[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]



OVERSIGHT HEARING ON POST TRAUMATIC STRESS DISORDER (PTSD) AND TRAUMATIC BRAIN INJURY (TBI): EMERGING TRENDS IN FORCE AND VETERAN HEALTH
Thursday, September 28, 2006
House of Representatives,
Subcommittee on Health,
Committee on Veterans Affairs,
Washington, D.C.

 

The Committee met, pursuant to call, at 10:00 a.m., in Room 334, Cannon House Office Building, Hon. Henry Brown [Chairman of the Subcommittee] presiding.
 

Present:  Representatives Brown of South Carolina, Moran, Michaud, Michaud, Filner, Snyder.
 

Also Present: Representatives Boswell, Cantrell.

  Mr. Brown.  The Subcommittee will now come to order. Good morning, and welcome to todayï¿½s hearing on an issue that is very important to all of us.  I am pleased to have assembled, with the help of Ranking Member Mr. Michaud, the panel that we have in front of us here today.
  As most of you here today know, much has been written and discussed relative to Post Traumatic Stress Disorder, or PTSD, since the beginning of Operations Enduring and Iraqi Freedom.  We are fortunate to have before us some of those who are responsible for providing us critical data on this mental health condition, and I am eager to take this opportunity to learn more about the nature of the disorder and its prevalence amongst our returning servicemen and women.
  And while PTSD seems to have captured a majority of the headlines over the last few years, an equally challenging condition is being seen in increasing numbers at the VA; Traumatic Brain Injury, or TBI.  Due to the concussive nature of many of the war-related injuries being seen in Iraq and Afghanistan, TBI can take many forms, ranging from quite mild, almost undetectable, to very dramatic.
  We will be interested in hearing how the VA is meeting the increased demand, how the four polytrauma centers are handling that workload, and what best practices are being shared with other VA medical centers to ensure that the best care is being provided all around the nation for those who have suffered some form of TBI.  In addition, we are going to examine some of the similarities between PTSD and TBI in terms of how the conditions manifest, how they are identified and ultimately how they are treated.
  The important point I would like to add to this is that these injured servicemembers, in particular those with PTSD, can be treated and a sense of normalcy can be attained. Having said that, in the absence of in-theater risk mitigation techniques, effective early identification, and aggressive outreach and treatment, normalcy and appropriate adjustment may be difficult to realize for some returning from theater.
  This is an important topic and I want to again thank those assembled before us today for taking the time to help us better understand some of the emerging health challenges that both DoD and VA will continue to face.
  [The statement of Mr. Brown appears on p. 38]

  Mr. Brown.  I now yield to the Ranking Member, Mr. Michaud, for an opening statement.
  Mr. Michaud.  Thank you very much, Chairman Brown, for holding this very important oversight hearing.  Fatalities to our troops in Iraq and Afghanistan from blast-related injuries are lower than in previous conflicts, due to improved protective combat equipment and advances in the delivery of medicine on the battlefield.
  However, those who survive blasts are at great risk for Traumatic Brian Injury, or TBI.  Severe, moderate and even mild TBI can affect veterans and their families for the rest of their lives.  Brain injuries can impair functions including short-term memory, concentration, judgment.  As well, many TBI cases experience degrees of impaired vision. It can also affect a veteranï¿½s ability to return to work.
  The emotional and behavioral changes that result from TBI can place a tremendous burden on families and friends. Many veterans with mild TBI may have their symptoms misdiagnosed as a mental health disorder.  These veterans need targeted care to help them function better.    Post traumatic stress disorder (PTSD) is also a wound that many of our returning veterans carry home.
  Unfortunately, the stigma of mental illness often leads veterans to ignore or deny that they had any problems, even when they see their relationships and lives crumble under the weight of the symptoms of PTSD.  Untreated PTSD is linked with substance abuse, severe depression and unfortunately, even suicide.  Sadly, we have already seen too many Vietnam veteransï¿½and now veterans from Iraqï¿½go down this tragic path.
  Access to VAï¿½s mental health programs and TBI programs, and the quality of these programs depend on adequate funding. VA mental health care experts have recognized that VAï¿½s program have gaps in quality.  In response, Secretary Principi rightly adopted a mental health strategic plan with initiatives to address the gap in VAï¿½s mental health care efforts.  The Administration promised to commit $100 million in fiscal year 2005 and $200 million in fiscal year 2006 to fund these mental health care initiatives.
  Last fall, Ranking Member Lane Evans and I asked GAO to study whether the administration fulfilled this commitment to fund the new mental health initiatives.  Today, GAOï¿½s testimony provides its preliminary findings of the study. Sadly, the Administration is far short of fulfilling its commitment.  VA did not provide $100 million in fiscal year 2005 for new mental health care efforts.  VA only funded approximately $53 million.
  VA claimed to GAO that it also provided $35 million in funds generally distributed to VA hospitals and clinics.  GAO found, and VA concedes, that VA never told medical facility directors that the $35 million was to be used to rebuild mental health services.  GAO also found that some of the $53 million went unspent.  The preliminary findings for fiscal year 2006 were also disappointing.  VA allocated, at best, $158 million of the promised $200 million.  Again, GAO found that some of this money might not be spent.
  Gaps in mental health care services remain.  The mental health strategic plan is good.  However, without real commitment to funding, the plan will not become a reality. Members on both sides of the aisle want and need to address this very important issue.  We must keep our promise to our veterans and dedicate mental health care staff who want to help them recover from the psychological wounds of war.
  Funding and implementation of VAï¿½s mental health plans will require vigorous oversight from this Committee.  That is why I am pleased, Mr. Chairman, that we are holding this hearing.  Further, it is my intention to continue to press for passage of Lane Evansï¿½ Comprehensive PTSD Bill, H.R. 1588.  It is also my intention to re-introduce an updated version of this legislation in Lane Evansï¿½ name in the 110th Congress to ensure that his noble efforts are carried on in order to meet the critical mental health challenges that we face.
  So with that, Mr. Chairman, I want to thank you very much, and I also would like to welcome both Representative Pascrell, and Representative Boswell.  And I want to thank Chairman Brown for allowing them to join us at this hearing, because I know they have a deep commitment to veteransï¿½ issues, and they definitely will add a lot to this discussion.  So thank you very much, Mr. Chairman.
  [The statement of Mr. Michaud appears on p. 41]

  Mr. Brown.  And thank you, Mr. Michaud, for the opening statement.  And I know both of the other gentleman from other committees, and they have got other responsibilities, so if it is the will of the Committee to allow them to speak out of order, and to speak for two minutes?
  [No response.]
  Okay, without objection.  Okay, Mr. Pascrell?

STATEMENTS OF HON. BILL PASCRELL, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY, AND HON. LEONARD BOSWELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF IOWA

STATEMENT OF HON. BILL PASCRELL

  Mr. Pascrell.  Thank you Mr. Chairman and Ranking Member Michaud, and also Committee members, for dedicating so much of your time to this very critical issue.  I salute the Veterans Committee.  Your work many times goes unnoticed, I understand that.
  I would like to ask that my entire testimony be inserted into the record, if you would?
  Mr. Brown.  Without objection.
  Mr. Pascrell.  As a cofounder of the Congressional Brain Injury Task Force, I am committed to improving the lives of individuals with Traumatic Brain Injury, TBI.  I would like to focus on an issue that has gained more and more publicity over the last year; dramatic brain injury in our nationï¿½s servicemen and women, past and present.
  Traumatic brain injury is defined as a blow or jolt to the head, or a penetrating head injury that disrupts the function of the brain.  This has been called the ï¿½ silent epidemic.ï¿½  A million five-hundred-thousand people are affected in the United States every year.  When I first learned of this, seven years ago, and I want to tell you, Mr. Chairman, I was just shocked out of my wits.  I never thought, until folks in my own district came to me, you know, we need to be educated on these things, and certainly members of Congress should be, if we are going to talk about it.
  Military duties increase the risk of sustaining TBI. For our armed forces, TBI is an important clinical problem in peace and war, and its consequences may extend for many years.  Over 1500 military personnel involved in the global war on terror have been seen and treated by DVBIC.  At Walter Reed alone, over 650 soldiers with brain injuries from Iraq and Afghanistan have been treated.  That represents 40 percent of all the troops evacuated to Walter Reed Medical Center so far.  About 10 percent of the servicemembers in Iraq, 20 percent of the troops on the front lines returned from combat tours with concussions.
  DVBIC, the Defense and Veteransï¿½ Brain Injuries Center, was established in 1992, after Desert Storm.  Until then, there was no overall systematic program for providing brain injury-specific care and rehab within the department of defense, or the Veterans Administration for that matter.
  The changing nature of warfare demands corresponding improved and specialized medical care.  It has been estimated that 50 percent of all combat injuries are blast injuries. So as part of the recently-passed blast injury prevention and mitigation and treatment initiative, the DVBIC is leading the effort to illuminate patterns of brain injury from blasts including providing guidelines for the assessment.
  I must say, Mr. Chairman, the last five years has seen more advancement in this area than probably in the past couple of hundred years, so that parts of the brain that have not been affected in a negative way can be developed, so that we can compensate.
  These are great times.  You know, I tell kids in the schools, ï¿½ Donï¿½t let your parents tell you, oh, for the good old days.ï¿½   These are the times when we can address these very serious injuries in terms of modern warfare.  The Defense and Veteransï¿½ Brain Injury Centerï¿½s mission is to serve active duty military, their dependents, and veterans with TBI, through state-of-the-art medical care, innovative clinical research initiatives, and educational programs.
  In order to better recognize TBI, the DVBIC has begun to employ improved diagnostics, increase brain injury training of battlefield medics, and clinical research on blast injury.
  Now, what I want to emphasize in concluding, Mr. Chairman, is the need to improve and expand the Special Committee on Post Traumatic Stress Disorder.  And the Committee on Care of Veterans with Serious Mental Illness recommended to the Veterans Administration, under the Secretary of Health, that VA establish a screening process to identify veterans with mild TBI.  I recommend that we look into that screening process.
  Also noted was the need for the VA to establish a TBI registry that can be used to create more sophisticated evidence-based, cost-effective assessment and treatment strategies.  We have passed general legislation to do this throughout the nation for civilian TBI.  We need to do it in terms of the special situation that we face as Americans.
  In July 2006, the Veterans Administration Inspector Generalï¿½s office reported on a lack of consistency in VA case management, citing that the effectiveness of case managers ranged from outstanding to inadequate.  The Inspector General also reported on a major weakness in the VAï¿½s TBI care, and its participation in the DVBIC program.  The number of TBI bedsï¿½I was shocked to find this outï¿½in head-brain injury treatment resources do not correspond to the scope of the problem.  That was the case since 1999; it is the case today, also.
  And very briefly, Mr. Chairman, I would ask youï¿½beg youï¿½ to look at the funding.  According to a recent study by researchers at Harvard and Columbia, the cost of medical treatment for individuals with TBI from the Iraq war will at least cost $14 billion over the next 20 years.  This is a sustaining situation; not going to be hit or miss.  Without our support, DVBICï¿½s congressionally directed mission of coordinating clinical health care, executing research that will result in better characterization and management of the problem, and education of both military and civilian communities will come to a halt.
  This is one of TBI tasks forceï¿½s primary mission.  As such, in conclusion, the task force along with other concerned members request an additional $12 million for the DVBIC in the Military Quality of Life, and Veterans Affairs Appropriations Bill for fiscal year 2007, for a total of 19 million.
  I know the Committee shares these sentiments, and I am absolutely thankful for the fact that you have let me testify.
  [The statement and attachment of Mr. Pascrell appears on p. 45]

  Mr. Brown.  Well, let me also thank you, Mr. Pascrell for taking your time to be part of this discussion.  We have got assembled a great panel that I am sure has listened very intently to some of your recommendations, and thank you for coming.  You can stay for the whole meeting if you would like, but we wanted to afford you the opportunity to speak first.
  And Mr. Boswell, if you could take a couple minutes, so we can proceed.

STATEMENT OF HON. LEONARD BOSWELL

  Mr. Boswell.  I heard the ï¿½couple minutes,ï¿½ and I will try to do that, sir.
  And I do thank you kindly, you and Mr. Michaud, for allowing us to do this.  As Congressman Pascrell has already said, very kind of you.  I have been respecting your work on this for a long time, and I salute you too, sir, because I know your heart is in this, you are focused, and we cannot thank you enough.  There are probably over a hundred of us here in this room and otherwise that are veterans.  And so we thank you.  I feel very fortunate.
  I would like to share with you before I start, I have a veteran that is from Iraq that is on my staff, and I would like to introduce you to this veteran.  She is standing right over there, Alexis Taylor; she has joined my staff, an Iraq veteran.
  Mr. Brown.  Glad to have you with us today.
  Mr. Boswell.  Again, Mr. Chairman, I would say this, that we all know it has been said that for more and more veterans are returning from tours of duty in Iraq and Afghanistan, there are many new issues and we have heard some of them.  But it is an issue that I donï¿½t think we canï¿½t ignore, and I am not suggesting that we are.
  The number of veterans returning with post traumatic stress disorder is alarmingly high.  A recent study found that 17 percent of soldiers and marines returning from Iraq screened positive for PTSD.  Our men and women in uniform returning from combat are fighting a different type of war, and a different type of enemy.  I thought maybe I had seen it all in Vietnam.  It was different, and there is no front line there, either.  I helped to put too many of our young men and women in body bags, and it makes a lasting impression.
  The National Center for PTSD found several things associated with individuals diagnosed with PTSD, such as physical pain, sleep disturbance, nightmares, substance abuse, self-harm, or suicide.  I believe obviously there is a connection between PTSD and suicide.  Some estimates have found that almost one thousand veterans receiving care from the Department of Veterans Affairs commit suicide each year, and research shows that one out of 100 veterans who have returned from Iraq have considered suicide.  I find this very disturbing.
  Since March 2003, 80 individuals who have served in Iraq or Afghanistan have committed suicide. Our young men and women serving our country have kept us safe for so long, it is our job, as you know, to protect them.  A few months ago I learned of a young man from my district, Joshua Omvig, who experienced undiagnosed PTSD after returning from an 11-month tour in Iraq.  His family and friends did not know how to help him.  Goodness knows they tried.  Then in December of last year Joshua tragically took his life.  He was only 22 years old.
  His parents were very close.  They knew something wasnï¿½t right, and they were trying everything they could think of. He was staying with them, going to work, and trying to get adjusted.  And one morning, his mother felt the intensity, and she stayed right with him as he went out to get in his pickup to go to work, and he shot himself in front of his mother, in the pickup.
  After I heard his story I was shocked to find one in a hundred Operation Iraq Freedom veterans have reported thinking about suicide.  I knew something had to be done, as anybody would feel.  That is why we have introduced H.R. 5771, the Joshua Omvig Veterans Suicide Prevention Act.  This legislation will mandate the Department of Veterans Affairs to develop and implement a comprehensive program to regularly screen and monitor all veterans for risk factors for suicide within the Veterans Affairs system.
  At any point in a veteranï¿½s life, if they were found to have specific risk factors for suicide they would be entered into a tracking system; ensuring they do not fall through the cracks.  Then they would be entered into a counseling referral system to make certain those veterans receive the appropriate help.  It would provide education for all VA staff, contractors, and medical personnel who have interaction with the veterans.  In addition, it would make available 24-hour mental health care for veterans found to be at risk for suicide.
  Currently, the Department of Veterans Affairs regularly screens veterans for depression, PTSD, and substance abuse, but not suicide specifically.  I am saddened by the circumstances that this legislation grew out of, but I know that if enacted, this program could save lives.  We treat their physical injuries, which goodness knows we should.  Now it is time to treat the wounds that are not visible.  It is my hope that a comprehensive veterans bill will result from this hearing and that any bill considered will include provisions for the Joshua Omvig Veterans Suicide Prevention Act.  This important issue cannot go another day without the attention it needs.
  And Mr. Chairman, I say this and I am looking you square in the eye, and I am very, very serious: it is not important to Leonard Boswell to have my name on that Bill.  It is not. We are in the political season, and we know that.  It is important that this need be taken care of, and I would be delighted if you, Mr. Chairman, Mr. Michaud, wanted to take this and make it your bill.  I donï¿½t care.  I know there is a need, and I think we all know that. And that is the way I deeply feel about it.
  It unfortunately came to my attention the manner it did. We stayed very close to the family, very close.  When we built this idea, we went and talked to them about it, because they have come out in a sense.  They want to help others. They are in their grief, and their shock, and it will go on the rest of their lives, but they want to do something to help others.
  And so we felt like we could, so I very carefully, very quietly went and talked to them with staff that was working on it, and said this is what we had in mind, what would they think about it?  And after a few tears, they said this would be wonderful.  I said, ï¿½ Now, it is up to you.  If allowed, I will name this the Joshua Omvig Bill.ï¿½   And they looked at each other and they said that they would be honored.  So that is the reason that it is on there.
  And I seriously donï¿½t care who gets credit for sponsoring this bill.  I want you to know that, Mr. Chairman. I say this in all sincerity: it needs action, and I have confidence that you and Mike will give it your attention.
  And I thank you very, very much for allowing me to make this testimony, and I will leave this for the record.
  Mr. Brown.  And we will certainly, with unanimous consent, allow the statement to be submitted for the record.
  [The statement of Mr. Boswell appears on p. 60]

  Mr. Brown.  And Mr. Boswell, I really do appreciate you and Mr. Pascrell coming and being a part of this discussion.  This has been a Committee hearing that has been late coming, and I am grateful for you allï¿½s input.  I know we have all got stories we can tell about personal involvement.  I know last July, I had my appendix taken out in Bethesda on the fifth floor, and had a chance to interact about four or five days with those young men and women coming back from harmï¿½s way.  And you know, you could see some visible injuries, you know, if so many came back without an arm or a leg, those were easily identifiable.
  I went into a room for this young guy from Florence, South Carolina, and it had half of his skull actually blown away, and they have got the computer technology to replace the image of that skull, and they all could draft hair on it, you know, to make a kind of look back like it was normal. But you could tell, as you look at that young manï¿½s eyes and you talked to him, that you knew that he was going to have a lasting problem with that brain injury.
  And so this is a major concern, and we are grateful for you allï¿½s input.  And you can stay as long as you would like, if you would like.
  Mr. Boswell.  Thank you what you just said.  And you know, with todayï¿½s technology, we do the battery of tests when the young men and women leave the service.  We have got the ability to see what is going on in their minds, and we have just got to do something about it.  And we thank you. We wouldnï¿½t ever think about doing something for the physical injury, as you well know.
  Mr. Brown.  Right.
  Mr. Boswell.  We would do everything we possibly could.  And the mental injury is just as important.
  Mr. Brown.  Thatï¿½s right.  Thank you so much.
  And our Ranking Member, acting Ranking Member, do you have an opening statement?
  Mr. Filner.  Yes, I would like to submit my opening statement for the record.
  Let me just thank Mr. Pascrell and Mr. Boswell not only for your expertise, but for your passion.  We need that energy, and I would say to the panel something I generally say after you all have testified: please donï¿½t hide behind statistics and bureaucrat-ese and written statements.  Let us know that you have some passion for doing this, for solving this issue.  I think we want to hear that more than anything else; more than any defensiveness about what youï¿½re doing, about things that you want to point out.  We want to make sure that you have the passion that many of us have from personal experiences.  I know you all do, too, but in these Committee hearings, it doesnï¿½t always come out.
  And let me say, I think we are letting our veterans down today.  The young men and women who are, as you have shown one of us here, Mr. Boswell, coming back, are the bravest young people in the world.  And yet we are not giving them the attention or the expertise that we have as a society.  We donï¿½t do outreach sufficiently.  We donï¿½t make sure that the mental, as has been said here, is seen as important as the physical health.  The mental scars will last probably longer or at least equally, and may have a deeper impact.
  And yet, when these young men and women come back, they donï¿½t even know what they got.  And when we have diagnoses of PTSD, the first thing the VA does, instead of saying, ï¿½ We have got to have more facilities, and more resources to deal with it,ï¿½  the first thing they do is investigate why we have so many diagnoses of PTSD.  That is disgraceful, that that is the response that these two men and women get, and the doctors who are dealing with him.
  And the tragedy, as I think both of our guests have said, is that we know how to deal with these issues today better than we ever have.  And we watch the same things for these returning Iraqi vets that we saw in Vietnam, when we knew less.  They come home without knowledge of what is going on. The family doesnï¿½t have any idea.  There is violence in the family, perhaps spousal abuse, kids run away, alcohol and drug abuse, loss of job, homelessness, suicide.
  I think the figures that I have seen, Mr. Pascrell, are much higher.  I have seen figures of several hundred suicides, and a much higher rate, as you point out, than either in the general veteransï¿½ population, or in the general population.  This is a tragedy.  The administration says, ï¿½ Support our troops, support our troops, support our troops.ï¿½ When they come home, we donï¿½t have the outreach for them, we donï¿½t have the resources for them.  We know that whatever percentage it is, whether it is one-half or one-third of our veterans that have PTSD, we donï¿½t have the resources to deal with it.  I have been at the PTSD clinics in San Diego.  They are wonderful.  We know how to deal with it.  But we are not getting these services to all the people that need them.  And we are not given the resources to make sure that we can handle them if we did.
  We even have now, as I think you pointed out, ways to perhapsï¿½knowledge of the brain that says we can physically identify who has certainly a higher risk of PTSD.
  So let us as a nation commit ourselves.  We made a tremendous moral mistake by not dealing with these issues for Vietnam.  It is not too late, by the way.  Half of the homeless on the streets tonight are probably Vietnam vets, probably with intense mental situations.  We need to bring them back, if we can.  But let us not lose more, who are returning from Iraq, to this terrible situation.
  So we want to give you all the resources that you need as professionals, but we have to look at this in a passionate way like our two guests have shown, and we have to, as a nation, say we are going to support our troops, we are going to treat these mental illnesses with the knowledge that we have, and we are not going to let them be lost and unable to further contribute to our society.
  Thank you Mr. Chairman.
  [The statement of Mr. Filner appears on p. 43]

  Mr. Brown.  Okay.  Thank you, Mr. Filner.
  Dr. Snyder, do you have an opening statement?
  Mr. Snyder.  I do not, Mr. Chairman, thank you.
  Mr. Brown.  Okay, thank you very much.
  We are absolutely impressed that we have got such an outstanding panel before us today, and let me introduce our panel.
  I welcome Dr. Gerald Cross, the Acting Principal Deputy Under Secretary for Health at the VA.  He is accompanied by Dr. Katz, the Deputy Chief Patient Care Services Officer for Mental Health, and Dr. Sigford, VAï¿½s National Program Director for Physical Medicine and Rehabilitation.
  Representing the United States Army, we are pleased to have Colonel Elspeth Cameron Ritchie and Colonel Charles W. Hoge.  Doctor Ritchie is the Psychiatry Consultant to the Surgeon General of the United States Army, and Doctor Hoge is the Director of the Division of Psychiatry and Neuroscience at the Walter Reed Army Institute of Research.
  They are accompanied by Colonel Labutta, the Chief of the Department of Neurosurgery at Walter Reed.
  We will now proceed with Dr. Cross.

STATEMENTS OF GERALD CROSS, M.D., ACTING PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY IRA R. KATZ, M.D., PH.D, DEPUTY CHIEF PATIENT CARE SERVICES OFFICER FOR MENTAL HEALTH; BARBARA SIGFORD, M.D., PH.D, PROGRAM DIRECTOR, PHYSICAL MEDICINE AND REHABILITATION SERVICES; COL. ELSPETH CAMERON RITCHIE, M.D., M.P.H., PSYCHIATRY CONSULTANT TO THE U.S. ARMY SURGEON GENERAL, UNITED STATES ARMY; COL. CHARLES W. HOGE, M.D., DIRECTOR, DIVISION OF PSYCHIATRY AND NEUROSCIENCE, WALTER REED ARMY INSTITUTE OF RESEARCH, UNITED STATES ARMY, ACCOMPANIED BY COL. ROBERT J. LABUTTA, MC, CHIEF, DEPARTMENT OF NEUROLOGY, WALTER REED ARMY MEDICAL CENTER

STATEMENT OF GERALD CROSS, M.D.

  Dr. Cross.  Mr. Chairman and members of the Committee, good morning.  I am accompanied by Dr. Arthur Katz, Chief Patient Care Services Officer for mental health, and Dr. Barbara Sigford, director of physical medicine and rehabilitation service.
  At first, let me say I can assure you, Mr. Chairman, we from VHA do have passion, and we have that passion in caring for our veterans.
  I would like to submit my written testimony for the record.
  In beginning my testimony, I would like to address an issue that I know is of concern to many members.  Recently, VAï¿½s Inspector General issued a report on our ability to care for patients with traumatic brain injuries.  While the report identifies areas in which we can improve on our performance, its executive summary is very clear.  It states that our patients have very similar outcomes when compared with a matched group of TBI patients from the private sector.
  Given that our patients have more severe injuries than the average patient, and given that it takes longer for them to begin rehabilitation because of the complexity of their wounds, and because of the distance they must travel from the theater of war to begin treatment for those wounds; the fact that our patients do as well as those in the private sector demonstrates that we are doing an outstanding job in supporting their recovery, and that we are providing the exceptional care Congress and all Americans expect of our department.
  VA is succeeding in treating many TBI patients with multidisciplinary approaches that include a sensitivity to the physical, cognitive, emotional, functional, and behavioral manifestations of brain trauma.  Our polytrauma system of care includes four primary polytrauma rehabilitation centers, which provide exemplary care for veterans with multiple injuries, including brain injuries, and fully involves their families in their care and treatment.
  Twenty-one new polytrauma network sites are opening this fall, enhancing access, and ensuring lifelong coordination of care for these men and women.  And a hotline for all polytrauma patients, and their families, is staffed 24 hours a day, seven days a week, 365 days a year.
  To ensure that we identify every veteran with TBI, VA clinicians are receiving additional training in recognizing both acute and delayed symptoms of brain trauma, and then providing the prompt identification, and multidisciplinary evaluation and treatment, which is essential for their successful recovery.
  We are improving our ability to coordinate the care of TBI patients by assigning a permanent social worker-case manager to every patient we have seen at our polytrauma centers.  And we recognize the need for family support in caring for loved ones.
  Our intent is to restore every patient to his or her fullest possible level of functioning.  We will not fail in that effort.
  Mr. Chairman, members are also concerned that we have the capacity and the funds to treat OIF-OEF veterans with PTSD.  Let me assure the Committee that we do.  Among our accomplishments, we have been adding 100 OIF-OEF veterans to our vet center staff to provide clinical peer support.  We have expended substantial funds to expand mental health services at our community-based outpatient clinics, and we have added tele-mental services to serve remote locations.
  Altogether, VHA now operates approximately 200 specialized PTSD programs in addition to our 207 vet centers which, by the way, will increase in number to 209 by October of this year.
  Working closely with our colleagues in DoD and other federal agencies, our researchers are working on new pharmacological, psychological, and other treatments, and we are finding ways to harness these technologies to extend our ability to care for veterans with this illness.  And we are placing a special emphasis on finding more effective ways to treat veteransï¿½including women veteransï¿½at risk for PTSD.
  Mr. Chairman, todayï¿½s veterans with PTSD and TBI are receiving state-of-the-art care throughout VHA.  We are committed to improving our abilities to address TBI and PTSD, and to meet the specific needs of veterans returning from the global war on terror, who have earned and are receiving the best care available anywhere.
  Thank you for your time, sir.
  [The statement of Gerald Cross, M.D. appears on p. 62]

  Mr. Filner.  Sure glad I gave that lecture on passion, Mr. Chairman.
  Mr. Brown.  Thank you very much, gentlemen, for being a part of this, and thank you for your passion and for your understanding, and for your expertise.
  And with that, I will ask Colonel Ritchie to testify.

STATEMENT OF COL. ELSPETH CAMERON RITCHIE

  Colonel Ritchie.  Mr. Chairman, distinguished members, Mr. Michaud, thank you for the opportunity to be here and to share with you our concern and our passion about taking care of our soldiers and veterans.
  Going to war affects all soldiers.  The number of soldiers with Post Traumatic Stress Disorder, PTSD, has gradually risen.  Since 911, the Army medical department has taken care of soldiers at the Pentagon during 911, in Afghanistan, in Iraq, and throughout the world.  We take care of soldiers with physical wounds, and with psychological issues from combat.
  We are committed to providing and ensuring that all returning veterans receive the physical and behavioral health care they need.  An extensive array of mental health services has long been available.  However, since 911, we have augmented and improved behavioral health services throughout the world, especially at Walter Reed Army Medical Center and the other Power for Vets projection platforms and major army installations, where we mobilize, train, deploy, and demobilize army forces.
  We anticipate that the need for these services will not decrease.  We are committed to providing the necessary help. The Army medical department has performed behavioral health surveillance in an unprecedented manner.  There have been four mental health advisory teams, three previously in Iraq, one in Afghanistan, and currently one in Iraq at this time. Charles Hoge, Colonel Hoge, will present his research.
  We have also performed several epidemiological consultations, called EPICONs, at installations in the United States, such as the assessment following the cluster of suicide-homicides at Fort Bragg in North Carolina in 2002.
  There are numerous other initiatives for us to learn from the war.  We held a workshop on updates in combat psychiatry at the Uniformed Services University of the Health Sciences, in 2004, where we gathered together those who had been in theater with academicians and policymakers.  We have used the results of all of these assessments to improve the behavioral health services that we offer our soldiers.
  The Army Deputy Chief of Staff for Personnel, and the Army Surgeon General, share responsibility for the prevention and screening for PTSD for soldiers, both active and Reserve, from the global war on terror.  Derived partly from the EPICON results from Fort Bragg, we have come up with a new deployment cycle support program that has been in place for several years to help our soldiers and their families.
  Since the beginning of the war, there has been a robust combat and operational stress control presence in theater. Today, more than 200 behavioral health providers are deployed in Iraq, and another 25 in Afghanistan.  The mental health assessment team reports have demonstrated both the successes and some of the limitations of these combat stress control teams.  As a result of learning of the limitations, we have improved the distribution of behavioral health providers throughout the theater.  Access to care and quality of care have improved as a result.
  Before deployment, soldiers are screened for medical issues including family problems.  Then, as part of the reintegration process, soldiers are briefed on what stressors to expect, the common symptoms of post-deployment stress, such as hyper-arousal, and ways to mitigate these symptoms.
  The post-deployment health assessment, when soldiers are coming home, is used to screen the soldiers again for physical complaints and psychological complaints.  And then last year, the Assistant Secretary of Defense for Health Affairs directed an extension of the current program so that we now have a post-deployment health reassessment; and the army requires that all soldiers redeployed from combat zone, whether they are active or Reserve, complete this new PDHRA screen at three to six months following deployment.  The PDHRA program was fully implemented in January of 2006.
  If a soldier has post traumatic stress disorder, or other psychological difficulties, they will be further evaluated and treated, using well-recognized treatment guidelines, including psychotherapy and pharmacotherapy.
  Traumatic brain injury is also a focus of our attention. TBI, as it is often called, is a broad grouping of injuries that range from mild concussions to penetrating head wounds. Many of these symptoms are similar to post traumatic stress disorder, especially the symptoms of difficulty concentrating, and irritability.  I have Col. Labutta here, chief of neurology, with me today to answer any questions you may have on screening, diagnosis, and treatment of TBI.
  We recognize that there is a perceived stigma. Therefore, we are moving to integrate behavioral healthcare into primary care, wherever possible.  Our pilot program at Fort Bragg, Respect.Mil, has been very successful, and we are moving to implement it throughout the Army.
  There is a legitimate concern about our isolated Reserve component soldiers.  The Army one-source program was put into place, and is now becoming the military one source to provide free confidential counseling.  Our physically wounded soldiers have also been the focus of attention.
  Finally, we have been working on improving our suicide prevention programs.  Every suicide is a tragedy.  The DCSPER is the proponent for suicide preventions, while the chaplains conduct suicide prevention classes, and behavioral health is also doing surveillance.  However, several years ago we leveraged a new report, the Army Suicide Event Report, the ASER, to improve our surveillance.  All suicides and serious suicide attempts require this report to be filled out, and we are in the process of setting up a new suicide prevention office within the Army medical department.
  So continuing to assess the quality of our services, we learn.  Lieutenant General Kiley is a co-chair of the Department of Defense Mental Health Task Force, with a report due in May of 2007.
  We are ongoing training of our leadership in numerous venues.  You have already heard about after the soldier leaves and goes to the VA, it is critically important also that we provide education to our civilian providers; that they learn to ask, ï¿½ Are you a veteran?ï¿½  and, ï¿½ Have you been exposed to a blast injury?ï¿½   And we have numerous efforts.
  In summary, we have been at war for five years.  War challenges the psychological health of our troops and their families.  We have been in continual process of improving our efforts.  This is not just an army issue, it is not just a VA issue, it is a national issue.  We have the tools that we need to recognize and treat soldiers and their families.
  Thank you very much for your attention.
  [The statement of Colonel Elspeth Cameron Ritchie appears on 
p. 72]

  Mr. Brown.  And I thank you, Colonel Ritchie, for your service.  And at this time, we would hear from Colonel Hoge. 

STATEMENT OF COL. CHARLES HOGE, M.D.

  Colonel Hoge.  Thank you, Mr. Chairman and distinguished members.  Thank you for inviting me here.
  I direct a research program focused on assuring that soldiers who serve in Iraq and Afghanistan get the best mental health services that we can provide.  And since my testimony to this Committee in July of 2005, we have continued to collect data, and continue to try to refine our programs and improve our programs, based on the lessons learned from the data that we collected.
  Soldiers are remarkably resilient.  They are doing heroic things day after day for a year or longer.  Some of them are going back for their second or third rotation.  They are working in highly dangerous and unpredictable environments.  And it is normal to experience symptoms after these combat experiences.  Most soldiers transition very well when they come home, and have resolution of those symptoms. Some need help, and that has been the primary focus of the research that we have been conducting.
  Based on the data from several sources, and we now have robust data from a number of different sources, we estimate that 10 to 15 percent of Army soldiers develop post traumatic stress disorder after deployment to Iraq.   Another 10 to 15 percent have significant symptoms of PTSD, depression, or generalized anxiety, and may benefit from care.  Alcohol and family problems can add to these concerns.
  The Army has a comprehensive strategy to encourage soldiers to seek help early, before these symptoms become severe, or interfere with their lives, seriously interfere with their lives, such as the example that we heard earlier today.
  We learned that soldiers may not express mental health concerns until several months after they returned from deployment, and as a result, the post deployment health assessment now includes the reassessment that Dr. Ritchie discussed earlier.  So far, over 60,000 soldiers who have returned from Iraq have completed this health assessment.  Of these, 35 percent reported some sort of mental health concern on general screening questions.  And after speaking with a health care professional, about 18 percent were recommended to seek assistance from one of the many mental health sources of care.
  One new finding from post-deployment health reassessment program is that Reserve component soldiersï¿½that is, National Guard and reservistsï¿½report higher rates of mental health concerns, and higher rates of referral, compared to active component soldiers.  It is important not to misinterpret these data as suggesting that they are in some way less mentally healthy than the active component soldiers.  Reserve component and active component soldiers have nearly identical rates of mental health concerns in theater and immediately post deployment.  And these differences donï¿½t appear to emerge until several months after they return home.
  We donï¿½t know exactly why this is, but potential factors that could relate to this include concerns about ongoing access to health care among Reserve component soldiers after they have been home for some period of time, and the fact that active component soldiers stay with their unit, and they continue to work full time with their unit, with the peers who they have shared their combat experiences with, and that provides a very supportive environment for resolving symptoms when they have been home.
  So far, we are not seeing higher rates of mental health concerns among soldiers who are deployed more than one time to Iraq, compared to those who have deployed once.  However, it is difficult to measure the effect of multiple deployments, because the rate of leaving military service is somewhat higher for those who have been to Iraq one time. Although we have data indicating that our efforts are working to encourage soldiers to get help for combat related mental health problems, our surveys indicate that many soldiers with mental health concerns still donï¿½t seek care, and perceive that they will be stigmatized if they do; that is, viewed or treated somehow differently by their peers or leaders.
  The data on stigma have led to new approaches to improve the availability of mental health in primary care settings and training for soldiers and leaders to improve their recognition of mental health issues, reduce the perception of stigma, and assure successful transitions throughout the deployment cycle.
  In the area of training, my team has developed and tested a new training program called BATTLEMIND, with these goals in mind.  This new training highlights the skills that help soldiers survive in combat, and how to transition the skills when they get home.  The training has been incorporated into the army deployment cycle support program, and is being utilized in a variety of ways, including at VA facilities and VA vet centers.  Further information on the training materials can be obtained at www.BATTLEMIND.org.
  Thank you very much for your continued interest in our research, and your support for the men and women who are serving in Iraq and have served in Iraq and Afghanistan, and other locations.
  [The statement of Colonel Charles W. Hoge appears on p. 79] 

  Mr. Brown.  Thank you, sir, for your testimony and for your involvement in this program.
  My first question would be that understanding that the post deployment health assessment, and the post and limit health reassessment are self-reporting tools, are you personally convinced that they are powerful sufficient to be used as predictable tools?  and if not, how can they be improved?
  Colonel Hoge.  The post-deployment health assessment and the post-deployment health reassessment include a self- report portion of the survey, but basically, all individuals sit down with a primary care professional to review the answers that they have put on those surveys.  So in essence, the survey questions are really just prompts to help the primary care professional identify what issues need to be discussed further.
  Colonel Ritchie.  If I may add to that, it is also important to recognize that the soldiers have a number of other venues to seek help, and we encourage the unitï¿½and I believe the unit leaders are very much doing thisï¿½to provide outreach and education.  And then there is a number of other efforts, such as the combat stress control teams, to provide outreach, education, and treatment if necessary.
  Mr. Brown.  But I assume that all the young men and women leaving service are leaving the battlefield, they have this battery of tests, or this observation; and I guess the ones that show signs, I guess they are sort of put into the system.  But is there a process to later go back and reevaluate the ones not detected early on after they leave the battlefields, to see if there is a later-developing problem?
  Dr. Cross.  Sir, that is one of the main reasons that the post-deployment health reassessment was established, to be done three to six months after the soldier has returned from combat.  I think it is very important that we have numerous opportunities in our system and in the VA system for the soldier to seek treatment, because we do recognize that many soldiers will not seek treatment right away.
  Mr. Brown.  And if I might ask, how are the service chaplains being integrated into the theater-based assessment team?  Do you bring those chaplains on board to help do the assessments?
  Colonel Ritchie.  If I understand the question correctly, you ask how the chaplains are integrated into theater, and also after the return home?
  Mr. Brown.  My question is just how are they integrated in the assessment of the troops after they leave the battlefields?
  Colonel Ritchie.  Chaplains are an integral part of our system.  In general, each battalion has its own chaplain who will work very closely to the soldiers, and this is extremely important because it provides a non-stigmatizing, confidential way for the soldier to seek help.  Chaplains have also been part of our mental health assessment teams. In terms of after they come back, again, the chaplains will be present, and in every battalion.  And as a result of the evaluations, the post-deployment health assessment or reassessment, the soldier can either seek out a chaplain or a behavioral health provider.  So again, they are very well integrated, and we really could not do our mission without them.
  Mr. Brown.  Do you have some thing to add, Dr. Hoge? Do you have anything further to add on that question about the chaplains, or are you pretty satisfied?
  Colonel Hoge.  I agree completely.  They are very well integrated, and a very important part of the well-being of soldiers in every unit.
  Mr. Brown.  Okay, thank you.  We will probably come back for some other questions, and I will also offer the other members of the Committee to question later.  But let me further my question to Dr. Cross and Dr. Katz, if I could.
  One of the biggest challenges that we continue to hear a lot about is the transitional rehab capacity of the VA for those with TBI.  Dr. Cross, Dr. Katz, or Dr. Sigford, please describe the resources available to our men and women after they have been discharged from a VA facility.
  Dr. Cross.  If I understood your question, sir, it relates to the resources available to them after separated from the military?
  Mr. Brown.  Right.
  Dr. Cross.  For both PTSD and TBI, we have very significant programs available.  I wanted to highlight particularly both in the programs that we have to address their needs, and in outreach, our vet centers.  Our vet centers are a unique resource within our organization, and I wanted to point out a couple of things about them.
  As of August, counseled 16,933 outreach services for 111,000-plus, and also counseled with 1215 families.  A unique resource, where the new veteran can just walk in, no wait, say ï¿½ hello,ï¿½  be welcome, say ï¿½ Have a cup of coffee, take it easy, letï¿½s talk,ï¿½  and I think that is very important.
  We also have a comprehensive system of primary care.  We are training our primary care providers to make sure that they understand, in addition to all of their other training, that they can recognize TBI or PTSD.  We have put out this training manual, and an online course that we now mandate for our primary care providers working with polytrauma patients and others.
  And of course, our PTSD programs, 112 inpatient and over 200 specialty service programs.  And I will ask Dr. Katz to expand on that.
  Dr. Katz.  The first task is to overcome the barriers to veterans getting into our systems.  For that, their interactions with DoD, vet centers are also very important sources of outreach.  In our medical centers and clinics, we also run outreach programs.  Over recent years, we have funded 84 outreach providers to go out to the community, Reserve, and Guard units, and also to do in-reach; to work with the veterans in primary care, and rehabilitation programs after physical injury, to educate veterans and families about mental health conditions, and to give the message the treatment works.  We are working very hard to get patients somewhere.  The no-wrong-door theme that we have learned from the vet centers applies all over the system. Our goal is to get people in treatment, knowing the treatment works, and that it can prevent disability.
  Mr. Brown.  Let me follow up on that if I could.  What type of collaborative arrangements exist with the DoD to providing continued care for these folks?  The September 2004 GAO report stated that VA lacks the information it needs to determine whether it can meet an increasing the demand for VA PTSD services.  VA stated that it planned to aggregate, at the national level, the number of veterans receiving PTSD services at VA medical facilities and vet centers, and share this information with GAO.  Has this been achieved?
  Dr. Cross.  Sir, with regard to collaboration with DoD, we are making remarkable efforts in that area.  We put our own staff in the eight military treatment facilities where returning service numbers are most likely to come.  We are collaborating on information exchange to make sure that data that is found, obtained in the DoD system, is conveyed over to us.
  I have observed personally an interaction between our Tampa facility for polytrauma, Walter Reed in Bethesda, talking about a patient online on video teleconference, simultaneously with a doctor in Baghdad, who had actually treated that patient initially.  A remarkable degree of communication.
  Mr. Brown.  Is that a seamless transferring of information, or is that a manual transfer of information?  Do you have, like, is your computers compatible, and can you share those records electronically?
  Dr. Cross.  We are receiving electronic information from DoD, but we are also, on a patient-by-patient basis, making sure that we talk to each other, to compare notes.
  Mr. Brown.  Okay.
  Dr. Cross.  And we are talking about the very, very seriously injured polytrauma patients.
  Mr. Brown.  Right, okay.  I thank you very much.
  Mr. Michaud, do you have some questions?
  Mr. Michaud.  Thank you very much, Mr. Chairman.  Once again, I want to thank the panel for your testimony.
  Colonel Hoge, your research shows real differences in how the National Guard members and reservists respond to PTSD screening questions three through six, most after deployment, as compared to active components of servicemembers.  Is this because the National Guard and Reserve members do not have the same access to mental health services, or support?
  Colonel Hoge.  Sir, we are not really sure.  This is new data.  The PDHRA program has just been implemented, and this is the first time we have seen this.  To date, all of our data has shown very comparable rates between active component and Reserve component.  So something is happening in terms of the level of concern rising in Reserve component soldiers, among Reserve component soldiers, after they have been home for several months.  And I donï¿½t know if that is concern that they may have issues that may be ongoing and whether they have concerns about getting health care on an ongoing basis.
  Also, we have a relatively small sample of Reserve component soldiers who have completed the post-deployment health reassessment, and that sample may not be representative of all Reserve component soldiers.  So this these to be continued to be studied.  But we were asked specifically about what we are seeing on the PDHRA, and I felt like it was important to share those data, even though they are fairly preliminary.
  Mr. Michaud.  Thank you.
  Dr. Cross, what challenges do you see in helping families of veterans with TBI to navigate the VA and the DoD health care systems?  And what is the VA doing to help?
  Dr. Cross.  Sir, the greatest challenge that we have faced, in my opinion, is communication.  It has been so very important for us to make those family members feel and actually be a part of the treatment care team, to be involved in making the decisions that will affect their loved one.  We are learning to do that better and better, but this is something that we have really put a great deal of effort in. Communication I think is at the core of success; not only of treating the patient himself, but the family as well.
  Mr. Michaud.  Also, we have heard that mild TBI can go undiagnosed or misdiagnosed.  What is VA doing to ensure that veterans with mild TBI are correctly diagnosed?  Dr. Cross?
  Dr. Cross.  We are working with our primary care providers and all of our staff to deal with polytrauma in any of its forms, to make sure that in addition to their education that they already have, their medical education for instance, that they receive supplemental training to make sure that they understand those fine distinctions.  Not just to recognize the severe cases, but the mild and moderate, as well.
  Mr. Michaud.  Okay.  Why is it that VA is not using the brief traumatic brain injury screen development by the Department of Defense in the Veterans Brain Injuries Center to screen veterans for mild TBI?
  Dr. Cross.  We are vitally interested in screening. We take great interest in the work that DoD is doing with the screening in the Veterans Brain injuries Center.  We want to make sure that any screen that we adopt is evidence-based and applicable to the population, the much larger population that we serve.  We are following this with great interest, and we are doing research of our own.
  Mr. Michaud.  But Col. Labutta, has a brief traumatic brain injury screen been validated as a screen for mild TBI?
  Colonel Labutta.  The screening questions are validated to the point of the mid-80s, 85 percent or so, of sensitivity at this time.  Some of those questions have been asked to redeployed returning units, and have not been wider applied until we know more about that, and to apply them both for more redeployed units, and to apply those or modified versions of those questions, into the VA system.
  Mr. Michaud.  So it has been 85 percent validated? That is a pretty high percentage.  So why isnï¿½t VA using it? Are you looking for a hundred percent?
  Dr. Cross.  We are not looking for a hundred percent. We are looking to make sure that it is applicable to the patient population that we serve.  I have read the study that has been referred toï¿½I believe it is one studyï¿½and as I said, we want to make sure that we donï¿½t inappropriately label, that we donï¿½t expose to imaging studies that are unnecessary.  We want to make sure that we have a test that works for our population.  Dr. Sigford?
  Mr. Michaud.  Are you testing it right now?
  Dr. Cross.   No, Sir.  We are doing research on developing tests.
  Mr. Michaud.   And how long will that be?
  Dr. Cross.  We are expecting research grants on those subjects this year.
  Mr. Michaud.  So you will have some results on that research this year?
  Dr. Cross.  I canï¿½t promise you that, sir.  We will do the research this year.
  Mr. Michaud.  Okay.  I know Dr. Ritchie made a statement that you have the tools. You might have the tools, for those that can access those tools.  My concern is talking to a lot of veterans, they do not have access to those tools, and that is a big difference. The tools are no good if a veteran cannot access them.  And that is my major concern, particularly for veterans that live in rural areas who have even a greater problem of accessing tools when you look at, under the CARES process, a lot of the recommendations have not even been implemented to make the tools available to rural areas.
  So I am really concerned with that.  I am also very concerned that the VA did not provide the $100 million that Secretary Principi had talked about for fiscal year 2005 for new mental health care efforts.  As well as the additional $35 million that VA said that they would be using, and they sent out to the VISNs; they never stipulated that it was for mental health care areas, which they can use to make up shortfalls in a lot of different areas.
  And the other area that I am really concerned about is the fact that when you look at Iraq and Afghanistan veterans, and what is happening with them with TBI and PTSD; the war over in Iraq and Afghanistan is triggering effects of veterans from Vietnam.  Will they be able to get the access, because they might fall into category eight?  And because of the current war, it is really having a negative effect on them.
  These are a lot of concerns that I have, and when you mention that you have the tools, I beg to differ. Everyone does not have access to those tools, and we are not doing our job to make sure that they are.  I think it is incumbent upon each and every one of us here at this table, in Congress, and each and every one of you at that table, to make sure that we provide these services for our veterans.
  I realize that you are in a different situation, that you have to get your statements approved, but I do not have to get my statements approved.  I can tell you, having heard from veterans yesterday, and having heard from other veterans in the past, Blake Miller, Mrs. Pelkey, who lost her husband to suicide; veterans are not getting the help that they need.  I would implore each and every one of you to do what you have to do to convince your boss and your superiors to do what they have to do to provide the resources, so our veterans can get it.
  This is a family values issues.  It doesnï¿½t affect only the veteran; it affects their families.  And if you care about family values, and if you care about veterans, you will do everything in your heart and soul to convince your superiors to do what is right, and that is to take care of the veterans.
  Thank you Mr. Chairman.
  Mr. Brown.  Thank you, Mr. Michaud.
  Mr. Filner, do you have a question?
  Mr. Filner.  Yes, thank you.  Thank you for your statement, Mr. Michaud.
  Can anyone there tell me how many suicides we have had from returning Afghanistan-Iraqi troops?
  Dr. Cross.  Sir, I donï¿½t have that numberï¿½
  Mr. Filner.  Iï¿½m sorry, can you speak a little louder?
  Dr. Cross.  Sir, I donï¿½t have that number with me, but I will take it for the record and get you that information.
  Mr. Filner.  Give me a guess, Mr. Cross.  Come on. You donï¿½t have it with you?  Is it in the thousands?  Is it in the millions?  Is it 10, is it 100?  Come on.
  Dr. Katz.  We have requested information from the National Death Index, which recordsï¿½
  Mr. Filner.  Nobody there knows how many suicides there have been from returning Iraqi soldiers?  Nobody there knows? This is disgraceful.  You guys are the experts.  Many people have attributed suicidesï¿½not everyone, but the connection between PTSD and suicide is very clear.  Surely you would want to know how many suicides there are, to see if this is a problem or not.
  Colonel Ritchie.  Perhaps I can answer that question. I believe that the number of suicides in active duty soldiers after they have returned from Iraq is about 78.  However, I will need to confirm that exact number.
  Mr. Filner.  I have seen higher, much higher estimates.  I donï¿½t know, you haveï¿½you have hedged it with ï¿½ active duty.ï¿½   I donï¿½t know what that means.  I have seen in the hundreds.  I have also seenï¿½and if you dispute this, let me knowï¿½that the suicide rate is much higher in this population than in either the normal veteran population or the normal civilian population; is that true, or not?
  Colonel Hoge.  Sir, no, the suicide rate actually consistently has been lower in the military than civilian populations that are comparably matched in terms of the age and demographics.
  Mr. Filner.  I am saying the returning Iraqi- Afghanistan soldiers.  Use my language.  You take whatever I say and use your own language, and which gives all kinds of caveats and bureaucraticï¿½I said one thing, you said ï¿½ the military.ï¿½   That means everybody, now, in the military, including all the guys at the desks, right?
  So is the suicide rate of returning Iraqi and Afghanistan soldiers, Marines, and anybody who is involved there, even civilians, higher or not, than the general population?
  Colonel Hoge.  No, sir.
  Mr. Filner.  I have different information.  I think that is at least a matter of debate.
  But, as I think Col. Ritchie said, any suicide would be important.  Of course, you cloak that concern with all kinds ofï¿½suicidal events, what the hell is a ï¿½ suicidal event?ï¿½ Itï¿½s an attempted suicide or a real suicide, probably, but the way you talk about them dehumanizes it, it takes the passion out, takes the emotion out.
  Okay, whatever the rate is, letï¿½s say it is 83, somebody said 83 earlier.  You said 78.  I have seen hundreds.  Have we done everything we could to prevent those, is what I want to know.  Every one of you said what a great job we are doing.  I donï¿½t question that we are doing a lot.  I donï¿½t question your own commitment to this.  I donï¿½t question your own sincerity in this.
  But you have an opportunity here, in front of people who have said they are concerned and control the resources that you get.  What do you need to do your job better?  Tell us. What resources do you need?  Not one person has said ï¿½ We need additional resources,ï¿½  or ï¿½ We would like to have additional this.ï¿½  You have said ï¿½ Everything is fine.ï¿½   Col. Ritchie said, ï¿½ We have all the tools that we need.ï¿½   Everybody else, ï¿½ Oh, we are doing such remarkable things.ï¿½
  How come every one of us here, and Iï¿½m sure you, too, have heard story after story after story that we are not doing our job?  Because we are doing part of it, but we are not doing a lot.  To whom much is given, much is required.  We are the richest nation in the history of the world.  If we canï¿½t devote the resources we need to do this, to take care of every single person who needs the help, we are not doing our job.
  So what else do you need to do your job?  Not one of you has said that to us.  You have got some very sympathetic people here.  We want to give you resources.  What would you do?  How would you do your job better?  Every one of you, how would you do your job better if you have more resources?
  Dr. Cross.  Sir, we are committed to doing the best job that we canï¿½
  Mr. Filner.  Oh, come on, Dr. Cross.  Tell me what you need to do the job better.
  Dr. Cross.  I screen every single patient that we have for depressionï¿½
  Mr. Filner.  But as Mr. Michaud said, maybe halfï¿½we donï¿½t know, maybe half the people arenï¿½t even coming in to you.  How do we reach out to them?  Do you need any more outreach help?
  Dr. Cross.  We are making a tremendous effort in outreach.
  Mr. Filner.  I canï¿½t believe you guys.
  Dr. Cross.  Can I tell you about some ofï¿½
  Mr. Filner.  I canï¿½t believe you, all of you.  We are giving you a chance to say what you need.  Let us see, we have 150,000 troops in Iraq now, probably several hundred thousand have come back, probably another couple hundred thousand are going.  I would say that adds up to maybe a million children of families.  What are we doing for the children to tell them about PTSD when their daddy comes home and their mommy comes home?  What do we tell them about the nightmares that their parents are going to have?  What do we tell them about why they are being slapped in the face, or why their father tried to kill himself?  What are we doing for the children?
  Colonel Ritchie.  Perhaps I can address that one.  We have got a number of new educational products, which is part of the solution, but not all of the solution.
  Mr. Filner.  You held up a training manual, one of you.  Where is the comic book that will help kids understand what is going on?
  Colonel Ritchie.  Well, there are those products out there.  There is a new Sesame Street video for children of deployed families, there is a new ï¿½ Mr. Poe Goes to Warï¿½ educational productï¿½
  Mr. Filner.  Tell me about those.  Those sound very interesting.  Is everybody given one?  How do they get them?
  Colonel Ritchie.  Okay.  They are available in a number of sites from our Army community serviceï¿½
  Mr. Filner.  Does anybody go to the families and deliver theï¿½
  Colonel Ritchie.  The Army community service has been very active in outreach to families, and they are hung on a number of websitesï¿½
  Mr. Filner.  And everybody who would need this has gotten their hands on it?  Would you say that?
  Colonel Ritchie.  No, I would notï¿½
  Mr. Filner.  So what would you do to make sure that everybody gets access to them?
  Colonel Ritchie.  Well, I think we are in the process of doing that right now, but we are not there yet.
  Mr. Filner.  So what do you need to do the job better? How many times do I have to ask it?
  Colonel Ritchie.  I think, sir, if I could say in my personal opinion, my personal opinionï¿½
  Mr. Filner.  I know, is not approved by OMB.  That is what I would love to hear.
  Colonel Ritchie.  The area that I am very concerned about is the family members of the deceased, and the family members of the wounded.  And the family members of the deceased in many cases move off our installations, off our posts.  And I think we need to, as a system, continue to do more.
  Now, the vet centers do offer them counseling through their readjustment centers.  But I am not sure if everybody knows about that.  So that is one area where personally, I think we need to do more.  Over the long term, not just the short term.
  Mr. Brown.  Mr. Filner, I think you much for your questions.  Your time has expired.
  Mr. Filner.  Are we going to have another round, Mr. Chairman?
  Mr. Brown.  We will have another opportunity.
  Mr. Filner.  Thank you.
  Mr. Brown.  Okay.  Mr. Moran, do you have a question?
  Mr. Moran.  Mr. Brown, thank you very much, Mr. Chairman.  Thank you for convening this hearing.  I think this topic is one that is of significant importance.  And I apologize for not hearing your testimony, although I have read at least in part your testimony, and I apologize for not hearing the other questions.
  The reason that I wanted to make certain that I was here was this question in particular.  I have been reading these statistics, the press stories of increased post-traumatic stress syndrome, that the numbers are growing, and which our servicemembers are suffering from this condition.
  My question is, is there any statistical evidence related to the length of deployment and the number of times that a serviceman or woman is deployed in Iraq or Afghanistan? One of the things that I am greatly concerned about is the request that we are making of our servicemen and women to serve longer and longer periods of time, deployed in the war on terror, and the number of times that they are redeployed back to those theaters.  And my question is, is there a relationship between the presence of post traumatic stress syndrome symptoms and the number of deployments, and the length of deployment?
  Colonel Hoge.   Yes, sir. In the early part of the war, there were combat units that were from the Army that were rotated into Iraq for varying periods of time.  Some were there for less than six months.  Others were there for longer, between six months and a year.  And others were in fact there for longer than a year.
  Among those, looking at those data, we did see a linear increase in the rate of concerns of post traumatic stress symptoms, and other mental health concerns was increased for those who had been there longer.  Now in the Army, most units are rotating for a year, so we really canï¿½t look at that at this time.
  Mr. Moran.  What about the number of deployments?  And this is perhaps more National Guard and Reserve units, but again, it appears to me that we areï¿½no, it doesnï¿½t appear; it is trueï¿½we are utilizing our Guard and Reserve in significant increases in number of deployments.  And I know from time to time that our servicemen and women are returned home, they in some cases believe that they have completed their service in theater, and only a matter of a few weeks later, learned that they are being redeployed.  Is there a mental health consequence to that redeployment, or that series of redeployments?
  Colonel Hoge.  We have some data from the post- deployment health reassessment, and from some of our other surveys that we have done, that actually shows that soldiers who have rotated two or more times to Iraq have similar rates of mental health concerns, compared to soldiers who have rotated only one time to Iraq.
  But that is difficult to study, and that doesnï¿½t really answer the question, because we also know that soldiers who have been to Iraq the first time, for one rotation, have a somewhat higher rate of leaving military service than soldiers who have in, for instance, to Afghanistan or other deployment locations.  So there may be a multiple deployment effect that we canï¿½t measure because there is a higher rate of attrition from service among those who have been to Iraq.
  Mr. Moran.  Well, commonsense, at least my commonsense tells me that there would be a relationship, and that being redeployed has to be a significant event in oneï¿½s life and their familyï¿½s life, with what I would think would be just necessary mental health components to that redeployment.
  Colonel Ritchie.  Sir, if I could add to that.  We agree with your interest and concern, and we are looking at that closely.  The Army leadership is very interested in that.  I mentioned before that we have a mental health advisory team in theater again right now for the fourth time in Iraq, and they are looking at that very issue, the post- deployment health reassessment is looking at that.  I expect that we will have more data emerge over time, as multiple deployments continue.
  Mr. Moran.  What kind of time frame do you think that you would have more data in which we could better analyze the answer to these questions?
  Colonel Ritchie.  In general, the results of the mental health assessment teams have been coming out yearly. We have the results from the mental health assessment team sometime this fall, the current MHAT three, the ones from MHAT four will probably be next summer or fall.  So over time.
  In addition, we have the results of the post-deployment health reassessment, which is coming out continually.  So I would say over the next year, there will be a number of different sources of data.
  Mr. Moran.  Anyone else?  Thank you very much for your response.  I just had a genuine concern about what we are doing to soldiers and their families, and todayï¿½s circumstances that they face.  And my guess is this is one component, one symptom of the results of multiple deployments, and long periods of deployment.  And any information that you garner in the short run which is of value to us in making decisions and encouraging the Department of Defense to do things differentlyï¿½in other words, sooner knowing that information is better, before it is no longer relevant.
  Thank you very much.  Thank you, Mr. Chairman.
  Mr. Brown.  Thank you, Mr. Moran.  Dr. Snyder, do you have any questions?
  Mr. Snyder.  I do.
  Colonel Ritchie, following up on your bringing up the family members, and I appreciate you bringing up the family members: if a base and a family, a spouse get noticeï¿½and they are living on the baseï¿½that their active-duty member has died overseas, what is the time period in terms of notification, and having to be out of the housing and off the base?
  Colonel Ritchie.  I believe that the answer to that is one year.  I would need to double check for you.  That doesnï¿½t directly fall into the medical lane, but I believe that it used to be six months, and now it is extended to a year.  And I will take that for the record, also, to confirm.
  Mr. Snyder.  Because we talk a lot about the support network, that they lose that support network, at some point.
  Dr. Hoge, on page nine of your written testimony, you say that there are gaps in mental health research.  You say, quote, ï¿½ specifically, research is limited in the areas of establishing standardized treatment strategies for combat related PTSD, long-term longitudinal studies, and studies on the impact of deployments on military families,ï¿½  end of quote.
  Why is the research limited?  Do you all need more medical research dollars from us?  Could you benefit from more medical research dollars?  Do you have some estimate on how many additional dollars you need, or are there other factors?  What is the limitation here?
  Colonel Hoge.  I am only speaking for research within DoD among our soldiers, among our men and women who are serving.  And in general, I think we have done a good job with identifying the problems, and reducing stigma barriers to care, but I think there is a lack, a potential lack of standardization of the treatment that soldiers receive, in that soldiers really speakï¿½there is a way of communicating with soldiers about mental health issues.
  Mr. Snyder.  So you are describing the problem, but what is it going to take to solve the problem?  I appreciate what you are saying there, but what kind of money, or what is it that is keeping you from doing that kind of study?
  Colonel Hoge.  I hesitate to quote a specific dollar figure, because I donï¿½t think I am allowed to do that.  But I would take that for the record, and I would be happy to provideï¿½
  Mr. Snyder.  We can read the First Amendment to you, Colonel.  It applies in this building.
  Without quoting a specific amount, would it be helpful if you had additional dollars?
  Colonel Hoge.  Absolutely.  Absolutely.  We really do not have anyï¿½we really have very few treatment studies within DoD that focus specifically on what medications are effective for troops in the combat environment; for instance, what are the best cognitive behavioral techniques that speak the language of the soldiers?
  And we are doing a lot.  We know a lot.  We know that pharmacological interventions are effective.  We know that cognitive behavioral therapy are effective.  And we rely on a lot of good research studies that have been conducted outside of DoD.  But I think more could be done in the area of specific treatment studies for our soldiers, you know, within the military, before they leave service.
  Mr. Snyder.  Thank you.
  Dr. Cross, in your testimony, on page six of your written testimony, you talked about research collaboration between NIH and DoD, and you mentioned 55 proposals were received, and that ï¿½ those with merit are expected to start later this year.ï¿½  Of the ones that you considered to have merit, were all of them funded?  And again, obviously it is a bottom line question.
  Dr. Cross.  For this year, we plan to fund at least six new major scientific projects related to TBI in fiscal year 2007.  Spending for fiscal year 2007, including research on polytrauma, neurotrauma, amputation, prosthetics, I would estimate to be approximately 75 million.
  Mr. Snyder.  That wasnï¿½t my question.  My question was, do you have proposalsï¿½of these 55ï¿½this is your statement, I am just reading from your statement.
  Dr. Cross.  Yes, sir.
  Mr. Snyder.  You said you have 55 proposals you received, and that those with merit are expected to start later.  My question is, do you have funding to start all the ones that have merit?  Or were some of those 35 not able to be started even though you considered them to have merit, because you did not have adequate funding?  Could you have benefitted from some more research dollars?
  Dr. Cross.  We are going to fund them based on their methodology.  We are not going to fund them all.  Those that meet the criteria that we set, those are the ones that will be funded.
  Mr. Snyder.  I should have become a dentist. Sometimes you have to pull teeth around here, donï¿½t you?
  Dr. Cross.  Sir, honestly I donï¿½t know where the line is going to be drawn on that, in terms of the methodology.
  Mr. Snyder.  Is money part of your methodology?  Is that on yourï¿½I mean, we have had previous testimony.  This is not a mystery.  We have had previous testimony that there was notï¿½matter of fact, it was in somebodyï¿½s written statement from the VA, I think, was it from the VA?  That there was not enough money to fund all the traumatic brain injury studies.  And that was several months ago, and I am just trying to get a follow-up.  We canï¿½t help you if we donï¿½t have information.
  Dr. Cross.  I have with me Dr. Kupersmith, who is heading our research effort.  If I could introduce him?
  Mr. Snyder.  Sure.
  Dr. Kupersmith. We often have a category of meritorious but not funded.  I donï¿½t have the numbers for you on that particular review.  Our general funding rate is about 20 to 25 percent, and that is where we target the meritorious proposals.  We work with people who are below those levels to try to upgrade their proposals, usually, and you know, we review them on the next round.  But I donï¿½t know in that particular review whether there was a category of meritorious but not funded.  I will get that information for you.
  Mr. Snyder.  Yes, we would like it.  We have had previous testimony to that effect, but more good work could have been done if there was adequate funding.
  Thank you, Mr. Chairman.
  Mr. Brown.  Thank you, Dr. Snyder.  And we will entertain a second round of questioning, and I have got a question of Dr. Hoge.
  It is often reported that 30 percent of servicemembers returning from Iraq and Afghanistan suffer from PTSD.  That is an alarming statistic.  As a recognized leader in research in this area, what do you thinkï¿½this is true incident rate of PTSD among those returning from OEF or OIF?
  Colonel Hoge.  I am sorry, I misunderstood the question, sir, the last part of your question?
  Mr. Brown.  Is 30 percent the right number, or is there some other number?
  Colonel Hoge.  Thirty percent is certainly the right number, at least for individuals who experience symptoms. But that doesnï¿½t mean that they have the disorder of PTSD. Our estimates based on a variety of data sources is that about 10 to 15 percent of soldiers who return from Iraq have the disorder of PTSD, and need treatment.  And then there are additional soldiers who experience symptoms to a varying degree, that may need some assistance but donï¿½t necessarily reach the criteria for actually having the disorder.
  Colonel Ritchie.  And if I could add to that; by ï¿½ symptoms,ï¿½  what we are seeing very commonly is hyper- vigilance, the increased arousal, nightmares, and sort of just being on edge all the time.  And that should in most cases resolve on its own over time.  The message we are trying to put out to our troops and our leaders is that if that doesnï¿½t resolve, if it gets in your way with either your family life or your work life, come in and see us.  And ï¿½ us,ï¿½ we include is chaplains, behavioral health, primary care, military one-source.  So we try to offer a really wide range of options, low-stigma ways that people can come and get the help that they need.  In many cases, just the education that this is normal is helpful to the soldier.
  I would like to add, too, that I think an important push for us that we are doing right now with the aid of Colonel Hoge and his troops is BATTLEMIND training for spouses and family members, and parents of soldiers, how can we make sure they are educated in these symptoms?
  I had a mother of a soldier tell me a very eloquently how shocked she was when her son came home for R&R, and he was just not acting right.  And she felt she needed more education on that issue, to realize their son might not a very nice guy when he came back for the R&R.  So that again is part of our increased educational effort to the whole collective military family.
  Mr. Brown.  Do you find that most of the cases coming back, are they treated with medicine, or just by coming back in and having the community support and family support, that tends to help them overcome that, you know, that stress?
  Colonel Ritchie.  I think Committee support is absolutely essential.  I do not have hard data for you on that, but anecdotally, it makes a lot of difference to have the uniform be recognized, to have people be thanked for their service.  Tremendously important.
  Mr. Brown.  Then what percent would you say would have to be treated with some medicine, orï¿½
  Colonel Hoge.  I think the question is, what percent need to be treated?  Is that correct, sir?
  Mr. Brown.  Yeah.  I know there are all sorts of treatments, and I guess going, having sessions, andï¿½but I am just thinking, if there is some long-lasting treatment that would have to be on some, you know.
  Colonel Hoge.  Among the soldiers who have come back from Iraq, about a third have received some sort of mental health evaluation or treatment.  A lot of this is preventative, educational type services, and not necessarily treatment for disorders.  About 12 percent of the troops who come back from Iraq have been diagnosed with some sort of mental health problem.  That is within the year of return, and within our military treatment facilities.
  Once they leave the military and go into the VA system, I think the VA has data as well on what percent of individuals who access the healthcare system at the VA receive a diagnosis of a mental health problem or presumptive diagnosis of a mental health problem.  And their overall data that I have seen that has been made public, the overall rate of accessing care for mental health issues is actually fairly similar, though there is a lot higher use of mental health diagnoses.
  I donï¿½t know if that is clear, but it is about a third of individuals access care, and somewhere in the neighborhood of at least 10 percent receiving a diagnosis of a mental health problem within the first year of coming home.
  Mr. Brown.   Dr. Cross, is that a similar number with you?  I am really just looking to see how many are long-term users of some kind of corrective medicine?
  Dr. Cross.  Sir, I would ask that Dr. Katz answer that, but if I might justï¿½I wanted to say one word on how much I appreciate our BATTLEMIND technique that has been brought forward by DoD.  We have adopted this.  We are using it in our vet centers.  We are finding it to be very practical, and very effective, and I want to thank my DoD colleagues for their work on that.
  And now I will ask Dr. Katz to respond to your specific question.
  Mr. Brown.  Thank you, okay.  Doctor?
  Dr. Katz.  In terms of the number of people we are seeingï¿½VA sees about 31 percent or so of returning veteransï¿½about a third of them have mental health concerns or diagnoses.  15 percent have PTSD.  Other conditions, as Dr. Hoge suggested, like depression, anxiety, alcohol use problems, are also common.
  Information from our National Center for PTSD suggests that among those exposed to a significant trauma in military or civilian life, about 25 percent will exhibit significant symptoms over time.  Most of them, though, will recover on their own, or with brief interventions.  About eight to 10 percent will require more extended treatment.  And about 60 percent of those that receive either medicationsï¿½certain antidepressants, for exampleï¿½or certain forms of psychotherapy, will respond.
  Mr. Brown.  Okay, thank you very much.
  Mr. Michaud, you have a follow-up question?
  Mr. Michaud.  Yes, thank you, Mr. Chairman.
  Dr. Cross, what happens to the mental health care initiatives that are supposed to be beefed up, VA resources for mental health care, when the allocated funds sunset? What happens to those initiatives?  And when does it sunset?
  Dr. Cross.  The enhancement funds that I believe you are talking about?  The enhancement funds?
  Mr. Michaud.  Yes.
  Mr. Moran.  We are still fully committed to using the full amount of those enhancement funds.  Here is what we are doing: we want to make sure that every one of those dollars that are put forward for that is used appropriately.  It is taking a bit longer to do that, but we want to make sure that those dollars go to the very best purpose, to actually make a difference for each of those veterans.  So we are doing this carefully.  We are taking some time, but we are doing it as expeditiously as we can, while making sure that it is used very effectively.
  Mr. Michaud.  So when those funds sunset, what happens to the initiatives?  And when does it sunset?
  Dr. Katz.  We have been talking about 2008 funding. We canï¿½t speak about funding until you speak about funding. I was hired four months ago to implement the strategic plan; and empowered to do it, we will do it.
  Programs are out there, but it is more than spending money.  Implementing the strategic plan really involves culture change.  Issues like Dr. Ritchie and Dr. Hoge were talking about, integrating mental health and primary care is a matter of money, but not just a matter of money. Reorienting the specialty mental health sector to provide rehabilitation and recovery-oriented care is a matter of cultural change that we are working intensively on.  It will be done, but it will take time.
  Mr. Michaud.  Okay.  Okay, actually I was just told that once the money runs out, then the facilities will have to pick up, soï¿½
  Dr. Katz.  Yes.  One of the conditions of the money going to a facility or a VISN, or regional network, is a commitment that staff hired will be permanent staff.  And when designated funds run outï¿½if they doï¿½the programs and the positions will be continued by the facility, or the VISNs.
  Mr. Michaud.  So if a VISN is running low on money, and they see this program, then they probably will not want to accept it, knowing that they will have to pick up the cost.
  Dr. Cross.  Sir, for the VISNs on mental health, we are putting out enough money to make sure that they can carry out whatever program they need to carry out.  Looking at 2005 to 2006, and on to 2007, we are looking at about a 30 percent increase in funding for that period of time.  The service enhancements are going to make a difference.  We are going to carry them out.  We are going to do good things for these veterans, and we are going to make sure that those programs that we fund are actually effective, and make a difference.
  Mr. Michaud.  Well, I respectfully disagree, because I know some VISNs that were supposed to have a CBOC within the VISN, they refused to submit a business plan because they know they donï¿½t have the money to implement it.  So I canï¿½t see them doing this.
  What steps is the VA taking now to be able to release funds quickly for the new mental health initiatives for 2007?
  Are you doing anything now for the 2007?
  Dr. Cross.  Sir, we have already got a great deal of work done, and we are working on a mental health primary care initiative.  You talked about stigma.  We want to make sure that that is not an issue.  People are comfortable in coming in to, usually, a primary care facility, and seeing people that they already know.
  What we want to do is to make sure that when we do detect any mental health condition, especially things like depression, we want to make sure that when we detect it, that we then follow through, and have the capability in those primary care clinics.  So we have brought forward a mental health primary care initiative on which we are going to expand very substantial funds, over the coming years.
  Mr. Michaud.  And my last question is, how many and how much?
  Dr. Katz.  Our talk about the primary care initiative is roughly a $40 million program.  We received 85 responses to requests for proposal, and we will be funding the overwhelming majority of them.  Other plans for the year are to target specific needs, both in established programs where there are gaps, and also in new programs.  For example, part of our plan for the year includes suicide prevention counseling very much like the ones that Mr. Boswell spoke about.
  Another plan is to put recovery and rehabilitation coordinators in the field, really to facilitate, at the local level, the transformations discussed in the strategic plan.
  Mr. Michaud.  Thank you.  Thank you Mr. Chairman.
  Mr. Brown.  Thank you, Mr. Michaud.  Mr. Moran?
  Mr. Moran.  Thank you Mr. Chairman.
  The issues surrounding brain rehabilitation, traumatic brain injury, what is the status of the ability for Bethesda and Walter Reed Army Medical Center to meet those needs of our military men and women?  Do we have sufficient capacity?
  Colonel Labutta.  I think your question was, do we have the capacity to meet the rehabilitation needs at Walter Reed and National Navy Medical Center?
  Mr. Moran.  Yes, sir.
  Colonel Labutta.  Thank you.  We could certainly do more inpatient rehab at both those facilities for traumatic brain injury.  I think that when we have a soldier there who has had a brain injury and is there for prosthetic care for a year, and also had a brain injury; the prosthetic care and the prosthetic rehab seems to take first place.  When there isnï¿½t another injury, what we usually do is try to have that soldier transferred to one of the VA polytrauma centers, where they have active traumatic brain injury rehab.
  So hopefully, to answer one of the questions of what is a need, there is a gap, if you will, for those soldiers who need some inpatient rehab during their acute care, while they are getting acute care, at the MTFs.
  Mr. Moran.  Is that gap caused by lack of dollars, lack of personnel, or lack of physical space?
  Colonel Labutta.  I think the answer to that question, sir, would be yes.
  Mr. Moran.  And I guess also what you are telling me, though, is aside from the inpatient treatment that is occurring during the immediate return and medical care and treatment at the Bethesda or Walter Reed; then, we are utilizing the VA system to help meet that gap in other circumstances?
  Colonel Labutta.  Yes, sir.
  Mr. Moran.  And the capacity within the VA?
  Colonel Labutta.  I am sorry?
  Mr. Moran.  Is there sufficient capacity within the VA for this treatment?
  Dr. Cross.  Sir, looking at our polytrauma treatment centers, the floor of them, 12 beds each; occupancy rate about 71 percent.
  Mr. Moran.  I thank you.  Thank you Mr. Chairman.
  Mr. Brown.  Thank you, Mr. Moran.  Mr. Filner?
  Mr. Filner.  Thank you Mr. Chairman.  Thank you for having this hearing today, I think it is very important to our nation.
  I am not going to get too muchï¿½with questions.  Let me just briefly say I am more than a little disappointed from the testimony today.  I said in my opening statement that we are letting our veterans down.  That judgment is based on representing San Diego, California, probably the biggest military and veterans community in the country.  If not the biggest, one of the biggest.  And I talk to my constituents every day.  We had a lot of statistics from Dr. Katz.  I appreciate that, but I assume those statistics are based on the patients that come in.  I mean, two thirds of the almost 600,000 returnees from Iraq and Afghanistan donï¿½t access that system, so I am not sure if you haveï¿½whatever your statistics are, we are missing an incredible amount of our population.
  And what saddens me is that we have the expertiseï¿½and I donï¿½t question your expertiseï¿½we have the expertise and the resources not to let these young men and womenï¿½and some older men and womenï¿½down.  We know that whatever your statistics say, the Guard and Reserve forces who are taking a much more prominent role, as you know, in this war; when they get those papers that they have to check boxes on, all they want to do is get home.  And they can check anything that stops that, and if they had to go for a medical inquiry for two or three days, they ainï¿½t going to check that box.  And they are going to have those problems.
  Treating our veterans, as you know, should be seen as a cost of the war.  We are spending $1 billion every 2 and a half days in Iraq.  If we canï¿½t take the money that you all need to do your job better, we ought to be ashamed of ourselves.  We have the money.
  And Mr. Chairman, maybe you and some of the other leaders of the Committee could talk to their bossesï¿½I hope they talk to their bosses.  Talk to the Secretary of Defense, talk to the Secretary of Veterans Affairs.  The rules under which you are here, and the kind of statements that you are allowed to make, are not helping our veterans.  Personally, I know you want to help them.  You are not doing it with this kind of testimony, and the way you responded to our questions.  You are simply not doing the job that you can do, and if we have to change the rules, Mr. Chairman, and make those arrangements with their secretaries, we ought to do that.  These people know a lot more, need a lot more, then they are telling us here.  And you have lost an opportunity for our veterans.  We have lost an opportunity to use your expertise.  That saddens me, and I wish we could find a way to talk more freely, because as Dr. Katz says, you know, we have the money.  You have the expertise.  Let us join those two together.  We want to give you the money.  We want to make your arguments, but you are not helping us, and I wish you could find a way to do that in a better way.
  And I thank you, Chairman.
  Mr. Brown.  Thank you, Mr. Filner.
  Mr. Michaud, for a brief statement.
  Mr. Michaud.  Thank you very much, Mr. Chairman, once again for having this hearing.  I also want to thank the panel, for your willingness to come here, and I look forward to working with you.  I want to thank Mr. Filner, as well.
  In closing, Mr. Chairman, I just want to say that actually, Mr. Filnerï¿½s remark actually reminded me, yesterday, we actually heard from two veterans that came back from Iraq, and one of them, exactly how they answered the question, made a difference in whether or not they get home immediately or not.  So it forced them to answer the question in such a way that they could go home to see their loved ones.  So there are problems out there, and as Mr. Filner has mentioned, and others, hopefully that each and every one of you will look down deep in your heart, and reallyï¿½because I know you know what is going on out thereï¿½and encourage your bosses to come forward and put forward an aggressive program that is funded.  You have the tools, but we have got to make sure that each and every veteran has access to those tools, and that you donï¿½t have to wait for services.
  So once again, I want to thank the panel for coming today.  And thank you especially, Mr. Chairman.
  Mr. Brown.  Thank you, Mr. Michaud.  And let me tell you, I want to thank you and Mr. Filner and the other members for their participation today, and certainly thank the panel for what you do with the resources that are available to you, for solving such a pressing problem, that we feel like we need to reach across all lines to help our young men and women in their time of need.
  Without further ado, I would like to ask unanimous consent that all members have five legislative days in which to submit an opening statement, or to revise the extent of their remarks.
  And with nothing further, the hearing stands adjourned, and thanks to you all again for your service.
  [Whereupon, at 11:50 a.m. the hearing was adjourned.]