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Office of Public and Intergovernmental Affairs

Remarks by Former Deputy Secretary W. Scott Gould

VHA National Mental Health Conference
Baltimore, MD
July 23, 2009

Thank you, Ira. And thank you, all, for your kind reception. It’s a pleasure to join you this morning. First-off, as leaders in VA mental health services, I want to take this opportunity to tell you that you’re doing a great job … really outstanding work. I say that from the perspective of four intense months on the job, as well as from a very personal understanding of VA care, because for the last 11 years of his life, my dad was an Alzheimer’s patient in the VA system.

I’ve seen, first-hand, the depth of your dedication to patients suffering with neurologic and other mental health disorders, and to their families as well. My own family and I understand the duality of dealing with an imposing bureaucracy and wanting the very best for a loved one. To a person, the VA employees I met leveraged great clinical care—and coupled it with even greater compassion—to do a tremendous job in caring for my dad.

Inherently, your work has a profound potential for doing good—for Veterans … and for the families who care about and support them.

We all know that the human mind is mankind’s most fundamental resource, yet the stats for mental illness in the American population at large are startling: In any given year, about one-in-four adults suffer from a diagnosable mental disorder. Similarly, in our own system, of the more than 5.5 million Veteran-patients we saw last year, over a million-and-a-half received a mental health diagnosis.

In this time of war, when approximately 1.6 million service members have been deployed to Southwest Asia, conditions ranging from PTSD to Traumatic Brain Injury—and everything in between—are occurring more frequently, affecting more Veterans, requiring more expansive and prolonged treatments, causing more suffering, and, all too often, causing some to choose death as the only firm hope of relief.

The numbers tell the story. Among OEF/OIF Veterans seen by VA from 2002 through 2008, a disturbing percentage have records indicating some mental health diagnosis, or are being further evaluated because of concern about a possible diagnosis.

And while OEF/OIF Veterans represent no more than 11% of all Veterans being seen for mental health care, these figures are sobering for a number of reasons, not the least being that this generation of troops—the first of the 21st century—will be with us for a very long time.

Theaters of combat, by their very nature, demand courage; we know that. But as the Roman philosopher, Seneca, observed two millennia ago, for many Veterans struggling with mental illness, ‘sometimes even to live is an act of courage.’

We see that courage of life, every day, in our medical centers and clinics. And whether we call it ‘Shell Shock,’ ‘Battle Fatigue,’ or PTSD, the silent, unseen wounds of war can be just as severe, in terms of human suffering, and just as lethal as the most traumatic physical injury sustained on the battlefield.

The urgency in addressing this issue is evident in the headlines telling us that 131,000 Veterans are homeless on any given night, over a million run afoul of the legal system, and 18 Veterans commit suicide each day—a tragedy. In fact, when we look at the entire Veteran population, there have been more Veterans’ lives lost to suicide since 2001 than on the battlefields of Iraq and Afghanistan. And all this doesn’t take into account the countless numbers of shattered relationships and dysfunctional families caused by PTSD.

Our OEF/OIF contingent has our department’s concern and focus right now. Their increased rates of alcohol and drug abuse and domestic violence demand our attention as troops withdraw from Iraq and deploy to Afghanistan … and as they confront reintegration issues back home.

In these areas, and across the full spectrum of VA care, we are committed to all Veterans—from our Greatest Generation to our latest generation.

The job at hand is to set and maintain the cutting edge of advance in mental health care. Period. We need to ‘set it right’ to ‘get it right’ if we are to align our 19th century mandate with our 21st century mission. You—the mental health leaders in this room—have been doing just that through your daily work and meetings like this fifth anniversary mental health conference.

I can’t tell you how proud I am of what you do—from my own perspective, and from the affirming personal stories I hear from others. I can tell you, however, that as the nation’s largest provider of mental health services, VA intends to press its mental health transformation even further.

Our Mental Health Services Handbook update—so much the focus of this week’s discussions—is the foundation for quality mental health care in the 21st century, at once Veteran-centric, uniform, and accessible.

Implementation of the Handbook will require us to synchronize people, process, and technology. As our organizational ‘bible’ for the structure, protocols, and governance of our services, it establishes research as the bedrock of VA’s mental health services.

Our research should encompass complementary and alternative medical treatments—known as CAMs—so that we can determine which are most effective in relieving suffering and restoring health. I want to be clear that, as we encounter ever-newer alternative methods of treatment, we will explore them.

We need to be open to CAMs and assess how they may fit into our overall approach to mental health care. We should work to find new approaches and technologies that can more quickly and accurately detect PTSD and other conditions.

For instance, right now there is no proven technology for detecting PTSD; there are, however, promising technologies under development that may make detecting the number and severity of concussive events possible. In addition, evolving methods for measuring changes in brain wave activity may have the potential to help us identify and evaluate TBI.

In my view, we should be open to not imposing our conventional approaches but also to expanding our evidence-based approach for alleviating suffering and restoring health. I know that VA already employs meditation, yoga, and acupuncture in treatment; and we fully support approaches, like these, which achieve good results for our patients—after all, that’s our goal. Clearly, though, we will need to fund pilots to gather evidence on treatment effectiveness and then use this evidence to choose the right methods for treating individual Veterans.

My message here is that we are open to innovation. As mental health practitioners, your ideas and initiatives are welcome and I encourage you to share your thoughts and discuss them with your VISN and medical center directors.

We also need to find better ways to define what conditions coexist with—and can be confused with PTSD—which detract from treatment efficiency and success. And while we want to embrace new ideas, our research must unfailingly hold novel, unconventional therapies and regimens to the same rigorous standards of scrutiny as more traditional approaches.

Our care and practices are based on evidence-based strategies that encompass everything from evaluation, diagnosis, and medication … to treatments and rehabilitation. In these trying economic times, it would be remiss not to touch on the subject of clinical comparative effectiveness and its role in improving care by directing our finite resources to where they will avoid illness and improve health and health care most effectively.

As you know, Congress has shown concrete support for Veterans by its substantial appropriations to our budget and in the stimulus funds it has authorized. VA’s mental health services budget request for the 2010 cycle, alone, is nearly $4.6 billion. I can tell you that growth in these levels of funding will not be open-ended.

As we continue to initiate, implement, and measure our improvements to care and services, we must be able to continue to demonstrate to the American taxpayers that they are getting good value for their money; that we are not only good clinicians but good stewards of the funds entrusted to us.

In other words, we need to be asking ourselves: Are we caring for Veterans with treatment protocols that deliver the most benefit for the cost of care? That question speaks to the importance of sound metrics, and outcomes rooted in quantifiable or quality-based results. As a Veteran who comes from the corporate community, I can tell you that you can’t manage, or manage well, what you can’t measure, whether it be widgets or—as challenging as it may be—quality-of-life.

Other aspects of our Handbook-prescribed care are rehabilitation tailored to individual needs and services that are both Veteran- and family-centered.

These are critical factors as we address, for example, the growing percentages of substance-use disorders in our OEF/OIF population to leverage the knowledge and know-how of Vet Centers and couple it with the enormously positive influence of family members and support groups.

Whether VA is teaming-up with families or with local community providers, we should keep in mind that collaborations of all kinds—public and private—are a hallmark of progressive 21st century organizations. They are force-multipliers to accomplishing any worthwhile mission; we need to augment their use if we are to maximize a Veteran’s ability to successfully manage day-to-day life and its challenges.

VA has come a long way since the Mental Health Strategic Plan was approved in 2004. Today, our system is much larger than it was just five years ago; our scope of care is broader and our quality of care has improved.

Take our mental health work force—it’s grown enormously. At over 18,600 employees, it includes about 6% of the psychiatrists in America and a comparable proportion of clinical psychologists. We’ve hired more than 4,000 new mental health care workers in the past three years. We’ve extended the horizons of outreach, which, in itself, has significant life-saving potential. We’ve dramatically improved our suicide prevention program, most notably by launching the National Suicide Prevention Hotline. To date, it has directly intervened in 3,900 cases where a Veteran was clearly in danger. Averaging 350 calls per day, over 6,000 calls have resulted in suicide prevention referrals.

In fact, we just took our suicide prevention program to the next level, when earlier this month, our pilot Veterans’ Suicide Prevention Chat Line began operations. This initiative makes VA the first government agency to offer an internet-based access alternative to more traditional suicide prevention services.

This is a great example of targeting our newest generation of active-duty soldiers and Veterans—men and women who’ve never known a world without the internet and instant messaging and, as a result, are more comfortable on-line than coming into a VA facility or calling the Hotline. Over the coming years, through innovations like this, we must continue to leverage web-mediated technology to best advantage and to the benefit of those we serve.

There are many encouraging success stories like suicide prevention, which, in great measure, stem from your commitment and compassion, and your skill and knowledge. The fact is—in spite of the science and evidence underlying our care—mental health care is still a matter of people helping people. It’s about the relationship between the patient and the provider, and it stands as a critical component of mental health care. I believe it always will.

And because the interaction between people is so important, Secretary Shinseki and I believe it is equally important to support employees as they go about their work supporting Veterans. We want VA to be not only Veteran-centric, but employee-focused. There is a documented link between investment in people and organizational performance.

In April, a colleague of mine, Linda Bilmes, and I published a book called The People Factor, which describes why the Government needs to revise its approach to human capital and replace its outdated, 20th century systems with ones more suited to the demands of the 21st century. We made the case for Government to view the Federal work force as a mission-critical, national resource and treat it as we would any other resource—as a vital, strategic asset worthy of our ongoing investment.

In short, we pressed for a people-focused culture where there’s a commitment to performance and innovation. Where high-value systems, like acquisitions and information technology, are used to enhance our ability to deliver care. And where there’s a premium put on training and development and individual initiative.

This conference promotes that same line of thinking. It’s a forum for forward-leaning activities that directly contribute to the quality of our care: for team-building, networking, and information-sharing; for discussing lessons learned, best practices, and emerging trends; and for devising ways to expand our partnerships across-the-board as we work to strengthen our delivery of mental health care services.

It’s a terrific statement about our investment in people. And its return-on-investment will be counted in more knowledgeable, empowered employees; improved VA services; lives saved; and ultimately, better care for our Veteran-patients.

While people are the lynchpin to delivery of our mental health services, we can’t ignore the fact that, last year, VA provided 63,500 consultations to 28,000 Veteran-patients via telemental health using real time clinical video-conferencing. This represents an 18% growth in unique veterans served, and 29% more telemental health encounters compared to FY07. As I speak here this morning, over 2,400 Veterans are actively receiving mental health services in their homes.

These figures are impressive and are one of the reasons why VA is recognized as a national leader in telehealth development. Behind these stats are Veterans who depend on VA for their health and well-being; Veterans who receive care in the comfort of their homes; and Veterans who don’t have to travel long distances for care, or rely on someone else to take them, or worse, not receive care at all.

It has taken great skill and expertise to build and configure the IT infrastructure now in place, and still evolving. And it takes an even greater commitment to develop and maintain the therapeutic relationships that support Veterans with mental health conditions and help them live in the least restrictive settings possible.

Thanks to your work in this area, VA is now poised to establish a National Telemental Health Center at West Haven, Connecticut, to foster the clinical, technology, and business processes needed to further advance our services nationally. These ground-breaking programs further our goals for a Veteran-focused and future-oriented Department.

In a sense, VA Mental Health Services can be viewed as ‘walking point’ in a larger VA transformation. Your initiatives directly support the broad goals the Secretary has set out for our department: Veteran-centric, results-driven, and forward-looking. Goals that call for new thinking and new actions, and new approaches that bring about better outcomes.

While VA continues to be a leader in research and in the delivery of mental health care, and while we should be justifiably proud of our services, we should by no means be satisfied. Continuous improvement and measurable progress must be our bywords.

With that in mind, we intend to work with the Department of Defense, our academic affiliates, and a broad array of government and community partners, to not simply expand the current level of care and services, but to qualitatively advance it.

I am asking you, today, to build on the foundation of excellence that has been so solidly constructed and take it to higher and continuously improved levels. VA must and will find new methods of care that will enhance and improve the way we treat mental health conditions. We need to think about not only how we treat mental health problems once they occur, but also how we predict and prevent them. We must move forward in research to help us better understand the process of mental health disorders and target the most effective treatments. Very importantly, we must test CAMs to better understand and assess its relative clinical value, and then use it to enable us to improve treatment effectiveness and leverage our available resources to the best advantage. We must unravel the interconnection between different mental health disorders and define the best treatment, or combinations of treatments, for each condition, even when they coexist. Finally, we must break the cycle of mental health problems and associated homelessness for our Veterans.

To accomplish these goals, and to underscore the importance we attach to them, Secretary Shinseki and I will convene a Mental Health Summit later this year. We are asking that you use this upcoming conference to think in bold and innovative ways for envisioning VA services and care of the future. A future where mental health issues are prevented, demystified, accepted, and more effectively treated. We challenge you to participate in this effort with a sense of urgency and concern proportional to the importance of your mission.

I appreciate the opportunity to address you today. I want to personally thank each of you for all you’ve contributed to VA’s stature as a leading national mental health care provider.

Both Secretary Shinseki and I appreciate all of the good work that you are doing, and we look forward to your ideas and input over the months and years ahead.

And now, in the time remaining, I’d be happy to take any questions or comments.