User:Bruindre/Sandbox/Veterans Mental Health Benefits in the United States

Military flag

The United States provides benefits for veterans with post-traumatic stress disorder (PTSD), a severe anxiety disorder which persons, including military personnel, may develop after experiencing a psychologically traumatic event. For military personnel, the United States Department of Veterans Affairs (VA) will pay disability benefits to all service men and women diagnosed with PTSD and will also provide free health care so that they may seek proper treatment. To begin receiving these benefits, a veteran must first see a licensed psychiatrist or psychologist. In recent years the VA has increased efforts to ensure that all service men and women diagnosed with PTSD may seek and obtain proper care in their geographic area.

Post-traumatic stress disorder (PTSD)

Main article: Posttraumatic stress disorder

Posttraumatic stress disorder (also known as post-traumatic stress disorder or PTSD) is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. PTSD follows an event that causes severe fear and/or helplessness. Symptoms may develop shortly after the event or years later. Symptoms include nightmares in which the trauma is re-experienced, flashbacks, obsessive thoughts, avoidance of situations that remind the individual of the trauma, general increased anxiety, and heightened startle response. PTSD is mainly treated with psychological treatments, and some anti-anxiety medications are used to relieve symptoms. PTSD caused by chronic or ongoing traumas such as war have poorer prognoses than PTSD caused by acute or one-time traumas such as car accidents.

PTSD and the military

It is common for US Military personnel and veterans to experience PTSD symptoms. These symptoms may include reliving the traumatic event; thinking about the traumatic event despite the need to concentrate on something else, like work or school; avoiding situations that remind them of the event or avoiding crowds because they feel dangerous; feeling numb, emotionless or not having positive thoughts; and being easily startled and frightened by loud noises. These symptoms, and others not described here, may occur as a result of combat experience. Exposure to a combat environment can disrupt civilian life and can have a strong impact on a service member’s mental health and psychological well-being. Among just the U.S. troops returning from Iraq and Afghanistan, nearly 40 percent of soldiers, a third of Marines, and half of the National Guard members report symptoms of psychological problems. Experts believe that about 11-20% of Veterans of the Iraq and Afghanistan wars experience PTSD symptoms.

Another overarching concern is the stigma associated with disclosing mental health symptoms and asking for help within the military culture, both within the armed services and to a lesser extent in VA settings. The Department of Defense has been working on mental health services, particularly improving post-deployment mental health assessments to better understand the psychological effects of combat and related mental health care needs of those returning from combat.

Diagnosis

309.81 DSM-IV Criteria for Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following have been present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) markedly diminished interest or participation in significant activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect (e.g., unable to have loving feelings)

(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more

Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association

The American Psychiatric Association (APA) has defined the diagnostic criteria for PTSD. The person must have been experienced or witnessed a traumatic event that involved an actual or threatened death or serious injury and caused intense fear, helplessness, or horror (Criterion A). The traumatic event has since been persistently reexperienced (Criterion B), and the person actively avoids anything that reminds him or her of the event (Criterion C). The person also experiences heightened arousal (Criterion D) and significant difficulty in carrying out social, occupational, and other functions (Criterion F). The symptoms must persist for more than one month (Criterion E). (See sidebar for full diagnostic criteria.)

The APA diagnostic criteria are most commonly used in the United States and are used by the Department of Veterans Affairs. The World Health Organization also has defined diagnostic criteria for PTSD. WHO criteria includes less stringent versions of Criteria A, B, C, D, and E from the APA criteria but does not include Criterion F.

Military Screening and Treatment Policy

• Removed portion below from main article 22APR11 - outside scope - focus of article should be on Vets.

US Army

For members of the United States Army, a series of Post-Deployment Health Activities are available. All of these Health Activities are required for all patients deployed outside the Contiguous United States (OCONUS) for more than 30 days to a location with a non-fixed Military Treatment Facility (MTFs). These Health Activities include a Post-Deployment Health Assessment (PDHA) and a Face-to-Face Health Assessment.

During the Face-to-Face Health Assessment, a member can meet face-to-face with a trained health care provider (which includes physicians, physician assistant, nurse practitioner, advanced practice nurse, independent duty corpsman, independent duty medical technician, or Special Forces medical sergeant). This assessment includes a discussion of mental health or psychosocial issues commonly associated with deployments. This would include 10-15% of post Operation Iraqi Freedom soldiers at risk for PTSD, according to Army data.

RESPECT-Mil

The Re-Engineering Systems of Primary Care Treatment in the Military (or RESPECT-Mil) is a system of primary care designed to enhance the recognition and high-quality management of PTSD and depression. The US Army Medical Command has directed wide implementation of RESPECT-Mil in Army primary care facilities. Designed by the United States Department of Defense's Deployment Health Clinical Center (DHCC), RESPECT-Mil is a treatment model used to screen, assess and treat active duty soldiers with depression and/or PTSD. RESPECT-Mil is modeled directly after a program that’s proven effective in treating civilian patients with depression.

RESPECT-Mil uses the Three Component Model (3CM) of care, featuring the coordination of primary care clinician (PCC), care facilitators and behavioral health specialists (BH specialists) in the unique service of soldiers with behavioral health needs. The 3CM works in the following stages:

• Soldiers attending primary care clinics for sick call and other reasons are routinely screened for depression (two questions) and PTSD (four questions);
• Those with positive screens complete appropriate diagnostic and severity instruments before seeing the PCC;
• If the instruments suggest that behavioral health issues require exploration and the PCC’s diagnostic interview confirms the diagnosis of depression or PTSD, treatment is initiated by the PCC who will continue to follow the patient closely;
• In addition to primary care follow-up visits, soldiers in treatment are provided with telephone support from a specially trained RESPECT-Mil Care Facilitator, a registered nurse, who promotes adherence to the management plan and monitors response to treatment using validated quantitative instruments. The Care Facilitator communicates routinely and staffs cases with a BH Specialist who will provide management suggestions communicated in reports from the Care Facilitator to the PCC. The BH Specialist is usually a psychiatrist because of the current primary care treatment focus on psychotropic medications. The BH Specialist also assists in linking a Soldier to behavioral health services when indicated or requested;
• Thus, a partnership with the patient is shared among the PCC, a Care Facilitator, and BH Specialists.

Benefits: Disability compensation and free health care

The U.S. government has long recognized the need to provide disability compensation to veterans for health problems associated with military service. Post-traumatic stress disorder is a common type of health problem for which veterans request disability compensation.

The Department of Veterans Affairs (VA) will pay disability compensation to all veterans diagnosed with PTSD and provide free health care. Disability compensation is paid to a veteran because of injuries or diseases that happened while on active duty, or were made worse by active military service. Disability compensation is tax free.

You may be eligible for disability compensation if you have a service-related disability and you were discharged under other than dishonorable conditions.

The VA also provides free health care and encourages all veterans to seek treatment for PTSD. Treatment can work, and early treatment may help reduce long-term symptoms. Every VA Medical Center has PTSD specialists who can treat veterans with PTSD. Veterans can also access any of the VA's 200 specialized PTSD treatment programs after obtaining a referral. VA PTSD treatment programs include a mental health assessment, medicines if necessary, and personal and family counseling.

Applying for benefits

Veterans must undergo medical evaluations for each condition they are claiming and must file claims with the Veterans Benefits Administration, which rate service-related injuries on a sliding scale. These ratings assess the effects on earning capacity from such injuries and disabilities. However, the fairness of this approach has raised concern because while a disability may not impair the ability to work in many occupations, it may still significantly affect quality of life, which has historically not been a major factor in disability ratings.

The first step to receiving disability compensation or mental health care for PTSD is to be diagnosed with PTSD by a VA or other licensed psychiatrist or psychologist. A veteran must also establish, with the licensed professional, that the PTSD is a result of his military service. According to the VA, under a new regulation for PTSD claims effective July 13, 2010:

"A Veteran will be able to establish the occurrence of an in-service stressor through his or her own testimony, provided that: (1) the Veteran is diagnosed with PTSD; (2) a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has :contracted confirms that the claimed stressor is adequate to support a PTSD diagnosis; (3) the Veteran's symptoms are related to :the claimed stressor; and (4) the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s :service and the record provides no clear and convincing evidence to the contrary. This will eliminate the requirement for VA to :search for records, to verify stressor accounts, which is often a very involved and protracted process. As a result, the time :required to adjudicate a PTSD compensation claim in accordance with the law will be significantly reduced."

To begin the process, talk to your family doctor, or contact your local VA hospital or Vet Center. Your family doctor or a VA department psychologist or psychiatrist will screen a veteran to verify that the stressful experiences they recall are consistent with their military service and PTSD symptoms, including irritability, flashbacks, deep depression, and other emotional or behavior problems.

Next, a veteran can apply for compensation benefits by filling out VA Form 21-526, Veterans Application for Compensation and/or Pension. Along with the application, any of the following information may also be submitted:

• Discharge or separation papers (DD214 or equivalent)
• Dependency records (marriage & children's birth certificates)
• Medical evidence (doctor & hospital reports)

The application is also available online using the Veterans On-Line Application (VONAPP) System.

Legal basis

Veterans Health Care Act of 2005

In December of 2005 the 109th United States Congress designated $95 million for fiscal year 2006 and $95 million for fiscal year 2007 to improve and expand the treatment services and options available to veterans in need of mental health treatment from the Department of Veterans Affairs. In particular, the money was designated for the following:

SEC. 8. IMPROVEMENTS AND EXPANSION OF MENTAL HEALTH SERVICES.

The Secretary of Veterans affairs shall—
(A) expand the number of clinical treatment teams principally dedicated to the treatment of post-traumatic stress disorder in medical facilities of the Department of Veterans Affairs;
(B) expand and improve the services available to diagnose and treat substance abuse;
(C) expand and improve tele-health initiatives to provide better access to mental health services in areas of the country in which the Secretary determines that a need for such services exist due to the distance of such locations from an appropriate facility of the Department of Veterans Affairs;
(D) improve education programs available to primary care delivery professionals and dedicate such programs to recognize, treat, and clinically manage veterans with mental health care needs;
(E) expand the delivery of mental health services in community-based outpatient clinics of the Department of Veterans Affairs in which such services are not available as of the date of enactment of this Act; and
(F) expand and improve the Mental Health Intensive Case Management Teams for the treatment and clinical case management of veterans with serious or chronic mental illness.

ACCOUNTABILITY FOR THE PROVISION OF MENTAL HEALTH SERVICES.—

The Under Secretary shall take appropriate steps and provide necessary incentives (including appropriate performance incentives) to ensure that each Regional Director of the Veterans Health Administration is encouraged to—
(A) prioritize the provision of mental health services to veterans in need of such services;
(B) foster collaborative working environments among clinicians for the provision of mental health services; and

(C) conduct mental health consultations during primary care appointments.

The full 2005 Act is available here

Caregivers and Veterans Omnibus Health Services Act of 2010

In January 2010 the 111th United States Congress passed the Caregivers and Veterans Omnibus Health Services Act of 2010 which includes provisions to improve and expand the availability of mental health care for US veterans.

SEC. 202. TRAINING AND CERTIFICATION FOR MENTAL HEALTH CARE PROVIDERS OF THE DEPARTMENT OF VETERANS AFFAIRS ON CARE FOR VETERANS SUFFERING FROM SEXUAL TRAUMA AND POST-TRAUMATIC STRESS DISORDER.

(1) The Secretary shall carry out a program to provide graduate medical education, training, certification, and continuing medical education for mental health professionals who provide counseling, care, and services under subsection (a).
(2) In carrying out the program required by paragraph (1), the Secretary shall ensure that— (A) all mental health professionals described in such paragraph have been trained in a consistent manner; and (B) training described in such paragraph includes principles of evidence-based treatment and care for sexual trauma and post-traumatic stress disorder. Each year, the Secretary shall submit to Congress an annual report on the counseling, care, and services provided to veterans pursuant to this section. Each report shall include data for the year covered by the report with respect to each of the following: (1) The number of mental health professionals, graduate medical education trainees, and primary care providers who have been certified under the program required by subsection (d) and the amount and nature of continuing medical education provided under such program to such professionals, trainees, and providers who are so certified. (2) The number of women veterans who received counseling and care and services under subsection (a) from professionals and providers who received training under subsection (d).
(3) The number of graduate medical education, training, certification, and continuing medical education courses provided by reason of subsection (d).
(4) The number of trained full-time equivalent employees required in each facility of the Department to meet the needs of veterans requiring treatment and care for sexual trauma and post-traumatic stress disorder.

(5) Such recommendations for improvements in the treatment of women veterans with sexual trauma and post-traumatic stress disorder as the Secretary considers appropriate.

The full 2010 Act is available here

Quality & accessibility

Access to health care professionals qualified to treat PTSD has been found to be limited. Staffing for qualified professionals has been found to be concentrated in urban areas. For veterans seeking help for PTSD outside the VA, insufficient health insurance coverage may limit options for treatment. As a result of gaps in availability to PTSD treatments in some areas, states have taken it upon themselves to establish programs to provide services for their veteran population. Some of these programs are formed in a collaborative effort with the VA; others are independent programs by states.

Evidence has shown psychotherapy to be a more effective treatment for PTSD than medication. However, evidence-based training and quality improvement (QI) is not considered a normal part of training for professional psychotherapists. Therefore a lack of standard practices exists in dealing with PTSD - in particular for PTSD incurred as a result of combat exposure. Research has also shown treatments for depression and anxiety among veteran patients suffering from PTSD to be more effective when veterans receive care in an integrative health care setting. This is compared to traditional mental health care treatment, which separates physical and mental health, emphasizing pharmacological treatments for mental diseases.

Economics

Cases of PTSD and Severe Depression Among U.S. Veterans Deployed to Iraq and Afghanistan Between October 2001 and October 2007

It is estimated that PTSD among veterans in their first two years after deployment accounts for between $4.0 and $6.2 billion in total costs to society. The same report also estimated that 14% of troops reported symptoms of PTSD, and 14% reported symptoms of severe depression; 9% had symptoms of both PTSD and severe depression. Of the 1.64 million veterans who were deployed to Iraq and Afghanistan between October 2001 and October 2007, it is estimated that 303,000 are suffering from PTSD, major depression, or both. A report found that in 2005, out of 2.6 million veterans receiving benefits, PTSD was the major condition for 203,378 veterans, more than double that of any other condition. Among veterans rated by the VA as 100% disabled, the most common major diagnosis is PTSD (26% of completely disabled veterans).
PTSD and major depression produce costs to society in the form of lost lost productivity, suicide, poor physical health, engagement in risky behaviors, substance abuse, homelessness, and effects on spouses and children. The most significant cost to society is lost labor productivity. On a per case basis over the first two years post-deployment, it is estimated that costs to society are $5,904 to $10,298 for PTSD cases, $15,461 to $25,757 for depression cases; and $12,427 to $16,884 for cases of combined PTSD and depression. It costs approximately $7,300 per year to treat PTSD with depression and $5,860 to treat depression without PTSD.

Goals of Compensation

In deciding how to compensate disabled veterans, the goal of the United States government is to compensate veterans for economic losses incurred by being unable to work. The War Risk Insurance Act of 1917 establishes a rating system that "shall be based as far as is practicable upon the average impairments of earning capacity resulting from such injuries in civil occupations, and not upon the impairment in each individual case, so that there shall be no reduction in the rate of compensation for individual success in overcoming the handicap of a permanent injury."

External links

• MilitaryMentalHealth.org
• Where to get help for PTSD
• Understanding PTSD - From the US Department of Veterans Affairs
• PTSD Treatment Programs in the US Deaprtment of Veterans Affairs
• PTSD Support and Information