MINDVIEWIMPROVING THE QUALITY OF LIFE FOR VETERANS WITH PSYCHOSISVOL. 4 | ISSUE 3 | August 2011

visn 22 va desert pacific healthcare network mental illness research, education & clinical center

GUIdE TO VA MENTAl HEAlTH SErVICES fOr VETErANS & fAMIlIESNoosha Niv, Ph.D.

In 2008, the VA intro-duced the Uniform MentalHealth Services Handbookwhich established minimumclinical requirements forVHA Mental Health Serv-ices. The handbook de-scribed the essentialcomponents of mentalhealth services thatwere to be imple-mented nationally andspecified exactly whichservices must be pro-vided to veterans andtheir families at eachVA Medical Center andeach Community-BasedOutpatient Clinic(CBOC). Incorporatingthe new standard re-quirements for VHAmental health servicesnationwide, the hand-book was issued to en-sure that all veteranshave access to neededmental health services,no matter where inVHA they obtain care.

The VISN 16MIRECC ConsumerGuide Workgroup hasdeveloped an excellentguide that is a shorter, sim-plified version of the hand-book intended for thegeneral public. Developedspecifically for veterans,family members, or anyone

The guide provides in-formation about the types ofevidence-based treatmentsavailable for the most com-mon mental health problemsexperienced by veterans, in-cluding depression, anxiety,posttraumatic stress disor-

der, substance abuse,and severe mental ill-ness (i.e., schizophrenia,schizoaffective disorder,and bipolar disorder).Special programs forveteran populationswith special needs arealso covered. Specifi-cally, the guide pro-vides an overview ofVA programs forwomen veterans, veter-ans just returning fromdeployment, homelessveterans, older veter-ans, and veterans in-volved with thecriminal justice system.Suicide preventionservices and militarysexual trauma servicesare also discussed.

The appendix sec-tion describes the men-

tal health services VAmedical centers and clinicsare required to provide de-pending on their size andtype. It also provides a glos-sary of common VA mentalhealth terms.

else interested in VA mentalhealth care, this 20-pageguide provides a greatoverview of the mentalhealth services that VA facil-ities offer to veterans. Theguide covers many impor-tant topics, such as the guid-

ing principles of mentalhealth care, how to findmental health care, and thevarious treatment settings inwhich the VA offers care(e.g., hospitals, clinics, andthrough telemedicine).

UPCOMING EVENTS

To download the guide, please visit:http://www.mirecc.va.gov/visn16/docs/guide_to_va_mental_health_srvcs_final12-20-10.pdf

INTEGRATED BEHAVIoRALCouPLES THERAPy WoRkSHoPAugust 29 – September 1, 2011Location: Long Beach, CAContact: sglynn@ucla.edu

MIRECC TRAINING RETREATSeptember 14-15, 2011Location: Long Beach, CAContact: noosha.niv@va.gov

Mental Illness Research, Education and Clinical Center MENTAL ILLNESS RESEARCH, EDUCATION & CLIN

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IN THIS ISSUE

1 Guide to VA Mental Health Services for Veterans & Families

2 Letter from the Director

2 VA Launches New Personalized Veterans Health Benefits Handbook

3 The Interface Between Perception and Attention: Clarifying the Timeline of Cognitive Impairment in Veterans with Schizophrenia

4 Veterans Administration Celebrates 81st Anniversary: ABrief History

5 Military Sexual Trauma Directive

5 VISN 22 Military Sexual Trauma Coordinators

6 Trauma Support Goes Mobile

6 2011 Stand Down for Homeless Veterans

7 Honoring Dr. Gary Wolfe

7 Recent MIRECC Publications

8 New Grants and Awards

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lETTEr frOM THE dIrECTOrStephen R. Marder, MD

One of the most important prin-

ciples of recovery is that individuals

with serious mental disorders should

be empowered to take greater control

over the management of their ill-

nesses. For this to happen, these in-

dividuals need to have a greater

knowledge of their own illnesses as

well as their treatment options. In

addition, when consumers of care are better informed,

they can be effective agents for improving systems of

care.

This issue of MindView documents innovate ap-

proaches for informing VA mental health patients about

important services. The VISN 16 guide to services for pa-

tients and family members summarizes important infor-

mation from the Uniform Mental Health Services Hand-

book. This Handbook, originally developed for clinical

managers and clinicians, documents services that should

be available to every veteran who needs mental health

care. The VISN 16 guide adapts a consumer’s view and

can help an individual learn about his or her illness, the

treatments that have been found to be effective for the ill-

ness, and how to access those treatments.

The article by Niv and Bonet describes PTSD Coach,

an application for mobile phones that can help individu-

als with Post Traumatic Stress Disorder. As noted in the

article, it can help these individuals learn about their

symptoms and manage them through methods such as

muscle relaxation and deep breathing. In addition, it can

help individuals connect with VA services that are pro-

vided at VA facilities and the National PTSD hotline.

The Department of Veterans Affairs (VA) is currently

piloting a new, personalized Veterans Health Benefits

Handbooks. The handbooks are tailored to provide en-

rolled Veterans with the most relevant health benefits in-

formation based on their own specific eligibility. In essence,

each handbook will be written for the individual Veteran.

"These handbooks will give Veterans everything they

need to know and leave out everything that doesn't apply

to them," said Secretary of Veterans Affairs Eric K. Shinseki.

"Our Veterans will now have a comprehensive, easy to un-

derstand roadmap to the medical benefits they earned with

their service."

In addition to highlighting each Veteran's specific

health benefits, the handbook also provides contact infor-

mation for the Veteran's preferred local facility, ways to

schedule personal appointments, guidelines for communi-

cating treatment needs and an explanation of the Veteran's

responsibilities, such as copayments when applicable.

"Enhancing access isn't just about expanding the kinds

of services VA provides. It also includes making sure we

do everything we can to ensure Veterans have a clear un-

derstanding of the benefits available to them so they can

make full use of the services they have earned," Shinseki

said.

The new handbook is currently available only to cer-

tain Veterans in Cleveland and Washington, D.C. areas.

Following the pilot phase, full implementation across the

country is scheduled to begin in the Fall of 2011.

VA lAUNCHES NEw PErSONAlIzEd VETErANS HEAlTH BENEfITS HANdBOOk

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directly assessed in large samples of veterans with schiz-ophrenia and healthy comparison participants. This studyemployed a paradigm known as the Attentional Blink, inwhich the participants are asked to identify visual targetsembedded within a rapidly presented stream of visualdistractors. This paradigm was designed to assess the in-terface between perception and attention and to evaluatevisual processing at the level of milliseconds. The resultsof this study indicate that patients experience two typesof impairment: 1) at the interface between the early, per-ceptual stages and the later, attentional stages of process-ing and 2) a later, attentional deficit present throughoutthe processing timeline.

To clarify the findings of this study, we have con-ducted a follow-up study using electroencephalography(EEG) to allow us to tease apart the observed attentionaldeficit from the deficits at the interface between the per-ceptual/attentional interface. Our analyses of the EEGdata suggest that after attempting to control for the gen-eral attentional deficit, two distinct impairments re-mained: 1) a basic perceptual deficit and 2) a higher orderdeficit that is specific to later attentional processes andrelatively independent from deficits occurring earlier inthe processing timeline. These findings will aid us in dis-entangling the mechanisms in the brain associated withthe observed deficits as we continue this line of research.

The ongoing research being conducted in the Treat-ment Unit has helped to extend our understanding ofcognitive impairments by identifying the specific stagesof processing at which deficits occur for veterans livingwith schizophrenia and has contributed to increasingawareness of the importance of studying and eventuallytreating these impairments.

Among the many challenges faced by veterans livingwith schizophrenia is a wide array of cognitive impair-ments. The mental processes impacted by these impair-ments range from the most fundamental, such asperceiving basic geometric shapes or letters, to the highlycomplex, such as interpreting ambiguous social situations.Most of these impairments are resistant to current inter-ventions, and many are related to community functioning.The Treatment Unit of the VISN 22 MIRECC, in collabo-ration with the Clinical Neuroscience and Genomics Unit,has endeavored to specify the nature of these cognitiveimpairments and to identify the brain mechanisms under-lying them. These efforts have had as their ultimate goalthe development of treatment programs that would ad-dress the cognitive impairments directly and amelioratetheir impact on community functioning.

Several studies conducted recently within the unithave focused on differentiating impairments occurring atvarious stages of processing basic visual stimuli. The mo-tivation to conduct these studies was to improve our un-derstanding of how early processing stages associatedwith perception interact with later processing stages as-sociated with attention. Previous research has shown thatveterans with schizophrenia exhibit impairment at boththe early and later visual processing stages, and there isongoing debate regarding how the observed deficits inthese stages interact. Resolving this debate could helpfocus treatment development on addressing the earlydeficits, the later deficits, or on the interaction betweenthe two classes of deficits.

A recent publication authored by members of theTreatment Unit describes a study in which the interactionbetween early and later stages of visual processing was

THE INTErfACE BETwEEN PErCEPTION ANd ATTENTION: ClArIfyING THE TIMElINE Of COGNITIVE IMPAIrMENT IN

VETErANS wITH SCHIzOPHrENIAKristopher I. Mathis, Ph.D.

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July 21st was the 81st An-niversary of the creation of the“Veterans Administration.”The VA was established in 1930when Congress authorized thepresident to “consolidate andcoordinate Government activ-ities affecting war veterans.”President Hoover signed thebill creating the VA on July 21,1930.

The concept that govern-ment should care for its Veter-ans was not a new one. TheEnglish colonies in NorthAmerica provided pensions todisabled veterans who had de-fended the colonies against In-dians. The first of these lawswas established in Plymouthin 1636. In 1776, the Continen-tal Congress passes the na-tion’s first pension law.Payments were left to thestates, however, as the Con-gress did not actually have theauthority or the money tomake pension payments. The

first federal pension legislationwasn’t passed until 1789 whenthe first Congress assumed theresponsibility of paying vet-eran benefits following the rat-ification of the U.S.Constitution. The establish-ment of Naval Home inPhiladelphia in 1812 was thefirst national effort to providemedical care to disabled veter-ans. In 1833, Congress author-ized the creation of the Bureauof Pensions, the first adminis-trative office dedicated solelyto the aid of veterans.

The Veterans Bureau wasestablished in 1921, consolidat-ing programs previously man-aged by three agencies: theBureau of War Risk Insurance,Public Health Service and theFederal Board of Vocation Ed-ucation. At this time, the vari-ous Veteran benefits wereadministered by three differentfederal agencies: the VeteransBureau, the Bureau of Pensions

of the Interior Department,and the National Home forDisabled Volunteer Soldiers.The 1930 Executive Order,signed by President Hoover,consolidated these three agen-cies to form the new VeteransAdministration. BrigadierGeneral Frank T. Hines, whodirected the Veterans Bureaufor seven years, was named asthe first Administrator of theVeterans Administration, a jobhe held until 1945.

In 1944, Congress passedthe Servicemen’s Readjust-ment Act, the “GI Bill ofRights.” Signed by PresidentRoosevelt, the bill significantlytransformed the concept ofveterans’ benefits with threekey provisions: 1) up to fouryears of education and train-ing, 2) federally guaranteedhome, farm and business loanswith no down payment, and 3)unemployment compensation.The Veterans’ Preference Act of1944 also gave veterans hiringpreference where federal fundswere spent.

President Reagan signedlegislation in 1988 to elevate

the VA to Cabinet status. Pro-ponents of this change arguedthat the agency should havedirect access to the presidentgiven that about one-third ofthe U.S. population was eligi-ble for veterans’ benefits andthat the VA was second only tothe Department of Defense inthe number of employees ithired. On March 15, 1989, theVeterans Administration be-came the Department of Veter-ans Affairs, and Edward J.Derwinski, was appointed thefirst Secretary of Veterans Af-fairs.

In 1930, the VA had an op-erating budget of $786 millionand served 4.6 million veter-ans. Today, the VA has abudget of over $120 billion,provides care to more than 5.6million unique patients, andhires approximately 280,000employees. VA maintains thelargest integrated health caresystem in America and is ded-icated to fulfill President Abra-ham Lincoln’s call “To care forhim who shall have borne thebattle and for his widow, andhis orphan.”

VETErANS AdMINISTrATION CElEBrATES 81ST ANNIVErSAry: A BrIEf HISTOryNoosha Niv, Ph.D.

The VA is dedicated to fulfilling President Abraham Lincoln’s call “To care

for him who shall have borne the battle and for his widow, and his orphan.”

President Herbert Hoover, General Hines and staff, following the signing of Executive Order 5398 creating the Veterans Administration.

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In July 2010, the VA issueda policy directive regardingclinical care, monitoring, staffeducation, and informationaloutreach related to militarysexual trauma (MST) services.The directive defined MST as“psychological trauma, whichin the judgment of a mentalhealth professional employedby the Department, resultedfrom a physical assault of asexual nature, battery of a sex-ual nature, or sexual harass-ment which occurred while theVeteran was serving on activeduty or active duty for train-ing.” Sexual harassment wasfurther defined as “repeated,unsolicited verbal or physicalcontact of a sexual nature,which is threatening in charac-ter.” Public Law 103-452 re-moved limits on the durationof the care provided related toMST and specified that treat-

ment must be available to bothmale and female survivors ofMST.

Veterans and eligible indi-viduals who experienced MSTwhile on active duty or activeduty for training do not needto file a disability claim, beservice connected, or provideevidence of the sexual traumato receive MST-related care.They may receive MST-relatedcare even if they are not deter-mined to be eligible for otherVA health care benefits. AllMST-related health care, in-cluding medications, is pro-vided free of charge. Allveterans and potentially eligi-ble individuals must bescreened for MST experiencesusing the MST Clinical Re-minder in CPRS, and all VA fa-cilities must have appropriatephysical and mental healthcare available for MST- related

conditions.Every facility now has a

designated MST Coordinatorwhose responsibilities includemonitoring and helping to en-sure national and VISN-levelpolicies related to MST screen-ing, treatment and informa-tional outreach to veterans areimplemented at the facilityand associated CBOCs. MSTCoordinators serve as a pointof contact, source of informa-tion, and problem solver forMST-related issues. MST Coor-dinators are also responsiblefor staff education related toMST. Training may includetopics such as: sensitivity andconfidentiality; treatment op-tions; importance of, and ra-tionale for, screening; potentialimpact of an MST history onprovision of care; and back-ground information on MST.A mandatory training for all

VA providers will soon berolled out.

Each VISN now also has adesignated MST VISN-levelPoint of Contact (POC). It isthe responsibility of the POCto provide support to the MSTCoordinators within the VISN,to communicate with national,VISN, and facility-level leader-ship and other stakeholders,and to monitor and help en-sure that national and VISN-level policies related to MSTare implemented at VISN med-ical centers and CBOCs.

The national MST SupportTeam was established underthe direction of Amy Street,Ph.D. and Margaret Bell, Ph.D.Networking and training havebeen a priority with monthlyMST calls that feature talks rel-evant to the topic of MST andto the work of the MST Coor-dinators.

VISN 22 MIlITAry SExUAl TrAUMA COOrdINATOrS

MIlITAry SExUAl TrAUMA dIrECTIVENoosha Niv, Ph.D.

Greater Los Angeles

Carole A. Goguen, Ph.D.

213-253-2677 x4716

Carole.Goguen@va.gov

Long Beach

Lori Katz, Ph.D.

562-826-8000 ext. 4919

Lori.Katz@va.gov

San Diego

Carolyn Allard, Psychologist

619-400-5189

Carolyn.Allard2@va.gov

Southern Nevada

Diane Sakal-Gutierrez LCSW

702-636-4060

Diane.Sakal-Gutierrez@va.gov

Loma Linda and VISN 22 Point of Contact

Angie Tremmel, LCSW

909-825-7084 ext. 2595

Angela.Tremmel@va.gov

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Got PTSD? There’s an app

for that. There is now mobile

help for those suffering from

Post Traumatic Stress Disorder

(PTSD). A new mobile applica-

tion, PTSD Coach, has been

created by the VA National

Center for PTSD and the De-

fense Department's National

Center for Telehealth and

Technology to help individu-

als dealing with symptoms of

PTSD cope with the challenges

of readjustment and obtain as-

sistance anonymously. The

"PTSD Coach" is one of the

first in a series of free smart-

phone applications developed

by the DVA and DOD.

Although the app was de-

signed to work in conjunction

with traditional therapy, it can

be helpful for those who are

considering treatment or who

would simply like to learn

more about PTSD. The app

was specifically developed for

veterans and features tools for

tracking PTSD symptoms, in-

formation about PTSD, tools

to manage and cope with

symptoms, and direct links to

support and help. The symp-

tom tracker allows for self-as-

sessment and even suggests

that users should get profes-

sional help when symptoms

increase. The app addresses

frequently asked questions re-

garding PTSD and provides

information on coping skills

designed to help with various

symptoms. For example, it

provides step-by-step instruc-

tions in muscle relaxation and

deep breathing and integrates

personal photos and music

that can be utilized during

stressful periods. The app in-

cludes multiple links to vari-

ous treatment and support

centers, including the National

Suicide Prevention Hotline.

Users can set up their own

personalized support network

as well.

“This is about giving Vet-

erans and Servicemembers the

help they earned when and

where they need it,” said Sec-

retary of Veterans Affairs Eric

K. Shinseki. “We hope they,

their families and friends,

download this free app. Un-

derstanding PTSD and those

who live with it is too impor-

tant to ignore.”

PTSD Coach was

launched in April 2011 and has

been downloaded more than

14,000 times in 41 countries as

of July 2011. PTSD Coach is

available for download via

iTunes and the Android Mar-

ket.

TrAUMA SUPPOrT GOES MOBIlENoosha Niv, Ph.D. and Vanessa Bonet, BA

Stand Downs are onepart of the Department ofVeterans Affairs’ efforts toprovide services to home-less veterans. The 24th An-nual Stand Down tookplace on July 15-17, 2011 atSan Diego High School.Over two hundred VA em-ployees volunteered for theevent, which provided var-ious services includingmedical, dental and legal af-fairs to former servicemenand women. Over a thou-sand Veterans utilized vari-ous services provided bythe VA including dispen-sary needs, testing for HIVand Tuberculosis, skin andfoot care, and mental healthand substance abuse refer-ral.

2011 STANd dOwN fOr HOMElESS VETErANS

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rECENT MIrECC PUBlICATIONS

Harvey, P-O., Lee, J., Cohen, M.S.,Engel, S.A., Glahn, D.C., et al.(2011). Altered dynamic coupling of lateral occipital complex during visual perception in schizophrenia.NeuroImage, 55, 1219-1226.

Harvey, P-O., Lee, J., Horan, W.P., Ochsner, K., & Green, M.F. (2011). Do patients with schizophrenia benefit from aself-referential memory bias? Schizophrenia Research, 127, 171-177.

Rassovsky, Y., Horan, W.P., Lee, J. Sergi, M.J., & Green, M.F. (2011). Pathways between early visual processing and functional outcome in schizophrenia. Psychological Medicine, 41, 487-497.

Sun, Y., Farzan, F., Barr, M.S., Kirihara, K., Fitzgerald, P.B., et al. (In press). Gamma oscillations in schizophrenia: Mechanisms and clinical significance.Brain Research Reviews.

HONOrING dr. GAry wOlfENikki Frousakis, Ph.D. and Noosha Niv, Ph.D.

Each year the Association of VA PsychologistLeaders (AVAPL) presents a Professional ServiceAward to a psychologist in recognition of outstand-ing service and accomplishment in psychology inservice to the VA. Gary Wolfe, Ph.D., has beennamed this year's recipient of the AVAPL Profes-sional Service Award. He was honored for his serv-ice at this year’s American PsychologicalAssociation Convention on August 5th in Washing-ton, DC. Dr. Wolfe was also awarded the AVAPLLeadership Award in 2007.

Dr. Wolfe has worked at the VA for 35 years.During this time, he spent 11 years as the TrainingDirector of the APA-approved Psychology Intern-ship Training Program at the Downtown Los Ange-les Outpatient Clinic (now called the Los AngelesAmbulatory Care Clinic or LAACC). Since 1998, hehas been the Department Chair in Psychology forthe VA Greater Los Angeles Healthcare System andAssociate Chief of Mental Health for LAACC. Dr.Wolfe has made invaluable contributions to mentalhealth for countless veterans and has served as amentor to numerous clinicians who have moved onto leadership positions both at the VA and at otherfacilities.

Dr. Wolfe will retire in January 2012. He is anavid cyclist, and his plans for retirement includeplenty of bicycling. Additionally, he plans on re-maining involved in research as a consultant onstudy design and statistics.

Thank you, Dr. Wolfe, for your service to theVA. You will be missed!

MENTAl IllNESS rESEArCH, EdUCATION

ANd ClINICAl CENTErVA Desert Pacific Healthcare Network

Long Beach VA Healthcare SystemEducation and Dissemination Unit 06/116A

5901 E. 7th StreetLong Beach, CA 90822

dIrECTOrStephen R. Marder, MD

CO-dIrECTOrS, EdUCATION ANd

dISSEMINATION UNITNoosha Niv, Ph.D.

Christopher Reist, MD

MINdVIEw EdITOrNoosha Niv, Ph.D.

CONTrIBUTOrSVanessa Bonet, BA

Nikki Frousakis, Ph.D.Kristopher I. Mathis, Ph.D.

MINdVIEw QUESTIONS Or COMMENTS

Contact Noosha Niv at noosha.niv@va.gov

VISIT US ON THE INTErNET AT:

www.mirecc.va.gov/visn22

Mental Illness Research, Education and Clinical Center MENTAL ILLNESS RESEARCH, EDUCATION & CLIN

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VA D

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NEw GrANTS

“Gating and Inhibition in Schizophrenia:

Studies of Startle Plasticity in Schizophrenia

Patients and Related Animal Models”

Principle Investigator: David Braff, M.D.

Funded by National Institute of Mental Health

Congratulations to Dr. Alexander Young and the

MIRECC Health Services Unit! Their talk, “Im-

plementation of Evidence-Based Weight Prac-

tices in Specialty Mental Health,” was selected

as the Best Abstract in Behavioral Health at the

2011 Academy Health National Conference.

NEw AwArdS