JULY 16, 2007



NICHOLSON: Good afternoon, everyone. Delighted to be here. Been really looking forward to this. 

I've just rushed over here from addressing a conference over across the river, a session of the World Congress on Improving Health Care through Public and Private Partnerships. And glad to have made it here on time. 

And I want to extend a very warm Washington V.A. welcome to all of you, my colleagues from the V.A. and representatives that are here from Department of Defense, veteran service organizations, mental health organizations and others who are here with us today.

This is really a gathering of eminent public and private sector clinicians and researchers, counselors, educators and veteran's advocates.

So I want to thank each of you participating in this landmark conversation, if you will, on mental health care for our veterans.

The V.A., as you know, I hope, is a longstanding leader in mental health. But as the newest generation of combat veterans returns home, we need and we want to make sure that we're getting it right and providing them with the very best mental health care and treatment possible. They deserve nothing less.

We're also at the midpoint of our five-year plan to implement V.A. comprehensive mental health strategic plan. So the time is right to assess our achievements and to renew and reenergize our efforts in this vitally important work.

And so for that reason, among others, I want to compliment publicly Dr. Kussman, our newly confirmed and extremely able, committed, dedicated undersecretary for health administration for his initiative in putting this conference together. 

We appreciate your joining us as we examine these issues, as we discuss best practices, and strengthen our approaches thereby to treating veterans who come to us for mental health care.

In this time of war, it is a topic of even greater importance, even greater responsibility.

President Lincoln's 19th century clarion call to the nation, to the union that looked like it was going to hold, and during his second inaugural, his call to care for him who has borne the battle, and his widow, and his orphan, has taken on a new and expanded meaning now in the 21st century.

NICHOLSON: The wounds of war are not always evidenced in severed limbs and torn flesh. They can sometimes be unseen and cloaked in silence. And if left untreated, they can be every bit as lethal.

Whether it's called soldier's heart, shellshock, battle fatigue or post-traumatic stress disorder, PTSD, the effects of the stress of combat demand and deserve our full and immediate attention. And the V.A., as the nation's principal advocate and caregiver for veterans, has taken the lead in addressing this issue, particularly as it manifest in our service members returning from the global war on terror.

The V.A. has consistently led the health care community in innovative approaches to health care, both mental and physical. And I want to take this opportunity to say that our successes are due, in great measure, to the compassionate care and unsurpassed skill of our health care professionals.

And I want to personally thank all of our V.A. employees who are here with us, together, today.

Increasingly, our focus is on mental health. With an annual budget now of nearly $3 billion for mental health services alone, the V.A. is the largest provider of mental health care in the nation. We employ more than 9,000 front-line mental health professionals, which is up more than 15 percent in just the last four years.

Today mental health services are provided at each of the V.A.'s 153 major medical centers and each of our 882 outpatient clinics. Every V.A. hospital now has a PTSD capability.

We understand, more than ever, what President Lincoln meant when he once said also, quote, "We must rise with the occasion. We must think anew and act anew," end of quote.

Clearly the national and international landscape has changed greatly since 9/11.

NICHOLSON: And the implications for the Department of Veterans Affairs are greater still. 

True to Lincoln's legacy, the V.A. is thinking anew and acting anew in response to new occasions of change and challenge. We are doing so from health care to benefits and everything in between, but none more so than our broad-based mental health strategic planning.

At this conference, we want to tell you what we are doing and request your input if you think we are missing anything. The V.A. has significantly increased its mental health care capacity across the full range of mental health conditions. 

This means that we have increased psychology, psychiatry, social work and mental health nursing staff at approximately 150 V.A. medical centers in over 300 community-based clinics.

The fact remains, however, that all of the expert staff in the world would not be enough if our veteran patients cannot reach our providers for the care they need. That is why the V.A. is also aggressively working to increase access to mental health services and to eliminate geographic disparities in levels of care.

We are successfully doing this by increasing mental health care staffing at selected V.A. locations, especially remote ones, and by promoting tele-health capabilities throughout the V.A. system. Tele- mental health is an emerging V.A. good news story. No longer is traveling long distances to a dedicated V.A. mental health site the only option for veterans in need of mental health treatment.

As in so many other areas of care, technology has changed the way that the V.A. delivers mental health care.

NICHOLSON: We now offer tele-mental health at 164 community- based clinics, 89 medical centers, 21 vet centers and 23 sites that support home tele-health. Last year, almost 20,000 veteran patients with mental health conditions received consultations through our expanding tele-mental health system. 

As with our physical health care, the V.A.'s goal for mental health care services can be summed up, then, in one word: accessibility. Starting this year, the V.A. is further advancing that access by funding the integration -- the co-location, if you will -- of mental health services within primary care settings. 

The purpose of this initiative is to provide assessment and brief treatment for veterans who may not require specialty mental health care. 

There is also another salient reason: stigma. Given the possible reluctance of some veterans to talk about emotional problems, increasing our mental health presence in primary care settings will give veterans a familiar venue in which to receive care, without actually going into an identified mental health clinic and being identified as a mental health patient.

The V.A. has moved to integrate additional mental health care into geriatrics. Those of us who serve veterans know that all too often the trauma of battle can often re-emerge as life goes on, or in later life. 

In support of this initiative, a psychologist has been funded for every one of our home-based primary care teams. These team members provide cognitive and psychological assessment, counseling as well as training for family members to better address the emotional needs of their loved one.

NICHOLSON: We are really concentrating on rehabilitation and recovery. Our key initiatives are designed to ensure that services and treatments are veteran- and family-centered, and focus on a veteran's ability to successfully manage day-to-day life and its challenges.

Our newly-established psychosocial rehabilitation and recovery centers serve as another point of care for veterans who may need addition or continuing levels of information, service and support as they recover from their mental illness.

To effectively support all our new programming, it is critical that all our staff is educating in the best mental health care practices known. Therefore, we are developing programs to train our health care providers in the detection and delivery of evidence-based psychological treatments for PTSD, depression and other forms of serious mental illness. That kind of mental health training has had a very positive value both in and out of V.A. facilities. 

Jim Sardo, a psychologist, is part of the PTSD clinical team and substance abuse treatment program at our Portland, Oregon, V.A. medical center. He served in the global war on terror twice, deployed in 2003 and 2006 to Leya (ph) Air Base in south central Iraq, the only mental health provider there who is serving between 8,000 to 12,000 troops.

He provided individual, group therapy, worked 12 hour days Monday through Saturday and most Sundays. Last year's deployment was to Balad Air Base in the Sunni Triangle. He provided outpatient mental health and emergency services, as well as individual therapy and TBI, neuropsych screening on troops who had survived IED blasts. 

In Jim's own words, "It was a privilege to serve our troops there."

NICHOLSON: "The mission was so close to the V.A.'s mission it sometimes felt as if I'd never left. My sense is that 10 years of V.A. employment was the best training for serving our troops I could have asked for."

Thank you, Dr. Sardo.


PTSD, in particular, is a growing challenge. We are seeing increasing numbers of clinical diagnoses of this, and other depressive disorders among the veterans returning to us from Southwest Asia.

Improved screening has made this possible. 

To answer the challenge, we are taking and will continue to take strong, broad steps to help veterans receive comprehensive, accessible and compassionate care for PTSD and related issues. We are well positioned to do so because the V.A. is the undisputed leader in the treatment of PTSD. Our National Center for PTSD is internationally recognized for its seminal research into combat-related mental health issues, as well as noncombat mental health trauma.

The fact is that over the past several years the V.A. has increased funding for new and enhanced mental health programs for veterans of Operation Iraqi Freedom and Operation Enduring Freedom.

As a result of this targeted funding for OIF/OEF veterans, speciality mental health teams are embedded now across our system of care. Each focuses on providing rapid assessment and case management services for both returning veterans and their families, particularly for those who have been injured.

Psychologists and social workers are part of the interdisciplinary teams working in our polytrauma centers to care for our most severely injured troops, including patients with traumatic brain injuries.

NICHOLSON: These men and women provide a broad spectrum of support, ranging from assessment to counseling to family therapy to psychotherapy and case management.

Today the V.A. operates over 80 hospital-based OIF, OEF mental health programs, operating in collaboration with more than 200 specialized PTSD programs, over 150 general mental health clinics, and more than 150 primary care facilities. And more are under development.

And we expect that 90 hospital-based OIF, OEF mental health programs will be operating by the end of this fiscal year.

So, with all of this said, how are we doing?

Essentially, that is what I would you will tell me -- you will tell us -- by being introspective and candid here during this conference.

Recently I read an account of a veteran treated by Dr. Kathleen Chard (ph), the director of our PTSD and Anxiety Disorders Division at the Cincinnati V.A. medical center.

An OIF veteran who was convinced that he had become a monster -- excessive drinking, substance abuse, dropped out of college, difficulty keeping a job. After two fellow soldiers committed suicide, he sought help. He felt he would take his own life soon, too.

He entered a residential treatment program and was embraced by Vietnam veterans. During seven weeks, he progressed well and encouraged many of the seemingly inflexible Vietnam veterans to work harder in the program.

NICHOLSON: At the program's end, this young veteran again enrolled in college with the hope of earning a master's degree in social work. He wants to help other veterans. 

The lesson learned: Respond quickly to the needs of our OIF, OEF veterans, offer fast-paced, interactive treatment to rapidly alleviate symptoms and return them to their prior lives.

Thank you, Dr. Chard (ph), for what you've done for this veteran.


Suicide prevention is a critical issue, and we take it very seriously. We are implementing a number of changes immediately to strengthen our response to potential suicides. We are hiring suicide prevention coordinators for each of our medical centers. We are educating all our health care providers in recognizing the sometimes subtle signs of individuals in crisis, as well as screening veterans in our primary care clinics.

Again, we are ensuring access to mental health care. For example, veterans requesting or referred for treatment will receive an initial evaluation within 24 hours. Our emergency departments have mental health coverage on a 24/7 basis. And we will very shortly activate a full-time suicide prevention hotline to intervene in instances where an at-risk veteran can reach out to another human being for immediate help.

Although we are directing our outreach efforts to support OIF-OEF veterans, we cannot forget the fact that traumatic events can trigger overwhelming emotions in veterans already prone to or suffering from service-related psychological difficulties. Every day, V.A. counselors see unresolved combat-related problems expressed in PTSD, alcoholism, drug and domestic abuse, gambling addictions and a host of other war re-adjustment issues. 

NICHOLSON: We know that many veterans were retraumatized by 9/11, the uncertainties of elevated threat levels, the current conflict on Southwest Asia, and all that evoke those same emotions that they experienced earlier.

This, of course, poses many questions about the future direction of psychological counseling for war-related experiences. And while we've seen increases in the number of older veterans who have come to us for assistance and care, it may be a long time before we know the full extent of that increase. This is where our re-adjustment counseling service, or vet centers, have shown themselves to be a vital component of our overall mental health program. 

Although program eligibility was originally targeted just for Vietnam veterans, it now serves all returning combat veterans. Our 209 community-based vet centers provide mental health screening and PTSD counseling that is the undisputed gold standard in veteran satisfaction, rated at 98 percent across measurable indicators of quality and effective care.

Let me tell you why. Here's an account from my hometown, where V.A. social worker Ms. Julian Honeywell-Habrecheck (ph) works at the Denver Vet Center. She treated a United States Navy corpsman in Fallujah, Iraq. While on convoy, his Humvee was hit by an IED. He was shot in the arm.

NICHOLSON: Five surgeries left him with only limited motion and chronic pain. 

He had readjustment problems, PTSD symptoms, a sense of hopelessness. The veteran had planned to make the military his career but was honorably discharged.

Counseling allowed the veterans to tell his story and come to terms with his combat experience. The result: Improved functioning in life and in the community, a resumed interest in a career, and he has enrolled in college to complete his education.

Thank you, Ms. Honeywell-Habrechek (ph), thank you for your service to America's veterans.


Vet centers like Ms. Habrechek's (ph) are hubs for an array of counseling, guidance and information for veterans and their families. We let veterans know that mental health issues and other military- related readjustment problems are not their fault. They're not the result of their human failing. And we let them know that we can help them and that they can get better. And the probabilities go up the earlier that we can intervene.

Vet centers make it easy for veterans to get treatment. They make sure veterans don't feel stigmatized or threatened by the idea of seeking mental health treatment.

Services run the gamut from individual counseling and substance abuse assessments to employment counseling and referrals to other community resources. 

Our vet center program is recognized as a national model for outreach and readjustment services. It is being emulated in other countries, like Australia, Croatia and El Salvador in their efforts to ease the readjustment of combat veterans to civilian life.

In fact, the V.A.'s vet center program is the prototype for the President's New Freedom Commission on Mental Health.

I recently approved the hire of 100 additional OIF, OEF combat veterans to support the vet center program by reaching out to active National Guard and Reserve veterans returning from the combat zone.

NICHOLSON: This will advance the continuing success of our vet centers in their ability to assist our newest veterans and their families. 

Very importantly, by the end of 2008, we will have expanded the number of vet centers to 232, as we will open 23 new centers at locations across the country in the next 18 months. 

So you can see, I hope, that the V.A. is advancing its mental health program in a full court press. Our work here today is only the beginning. We will soon be hosting regional mental health conferences to bring together our partners at the state, local and community level. We want to build a hands-on coalition of support for the men and women who so courageously protect and defend us.

Today's veterans, their families and the American people rightfully expect service and innovation at levels unimagined just a decade ago. And our veterans deserve that. 

We know it is up to us to meet those new expectations and successfully address new needs and emerging requirements. As Lincoln said, we must rise to the occasion. 

Your help is needed. Your being here will ensure that the V.A. continues to set the pace and indeed rises to the occasion. 

So thank you for your participation, for your coming here and for all that you do for America's veterans. 

Thank you.




Jul 16, 2007 16:52 ET .EOF