Mental Health Care for Veterans Disputed

As troops return from Iraq and Afghanistan -- including thousands with combat-related mental disorders -- they enter a Veterans Affairs healthcare system sharply divided about how to care for them.

In the last decade, veterans hospitals across the country have sharply reduced the number of inpatient psychiatric beds, replacing them with outpatient programs and homeless services.

The new offerings, officials say, cost less and are just as effective.

“It used to be with mental illness that once you got it, you never got rid of it,” said Dr. Mark Shelhorse, a national VA mental health official. But “mental illness is perceived as a disease now just like hypertension and diabetes. We have medicines to treat it. We know that people recover and lead fully normal lives.”

But veterans’ advocates and even some VA psychiatrists say the hospitals, including the massive Veterans Affairs Greater Los Angeles Healthcare System, are flirting with disaster. They say the facilities are ill-equipped to deal with veterans who need the most extensive help for psychosis, substance abuse, suicidal impulses and post-traumatic stress disorder.

Last year, the Los Angeles hospital closed its psychiatric emergency room, a move that heightened the anger of the VA’s critics.

“We were too easily swayed in the past by the argument that after a while, it [PTSD] will go away,” said Jay Morales, a Vietnam veteran who chairs the mental health consumer advisory council at the Los Angeles hospital. “But there are Vietnam vets walking around today, 30 years after the war ended, having these problems.”

Dr. William Wirshing, a psychiatrist for 23 years at the Greater Los Angeles VA, agreed. “It’s absurd how much they’ve cut -- and it’s absurd how much they continue to cut,” he said.

A decade ago, VA hospitals in Los Angeles had rooms to treat 450 mentally ill patients each day. After a series of cutbacks and consolidations, the main Wadsworth hospital on Wilshire Boulevard can now accommodate only 90 veterans overnight in its psychiatric wards.

During the same 10-year period, the overall number of mental health patients treated by the VA Greater Los Angeles increased by about 28%, to 19,734 veterans in 2004.

The VA hospital in Los Angeles, the largest veterans hospital in the nation, treats 80,000 veterans annually with a budget of more than $450 million. It includes the hospital, nursing homes, a domiciliary, three main outpatient care sites and 10 community clinics. There are an estimated 510,000 veterans in Los Angeles County alone.

VA officials say that despite the cutbacks, the Los Angeles VA hospital offers more mental health services today than ever. Instead of keeping patients in locked wards overnight, the VA offers them outpatient programs and temporary accommodations in partnership with nonprofit groups, officials say.

“It’s not like we went into a hospital that was fully occupied and we said, ‘We don’t need this unit anymore,’ ” said Dr. Andrew Shaner, the hospital’s acting director of mental health. “We built programs that kept people relatively well and therefore out of the hospital, and that’s why we were able to do it.”

The question remains: Are the current offerings enough?

A report last fall by the U.S. Government Accountability Office cited estimates that 15% of service members stationed in Iraq and Afghanistan would develop post-traumatic stress disorder. As of December, about 1 million troops had spent time in one of the two war zones (about one-third have done more than one tour).

The GAO determined that the VA did not have enough information to know if it could meet the increased demand.

Shelhorse, the VA’s acting deputy consultant for patient care services for mental health, said the agency is monitoring the situation carefully and is pumping millions of dollars into mental health programs.

The shift from inpatient to outpatient mental health services has become a controversial issue throughout the VA system. A 1996 federal law prohibits the VA from reducing specialized treatment and rehabilitation for disabled veterans, including mental health services.

A VA committee has found that the agency hasn’t abided by that law. While VA hospitals may be treating more mentally ill patients, they aren’t spending as much money doing so. At the West Los Angeles VA, the amount spent on mental health has decreased from $74 million in fiscal 1997 to $64.4 million in fiscal 2003, according to a national monitoring system.

Experts disagree on whether outpatient care can replace inpatient treatment.

“I don’t think that intensive community treatment can take care of all the people that no longer have the availability of inpatient beds,” said Dr. H. Richard Lamb, a psychiatry professor at USC.

Lamb said the trend has led to an increase in homeless mentally ill and those in jails.

But Dr. Robert Rosenheck, director of the VA’s Northeast Program Evaluation Center, said changes in the VA system have not produced those results.

Studies, he said, have not shown an increase in jailed veterans after inpatient psychiatric beds have been cut. Nor, he said, have there been significant increases in suicides or veterans showing up at non-VA hospitals for care.

“Veterans very much preferred coming in and being in a supportive environment for an extended period of time,” Rosenheck said. But “when you look at objective outcomes, we don’t see scientific evidence of adverse effects” because of the cutbacks.

Even so, veterans’ advocates and psychiatrists have been complaining for years about cutbacks at the Greater Los Angeles VA.

For many, the final straw came in May when the hospital closed the psychiatric emergency room and shifted mental health emergencies to the main ER. Troubled patients are now cared for by nurses and other staff who, according to the critics, are not adequately trained to handle psychiatric emergencies.

Critics point to several instances since the transition in which psychiatric patients were admitted to inpatient wards without any written orders or treated with disrespect by ER nurses who didn’t understand their disorders. At least one female patient with PTSD attempted suicide.

“This is a dangerous situation,” said Guy Mazzeo, a veteran and member of the L.A. mental health consumer advisory council. “None of us” was consulted before the change, he said, referring to advocates for veterans and the VA’s outside advisory groups. And none agree with it, he said.

The veterans and their doctors have been joined in their criticism by Rep. Henry A. Waxman (D-Los Angeles), whose district includes the VA health center.

He asked the VA in January to hire a full-time psychiatrist for the emergency room and arrange for specially trained psychiatric nurses to work there, among other things. The VA declined his requests.

“I’m disappointed that the VA has not responded more aggressively,” Waxman said in an interview. “With Iraq and Afghanistan war veterans returning, these demands are only going to increase.”

VA officials say the criticism is unfair. Care in the main ER is more coordinated than the care given in the stand-alone psychiatric emergency room, they say. Patients can get their medical and mental problems treated in one place, instead of having to be shuttled between two.

Administrators say ER staff members have received extensive training. And they say that there’s no evidence that patients are receiving inferior care.

Dr. Dean Norman, the hospital’s chief of staff, said the closure of the psychiatric ER made sense because the number of patients using it had been decreasing for years, and the hospital did not have enough staff.

“One of our goals is to be good stewards of taxpayer dollars,” Norman said. “We didn’t make this in a precipitous or reckless fashion. This was well thought out, and we had good reasons for doing this.”

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Times staff writer John Hendren contributed to this report.