload of over 60,000 visits
per year, and specialized treatment programs for patients with
schizophrenia, post-traumatic stress disorder, depression, and sub-
stance abuse. Further, we have been developing a variety of psy-
chiatric rehabilitation programs designed to help patients with
chronic mental illness obtain adequate housing and return to pro-
ductive vocational pursuits.
The Psychiatric Research Program at our VA is among the larg-
est in the VA health care system. For example, we are the site for
the Clinical Neuroscience Division of the National Center for Post-
Traumatic Stress Disorder, of which Dr. Friedman is the overall di-
rector. We have one of the two VA-funded Alcohol Biological Re-
search Centers and one of the three VA-funded Schizophrenia Bio-
logical Research Centers. In addition, we house the principal site
for a VA-funded 15-hospital, multicenter study designed to deter-
mine the long-term efficacy of a new antipsychotic drug called
Clozapene.
Most of the psychiatrists at our medical center are not only ex-
pert clinicians dedicated to care of the veterans, but are also VA,
NIMH, NIDA, and lAAA-funded investigators committed to the dis-
covery of new and improved treatments for our patients. In fact,
it's this characteristic ofapplied research that in many ways distin-
guishes the research at VA medical centers. That is, the research
is designed to improve treatment rather directly.
The psychiatrists and psychologists at our medical center are
also, in general, full-time faculty members at the Yale University
School of Medicine and, as such, are devoted to the education of
Yale medical students and psychiatric residents. Thus, in view of
my own personal clinical care research and educational responsibil-
VA
ities in the health care system, I appreciate the opportunity to
discuss with the Committee issues related to VA clinical programs
for the chronically mentally ill, VA-funded psychiatric research ini-
tiatives, and the importance of maintaining strong and mutually
beneficial medical school affiliations.
Thank you very much.
[The prepared statement ofDr. Chamey appears on p. 84.]
Chairman Rockefeller. Thank you, sir, very much.
Dr. Friedman, you've already been referred to by the first wit-
ness. We welcome your testimony, sir.
STATEMENT OF DR. MATTHEW J. FRIEDMAN, EXECUTIVE DI-
RECTOR, NATIONAL CENTER FOR POST-TRAUMATIC STRESS
DISORDER, WHITE RIVERJUNCTION, VERMONT
Dr. Friedman. Thank you very much. My name is Matt Fried-
man. I am the Executive Director of the National Center for Post-
Traumatic Stress Disorder, and Professor of Psychiatry and Phar-
macology at Dartmouth Medical School.
The National Center for PTSD was mandated by the U.S. Con-
gress in 1984, and the current National Center has been in exist-
ence almost 4 years. During that period of time, we have estab-
lished ourselves, I think, as a world leader in research on the psy-
chological, psychophysiological, and neurobiological aspects of
PTSD. Our research, as Dr. Charney mentioned, who heads one of
our seven divisions, includes development of clinically relevant re-
search concerns, such as developing diagnostic assessment tools,
identifying biological markers, and testing different kinds of treat-
ments.
Although we have a core recurring budget that supports many of
our staffmembers, we depend very much on outside research fund-
ing, both VA and NIMH as well as private foundations, to carry out
the activities in which we have been engaged. I have furnished the
Committee with our annual reports, so you have a complete list of
the many research activities in which we have been engaged, as
well as a short list included in my previously submitted written
testimony.
In addition to research, the National Center is responsible for
providing education and support for the many VA PTSD programs,
both hospital-based and Vet Center programs. In that regard, we
have carried out a variety ofeducational and training activities, in-
cluding publications in journals, making formal presentations, pro-
viding on-site clinical training, providing consultation, mini-
residencies, teleconferences, et cetera.
In addition, one of the problems in the National Center is trying
to get the word out to the field, and we have two newsletters that
partly do that. We have a clinical newsletter with a circulation of
6,000 to VA and non-VA clinicians and we have the PTSD Research
Quarterly, which is distributed to 5,000 scholars and PTSD re-
searchers throughout the world.
What's been very interesting in the 4 years of running the Na-
tional Center is that when you run a national center, you have to
be responsive to the national needs, so our own agenda has fre-
quently been interrupted by major events, such as Operation
Desert Storm, in which we collaborated closely with the Depart-
ment of Defense, and a variety of natural disasters, such as the
Loma Prieta earthquake and the three hurricanes, Andrew, Iniki,
