FY 2010 Appropriations for Mental Health Research and Services for Veterans (Written Testimony)
Subcommittee on Military Construction & Veterans Affairs
Committee on Appropriations
U.S. House of Representatives
American Association for Geriatric Psychiatry
Testimony of the American Association for Geriatric Psychiatry for the Subcommittee on Military Construction & Veterans Affairs
Committee on Appropriations
U.S. House of Representatives
On Fiscal Year 2010 Appropriations for the Department of Veterans Affairs
The American Association for Geriatric Psychiatry (AAGP) is pleased to have the opportunity to testify on Fiscal Year (FY) 2010 appropriations for mental health research and services for veterans. AAGP is a professional organization dedicated to promoting the mental health and well being of older Americans and improving the care of those with late-life mental disorders. Our membership consists of approximately 2,000 geriatric psychiatrists as well as other health professionals who focus on the mental health problems faced by senior citizens.
Although we agree with others in the mental health community about the importance of Federal support for mental health research and treatment, AAGP brings a unique perspective to these issues because our members serve the older adult patient population.
We appreciate the Subcommittee’s support for the highest quality health care for our nation’s veterans and for the research necessary to advance the quality of their care. Our veterans put forth their lives for our nation, and they deserve access to quality health care.
The Challenge of Meeting the Mental Health Needs of the Aging Veteran Population
Of the nation’s 25.5 million veterans, nine million--approximately 35 percent–-served in World War II or the Korean War. Another eight million aging Vietnam era veterans will soon join this older cohort and will bring increased challenges to the VA, including increased cases of post-traumatic stress disorder (PTSD) and, perhaps, a higher burden of substance abuse. The VA must be able to provide the specialized mental health care that these older veterans will need.
Between the years 1990 and 2000, the number of veterans in the 45-54 year-old age group who received mental health services from the VA more than tripled. As the nation continues to pursue the wars in Iraq and Afghanistan, thousands of younger veterans will turn to the VA for the special care and services only it can provide. All of these individuals will swell the ranks of those who will ultimately require geriatric care.
However, the most rapid growth in demand during the last decade was among older veterans. During that time, there was a four-fold increase in the number of veterans aged 75-84 who received VA mental health services. This substantial increase in utilization is even more striking when one considers that research has revealed an ongoing problem with under-diagnosis of mental disorders in older age groups.
More than half a million veterans are 85 years of age or older, and the VA predicts that this oldest group will reach 1.2 million in 2010. Historically, as many as one-third of all veterans seeking care at the VA have received treatment for mental disorders; and research indicates that serious mental illnesses affect at least one-fifth of the veterans who use the VA health care system. In addition, those who are older often suffer from co-existing medical conditions such as heart disease, hypertension, diabetes, lung disease, debilitating arthritis, or other conditions. For these patients, treatment of their medical illnesses is often complicated by psychiatric disorders. Conversely, their psychiatric care is more complex because of the co-occurrence of medical illness, which commonly requires treatment with multiple medications. Thus, for older veterans with mental health problems, psychiatric treatment must be integrated and coordinated with their general medical care.
The increasing need for coordinated mental health and general health care services for rapidly growing numbers of older veterans demands adequate, ongoing funding for VA mental health services, training, and research to meet the needs of the aging veteran population.
Comprehensive, Integrated Mental Health and General Health Care for Aging Veterans
The AAGP is pleased that the Mental Health Enhancement Initiative (MHEI) has grown from $100 million when this special purpose fund was created in 2005, to $557 million in 2009. Through the MHEI, VA has ensured the availability of mental health staff to treat elderly veterans who receive their general health care through Home-Based Primary Care (HBPC) programs and in Community Living Centers (CLCs, previously known as Nursing Home Care Units). The integration of mental health services into primary care and related settings has made it easier for older veterans to access mental health care, and has improved the continuity of care for the complex problems of this population.
AAGP notes that it has been five years since the development of the VHA Uniform Mental Health Services Strategic Plan, and five years since the MHEI was made available to support that plan. AAGP looks forward to the time when the Mental Health Strategic Plan is fully implemented. However, it is anticipated that, after 2009, the MHEI will be rolled over into the Veterans Equitable Resource Allocation (VERA). While we believe VA’s intent is to maintain the enhancements described above, AAGP has concerns about VA’s ability to achieve full implementation of the Mental Health Strategic Plan without sustained, dedicated funding. We therefore urge Congress to enact safeguards to prevent diffusion of the ongoing support that is required to reach this goal. AAGP appreciates that there is an important existing safeguard in appropriations language that requires no less than $3.8 billion to be spent for mental health purposes and an additional $130 million in spending on programs for the homeless. However, further safeguards are necessary to ensure continuation of funding specifically dedicated to full implementation of the VHA Uniform Mental Health Services Strategic Plan.
AAGP would also like to point out to Congress that the historic investment in aging research and services is paying off. VA has played a leading role in developing the scientific evidence base for understanding and treating health problems that are common in late-life, such as cognitive impairment, musculoskeletal disorders, and chronic pain. VA expertise in managing these complex, interacting infirmities of aging now informs the approach to younger veterans with similar problems. The cross-fertilization made possible by advances in geriatric mental health care will be especially important in working with returning OEF/OIF veterans who have poly-trauma which results in functional limitations due to a combination of cognitive impairment and physical disability. A related concern is the previously recognized association between head trauma and increased risk of developing Alzheimer’s disease, which anticipates the possibility of accelerated brain aging in these younger veterans. AAGP urges Congress to support the VA in monitoring and managing the downstream clinical outcomes of traumatic brain injury and its associated cognitive and physical disabilities—beyond the initial recovery period—as these veterans continue to age.
Mental Healthcare Workforce and VA Recruitment and Training in Geriatrics
In light of the demonstrated toll of mental illness among veterans who have served in Iraq and Afghanistan in recent years, the Veterans Administration has added thousands of mental health professionals to meet their mental health needs. This build-up of the VA mental health workforce is clearly needed and is welcomed by the mental health community as a life-saving measure for these veterans and their families. Although the large increase in staffing has been focused on younger adults, it is crucial to remember that the majority of patients currently served by the VHA are aging middle-aged and older veterans, and that these are the veterans that most of the newly hired mental health staff will treat. The VA should ensure that they are adequately trained to meet the unique needs of veterans in late-life.
The 2008 Institute of Medicine (IOM) report on the geriatric workforce emphasizes the dearth of healthcare professionals trained in geriatrics. The shortfall is especially critical in the field of geriatric mental health. AAGP is concerned that, as the VA continues to increase the number of mental health professionals in its workforce, it can be expected to encounter serious challenges in attempts to recruit geriatric psychiatrists, psychologists, social workers, and other geriatric mental health practitioners who have specific training and experience in the care of older adults. In light of these challenges, AAGP commends VA for its record of leadership in training geriatric mental health professionals. This has been accomplished, in part, through funding of the Mental Illness Research Education and Clinical Centers (MIRECCs), Geriatric Research Education and Clinical Centers (GRECCs), and Parkinson Disease Research Education and Clinical Centers (PADRECCs). AAGP recommends that, in response to the 2008 IOM geriatric workforce report, Congress enact safeguards to ensure continued funding for the training of geriatric mental health professionals through these VA-based centers.
Veterans and Long-term Care
An estimated 30 percent of the patients in veterans’ nursing home facilities currently suffer from Alzheimer’s disease or other types of dementia. There are many more veterans still living in the community who are at risk for nursing home placement as their cognitive and functional status decline, and as their family caregivers become unable to care for them. As the elderly veteran population increases, the demand for long-term care services is expected to grow. Also, a substantial number of returning OEF/OIF veterans with traumatic brain injuries will require long-term residential care, now and in the near future.
AAGP is concerned that the capacity of traditional veterans’ nursing home facilities to care for veterans with cognitive and functional impairments due to Alzheimer’s disease and traumatic brain injuries will soon be overwhelmed. We anticipate that VA will therefore need to increase its capacity to provide long-term residential health care, in part by continuing its efforts to expand non-institutional options while preserving and improving its network of nursing homes. Quality of care for veterans with long-term care needs across the lifespan will require substantial attention to the epidemiology of mental illness (including dementia and other cognitive disorders) in this population, and the provision of geriatric mental health services that are vertically integrated into both institutional and non-institutional programs and horizontally integrated with general medical care and mental health services. This is the only way to prevent aging veterans with medical-psychiatric co-morbidity and associated physical disabilities from falling through the “service system” cracks.
Returning OEF/OIF veterans state that, if their injuries require residential care, they would not be comfortable living in traditional nursing homes, built in the past for older adults, that isolate them from the community. Another important innovation, currently underway at VA, is the program for cultural transformation of existing Nursing Home Care Units into Community Living Centers. AAGP applauds this VA project that will benefit both older and younger veterans who require residential care, providing a more home-like environment, enhancing dignity for recipients of care, and ensuring opportunities for continued participation in community life.
AAGP is also pleased with the development of a VHA strategic plan specifically for care of veterans with Alzheimer’s disease and related dementias, and we urge Congress to support continued innovation in the approaches utilized by VA health personnel in treating veterans with Alzheimer’s disease. The VA should also be supported in its efforts to develop family and caregiver support programs to enable veterans to remain at home for an extended period, and to receive community-based support services before nursing home care becomes necessary. AAGP recommends the creation of a new line of mental health research funding for the development, testing, and dissemination of interventions to manage the psychiatric and behavioral manifestations of Alzheimer’s disease and related dementias. AAGP is especially concerned about the occurrence of agitation and aggression, which are frequent and severe behavior problems confronted by caregivers of patients with dementia living at home as well as in long-term care facilities. Scientific evidence for safe and effective treatments for the psychiatric and behavioral symptoms of dementia is limited. We therefore propose that the VA undertake studies to address ways to manage agitation and aggressive behavior in older veterans in long-term care and domiciliary facilities.
Although the VA has made genuine progress in psychiatric research in recent years, the level of research funding remains disproportionate to the utilization of mental health services by veterans. Despite the fact that veterans with mental illness account for approximately one-third of all veterans receiving treatment within the VA system, VA resources devoted to psychiatric and behavioral health research have lagged far behind those dedicated to research on other medical conditions. As the elderly veteran population expands and the number with dementia and other mental disorders grows, strengthening the research base in geriatric psychiatry becomes increasingly urgent. VA sponsored research into mental disorders of aging benefits all Americans, not just our veterans.
AAGP also has concerns about the future incidence of Post-traumatic Stress Disorder (PTSD) in the aging veteran population. While there are obvious war-related traumas that lead to PTSD in younger OEF/OIF veterans, aging veterans are exposed to various catastrophic events and traumas of late-life that can lead to new-onset PTSD or may trigger reactivation of pre-existing PTSD. Reactivation of PTSD has been seen more frequently in recent years among World War II, Korean conflict and Viet Nam era veterans. As the cohort of Viet Nam era veterans exhibits the infirmities of aging, with extensive co-morbidity and disability from interacting medical, psychiatric, and substance use disorders, they may be especially vulnerable to PTSD. AAGP therefore urges that funding for research and services related to PTSD be directed to the care of veterans across the entire lifespan.
A vitally important VA program for coordinating mental health research with education and clinical care are the Mental Illness Research, Education, and Clinical Centers (MIRECCs). Since 1996, Congress has authorized the VA to establish ten of these centers dedicated to mental illness research, education and clinical activities. AAGP believes the MIRECCs have successfully demonstrated that coordinated research and education projects can achieve rapid translation of new scientific knowledge into improved models for clinical services for veterans with mental illness. The investment that Congress has made in MIRECC research has paid substantial dividends, giving VA healthcare professionals more and better tools to treat patients with mental disorders. MIRECCs focus on problems highly relevant to veterans with schizophrenia, PTSD, and other serious mental illnesses, including those whose treatment is complicated by homelessness, substance abuse, or alcoholism. AAGP wishes to emphasize the value of those MIRECCs that focus on issues related to aging, including dementia, and psychiatric disorders in older veterans with concurrent medical illness and/or substance use disorders. AAGP urges Congress to continue funding of the MIRECCs.
In addition, AAGP strongly supports the work of Geriatric Research, Education and Clinical Centers (GRECCs). The GRECCs are centers of geriatric excellence designed for the advancement and integration of research, education, and clinical achievements in geriatrics and gerontology. Mental health has played a central role in the entire GRECC program since its inception in the mid-1970’s. GRECCs focus on quality of life and care for the aging veteran and are at the forefront of innovative research and education. Research results have influenced therapies for diseases affecting older veterans and have also been exported outside the veteran community, and AAGP urges continuation and strengthening of these most important research centers.
In conclusion, AAGP commends this Subcommittee for its continued support for VA mental health services, research and training. Representing physicians who are specialists in geriatric psychiatry, AAGP believes that strengthening clinical services, research and training in geriatric mental health will enhance treatment not only for elderly veterans, but also for those who are currently young and middle-aged. Younger veterans are at risk for complications of their mental disorders as they grow older, and they clearly stand to benefit from cross-fertilization of successful treatment approaches that are developed for old, frail veterans with complex, interacting mental and physical problems.
Delivering quality health care for all veterans—integrating both physical and mental health care—must be a top priority. We therefore urge the Subcommittee to increase support for mental health services, training, and research; and to commit the resources necessary to provide our nation’s veterans with access to quality, affordable, well-coordinated physical and mental health care.
The American Association for Geriatric Psychiatry appreciates the opportunity to submit this statement for the Subcommittee’s consideration. AAGP looks forward to working with members of the Subcommittee to ensure that all veterans have access to quality affordable mental health care.