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The NYSPA Report: The Changing Face of the VA

Much has been written in the last several years about returning Veterans and their mental health issues. The VA health care system has gone from being a rather low-key assortment of hospitals and clinics around the country, often situated in urban areas or close to military bases, to a “hot topic” in the media and in politics. Funding of VA services has increased exponentially to keep pace with the needs of the Veterans and the increase in government and public attention.

Prior to 2002 VA mental health services were still, by and large, utilized by Vietnam era (or earlier) Veterans. This meant that the majority of patients were male, and rapidly aging (at least 50 years of age, or older)! Over the last 10 years the profile of the “typical” Veteran receiving health care services at a VA facility has changed dramatically. In fact, there are now two distinct groups of vets; the “traditional” ones, that is, the older, usually male, Vietnam era Veteran and the “new” Veterans from Desert Storm and the Iraqi and Afghanistan wars.

These new returning Veterans present significant challenges to the VA system in many areas. First, of course, are the sheer numbers of returning Veterans seeking services. Recent statistics show that since 2002 about 1.5 million Veterans have left active duty and become eligible for VA health services, of which about 56% are former active duty troops and the other 44% are Reserve and National Guard. It is also important to note that Reserve and National Guard Veterans often return to areas of the country which have relatively sparse VA services. Since 2002 about 800,000 (54%) of those eligible have obtained VA health care, with about 93% being seen only as outpatients and about 7% having been hospitalized at least once in a VA facility. As mentioned above, there are many more women Veterans than in the past (12% of the 800,000 seen were women). Approximately 50% of the 800,000 seen were 30 years old or younger! Of these returning Veterans 52% were seen for “Mental Disorders” (clearly a broad diagnostic classification). About 55% were seen for “Diseases of the Musculoskeletal System” (back and shoulder pain, etc.) and about 45% were seen for “Diseases of Nervous System” (Traumatic Brain Injuries/TBI, etc.). Traumatic Brain Injuries are much more prevalent now than in any time previously because of advanced techniques both in weapons (IEDs) and in medical life-saving techniques. Of course, what is not detailed in these statistics is the incredible amount of overlap in these diagnoses. It is not at all uncommon for a returning Veteran to present to the VA with a combination of TBI, significant back and shoulder problems (from the extremely heavy loads of equipment carried), PTSD, and an addiction to drugs and/or alcohol, all at the initial intake interview. Clinical staff from various medical specialties must work collaboratively with each other and with the Veteran to put together a treatment plan to address all these, often overwhelming, problems in as short a time as possible to ensure that the Veteran can begin to readjust to life outside the military.

The VA had become accustomed to treating older Veterans who had over many years adapted to their conditions, which by and large had become chronic, both psychiatrically (such as PTSD) and medically. This new influx has presented the VA with challenges to adapt to much more acute traumatic stress symptoms of poor frustration tolerance, impulsivity, mood swings and often significant substance abuse issues. Additionally, with the significant increase in TBI the need for all branches of medicine to work together has increased dramatically. This has put additional burdens on the Veterans with having to coordinate multiple appointments often in different physical locations. The psychosocial problems for these Veterans have been tremendous: interpersonal conflicts, family problems, domestic violence, unemployment, problems in school, legal problems, etc.

The VA has become a much more aggressive health care system and has begun the very difficult task of integrating all of the services which are needed. One example is the creation of specific offices and services devoted specifically to the returning Veteran. At the VA Hudson Valley Health Care System (HVHCS) these staff are the front-line staff for all returning Veterans to this area. They reach out to all of them and provide overviews of the VA services. For example, in May 2012 the VA HVHCS staff enrolled approximately 1,750 returning Veterans in VA services from the surrounding areas. Each of these Veterans is offered a “Post Deployment Screening” and a TBI Screening. The staff offer drop in services and see themselves as a “safety net” for those who have difficulty trying to come to appointments and get services. The staff also “follows” the Veterans through the continuum of care, and attends meetings at the inpatient, residential and outpatient settings.

The VA across the country has also become a leader in Telehealth (using video to provide health care services). Telehealth is used in both general medicine and in psychiatry. The VA HVHCS has a number of “CBOC’s” (Community Based Outpatient Centers), such as in Port Jervis, New City, Goshen, etc., but even with that, the need for Telehealth is great. A dermatologist at Castle Point can consult with a primary care doctor and patient at Goshen and can quickly and efficiently help the patient and the primary care doctor decide what the next step needs to be, if any. Additionally, a psychiatrist at Montrose can consult with a therapist and a patient at New City and help diagnose and treat Major Depression. Of note is that in 2003 8,000 VA patients received mental health care via telemedicine. In 2011 this figure had jumped to more than 55,000. Telemental health at the VA is done by psychiatrists, psychologists, social workers, nurse practitioners, and all other clinical specialists.

Even with all the increase in services provided by the VA, many Veterans still seek and receive medical and mental health services in the private healthcare community. Because of this the New York State Psychiatric Association (NYSPA) has applied for and received a grant from New York State to educate primary care physicians and other professionals in primary care on Veteran-specific mental health issues, such as PTSD, TBI, suicide and other mental health conditions including alcohol and/or substance abuse. There is much new clinical information regarding treatment of PTSD (both medications and therapy, e.g. Cognitive Processing Therapy), co-occurring Substance Abuse (e.g., Motivational Interviewing), interface of TBI and psychiatric problems, and differential diagnoses of anxiety, panic and ADHD. All clinicians who treat Veterans need up-to-date clinical information to ensure that they receive the best medical and psychiatric health care we can provide. If you or a loved one need access to health care at the VA, please contact the Returning Combat Veteran Program at (866) 400-1237, a national outreach number, or www.oefoif.va.gov. Additionally, the afterhours Nurses Helpline is (800) 877-6976.

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