AMVETS National Headquarters, March 13, 2019 – The results of the “2018 Annual Report: VA Mental Health Program and Suicide Prevention Services Independent Evaluation” required by the Clay Hunt SAV Act, provided scant evidence of improvements to veterans lives despite tens of billions of dollars being spent over the past decade, and a generally unaffected rate of suicide.
“Our independent review of these outcomes are simply not as chipper as those apparently paid millions to do the same, and other work, by the VA. We don’t smell smoke, this is a five-alarm inferno, and our vets are paying with their lives,” said AMVETS National Commander Rege Riley.
More than four years after passage, the report highlights significant service delivery gaps and an over-emphasis on continued funding of the same type of care both VA and DoD have provided for a significant period of time.
“There is no doubt in my mind that this report is what led to the recent Executive Order by the President. They rightfully realized that we are simply on a track headed to the same ineffective results, buried this report, and immediately scrambled for a new way forward,” said Joe Chenelly, AMVETS Executive Director.
The report was dated October 2018, though it was sent to Congress the night after Christmas. Certain Committee Staff from the House Veterans Affairs Committee refused to provide AMVETS a copy of the report, prior to hosting an invitation only Mental Health Care Roundtable. Many key congressional staff have yet to be made aware of the report or have been provided with a copy of it, despite its alarming findings.
“We will not tolerate closed doors and secrets on this issue. Too much is at stake. Our system is broken. We are effectively starting from zero, and we need to accept that and start building a mental health system that works. We need all ideas on the table and they need to be tested,” said Commander Riley.
AMVETS Key Findings of the Report:
• Considering the incredible amount of resources the VA has been given to address the epidemic of veteran suicide, the report found that suicide continues to be a significant problem in the veteran population. The report noted that Veteran Health Suicide (VHS) prevention programs appear to have some positive impacts due to reductions in suicidal behavior and ideation. In reality, the number/rate of suicides has not declined, which is the most important outcome to be considered when assessing the effectiveness of suicide prevention programs.
• It is important to note that approximately 6 out of 10 veterans report the mental health services they receive as “High Quality.” This means 4 out of 10 Veterans feel VA care is of “Medium to Low Quality.” This is concerning since the VA tends to boast about the high level of satisfaction of veterans regarding healthcare services.
• In sum, it is highly concerning that only minimal improvements have been noted in the treatment of posttraumatic stress disorder and general mental health. Moreover, no positive impact with regard to suicide has been noted as a result of completion of VA suicide prevention programs. The VA has spent millions of dollars and years studying standard “evidence-based” treatments for conditions like PTSD, depression and suicide. It is time that other approaches to psychological wellness be considered. As noted in the August 2015 edition of the Journal of the American Medical Association (JAMA) about existing treatments for PTSD, “New innovative and engaging approaches for the treatment of PTSD are needed…” and “…it is essential to develop therapeutic alternatives for patients to achieve their personal therapeutic goals (Kearney & Simpson, 2015).” Veterans can no longer rely on organizations relying on the fallacy of sunk costs when it comes to finding effective mental health treatments for our Nation’s Veterans.
Kearney, D. J. & Simpson, T. L. (2015). Broadening the Approach to Posttraumatic S tressDisorder and the Consequences of Trauma. JAMA, 314(5), 453-455.
• Based on the outcomes of the evaluation, it is surprising that the report was not more critical of the effectiveness of the various programsstudied. Changes in clinical outcomes were minimal; however, the authors of the report chose to comment on statistical significance (the changes in outcomes were not due to chance) versus clinical significance (the outcomes were noticeable and meaningful to the veteran). Below are examples of interpretation of the outcomes by the report’s authors for general mental health services, specialized posttraumatic stress disorder (PTSD) services, and suicide prevention services followed by alternative interpretations that focus on practical implications of the data: General Mental Health Services.
• The organizations involved in completing the independent evaluation of the VA mental health and suicide prevention programs and services receive millions of dollars in VA contracts. This raises questions regarding the “independent” nature of the evaluation.
BOTTOM LINE ANALYSIS FOR GENERAL MENTAL HEALTH: The Report authors are reporting statistically significant changes, but in reality, there is little practical improvement for the veterans. Overall, the changes are not large enough for the typical veteran to report any noticeable improvement in their general mental health.
SPECIFIC COMMENTS: Rating Scale: Kessler 6–measures general mental distress with ratings that range from 6 to 30. Scores above 19 indicate serious mental distress; lower scores are better/reflect improvements.
Results: Over a 90 day period, scores slightly decreased from approximately 16 to 15.
Report interpretation: “Statistically significant improvements.” This means the changes were not due to chance.
Alternative interpretation: Although the changes were not due to chance, they were not great enough to indicate any real improvement in the veteran’s life. There is little to no practical significance (i.e. the veteran doesn’t feel better).
Rating Scale: MSC12–measures mental components of general health with ratings that range from 10 to 70. The general population average runs from 45 to 53 depending on the version of the scale used; higher scores are better.
Results: Over a 90 day period, scores went from 37 to 39. Report interpretation: “Although they improved within 90 days of treatment, their mental functioning scores remained below the population norm.” In other words, they continued to have more mental distress when compared to civilians.
Alternative interpretation: Although it is true there was change in scores for mental functioning, the changes were not great enough to indicate any real improvement in the veteran’s life.
Rating Scale: ECHO–measures consumer satisfaction with mental health and substance use disorder care. Scores range from 3 to 15; higher scores are better.
Results: Scores increased from 10 to 10.5.
Report interpretation: “There were small but statistically significant changes for female veterans.”
Alternative interpretation: A movement from 10 to 10.5 on a 12 point scale is not realistically meaningful. There were virtually no changes in satisfaction among male veterans and very small change among female veterans.
PTSD Specialty Care Services
BOTTOM LINE ANALYSIS FOR PTSD SPECIALTY CARE SERVICES: The measures of clinical symptoms show no real improvement and the veterans report the same.
SPECIFIC COMMENTS: Rating Scale: PCL5–measures the presence of posttraumatic stress disorder symptoms. Scores range from 0 to 80; lower scores are better.
Results: Over a 90 day period, scores decreased from 45 to 41.
Report interpretation: “Significant decline in PTSD symptoms…need for further PTSD treatment.”
Alternative interpretation: Although the decline may have been statistically significant, it is not clinically significant. The average veteran likely retains the PTSD diagnosis after “successful’ PTSD treatment. The average veteran who receives services is unlikely to feel noticeably better after specialized PTSD treatment within the VA.
Rating Scale: Kessler6– measures general mental distress with ratings that range from 6 to 30. Scores above 19 indicate serious mental distress; lower scores are better/reflect improvements.
Results: Over a 90 day period, scores went from 18 to 17.
Report interpretation: “Veterans achieved scores that were below the threshold Indicative of serious mental illness.
Alternative interpretation: Veterans were already below the threshold of serious mental illness and did not get incrementally better. In other words, again, there was very little practical, clinical, or meaningful change for the veteran.
Rating Scale: ECHO–measures consumer satisfaction with mental health and substanceuse disorder care. Scores range from 3 to 15; higher scores are better.
Results: Scores went from approximately 9.7 to 10.4 (less than one point).
Report interpretation: “No statistically significant changes on the extent they believe their health has improved.”
Alternative interpretation: The average veteran reports that their overall health has not improved.
AMVETS Recommended Path Forward
• This report, which took four years to complete, highlights the general ineffectiveness in VA’s ability to deter suicide or to provide meaningful outcomes to our veterans mental health. In fact, over this same period of time we have seen increases in the rate of suicide in the Department of Defense, which relies on similar treatment modalities. AMVETS requests Congress hold immediate hearings on these findings and bring in truly independent researchers as well as VA researchers to effectively evaluate the data in a manner that more clearly articulates the facts.
• Per our recent testimony, we request that Congress immediately create a bicameral roundtable and taskforce that combined would hold an event at least once every other month highlighting and tackling this issue. Specifically, we are hopeful that Congress will closely evaluate the programs and methods currently funded at VA, their long-term effects and outcomes in helping veterans live high quality lives, while also considering any alternative approaches that are leading to positive outcomes by mitigating negative symptoms, creating notable improvements in quality of life and, ultimately, stemming the suicide epidemic.
• DoD also plays a critical role in this process as do the Armed Services and Mil-Con Committees. For many of our veterans, their downward spiral starts at their transition from the military. That moment when they leave behind their band of brothers and sisters, lose their mission and purpose, and often find themselves isolated. This is a critical final touch point, one in which crucial training can be provided prior to their geographic dispersion and to which DoD owns a significant role in a positive long-term mental health outcome.
• VA should fund outside approaches and research, and immediately implement, pilot, and research promising approaches throughout VA, and discard or incorporate promising findings from others. The organization is in need of a major reorganization in purpose and outcomes and needs to move away from defending the status quo and embracing a better future based on significant progress in veterans lives. AMVETs believes VA should continue to be the primary provider of mental health treatment, but immediate innovation is needed. We can no longer build onto the fallacy that the current approach is going to move the needle in any significant manner. What VA is doing is not working, we need to stop acting as such, and we need a vast and comprehensive restructuring of VA Mental Health to get us to a place where vets lives are significantly, and positively made better.
• 90 days of research appears to be a poor guideline. More needs to be done to better understand the effect that VA, DoD, and private Mental Health programs and approaches are having on veteran’s quality of life over sustained periods of time. “Evidence-based” needs to be evaluated in terms of what that means to veterans and over what period of time and how these “evidence based” approaches in totality seem to affect veterans quality of life over time. We can no longer afford to live by seemingly positive affects over 90 days as a standard. How are these veterans lives improved at 6 months, 12 months, 18 months, etc.? If there is not “significant positive change” over time, scrap it; it is not likely a path worthy of pursuit.
• The report in its entirety focuses only on symptom reduction and in no way discusses how these services are leading veterans to happier healthier lives. A new approach should first focus on outcomes over time for veterans, not symptomology reduction only.
“Today we are sending a letter of support to Senators Tester and Moran for new legislation named after another veteran who died by suicide. We still have not done much for the memory of Clay Hunt, and I am growing weary of many new pieces of legislation being named after fallen veterans and service members. More than 24,000 veterans have died by suicide since the passage of the Clay Hunt Act, in February of 2015, and this report in his name has largely been buried. God willing, we won’t be stuck with the same system we have now in 2023, with a new report that highlights: what you keep doing, continues to not work,” said AMVET’s National Commander Riley.
AMVETS is the nation’s largest and oldest Congressionally-chartered veterans service organization that is open to and fights for all veterans who served honorably, including reservists & guardsmen. AMVETS has been a nonpartisan advocate for veterans and their families for more than 70 years. amvets.org