FORRESTON, Ill. -- On Thanksgiving morning in 2005, in the metal pole barn that housed his family's
electrical business, Timothy Bowman put a handgun to his head and pulled the trigger. The bullet only grazed his forehead.
So he put the gun in his mouth and pulled the trigger again.
He had been home from the Iraq war for only eight months. Once a fun-loving, life-of-the-party type,
Bowman had slipped into an abyss, tormented by things he'd been ordered to do in war.
"I'm OK. I can deal with it," he would say whenever his father, Mike, urged him to get counseling.
The Department of Veterans Affairs is facing a wave of returning veterans like Bowman who are struggling
with memories of a war where it's hard to distinguish innocent civilians from enemy fighters and where the threat of suicide
attacks and roadside bombs haunts the most routine mission.
Since 2001, about 1.4 million Americans have served in Iraq, Afghanistan or other locations in the
global war on terror.
The VA counts post-traumatic stress disorder, or PTSD, as the most prevalent mental health malady
-- and one of the top illnesses overall -- to emerge from the wars in Iraq and Afghanistan.
VA Secretary James Nicholson and other top administration officials have said the agency is well-equipped
to handle any onslaught of mental health issues and that it plans to continue beefing up mental health care and access under
the administration budget proposal released last week.
But an investigation by McClatchy Newspapers indicates that even by its own measures, the VA isn't
prepared to give returning veterans the care that could best help them overcome destructive, and sometimes fatal, mental health
McClatchy relied on the VA's own reports from the mid-1990s through 2006, as well as an analysis of
VA data released under the federal Freedom of Information Act. McClatchy conducted a database search of 200 million records,
including every inpatient and outpatient visit for 2005, accessed VA documents and spoke with mental health experts, veterans
and their families from around the country.
Among the findings:
• Despite a decade-long effort to treat veterans at all VA locations, nearly 100 VA clinics
provided virtually no mental health care in 2005. Beyond that, the intensity of treatment has lessened. Today, the average
veteran with psychiatric troubles gets about one-third fewer visits with specialists than he would have received about a decade
• Mental health care is wildly inconsistent from state to state. In some places, veterans get
individual psychotherapy sessions. In others, they meet mostly for group therapy. Some veterans are cared for by psychiatrists;
others see social workers.
And in some of its medical centers, the VA spends as much as $2,000 for outpatient psychiatric treatment
for each veteran; in others, the outlay is only $500.
• The lack of adequate psychiatric care strikes hard in the Western and rural states that have
supplied a disproportionate share of the soldiers in the wars in Iraq and Afghanistan -- often because of their large contingents
of National Guard and Army Reserves. More often than not, mental health services in those states rank near the bottom in a
key VA measure of access. Montana, for example, ranks fourth per capita in sending troops to war, but last in the percentage
of VA visits provided in 2005 for mental health care.
Moreover, the return of so many veterans from Iraq and Afghanistan is squeezing the VA's ability to
treat yesterday's soldiers from Vietnam, Korea and World War II. And the competition for attention has intensified as the
vivid sights of urban warfare in Iraq trigger new PTSD symptoms in older veterans.
"We can't do both jobs at once within current resources," a committee of VA experts wrote in a 2006
report, saying it was concerned about the absence of specialized PTSD care in many areas and the decline in the number of
PTSD visits veterans receive.
"There are VA facilities that were fine in peacetime but are now finding themselves overwhelmed,"
said Steve Robinson, government relations director of the Washington-based advocacy group Veterans for America. "So they're
pitting the needs of the veterans of previous wars against the needs of Iraq veterans."
While the debate in the VA about the level of its psychiatric care is often frank, the public assurances
of top officials are oddly optimistic.
"Mental health is a very high priority of ours," VA Secretary Nicholson said last March. "The VA possesses
-- this will sound boastful, but ... as we used to say back home, it ain't bragging if it's true -- but we have the best expertise
in post-traumatic stress disorder in the world. ... So we are ramped upward, and we have a terrific cadre of experts in that
area, and we are adequately funded to deal with it."
"We feel very well poised to meet the needs," said Antonette Zeiss, a VA health official who is helping
to oversee the mental health system, in a November interview with McClatchy Newspapers.
In the past two years, the VA has committed more money to mental health care and brought services
to previously underserved areas. But it has also changed its accounting system, so it's difficult to compare spending after
2005 with that of prior years.
Veterans have fewer visits to mental health professionals, on average, than they did before. Between
1995 and the first half of fiscal 2006, for example, general psychiatry visits for those in the mental health system dropped
from an average of 11.7 a year to 8.1 a year per veteran, according to VA data.
VA experts said the system already was straining to provide veterans with what they needed before
the United States attacked Afghanistan in October 2001. "Even before the war in Afghanistan," Matthew Friedman, a top VA mental
health official, told Congress in 2004, "VA PTSD treatment capacity had been overtaxed."
The nearest VA outpatient clinic to Tim Bowman's hometown is part of the Madison, Wis., network. Like
a third of all the VA medical centers in 2005, Madison didn't have a specialized PTSD clinical team, according to VA records.
That's the case despite two decades of urging by VA experts that each medical center should have such
"Such specialization has long been recognized as an essential feature in treatment of military- related
PTSD," a 2006 VA report said. "Treatment of PTSD requires specific familiarity with the kinds of trauma veterans encountered
while in military service."
Its absence in many centers exemplifies a significant -- and growing -- problem in the VA: the wide
disparities in mental health services.
The VA's mental health experts started pushing for specialized PTSD programs in all medical centers
in the 1980s. Top VA officials agreed "in concept" that it would be a good idea. But in 2005 and 2006, despite telling Congress
that it was setting aside an additional $300 million for expanding mental health services, such as PTSD programs, the VA didn't
get around to spending $54 million of that, according to the Government Accountability Office.
At medical centers with no specialized PTSD teams, veterans still get PTSD treatment, but not from
the specialists whom the VA considers to be most essential.
In all, only 27 percent of veterans receiving PTSD care received it in one of the VA's specialized
programs, VA data show. And that varies widely: In the region that includes Wisconsin, 13 percent of veterans with PTSD got
care from specialized teams. In Ohio, 45 percent did.
That uneven mental health treatment can be traced to the VA's health system reorganization that started
more than a decade ago, which gave a lot of leeway to local managers.
McClatchy reviewed two dozen mental health indexes, based in part on an analysis of every inpatient
and outpatient visit in the VA health system in 2005. The 200 million records were contained in two fiscal 2005 databases.
Among the findings:
• Some veterans get in for visits far more than others. The average number of visits per veteran
with PTSD ranged from 22 in the Hudson Valley, N.Y., medical center and clinics to a low of 3.1 in Fargo, N.D. The national
average was 8.1.
• Some VA medical centers spend far more on mental health care than others. In Connecticut,
it was an average of $2,317 for each veteran's outpatient psychiatric care. In Saginaw, Mich., it was $468.
• Some veterans get in quickly. Others wait. At the VA network in Loma Linda, only 39 percent
of new mental health patients were able to get appointments within 30 days, the VA's standard. In other networks, 90 percent
or more did.
• Once they're in the door, some veterans get visits of 75 to 80 minutes, while others get 20-
to 30-minute appointments, the shortest psychotherapy appointments listed in the system. Of all the individual sessions for
veterans with PTSD, those in the Amarillo, Texas, network got the shortest possible visits 87 percent of the time, while those
in Butler, Pa., were given those short visits 6 percent of the time.
Asked about the disparities, the VA's Zeiss said: "It's true there are disparities. ... Disparity
is a part of health care. ... I can tell you that the data you're looking at we're looking at too, and we're using it
to make decisions about how to close the gap and ensure a standard of care nationally."