By Bob Brewin
May 5, 2008
Suicides among veterans of wars overseas occur "just like cancer occurs," and are not an indication of negligence by Veterans Affairs Department mental health care providers, a top VA official has argued in a lawsuit filed by two veterans groups. The official said he does not know how well VA hospitals are complying with a directive to provide 24-hour referrals to veterans with mental health problems.
Last year, two groups, Veterans for Common Sense and Veterans United for Truth, filed suit in U.S. District Court in San Francisco, charging that VA had failed to make mental health services immediately and widely available to returning veterans. Testimony in the non-jury trial ended last week.
Documents filed in the case revealed that the Justice Department tried to have the lawsuit thrown out on the grounds that language in the department's appropriations bills and prior case law "specifically and substantially limits VA's obligation to provide care … [and] creates no such expectation [that veterans are entitled to care] (emphasis and brackets added by Justice)."
Internal VA memos released at the trial in April disclosed that in February, the department knew it was facing 1,000 suicide attempts per month, which the veterans groups argued could have been avoided if VA had adhered to its 2004 Veterans Health Administration Mental Health Strategic Plan, which called for development of a "national, systemic program for suicide prevention."
A deposition by a VA medical center psychiatrist caring for veterans of the wars in Iraq and Afghanistan backed up the veterans groups' assertion that the department had not done enough to provide adequate mental health care for all veterans.
Dr. Marcus Nemuth, medical director of Psychiatry Emergency Service for VA's Puget Sound Health Care System in Seattle, which operates three hospitals, said in his deposition on March 25 that he expected a high volume of post-traumatic stress disorder cases among veterans returning from Afghanistan and Iraq. He said he was concerned with both with the quantity and quality of care provided to those veterans.
Nemuth said during the past year he had seen such a growth in the caseload of Afghanistan and Iraq veterans seeking psychiatric emergency help at the Seattle VA hospital that he concluded the department faced a "tsunami of medical need."
But William Feeley, the Veterans Health Administration's deputy undersecretary for health for operations and management, said in an April 9 deposition that VA did not have a metric to track suicides or attempts. He added that he could not recall a time since he took office in February 2006 when VA had conducted a quarterly review of suicides or attempts among the department's 21 Veterans Integrated Services Networks.
When asked in the deposition if any regional health care network directors had been disciplined or demoted because of increased rates of suicides or attempts, Feeley answered, "A suicide does not mean negligence on the part of a medical center director or a network director. Suicide occurs just like cancer occurs."
Feeley said he did not know how many Afghanistan and Iraq veterans in VA's care had committed suicide since February 2006. "I would consider that suicides go on with all war eras, and a particularly vulnerable population is a 55- to 65-year-old veteran as well, so I have not broken it out, or no one, to the best of my knowledge, has broken it out related to war era."
VA spokeswoman Laurie Tranter said VA would not provide additional comment on Feeley's remarks pending resolution of the lawsuit.
Before taking his job at VHA headquarters in Washington, Feeley served as director of the Veterans Integrated Services Network in upstate New York for three years, including 19 months after VA released its mental health action plan in June 2004. Though the plan required Veterans Integrated Services Networks take immediate action on a number of recommendations, including a requirement that the networks ensure that all community-based outpatient clinics with a population at least 1,500 veterans provide on-site, contract or telemedicine mental health services, Feeley said at his deposition that he had only read an executive summary of the plan while serving as a network director.
The plan contained 260 recommendations and mandates to be implemented in fiscal 2004, 2005, 2006 and 2007. But Feeley said in his deposition that he did not know as of June 2007 "whether [the plan] had been implemented." He added he did not know whether the national program for suicide prevention had ever been developed and deployed throughout VHA.
In June 2007 Feeley sent out a memo to Veterans Integrated Services Network directors requiring hospitals and community-based outpatient clinics to provide an initial evaluation within 24 hours to veterans who requested or were referred for mental health evaluation and/or substance abuse treatment.
Feeley also told network directors that as of Aug. 1, 2007, follow-up to these evaluations should occur within 14 days.
In his deposition Feeley said the June 2007 memo was sent in part in response to a May 2007 VA inspector general report that found initiatives detailed in the mental health plan pertaining to 24-hour crisis availability, outreach, referral and development of methods for tracking veterans at risk had not been deployed systemwide.
The inspector general recommended that VHA facilities make arrangements for 24-hour crisis and mental health care availability, either on site or through a hot line staffed by trained personnel. In addition, the IG said, an on-call mental health specialist should be available to crisis staff.
Feeley could not say during his deposition whether the policies laid out in his memo for 24-hour mental health referral and 14-day follow-up had been adopted throughout VHA. And aside from the suicide hot line, he could not say whether VHA had complied with other recommendations contained in the IG report. He said he "would have some trust in the organization" that the memo had been met with compliance. Otherwise, he said, "we will be spending millions of dollars related to auditing procedures."
Melvin Goldman, an attorney at Morrison & Foerster, the San Francisco law firm representing the veterans groups, asked Feeley: "If those millions of dollars resulted in the saving of one veteran's life, wouldn't they be worthwhile?" Feeley answered: "I think we have to make tough judgments in the industry on how to best measure success."
Feeley said he intended to ensure compliance with his memo through random site visits, saying he had completed five or six such visits as of April. But Antonette Zeiss, deputy chief consultant for patient care services at VA's Office of Mental Health Services, said at a pretrial hearing in March that site visits had been completed at only two VA facilities, in Los Angeles and Pittsburgh. Zeiss did not provide details on compliance in Pittsburgh, but said the Los Angeles facility was not in full compliance.
Gordon Erspamer, a Morrison & Foerster attorney, said in a trial brief that the 24-hour mental health evaluation procedures detailed in the Feeley memo as well as other suicide prevention steps taken by VA, such as the suicide hot line, amount to "nothing more than an empty promise on which too many veterans have tragically learned they cannot rely."
Justice Department attorney Daniel Bensing in his closing argument on April 30 called the charges by the veterans' groups "extreme and outrageous," adding that VA is providing "world-class health care in the mental health area."
Judge Samuel Conti is not expected to issue his ruling for a number of weeks.
The House Veterans Affairs Committee has scheduled a hearing for Tuesday on veteran suicides. The committee, chaired by Rep. Bob Filner, D-Calif., is expected to question top department leaders, including VA Secretary Dr. James Peake; Gerald Cross, principal deputy undersecretary for Health; and Dr. Ira Katz, deputy chief patient care services officer for mental health.
By Bob Brewin
May 5, 2008