[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]



                         [H.A.S.C. No. 110-137]



                                HEARING

                                   ON
 
                   NATIONAL DEFENSE AUTHORIZATION ACT

                          FOR FISCAL YEAR 2009

                                  AND

              OVERSIGHT OF PREVIOUSLY AUTHORIZED PROGRAMS

                               BEFORE THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                MILITARY PERSONNEL SUBCOMMITTEE HEARING

                                   ON

              BUDGET REQUEST ON THE MENTAL HEALTH OVERVIEW

                               __________

                              HEARING HELD

                             MARCH 14, 2008

                                     
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13

                                     


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                    MILITARY PERSONNEL SUBCOMMITTEE

                 SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas                 JOHN M. McHUGH, New York
LORETTA SANCHEZ, California          JOHN KLINE, Minnesota
NANCY BOYDA, Kansas                  THELMA DRAKE, Virginia
PATRICK J. MURPHY, Pennsylvania      WALTER B. JONES, North Carolina
CAROL SHEA-PORTER, New Hampshire     JOE WILSON, South Carolina
NIKI TSONGAS, Massachusetts
                David Kildee, Professional Staff Member
               Jeanette James, Professional Staff Member
                     Rosellen Kim, Staff Assistant

                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2008

                                                                   Page

Hearing:

Friday, March 14, 2008, Fiscal Year 2009 National Defense 
  Authorization Act--Budget Request on the Mental Health Overview     1

Appendix:

Friday, March 14, 2008...........................................    55
                              ----------                              

                         FRIDAY, MARCH 14, 2008
FISCAL YEAR 2009 NATIONAL DEFENSE AUTHORIZATION ACT--BUDGET REQUEST ON 
                       THE MENTAL HEALTH OVERVIEW
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, 
  Chairwoman, Military Personnel Subcommittee....................     1
McHugh, Hon. John M., a Representative from New York, Ranking 
  Member, Military Personnel Subcommittee........................     3

                               WITNESSES

Casscells, Hon. S. Ward, M.D., Assistant Secretary of Defense for 
  Health Affairs.................................................     4
Gannaway, Maj. Bruce, U.S. Army..................................    33
Gannaway, Sarah..................................................    35
Gutteridge, Richard G., Chief Warrant Officer IV, U.S. Army......    38
MacDermid, Dr. Shelley M., MBA, Ph.D., Co-Chair, Defense Health 
  Board Task Force on Mental Health, Director, The Center for 
  Families at Purdue University, and Director, Military Family 
  Research Institute.............................................    11
Robinson, Vice Adm. Adam M., USN, Surgeon General, U.S. Navy.....     7
Roudebush, Lt. Gen. (Dr.) James G., USAF, Surgeon General, U.S. 
  Air Force......................................................     9
Scheuerman, Christopher M., Sr., Master Sgt. (Ret.), U.S. Army...    30
Schoomaker, Lt. Gen. Eric B., USA, M.D., Ph.D., The Surgeon 
  General of the U.S. Army and Commander, U.S. Army Medical 
  Command........................................................     5

                                APPENDIX

Prepared Statements:

    Casscells, Hon. S. Ward, M.D.................................    64
    Davis, Hon. Susan A..........................................    59
    Gutteridge, Richard G........................................   129
    MacDermid, Dr. Shelley.......................................   120
    McHugh, Hon. John M..........................................    62
    Robinson, Vice Adm. Adam M...................................    92
    Roudebush, Lt. Gen. (Dr.) James G............................   108
    Scheuerman, Christopher M., Sr...............................   126
    Schoomaker, Lt. Gen. Eric B..................................    82

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Mrs. Boyda...................................................   137
    Mr. Jones....................................................   138
    Mr. McHugh...................................................   137

Questions Submitted by Members Post Hearing:

    [There were no Questions submitted post hearing.]

FISCAL YEAR 2009 NATIONAL DEFENSE AUTHORIZATION ACT--BUDGET REQUEST ON 
                       THE MENTAL HEALTH OVERVIEW

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                           Military Personnel Subcommittee,
                            Washington, DC, Friday, March 14, 2008.
    The subcommittee met, pursuant to call, at 9:06 a.m. in 
room 2118, Rayburn House Office Building, Hon. Susan A. Davis 
(chairwoman of the subcommittee) presiding.

OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
    CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE

    Mrs. Davis. The meeting will come to order.
    I want to welcome you all to this hearing today. The 
purposes of our hearing are many and diverse.
    First, we will receive an update on how the Department of 
Defense (DOD) has implemented the recommendations of the 
Defense Task Force on Mental Health. The Task Force was 
mandated by Congress in the 2006 National Defense Authorization 
Act (NDAA), and was charged to both assess the military mental 
health care system and to make recommendations on how to 
improve it.
    Second, we will have an opportunity to hear about the 
findings of the Army's Mental Health Advisory Team (MHAT)-V. 
The results of other MHATs have provided great insight into the 
mental health needs of our military because the teams conduct 
their research and interviews on the ground in Afghanistan and 
Iraq.
    Finally, we will have the opportunity to hear about what 
individual mental health needs are and are not being met from 
service members and family members.
    Today, we will have two panels, and we greatly welcome both 
of these panels here today.
    The first panel before us now includes Dr. Ward Casscells, 
the Assistant Secretary of Defense for Health Affairs; 
Lieutenant General Eric Schoomaker, Surgeon General of the 
Army; Vice Admiral Adam Robinson, Surgeon General of the Navy; 
Lieutenant General James Roudebush, Surgeon General of the Air 
Force; and Dr. Shelley MacDermid, the Director of the Center 
for Families at Purdue University, the Co-Director of the 
Military Family Research Institute and the Co-Chair of the 
Department of Defense Task Force on Mental Health.
    These senior medical leaders will tell us what has changed 
since our last hearing and what they are doing now and what 
they have planned for the future. Dr. MacDermid will help frame 
these responses in relation to the findings and recommendations 
of the Task Force.
    Welcome to you all. I do want to say that, if you can stay 
for the second panel, we would greatly appreciate that, and we 
certainly do not want anyone to think that our second panel is 
under any influence from the first, but we really would 
appreciate it, if it is possible, for you would stay. Perhaps 
there would be some questions that would be directed to you 
after they have had a chance to speak, as well.
    The second panel will have two currently serving soldiers--
Chief Warrant Officer IV Richard Gutteridge and Major General 
Gannaway, who have been treated for mental health conditions 
and are willing to share their experiences.
    Thank you both for your courage and for being willing to 
testify.
    We are also very fortunate that we will hear from the 
spouse of one of these soldiers, Mrs. Sarah Gannaway, so we can 
understand the experience from the family's point of view as 
well as we can learn what mental health services our family 
members require.
    Finally, Mr. Christopher Scheuerman will share with us a 
story of his son, Private First Class (PFC) Jason Scheuerman, 
who committed suicide in Iraq in 2005. I think this story is 
very painful for all of us to hear, but it is illustrative of 
how the system failed a soldier, and it will provide us some 
insights into just how comprehensive and integrated military 
mental health services need to be.
    To all of the witnesses on the second panel, again, thank 
you so much for your willingness to share such intimate and 
painful experiences with us and to help ensure that others do 
not have to suffer as much.
    All of the members of this subcommittee remain unanimous in 
their support for our service members and for their families. 
With multiple, long-term deployments now the norm for our 
military, mental health is more important than ever. It weighs 
heavily upon the readiness of our force, on our ability to 
retain combat veterans and on our obligation to care for those 
who volunteer to serve our Nation.
    At our last mental health hearing, I made it clear that 
this was going to be a long process. It will take a sustained 
effort from all concerned for the foreseeable future to make 
required changes to the Defense Health Program. We will face 
challenges in recruiting or training additional mental health 
providers. We will encounter institutional resistance from 
those who think the current system is adequate. We will also 
face fiscal challenges, great fiscal challenges. The structural 
and cultural changes needed will require significant and 
continuing financial outlays, but our service members and their 
families deserve no less.
    Finally, I would like to make mention of the fact that all 
of the second panel witnesses and many of the topics for the 
first panel are in some way connected to the Army, and this is 
not because we feel that the Army is the only service that 
faces mental health challenges. Far from it. We feel that all 
of the services need to be better. In fact, we will hear from 
all of the services about the different programs that they 
have.
    So why then is the Army figuring so prominently in hearing?
    Well, first, the Army has the largest number of personnel 
in both Afghanistan and in Iraq. Second, the Army has 
undertaken a number of self-assessments on mental health issues 
and has unselfishly shared them. Finally, when the staff of the 
subcommittee interviewed potential witnesses, there were those 
with experiences that really stood out as excellent examples of 
what improvements have been made and of what still needs to be 
done. By random chance, those happen to be in connection to the 
Army.
    It would be a disservice to the Army to assume that these 
coincidences single it out as having more problems than any 
other services. Instead, I think we need to be grateful to the 
Army that so much information is available to help us guide our 
discussions.
    Once again, I welcome you all today. I look forward to a 
very fruitful discussion.
    I would like to turn to the ranking chair, Mr. McHugh, for 
his introductory remarks.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 59.]

  STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE FROM NEW 
     YORK, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

    Mr. McHugh. Thank you very much, Madam Chairman.
    I have an extensive opening statement that I will submit 
for the record for its inclusion in its entirety.
    I just want to very briefly echo your words of welcome. 
Some of our panelists are appearing for the second time this 
week. That seems to me to be beyond cruel and unusual 
punishment, but I think it speaks very well of their devotion 
to these mental health and health concerns that we all share. 
We are very grateful to have such a distinguished first panel.
    Dr. MacDermid, particularly, thank you for your work on the 
Task Force. We look forward to hearing your comments, of 
course, and look forward to hearing from our good Secretary, as 
well as the Surgeons General, as to how we can work together 
and provide these very critical services.
    I would echo the statements and the Chair's remarks about 
our particular appreciation for the second panel. These good 
folks will provide us with a particularly important, a 
particularly unique perspective on, I know, what we all 
recognize as a challenge. Recognition is critical; it is the 
first step in providing these services.
    But we have got a ways to go. Hopefully, today's hearing 
can help us take a few more steps down that path.
    So, with that, again thank you for being here. I look 
forward to everyone's comments.
    Madam Chair, I will yield back.
    Mrs. Davis. Thank you, Mr. McHugh.
    [The prepared statement of Mr. McHugh can be found in the 
Appendix on page 62.]
    Mrs. Davis. Dr. Casscells, would you like to begin?

STATEMENT OF HON. S. WARD CASSCELLS, M.D., ASSISTANT SECRETARY 
                 OF DEFENSE FOR HEALTH AFFAIRS

    Dr. Casscells. Thank you, Madam Chairwoman and Mr. McHugh. 
We appreciate the opportunity to come before you again and 
report on our response to the problems which have manifested 
themselves and, particularly, to respond to the guidance we got 
from you almost a year ago.
    As you say, Mr. McHugh, we are making progress, and we do 
have a ways to go. We are pleased that we on our end, on the 
military side, at least, have agreement on the road by which to 
get there, and we have had plenty of advice, particularly from 
Dr. MacDermid and her colleagues on the Task Force and 
throughout the academic world. I think we are grappling with 
this about as hard as we can.
    We have been generously funded by Congress. We hope to 
reach a place where our program that we have stood up now will 
begin at the earliest stage of a member's career, as Dr. 
MacDermid recommended in her report, in the Mental Health Task 
Force report, and will continue throughout the career and will 
include improved screening, because not everyone needs to be a 
warfighter. People can serve in other ways.
    It will include what we call resiliency training, so that 
people can become stronger in mind as they do in body. It will 
include better monitoring so that we can begin to find people, 
identify them when they are struggling. Currently, we are 
already charging their battle buddies, their enlisted leaders 
and their company commanders to identify people who are 
struggling; and we are pleased that the line has recognized 
that this is important.
    But early detection is important so that people can get 
three hots and a cot, or even medications in some cases, 
recover, and return to the fight. You know, sometimes it is 
just a misunderstanding that needs to be clarified. So this is 
terribly important, early detection.
    Treatment is a struggle. We do not really know very well 
what treatments work. We recognize this, and we are committed 
now to taking a hard look at these treatments and comparing 
them. In the fields of psychology, psychiatry, psychiatric 
social work, we have struggled in reaching common definitions 
and standards and in agreeing on the way ahead and in agreeing 
on how to collect data, what data to collect, and we are making 
major progress in this, led by Colonel (Promotable) Loree 
Sutton, M.D., an Army doctor, who is coordinating these 
efforts.
    So treatment needs a lot of work, and then rehabilitation 
and reintegration. This is the spectrum of the things we are 
trying to do.
    It is my job as the cheerleader and coach to make sure we 
have got the right players in the field, that they have got the 
right playbook, that they understand the playbook. 
Occasionally, of course, if we are not scoring goals, I have 
got to shuffle the play and call in some plays from the 
sidelines. That is my job as the steward of quality and 
oversight responsibility.
    I am pleased to tell you, ma'am and sir, that we have a 
terrific team on the field now, and we are moving down the 
field. We are going to have, I think, a standard in mental 
health care over the next few years, which will be the best in 
the world, back in the days when the military led the world in 
mental health, and we will be defining ``trauma'' as a 
continuum of mind and body. In so doing, by intervening early, 
we will actually reduce costs because we recognize now that 
depression and post-tramatic stress disorder (PTSD), while they 
only affect about 20 percent of the returning soldiers and 
marines and sailors and airmen, actually account for about 80 
percent of the problems and the costs.
    When you look at the operational errors that you alluded 
to, ma'am, these can be very expensive indeed. So, with this 
early intervention and with these programs that you have helped 
us with, I think we are on the edge of a new era in military 
psychology and psychiatry, and we are pleased today to take 
your questions and answer them to the best of our ability and 
to get your advice.
    Thank you very much.
    Mrs. Davis. Thank you.
    [The prepared statement of Dr. Casscells can be found in 
the Appendix on page 64.]
    Mrs. Davis. General Schoomaker.

STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, USA, M.D., PH.D., THE 
   SURGEON GENERAL OF THE U.S. ARMY AND COMMANDER, U.S. ARMY 
                        MEDICAL COMMAND

    General Schoomaker. Well, Chairwoman Davis, and Ranking 
Member McHugh and distinguished members of the personnel 
subcommittee, thank you for this opportunity to come here today 
and to discuss the Army's efforts to improve mental health care 
for our soldiers and family members.
    Army leadership strongly supports efforts to improve the 
quality and access to mental health services, and they have 
been actively leading to eliminate the stigma associated with 
seeking mental health care. As you know, this stigma is not 
just found in the Army. It is not just found in the military. 
It is a national concern that needs to be addressed across all 
communities.
    Ma'am, I really appreciate your earlier comments about, 
although this appears to be centered on Army patients and Army 
issues, this is really a problem for the Nation as a whole.
    Our soldiers in our Army are doing truly amazing work. It 
is demanding. It has a high operational tempo, as you know, 
today, but our soldiers and our families are stressed. We 
appreciate your bringing soldiers and families here for this 
hearing today, and I want to personally extend my appreciation 
to these soldiers for publicly coming forward and for 
discussing their experiences.
    I am often asked why I cannot order soldiers to come 
forward and talk to you about their issues, and of course, I 
cannot do that. But when experienced soldiers and families want 
to come forward and give us their issues, it helps us to dispel 
stigma; it helps us to identify problems, resistant problems, 
that we can overcome. So I extend my admiration and 
appreciation to them.
    The global war on terror has placed increased operational 
demands on our military force. We know that repeated and 
extended deployments have led to increased stress on families 
and on individual soldiers and have led to other psychological 
effects of war, such as depression, anxiety, withdrawal, and 
social isolation or have led to symptoms of post-traumatic 
stress, which we also know, if not identified and addressed 
promptly--as we learned in prior wars, notably in Vietnam--may 
evolve into a more resistant psychological----
    Mrs. Davis. General, excuse me. If you could just bring the 
mike a little closer----
    General Schoomaker. Yes, ma'am.
    Mrs. Davis. Thank you.
    General Schoomaker. Post-traumatic stress--that is post-
combat stress and stresses of trauma--if not addressed promptly 
will result in a much more resistant psychological injury known 
as post-traumatic stress disorder.
    Let me assure you that the Army is absolutely committed to 
ensuring that all soldiers and families are healthy, both 
physically and psychologically, as Dr. Casscells has addressed.
    Today, on your second panel, you are going to hear from two 
members of the Walter Reed Warrior Transition Brigade, Major 
Bruce Gannaway and Chief Warrant Officer IV Richard Gutteridge, 
as well as from Sarah Gannaway, Major Gannaway's wife. As I 
have said, I really appreciate their coming forward and talking 
to you about their issues and about our continued problems.
    I believe that as an Army and as a Department of Defense we 
have embraced the recommendations of the DOD Task Force on 
Mental Health and of the Mental Health Advisory Teams that we 
have now sent out for the past five years. We are striving to 
truly provide the best mental health care for our soldiers and 
for their families. I would like to touch upon just a few of 
those initiatives that I know are making a profound impact on 
soldiers and families.
    First of all, you have already alluded to these Mental 
Health Advisory Teams. These are a groundbreaking achievement. 
Never before has a military or a fighting force studied the 
psychological strains of combat as intensely during the 
conflict. Sometimes it is not pleasant to hear what we have 
found--self-assessment is not often pleasant--but it is 
important that we hear their unvarnished feedback so that we 
can take the necessary steps to improve; and we have done that.
    Second, the Army's unprecedented leaders' chain teaching 
was a powerful initiative that started at the very top of the 
Army. It simultaneously and powerfully addresses leadership, 
our culture and advocacy. We have trained over 900,000 soldiers 
in a massive educational effort that began in the summer and 
fall of 2007. We are now incorporating that into all of our 
soldier and leader training programs.
    Next, we have the Battlemind Training program. This is an 
outgrowth of our Mental Health Advisory Teams. It focuses on 
building fitness and resilience. The findings of the latest 
MHAT-V indicate that Battlemind is hitting the target and is 
making soldiers less susceptible to combat stress and is 
building resilience. Finally, we have our Re-Engineering 
Systems for the Primary Care Treatment of Depression and PTSD 
in the Military (RESPECT-MIL) program, which addresses access 
from different perspectives to include primary care.
    I do not bring up these points to say that we are solving 
everything, but we do have a focused, reasoned approach.
    I applaud Congress and this committee for standing up the 
Task Force on Mental Health in 2006. I applaud Congress for 
directing the establishment of our Center of Excellence for 
Psychological Health and Traumatic Brain Injury. I look forward 
to continuing to work with you in improving the delivery of 
mental health services and in answering your questions today. 
Thank you.
    Mrs. Davis. Thank you very much.
    [The prepared statement of General Schoomaker can be found 
in the Appendix on page 82.]
    Mrs. Davis. Admiral Robinson.

STATEMENT OF VICE ADM. ADAM M. ROBINSON, USN, SURGEON GENERAL, 
                           U.S. NAVY

    Admiral Robinson. Madam Chairwoman, Representative McHugh 
and distinguished members of the committee, I appreciate the 
opportunity to share with you Navy Medicine's efforts in 
preventing, diagnosing and treating psychological health issues 
affecting our active duty and Reserve sailors and marines and 
their families.
    As the provider of medical services for both the Marines 
and Navy, we have to be prepared to meet the needs of these 
similar and yet unique military populations. My colleague, Rear 
Admiral Bill Roberts, who is seated behind me, currently serves 
as the Medical Officer of the Marine Corps. We share a vision 
on how to meet the needs of marines both in theater and in 
garrison. We also work very closely with our aligned 
leadership, the Chief of Naval Operations and the Commandant, 
to implement Navy/Marine centered care initiatives to address 
everything from combat stress to predeployment training and 
wounded marine care.
    Since the beginning of the global war on terror, Navy 
Medicine has been continuously adapting to meet the short- and 
long-term psychological health needs of service members and of 
their families before, during, and after deployment. We are 
well aware of the fact that the number and length of 
deployments have the potential to impact the mental health of 
service members as well as the well-being of their families.
    The current operational tempo is unprecedented. Our 
experiences in previous conflicts, most notably Vietnam, 
suggest that delays in seeking mental health services increase 
the risks of developing mental illness and may exacerbate 
physiological symptoms. This is also the case for individuals 
who may be considering suicide. Although suicide rates in the 
Navy and Marine Corps have not significantly fluctuated in 
recent years, we remain vigilant of the potential long-term 
impact our mission requirements will have on the physical and 
mental health of our sailors and marines and their families.
    In response to the recommendation by the DOD Mental Health 
Task Force, Navy Medicine expanded or, when necessary, 
developed programs to address the four interconnected goals 
outlined in the report. The goals include, one, build a culture 
of support for psychological health; two, ensure a full 
continuum of care is available; three, allocate sufficient and 
appropriate resources; four, empower the leadership to advocate 
for a culture of psychological health.
    Reducing the stigma associated with seeking psychological 
health services is a critical component of our efforts to build 
and to strengthen the culture that supports psychological 
health. To reduce stigma, we have expanded our training efforts 
in collaboration with the Chief of Naval Personnel. These 
training programs are available at each career training point 
and help educate service members on the importance of not 
delaying psychological health services. The same way physical 
conditioning prepares sailors and marines for the rigors and 
challenges of high-tempo operational deployments, we are 
psychologically preparing service members and their leaders to 
build resiliency, which will help manage the physical and 
psychological stresses of battle.
    The Marine Corps' Marine Operational Stress Surveillance 
and Training Program, MOSST, includes briefings, health 
assessments and tools to deal with combat and operational 
stress. The MOSST Program includes warrior preparation, warrior 
sustainment, warrior transition which happens immediately 
before marines return home, and warrior resetting.
    In addition to training sailors, marines and their families 
to identify the signs of stress in themselves and in their 
colleagues, we are expanding caring-for-the-caregiver training 
programs for psychological health, traumatic brain injury and 
post-traumatic stress disorder. To ensure the full continuum of 
mental health care services are available to sailors and 
marines, we have made psychological health screening an 
effective and normal part of military life before, during, and 
after deployments.
    Since the late 1990's, Navy Medicine has embedded mental 
health professionals with operational components of the Navy 
and of the Marine Corps. Clinical psychologists have been 
regularly embarked aboard all of our aircraft carriers and have 
become a valuable member of ship's company. Not only have 
mental health assets helped crews deal with the stresses 
associated with living in isolated and unique conditions, but 
medevacs and administrative discharges for conditions typically 
managed by mental health personnel have decreased. Having a 
mental health professional who is easily accessible and who is 
going through many of the same challenges has increased 
operational and battle readiness aboard these floating 
platforms, saving lives as well as hundreds of thousands of 
dollars in operational costs.
    For the Marines, Navy Medicine Division psychiatrists who 
are stationed with marines developed OSCAR teams, Operational 
Stress Control and Readiness, which embed mental health 
professionals as organic assets in operational units. OSCAR 
teams provide early intervention and prevention support through 
all of the phases of deployment. The same team providing care 
in garrison also deploys with the unit, which improves cohesion 
and helps to minimize stigma.
    Since the beginning of Operations Enduring Freedom and 
Iraqi Freedom, mental health-related medical evacuations for 
marines have been significantly lower among units supported by 
OSCAR. Currently, there is strong support for making these 
programs permanent and for ensuring that they are resourced 
with the right staff and funding.
    To meet the goals of allocating sufficient and appropriate 
resources to address the mental health needs of sailors and 
marines, we have made mental health professionals more easily 
accessible by bringing the portals of care closer to the 
service members. Beginning in 2006, Navy Medicine established 
deployment health centers to serve as nonstigmatizing points of 
entry at high fleet and Marine Corps concentration areas and to 
augment primary care services offered at the Military Treatment 
Facility (MTFs) or in garrison. Staffed by primary care 
providers and mental health teams, the centers are designed to 
provide care for marines and sailors who self-identify mental 
health concerns on the post-deployment assessment and 
reassessment. We now have 17 such clinics up from 14 last year.
    In urgent or extraordinary situations, Navy Medicine meets 
the psychological health needs of sailors and marines in their 
communities by deploying Special Psychiatric Rapid Intervention 
Response Teams, SPRINT. These teams have been in existence for 
over 15 years, and provide short-term mental health and 
emotional support immediately after a disaster, with the goal 
of preventing long-term psychiatric dysfunction or disability. 
The team may provide educational and consultative services to 
local supporting agencies for long-term problem resolution.
    A new program for Navy SEALS, seabees and marines is called 
FOCUS. Families Overcome and Coping Under Stress is aimed at 
families most at risk, and it will be located at marine bases 
at Camp Pendleton, Camp Lejeune, Twentynine Palms, and Okinawa. 
This program is a prevention, very early intervention program 
consisting of 10 to 12 counseling sessions with a team of 
specially trained counselors.
    Mrs. Davis. Admiral, could I ask you to try and wrap up 
quickly? We have to rush because we have a vote coming, and I 
want to be sure we get everybody in. Thank you.
    Admiral Robinson. Yes, ma'am.
    In summary, let me say that we in Navy Medicine and in the 
Marine Corps are doing everything to make sure that we look at 
the behavioral health needs of our service members and of their 
families, that we have a culture that is of psychological 
health, that we destigmatize as much as possible the effects of 
seeking psychological help, and that we think that patient- and 
family-centered care is the essence of the standard of care 
that we give to our patients.
    Thank you.
    Mrs. Davis. Thank you very much.
    [The prepared statement of Admiral Robinson can be found in 
the Appendix on page 92.]
    Mrs. Davis. Dr. MacDermid.
    Dr. MacDermid. I do not want to make you late for your 
vote.
    Mrs. Davis. Oh, I am sorry. General Roudebush.
    Go ahead, General. I am sorry.

 STATEMENT OF LT. GEN. (DR.) JAMES G. ROUDEBUSH, USAF, SURGEON 
                    GENERAL, U.S. AIR FORCE

    General Roudebush. Madam Chairwoman, Ranking Member McHugh 
and distinguished members of this subcommittee, I welcome the 
opportunity to speak with you today concerning the Air Force 
and the Air Force's medical focus on the operational stress 
that our airmen are enduring both at home and in harm's way in 
combat, and our efforts and activities to, one, prevent and, 
two, to treat as quickly and as effectively as possible when 
these do occur.
    Your Air Force is America's force of first and last resort 
to guard and to protect our Nation. To that end, we Air Force 
medics work directly for our line to address our Air Force's 
top priorities--winning today's fight, taking care of our 
people and preparing for tomorrow's challenges. The future 
strategic environment is complex and uncertain, but be assured 
that your Air Force and your Air Force Medical Service are 
ready for today's challenges and are preparing for tomorrow.
    It is important to understand that every Air Force base, at 
home station and deployed, is an operational platform; and Air 
Force medicine supports warfighting capabilities at each of our 
bases. It begins with our Air Force medical treatment 
facilities that provide combatant commanders a healthy, fit 
force, capable of withstanding the physical and mental rigors 
associated with combat and with other military missions.
    Our emphasis on fitness and prevention has led to the 
lowest disease, nonbattle injury rate in history. The daily 
delivery of health care at our medical treatment facilities 
maintains critical skills that guarantee our readiness to 
provide that healthy, fit force and to care for our families, 
to respond to our Nation's call supporting our warriors in 
harm's way, and to provide humanitarian assistance to countries 
around the world.
    To execute these broad missions, the services--the Air 
Force, the Navy and the Army--must work together interoperably 
and interdependently. Every day, together, we earn the trust of 
our All-Volunteer Force and their families, and we value that 
trust above all else.
    Today, we are here to address the psychological health 
needs of our airmen and of their families. The Air Force and 
the Air Force Medical Service is focused on the psychological 
needs of our airmen and reducing the effects of operational 
stress. Post-traumatic stress disorder is low in the Air Force, 
diagnosed at less than one percent of our deployers, but it is 
no less important. Every airman affected deserves the best care 
available.
    The Air Force Suicide Prevention Program is also a 
commander's program that has achieved a 28 percent decrease in 
Air Force suicides since its inception in 1996. All airmen 
receive annual suicide training. This year, we released the 
front lines supervisors' course as an added tool for 
commanders.
    We continue to use a community approach centered on 
effective detection and treatment, and it is working. The 
entire constellation of our psychological health programs are 
continuously being refined for better support to our airmen and 
to their families.
    In closing, Madam Chairwoman, I am humbled by and am 
intensely proud of the daily accomplishments of the men and 
women of the United States Air Force Medical Service. The 
superior care routinely delivered by Air Force medics and our 
joint partners, the Army and the Navy, is a product of 
preeminent medical research training programs and a culture of 
personal and professional accountability. With your help and 
the help of this committee, the Air Force will continue our 
focus on the health of our warfighters and of their families.
    I thank you and look forward to your questions.
    Mrs. Davis. Thank you, General.
    [The prepared statement of General Roudebush can be found 
in the Appendix on page 108.]
    Mrs. Davis. Dr. MacDermid.

 STATEMENT OF DR. SHELLEY M. MACDERMID, MBA, PH.D., CO-CHAIR, 
DEFENSE HEALTH BOARD TASK FORCE ON MENTAL HEALTH, DIRECTOR, THE 
    CENTER FOR FAMILIES AT PURDUE UNIVERSITY, AND DIRECTOR, 
               MILITARY FAMILY RESEARCH INSTITUTE

    Dr. MacDermid. Good morning, ma'am.
    Chairwoman Davis, Representative McHugh, distinguished 
members of the subcommittee, and others, I am honored to be 
here today. I must hasten to correct, however, the reference to 
my task force. I was one of only 14 people who worked long and 
hard on these issues, and I want to especially acknowledge the 
exemplary leadership demonstrated by both General Kiley and 
Admiral Arthur, who are not here today.
    I have submitted a full report of the Task Force for the 
record. As you know, the report presented an achievable vision 
for supporting the psychological health of military members and 
their families.
    [The information referred to is retained in the committee 
files and can be viewed upon request.]
    Dr. MacDermid. The Task Force made 95 recommendations, 
almost all of which were endorsed by the Secretary of Defense; 
and I know that many dedicated people have been working very 
hard on the recommendations, many of whom are in this room. 
Many of the recommendations were targeted for completion by May 
2008, just a few short weeks from now. I would like to identify 
a few issues that I am especially eager to hear about in terms 
of progress.
    The first is TRICARE. The Task Force recommended several 
specific changes needed to ensure that the TRICARE system could 
provide adequate care. I have prepared an example for you 
today, and I have learned in the period right before the 
testimony that I do not need that paragraph anymore. Dr. 
Casscells assured me that this particular issue will be taken 
care of shortly, so I will let that paragraph go, and we can 
talk about other things, if you wish, later.
    The second issue I would like to address is the supply of 
professionals who are well prepared to provide the prevention, 
assessment, treatment, and follow-up services to military 
members and to their families who require care.
    A question Admiral Arthur and I are often asked is, how 
many more professionals are needed to meet the need. The Task 
Force did not answer this question, and Admiral Arthur and I 
never answered this question because it required the 
development of a new model for allocating the staff who support 
psychological health, specifically a risk-adjusted, population-
based system.
    The existing staff allocation system is based on relative 
value units that undercount prevention activities and unmet 
demand. The Task Force recommended that staff, instead, be 
allocated according to the size of a population in a given 
area, be adjusted according to the presence of risks, such as 
combat deployments and other challenging conditions. According 
to the Secretary of Defense's work plan released in September, 
the new model has been designed, and that should make it 
possible to identify quite precisely where sufficient staff are 
in place to meet the estimated need, where the numbers are 
insufficient and by how much.
    I am also eager to learn about successes in recruiting and 
in retaining mental health professionals. The Task Force 
received numerous indications that it is difficult to get and 
to keep highly qualified mental health professionals. I hope 
that the importance of the individuals who do that work is 
being recognized by very strong efforts to recruit and retain 
them, including incentives and opportunities for career 
development.
    Also, in the area of staffing, I am eager to hear about 
changes in contracting procedures. The Task Force made site 
visits to 38 installations where we heard over and over again 
that contracting mechanisms were cumbersome and delayed, making 
it difficult to keep staff, and in general, it interfered with 
the ability to offer good care.
    While Congress has been helpful in allocating funds, I am 
eager to hear whether the right mix has been provided. 
Substantial funds have been allocated on a nonrecurring basis, 
which makes it difficult to assess infrastructure issues and 
makes it difficult to hire the best staff.
    The Task Force report emphasized that the shortcomings we 
observed were not caused by the protracted conflicts in which 
the United States is now engaged and are unlikely to disappear 
when they end. Nonrecurring funds, while helpful, do not allow 
the fundamental challenges to be addressed.
    Finally, as someone who has devoted her life to studying 
and advocating for families, I will close by saying that I am 
especially eager to hear how services for family members have 
been improved since the Task Force submitted its report. We 
have made several specific recommendations in this area.
    For example, we wanted to be sure that parents or others 
caring for wounded or injured service members could easily get 
access to installations' care managers or other services. 
Because they have no official status as family members within 
military systems, parents sometimes face barriers which 
systematically disadvantage young, unmarried service members.
    We also recommended that the substantial delays many 
children were experiencing in accessing care be addressed.
    We recommended that inequities between families who were 
nearby and who could receive their treatment at military 
treatment facilities and families who were far away and had to 
rely on TRICARE be eliminated. I am eager to hear about 
progress in all of these areas.
    In conclusion, Madam Chairman and distinguished members, I 
appreciate your sustained attention to these issues. I also 
very much appreciated the prompt and detailed plans submitted 
by the Secretary of Defense, but many weeks have elapsed, and I 
know the strong sense of urgency we all feel pales before the 
daily struggles that confront many military families. I am very 
much looking forward to the day the plans are fully 
implemented.
    That concludes my remarks.
    Mrs. Davis. Thank you very much.
    [The prepared statement of Dr. MacDermid can be found in 
the Appendix on page 120.]
    Mrs. Davis. Dr. MacDermid, you mentioned a number of things 
that you would like to hear. I think those are the same things 
that we also would be eager to hear. I wonder if, perhaps, our 
witnesses could--as quickly as possible, I think--just 
address--there are issues around processing and being able to 
get the mental health professionals out there without undue 
delays. I wonder if you could address that quickly, whether 
there was a better system or whether you think that those 
issues have been addressed.
    I know there was another issue, I think around TRICARE and 
paperwork. I am assuming that, maybe, you had a conversation 
about that.
    Dr. MacDermid. Dr. Casscells assured me that issues 
regarding restrictions and intensive outpatient services are in 
the process of being removed, so that is one specific TRICARE 
recommendation that it sounds like has been taken care of.
    Mrs. Davis. Okay. We will be eager to follow up on that as 
well. Then the access for families to receive mental health 
services as well.
    Dr. Casscells, would you like to pick that up?
    Dr. Casscells. Madam Chairwoman, the biggest effort here is 
the Army's effort to hire 200 mental health workers. That has 
been an intense effort.
    As you know, in the country at large, we have squeezed 
mental health for some time now, and getting people into 
uniform or getting them in as contractors is a challenge. The 
Army is over halfway there, and the Army Surgeon General will 
speak to that, Dr. Schoomaker.
    I would say that we have been working to reduce barriers in 
the Pentagon of which there are numerous bureaucratic obstacles 
to identifying people, to getting policies in place that 
identify the characteristics of the people we need. Certainly, 
we have been looking to find alternatives--you know, deputizing 
people to be involved in care whether it is, you know, 
internists, such as myself, or nurses or medics.
    I think Dr. Schoomaker could tell you we will be training 
the 68 Whiskeys shortly in Battlemind Training. So this has, by 
necessity, become everyone's job--the line officers', the 
enlisted leaders'--and we increasingly involve the family 
members. This is a communication effort.
    Just last night, I got an e-mail from an enlisted soldier 
to her sergeant, and the sergeant had sent it up the chain, and 
it came over to me, saying, Why don't we have a website where 
family members of soldiers with PTSD can communicate with each 
other and share tips? Well, we have been developing that darned 
thing for months, and it is going to be launched soon.
    So--in addition to MilitaryOneSource.com, we are developing 
these services, so we are on the move. We are a little more 
than halfway there in terms of hiring people. Further details 
that are Army-specific I will leave to General Schoomaker.
    Mrs. Davis. Okay. Thank you.
    Dr. Schoomaker.
    General Schoomaker. Really quickly, ma'am, there are three 
areas, that I think Dr. MacDermid raised, that we can talk 
about quickly.
    The first is the supply of professionals. As the Secretary 
mentioned, we, the Army, last year went out with a risk-
adjusted, population-based model across our communities. As you 
know, Army Medicine is organized into regional commands: The 
regions each have individual installations within them. Each of 
those regions then went out to individual installations center 
around communities and where our Army was. They were asked what 
additional mental health resources they needed.
    In the continental United States, we estimated a need for 
about 268 mental health professionals. We at this point have 
contracted for about 150 of those who are at work around the 
Army, civilians.
    Our problem in many of those places is, quite frankly, as 
Congressman McHugh knows from Fort Drum, that it is very 
difficult in some of our communities to hire and to recruit in 
these rural populations.
    The second issue I would speak to is about access for 
family members, and especially nontraditional family members. 
One of the benefits and successes of the Army Medical Action 
Plan has been to identify nontraditional family members and to 
provide invitational travel orders and access to parents, to 
fiancees, to best friends, to buddies. That has been 
successful. In the NDAA 2008, you included some provisions for 
defining these family members in a nontraditional way, and we 
appreciate the help that you have given us on that.
    Finally, I would just like to address the fact that, as my 
colleague Admiral Robinson talked about, we really focus on 
beginning at the primary care level in delivering care. So 
primary care providers, family medicine doctors, nurse 
practitioners, physician assistant (PAs), and internists are a 
part of this equation; and we are training those folks just as 
aggressively as we are acquiring mental health.
    Mrs. Davis. Thank you. I think, perhaps, we will address 
later on in the hearing whether there is a special category 
that we might point to as well and think about, in terms of 
those who have served, who perhaps would entertain a different 
career than they had before, where they have some skills that 
could be utilized in this way.
    I wonder if you could just take a look at how long it is 
taking in the application process for some of these mental 
health professionals to come into the system because, you know, 
there is a very important vetting process of looking at the 
prior experience that they have had; but that seems to be a 
prolonged process in many communities, and people will wait 
around just so long for that to be completed.
    It concerns me. It seems to be taking a long time in 
several situations.
    Thank you very much.
    Mr. McHugh.
    Mr. McHugh. Thank you, Madam Chair.
    Let us talk a little bit more about recruiting. General 
Schoomaker just mentioned rural areas.
    It seems that we have our challenges throughout the system. 
One of the recommendations of the Task Force was in noting that 
the Department has the authority to adjust reimbursement rates 
across the board. Yet, my understanding is, to this point, 
there have been no adjustments in the use of that authority to 
increase reimbursement rates for mental health services.
    Dr. Casscells, have you had an opportunity to think about 
that a little bit? Might that not be helpful in gaining access?
    Dr. Casscells. Mr. McHugh, I think that we did adjust them 
in Fort Bragg, around Fayetteville, but many times when we have 
gotten calls about the lack of access in a given area, it has 
been a misunderstanding about the rules and about the fact that 
people are actually permitted to get coverage 25 miles away and 
so forth and so on. A lot of these things are miscommunications 
that get clarified.
    So we have not made as many adjustments in the local--you 
know, in the micro-regional reimbursement rates as we thought 
we would when our effort began. There really have been just a 
few.
    I can get back to you with more detail if you think that 
would be helpful. If we have overlooked some, we would like to 
hear about them.
    [The information referred to can be found in the Appendix 
beginning on page 137.]
    Mr. McHugh. Well, of course, we would very much appreciate 
your getting back to us.
    I am reacting just intuitively. More money usually gets you 
more things--I do not know; that is the way I was brought up, I 
guess.
    Clearly, what we do hear about TRICARE in general--and I 
know all of you are very well aware of this--is that 
reimbursement rates amongst medical professionals is a 
disincentive in many instances.
    I would defer to Dr. MacDermid. That was kind of at the 
core of the Task Force recommendation, was it not?
    Dr. MacDermid. It was. Although, to be fair, I must report 
that this is what providers told us on our site visits.
    We did not have the authority or the ability to really do a 
systematic comparison of data from hospitals. We were able to 
actually get data from one hospital about TRICARE versus other 
payers. This was not part of a negotiated rate, so we were 
given to believe that they were sort of the normal rates that 
you would expect from TRICARE.
    The TRICARE rates were less than half of any of the other 
payers, which is very puzzling when you think about the legal 
requirements for how TRICARE rates are pegged. We do not 
understand it. It is possible that when mental health is a 
carve-out in the contract, that somehow that affects 
reimbursement rates. It is a puzzle.
    So I believe that in that recommendation, we did not 
explicitly say rates should be raised. I think what we said 
was, it needs to be looked at carefully and that, in 
particular, there needs to be conscious scrutiny of mental 
health issues because there are certain gaps in procedures that 
mean that mental health does not get exactly the same kind of 
scrutiny that other kinds of medical care do.
    Mr. McHugh. Okay. I appreciate that.
    Mr. Secretary, if you get a chance to look a bit more in 
detail at what has happened in those areas where you have 
changed rates, I think that would be helpful to us.
    Regardless of what the rates are, if you do not have the 
professionals in a particular geographic area, you are not 
going to be able to gain access. In fact, when Secretary Winter 
appeared before the full committee, he talked about the need 
for increased bonuses for doctors, nurses, et cetera. The Task 
Force mentions that very fact as well.
    If you look at the recently passed National Defense Act, 
the 2008 act, if our math is correct, we currently have 
authorized bonuses. For a new board-certified doctor who signs 
to a four-year commitment, the pay for just that signing up is 
$824,000. What do we need to do beyond that?
    Dr. Casscells. Sir, I am sorry. I have taken down your last 
task there. Could you rephrase that?
    Mr. McHugh. Okay. You have got to be able to recruit. The 
Task Force said and Secretary Winter mentioned in his testimony 
before the full committee that increased bonuses could be 
helpful in recruiting not just mental health care, but health 
care professionals across the board. The new 2008 National 
Defense Act authorizes a new board-certified doctor who makes a 
four-year commitment a signing bonus of $824,000.
    What do we need to do beyond that kind of bonus option to 
help meet that recruiting need where the Task Force and others 
are telling us we need to put into place more bonuses?
    Dr. Casscells. Thank you, sir.
    I agree with Secretary Winter. I did not hear his 
testimony.
    As you know, the retention bonuses and the recruiting 
bonuses have both been pretty effective. We really got them 
there last year just in time. It has been effective for trauma 
surgery, for example.
    We may well need to do more for psychiatry and psychology, 
not just in the bonuses but in letting people know about them, 
and also in signaling that this is a culture that really 
welcomes, you know, people to come in midcareer, that welcomes 
people who are passionate about mental health.
    There is a cultural disconnect that we are trying to get 
past as well, so it is not just a matter of assigning some 
extra DOD dollars. There is also the issue of outreach here, 
and we are working hard on that--scheduling meetings with the 
American Psychological Association, with the psychiatrists, 
with the American Medical Association (AMA), and in going to 
campuses. We have a whole program that we are getting ready to 
launch in this, because we have got to get the word out.
    Mr. McHugh. Well, I thank you. My time has expired.
    I would just say, if I may, Madam Chair, that, obviously, 
we would value your guidance. I cannot speak for the 
subcommittee, let alone for the full committee, but we do have 
a history of trying to be sensitive to those kinds of needs on 
targeted bonuses and pay. So specific recommendations would be 
of great value as we go forward.
    Thank you, Madam Chair.
    Mrs. Davis. Thank you, Mr. McHugh. I would echo your 
comments as well, though in terms of reimbursement, because 
that is an ongoing problem that I hear about, particularly in 
the San Diego community, as well as just the burden of 
paperwork. That does discourage people from getting involved 
and from getting into the system.
    Ms. Boyda.
    Mrs. Boyda. Thank you, Madam Chairwoman.
    I think, as my second year of Congress begins--you know, 
this was such an important issue back in the district. We have 
Fort Riley and Fort Leavenworth, so I feel like we are really 
coming together to address these issues; and understanding them 
is very important.
    General Schoomaker, I very much appreciate your help in 
dealing with some very specific areas of concern that we have. 
At some other point--not right now--I would like to talk about 
some potential mental health provider issues that might be 
available as a good thing at Fort Riley, that we might be 
doing. It is not appropriate to talk about it now, but it would 
be when it is timely.
    General Schoomaker. Yes, ma'am.
    Mrs. Boyda. So I would like to talk about that sooner than 
later, if we could.
    You know, I have heard that the Army did this--what do you 
call the training when you do it level by level?
    General Schoomaker. Our Battlemind Training, ma'am?
    Mrs. Boyda. Yes, but do you have a process when everybody 
trains somebody down----
    General Schoomaker. Oh, leader chain teaching.
    Mrs. Boyda. Chain teaching. Thank you very much.
    That is complete at this point?
    General Schoomaker. Yes, ma'am. That was executed in the 
early fall of last year. It went through the entire force. The 
Chief and the Secretary then challenged me to institutionalize 
that.
    What do we do next? We have done it once over the force. A 
considerable amount of the force, as you know, is deployed in 
Iraq and Afghanistan. Efforts were made to bring that right 
down into the deployed force.
    What we need to do, now that new soldiers have come on 
board and that troops have rotated, is to institutionalize that 
across Army training; and we are doing exactly that with every 
soldier as they go through the non-commissioned officer (NCO) 
training program or officer training program. Every health 
professional, as well, goes through a series of individual 
Battlemind Training focused on resilience and mental health 
issues identification as well as group training.
    Mrs. Boyda. Are the other branches of service doing that as 
well? The Marines?
    Admiral Robinson. We have a combat operational stress 
program that is similar, but we embed it from the recruitment 
all the way through the war college. We have, as I labeled in 
my statement, the MOSST process, which is the Marine 
Operational Stress and Surveillance Training, which is a method 
to train the lowest level and also the midlevel commanders.
    Also to make sure that the commanders are absolutely 
engaged and are also empowered to have a psychological health 
climate, additionally, we have embedded with our marine units 
psychological and psychiatric professionals who are there, who 
become a part of the unit, so that it is no longer a referral 
to medical. Those people are actually in the operational units.
    We do the same thing on the Navy side by putting in 
psychologists and social workers, but particularly 
psychologists, on board our ships so we have them there.
    We also have our chaplains who for the longest time have 
been quite effective here and who are still very effective. 
Every once in a while, I have to make sure that I mention them, 
because they have been doing this since the beginning of the 
Marine Corps and the Navy----
    Mrs. Boyda. Probably before that, too.
    Admiral Robinson. Well, I am just talking about the 
services, but the key is that they have been doing it, and we 
continue to do that.
    Mrs. Boyda. Thank you very much.
    Admiral Robinson. Yes, ma'am.
    Mrs. Boyda. What I was wondering, General Schoomaker, is, 
now that we have implemented that, is there any follow-up to 
see what its efficacy has been if we challenge the system or 
have we measured anything afterwards to see how effective that 
has been?
    General Schoomaker. Yes, ma'am. In the most recent Medical 
Health Advisory Team report, MHAT-V, you will see that there 
was a focused question. We did not do a formal scientific 
study, but we had a certain number of soldiers in that study 
who were deployed who had received Battlemind Training, and a 
certain number who had not; and it gave us an opportunity--it 
gave the team an opportunity to see, was there an outcome in 
improvement. In fact, there was. Those soldiers who received 
Battlemind Training self-reported that their anxiety and that 
the psychological consequences of the deployment in combat 
operations were less intrusive than----
    Mrs. Boyda. If there is a summary of that anywhere, I just 
would like to----
    General Schoomaker. Yes, ma'am. It is part of the MHAT-V.
    Mrs. Boyda. For the record, the whole thing about suicide 
rates.You know, I get a lot of questions, clearly about high 
school retention, or recruits, and all of these sorts of 
standard questions that we all get about this.
    Just for the record, I would love to see what the suicide 
rates are for the Army and for the Marines and be able to 
compare it to what that was before we went into Iraq.
    General Schoomaker. Yes, ma'am. We will follow that 
closely.
    [The information referred to can be found in the Appendix 
beginning on page 138.]
    Mrs. Boyda. Thank you.
    Mrs. Davis. Thank you.
    Mr. Murphy.
    Mr. Murphy. Thank you, Madam Chairman.
    I saw that the 2004 New England Journal had the numbers of 
16 percent of Iraq veterans have major depression, anxiety or 
post-traumatic stress disorder.
    Would you all like to elaborate on that? Do you think that 
is an accurate number? Do you think it is higher? I would enjoy 
your comments.
    General Schoomaker. That was a derivative of, again, one of 
the earlier iterations of the mental health advisory team, and 
that alluded to the incidence among redeploying units of 
symptoms associated with post-traumatic stress. And in every 
one of these four, I try to make sure that we highlight the 
fact that this is post-traumatic stress symptoms, that it is 
not well-established post-traumatic stress disorder, which is 
what most political people and the press often reports on. That 
is a mental health diagnosis from unresolved, unidentified and 
untreated symptoms of post-traumatic stress, which can result 
from combat, from major childhood trauma, from national 
disaster, motor vehicles, any amount of--any cause of stress.
    What that report showed us was that soldiers redeploying 
from a combat zone, depending upon their exposure to combat and 
trauma, had somewhere between 10 and 30 percent rates of 
symptoms associated with post-traumatic stress, but that if we 
do not screen for and promptly treat would, we feared, emerge 
or evolve into or mature into post-traumatic stress disorder. 
Our experience is that with good screening after the fact--and 
this is, in fact, why Dr. Casscells's predecessor mandated a 
policy of post-deployment health reassessment at the 90- to 
180-day period. You will hear our soldiers talking later about 
the fact that at redeployment, frankly, the reintegration 
excitement obscures many of these symptoms, but 90 to 180 days 
later they emerge, and families see this, unit leaders see 
this. And so we screen for the symptoms and then address the 
symptoms through specific treatment.
    Mr. Murphy. And I apologize, General. I thought that Chief 
Gutteridge's written testimony so far has been very 
enlightening to us. But what do you think as far as the number; 
is that accurate?
    General Schoomaker. I think that accurately reflects it. I 
think it would be higher in units that have higher combat 
exposure, and it would be lower in those that don't. In the 
unit that may be restricted to the FOB, to a forward operating 
base, and not work outside the wire and not work in an area of 
intense combat, I think you would expect that it would be 
lower.
    Mr. Murphy. How about as far as the majority of our 
soldiers now and our troops and our marines are married, unlike 
in Vietnam, how about that it is not so--it is not just the 
individual trooper that is affected and that might suffer from 
this, but it is also the family members. What have we done as a 
Department of Defense to help and assist the families as well? 
I know I applaud the 90- to 120-day review for the troopers, 
but what are we doing for the families as well? If you could 
elaborate on that, I would appreciate it.
    General Schoomaker. I will say quickly, and then my 
colleagues can speak to the family center care, as the Army 
does, too, that we extend battlemind training to the families. 
We recognize that families are often the first to identify 
problems with redeploying soldiers and try to make them 
obviously a part of the solution as well as a recipient for the 
services. Army has spent a fair amount of effort as well into 
providing marital and family counselors on our installations, 
and that has been very effective.
    In other words, to go to the root causes of many of our 
problems, you spoke earlier, Madam Chairwoman, about suicide. 
We know that one of the major causes of--or precipitants of 
suicide is a ruptured relationship with the wife, husband, 
girlfriend and the like, or was the Army itself. We know that 
misconduct that results in, let's say, Uniform Code of Military 
Justice (UCMJ) can precipitate a suicidal gesture in a soldier 
who sees their relationship with the Army as one of their most 
important and fragile relationships.
    Mr. Murphy. Roger, sir, I am tracking that. But I think my 
question is more specific. Let me ask, is there some type of 
mandatory screening where we contact and be proactive in 
contacting the spouses to make sure that they are okay? I know 
the centers there that it seems like react to the ones who call 
or come to the doors or the website. But is there the screening 
of the spouses, of the loved ones of our troopers?
    General Schoomaker. I think the operative word there is 
``mandate.'' We don't have authority to mandate for family 
members, but we certainly offer the services to those families, 
and we make them--we sensitize them to the need for them to 
receive that care. Yes, sir.
    General Roudebush. And I think we can speak to the 
activities particularly on departure and then reintegration. 
For the Air Force we used very much a community-based approach 
which is inclusive of the families. And the commanders are--
that remain at the station of origin are also responsible for 
tracking with those family members during the period of 
deployment to assure that the needs are being met, that the 
issues are there.
    I agree with General Schoomaker, there is not a mandate for 
that, but our programs are structured to do that. And I would 
offer, relative to the screening tools, the postdeployment 
survey and the resurvey 90 to 180 days out, those have been 
continually refined to increase the sensitivity to elicit any 
symptoms; to assure that if assistance is required, that we get 
those folks to the assistance that is needed in the most 
expeditious way.
    Admiral Robinson. Congressman Murphy, the Navy has two 
programs, Navy Medicine--actually it is Navy/Marine Corps, 
because the Marine Corps key volunteer member and also the Navy 
ombudsman work with families and work with families 
predeployment and postdeployment. There is nothing mandated, 
but there is certainly a close relationship.
    I think we are trying to get a little bit more proactive, 
especially in the Special Ops community which have huge numbers 
of deployments related to other folks, and that is the focus 
program which is the families overcoming and coping under 
stress. And that is a program we are trying to get into place 
that will do counseling and very, very early intervention with 
families, because we know that deployment time, length of 
deployment and also number of deployments are direct factors in 
psychological stress. And we--we are trying to deal with that 
using that program.
    Mr. Murphy. Doctor--ma'am, can he just answer? He had his 
hand up real quick.
    Dr. Casscells.
    Dr. Casscells. Thank you for your service. I can tell you 
are politely hinting at this issue that we have not yet got a 
rigorous program to identify all of the lost sheep, 
particularly among the Reserve who are drilling Individual 
Mobilization Augmentee (IMAs). I am one of them, Guard. 
Guardsmen, guardswomen. And they go home, and they sometimes 
either don't have a family, or the family has got plenty of 
other things for them to do besides, you know, offer a shoulder 
to cry on. So I am talking to all of our chaplains together in 
a few weeks and asking them for their help in reaching out to 
these people and making sure that the family is doing okay and 
that the servicemember is doing okay, because if we don't hear 
back from them on our postdeployment health reassessment tool, 
and we--about a quarter of them, they are--go home, and we 
don't hear from them. We have got to reach out and identify 
every single one of them. And how to do that, you know, because 
they move, it is not that easy. But we are working on it. So 
thank you.
    Mr. Murphy. Thank you.
    Mrs. Davis. Thank you, Mr. Murphy.
    Mr. Johnson, actually when we were at Camp Lejeune and in 
Mr. Jones's district there, we did see some aggressive follow-
up. I think some of that can be done. And I think certainly 
that is a possibility.
    Mr. Jones, thank you.
    Mr. Jones. Madam Chairwoman, thank you very much.
    Dr. Casscells, it is good to see you again as well as other 
members of the panel. I have got a question, but I will just 
read a couple things in this article that is in the Post.
    ``Care for Injured Vets Rises Questions''--I know a lot of 
this deals with the VA. You are not the Veterans Administration 
(VA), that I understand. But I want to make a point because of 
this article.
    There is a book that I just ordered that I would hope I 
could recommend to anyone: The Three Trillion Dollar War. It is 
an analysis of the cost of the war and what the cost will be 
after the war. And I think any American, quite frankly, should 
read this book. I wish I could buy it for them, but I can't. 
But the point of this is that the--Dr. Cross with the VA said 
during this week, and this is March 8: Lawsuit hearings at 
120,000 vets from Iraq and Afghanistan using VA care for 
potential mental health problems.
    Obviously they are now under the care at the VA, but they 
were in the military. And that is the point that my colleagues 
have been making. And nearly 68,000 of them have potential 
PTSD. We did hear--and I agree with the Chairman, I think the 
committee that did attend, going out at Camp Lejeune, was very 
impressed with many good things that are happening. There are 
many challenges, as well as there are with you.
    I want to know a little bit more about how you recruit. You 
mentioned this earlier that you were going to be more 
aggressive, but is it a problem for the Department of Defense 
to go on university bases--Mr. Etheridge from North Carolina 
has joined us. He is not on this committee, but obviously he 
has an interest, or he wouldn't be here.
    We have one of the strongest university systems in America 
in North Carolina, and the president of the university system 
is Erskine Bowles, who used to be the Chief of Staff to Bill 
Clinton, and he is a fine, fine gentleman.
    I would like to know how you do recruit these mental health 
professionals or these graduates of mental health programs at 
the university. And is there good cooperation? Or do you have 
the stigma that you do at some universities, well, this is the 
military, and then they bring in this idea of the war, whether 
they are for or against it. Can you tell me, explain to the 
committee a little bit how you do recruit these health 
professionals at universities and colleges?
    Dr. Casscells. Congressman Jones, thanks for this. 
Recruiting is strong in North Carolina, I am happy to tell you, 
like it is in Texas, and we have trouble at my alma maters, 
both at Yale and Harvard, to get people to join up. I am 
working personally on that. And, you know, for a while there, 
some universities wanted to keep us off campus until they were 
reminded that they receive Federal funding, and that has been 
helpful.
    Of course, we would rather have people enthusiastic and, 
you know, welcome our recruiters, and their recruiting is not 
done by Health Affairs or by the Surgeons General. We assist in 
that. And we are doing things like helping with a movie, you 
know, called Fighting for Life. It is just launching out 
nationwide about our medical school, for example.
    So there are lots of ways we can be active in this. The 
bonuses, of course, are one of them. At the end of the day, a 
big part of it is individuals recruiting friends and 
colleagues. And so we are trying to get across the idea that 
everyone is a recruiter, everyone is a recruiter. And it is a 
privilege and an adventure to serve. And I will tell you, I 
love telling that story because, for me, joining the Army 
Reserve and being deployed at 53, 54 years old, and at 55, it 
has been the adventure of a lifetime, and it is so rewarding. 
It is the easiest story to tell.
    But there is a lot of information out there, and getting 
through--getting the information out and getting heard is a 
challenge. But bonuses, bonuses are there. The recruiting 
dollars are there. Would more help? Sure, more would help. I 
don't know of any statutory barriers that you could help us 
with, but if you could think of some suggestions, my gosh, 
recruiting and retention are on the edge for us, on the edge, 
sir.
    Mr. Jones. Well, General, would you like to speak to this 
as well?
    General Schoomaker. Well, I was going to say we can't 
promise any Army doctor who is recruited in the Army that they 
are going to eventually become the Assistant Secretary of 
Defense for Health Affairs, but we certainly want that as part 
of the career track.
    So the Army and the Air Force, I will speak for the Army 
medical system, because you are really talking about two 
different programs. One is recruitment of civilian, government 
service employees. That is what we talked about earlier. That 
is a program that is done through the recruitment of any 
government service employees. We have done a targeting 
recruiting for those, and that really powered down contracting 
in the hiring of those folks, and vetting other credentials to 
individual treatment facilities in our regions.
    For uniforms, we have a very aggressive program on 
recruiting that is linked to the recruiting community of the 
Army, but is increasingly carved out to address the specific 
markets of health professionals, because as Dr. Casscells said, 
it is a health professional that recruits another health 
professional. We are in over 100 medical schools, for example, 
in the country today and nursing schools. We have got great 
programs out there. We are very well supported. Some programs 
are obviously better than some other programs. But I think 
Army, Navy and Air Force all have very aggressive programs.
    Quite frankly, frankly, the Health Professional Scholarship 
Program today for medical students is an example--for nursing 
students and dentists--is one of the most generous and best 
programs available and offers them careers that are 
unprecedented.
    Mrs. Davis. Thank you.
    Ms. Tsongas.
    Ms. Tsongas. Thank you for your testimony, and it is 
encouraging to hear the serious work you are putting in to 
addressing this.
    The question I have--and again, this is to play off the 
recent trip we had to Camp Lejeune where we met with many who 
had been wounded--was the issue of how--as you recruit 
civilians into the military either in a contracted way or to 
become part of the military to deal with mental health, how do 
you sensitize these professionals to a world they may not 
understand? I heard from a young soldier that there is a 
hesitancy to go to physicians who have no understanding of what 
they experience, you know, who have not experienced war, who 
are not a product of the military, and who don't have the 
credibility to really help them with the challenges they face.
    Is there a training program, something as you bring people 
in so that they do understand what a unique--post-traumatic 
stress syndrome is obviously a function of service in war, but 
if you haven't experienced war yourself, if you are not the 
product of the military, you may not really understand how to 
go about helping these young people. So I wondered, do you have 
something in place to work that through as you--so that these 
professionals can be effective in the work they are trying to 
do?
    General Schoomaker. Yes, ma'am. You said ``soldier,'' but 
you have visited a Marine camp, so I am going to be real quick. 
I am the soldier up here, and the Marines are represented, of 
course, by Admiral Robinson.
    Ms. Tsongas. This just happened to be the particular young 
people we met with, but I am sure this is across all the 
services.
    General Schoomaker. Yes, ma'am. First of all, for the 
individual combatant, individual soldier, and his or her 
family, we talked earlier about the teaching that took place 
across the Army that has now touched 800,000 to 900,000 
soldiers from the top of the Army, the Chief of Staff, to the 
newest private. For health care professionals, especially those 
who are going into deployment, we now require a combat 
operational stress training course that is conducted at our 
Army Medical Department Center and school in San Antonio. This 
has been very successful. We have also piloted that program to 
be given to our combat medics, who we have now trained about 
800 of our newest combat medics in identification of issues 
having to do with mental health in the theater of operation.
    But that is an effort, as the Navy has done and others, to 
standardize the training that is given to professionals going 
into the theater of operation to sensitize them specifically to 
the challenges of mild concussive brain injury as well as post-
traumatic stress and anxiety associated with it.
    General Roudebush. Yes, ma'am. Likewise in the Air Force we 
perform that training for our uniform members, certainly, as 
part of their predeployment training, and for those that are 
going to be in theater specifically to be sure they are fully 
up on the traumatic brain injury and those activities.
    For the civilian providers that we bring on, we train them 
as well in the diagnostic issues of post-traumatic stress 
disorder, tramatic brain injury (TBI). They are not left out of 
that at all. Now, there is not necessarily a formal 
enculturation process. But as we bring those folks into our 
clinics, hospitals and medical centers, they become very much 
part of the team. And everything that happens within that 
venue, they are a full-up round within it. So they are brought 
along as part of that health care delivery team.
    Ms. Tsongas. I guess a follow-up question might be, then, 
do you see a resistance on the part of those being treated to 
working with civilian--people who have been primarily in the 
civilian world to help them deal with their mental health 
challenges? Or is it--I mean, just given the lack of experience 
some of these professionals may not have had in a theater of 
war. I mean, is there a resistance, or can you supplement it, 
offset it in other ways, or is it just the reality that you 
have to--given the difficulty of recruiting and getting mental 
health professionals, finding the ones you need, that you have 
to make do with the best you can?
    General Roudebush. Ma'am, I would turn that around. And as 
opposed to resistance, which there may be, I would suggest that 
there is a preference for these individuals to see parts of the 
team that they resonate with and identify with. Providers in 
uniform are within our direct care system. For those that we 
are not able, for whatever reason, to treat within the direct 
care system, I believe it is incumbent on us to manage their 
care and to assure that their needs are being met wherever that 
care is being delivered. And that is part of the responsibility 
of that medical group commander and staff.
    Ms. Tsongas. Thank you.
    Admiral Robinson. Congresswoman Tsongas, there is no 
question that Marine Corps, Navy, Active Duty and families 
would rather see uniformed psychiatrists and uniform mental 
health providers. That is not always the case because we don't 
always have enough of them. But there is no question that they 
have made this clear to me as the Surgeon General of the Navy, 
and to the Medical Office of the Marine Corps and other 
leaders. That is number one.
    Number two, if you read Heidi Kraft, who is a former Navy 
psychologist who has written a book, Rule Number Two, and she 
emphasizes that very point that you are making. There is a 
sensitivity, and there is an understanding and there is a 
connection that you have. I think that as--and this is 
specifically civilian mental health workers who are coming into 
our facilities and working, and civilian mental health members 
who are through the TRICARE who are actually out.
    Now, this is the heart of the problem because that is in 
the community. But people coming into our facilities can 
certainly get orientation and indoctrination into some of the 
stresses and some of the conditions that the patients and 
families have. But to be very honest with you, no one is going 
to give what someone in uniform can give you under comparable 
conditions. Someone in uniform that has experience and has been 
with you is going to be more effective.
    Ms. Tsongas. Thank you.
    Mrs. Davis. Doctors, I am going to have to move because, we 
are going to really end up--run out of time, and we want our 
second panel to come forward.
    Ms. Shea-Porter.
    Ms. Shea-Porter. Thank you. And I will try to be very quick 
about this.
    My question is what percentage of people who need treatment 
are falling through the cracks right now? I have read different 
estimates of the number of untreated or undertreated soldiers 
and family members. Would anyone like to take a guess at what 
you think the number we are missing?
    Dr. Casscells. Ms. Shea-Porter, we don't have an exact 
answer, as you might expect, because some of the people who 
most need care are most afraid because of the nature of mental 
stress. People who are not just stressed, as Dr. Schoomaker 
said, but have stress disorder are people who are not seeing 
clearly in many cases. They are blaming themselves. They are 
afraid that if they ask for help, they will be stigmatized, 
lose their security clearance, lose their, you know, weapon if 
they are in theater, for example. They are afraid of letting 
down the team. They are afraid that they won't be promoted. 
They are also afraid of losing their civilian job.
    In the case of the reservists, this is terribly important, 
because one of the--some of the collateral damage of all this 
attention to psychological health and mental and combat stress 
is that some employers are using this as an excuse not to 
rehire, not to keep those jobs open. And I have to emphasize to 
them over and over again that even though, let's say, suicide 
rates have increased in this past year in the longest war in 
our history, they are still just below the civilian levels. And 
when our guys and gals come home, their rates of domestic 
abuse, of misdemeanors, felonies, broken marriages, and drug 
abuse, this all remains well below the civilian levels. We are 
very proud of this.
    Ms. Shea-Porter. Well, I have to say, it is confusing, 
because I, too, am reading all of the numbers. And I know not 
too long ago a major newspaper had a headline saying that 
mental illness was the number two illness now for our troops 
who have seen combat.
    Dr. Casscells. Yes, ma'am. It is because we have just about 
eliminated most of these infectious causes. Accidents are way 
down, what we call disease and nonbattle injury way down, you 
know, a lot of better protective equipment. You know, 
prevention is the best thing we have got. We have tried--trying 
harder to assign people to the right military occupational 
specialties, to identify them early when they are struggling. 
And the residue is--we do have people who really wanted to 
serve their country. They are young. They don't have much track 
record. They get into the situation of combat stress. It is 
hard for them, and they have--they struggle to recover from it.
    Ms. Shea-Porter. Thank you. And I would agree with that, 
but I think we are missing a large number of them still.
    Dr. Casscells. We are.
    Ms. Shea-Porter. What I am reading, and what I am hearing, 
and then what I am seeing in other reports, there seems to be a 
huge difference.
    But anyway, the point I wanted to make is I know we are 
following traditional and some nontraditional methods of 
reaching out to troops and also to their families, but I think 
that we could extend this. And I was going to ask you, I know 
in my own State of New Hampshire, community organizations are 
working to find them. But I also wonder if we have a just kind 
of practical right-on-the-ground-level way of outreach by 
putting up information in places where these young soldiers and 
their young families tend to go, which is fast-food restaurants 
and laundromats and places where they might not have any 
connection with the military at all, but they are hanging 
around for a couple of minutes, and they have a chance to see--
see a sign there for them. Is there any effort at all being 
made to reach out on a very basic level, which is where people 
tend to go today?
    Dr. Casscells. Yeah. We just asked our colleagues at 
Personnel and Readiness, for example, to put on every shopping 
bag in the Post Exchange (PX) and commissary a note about the 
website and telephone number where you can go to get help. We 
have not done it at McDonald's. This is the kind of thing we 
need to test and, you know----
    Ms. Shea-Porter. I encourage you to do that because that is 
the common denominator where people gather, especially young 
families who might be afraid to approach the military.
    General Schoomaker. Ma'am, if I could make one point. I 
appreciate your question for a different reason, and it has to 
do with definitional. We are using words here that I think are 
highly charged. We talked earlier with Congressman Murphy about 
the fact that on the one hand we report symptoms, but they are 
interpreted as a full-blown mental illness. What we are being 
very, very sensitive about and going after very aggressively 
are the earliest symptoms of stress, which I think the public 
should not interpret as resistant forms of well-established and 
highly intrusive disorders and mental illness. I think that 
there is a problem there.
    Ms. Shea-Porter. I understand the difference. So I do know 
what you are saying. And certainly most soldiers and their 
families are doing----
    General Schoomaker. The other thing I would say real 
quickly, and I think the Chief talked about this, a large 
number, in some cases the majority, of our most affected 
soldiers have not been deployed at all.
    Ms. Shea-Porter. Yes.
    General Schoomaker. They were carrying into service these 
problems.
    Ms. Shea-Porter. If I could make one last point, please. 
The other thing I would like to add is I do know there are 
some--some glitches on, say, pay and other problem areas that 
are causing extra stresses on these families and contribute to 
this sense of an ill ease or problems, and perhaps we need to 
look closer within our--their own structure and see if there 
are ways we can alleviate the pressure on these families who 
have a spouse or relative serving overseas and then have to 
struggle internally with pay issues or just problems, to help 
in that department, too. Thank you very much.
    Mrs. Davis. Thank you.
    Dr. Snyder.
    Dr. Snyder. Thank you, Madam Chairwoman. Sorry I was a 
little late getting here.
    Dr. MacDermid, I would like to ask you a series of 
questions, a few questions comparing what your opinion is of 
the opportunities for quality care, comparing those 
opportunities between the military family today and a 
nonmilitary family in America, if that is a fair question. So 
if I am a military family with an autistic child, do I have a 
better chance or a less chance of finding care in the military 
versus not being a military family?
    Dr. MacDermid. Well, you are certainly asking me to stretch 
my area of expertise a little bit, but I think a very safe 
answer is it depends a great deal on where you are. As you 
know----
    Dr. Snyder. The problem with military families is they may 
be in 6 places in 10 years and get a great set of--we were 
talking about that the other day.
    Dr. MacDermid. Sure. I do know that the military does have 
explicit procedures in place to try to accommodate the needs of 
families with special needs children.
    Dr. Snyder. My second scenario is part of the same answer 
then. If I was a military family with a child with 
schizophrenia, say, a teenager with schizophrenia, would my 
opportunity be better or worse than if I was a nonmilitary 
family for getting care?
    Dr. MacDermid. I think, frankly, with schizophrenia it is 
tougher.
    Dr. Snyder. Tougher for a military family?
    Dr. MacDermid. It is tougher than autism, I think, because, 
for example, autism, schools are used to dealing with kids with 
autism, and they have individualized experience plans. And 
military and civilian kids both, because it is a much more 
common sort of disorder, schools are more used to dealing with 
it. Kids with diagnosable psychiatric disorders are in tough 
shape in both military and civilian worlds because there aren't 
that many child psychiatrists.
    Dr. Snyder. Excuse me for interrupting.
    Dr. MacDermid. Certainly.
    Dr. Snyder. We have short time. I want to ask--I appreciate 
your comments. If I am a military family, and I have a teenager 
with either an alcohol or a drug problem, what are my 
opportunities for appropriate rehabilitation and treatment for 
a military family compared with a nonmilitary family?
    Dr. MacDermid. Based on the task force's work, I am fairly 
confident in saying you have a more difficult time in the 
military, and in particular if you don't have access to a 
military treatment facility.
    Dr. Snyder. I wanted to ask--this will be my last question, 
Madam Chairman, and get a response from each person. And again, 
I think I missed a lot of this discussion about how we go about 
increasing our mental health providers. You need to recruit 
more military people, you can hire more civilian folks, or you 
contract. And I wanted to ask you all's opinion of the 
contracted aspects of it. I think there was some reference--
General Schoomaker, I think you talked about some policy 
hurdles.
    I want to know specifically what things need to be changed 
or improved either statutorily or by the policies that you all 
have control over to enhance and quicken your ability to have 
some agility with regard to contracting for mental health 
services. We will start with you, Admiral, and just go down the 
line.
    Admiral Robinson. I think the first thing we would need to 
do is to make sure that we hire mental health or any other 
professionals that we have on more than one or two-year money. 
In other words, I can't retain people unless they understand 
that this is a job that they can have for a duration of time, 
duration that is longer than one or two years.
    The second thing is part of the problem with mental health 
professionals, I think, is the longitudinal problem that we 
have in the longitudinal studies on health care professionals, 
and that is I am not sure that there are--there are--certainly 
is a shortage. I am not sure if we are going to be that 
successful in getting the numbers to come into the military 
even on the civilian side unless we have other incentive 
programs that make it nice for them to come in. In other words, 
they have opportunities, and they are doing just what our 
dentists are doing: They are looking at the other 
opportunities.
    But I think that the major thing is that we need to have a 
career pathway for our contract professionals that shows that 
we are interested in them over a long period of time, and that 
when we bring them into our system, we have them for a period 
of time. And I don't think we have been able to do that very 
well. That is my one issue.
    Dr. Casscells. Dr. Snyder, as one doctor to another, I just 
say that our shortest route to getting services is to look 
beyond the M.D.'s and even beyond the Ph.D.'s and to get more 
nurse practitioners, more----
    Dr. Snyder. I am talking about the issue of contracting 
those.
    Dr. Casscells. Yes, sir. That relates to whether we are--
what authorities we have and what restrictions we may have in 
terms of our credentialing and criteria. We have some barriers, 
I think, to getting more counselors involved, and I think this 
is terribly important because we have relatively few 
psychiatrists and psychologists. And we have a largely male 
structure in the military. And we have got a lot of young guys, 
and some of them from broken homes. We really need to--and we 
are looking at this now to getting the counselors we need, and 
they are not--they are not going to typically be contracted 
M.D.'s and Ph.D.'s. It is going to be a broader group of 
counselors.
    I am not sure we need any statutory relief on this. We are 
looking at this. The Army is doing a great job. They have got 
150, as you have just heard, but we may need more. We are 
getting close to where we have enough, and that plus getting 
the family involved more, the battle buddies, the regular 
doctors, you know, deputy mental health people, may be enough. 
But we certainly need to take a broad look at this.
    Contracting in general, you know, my feeling is that we 
don't need a whole lot more of this military-to-civilian 
conversion. What we need is help on our recruiting. And I am 
not sure this is a statutory issue. We just have to focus on 
it.
    Mrs. Davis. Thank you.
    I want to thank all of you very much for being here with 
the panel. As I said earlier, we welcome you to stay because 
there may be some questions that we have as a follow-up to any 
of the comments that the witnesses make. And I know that we 
have a lot more questions, and we will hope to follow up with 
those in the future. Clearly there has been progress, and we 
commend you all for that. We are in a different place. But we 
also know that we have a long way to go to be sure that we are 
taking proper care of the men and women who serve us. So thank 
you very much.
    And if we can move as quickly as possible for the next 
panel, that would be terrific. We will get going.
    Mr. Jones. Madam Chairman, before you start, could we ask 
Dr. Casscells to give to the committee a list of the 
universities and how many mental health professionals were 
hired from each university, say, going back to 2006--or 2005--I 
guess 2006 would be appropriate--just to get an idea, if you 
don't mind. Thank you.
    [The information referred to can be found in the Appendix 
beginning on page 138.]
    Mrs. Davis. I would be happy to, Mr. Jones. Thank you.
    I am delighted that you are here. It is very important. I 
wanted to ask unanimous consent that Mr. Bob Etheridge, the 
Congressman from North Carolina, could introduce Mr. 
Scheuerman, who is on the panel. He is a constituent and a 
gentleman that Mr. Etheridge had a lot of opportunity to work 
with over the past few years.
    So, Mr. Etheridge.
    Mr. Etheridge. Thank you, Madam Chair, and Chairwoman 
Davis, and Ranking Member and other members of the panel. Let 
me thank you for allowing me to be here with you today and sit 
in on this very important hearing on this very important 
subject. And I deeply appreciate your courtesy for allowing me 
to join you today and introduce my constituent Chris Scheuerman 
from Sanford, North Carolina.
    Chris is a soldier's soldier and an American hero. He 
retired as a Special Forces master sergeant and continues to 
train soldiers at Fort Bragg. Chris Scheuerman represents the 
finest tradition of an American soldier where duty, honor, and 
country it is not a mere slogan, but a way of life.
    Beyond his personal service, Chris continues to serve his 
country by raising a family of soldiers. The unspeakable pain, 
though, that this family has endured highlights a troubling 
problem in today's Army where far too many soldiers conclude 
that suicide is their best option. On July 30, 2005, Private 
First Class Jason Scheuerman, deployed with the 3rd Infantry 
Division at Forward Operating Base Normandy in Iraq, died from 
a self-inflicted gunshot wound from his M-16 rifle. He was 20 
years old. I am no expert in mental health care, but it is 
clear the system failed Private Scheuerman and is failing other 
soldiers.
    The way the Army withheld information from the Scheuerman 
family about the circumstances surrounding Jason's death 
betrays his service, intent on treating this as a public 
relations problem rather than a mental health problem. I am 
hopeful that this is beginning to change, and I commend this 
committee for examining policy options to achieve that very 
change. And I thank you.
    When I first talked to Chris about his son's case and read 
the documents that he was forced to obtain through the Freedom 
of Information Act, frankly I was flabbergasted. That is not 
the United States Army that I know. As a young man, I served as 
an enlisted man at Fort Bragg and several other bases, and for 
many years I have had the honor of representing that base and 
its surrounding communities.
    Just last month I made my third trip to Iraq to visit with 
our troops in the field, and I made a point to meet with mental 
health professionals there to talk with them. I am extremely 
proud of our men and women in uniform. Of course, military life 
is tough, and necessarily so, yet the chain of command must 
always treasure the lives and well-being of individual 
soldiers. That system failed Jason Scheuerman in the most 
important way possible.
    I personally spoke with Army Secretary Peter Geren about 
Jason's case, and to the great credit Secretary Geren 
immediately requested an investigation by the Army's inspector 
general into this case. This investigation is ongoing, and I 
thank you for that.
    It is now the duty of Congress and especially this 
committee to examine the policies' shortcomings that this case 
brings to light. We must learn from the mistakes made here and 
go forward with better policies and systems to protect our 
soldiers in the field. So I implore the committee to listen to 
the words of this true patriot and to take actions to put in 
place a better system so that we can arrest the disturbing 
trends that soldiers' suicides have brought to us and prevent 
other families from suffering the pain that the Scheuermans 
have endured every day for 2-1/2 years.
    Madam Chair, I stand ready to help, and I thank you for 
allowing me this courtesy.
    Mrs. Davis. Thank you. I appreciate your being here as well 
and making the introduction of Mr. Scheuerman. And Major and 
Mrs. Gannaway, we are very happy to have you here, and Chief 
Gutteridge.
    Mr. Scheuerman, would you like to start, please?

   STATEMENT OF CHRISTOPHER M. SCHEUERMAN, SR., MASTER SGT. 
                       (RET.), U.S. ARMY

    Mr. Scheuerman. Thank you, ma'am. I would like to thank 
Chairwoman Davis, the distinguished members of the subcommittee 
for allowing me to testify on an issue that has tragically been 
personalized in my life. I would like to thank Congressman 
Etheridge and his staff for their support and dedication.
    In July of 2005, my son, PFC Jason Drew Scheuerman, after 
losing his battle with depression, decided to take his life 
while fighting the war on terrorism in Iraq. Jason was 20 at 
the time of his death. I address you today not only as a father 
of a soldier who took his own life while serving our Nation, 
but also as a veteran, a combat veteran, with 20 years of 
service as an enlisted man and an officer in Army medicine.
    Though it is difficult to discuss the events proceeding my 
son's death, I believe it can serve as a catalyst to help us 
better understand and treat soldiers battling depression and 
mental illness.
    Not all suicides caused by depression are preventable, but 
most of them are. In an article dated January this year, 
Colonel Richie, the consultant for psychiatry to the Surgeon 
General, stated, we have got multiple portals to care through 
chaplains, through primary care, through behavioral health and 
through leadership. We also need to make sure the family 
members know who to call if they are worried about their 
soldiers.
    Three weeks prior to Jason's death, we called his unit 
after receiving a suicidal e-mail and pleaded for help, not 
knowing if our soldier was alive. We knew how to call. Jason 
was seen by his chaplain, who had earlier witnessed him sitting 
alone with his head bobbing up and down on his rifle. He later 
said in a sworn statement that he believed Jason to be 
possessed by demons and obsessed with suicide. He did nothing. 
Jason was ignored by his primary care provider.
    It was common knowledge throughout the unit leadership that 
Jason was experiencing problems. The leadership had been told 
that Jason had been seen sitting in his bunk with the muzzle of 
his weapon in his mouth. He was never seen by his battalion 
medical officer. He did nothing.
    After being on suicide watch, Jason was sent to an Army 
psychologist. The Army psychologist never contacted Jason's 
unit to hear of prior suicidal gestures. He relied solely on 
standardized tests; misdiagnosed and dismissed Jason back to 
his unit with recommendations that caused more harm than good. 
He made the situation worse.
    All of the access to care portals that Colonel Richie 
speaks of today existed in 2005, and they failed miserably. The 
first step in reversing the growing trend in soldier suicide is 
accountability. If a soldier has an environmental injury such 
as frostbite or heat stroke, and a subsequent investigation 
shows that to be preventable, then a commander and a leader is 
relieved. The same standard or accountability should exist for 
suicide. If a suicide is shown to be preventable, then people 
need to be held accountable; leaders need to be relieved. I 
believe if we hold people accountable and leaders are relieved, 
at that point we will see a significant statistical decrease in 
soldier suicide. Any program that we execute is only as good as 
the people who are running the program. Without accountability, 
we are going to be doomed to failure.
    Jason desperately needed a second opinion after his 
encounter with the Army psychologist. The Army did offer him 
that option, but at his own expense. How is a PFC in the middle 
of Iraq supposed to get to a civilian mental health care 
provider at his own expense? How alone my son must have felt. 
He had nowhere to go.
    I believe a soldier should be afforded the opportunity to a 
second opinion by a teleconference with a civilian mental 
health care provider of their own choice. Any standardized test 
that the soldiers take can be faxed or sent by secured e-mail 
to that provider, and then the soldier and the licensed mental 
health care provider can talk via webcam or other technology 
available. The civilian providers do not have to be in theater. 
They can be here, home in the States. This civilian provider 
can provide the checks-and-balances element from here. I know 
if that were available on the day Jason was seen, he would have 
most probably been with us today.
    There was a great disparity between the observations made 
by Jason's chaplain and the psychologist. Jason's chaplain 
clearly believed him to be extremely troubled and told Jason's 
mother in a conversation after his death that they had been 
watching Jason for some time. Jason's psychologist stated that 
he was capable of feigning mental illness in order to 
manipulate his command.
    There must be a mechanism put into place when there is such 
a discrepancy of opinion. A hotline should be established where 
a concerned member of the telecare team, be it the leadership, 
the chaplain or mental health care, can call when there is such 
a disagreement. And a board can be convened to review the 
specifics of the case, to ensure soldier safety, to make sure 
that no mistakes are made.
    Additionally, when a provider is examining a potentially 
suicidal soldier, it should be mandatory for them to call the 
family to gather pertinent background information. Who knows 
their soldier better? Who better to recognize a change than a 
spouse or a parent? We knew Jason was having problems. If they 
had called us, there would have been a different outcome. I 
believe these two simple steps will save lives.
    The last two years have been an ongoing struggle to gather 
documents and information to finally realize all the missed 
opportunities to save our son. None of these documents were 
given to us freely. I had to make multiple Freedom of 
Information Act requests in order to receive the documents. I 
would never know what would come when I got home from work, 
what I would receive in the mail. Initially the Army told me 
that Jason left no suicide note. I came home from work one day, 
there was a package in my mailbox. I opened it up. As I went 
through it, I found Jason's suicide note and read it. If we as 
a family were not willing to investigate the circumstances of 
Jason's death, we would never know how bad it had become for 
our son.
    I propose an independent panel made up of professionals 
from outside the Department of Defense, both medical and 
psychological forensic experts and trained investigators, do a 
retrospective analysis of all theater suicides to find other 
mistakes and/or commonalities so we can learn and improve from 
our understandings. The document that the Army uses to learn 
from suicides, the Army's suicide event report, was filled out 
by the psychologist that failed my son.
    Opportunities to learn from mistakes have been lost. Our 
family's loss could have been a powerful training tool for our 
soldiers and their leaders. We could have used Jason's story to 
recognize both the obvious and subtle signs of depression, 
mental illness and suicidality. I believe we always learn more 
from our failures than our successes.
    I would like to thank the committee for their efforts in 
providing funding, support, and bringing focus to this very 
important issue, something that I believe we as a Nation must 
get a grip on. Thank you.
    Mrs. Davis. Thank you very much, Mr. Scheuerman.
    [The prepared statement of Mr. Scheuerman can be found in 
the Appendix on page 126.]
    Mrs. Davis. And Major Gannaway and then Mrs. Gannaway. 
Thank you.

          STATEMENT OF MAJ. BRUCE GANNAWAY, U.S. ARMY

    Major Gannaway. Good morning. My name is Bruce Gannaway. I 
am a wounded warrior recovering at Walter Reed Army Medical 
Center.
    Mrs. Davis. Major, could you please bring the mic a little 
closer.
    Major Gannaway. I am an infantry major that was in command 
of a cavalry troop when I was wounded on December 21, 2007, in 
south Baghdad. I apparently triggered an Improvised Explosive 
Device (IED) during dismounted operations. The injuries I 
suffered from the blast include an amputated left foot, a large 
vascular wound to my right leg, and the most difficult injury 
is the amputation of my left middle finger and multiple broken 
bones in my left hand. This is the most difficult wound because 
it affects everything that I do from typing, dressing, eating 
and a whole range of other daily living tasks.
    My experience after I was wounded brought me through the 
medical evacuation system. I was initially treated at the 
combat support hospital in Baghdad. I was then evacuated from 
Baghdad, through Balad, Iraq, through Landstuhl, Germany, to 
Walter Reed. The trip took approximately four days from injury 
to my arrival in the United States.
    I was an inpatient at Walter Reed on ward 57 from December 
25 through January 18, 2008, when I became an outpatient and 
moved into the Malone House on the Walter Reed campus. 
Subsequently I chose to move to Silver Spring, Maryland, and I 
am currently renting a house in order to provide a better place 
for my family to raise our daughter. I am receiving care as an 
outpatient at the Military Advanced Training Center, or MATC.
    Mrs. Davis. Major, could I ask you to move your mic just a 
little bit closer? We just really want to hear you. Thanks.
    Major Gannaway. I am receiving care as an outpatient at the 
Military Advanced Training Center, or MATC, at Walter Reed, to 
include occupational and physical therapy.
    Also while at Walter Reed, my wife and I decided to take 
advantage of the mental health services offered at Walter Reed. 
We have a good, strong and stable marriage with good 
communication between us. Even though my wife is a health care 
provider and is used to working with trauma, an amputation is 
still a life-changing event. We decided that we should take 
advantage of the therapy that is provided to facilitate our 
communication with each other during this stressful time. We 
meet with a psychiatrist once a week, and occasionally either 
one of us will meet with him individually.
    My initial encounter with mental health was as an inpatient 
at Walter Reed. Walter Reed has a Blast Protocol where every 
servicemember that has been injured due to a blast is screened 
by most of the major disciplines to include speech, dental, 
optometry, and, of course, mental health. However, my 
impression with mental health evaluation was a quick question 
and answer (Q&A) session that was conducted very early on in my 
hospitalization, and I was still pretty heavily sedated. This 
session is the litmus test to see if I needed additional mental 
health intervention other than the weekly walk-through of the 
ward by a mental health specialist prior to the weekend.
    My peers in the MATC are all amputees. The typical 
population in the MATC is generally younger than I am. These 
soldiers or marines may or may not be married. Their faith, 
economic and social backgrounds are varied. Therefore, I am not 
the typical wounded warrior. I am too old, and I have too much 
rank. I have the self-confidence to be my own advocate to deal 
with the rotating providers who are carrying huge caseloads and 
to work with the supporting staff to get the appointments that 
I need. Many of the physicians that I see carry impractically 
large caseloads; consequently I often do not see the same 
provider from appointment to appointment and frequently need to 
get worked in because there is no scheduled time available.
    I am married to a health care provider and I have a stable 
marriage. I also have previous experience with occupational and 
physical therapy due to a motorcycle accident that I was 
involved in approximately 10 years ago.
    Again, my experience is with the amputee center, the MATC, 
at Walter Reed. I cannot speak to how mental health services 
interacts with other departments or wards at Walter Reed. I do 
want to state that I believe that I have received excellent 
health care during this recovery.
    Recommendations for mental health: You are fighting a 
culture and a stigma. The wounded warrior population in the 
MATC is young, inexperienced with mental health, and does not 
want to be perceived as weak. The stigma is better than it was 
when I first joined the service. Had I stated that I was going 
to counseling, my peers would have assumed that I was either 
crazy or headed for divorce. Mental health needs to be brought 
to where the groups of wounded warriors already are. Make 
mental health a part of their normal routine or a part of 
something they are already required to do.
    Mental health specialists should make early and frequent 
visits to the wounded warriors while they are an inpatient and 
follow them while they are an outpatient. A way to do this at 
the MATC would be just like the chaplain does. The chaplain 
makes routine visits to wounded warriors while they are an 
inpatient, and there he establishes a relationship with the 
soldiers and marines while they are on ward 57. The chaplain 
then follows us to the occupational and physical therapy rooms 
in the MATC while we are an outpatient.
    I understand from speaking with a therapist at the MATC 
that mental health had previously attempted without much 
success to establish support groups that met on a weekly basis. 
I think the support groups are already established within the 
patient population. There are patients and family members that 
are always at therapy and interact with each other. Use that 
connection right there. There is a friendly group that already 
communicates and shares with each other. If a mental health 
specialist has already established a good, friendly 
relationship with the group, they will be able to easily move 
in and out of the group as they circulate the therapy rooms.
    Thank you for your time here today. I am grateful for the 
care that I have received. It is truly a combat multiplier that 
soldiers and marines are confident that if injured, they will 
receive excellent medical care. Our wounded warriors deserve 
nothing less.
    Mrs. Davis. Thank you, Major.
    Mrs. Gannaway.

                  STATEMENT OF SARAH GANNAWAY

    Mrs. Gannaway. My name is Sarah Tate Gannaway. I am here 
today with a dual role. I am an Army spouse, military family 
member, and I am also a health care provider. I am an 
occupational therapist with expertise in critical care 
medicine. I also have been active in the Army life of my 
soldier. I have been involved with the Readiness Group, with 
Army family team building, and with a host of other military 
programs. I consider myself fairly experienced in the Army 
lifestyle. And I have also chosen to seek out more information 
about the health care that I do receive within the Army medical 
system. This is both personal and professional interests.
    My comments today pick up some on what has already been 
discussed by the previous panel. The challenges that I see 
within the Army medical system are some of what I would like to 
discuss today. I also do want to give--I have a short 
discussion about some of the improvements that I have seen over 
the years within the Army medical system, specifically within 
mental health.
    I am going to use the term ``TRICARE'' as a universal for 
Army medical care. I use the term ``TRICARE'' because that is 
what our insurance is called. TRICARE has both military 
uniformed providers, the civilian contractors, and a component 
of health care insurance on the economy, which would be a 
civilian provider who is not connected to a military treatment 
facility.
    Some of the challenges that I see in TRICARE are both for 
the mental health care services, but also for the physical 
health care services, some of the family medical providers that 
were discussed earlier today. Probably the biggest challenge 
that I see within TRICARE is the issue of reimbursement, as was 
discussed earlier. I am not privy to the information of what 
the dollar-for-dollar reimbursement is for health care services 
or civilian providers on the economy, but as Dr. MacDermid 
mentioned, it is somewhat lower than some of what the other 
insurance companies do provide.
    The perception within civilian providers on the economy is 
that TRICARE does not pay, and since TRICARE does not pay, why 
should we see military families? That proves to be a large 
challenge for military families because the military health 
care system is overworked, extremely understaffed. It is 
difficult to recruit civilian providers to become TRICARE 
providers if you don't reimburse. And the reimbursement is not 
comparable to what other private insurance companies pay.
    Within the uniformed services and the military treatment 
facilities, there is difficulty getting connected to military 
providers. There just are not enough of them. The hiring 
process to become a contract provider is onerous. It takes a 
very long period of time. You have to be extremely persistent. 
And while many of these contract providers do have a heart for 
Army families, having a heart for Army families only takes you 
so far. If you can go to your local hospital or go to your 
local group practice and make more money and work fewer hours 
and have a smaller, more manageable caseload, it is ridiculous 
not to.
    Most of the contract providers within military families 
just struggle. The caseloads are enormous, upwards of 800 
people in some cases. It is very difficult to establish a 
patient/physician relationship when you have 800 people that 
you are responsible for. It is also very difficult to establish 
that relationship when you don't see the same provider from 
appointment to appointment. That is something that family 
members struggle with, but it is also something that our 
uniform services struggle with, and it is simply a product of 
uniformed providers deploying and there not being enough 
contract providers.
    These guys have to have a break, and if you are able to get 
an appointment, you take what you can get. The consequence of 
that is that you spend a lot of time telling your story over 
and over again. Without a physician relationship and some 
continuity, you waste a lot of time, and that is unfortunate.
    The referral process for care, specialty care, is very slow 
and very cumbersome. This is applicable both for mental health 
care services on the outside, but also getting physical 
specialty care referrals. There are some rather unusual 
policies within some of the military treatment facilities that 
do make it a little bit more complicated to get care. At the 
facility where we were most recently stationed, you could not 
get a physician--or a prescription refill or a lab result 
unless you had an office visit, and that is wasteful for the 
patient's time, but it is also wasteful for the physician's 
time if you have to go to see the physician just to get a 
refill on something innocuous, like a prenatal vitamin. That 
does combine to make a shortage of office visits.
    I have personally had the experience of calling day after 
day after day, attempting to get an appointment, and being told 
that no appointments were available, call again tomorrow. This 
is complicated by the reluctance of some military treatment 
facilities to provide referrals to receive care on the economy, 
which is also complicated by the fact that you sometimes 
struggle to find a physician on the economy who will see you 
because the reimbursement is low.
    One of the things that I have noticed in the last several 
years is TRICARE used to have a nurse call line, a 1-(800) 
number, to call in if you had a question or if you had a 
concern or if you had a sick child and you needed to get a 
little bit of guidance from an experienced professional about 
whether or not you need to take your child to a doctor. That 
nurse call line has been dissolved. Consequently, people are 
bringing their children to the emergency room, taking 
themselves to the emergency room, attempting to get a same-day 
appointment for things that maybe were not necessarily needed 
for an office visit.
    There are some improvements that are already in place 
specifically related to military health care, military mental 
services that were mentioned earlier. Military OneSource is a 
great resource that offers six office visits without a need for 
a referral from a physician. All you do is call Military 
OneSource, and they refer you out to a provider in your 
community. It is a little bit like an Employee Assistance 
Program. Military OneSource offers six visits. They do need to 
be renewed, which means you have to be able to get an 
appointment with your primary care physician in order to get 
the renewal, which brings you back to the cycle of trying to 
get an appointment.
    TRICARE has recently developed a self-referral process so 
that you can call your local psychologist or licensed 
professional counselor and ask for an appointment. Through that 
program, you can get 8 to 12 visits. That is a vast improvement 
over what had been in place before, because you self-refer. You 
do not need to get a referral from your physician. After those 
8 to 12 visits, though, you do have to get a renewal from a 
primary care physician.
    There are some recommendations that I offer for you today, 
specifically--well, broadly for military medicine but also 
specifically for the mental health care. Streamlining the 
hiring process will make it easier to get contractors, not just 
contract physicians but also allied health professionals, your 
licensed clinical social workers, your masters in social work 
(MSWs), even allied health people--the therapists and the 
nurses.
    Offering a competitive salary to compete with the 
facilities in the community is very helpful because it makes it 
easier to get physicians and to get allied health 
professionals. There was some discussion earlier about a large 
signing bonus for physicians, but those programs are harder to 
come by if you are allied health, and there are more allied 
health people than there are physicians.
    Streamlining the referral process to make it easier to get 
care on the economy when a military treatment facility cannot 
offer care would be very useful. Receiving a referral is time-
consuming. It has to be done very specifically, and it has to 
be done by name. If the civilian provider that you request by 
name is no longer accepting new TRICARE patients, then you 
start your referral process over, and that lengthens the time 
that it takes to get your care.
    I would recommend that the military treatment facilities 
each reexamine their local policies to determine if there are 
some policies in place that make it more difficult for families 
to receive care, an example being the necessity to have an 
office visit in order to get a referral for prescriptions.
    Increasing reimbursement to civilian providers on the 
economy would make it more appealing to them to see military 
families. When I received my obstetrical care when I was 
pregnant with my daughter, the physician practice that I used 
had 10 physicians. They were all listed as TRICARE providers on 
the TRICARE Web site. However, only one of them was accepting 
new TRICARE patients, and that was not the one I wanted to see. 
So my choice was find another physician or change the physician 
in the practice that I was willing to see.
    Reinstating the nurse care line would be beneficial for 
families just as a resource, but also to help alleviate some of 
the burden of same-day appointments or of the seeking of same-
day appointments within military treatment facilities.
    Finally, increasing the number of authorized visits for 
mental health services offered through Military OneSource and 
through the TRICARE self-referral program would also be useful 
to families and would take some of the burden off the military 
treatment facilities.
    Mrs. Davis. Thank you very much. I appreciate it. Your 
recommendations are helpful.
    Chief Gutteridge.

 STATEMENT OF CHIEF WARRANT OFFICER IV RICHARD G. GUTTERIDGE, 
                           U.S. ARMY

    Chief Gutteridge. Chairwoman Davis, Ranking Member McHugh, 
distinguished members, especially Congressmen Snyder and 
Murphy, and fellow veterans--Mr. Scheuerman, I am sorry for 
your loss. It was nice hearing from you, Major Gannaway, as 
well as from your spouse. I wish my wife of 18 years, Kathrin, 
were here, but she cannot join me.
    I returned from my latest Iraqi Freedom tour in February of 
2007. I was very happy to return to my wife and two sons in 
Germany. The homecoming was very sweet. I was required to 
complete a post-deployment health assessment during the post-
deployment phase after returning. At that point, I did not have 
problems that needed immediate attention. Completing the needed 
forms was a ticket to begin leave. I did not want to be delayed 
in starting my leave. I had plans.
    I began to clear my unit in Freiburg, Germany. The 1st 
Brigade of the 1st Army Division was casing its colors and 
returning to the States. Freiburg was closing. While on my stay 
in Germany, I executed a consecutive overseas tour, COT, and 
moved to Ansbach, Germany. While I was in-processing my new 
unit, I was informed that I failed to complete the 90-day post-
deployment health reassessment (PDHRA). At this point, I was 
required to complete the survey. I now had been back from Iraq 
for about four months. I had started to have nightmares, and I 
was constantly reminded of being back in Iraq. I had intrusive, 
horrible thoughts about what happened in Iraq. I was finding 
myself easily becoming angry at little things. I was also 
having trouble sleeping, and I began to withdraw from my 
family. I considered the PDHRA more honestly this time. A 
medical doctor in Ansbach reviewed this assessment.
    As a result of reviewing this document with me, the doctor 
told me that I had chronic PTSD and combat stress. I was then 
referred to behavioral health in Ansbach. I then called and 
made an appointment. I began therapy sessions with a nurse 
practitioner psychiatrist in early August of 2007. I was 
pleased with the one-on-one therapy I was receiving.
    As a result of one of my earliest sessions, the nurse 
practitioner recommended that I adjust my Citalopram, otherwise 
known as Celexa, medication. I was told to call the clinic, if 
needed, after this adjustment. My condition worsened. I 
continued to have nightmares, and I felt as though I was losing 
control. I called the clinic in Ansbach a week later to see the 
nurse again. The nurse was on leave, and her next appointment 
was not for 20 days. I then inquired about seeing a doctor, and 
I was told that the next available appointment was 21 days from 
then. I then told the receptionist that I would drive to 
Landstuhl Hospital to see a doctor 2.5 hours away. I was told 
that was not possible. She then told me that she would place a 
telephonic referral for me to speak to a doctor who is 
deploying soon from Vilseck, Germany and who has 72 hours to 
contact me.
    I was then asked if I was suicidal. The only way to get 
immediate help was to be suicidal. I was not suicidal, and I 
told her so. At this point, I was very frustrated and angry. I 
then e-mailed the wounded warrior hotline--the Wounded Soldier 
Family hotline is what it is actually called--and stated that I 
need help now. I expressed the fact that I was a senior warrant 
officer with 24 years of Active Duty and that I had served in 
Iraq during Desert Storm and that I had two extended Iraqi 
Freedom tours. If this is how I was being treated, I asked how 
a young infantry soldier would be treated.
    Shortly thereafter, I received a phone call from the 
hotline. I then received a phone call that evening from the 
doctor who had my telephonic referral. We discussed my 
condition, and he made recommendations concerning my 
medication. I began to feel better.
    Weeks later, I continued my one-on-one care with the nurse 
practitioner. As time went on, anniversaries of traumatic 
events that occurred in Iraq began to come around. October and 
November were particularly disturbing. Reliving the horrors of 
evacuating fallen soldiers' and marines' remains, as well as 
searching through body bags for dog tags and watching soldiers 
die, was too much. I became more withdrawn and distant from my 
family. I was having what I was later told to be suicidal 
ideations. I also began to increase my use of alcohol to cope. 
I am not proud of this, and it is very difficult to admit.
    My life almost ended on Christmas Day. I no longer had a 
desire to continue. I felt as though my condition would never 
change. I just wanted to be like before, but I could not fathom 
this. Late Christmas evening, I found my nurse practitioner at 
home, and told her what was going on. I felt relieved in 
calling her, but I knew that, as soon as I placed the call, my 
career would be over. After I assured her that I was safe, she 
told me to come see her the following morning in her office.
    I drove to her office alone, and we met. She then told me 
that I needed help that she could not give. I was then advised 
that I could go to Landstuhl on my own or else I would be 
forced to. Seeing no way out, I gave in. I then opened her 
office door to see my wife with one of my suitcases. She was 
accompanied by my brigade commander and a chaplain. Reality 
kicked in. I was on my way to Landstuhl in a van with my 
brigade commander and the chaplain. I was very sad to leave my 
wife in the parking lot on such short notice. I never felt more 
alone in my life.
    Upon arriving at Landstuhl, I was admitted to the inpatient 
psychiatry ward, Ward IX Charlie. I was issued a hospital gown 
and socks that had tread woven into the soles. My entire 
belongings were inventoried. Once I snapped on the hospital 
bracelet, reality really set in. Having to be observed 24 hours 
a day, shuffling around in socks while being behind locked 
doors marked ``elopement risk'' was very humbling.
    I was observed twice daily for the next seven days for 
signs of alcohol withdrawals and was having to answer simple 
questions and was being instructed to hold my hand steady to be 
observed for shaking. Having to be watched by a private 1st 
class while shaving and eating with plastic utensils was 
humiliating. The only hope was the fresh-air breaks--having two 
quick cigarettes in succession while standing out in the cold 
German air, wearing socks and a hospital gown, under the 
constant supervision of one of the staff. These smoke breaks 
were the only event to look forward to.
    I soon realized that the purpose of my being in a lockdown 
ward was for my own safety. I quickly became assimilated, and I 
have nothing but great respect and admiration for all of the 
personnel who work on Ward IX Charlie in Landstuhl.
    As New Year's Day 2008 approached, I was told by one of the 
psychiatrists that he was recommending that I be medically 
retired and sent to Walter Reed to out-process the Army via the 
Warrior Transition Brigade. I was told that I would receive 
PTSD care after I was separated, at a Veterans Administration 
facility. I was heartbroken. I did not want to retire. I cried 
for the first time since returning from Iraq. I was able to 
have my wife and two sons come to say goodbye to me.
    I flew to Walter Reed by Medevac flight on New Year's Day. 
I had never been to Walter Reed, but I had heard the stories. I 
was very apprehensive upon arriving. I was very apprehensive. 
Upon arriving by bus to Walter Reed after the Medevac flight 
landed at Andrew's Air Force Base, I was allowed a quick smoke 
before being escorted to the hospital.
    I was then taken to Ward 54, the inpatient psychiatry ward 
at Walter Reed. Knowing the initial drill from having been at 
Landstuhl lessened my apprehension of in-processing the ward. I 
was soon back in the hospital again, and I received a new 
bracelet. I was now able to wear shoes without laces instead of 
socks. That was refreshing.
    Ward 54 had many patients. I soon reacquainted myself with 
a few of the soldiers I had met at Landstuhl. They assured me 
that Ward 54 was cool. I felt much better then. I soon began 
talking with psychiatrists and psychologists. They were very 
kind and understanding. I immediately expressed my desire not 
to be medically retired. I was then advised that I would be my 
best advocate. I then made a decision to make the best of the 
situation. I participated in group therapy and followed orders. 
I made friends with my fellow patients. The staff was courteous 
and professional. The smoke breaks continued to be all that I 
looked forward to, those and the phone calls that I could make 
to my wife.
    I was then made aware of the Specialized Care Program at 
Walter Reed that was specifically geared toward PTSD. Upon 
receiving this information, I made up my mind that getting into 
that program was my goal for getting better and for staying in 
the Army. I had hope for the first time in weeks.
    I continued the therapy on Ward 54. I quickly became 
disgruntled with the initial-entry soldiers that were also in 
Ward 54. These trainees were learning to be soldiers and were 
admitted to Ward 54 for various reasons. I soon became 
disenchanted with the group therapy after having to listen to 
people less than half my age complaining that they could not 
adapt to the Army, could not get along with their drill 
sergeants, et cetera. My disdain for this element on Ward 54 
was shared with the other combat veterans who had PTSD issues. 
We soon branched off into our own groups and shared our 
stories. I felt relieved that I was not the only one 
experiencing the same problems with PTSD. I worked toward my 
next goal of being moved to Ward 53, the outpatient psychiatry 
ward at Walter Reed. My whole being was focused on continuing 
my care.
    After almost 2 weeks on Ward 54, I was released to Ward 53 
and moved to Abrams Hall. This time, I almost cried tears of 
joy. Ward 53 was a breath of fresh air. The staff was very 
friendly and accommodating. The atmosphere was very refreshing, 
hopeful and professional. I made my intentions very clear early 
on of wanting to be inducted into the Specialized Care Program 
specifically geared toward the treatment of PTSD. I then began 
a series of interviews with psychiatrists and psychologists as 
well as with social workers from the Deployment Health Clinical 
Center here at Walter Reed. Initially, I was discouraged 
because I felt that I did not make the cut during the final 
phase of the process, but I did, indeed, begin the program on 
February 4th of this year.
    The Specialized Care Program was awesome. From the very 
first day, I knew I was in the right place. I looked at the 
other seven soldiers in the program, and I saw the same worn, 
haggard, distant look that I became accustomed to seeing in the 
mirror each morning. The three-week, intense PTSD program 
provided an overall health assessment as well as an 
understanding and recognition of symptoms of PTSD. I also 
learned how to normalize my reactions to combat experience. 
Learning coping skills such as breathing techniques and Yoga 
Nidra, coupled with one-on-one therapy with passionate mental 
health providers, helped to reduce my hyperarousal and 
vigilance. Group therapy with my fellow PTSD sufferers was what 
made the biggest difference by providing mutual support.
    I can now manage my depression and grief associated with 
PTSD. I am now aware of self-care and available resources. I 
feel like a husband and a father again. The program saved me. I 
owe my Dr. my life.
    I often contemplate my reintegration when I return to duty 
at my unit in Germany. I am not worried about my being 
stigmatized. I am worried about how my wife and sons will be 
treated once the small, close-knit community knows the truth 
about my mysterious three-month absence.
    I describe the perception of PTSD not as a stigma but as 
akin to having leprosy. Lepers are avoided, looked down upon 
and ostracized. Lepers also live and die slowly together in 
their own community. Lepers only have each other. PTSD 
sufferers are lepers without lesions. We are like discarded 
pennies on the ground. No one picks up pennies. Only shiny 
quarters are retrieved. Many of my fellow PTSD sufferers long 
for outward physical injuries, to be accepted here at Walter 
Reed. Looking normal or healthy on the outside is hard to 
explain in a hospital environment. There are no photo 
opportunities on the psych ward for politicians or celebrities. 
There is no prosthetic for a lost soul.
    I am sorry for your loss, Major.
    Some concepts that would improve the image of PTSD 
sufferers seem fairly simple. I do know the infrastructure of 
hospital psychiatry wards were designed for peacetime. No one 
expected this to be a long war, five years and counting.
    Segregating soldiers who have PTSD and combat stress from 
patients who are hospitalized for noncombat-related issues is 
paramount. The mutual support that PTSD sufferers receive from 
each other is incredibly therapeutic. It is very difficult to 
discuss PTSD issues in an open forum containing patients who 
are not suffering from PTSD in a psychiatric environment.
    I also feel that substance abuse and PTSD are not 
compatible. My abstinence from alcohol is a driving force in my 
accelerated recovery in coping with PTSD. It is very easy for 
PTSD sufferers to cope the wrong way by using illegal drugs, by 
huffing inhalants or by abusing alcohol. I feel that substance 
abuse counselors need to be incorporated into the PTSD recovery 
program, not isolated in a distant building away from the group 
therapy. They have to be part of the same program of recovery, 
not separate or in parallel programs. One feeds the other. I 
feel very strongly about this.
    The Warrior Transition Brigade (WTB) is an outstanding 
success, in my opinion. My only recommendation would be to 
slowly replace the initial group of cadre with noncommissioned 
officers and junior officers who are still viable in the Army 
but who are offered or forced into medical retirement. Having 
these nondeployable experts who have navigated the environment 
here at Walter Reed would pay huge dividends. Simply keep them 
here. Make the offer. Let them continue to contribute. The 
present cadre is dedicated, but you can only truly learn about 
programs and assistance that are available here if you have 
walked the walk.
    There are tremendous benefits available here that soldiers 
in the WTB discover on their own. Word of mouth soon spreads, 
enabling soldiers to enjoy sporting events, to learn to play 
the guitar and to kayak, to take advantage of airline miles 
donated, and to obtain items such as toiletries and clothing 
from the Red Cross. The benefits are endless.
    Finally, many soldiers celebrate their second birthday, or 
their ``life day,'' on the day that they survived being wounded 
in Iraq or Afghanistan. I do not celebrate that September day 
that I was shot by a sniper in the Anbar Province. I celebrate 
the day that I was enrolled in the Specialized Care Program for 
PTSD here at Walter Reed.
    In the words of Colin Powell, ``I will never not be a 
soldier.'' Thank you for this opportunity to tell my story.
    [The prepared statement of Chief Gutteridge can be found in 
the Appendix on page 129.]
    Mrs. Davis. Thank you very much. Thank you to all of you. 
This has been stirring, truly, to hear your stories.
    Mr. Scheuerman, of course we regret your loss greatly, and 
I am so impressed that out of your tragic story you have looked 
to what could be done to help other families, and that is 
greatly appreciated.
    We have a vote coming up. What I would like to do is to 
probably start with a question or two, but I am hoping that 
members can come back. As you know, we often give our witnesses 
about five minutes apiece, and you can tell that we did not 
want to stop you at all within your testimony because it is all 
so important to us to hear from you, and we greatly appreciate 
that.
    Your story of renewal, Chief, gives great hope, I think, to 
many, many people who have suffered as you have.
    We are always very, very happy to hear from all of you as 
to what has happened and the interaction of spouses as well. If 
there is one, I guess, message if people are not able to come 
back or are not able to go on with the hearing--you have all 
had a recommendation or two about partly how we make certain 
that there is an opportunity to have a second opinion, you 
know, to have somebody there who can speak up and say, ``Hey, 
wait a minute. You know, I have seen something that you all are 
not seeing, and I need to be able to share that.''
    Chief, somebody could have just kind of written you off, 
and I think that you were about ready to write yourself off at 
one point, and we need to try and intervene.
    Is there one particular recommendation that you feel that 
you just want to make certain that you have just hit home with 
us so hard? If you would like to--you know, I do not want you 
to have to repeat what you said but, rather, just make certain 
that we have heard it.
    Mr. Scheuerman.
    Mr. Scheuerman. Yes, Chairwoman Davis.
    All of the soldiers who are serving in Iraq, they do have 
the option to get a second opinion, and they sign the paperwork 
that their commander gives them, and it says at their own 
expense. It is impossible for them to do that, but they must be 
afforded that opportunity.
    I had been in Army medicine for a long time prior to when I 
retired. You see a lot of patients. It takes a lot of time. You 
make mistakes. Mistakes are made. There has to be a check and 
balance. The only thing that I can think of that would cure 
that problem would be a hotline, a telephone number, that 
either the soldier could call or someone within the chain of 
command could call, or anyone with contact to that soldier who 
recognizes something that no one else sees. They can call that 
number, and then that soldier can get help. There has to be a 
safety net, and I do not believe that right now there is a 
safety net for the ones who fall through.
    Mrs. Davis. Major Gannaway.
    Major Gannaway. As a commander in Iraq, troopers are 
constantly surrounded by their peers, and it is leader business 
to make sure that your soldiers are taken care of physically 
and mentally.
    Really, the system failed in your case, sir. I am very 
sorry about that.
    Battle buddies, squad leaders, platoon sergeants, platoon 
leaders, commanders, chaplains, all have to be involved in the 
lives of our soldiers and make sure that they are taken care 
of.
    On the rehabilitation side, some of these wounds are life-
altering, and I understand how soldiers go into depression and 
abuse. I can see how they can go down the road of illegal drugs 
and alcohol and start down that downward spiral.
    I believe if mental health were more involved in the daily 
life of the soldiers, it would remove some of the stigma. 
Instead of having to go to another part of the hospital and 
speak to somebody in a white coat, if they came down to Iraq 
with the soldiers during their therapy and talked to their 
therapist, I think they would have a better understanding of 
how the soldier is doing.
    Mrs. Davis. Thank you. Mental health screening for 
everybody? Just routine?
    Major Gannaway. During recovery, yes.
    Mrs. Davis. Okay. Mrs. Gannaway. I guess, as a spouse, is 
there one thing that you would like us to particularly focus on 
either when leaving or returning from a deployment that is 
important?
    Mrs. Gannaway. My recommendation would be to continue the 
efforts to increase availability of services. Second opinions 
or first opinions are sometimes very difficult to get because 
the providers are overwhelmed, and there is just not enough to 
go around. That is a challenge that is not exclusive to post-
deployment units. It is a challenge that is universal across 
Army medicine.
    So my recommendation would be to solve the problems related 
to staffing, because more staff who are better trained and who 
are less overburdened will be better able to meet the needs of 
Army families.
    Mrs. Davis. Chief Gutteridge.
    Chief Gutteridge. Yes, ma'am.
    You know, we can embed journalists in units. That is very 
popular. Why can't we embed more mental health providers?
    You are right, Madam Shea-Porter. People do have a 
resistance to talk to somebody about combat stress or things 
that happen in combat when that person has not been there. When 
you are a soldier in Iraq and you come off a mission and you 
are told that, hey, there is a rotating team of mental folks 
who are here to talk to everybody, first of all, you are tired; 
you are hungry; you need to restock ammo; you need to 
preventive maintenance checks & services (PMCS) your vehicles; 
you need some sleep; and you are a member of a team. If you are 
taken out of that team even for 20 or 30 minutes to talk to 
somebody who is an outsider, number one, you are setting 
yourself up to be ostracized.
    What I found that worked best in my unit, the 136th 
Infantry--we were in a remote area of the Anbar Province--was 
our battalion surgeon, Dr. Rumbaugh. Having a medical doctor 
who has a good rapport with soldiers and having those medics 
who have a good rapport with soldiers makes a huge difference. 
Once again, the only time you are going to be able to get well 
in a combat environment is to be taken out of that environment 
and to miss out on what is going on and to leave your buddies 
behind and to have a vacuum that has to be filled because you 
are not there.
    If you had a professional mental health-type person at 
least the battalion level in units, people who are actually 
deployed with you, who eat the same food, who suffer the same 
mortar attacks, who cry when you lose soldiers--they are just a 
part of you, just like that surgeon is. Chaplains are capable 
of that, but they are not trained for it. Quite frankly, 
chaplains are hit and miss when it comes to traumatic events 
such as that.
    That would be my recommendation, if we could embed mental 
health professionals at least at the battalion level who are 
down with the guys who are suffering. Thank you.
    Mrs. Davis. Thank you very much.
    We have about six minutes on that vote, Members. Then it is 
going to be about a half hour, I think, before we are going to 
be able to return.
    Is everyone able to do that? Are you able to stay? Because 
I know members will be happy to come back. Okay. Thank you 
again very, very much for being here.
    [Recess.]
    Mrs. Davis. Thank you all for returning. We are here, we 
think at least, for quite a number of minutes, and we are going 
to go through and make certain that all of the members have a 
chance to at least ask a question, and then we will try and 
finalize the hearing after that.
    Mr. McHugh.
    Mr. McHugh. Thank you, Madam Chair.
    I really do not have any questions. This is my 16th year in 
Congress, my 16th year on this full Armed Services Committee. I 
have heard a lot of testimony, but rarely have I heard a panel 
come with more well-thought-out, very straightforward 
suggestions. I want to thank you all for your service.
    Mr. Scheuerman, you have my deepest sympathy on your loss. 
I will tell you, as you acknowledged, Bob Etheridge is 
concerned deeply about this. Hopefully, your efforts with him 
can get you some answers. I think that is the least this Nation 
owes you.
    I can tell each and every one of you that the things you 
have said here today and your appearances here today will help 
another soldier, sailor, marine, airman, not have to face the 
challenges and difficulties and the heartbreak that you have. 
So thank you for being with us, and thank you for having the 
courage to step forward. I know it was probably not easy, but 
it is one of the bravest things that anybody could do, and we 
thank you so much for that.
    So, with that, Madam Chair, I will be honored and pleased 
just to sit and listen and learn some more as we go through the 
rest of the panel.
    Mrs. Davis. Thank you, Mr. McHugh.
    Mr. Jones.
    Mr. Jones. Madam Chairman, thank you very much.
    I have had a chance to speak to several of the panelists, 
and I join Mr. McHugh. I do, in a way though, want to ask Mr. 
Scheuerman and, actually, each one of you.
    Your son, Jason--and let me very quickly--I had a 
grandfather who was gassed at the Battle of the Argonne Forest 
and who took his own life when he was 31. I never knew him, and 
my daddy never talked much about him, but I did get his 
records. I know the mental pain and alcohol and drug abuse that 
became part of his life and ended his life early.
    I really do not understand--you know, I cannot help you. I 
wish I could help you and your wife and your family. I want to 
know how important--at least at some point you mentioned the 
chaplain; the major did; the warrant officer did. Did the 
chaplain see Jason's anguish? He was there to spiritually 
counsel him, but was he in a position where he could or did he 
reach up to the officers and say, ``This young man has 
trouble''?
    Mr. Scheuerman. Sir, the chaplain did observe Jason, and 
saw that he was having troubles, and made a recommendation that 
Jason get a psychological evaluation.
    Mr. Jones. Now, you might have said that in your testimony, 
and I just missed it.
    Okay. From that point forward of the chaplain's making the 
recommendation, is that when you were saying that nothing 
seemed to move forward to help Jason?
    Mr. Scheuerman. At that point, there was a total breakdown 
in communication. Once Jason was sent to see the psychologist, 
the psychologist never called back to the unit. There was no 
communication between the psychologist, the chain of command or 
the chaplain. Had the psychologist called back to the unit, he 
would have heard the stories of Jason's laying in his bunk with 
the muzzle of his weapon in his hand, of Jason's sitting in the 
corner with his head bobbing up and down on his rifle, of 
Jason's sleeping at the command post in a fetal position. He 
would have heard those stories, and perhaps his assessment of 
Jason would have been much different than ``feigning mental 
illness in order to manipulate his command.''
    Mr. Jones. Madam Chairman, I think this committee should 
ask for an investigation, quite frankly, of why when the 
chaplain made this request that it was dropped. I will tell you 
that I think truthfully that this--not just because of this 
family--but you just cannot not hear the cries of someone who 
is so anguished. If the chaplain went to his superior or to the 
ranking member of the military leadership and said ``This young 
man needs help'' and somebody did not do his job--I am going to 
tell you that I asked for an investigation when Chaplain 
Stertzbach was removed from his chapel in Iraq for praying over 
the body of a deceased soldier in the name of Jesus Christ, and 
they removed him. I think we need to ask for an investigation 
as to why this happened, so it will not happen again. I do not 
know if I can make that request, but I would like to make it.
    Mrs. Davis. Thank you, Mr. Jones. There is an active 
investigation.
    Is that correct, Mr. Scheuerman, as far as you know?
    Mr. Scheuerman. Right now, with the help of Congressman 
Etheridge, Congressman Etheridge asked Secretary Geren, the 
Inspector General of the Army, to conduct an investigation, and 
they are conducting that investigation at this time, sir.
    Mr. Etheridge. Madam Chair, if the gentleman would yield--
--
    Mr. Jones. Yes, I yield to the gentleman.
    Mr. Etheridge [continuing]. Secretary Geren has initiated 
an Inspector General (IG) investigation that is ongoing.
    What the committee might want to do, Madam Chair, is just 
follow up and take a special interest in that, because I know 
the Secretary has just been absolutely outstanding in this. He 
did not hesitate. He said we are going to do it and that it is 
going to be ongoing and that we are going to get to the bottom 
of it.
    The committee might want to see the report when it is 
completed. He has expressed an interest, and I think that would 
be most appropriate at this time. We will go ahead and let that 
investigation move along because it is ongoing at this point.
    Mr. Jones. Madam Chairman, since it is my time and I am 
about to lose it, I want to thank the gentleman from North 
Carolina for what you have already done. That is all I was 
trying to do is to make sure that we see the report so that we 
have a better understanding of what was not done so that it 
does not happen in the future.
    To the major and to the warrant officer and to your lovely 
wife, thank you for being here. May this county never forget 
that you have earned this benefit, and I will continue, as long 
as I am here with my colleagues, to fight and to make sure that 
Americans--instead of sending money overseas to help other 
countries, how about let's take care of those who have served 
this Nation in the military.
    I thank you. I yield back.
    Mrs. Davis. Thank you, Mr. Jones. We certainly will follow 
up with the investigation. We want to check and see when that 
is going to be available.
    I think many of the questions, of course, that you have 
raised in terms of communication are critical, and we need to 
be sure that we move forward and learn from them. Also, I think 
you mentioned an accountability piece, and I think that is an 
important one as well. Thank you.
    Dr. Snyder.
    Dr. Snyder. Thank you.
    Mr. Scheuerman, do you have other family members with you 
here today?
    Mr. Scheuerman. Yes. My wife, Anne, is here, sir.
    Dr. Snyder. I wanted to acknowledge your presence. We 
appreciate your being here today. I know this can be a 
difficult time to go through this, but it is very helpful to us 
and to other soldiers and soldiers' families. Thank you for 
being here also.
    Mr. Scheuerman. She has been my therapist, sir.
    Dr. Snyder. Mr. Scheuerman, you said one thing that I did 
not understand and that I have not heard before. When you 
talked about having to have some kind of written request for a 
second opinion, I did not understand that. Repeat that for me 
again, please.
    Mr. Scheuerman. When Jason received his command referral to 
go see the psychologist, it is a Department of Defense 
directive that they be read off their rights. One of their 
rights is to a second opinion at their own expense as a 
Department of Defense directive.
    If I may, as far as the investigation, all of the 
information that we got through the FOIA requests--and there 
were multiple FOIA requests, and they all came in piecemeal. It 
was our family that had to go through the Criminal 
Investigation Division (CID) report, that had to go through the 
15-6 investigation, that had to go through the psychological 
medical records to put all of the pieces together to say, 
``This is wrong. There were mistakes made.'' The Army had 
already closed that case and had moved on.
    Dr. Snyder. As you may have picked up in some earlier 
discussion, I am a family doctor, and we should be a lot 
smarter than--those were big warning signs; 25 years ago, I 
look back at some of the things that we would have missed in 
some of our colleagues, but those were very glaring warning 
signs, and it is absolutely appropriate to try to figure out 
what happened because, if it happened to your son, it is 
happening to other people, not just in the military but out of 
the military.
    Mrs. Gannaway, I appreciate the thoroughness of your 
discussion, but I am not sure--I thought that was a discussion 
just of someone who, you know, sat next to a hospital bed or 
went to counseling sessions with your husband, because you 
really had some much better systems analysis than most of us 
House Members. How did you get up to speed on a lot of these 
issues? Is there a group of folks you are working with or is 
this just something you have been poking around in on your own?
    Mrs. Gannaway. I have a vested interest in this issue----
    Dr. Snyder. Sure.
    Mrs. Gannaway [continuing]. Because of being an Army family 
member but also because of my experience professionally in the 
medical community----
    Dr. Snyder. As an occupational therapist.
    Mrs. Gannaway [continuing]. As an occupational therapist.
    I ask a lot of questions. I have been frustrated at times 
by some of the difficulty that I have had navigating the Army 
medical system. I did have a life prior to being in the Army, 
and had my own health insurance through a private company, and 
found it to be much more simple to use.
    My health care at our most recent duty station was provided 
at a satellite clinic. Initially, I had a relationship with one 
physician whom I saw on a regular basis when I needed it. The 
Army renegotiated the contract with that group of physicians, 
and he chose to leave. At that time, I got into a cycle of 
seeing different physicians and different providers over and 
over and over again. When that happened, I really started to 
pay attention to some of the things that I saw that could 
benefit from improvement.
    Dr. Snyder. Your comments were really helpful.
    Major Gannaway, in your statement, you talked about the 
culture of the young, which is that young folks do not like to 
acknowledge problems. It seems to me that we need to also be 
dealing with that culture before people get hurt or sick. I 
mean the fact that somebody goes out, you know, at age 22, 
never having been overseas, never having been exposed to the 
kinds of things that you all have been, and putting away five 
beers on a Friday night and joking about it on Saturday morning 
is a problem. I mean, we may think that is the culture of the 
young, but it is an unhealthy culture.
    Is it your experience in the military that we are 
addressing those kinds of things outside of the experience of 
people's being hurt or injured?
    Major Gannaway. I believe the military is getting better at 
addressing substance abuse problems and mental health issues 
and at reducing the stigma of acknowledging mental health with 
their servicemembers. It is not to a level where it is 
completely accepted to go see a mental health professional, and 
it may not be that way in civilian society yet either, but we 
are working toward it. A lot of that simply just comes down to 
leadership within a unit.
    Dr. Snyder. Chief, I am out of time, so you do not have to 
hear me ask the question if you are still smoking, so----
    Chief Gutteridge. But I am not under any type of 
performance-enhancing drugs at this time.
    Mrs. Davis. Thank you. I want to turn to Congressman 
Etheridge.
    Thank you very much for joining us. We appreciate that, 
particularly as you work through and help Mr. Scheuerman in 
this investigation. Thank you.
    Mr. Etheridge. I thank the gentlelady. Thank you for 
letting me join the panel, and thank you to all of you for 
letting me have the opportunity to make a comment, and to 
really ask a question.
    I join all of my colleagues here this morning in saying 
that in the years I have served in this body--and I have not 
been on the Armed Services, I have served on a number of other 
committees, even though I represent Fort Bragg and Fort Pope. I 
have a deep and abiding interest in having served in the 
military in Vietnam. A lot of the situations that you have 
talked about this morning, a number of my fellow soldiers who 
came back from Vietnam suffered from, and we should never let 
that happen in America again.
    I just want to make a couple of points and get a comment 
because it seems to me--before I came to Congress, I ran a 
pretty good-sized organization. I was a State superintendent of 
schools. It was a lot people. It is hard changing a big 
organization that has a culture that is just there, and it 
takes time to change it. It seems to me that we are living in a 
really different time in the world today than we were 20 years 
ago or even 15 years ago.
    As we start this process in our leadership in the military, 
from the top all the way down to the company commander and to 
the last trooper, we are going to change our culture, and that 
culture has to change to be accountable for more than just the 
weapons and the equipment. We have got to be accountable for 
people's health and for their mental health.
    It seems to me, Madam Chair, that that has to be something 
we encourage, that the mental health piece has to be a part of 
this process of keeping our soldiers safe and healthy. I 
believe that Mr. Scheuerman mentioned earlier that if that were 
a part of the requirement of leadership, that accountability 
piece, that it would be treated a whole lot differently. So I 
would encourage us to look at that.
    Each one of you in one way or another has said that. You 
may have said it in different ways, but that is really what you 
are saying. I think we need to hear it, and those of us in 
Congress need to take the actions, and we need to take whatever 
action it takes to get the system changed.
    I think one other thing was this whole issue of second 
opinions. I do hope we find out what that is, because it seems 
to me if I am a PFC in Baghdad or wherever I might be, and I am 
asked to have a second opinion and I have got to pay for it, 
number one, it may not be available; number two, you sure 
cannot get it there; and third, there ought to be a hotline.
    Chief, if you had not had your hotline, I shudder to think 
where you would be today. Thank you for being able to get to it 
and to call. We do need to make that available.
    For a lot of these young folks, as has been indicated, this 
is their first time away from home in some cases. For many of 
them, it is the first time they have ever been overseas. I 
think, Major, you touched on it, on the whole mental health 
issue, but it is all a total health issue. When we are in the 
States, we worry about speeding and driving, et cetera, and 
drinking, but the same has to be true of the total mental 
health overseas.
    Finally, I would be interested in your comments at least on 
two issues. One is this whole issue of the total accountability 
to include things like mental health and others. Second, what 
do we do to change the culture? Because that is an important 
part. It is a part of the training, but it is also a part of 
the continual retraining. I would be interested in any of your 
comments because you have been through it, each one of you, in 
one way or another. I hope that you would be instructive, to 
help us.
    Chief Gutteridge. Congressman Etheridge, one thing that I 
would recommend is, if you do have a mental health issue, you 
either go to a behavioral health clinic or you go to a mental 
health clinic. If you have the symptoms of, let's say, combat 
stress or of PTSD and where you are not quite yet diagnosed 
with PTSD, we could change the culture by simply changing the 
name. Instead of behavioral health--we could still keep that, 
but we could have a subset or a smaller compartment that is, 
perhaps, combat stress. You know, everybody loves the word 
``combat.'' You attach that to anything, it is acceptable; it 
is manly; it is okay.
    So, if you have combat stress and someone else tells you 
that you have a mental illness, you are going to pick combat 
stress every time. So I think it is something as simple as 
changing the wording of the programs, of the buildings, even 
the sign on the door or the number in the phone book. It is 
just how it is called. Just relate it somehow to combat or to 
operational stress as opposed to behavioral health. That would 
be my recommendation.
    Mr. Etheridge. Language is important.
    Chief Gutteridge. Yes, sir.
    Major Gannaway. Sir, you touched on the total system.
    You know, a leader is responsible for his soldiers' 
actions. He is responsible for making sure that he is up to 
date on his dental, on his shots, and so that includes a mental 
health screening. I think a way to reduce the stigma of mental 
health would be to make it part of a soldier's normal routine. 
Normalize it. If they have more exposure to it on a routine 
basis--predeployment, during deployment, post-deployment, and 
during train-up--it will lose some of the stigma and become 
more acceptable.
    Mr. Scheuerman. The Army has dealt with a lot of cultural 
changes in the past, sir, from sexual discrimination, racial 
integration, drunk driving. The Army has gone through a lot of 
cultural change, and a key to the Army's dealing with those 
cultural changes has been a near zero tolerance for anyone's 
not getting with the program.
    There was a time when I was a young soldier when, if you 
were caught drunk driving in Fayetteville, your 1st sergeant 
would come pick you up, and you would be on extra duty for 14 
days. That was it. They tolerated it. Once they stopped 
tolerating it, you did not see so many drunk drivers in 
Fayetteville. Sexual discrimination was almost rampant when I 
first joined the Army. The culture changed. The Army changed. 
They no longer tolerated it. It went away.
    Stigma against mental health in the Army exists today 
because we allow it to. If we do not tolerate it, it will go 
away.
    Chief Gutteridge. Sir, may I add one thing? Those are great 
points.
    What I would like to add is that one of the things that I 
am most proud of from being in the Army is that it is a value-
based culture. If you look back in history, it is the military 
and it is the Army that were the tip of the spear in changing 
society--segregation, dealing with different types of 
discrimination. We can do it. The Army can do it. The Army can 
lead society down the correct path of taking away the stigma. I 
look forward to that, and I think it can happen.
    Mr. Etheridge. Thank you very much. You have been very 
powerful today. It has been very instructive and very helpful.
    Madam Chair, thank you. Thank you for this hearing, and 
thank you for letting me join. I yield back.
    Mrs. Davis. Thank you very much. I just have a few very 
quick questions.
    I wanted to go to you, Chief Gutteridge, because you 
mentioned that we might want to capture those individuals who 
have gone through these experiences and who were not 
necessarily in the mental health fields to begin with, but who 
perhaps could be trained appropriately. If I recall, I think 
that even our first panel questioned whether or not there is, 
you know, a new group of counselors that we might look to who 
could add to or be part of this new cadre that you spoke of.
    I wonder if you wanted to just comment briefly on that. 
Where do you see that coming from? How realistic, I guess, do 
you think that is?
    Chief Gutteridge. Well, ma'am, to be very simple, drunks 
help other drunks not be drunks anymore. Mutual support in PTSD 
is absolutely critical. If you are in a group with just a 
couple of folks--they could be Vietnam-era veterans, they could 
be World War II--it is that common bond. The only people who 
understand that are people who have been in that situation.
    Now, I understand you have to have a master's degree in, 
let's say, social work in order to be a counselor at certain 
places. I understand that procedure, and that is very 
important. But if you could have some sort of informal PTSD 
support groups or combat stress support groups, much like you 
have with bereavement for lost soldiers--of course, there is 
nothing worse than losing a child, and I am not going to 
downplay that at all. It is mutual support, and where we could 
in some way create an environment where, ``hey, you know, there 
is a lunchtime meeting over here for guys who want to talk 
about combat stress and see how they are doing.'' Yes, it is 
doable.
    Mrs. Davis. Thank you.
    I think in many ways, I probably want to carry that a 
little bit further, in that it may be that some people are 
particularly talented, who may not have known that, to be able 
to work with other servicemembers, and that we may need to 
think about helping them develop that in an educational setting 
so that they could go back and even be at higher levels, 
whether it is social work or psychologists or psychiatrists, in 
the future.
    I just wonder whether we want to look to--and have people 
looking out for those individuals who, in fact, may have 
thought about separating from the service but who might be able 
to even stay in, in a different way. It all takes money, of 
course, but I was interested in what you had to say.
    Quickly, I wanted to just follow up about the safeguards 
that you all talked about and how critical it is to have them 
in place. One of the concerns that we have heard is whether we, 
in fact, have those safeguards; if a servicemember's chain of 
command tries to override a medical recommendation that a 
servicemember not be deployed, for example, or if there is a 
desire to keep people moving--constant deployments--and yet, 
that servicemember really is suffering, and that recommendation 
hasn't been adhered to that they not be deployed.
    Is that something in your experiences that you have seen in 
any way? Are you aware of people who are continuing to be 
deployed who, even in your own estimation, should not be?
    Chief Gutteridge. I have not had that experience, ma'am.
    Mrs. Davis. Major, is there anything you could just add to 
that in terms of what we ought to be looking for?
    Major Gannaway. When I was a commander, dealing with a 
soldier's medical problems was very critical to combat 
readiness. You do not wait until the last day to make sure the 
soldier has his shots. You know, you start looking six months 
out and start identifying problems and go after them. If a 
soldier needs to go to the dentist, you get him there.
    So, if there are problems and you pay attention to your 
soldiers and you get to know them and their families, you 
identify those problems and try to take care of them and deal 
with them before it is time to walk out the door and deploy.
    Mrs. Davis. Mr. Scheuerman, did you want to comment? You 
have obviously spoken with families who, perhaps, have suffered 
as you have. Is there anything you would like to add to that?
    Mr. Scheuerman. It is the most difficult thing in the world 
to lose your child. It was the worst day of my life and Anne's 
also. The only thing that I really want to say to the panel is, 
this is a problem that we have to get grips with because, as 
our kids come home this is only going to get worse. As they 
leave the service and they are not under daily supervision, 
this is only going to get worse. So we have to find a way to 
make this better. I do not want another set of parents to have 
to experience what we have.
    I think we, as a Nation, can do it.
    Mrs. Davis. Thank you.
    I know that we are all better off having heard from you 
today, and we know that we also have issues within our general 
culture around mental illness, and we are trying to deal with 
that as well. Mental health parity is just one example. 
Hopefully, the services in many ways may be able to lead the 
way, actually, for the country on this one, and that would be a 
very good thing.
    Thank you all very much for joining us. We look forward to 
moving on with these issues, to addressing them critically and 
very seriously. Your presence, again, does make a difference. 
Thank you.
    [Whereupon, at 12:35 p.m., the subcommittee was adjourned.]


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                            A P P E N D I X

                             March 14, 2008

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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                             March 14, 2008

=======================================================================

      
              RESPONSE TO QUESTION SUBMITTED BY MR. MCHUGH

    Dr. Casscells. By law, title 10, United States Code (U.S.C.), 
section 1079(h)(1), as implemented by title 32, Code of Federal 
Regulations (CFR), Part 199.14(j), TRICARE's reimbursement rates for 
all medical services from individual health care providers are tied to 
Medicare reimbursement rates for such services through the CHAMPUS 
Maximum Allowable Charge (CMAC) system, a nationally determined 
allowable charge level that is adjusted by locality indices and is 
equal to or greater than the Medicare Fee Schedule amount.
    TRICARE adjusts its reimbursement rates, as necessary, to maintain 
the statutorily required relationship with Medicare's reimbursement 
rates. Often, network providers have committed in their independent 
agreements with our Managed Care Support Contractors (MCSCs) to accept 
reimbursement rates lower than CMAC. That is a business decision each 
provider makes independently.
    Non-network providers may, under the same statutory requirements, 
charge the same percentage as the Medicare limiting percentage for non-
participating Medicare providers, which is currently 15 percent above 
the CMAC rate. In the case of individual providers or particular Common 
Procedural Terminology codes, there are statutory provisions permitting 
TRICARE to raise its reimbursement rates up to 15 percent above the 
CMAC level upon official determination of the existence of network 
inadequacy (10 U.S.C. 1097b(a), as implemented by 32 CFR 199.14(j)) or 
to increase them without any specified limitation in cases of severe 
access to care deficiencies (10 U.S.C. 1079(h)(5), as implemented by 32 
CFR 199.14(j)). In those areas where severe access problems are 
demonstrated, TRICARE has the authority to waive, on a case-by-case 
basis, the CMAC levels for providers beyond the 15 percent for network 
providers.
    To date, TRICARE Management Activity has received one request for a 
locality based waiver for mental health services. The request was for 
all psychiatric services in the code range of 90800-90899 for patients 
age 18 and under in zip code 33040 in Key West, Florida. The amount of 
increase requested was 50 percent and was approved on January 7, 2008. 
In early 2008, a comprehensive review was conducted of our 
reimbursement rates compared to commercial and Medicaid rates as well 
as a review of access to mental health care. Access to care in all 
three regions was found to be adequate. [See page 15.]
                                 ______
                                 
             RESPONSES TO QUESTIONS SUBMITTED BY MRS. BOYDA
    General Schoomaker. The suicide rates (per 100,000) for the U.S. 
Marine Corps from calendar year 1999 through calendar year 2007 are as 
follows:

    1999-15.0
    2000-13.9
    2001-16.7
    2002-12.5
    2003-13.4
    2004-17.5
    2005-14.4
    2006-12.9
    2007-16.5

    A comparison of the four years prior to Operation Iraqi Freedom 
(OIF) and four years after the commencement of OIF follows. Calendar 
year 2003 is excluded because it was a partial year as OIF commenced in 
March 2003.

          Average Annual Suicide Rate

              1999-2002--14.525
              2004-2007--15.325

    The difference between the average annual suicide rate from 1999-
2002 is not statistically significant from the average annual suicide 
rate from 2004-2007 (t-test=0.289.) [See page 18.]
    General Schoomaker. Army and United States Marine Corps (USMC) 
Suicide Rates before and after onset of Operation Iraqi Freedom:



         Year                     ARMY                    USMC

                2001                      9.0                    16.7
                2002                     11.5                    12.5
                2003                     11.4                    13.4
                2004                      9.6                    17.5
                2005                     12.7                    14.4
                2006                     15.3                    12.9
                2007                     16.8                    16.5


    * Suicide rates reported as number of suicides per 100,000 per year
    ** USMC rates are typically higher due to greater percentage of 
young males, and more variable due to being a smaller population. [See 
page 18.]
                                 ______
                                 
              RESPONSE TO QUESTION SUBMITTED BY MR. JONES
    Dr. Casscells. We have data for military active duty physicians. 
Psychiatrists are a subset of that group. The majority of Physicians 
are accessed through the Uniformed Services University of the Health 
Sciences (USUHS) and the Health Professions Scholarship program (HPSP). 
Approximately 14% of accessions are from USUHS, 82% from HPSP and 4% 
are direct accessions. In terms of medical schools that produce active 
duty military physicians, the number one school is USUHS. The following 
table is a list of the top 25 (two-way tie for 25) civilian medical 
schools, ranked by the number of HPSP scholarships:


----------------------------------------------------------------------------------------------------------------
                          Medical Schools                                       Location               # HPSP
----------------------------------------------------------------------------------------------------------------
Lake Erie College of Osteopathic Medicine                            Erie, PA                                68
----------------------------------------------------------------------------------------------------------------
Philadelphia College of Osteopathic Medicine                         Philadelphia, PA                        67
----------------------------------------------------------------------------------------------------------------
Edward Via Virginia College of Osteopathic Medicine                  Blacksburg, VA                          63
----------------------------------------------------------------------------------------------------------------
Kansas City Univ of Medicine and Bio Sciences                        Kansas City, MO                         57
----------------------------------------------------------------------------------------------------------------
A.T. Still University of Health Sciences                             Kirksville, MO                          49
----------------------------------------------------------------------------------------------------------------
Nova Southeastern Univ of Osteopathic Medicine                       Fort Lauderdale, FL                     48
----------------------------------------------------------------------------------------------------------------
Des Moines University-Osteopathic Medical Center                     Des Moines, IA                          44
----------------------------------------------------------------------------------------------------------------
Midwestern University at Glendale                                    Glendale, AZ                            43
----------------------------------------------------------------------------------------------------------------
Touro University of Osteopathic Medicine SF                          San Francisco, CA                       42
----------------------------------------------------------------------------------------------------------------
West Virginia School of Osteopathic Medicine                         Lewisburg, WV                           31
----------------------------------------------------------------------------------------------------------------
New York University                                                  New York, NY                            23
----------------------------------------------------------------------------------------------------------------
Midwestern University in Illinois                                    Downers Grove, IL                       20
----------------------------------------------------------------------------------------------------------------
Georgetown University                                                Washington, DC                          18
----------------------------------------------------------------------------------------------------------------
Boston University                                                    Boston, MA                              16
----------------------------------------------------------------------------------------------------------------
University of Illinois at Chicago                                    Chicago, IL                             14
----------------------------------------------------------------------------------------------------------------
Philadelphia College of Osteopathic Med @ GA                         Atlanta, GA                             14
----------------------------------------------------------------------------------------------------------------
Howard University                                                    Washington, DC                          14
----------------------------------------------------------------------------------------------------------------
Western University of Health Sciences                                Pomona, CA                              14
----------------------------------------------------------------------------------------------------------------
Eastern VA Medical College of Hampton Roads                          Norfolk, VA                             13
----------------------------------------------------------------------------------------------------------------
University of Texas--All Campuses Combined                           TX                                      11
----------------------------------------------------------------------------------------------------------------
Temple University                                                    Philadelphia, PA                        11
----------------------------------------------------------------------------------------------------------------
Creighton University                                                 Omaha, NE                               11
----------------------------------------------------------------------------------------------------------------
Wright State University                                              Dayton, OH                               6
----------------------------------------------------------------------------------------------------------------
Ohio State University                                                Columbus, OH                             6
----------------------------------------------------------------------------------------------------------------
University of North Texas HSC                                        Fort Worth, TX                           5
----------------------------------------------------------------------------------------------------------------
Meharry Medical College                                              Nashville, TN                            5
----------------------------------------------------------------------------------------------------------------

    [See page 29.]
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