[Senate Hearing 110-631]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-631
 
  THE FINDINGS AND RECOMMENDATIONS OF THE DEPARTMENT OF DEFENSE TASK 
FORCE ON MENTAL HEALTH, THE ARMY'S MENTAL HEALTH ADVISORY TEAM REPORTS, 
   AND DEPARTMENT OF DEFENSE AND SERVICE-WIDE IMPROVEMENTS IN MENTAL 
HEALTH RESOURCES, INCLUDING SUICIDE PREVENTION, FOR SERVICEMEMBERS AND 
                             THEIR FAMILIES

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

                                HEARING

                               before the

                       SUBCOMMITTEE ON PERSONNEL

                                 of the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 5, 2008

                               __________

         Printed for the use of the Committee on Armed Services

?

                     U.S. GOVERNMENT PRINTING OFFICE
45-652 PDF                 WASHINGTON DC:  2008
---------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512ï¿½091800  
Fax: (202) 512ï¿½092104 Mail: Stop IDCC, Washington, DC 20402ï¿½090001


                      COMMITTEE ON ARMED SERVICES

                     CARL LEVIN, Michigan, Chairman

EDWARD M. KENNEDY, Massachusetts     JOHN McCAIN, Arizona
ROBERT C. BYRD, West Virginia        JOHN WARNER, Virginia,
JOSEPH I. LIEBERMAN, Connecticut     JAMES M. INHOFE, Oklahoma
JACK REED, Rhode Island              JEFF SESSIONS, Alabama
DANIEL K. AKAKA, Hawaii              SUSAN M. COLLINS, Maine
BILL NELSON, Florida                 SAXBY CHAMBLISS, Georgia
E. BENJAMIN NELSON, Nebraska         LINDSEY O. GRAHAM, South Carolina
EVAN BAYH, Indiana                   ELIZABETH DOLE, North Carolina
HILLARY RODHAM CLINTON, New York     JOHN CORNYN, Texas
MARK L. PRYOR, Arkansas              JOHN THUNE, South Dakota
JIM WEBB, Virginia                   MEL MARTINEZ, Florida
CLAIRE McCASKILL, Missouri           ROGER F. WICKER, Mississippi

                   Richard D. DeBobes, Staff Director

              Michael V. Kostiw, Republican Staff Director

                                 ______

                       Subcommittee on Personnel

                 E. BENJAMIN NELSON, Nebraska, Chairman

EDWARD M. KENNEDY, Massachusetts     LINDSEY O. GRAHAM, South Carolina
JOSEPH I. LIEBERMAN, Connecticut     SUSAN M. COLLINS, Maine
JIM WEBB, Virginia                   SAXBY CHAMBLISS, Georgia
CLAIRE McCASKILL, Missouri           ELIZABETH DOLE, North Carolina

                                  (ii)

  




                            C O N T E N T S

                               __________

                    CHRONOLOGICAL LIST OF WITNESSES

  The Findings and Recommendations of the Department of Defense Task 
Force on Mental Health, the Army's Mental Health Advisory Team Reports, 
   and Department of Defense and Service-Wide Improvements in Mental 
Health Resources, Including Suicide Prevention, for Servicemembers and 
                             Their Families

                             march 5, 2008

                                                                   Page

Boxer, Hon. Barbara, U.S. Senator from the State of California...     2
Arthur, VADM Donald C., USN (Ret.) Co-Chair, Department of 
  Defense Task Force on Mental Health............................    19
MacDermid, Dr. Shelley M., Co-Chair, Department of Defense Task 
  Force on Mental Health.........................................    19
Hoge, COL Charles W., USA, Director, Division of Psychiatry and 
  Neuroscience, Walter Reed Army Institute of Research; 
  Accompanied by COL Carl A. Castro, USA, Research Area Director, 
  Military Operational Medicine Research Program.................   121
Schoomaker, LTG Eric B., USA, Surgeon General of the United 
  States Army and Commanding General, United States Army Medical 
  Command........................................................   129
Robinson, VADM Adam M., Jr., USN, Surgeon General of the United 
  States Navy and Chief, Bureau of Medicine and Surgery..........   134
Roudebush, Lt. Gen. James G., USAF, Surgeon General of the United 
  States Air Force...............................................   143
Sutton, COL Loree K., USA, Special Assistant to the Assistant 
  Secretary of Defense (Health Affairs), Psychological Health and 
  Traumatic Brain Injury.........................................   148

                                 (iii)


  THE FINDINGS AND RECOMMENDATIONS OF THE DEPARTMENT OF DEFENSE TASK 
FORCE ON MENTAL HEALTH, THE ARMY'S MENTAL HEALTH ADVISORY TEAM REPORTS, 
   AND DEPARTMENT OF DEFENSE AND SERVICE-WIDE IMPROVEMENTS IN MENTAL 
HEALTH RESOURCES, INCLUDING SUICIDE PREVENTION, FOR SERVICEMEMBERS AND 
                             THEIR FAMILIES

                              ----------                              


                        WEDNESDAY, MARCH 5, 2008

                               U.S. Senate,
                         Subcommittee on Personnel,
                               Committee on Armed Services,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:35 p.m. in 
room SR-232A, Russell Senate Office Building, Senator E. 
Benjamin Nelson (chairman of the subcommitee) presiding.
    Committee members present: E. Benjamin Nelson, Lieberman, 
and Graham.
    Committee staff member present: Leah C. Brewer, nominations 
and hearings clerk.
    Majority staff members present: Gabriella Eisen, counsel; 
and Gerald J. Leeling, counsel.
    Minority staff members present: Diana G. Tabler, 
professional staff member, and Richard F. Walsh, minority 
counsel.
    Staff assistants present: Jessica L. Kingston and Ali Z. 
Pasha.
    Committee members' assistants present: Frederick M. Downey, 
assistant to Senator Lieberman; Andrew R. Vanlandingham, 
assistant to Senator Ben Nelson; Jon Davey, assistant to 
Senator Bayh; Clyde A. Taylor IV, assistant to Senator 
Chambliss; and Andrew King, assistant to Senator Graham.

   OPENING STATEMENT OF SENATOR E. BENJAMIN NELSON, CHAIRMAN

    Senator Ben Nelson. Our ranking member, Senator Graham, is 
on his way. He'll be a little late, but he has suggested we go 
ahead and start the subcommittee hearing this afternoon, so we 
can give Senator Boxer an opportunity to address us on a series 
of very important issues.
    Let me start by saying the Personnel Subcommittee hearing 
will come to order. I have a short initial statement which I'll 
read and then, Senator Boxer, it'll be our pleasure to have 
your testimony.
    The subcommittee meets today to receive testimony on the 
findings and recommendations of the Department of Defense (DOD) 
Task Force on Mental Health, the Army's Mental Health Advisory 
Team (MHAT) reports, and DOD and Service-wide improvements in 
mental health resources, including suicide prevention, for 
servicemembers and their families.
    This subcommittee is responsible for the most important 
aspect of the United States military system, our men and women 
and their families who volunteer to serve our great Nation. The 
repeated and extended deployments and the intensity of the 
conflicts in Iraq and Afghanistan are taking a toll on the 
mental health of our troops and their families. This hearing 
will help us to understand more clearly what help is currently 
available to them and, importantly, what more is needed.
    It's been an honor to be able to work alongside my ranking 
member, Senator Graham. We've switched positions a time or two. 
We continue to work well together because there is nothing 
partisan about the mental health of our military.
    Perhaps the most important piece of what we're about today 
in looking after the mental well-being of our Armed Forces and 
their greatest support, their families, is an opportunity to 
learn more about what is being done, but also what more should 
be done.
    We're pleased here in the first panel to have Senator 
Boxer, who for years has been a tireless advocate for our 
servicemembers. She has taken the lead on this issue of mental 
health and offered the amendment to create the DOD Task Force 
on Mental Health, which was included in the National Defense 
Authorization Act for Fiscal Year 2006. She is here to discuss 
her efforts in this area. So we thank you for being with us 
today.
    I'll talk one second about our second panel. We're honored 
to have several experts on the subject of mental health care 
and treatment in the military environment. They're here to 
share with us the findings and recommendations of the DOD Task 
Force on Mental Health, as well as the findings of the other 
reports. I'll introduce them when the second panel convenes.
    The third panel will consist of the DOD official charged 
with implementing the recommendations of the task force and the 
surgeons general from each of the Services. They're here to 
discuss the programs, plans, and initiatives that the Services 
and DOD have in place already or plan to put in place to 
respond to the findings of the Army's MHAT reports and to 
implement the task force's recommendations. I'll introduce them 
when we begin the third panel.
    So we look forward to the testimony today and we'll ask 
Senator Graham to make his statement when he is able to join 
us. In the mean time, Senator Boxer, thank you very much for 
being here.

STATEMENT OF HON. BARBARA BOXER, U.S. SENATOR FROM THE STATE OF 
                           CALIFORNIA

    Senator Boxer. Senator Nelson and Senator Lieberman, I'm 
very honored to be before your subcommittee. If we remember 
back, with the gracious help of this committee, Senator 
Lieberman and I working together, were able to include language 
establishing the Mental Health Task Force in the National 
Defense Authorization Act for Fiscal Year 2006.
    At that time, we were roughly 2 years into the Iraq war and 
we were beginning to hear countless stories that showed we did 
not have an adequate mental health care system in place. I 
can't tell you how many phone calls I got from nameless 
families who said: We're just scared.
    Over a 1-year period, the task force took a comprehensive 
and a very thoughtful look at the state of mental health care 
and services for our servicemembers and their families. 
Frankly, what they found, Mr. Chairman, was simply not good. In 
particular, the task force found that--and I'm quoting--
``Significant gaps in the continuum of care for psychological 
health exist,'' and that ``the military health system lacks the 
fiscal resources and the fully trained personnel to fulfill its 
mission to support psychological health.''
    In response to those findings, the task force developed a 
series of 95 comprehensive recommendations to dramatically 
improve the way that the DOD both views psychological health in 
general and provides treatment and care for those who need it.
    I am tremendously proud of their work and I have told them 
so, and particularly I am proud of the outstanding leadership 
of the two co-chairs, who will testify next: Vice Admiral 
Donald Arthur and Dr. Shelley MacDermid.
    It is my understanding that the DOD elected to adopt all 
but one of the task force recommendations. I am here today to 
both commend the work of the task force and to ask that you as 
the Senate committee charged with overseeing military health 
care, and particularly this subcommittee, provide the DOD with 
all of the resources and support necessary to implement these 
far-reaching changes. I am sure that you all agree, and from 
listening to the chairman's heartfelt opening, you all agree 
that we have a big problem on our hands that is only going to 
get worse if we don't do something big now, something that 
really fills the void.
    According to a study published in the Journal of the 
American Medical Association on November 14, 2007, 20 percent 
or one in five of all Active Duty Army soldiers and 42 percent 
of all Reserve component soldiers, including Army Reserve and 
Army National Guard, who served in Iraq are reporting that they 
need mental health treatment for a range of problems--one in 
five. This means that tens of thousands of men and women need 
and deserve the best mental health care that we can provide.
    I have to say, Mr. Chairman and Senator Lieberman, in all 
the years that I've been in Congress, and for a period of time 
in the 1980s I served on the Armed Services Committee, I saw 
that when the military decides to do something they do it right 
and they do it as a model for the rest of the Nation. I don't 
care whether it's child care or health care or whatever it is. 
So I am so optimistic that with the resources that we can make 
sure they can really not only solve the problems that we're 
facing in the military, but send a very clear signal to the 
civilian community of what the civilian community must do.
    Too many servicemembers have been discharged for 
preexisting personality disorders when they actually had mental 
health problems from their combat experience. Imagine, they 
were discharged for preexisting conditions when they had mental 
health problems from their combat experience. That's wrong, 
because those people are not going to get the help they need.
    Too many servicemembers have turned to drugs and alcohol, 
and the number of DUIs has risen at bases across this Nation. 
Too many servicemen and women have attempted or committed 
suicide. In 2007 alone, 121 soldiers committed suicide and 
another 2,100 attempted suicide, a six-fold increase since 
2002. This is tragic. I know you agree with me because I've 
talked to you about these things.
    If we don't act soon, we will see more devastating 
consequences of these wounds play out in the years to come on 
our streets with homeless and substance abuse. I still, when I 
talk to the homeless, find homeless vets from the Vietnam era.
    Senators, we can't have this continue. We see homelessness. 
We see substance abuse. We see violence. We see divorce, and 
that's why we have to do more to confront these challenges 
today.
    I am so proud of the work that we have done together, 
particularly with my colleague Senator Lieberman. We have 
successfully passed legislation to establish a center of 
excellence for military mental health and traumatic brain 
injury (TBI). We have helped to set standards for deployment 
for servicemembers with diagnosed mental health conditions and 
to examine issues involving women and combat stress.
    But there is much more to be done. That is why I am 
continuing to work on legislation with Senator Lieberman to 
address mental health workforce shortages and to address the 
issue of suicide within the armed services.
    We also must shatter the stigma associated with seeking 
mental health care that says a soldier, sailor, airman, or 
marine is weak if he or she wants to talk with a mental health 
professional about experiences in Iraq or Afghanistan. We must 
ensure that we have adequate numbers of uniformed mental health 
providers who can train and deploy with our troops and be there 
when they're needed. It doesn't help them if they can't find 
help quickly. We must give our servicemembers the tools they 
need to be able to cope with the stress upon them and the 
experiences that many of them face each and every day.
    That is why it is so important that this subcommittee fully 
supports the recommendations of the DOD Mental Health Task 
Force.
    Mr. Chairman, it's rare that Members of Congress look at a 
special committee that was set up to work within the DOD and 
say you're right on every count, you have done your work well. 
We are of one mind on this. Now, I know there are differences 
about the war in Iraq. There are bitter differences, difficult 
differences. But I know that all of us agree, regardless of how 
we feel about the war, we all feel the same way about the 
warriors. We honor them, we trust them, we want to stand by 
their side.
    I think today, Mr. Chairman, with your leadership and that 
of Senator Graham and Senator Lieberman, who I'm so pleased is 
here, I really think we can take some bipartisan actions to 
ensure that our troops are treated.
    In conclusion, let me say when we do this right it's going 
to help our military in the long run. It's going to enable us 
to attract more people when they know that if they do have this 
type of problem they'll be cared for, they'll be made whole, 
and it will help us recruit the best people and keep the best 
people.
    Thank you so very much for this chance to speak to you.
    [The prepared statement of Senator Boxer follows:]

              Prepared Statement by Senator Barbara Boxer

    Mr. Chairman, with the gracious help of this committee, I was able 
to include language establishing the Mental Health Task Force in the 
National Defense Authorization Act for Fiscal Year 2006.
    At that time, we were roughly 2 years into the Iraq war and 
beginning to hear countless stories that showed we did not have an 
adequate mental health care system in place.
    Over a 1 year period, the task force took a comprehensive and 
thoughtful look at the state of mental health care and services for our 
service men and women and their families. What they found was not good.
    In particular, the task force found that ``significant gaps in the 
continuum of care for psychological health'' exist, and that the 
``Military Health System lacks the fiscal resources and the fully-
trained personnel to fulfill its mission to support psychological 
health.''
    In response to their findings, the task force developed a series of 
95 comprehensive recommendations to dramatically improve the way that 
the Department of Defense both views psychological health in general, 
and provides treatment and care for those who need it.
    I am tremendously proud of their work, and particularly the 
outstanding leadership of the two co-chairs who will testify next, Vice 
Admiral Donald Arthur and Dr. Shelley MacDermid.
    It is my understanding that the Department of Defense elected to 
adopt all but one of the task force recommendations.
    I am here today to both commend the work of the task force and to 
ask that you--as the Senate committee charged with overseeing military 
health care--provide the Department of Defense with all of the 
resources and support necessary to implement these far-reaching 
changes.
    I am sure that you all agree that we have a big problem on our 
hands that is only going to get worse if we don't do something big now.
    According to a study published in the Journal of the American 
Medical Association on November 14, 2007, 20 percent (or 1 in 5) of all 
Active Duty Army soldiers and 42 percent of all Reserve component 
soldiers, including Army Reserve and Army National Guard, who served in 
Iraq are reporting that they need mental health treatment for a range 
of problems.
    This means that tens of thousands of men and women need and deserve 
the best mental health care that we can provide. We can and must do 
better.
    Too many servicemembers have been discharged for pre-existing 
personality disorders when they actually had mental health problems 
from their combat experience.
    Too many servicemembers have turned to drugs and alcohol, and the 
number of DUIs has risen at bases across the Nation.
    Too many service men and women have attempted or committed suicide. 
In 2007 alone, 121 soldiers committed suicide and another 2,100 
attempted suicide, a six-fold increase since 2002. This is tragic.
    If we don't act soon, we will see more devastating consequences of 
these wounds play out in the years to come--homelessness and substance 
abuse; violence and divorce. That is why we can and must do more to 
confront these challenges today.
    I am proud of the work I have been able to do so far, much of it 
with my colleague Senator Lieberman. We have successfully passed 
legislation to establish a Center of Excellence for Military Mental 
Health and Traumatic Brain Injury. We have helped to set standards for 
deployment for servicemembers with diagnosed mental health conditions, 
and to examine issues involving women and combat stress.
    But there is more to be done.
    That is why I am continuing to work on legislation with Senator 
Lieberman to address mental health workforce shortages and to address 
the issue of suicide within the Armed Forces.
    We also need to shatter the stigma associated with seeking mental 
health care that says a soldier, sailor, airman, or marine is weak if 
he or she wants to talk with a mental health professional about 
experiences in Iraq or Afghanistan.
    We need to ensure that we have adequate numbers of uniformed mental 
health providers who can train and deploy with our troops and be there 
when they are needed.
    We must give our servicemembers the tools they need to be able to 
cope with the stress of combat and the experiences that many of them 
face each and every day.
    That is why it is so important that this subcommittee fully support 
the recommendations of the Department of Defense Mental Health Task 
Force.
    I know that there are different views about the war in Iraq on this 
committee and in the Senate. But all of us agree that we should honor 
the service of the brave men and women of our military. We can and must 
come together to serve them as well as they have served us.
    I look forward to continuing to work with you on this most 
important issue.

    Senator Ben Nelson. Thank you, Senator.
    Senator Lieberman, I understand you may have an opening 
statement you'd like to make. I didn't mean to pass over you so 
quickly.
    Senator Boxer. I would love to hear it.
    Senator Lieberman. Just very briefly, I'm going to put my 
statement in the record.
    Thank you for convening this hearing. Thanks, Senator 
Boxer. We've formed a partnership in shared concern, as you 
quite rightly said, about the warriors, even though we had 
differences of opinion about the war, and that's something that 
I think expresses the unity that the American people feel.
    There's been a lot of work done on this. I'm very proud of 
the mental health care for our Wounded Warriors Act, which was 
in the National Defense Authorization Act for Fiscal Year 2008. 
I appreciate the work that is being done within the health 
services in the military.
    I just want to focus for a moment on the two pieces of 
legislation you mentioned that we're working on, because the 
work is obviously not done. First, we've noted in all these 
Services a real shortage of uniformed behavioral health 
providers. That's why Senator Boxer and I are working on 
legislation that will increase and improve incentives for 
recruitment and training and retention of such providers. We're 
talking about psychologists, psychiatrists, social workers, and 
mental health nurses.
    The need for uniformed providers cannot be overemphasized 
when one considers their dual missions to not only deploy to 
combat zones, but staff garrison military treatment facilities 
(MTFs) across the globe.
    Incidentally, one of the things that Senator Boxer and I 
know you, Mr. Chairman and Senator Graham, understand is that a 
soldier, sailor, marine, or airman who is mentally fit is going 
to be a better fighter and is going to be a better team member 
with those in his or her unit.
    One of the interesting things that we've learned in our 
work on this, Senator Boxer and I, is that uniformed mental 
health professionals are critical. You can buy civilian 
services on a contract basis, but in the work that we've done 
and our staffs have done it's very clear particularly those 
returning from combat strongly prefer receiving care from a 
fellow servicemember. That's what this piece of legislation 
that Senator Boxer and I are offering focuses on.
    It's not going to be easy, particularly because of some 
very practical problems that some of our military installations 
are in places that are not, shall we say, in the middle of 
cosmopolitan metropolitan areas. Would those in uniform agree 
with that? Yes, and some of the mental health professionals 
prefer to be in such places.
    So we have to figure out ways to attract people.
    Second, suicide rates have become alarming. In the past 
year there have been a number of disturbing reports concerning 
suicide rates, particularly in the Army. In 2007--higher than 
at any other time since the statistic had been tracked by the 
military; higher also than the suicide rate in the civilian 
population.
    So the legislation Senator Boxer and I are working on would 
in short create a new across-the-Services prevention program 
modeled on a highly successful aircraft incident prevention 
program, which is run by the Air Force. I hope that my 
colleagues will look at both of these pieces of legislation and 
ideally, as you were kind enough to include the previous 
legislation in the National Defense Authorization Act for 
Fiscal Year 2008, perhaps we could include these two in the 
National Defense Authorization Act for Fiscal Year 2009.
    I thank you, Mr. Chairman, for your leadership, and again I 
thank Senator Boxer for her leadership here. Senator Graham, I 
don't want to leave you out. This is a real bipartisan concern, 
and you've been right at the leadership of those trying to do 
something about it.
    Thank you very much.
    [The prepared statement of Senator Lieberman follows:]

           Prepared Statement by Senator Joseph I. Lieberman

    Chairman Nelson, thank you for convening this important hearing on 
the status of the Department of Defense's mental health reforms.
    Soon after the conflicts in Iraq and Afghanistan began, the 
``hidden injuries'' resulting from the war began to surface. The 
statistics are not new to anyone here. An estimated one in six 
Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) 
servicemembers has a diagnosable condition of post-traumatic stress 
disorder and 1 in 10 has suffered a traumatic brain injury. Over one-
third of OIF/OEF veterans treated by the Veterans Administration has 
been diagnosed with a mental health condition, including post-traumatic 
stress disorder, depression, and substance abuse, among others.
    These realities have motivated this committee, and others including 
Senator Boxer, to work on a number of initiatives to improve our 
servicemembers' access to high quality behavioral health care. Numerous 
commissions and study groups have also contributed significantly to the 
effort and influenced our work on this committee. Specifically, I would 
like to applaud the seminal work of the Mental Health Task Force. The 
Task Force, led by Vice Admiral Arthur and Dr. MacDermid, has been 
critical in providing a blueprint for building a true continuum of care 
for psychological health, and I look forward to their testimony.
    I would also like to thank the committee for working with Senator 
Boxer and myself to include our legislation, S. 1196, the Mental Health 
Care for Our Wounded Warriors Act, in the National Defense 
Authorization Act for Fiscal Year 2008, which authorizes the 
establishment of a Defense Center of Excellence on psychological and 
brain injuries. This center will provide critical leadership to the 
Department's efforts to conduct research, develop treatments, and 
disseminate best practices on psychological health and brain injuries. 
I look forward to supporting the new Defense Center of Excellence and 
applaud Colonel Sutton in her efforts to bring critical leadership to 
this issue. The task ahead will not be easy--to not only fulfill the 
mandates passed in the National Defense Authorization Act for Fiscal 
Year 2008, but to implement many of the recommendations of the Mental 
Health Task Force. We ask that you come to this committee when you 
require additional resources or authorities to accomplish these goals.
    This hearing is very timely because we now have: a more 
comprehensive understanding of the psychological injuries affecting 
servicemembers, increasing research evidence to support the design of 
new interventions and models for delivering preventive and treatment 
services, and the political willpower to provide current and future 
servicemembers with the best behavioral health care. Therefore, we must 
now marshal our resources to implement long-term solutions that provide 
effective prevention and treatment services to those in uniform now and 
will promote resilience and early intervention and treatment for our 
future forces as well.
    First, we will not be able to increase access to behavioral health 
services to those in need now, and to inoculate against, or provide 
early treatment for psychological injuries if we do not increase the 
number of uniformed behavioral health service providers in each of our 
Services. That is why Senator Boxer and I are introducing legislation 
to increase and improve incentives for the recruitment and retention of 
uniformed behavioral health providers, including psychologists, 
psychiatrists, social workers, and mental health nurses. The need for 
uniformed providers cannot be overemphasized in light of their dual 
missions to not only deploy to combat zones, but staff garrison 
military treatment facilities across the globe. We have also learned 
that uniformed mental health professionals are critical because many of 
those returning from combat strongly prefer to receive care from a 
fellow servicemember. As we learn more about the mental health 
conditions that arise from repealed tours of duty, we must have the 
uniformed workforce in place to meet the demands of our returning 
servicemembers and the long-term challenges facing the Department to 
improve both the access to and the quality of mental health care. I 
believe this is critical to not only addressing the Department's 
immediate behavioral health care needs, but also in strengthening the 
resilience of our forces in the future.
    I will also be introducing a second piece of legislation focusing 
on suicide prevention. Our military's most valuable resource is the 
people who serve our country in uniform. In the past year, there have 
been a number of disturbing reports in the news concerning the Army's 
suicide rate, which was higher in 2007 than any other time this 
statistic has been tracked by the military, and significantly higher 
than in the civilian population. We must reverse the current trend. My 
legislation will create a new prevention program, modeled on the Air 
Force's highly successful aircraft accident prevention program, at the 
Department of Defense to investigate all suicides. An independent body, 
assembled by a four-star general, would produce a confidential report, 
including recommendations to address any recognized deficiencies. We 
must have the protocols in place to make sure we are able to determine 
when a servicemember needs help or immediate attention, and I believe 
my proposal will go a long way in preserving our most valuable 
resource--our men and women in uniform. Too much of our current debate 
on suicide has focused on whether or not there are statistically 
significant differences in suicides rates from 1 year to the next or 
when in comparison to those in the general population. Instead, I urge 
the Department to work with this committee and focus efforts on 
establishing protocols to investigate all suicides to determine causes 
and contributing factors, procedures to take immediate corrective 
action when necessary, and track the implementation of all Service-wide 
and force-wide recommendations emerging from such investigations.
    We can all agree that providing the best behavioral health care to 
our servicemembers is a priority for the current and future health of 
our force. I look forward to working with my colleagues on both sides 
of the aisle this year to tackle the challenges before us. We have 
asked our servicemembers to accept near-impossible trials and 
tribulations on the battlefield. The least we can do is to provide them 
with the best possible care and the attention they deserve.

    Senator Ben Nelson. Thank you.
    Senator Boxer. Thank you, Senators.
    Senator Graham, while you were gone I just said thank you 
so much for giving me this opportunity, because I think that 
this legislation is really needed and we would be so thrilled 
to have it included in the next DOD bill. Thank you very much.
    Senator Graham. Thank you, Senator. I agree with you.
    Senator Ben Nelson. Thank you, Senator. Senator Graham, do 
you have an opening statement?
    Senator Graham. Very briefly. When Senators Lieberman, 
Boxer, Nelson, and hopefully Graham can come together, that's a 
big day for the Senate. The topic brings us together, and I 
would just like to say to the witnesses, who are going to 
testify about the stress on the force, thank you for coming and 
telling us about what's going on out there. I think I have 
somewhat of an understanding how stressful it may be, but there 
have been so many acts of bravery and kindness of our troops in 
incredibly hostile circumstances and a lot of people have gone 
back more than twice, and it has to wear on them and their 
families.
    The only thing I can tell you in the opening statement is 
that if I could be king of the world, bad people would not do 
bad things. We're in a world where bad people have a desire to 
disrupt life for the rest of us, and we can sit on the 
sidelines and hope they go away or we can go fight them. We're 
going to go fight them, and we're going to take care of those 
who are doing the fighting. But there's no other option as far 
as I see it. What happened in Afghanistan should be a wakeup 
call for all of us. The consequences of losing in Iraq are 
enormous, and so those who are willing to leave their families 
and go to far-away places with strange-sounding names to make 
us all safe, God bless. You're needed. What you're doing is 
noble and we're going to help you and your family the best we 
can. But I can't promise you an end to this, because the evil 
we're fighting will not be compromised with; it has to be 
defeated.
    Senator Ben Nelson. Thank you, Senator Graham.
    Before we ask the second panel to step up, I ask unanimous 
consent that the statements submitted by outside organizations 
that the staff has already compiled be included in the record.
    Without objection, so ordered.
    [The prepared statements of the National Military Family 
Association and Sam D. Toney, MD, follow:]

     Prepared Statement by The National Military Family Association

    Chairman Nelson and distinguished members of this subcommittee, the 
National Military Family Association (NMFA) would like to thank you for 
the opportunity to present testimony today on the mental health 
services for the military and their families. We thank you for your 
focus on the many elements necessary to ensure quality mental health 
care for our servicemembers, veterans, and the families within the 
Department of Defense (DOD) health care system.
    NMFA will discuss several issues of importance to servicemembers, 
veterans, and their families in the following subject areas:

        Mental Health
        Wounded Servicemembers Have Wounded Families
        Who Are the Families of Wounded Servicemembers?
        Caregivers

                             MENTAL HEALTH

    As the war continues, families' needs for a full spectrum of mental 
health services--from preventative care and stress reduction 
techniques, to individual or family counseling, to medical mental 
health services--continue to grow. The military offers a variety of 
mental health services, both preventative and treatment, across many 
helping agencies and programs. However, as servicemembers and families 
experience numerous lengthy and dangerous deployments, NMFA believes 
the need for confidential, preventative mental health services will 
continue to rise.
    Recent findings by the Army's Mental Health Advisory Team (MHAT) IV 
report stated current suicide prevention training was not designed for 
a combat/deployed environment. Other reports found a correlation 
between the increase in the number of suicides in the Army to tour 
lengths and relationship problems. ``Armed Forces Suicide Prevention 
Act of 2008'' is a bicameral proposal calling for a review of existing 
suicide prevention efforts and a requirement for suicide prevention 
training for all members of the Armed Forces, including the civilian 
sector and family support professionals. NMFA is especially 
appreciative of the spouses and parents of returning servicemembers' 
provisions: providing readjustment information; education on 
identifying mental health, substance abuse, suicide, and traumatic 
brain injury (TBI); and encouraging them to seek assistance when having 
financial, relationship, legal, and occupational difficulties. NMFA 
supports this proposed legislation.
    It is important to note if DOD has not been effective in the 
prevention and treatment of mental health issues, the residual will 
spill over into the Veterans Administration (VA) health care system. 
The need for mental health services will remain high for some time even 
after military operations scale down and servicemembers and their 
families' transition to veteran status. DOD and the VA must be ready. 
DOD must partner with the VA in order to address mental health issues 
early on in the process and provide transitional mental health 
programs. Partnering between the two agencies will also capture the 
National Guard and Reserve population who often straddle both agencies' 
health care systems.
    The Army's MHAT IV report links the need to address family issues 
as a means for reducing stress on deployed servicemembers. The team 
found the top non-combat stressors were deployment length and family 
separation. They noted that soldiers serving a repeat deployment 
reported higher acute stress than those on their first deployment and 
the level of combat was the key ingredient for their mental health 
status upon return. The previous MHAT report acknowledged deployment 
length was causing higher rates of marital problems. Given all the 
focus on mental health prevention, the study found current suicide 
prevention training was not designed for a combat/deployed environment. 
Recent reports on the increased number of suicides in the Army also 
focused on tour lengths and relationship problems. These reports 
demonstrate the amount of stress being placed on our troops and their 
families. Are the DOD and VA ready? Do they have adequate mental health 
providers, programs, outreach, and funding? Better yet, where will the 
veteran's spouse and children go for help? Many will be left alone to 
care for their loved one's invisible wounds left behind from frequent 
and long combat deployments. Who will care for them now that they are 
no longer part of the DOD health care system? NMFA encourages this 
Subcommittee to talk with their VA committee counterparts on these 
important issues. We can no longer be content on focusing on each 
agency separately because this population moves too frequently between 
the two agencies, especially our wounded/ill/injured servicemembers and 
their families.
    DOD's Task Force on Mental Health stated timely access to the 
proper mental health provider remains one of the greatest barriers to 
quality mental health services for servicemembers and their families. 
NMFA and the families it serves have noted with relief more providers 
are being deployed to theaters of combat operations to support 
servicemembers. The work of these mental health professionals with 
units and individuals close to the combat action they experience has 
proven very helpful and will reduce the stress that impedes 
servicemembers' performance of their mission and their successful 
reintegration with their families. However, while families are pleased 
more mental health providers are available in theater to assist their 
servicemembers, they are less happy with the resulting limited access 
to providers at home. DOD's Task Force on Mental Health found families 
are reporting an increased difficulty in obtaining appointments with 
social workers, psychologists, and psychiatrists at their military 
hospitals and clinics. The military fuels the shortage by deploying 
some of its child and adolescent psychology providers to the combat 
zones. Providers remaining at home stations report they are frequently 
overwhelmed treating active duty members who either have returned from 
deployment or are preparing to deploy. They are also finding it hard to 
fit family members into their schedules, which could lead to compassion 
fatigue, create burnout, and exacerbate the problem. NMFA hears from 
the senior officer and enlisted spouses who are so often called upon to 
be the strength for others. We hear from the health care providers, 
educators, rear detachment staff, chaplains, and counselors who are 
working long hours to assist servicemembers and their families. Unless 
these caregivers are also afforded respite care, given emotional 
support through their command, and effective family programs, they will 
be of little use to those who need their services most.
    Access for mental health care, once servicemembers are wounded/ill/
injured, further compounds the problem. Families want to be able to 
access care with a mental health provider who understands or is 
sympathetic to the issues they face. The VA has readily available 
services. The Vet Centers are an available resource for veterans' 
families providing adjustment, vocational, and family and marriage 
counseling. Vet Centers are located throughout the United States and in 
geographically dispersed areas, which provide a wonderful resource for 
our most challenged veterans and their families, the National Guard and 
Reserves. These Centers are often felt to remove the stigma attributed 
by other institutions. However, they are not mandated to care for 
veteran or wounded/ill/injured military families. The VA health care 
facilities and the community-based outpatient clinics have a ready 
supply of mental health providers, yet regulations restrict their 
ability to provide mental health care to veterans' caregivers unless 
they meet strict standards. NMFA supports the Independent Budget 
Veterans Service Organizations recommendations to expand family 
counseling in all VA major care facilities; increase distribution of 
outreach materials to family members; improve reintegration of combat 
veterans who are returning from a deployment; and provide information 
on identifying warning signs of suicidal thoughts so veterans and their 
families can seek help with readjustment issues. However, NMFA believes 
this is just a starting point for mental health services the VA should 
offer families of severely wounded servicemembers and veterans. NMFA 
recommends DOD partner with the VA to allow military families access to 
these services. We also believe Congress should require Vet Centers and 
the VA to develop a holistic approach to care by including families in 
providing mental health counseling and programs.
    NMFA has heard the main reason for the VA not providing health care 
and mental health care services is because they cannot be reimbursed 
for care rendered to a family member. However, the VA is a qualified 
TRICARE provider. This allows the VA to bill for services rendered in 
their facilities to a TRICARE beneficiary. There may be a way to bill 
other health insurance companies, as well. No one is advocating for 
care to be given for free when there is a method of collection. 
However, payment should not be the driving force on whether or not to 
provide health care or mental health services within the VA system. The 
VA just needs to look at the possibility for other payment options.
    Thousands of servicemember parents have been away from their 
families and placed into harm's way for long periods of time. Military 
children, the treasure of many military families, have shouldered the 
burden of sacrifice with great pride and resiliency. We must not forget 
this vulnerable population as the servicemember transitions from active 
duty to veteran status. Many programs, both governmental and private, 
have been created with the goal of providing support and coping skills 
to our military children during this great time of need. Unfortunately, 
many support programs are based on vague and out of date information.
    Given the concern with the war's impact on children, NMFA has 
partnered with the RAND Corporation to research the impact of war on 
military children. The report is due in April 2008. In addition, NMFA 
held its first ever Youth Initiatives Summit for Military Children, 
``Military Children in a Time of War'' last October. All panelists 
agreed the current military environment is having an effect on military 
children. Multiple deployments are creating layers of stressors, which 
families are experiencing at different stages. Teens especially carry a 
burden of care they are reluctant to share with the non-deployed parent 
in order to not ``rock the boat.'' They are often encumbered by the 
feeling of trying to keep the family going, along with anger over 
changes in their schedules, increased responsibility, and fear for 
their deployed parent. Children of the National Guard and Reserve face 
unique challenges since there are no military installations for them to 
utilize. They find themselves ``suddenly military'' without resources 
to support them. School systems are generally unaware of this change in 
focus within these family units and are ill prepared to look out for 
potential problems caused by these deployments or when an injury 
occurs. Also vulnerable, are children who have disabilities that are 
further complicated by deployment and subsequent injury. Their families 
find this added stress can be overwhelming, but are afraid of reaching 
out for assistance for fear of retribution on the servicemember. They 
often choose not to seek care for themselves or their families.
    NMFA encourages the DOD to partner with and reach out to those 
private and non-governmental organizations who are experts in their 
field on children and adolescents to identify and incorporate best 
practices in the prevention and treatment of mental health issues 
affecting our military children. At some point, these children will 
become children of our Nation's veterans. We must remember to focus on 
preventative care upstream, while still in the active duty phase, in 
order to have a solid family unit as they head into the veteran phase 
of their lives.
    Family readiness calls for access to quality health care and mental 
health services. Families need to know the various elements of their 
military health system are coordinated and working as a synergistic 
system. NMFA is concerned the DOD military health care system may not 
have all the resources it needs to meet both the military medical 
readiness mission and provide access to health care for all 
beneficiaries. It must be funded sufficiently so the direct care system 
of military treatment facilities (MTF) and the purchased care segment 
of civilian providers can work in tandem to meet the responsibilities 
given under the TRICARE contracts, meet readiness needs, and ensure 
access for all military beneficiaries.
    National provider shortages in this field, especially in child and 
adolescent psychology, are exacerbated in many cases by low TRICARE 
reimbursement rates, TRICARE rules, or military-unique geographical 
challenges (large populations in rural or traditionally underserved 
areas). Many mental health providers are willing to see military 
beneficiaries in a voluntary status. However, these providers often 
tell us they will not participate in TRICARE because of what they 
believe are time-consuming requirements and low reimbursement rates. 
More must be done to persuade these providers to participate in TRICARE 
and become a resource for the entire system, even if that means DOD 
must raise reimbursement rates.
    Many mental health experts state that some post-deployment problems 
may not surface for several months or years after the servicemember's 
return. We encourage Congress to request DOD to include families in its 
Psychological Health Support survey; perform a pre and post-deployment 
mental health screening on family members (similar to the PDHA and 
PDHRA currently being done for servicemembers as they deploy into 
theater); and sponsor a longitudinal study, similar to DOD's Millennium 
Cohort Study, in order to get a better understanding of the long-term 
effects of war on our military families.
    NMFA is especially concerned at the lack of services available to 
the families of returning National Guard, Reserve members, and 
servicemembers who leave the military following the end of their 
enlistment. They are eligible for TRICARE Reserve Select, but as we 
know Guard and Reserve are often located in rural areas where there may 
be no mental health providers available. We ask you to address the 
distance issues families face in linking with military mental health 
resources and obtaining appropriate care. Isolated Guard and Reserve 
families do not have the benefit of the safety net of services provided 
by MTFs and installation family support programs. Families want to be 
able to access care with a provider who understands or is sympathetic 
to the issues they face. NMFA recommends the use of alternative 
treatment methods, such as telemental health; increasing mental health 
reimbursement rates for rural areas; modifying licensing requirements 
in order to remove geographical practice barriers that prevent mental 
health providers from participating in telemental health services; and 
educating civilian network mental health providers about our military 
culture.
    Mental health professionals must have a greater understanding of 
the effects of mild TBI in order to help accurately diagnose and treat 
the servicemember's condition. They must be able to deal with 
polytrauma--Post-Traumatic Stress Disorder (PTSD) in combination with 
multiple physical injuries. We need more education for civilian health 
care providers on how to identify signs and symptoms of mild TBI and 
PTSD. Military families also need education on TBI and PTSD during the 
entire cycle of deployment. NMFA appreciates Congress establishing a 
Center of Excellence for TBI and PTSD. For a long time, the Defense and 
Veterans Brain Injury Center (DVBIC) has been the lead agent on TBI. 
Now with the new Center, it is very important DVBIC become more 
integrated and partner with other Services in researching TBI.
    Because the VA has as part of its charge ``to care for the widow 
and the orphan,'' NMFA is concerned about reports that many Vet Centers 
may not have the qualified counseling services they needed to provide 
promised counseling to survivors, especially to children. DOD and the 
VA must work together to ensure surviving spouses and their children 
can receive the mental health services they need, through all of VA's 
venues. New legislative language governing the TRICARE behavioral 
health benefit may also be needed to allow TRICARE coverage of 
bereavement or grief counseling. While some widows and surviving 
children suffer from depression or some other medical condition for a 
time after their loss, many others simply need counseling to help in 
managing their grief and help them to focus on the future. Many have 
been frustrated when they have asked their TRICARE contractor or 
provider for ``grief counseling'' only to be told TRICARE does not 
cover ``grief counseling.'' Available counselors at military hospitals 
can sometimes provide this service while certain providers have found a 
way within the reimbursement rules to provide needed care. However, 
many families who cannot access military hospitals are often left 
without care because they do not know what to ask for or their provider 
does not know how to help them obtain covered services. Targeted grief 
counseling when the survivor first identifies the need for help could 
prevent more serious issues from developing later. The goal is the 
right care at the right time for optimum treatment effect. The VA and 
DOD need to better coordinate their mental health services for 
survivors and their children.
    The National Defense Authorization Act for Fiscal Year 2008 
authorized an active-duty TRICARE benefit for severely wounded/ill/
injured servicemembers once they are medically retired, but their 
family members were not mentioned in the bill's language. A method of 
payment to the VA for services rendered without financially impacting 
the family would be to include the medically retired servicemember's 
spouse and children. NMFA recommends an active duty benefit for 3 years 
for the family members of those who are medically retired. This will 
help with out-of-pocket medical expenses that can arise during this 
stressful transition time and provide continuity of care for spouses, 
especially for those families with special needs children who lose 
coverage under the Extended Care Health Option program once they are no 
longer considered active duty dependents.

              WOUNDED SERVICEMEMBERS HAVE WOUNDED FAMILIES

    Transitions can be especially problematic for wounded/ill/injured 
servicemembers, veterans, and their families. NMFA asserts that behind 
every wounded servicemember and veteran is a wounded family. Spouses, 
children, parents, and siblings of servicemembers injured defending our 
country experience many uncertainties. Fear of the unknown and what 
lies ahead in future weeks, months, and even years, weighs heavily on 
their minds. Other concerns include the wounded servicemember's return 
and reunion with their family, financial stresses, and navigating the 
transition process from active duty and the DOD health care system to 
veteran and the VA health care system.
    The two agencies health care systems should alleviate, not heighten 
these concerns. They should provide for coordination of care, starting 
when the family is notified that the servicemember has been wounded and 
ending with the DOD and VA working together, creating a seamless 
transition as the wounded servicemember transfers between the two 
agencies' health care systems and eventually from active duty status to 
veteran status.
    NMFA congratulates Congress on the National Defense Authorization 
Act for Fiscal Year 2008, especially the Wounded Warrior provisions, in 
which many issues affecting this population were addressed. We also 
appreciate the work DOD and the VA have done in establishing the Senior 
Oversight Committee (SOC) to address the many issues highlighted by the 
three Presidential Commissions. Many of the Line of Action items 
addressed by the SOC will help ease the transition for active duty 
servicemembers and their families to their life as veterans and 
civilians. However, more still needs to be done. Families are still 
being lost in the shuffle between the two agencies. Many are moms, 
dads, siblings who are unfamiliar with the military and its unique 
culture. There is certainly more work to be done by DOD and the VA. We 
urge Congress to establish an oversight committee to monitor DOD and 
VA's partnership initiatives, especially with the upcoming 
administration turnover and the disbandment of the SOC early this year.

            WHO ARE THE FAMILIES OF WOUNDED SERVICEMEMBERS?

    In the past, the VA and the DOD have generally focused their 
benefit packages for a servicemember's family on his/her spouse and 
children. Now, however, it is not unusual to see the parents and 
siblings of a single servicemember presented as part of the 
servicemember's family unit. In the active duty, National Guard, and 
Reserves almost 50 percent are single. Having a wounded servicemember 
is new territory for family units. Whether the servicemember is married 
or single, their families will be affected in some way by the injury. 
As more single servicemembers are wounded, more parents and siblings 
must take on the role of helping their son, daughter, sibling through 
the recovery process. Family members are an integral part of the health 
care team. Their presence has been shown to improve their quality of 
life and aid in a speedy recovery.
    Spouses and parents of single servicemembers are included by their 
husband/wife or son/daughter's military command and their family 
support and readiness groups during deployment for the global war on 
terror. Moms and dads have been involved with their children from the 
day they were born. Many helped bake cookies for fundraisers, shuffled 
them to soccer and club sports, and helped them with their homework. 
When that servicemember is wounded, their involvement in their loved 
one's life does not change. Spouses and parent(s) take time away from 
their jobs in order travel to the receiving MTF (Walter Reed Army 
Medical Center or the National Naval Medical Center at Bethesda) and to 
the follow-on VA Polytrauma Centers to be by their loved one. They 
learn how to care for their loved one's wounds and navigate an often 
unfamiliar and complicated health care system.
    It is NMFA's belief the government, especially the DOD and VA, must 
take a more inclusive view of military and veterans' families. Those 
who have the responsibility to care for the wounded servicemember must 
also consider the needs of the spouse, children, parents of single 
servicemembers and their siblings, and the caregivers. We appreciate 
the inclusion in the National Defense Authorization Act for Fiscal Year 
2008 Wounded Warrior provision for health care services to be provided 
by the DOD and VA for family members as deemed appropriate by each 
agency's Secretary. According to the Traumatic Brain Injury Task Force, 
family members are very involved with taking care of their loved one. 
As their expectations for a positive outcome ebbs and flows throughout 
the rehabilitation and recovery phases, many experience stress and 
frustration and become emotionally drained. The VA has also called for 
recognition of the impact on the veteran when the caregiver struggles 
because of their limitations. NMFA recommends DOD and VA include mental 
health services along with physical care when drafting the NDAA fiscal 
year 2008's regulations.
    NMFA recently held a focus group composed of wounded servicemembers 
and their families to learn more about issues affecting them. They said 
following the injury, families find themselves having to redefine their 
roles. They must learn how to parent and become a spouse/lover with an 
injury. Each member needs to understand the unique aspects the injury 
brings to the family unit. Parenting from a wheelchair brings on a 
whole new challenge, especially when dealing with teenagers. 
Reintegration programs become a key ingredient in the family's success. 
NMFA believes we need to focus on treating the whole family with 
programs offering skill based training for coping, intervention, 
resiliency, and overcoming adversities. Parents need opportunities to 
get together with other parents who are in similar situations and share 
their experiences and successful coping methods. DOD and VA need to 
provide family and individual counseling to address these unique 
issues. Opportunities for the entire family and for the couple to 
reconnect and bond as a family again, must also be provided.
    The impact of the wounded/ill/injured on children is often 
overlooked and underestimated. Military children experience a 
metaphorical death of the parent they once knew and must make many 
adjustments as their parent recovers. Many families relocate to be near 
the treating MTF or the VA Polytrauma Center in order to make the 
rehabilitation process more successful. As the spouse focuses on the 
rehabilitation and recovery, older children take on new roles. They may 
become the caregivers for other siblings, as well as for the wounded 
parent. Many spouses send their children to stay with neighbors or 
extended family members, as they tend to their wounded/ill/injured 
spouse. Children get shuffled from place to place until they can be 
reunited with their parents. Once reunited, they must adapt to the 
parent's new injury and living with the ``new normal.'' Brooke Army 
Medical Center has recognized a need to support these families and has 
allowed for the system to expand in terms of guesthouses co-located 
within the hospital grounds. The on-base school system is also 
sensitive to issues surrounding these children. A warm, welcoming 
family support center located in Guest Housing serves as a sanctuary 
for family members. Unfortunately, not all families enjoy this type of 
support. The DOD could benefit from looking at successful programs like 
Brooke Army Medical Center's which has found a way to embrace the 
family unit during this difficult time. NMFA is concerned the about the 
impact the injury is having on our most vulnerable population, children 
of our military and veterans.

                               CAREGIVERS

    Caregivers need to be recognized for the important role they play 
in the care of their loved one. Without them, the quality of life of 
the wounded servicemembers and veterans, such as physical, psycho-
social, and mental health, would be significantly compromised. They are 
viewed as an invaluable resource to DOD and VA health care providers 
because they tend to the needs of the servicemembers and the veterans 
on a regular basis. Their daily involvement saves VA health care 
dollars in the long run. According to the VA, `` `informal' caregivers 
are people such as a spouse or significant other or partner, family 
member, neighbor or friend who generously give their time and energy to 
provide whatever assistance is needed to the veteran''. The VA has made 
a strong effort in supporting veterans' caregivers. The DOD should 
follow suit and expand their definition.
    So far, we have discussed the initial recovery and rehabilitation 
and the need for mental and health care services for family members. 
But, there is also the long-term care that must be addressed. 
Caregivers of the severely wounded, ill, and injured servicemembers who 
are now veterans, such as those with severe TBI, have a long road ahead 
of them. In order to perform their job well, they must be given the 
skills to be successful. This will require the VA to train them through 
a standardized, certified program, and appropriately compensate them 
for the care they provide. The time to implement these programs is 
while the servicemember is still on active duty status.
    The VA currently has eight caregiver assistance pilot programs to 
expand and improve health care education and provide needed training 
and resources for caregivers who assist disabled and aging veterans in 
their homes. These pilot programs are important, but there is a strong 
need for 24-hour in-home respite care, 24-hour supervision, emotional 
support for caregivers living in rural areas, and coping skills to 
manage both the veteran's and caregiver's stress. DOD should evaluate 
these pilot programs to determine whether to adopt them for themselves. 
Caregivers' responsibilities start while the servicemember is still on 
active duty. These pilot programs, if found successful, should be 
implemented as soon as possible and fully funded by Congress. However, 
one program missing from the pilot program is the need for adequate 
child care. Servicemembers can be single parents or the caregiver may 
have non-school aged children of their own. Each needs the availability 
of child care in order to attend their medical appointments, especially 
mental health appointments. NMFA encourages DOD and the VA to create a 
drop-in child care for medical appointments on their premises or 
partner with other organizations to provide this valuable service.
    NMFA has heard from caregivers of the difficult decisions they have 
to make over their loved one's bedside following the injury. Many don't 
know how to proceed because they don't know what their loved one's 
wishes were. The time for this discussion needs to take place prior to 
deployment and potential injury, not after the injury had occurred. We 
support the recent released Traumatic Brain Injury Task Force 
recommendation for DOD to require each deploying servicemember to 
execute a Medical Power of Attorney and a Living Will. We encourage 
this subcommittee to address this issue.
    NMFA strongly suggests research on military families, especially 
children of wounded/ill/injured Operation Iraqi Freedom/Operation 
Enduring Freedom veterans; standardized training, certification, and 
compensation for caregivers; individual and family counseling and 
support programs; a reintegration program that provides an rich 
environment for families to reconnect; and an oversight committee to 
monitor DOD's and VA's continued progress toward seamless transition.
    DOD must balance the demand for mental health personnel in theater 
and at home to help servicemembers and families deal with unique 
emotional challenges and stresses related to the nature and duration of 
continued deployments. We ask you to continue to put pressure on DOD to 
step up the recruitment and training of uniformed mental health 
providers and the hiring of civilian mental providers to assist 
servicemembers in combat theaters and at home stations to care for the 
families of the deployed and servicemembers who have either returned 
from deployment or are preparing to deploy. Spouses and parents of 
returning servicemembers' need programs providing readjustment 
information, education on identifying mental health, substance abuse, 
suicide, and TBI.
    DOD should increase reimbursement rates to attract more providers 
in areas where there is the greatest need. TRICARE contractors should 
be tasked with stepping up their efforts to attract mental health 
providers into the TRICARE networks and to identify and ease the 
barriers providers cite when asked to participate in TRICARE. Congress 
needs to address the long-term continued access to mental health 
services for this population.
    NMFA would like to thank you again for the opportunity to present 
testimony today on the mental health needs for the military and their 
families. Military families support the Nation's military missions. The 
least their country can do is make sure servicemembers, veterans, and 
their families have consistent access to high quality mental health 
care in the DOD and VA health care systems. Wounded servicemembers and 
veterans have wounded families. DOD and VA must support the caregiver 
by providing standardized training, access to mental health services, 
and assistance in navigating the health care systems. The system should 
provide coordination of care and DOD and VA working together to create 
a seamless transition. We ask this subcommittee to assist in meeting 
that responsibility.
                                 ______
                                 
                Prepared Statement by Sam D. Toney, M.D.

    Chairman Nelson, Ranking Member Graham, and distinguished members 
of the subcommittee, thank you for the opportunity to present this 
written submission in lieu of a personal testimony, regarding the need 
for improved mental health access and treatment programs, including 
suicide prevention, for servicemembers and veterans within the VA and 
Military Health Systems.
    Challenges with mental health management are well documented and 
include, among other issues, social stigma and access for patients who 
reside in rural locations. Additionally, the demand for mental health 
services has been on the rise, particularly over the last few years.\1\ 
Studies suggestive of improvements in access as a result of an 
increased number of individuals with psychologic distress having 
contacted mental health professionals are misleading in that as 
recently as 2002 approximately two-thirds of adults with significant 
psychologic distress received no professional mental health care.\2\ 
The extent of this issue is one of global proportions. Several European 
studies, for example, examine the diminished use of mental health care 
services and explore the determinants of help-seeking interventions for 
mental health problems along with the factors that potentially 
influence treatment options.\3\ Here in the United States reports from 
the surgeon general and the President's New Freedom Commission on 
Mental Health have concluded that the mental health system is 
fragmented and that evidence-based treatments are insufficiently used 
with less than optimal results.\4\ Additionally, many studies have 
focused on adherence to treatment plans including an examination of co-
morbidities and elements that might be predictive of frequent 
hospitalization.\5\ Mental health disorders such as depression, for 
example, have been shown to impact one's inability to adhere to disease 
management treatment protocols thus worsening the course of the co-
morbid state.\6\
---------------------------------------------------------------------------
    \1\ Grembowski, 2002; Colton & Manderscheid, 2006; Maciejewski, et. 
al, 2007
    \2\ Mojtabai, 2005
    \3\ Hutschemaekers, Tiemens, & de Winter, 2007; Kovess-Masfety, et. 
al, 2007; Younes, 2005
    \4\ Satcher, 2000; Hogan, 2003
    \5\ Goldney, Phillips, Fisher, & Wilson, 2004
    \6\ Ciechanowski, Katon, & Russo, 2000; DiMatteo, Lepper, & 
Croghan, 2000
---------------------------------------------------------------------------
    Much of the veteran centric research in mental health examines 
problems specific to combat with a general focus on Post Traumatic 
Stress Disorder (PTSD).\7\ While, veterans have access to a health care 
system unavailable to most Americans, the Veterans Health 
Administration (VHA), research demonstrates that utilization patterns 
in this population are suboptimal as compared to the general 
population. In 2002, the VHA provided care to approximately 4.5 million 
veterans in a total veteran population estimated at that time to be 
25.3 million (10 percent of the total population).\8\ Furthermore, 
veteran centric data reports that rural-urban disparities across 
regional delivery networks exist in the veteran population.\9\ Such 
disparities exist in terms of optimal, effective treatment and what 
individuals in general receive in actual practice settings.\10\ This 
results in functional impairments that continue to drive medical costs 
upward.
---------------------------------------------------------------------------
    \7\ Ismail, 2002; Milliken, Aucherlonie, & Hoge, 2007; Ijff et. al, 
2007
    \8\ Liu, Maciejewski, & Sales, 2005
    \9\ Weeks, et. al, 2004
    \10\ Satcher, 2000; Rost, Nutting, Smith, Elliott, & Dickinson, 
2002; Katon et. al, 2005
---------------------------------------------------------------------------
    We have found that undiagnosed/untreated or suboptimal treatment of 
mental health conditions adversely affect the volume and levels of 
utilization of health care services overall. There are a number of 
barriers relative to the effective management of mental health 
conditions, including social stigma and the availability of 
psychiatric/psychotherapeutic providers in rural communities. The use 
of state of the art, population based predictive modeling/risk 
stratification methodologies in addition to traditional telephonic 
screening will enhance proactive identification of high risk veterans. 
These approaches coupled with a specialized telephonic mental health 
care coaching and consultation liaison program will serve to benefit 
those veterans who would otherwise not seek or have access to mental 
health care.
    The first step toward addressing and effectively managing these 
veterans with mental health needs is accurate identification and risk 
stratification. This is a step that goes beyond current efforts to 
screen the population for a variety of mental health conditions (such 
as depression and PTSD) for a number of reasons. First, screening 
efforts typically focus on a limited number of definitive behavioral 
conditions with an emphasis on identifying and addressing the mental 
health issues. This does not take subclinical conditions or 
psychosocial/personality traits into consideration. More importantly, 
these efforts do not typically evaluate the clinical status/utilization 
or risk of co-morbid medical conditions. Finally, predictive modeling 
and risk stratification methodologies utilizing data mined from 
electronic medical records can provide for an efficient evaluation of 
the entire population in the system and does not rely on the 
``participation'' of the veteran during screening campaigns. We believe 
this predictive modeling/risk stratification approach can be an adjunct 
to current screening processes both from a volume and content 
perspective.
    Telephonically delivered, education-based, disease management 
programs can facilitate the care patients receive from their 
physicians, particularly on the primary care level.\11\ Furthermore, 
population-based disease management programs ``provide education for a 
broad population, enabling contact with far more patients than would be 
feasible by other means and at a lower per-patient cost than more 
intensive programs.'' \12\
---------------------------------------------------------------------------
    \11\ Maizels, Saenz & Wirjo, 2003
    \12\ Feifer, et al., 2004, p.101
---------------------------------------------------------------------------
    Providers may not fully comprehend why their patients do not 
respond to management of chronic conditions despite best efforts to 
follow standards of care in treatment protocols. Poor adherence to 
medication regimens is the most common example of this.\13\ While it is 
acknowledged in the literature that physician practices and patient 
behaviors contribute to gaps in care, recognizing psychologic distress 
as the potential source of non-adherence to treatment plans is 
difficult without the benefit of adequate predictive profiling and risk 
stratification for a large segment of the population suffering from 
chronic conditions. Much of the veteran centric research in chronic 
conditions including mental health examines problems specific to combat 
with a general focus on PTSD.\14\ The VHA research demonstrates that 
utilization patterns in this population are suboptimal as compared to 
the general population. As referenced above, this may be secondary to 
social stigma or geographic challenges, given the facilities based VA 
care delivery model. Furthermore, veteran centric data reports that 
rural-urban disparities across regional delivery networks exist in the 
veteran population.\15\ Such disparities exist in terms of optimal, 
effective treatment and what individuals in general receive in actual 
practice settings.\16\ This results in functional impairments that 
continue to drive all aspects of medical costs upward.
---------------------------------------------------------------------------
    \13\ Osterberg & Blaschke, 2005
    \14\ Ismail, 2002; Milliken, Aucherlonie, & Hoge, 2007; Ijff et. 
al, 2007
    \15\ Weeks, et. al, 2004
    \16\ (Satcher, 2000; Rost, Nutting, Smith, Elliott, & Dickinson, 
2002; Katon et. al, 2005).
---------------------------------------------------------------------------
    It is widely recognized that access to care by rural veterans is a 
significant issue. While the VA system continues to improve by 
streamlining the appointment verification process, the distances many 
of our veterans are being asked to travel does not always seem 
feasible. In rural settings such as some parts of Nebraska or South 
Carolina, asking veterans to travel hundreds of miles each way does not 
seem appropriate. The VA has done an admirable job trying to 
accommodate as many veterans as possible but perhaps it is time to 
think ``outside the box'' to implement innovative and creative options, 
that extend beyond the VA's facilities based delivery paradigm, to 
address these geographic issues.
    Following the identification of a target population within the VA 
system through the use of predictive modeling and risk stratification, 
and telephonic screening, we believe that individual veterans within 
this group should be contacted proactively through a unique and tested 
telephonic outreach campaign, and managed in an integrated program as 
follows:

         Engage Members

    An enrolled veteran is defined as an individual who has been 
identified as eligible and appropriate for the program as described 
above and has agreed to enroll in a care coaching program. Veterans 
should be contacted for program engagement and enrollment using 
specially developed, individualized communications tools and 
techniques. Based on communications sciences, the tools are designed to 
quickly convey the value of the program, address and remove barriers to 
enrollment and active participation and ease the veteran into the 
program.

         Assess and Create Personal Intervention Plan

    We believe that behavioral health clinicians (RNs and masters level 
therapists, supported by MDs and PhDs) should be the primary care 
coaches for veterans who agree to participate in an integrated 
management program. These clinicians telephonically conduct a 
comprehensive veteran assessment (BioPsychoSocial (BPS)) that includes 
a number of behavioral health screens such as the PHQ-9 and PCL-17 as 
well as proprietary assessment criteria such as present conditions or 
health risks, depression history, condition knowledge, communications 
skills, health literacy, psychosocial barriers, motivation/readiness to 
change relative to depression and any other care gaps or barriers to 
treatment. The assessment criteria is used to develop a Personal 
Intervention Plan, specify the intervention level which defines the 
intensity and frequency of interventions, and to set care coaching 
goals focused on improving self-efficacy and sustaining behavior 
change. In addition, condition-specific modules (e.g. PTSD, depression) 
assess individual treatment plans against evidence-based guidelines, 
measure individual symptom severity, quality of life, productivity, 
treatment plan adherence rates and condition-specific knowledge. 
Specific mental health assessments also enable care coaches to identify 
risk factors for suicide and to effectively intervene with preventive 
measures which include psychoeducational techniques, reframing, 
clinical alerts, and medical director consultation. Medical directors 
(Board Certified Physicians with specific VA experience and training) 
review each case monthly for consistency in treatment plans as well as 
potential underlying psychopathology not yet identified or treated. 
Medical directors may engage in a collaborative telephonic consultation 
with the VA practitioner to assist in the diagnosis and further 
enhancement of the particular treatment plan.

         Follow Personal Intervention Plan

    A Personal Intervention Plan is oriented towards ``graduation'' 
from the program when the veteran has reached their care coaching 
goals, achieving sustained behavior change, treatment adherence and 
desired levels of self-efficacy. The intervention plan strategy 
includes Care Coaching, which involves motivational interviewing, 
working with tools to sustain behavior change, and follow up to assess 
and achieve progress towards goals. The second element to graduation is 
ensuring that all treatment plan interventions are consistent with 
evidence-based guidelines. As veterans are enrolled into an integrated 
program their initial assessment and individual psychosocial issues are 
communicated to the VA practitioner in a standardized reporting format.

         Measure Relevant Outcomes

    Because programs such as these are driven by outcomes, they are 
developed to measure and report key relevant metrics to demonstrate the 
impact of the program. For individual veterans, this includes behavior 
modification milestones and achievement of ``graduation'' criteria. 
Across the population, this provides reporting on the activity and 
progress for every aspect of the program.
    Again, I would like to thank the subcommittee for this opportunity 
and welcome the opportunity to serve as a resource to the subcommittee 
in the future.

    Senator Ben Nelson. With that, will the second panel please 
come forward as your name placard is being put forward. While 
that's happening, I did mention, Senator Graham, how we have 
worked together on this subcommittee for some time when you 
were chair and now that you're ranking member, and we've 
reversed our roles, but there's nothing partisan about mental 
health care for our troops.
    On our second panel we are honored to have Admiral Don C. 
Arthur, United States Navy, Retired; Dr. Shelley M. MacDermid, 
who are the Co-Chairs of the DOD Task Force on Mental Health, 
which, as I stated earlier, was a congressionally-mandated task 
force referred to by both Senator Boxer and Senator Lieberman. 
The task force, as indicated, was charged with conducting an 
assessment of and making recommendations for improving the 
efficacy of mental health services provided to members of the 
Armed Forces by the DOD, to include access to mental health 
care providers, the reduction or elimination of stigma in 
regards to seeking mental health care, and coordination between 
the Department and civilian communities with respect to mental 
health services, among many other things.
    We're also fortunate to have with us today Colonel Charles 
W. Hoge, United States Army, who is the Director of the 
Division of Psychiatry and Neuroscience at the Walter Reed Army 
Institute of Research. Colonel Hoge is well known in the 
medical community for his extensive work in the area of mental 
health care in the military.
    Accompanying Colonel Hoge is Colonel Carl A. Castro, United 
States Army, who is the Research Area Director of the Military 
Operational Medicine Research Program. Both colonels have 
participated in elements of all five of the Army's MHAT 
reports, so they're quite familiar with those reports.
    Let me say that I commend the Army for starting these MHAT 
studies on its own initiative.
    We look forward to hearing from each of you, and we will 
start first with Admiral Arthur--would you like to begin?

   STATEMENT OF VADM DONALD C. ARTHUR, USN (RET.) CO-CHAIR, 
       DEPARTMENT OF DEFENSE TASK FORCE ON MENTAL HEALTH

    Admiral Arthur. Senator Nelson, Senator Graham: Thank you 
very much for inviting us to this panel. It's a great honor. 
Indicative of the teamwork that went into the Mental Health 
Task Force report, I would actually like to turn it over to 
Shelley MacDermid for a moment, and we will tag team our 
presentations if that's okay.

    STATEMENT  OF  DR.  SHELLEY  M.  MacDERMID,  CO-CHAIR,  
    DEPARTMENT  OF  DEFENSE  TASK  FORCE  ON  MENTAL  HEALTH

    Dr. MacDermid. Thank you. The full report of the Task Force 
on Mental Health is being submitted for the record and I thank 
you very much for inviting both of us to speak today. I'm 
honored to be here and I'm honored to be among the very 
distinguished speakers that you will hear from today.
    The report presented an achievable vision for supporting 
the psychological health of military members and their 
families. The task force recommended building a culture of 
support for psychological health throughout DOD in order to 
combat stigma, shortages of staff and training, and procedural 
and policy barriers that were interfering with access to 
quality care.
    The task force also made recommendations aimed at ensuring 
a full continuum of excellent care for servicemembers and their 
families. Because of specific gaps that were found during its 
investigations, the task force recommended increases in 
resources and staff and changes in staff allocations in order 
to address shortages that were impeding adequate care.
    Finally, the task force recommended that leadership be 
created and empowered to ensure consistent attention to and 
advocacy for the psychological health of military members and 
their families.
    I will now turn to Admiral Arthur.
    Admiral Arthur. Thank you.
    Sir, this is the report. It's titled ``An Achievable 
Vision'' and it's titled ``An Achievable Vision'' because we 
can get there.
    I would like to talk about the three pillars of mental 
health as concentrated on by this report: prevention, 
mitigation, and treatment. In the prevention, we focused on 
establishing a culture in the military Services that looks at 
mental health as part of an overall health policy, looking at 
mental health fitness with the same degree of concern that we 
have for physical fitness. Today we measure mile runs and 
pushups and pullups, but we don't really measure how 
psychologically fit or resilient people are to the very 
difficult stresses of military service. We feel that 
vulnerability can and should be assessed in our military 
members and that we accept military members, officers and 
enlisted, who already have significant issues of stress in 
their lives, that we can measure and mitigate those stresses 
that they come to us with.
    We can measure their vulnerability to stress, and we can do 
two things with those measures. One is if we know that someone 
is vulnerable we can hopefully design programs, which will 
increase their resilience. We know that some are more resilient 
than others, and the more resilient the leaders, the less post-
traumatic stress they have, and the men and women who serve 
them have.
    So first we can recognize vulnerability and try to mitigate 
it. Second, we can tell people who are extraordinarily 
vulnerable that, for example, it would be nice if you could be 
a jet mechanic, a perfectly good military occupational 
specialty, but not necessarily put them into the stressful 
situations that may permanently harm their psychological well-
being, such as walking down the streets of Fallujah breaking in 
doors. Those things can be for the more resilient.
    This can also apply to a national level. You can see from 
the earthquake in Oakland and Hurricane Katrina in New Orleans 
that those two areas of the country dealt very differently with 
the environmental trauma, and I think that there could be some 
lessons learned from those two catastrophes and others; what is 
it that makes a community resilient and another community not 
as resilient, and try for the next time to build them up.
    My last point on prevention is that the families are very 
significantly affected by military service. Military service is 
tough during the best of times, but in combat it is very 
stressful for the spouses and especially the children. 
Congressman Walter Jones tells the story of going to Camp 
Lejeune to a grade school, talking with the kids there and 
saying: Is your mom or dad in the Marine Corps? One child said: 
``Well, yes, my daddy is in Iraq, but he is not dead yet.'' To 
think of the impact on the families by that innocent statement 
really speaks to the fact that we must do everything we can to 
build up the families of our veterans.
    The second is mitigation. That is, to try to prevent the 
effects of combat, which is an absolutely abnormal state. 
Everyone who comes back from combat suffers post-traumatic 
stress because that is a normal reaction. We can mitigate this 
by embedding psychological professionals into our clinics, into 
our deploying medical support, so that when you have a 
psychological issue, a soldier, sailor, airman, or marine, does 
not have to go to someone else, to the hospital, and become 
labeled as going to seek psychiatric help. He or she can see 
someone in the battalion, in the company, who understands 
exactly what the mission of that company is and day-to-day is 
prepared to mitigate those effects.
    We need to screen and train our military leaders that 
physical fitness--that tactics of battle--are no less important 
than the psychological fitness of the men and women who go into 
combat, and that taking care of that psychological fitness is 
just as important as the maintenance that we would do on high-
priced aircraft, tanks, and Humvees.
    The last point I would like to make on mitigation is that 
we have many ``volunteers''--and I put that in quotes--
organizations, such as the key volunteers of the Marine Corps, 
the ombudsmen of the Navy, and there are other organizations of 
spouses and other concerned people who support the families. 
These are volunteers. They're unfunded. I think that these 
programs ought to be in some way formalized, funded, so that 
every family member has a uniform degree of support.
    The last pillar is treatment. It requires a recognition and 
a destigmatization of mental health issues when people come 
back from combat or even from non-combat, but extraordinarily 
stressful deployments. Our military service is like no other 
service, not like working third shift at Kmart. There are 
stresses that people need to recognize as normal and celebrate 
it when we can put someone back into service.
    I was in Operation Desert Storm and was with a medical unit 
who had a battalion commander who was diagnosed with combat 
stress and admitted to us as an inpatient in Saudi Arabia. In 2 
weeks he was returned to his battalion, in time to engage in 
ground combat evolution. That was a battalion commander 
returned to function by not taking him out of the field, but 
addressing the issues and it was General Krulak who did this in 
the field. He said: ``Everybody's stressed; take care of that 
battalion commander and put him back in place. We have 
recruited, trained, and equipped the right people; now support 
them.'' We did.
    Again, the embedding of psychological professionals is 
important so that you don't have to go somewhere else to get 
care. You're getting care essentially from your military 
family.
    Access to MTFs, the Veterans Administration (VA) community 
assets, and other ways of getting the treatment that you need 
when you need it and where you need it is very, very important. 
One of the recommendations in the task force report is to have 
recruit stations be access points for people who are reservists 
or people who get out of the military and just pass by a 
recruit station and say: I have a problem; I was in Operation 
Desert Storm, or I was in Iraq, and I've had these feelings, 
these paranoia, these thought streams; can you give me some 
help? Yes, they would have a book, they could make 
appointments; they could get you into the VA. I think that's a 
great access point.
    Last on treatment is the continuum from the field to the 
clinic to the hospital, with the family-centered care, to the 
VA and beyond, is extraordinarily important.
    Underscoring all of this, as Senator Boxer well said, is 
the funding issue. The funding must be risk-adjusted, 
population-based. That is, to know what type of funding, what 
type of personnel assets you have to have based on the 
requirement; and it must be sufficient and predictable.
    With that, let me turn it back over to Shelley.
    Dr. MacDermid. Thank you.
    The task force made 95 recommendations, almost all of which 
were endorsed by the Secretary of Defense, who submitted a 
detailed implementation plan to Congress in September 2007, 
several months in advance of its statutory deadline. I know 
that many dedicated individuals within DOD and the military 
Services have been working very hard to improve support for 
mental health and several of the recommendations already have 
been fully implemented. Many remaining recommendations are 
targeted for complete implementation by May 2008.
    You have many experts here today who can tell you about 
what is being done and what has been done. So all that I will 
do in my remaining remarks is to identify three areas where I 
am eager to hear about positive progress.
    The first issue I would like to address is TRICARE. The 
task force recommended several specific changes needed to 
ensure that the TRICARE system could provide adequate care for 
the psychological health of military members and their families 
who cannot receive their care at MTFs. Some of these changes 
have been made. For example, TRICARE Reserve Select has been 
simplified to be more accessible and efforts have been made to 
make it easier to find mental health providers.
    I'm aware of little progress, however, on some of the other 
recommended changes. Let me give you one example which pertains 
to intensive outpatient services, a highly utilized benefit in 
most health plans and a cost-effective treatment of choice for 
many patients with substance abuse or other serious 
psychological problems. 18 months ago the task force heard 
testimony from staff in the TRICARE Management Activity and 
representatives of the TRICARE contractors that cumbersome 
TRICARE rules resulted in intensive outpatient care not being 
covered under TRICARE. They asked for change. We made a 
recommendation to correct the deficiency.
    Yet little progress appears to have been made. These 
services are offered and heavily used in VA, available at many 
MTFs, and are a frequently utilized service in Medicaid and 
Medicare. Thus, military members and their families whose 
primary source of health care is the TRICARE system have no 
access to care that is available to the poor, the elderly, 
veterans, and their military brothers and sisters who are 
fortunate enough to receive care at MTFs. On its face, this 
seems quite inequitable.
    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-on of services to military 
members and family members who require care. The task force 
made several recommendations aimed at increasing the number of 
such providers and I think several efforts are underway in this 
area. I'm especially eager to learn about progress in the area 
of recruiting and retaining mental health professionals.
    The task force received numerous indications that it is 
difficult to get and keep highly qualified mental health 
professionals, especially when there are already shortages in 
the civilian community and DOD must compete with the VA and 
others for staff. But as the cumulative load of deployments on 
the force mounts there is no question that the need to support 
psychological health is only becoming more urgent. I hope that 
the importance of individuals who do that work is being 
recognized by very strong efforts to recruit and retain them.
    Also in the area of staffing, I'm 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; temporary staff 
already in place often could not be retained because it wasn't 
possible to give them timely information about whether their 
contract would be extended; hiring and processing procedures 
for new temporary staff took so long that the funds were gone 
before the person could begin work; critical GS positions lay 
empty for long periods even when a qualified and willing person 
had already been identified.
    These procedural problems were significant hurdles in the 
race to meet the needs of servicemembers and their families. 
I'm eager to hear how they have been addressed.
    While Congress has been helpful in allocating funds, I am 
eager to hear whether the right mix has been provided. For 
example, substantial funds have been allocated on a 
nonrecurring basis, which makes it difficult to address 
infrastructure issues and makes it difficult to hire the best 
staff.
    The task force report emphasized that the shortcomings we 
observed in the military mental health system were not caused 
by the protracted conflicts in which the United States is now 
engaged and are unlikely to disappear when the conflicts 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 learn how services for family members have 
been improved since the task force submitted its report. We 
made several specific recommendations in this area. For 
example, we wanted to be sure that parents or others caring for 
wounded or injured servicemembers could easily get access to 
installations, care managers, and other services. Because they 
have no official status within the military system, parents 
sometimes face barriers which systematically disadvantage young 
unmarried servicemembers.
    We also recommended that the substantial delays many 
children were experiencing in accessing care be addressed, and 
we recommended that inequities between families who were nearby 
and could receive treatment at MTFs and families who were far 
away and had to rely on TRICARE be eliminated. I'm eager to 
hear about progress in all of these areas.
    In conclusion, Mr. Chairman and distinguished members, I 
appreciate your sustained attention to these issues. I also 
very much appreciated the prompt and detailed plan submitted by 
the Secretary of Defense. But many weeks have elapsed and I 
know the strong sense of urgency which we all feel pales before 
the daily struggles that confront families dealing with 
depression, substance abuse, children's disorders, or post-
traumatic stress disorder (PTSD). I'm very much looking forward 
to the day the plan is fully implemented.
    That concludes my remarks and I thank you for your 
attention and turn it back to Admiral Arthur.
    Admiral Arthur. Sir, because a veteran is a complex 
organism and post-traumatic stress is not the only thing that 
affects them in combat--it is also TBI; they come home and add 
some alcohol to it, they have family strife--it's very 
difficult to tease apart what is a mental health issue and what 
are some of the other social issues. So I'd like to conclude 
our portion by talking about TBI, which I think is a very big 
issue in this combat arena.
    I would like you to understand the fundamentals of how it 
differs from TBI that we see in the United States. First is the 
mechanism. In the United States, and all over the world, we 
have traffic accidents, we have football injuries, we have 
domestic violence, and they are relatively low velocity 
injuries. Something strikes the person's head and the brain 
moves, the skull moves, and it causes a bouncing and you get an 
injury where the strike was and an injury on the other side, 
and it's a relatively low velocity injury.
    That is not what is being seen in Iraq in blast injuries. 
This is not a tenth of a second, but a microsecond insult to 
the brain. The brain and the skull do not move as a unit. There 
tends to be a jiggle effect, in other words. The brain is not a 
solid piece of tissue that has uniform density. It has many 
different structures within it that are different densities, 
and at the density gradients you get a shear effect.
    It's more global than just a single injury to one part of 
the brain, and that's why, because of that diffuse mechanism, 
you get many symptoms that are not well localized. They are not 
often predictable. They can be individual as each person is 
affected differently.
    One of the things that we asked for in DOD when I was head 
of the TBI Task Force was for an omnidirectional blast 
indicator, something that you could wear into combat, and you 
could put on vehicles. Now we ask people, what was your blast 
exposure? They will say: ``Well, I was 100 feet from a blast.'' 
We don't really know how far 100 feet is in combat. We don't 
know whether they were in a vehicle, outside of the vehicle, 
behind a wall, in front of the wall. We don't know what the 
insult was to the individual soldier, sailor, airman, or 
marine.
    So we've asked the blast industry to construct an 
omnidirectional indicator that we can use, that will allow us 
to tell what the exposure has been, correlate that with the 
symptomatology and with treatment efficacy, and even give the 
VA an ability to base compensation on actual environmental 
exposure.
    Senator Graham. Where is that at?
    Admiral Arthur. I don't know, sir. That would be something 
you would have to ask my Service colleagues now. Since I left 4 
months ago, I have not kept pace with where that is.
    We also would like a baseline cognitive test. Football 
players, soccer players, already have that. If we had a 
baseline cognitive test going into combat or even coming into 
the Service, we could in the field assess an individual's 
exposure and the resultant cognitive effect and have some idea 
on the extent of their injury.
    When I had my TBI 2\1/2\ years ago, the psychologist gave 
me a whole battery of tests, and--in the air he drew a line--he 
said: ``But you're normal; you are here on the battery of 
tests, you score very high.'' I said: ``I know, but I did not 
start there; I started at some other level.''
    I think you know of General Manny and his struggles. I 
talked with him just this last week. A general officer, a judge 
in his local constituency down in Florida, did not start at a 
baseline average American intellect. So we have to have, I 
think, individual baseline testing.
    Third, we have to have recognition and treatment with 
research, and the recognition won't come from people presenting 
and saying: ``I have TBI.'' They will come with people saying: 
``You know, I can't remember things, I can't remember faces, I 
can't find my way out of Home Depot. My wife says that I forget 
her anniversary, and I'm blaming it on TBI.'' [Laughter.]
    ``I can't calculate how much to give on a tip at a 
restaurant. These are abnormal for me.'' So people will present 
with a myriad of symptoms that are not normal behavior for them 
and must be recognized and treated.
    Senator Boxer brought up the incidence of behavioral 
issues, of people going to non-judicial punishment because 
they've acted out of the context of what they had, or they're 
discharged for psychological issues existing prior to entry, 
when really it may be our failure to recognize TBI.
    Last is prevention. There are many things that we can do to 
prevent some of these TBIs. Let me give you one example of 
technology, and again I don't know where this one is either. 
But I was up in Massachusetts at Mass General in a 
collaboration between Harvard and MIT on these design issues of 
mitigation strategies. I talked to the head of the physics 
department at MIT and he said: We have this gel, which is very 
much like the gel you would use on a bicycle seat or something 
like that. You put your hand in it and it forms an impression. 
We can change the characteristic of that gel by adding 
electricity, and the amount of electricity we add to that gel 
will make it harder or softer. It will change the shape of the 
polymers, the molecules, and make it hard or soft. So it might 
be soft as a nice helmet liner when you have a motor vehicle 
accident and you're bouncing your head inside of a motor 
vehicle, but for a blast injury you may want it to have a 
different consistency, maybe a little harder, and the blast 
indicator could send a message to a microprocessor and provide 
an amount of electricity to that gel which would change its 
polymorphic configuration to be more blast-attenuating.
    So there are many things we could do, and the solution to 
TBI isn't just in the treatment or recognition; it's in the 
technology to prevent and mitigate.
    Senator Nelson, Senator Graham, thank you very much for 
this opportunity. It's a true honor to be able to come back and 
testify before you, and thank you for your attention that 
you're paying to this very important issue.
    [The prepared statement of Dr. MacDermid follows:]

         Prepared Statement by Shelley M. MacDermid, MBA, Ph.D

    Chairman Nelson, Senator Graham, distinguished members of the 
subcommittee, other distinguished Members of Congress, ladies and 
gentlemen, good morning. I am honored to be in the company of the 
distinguished speakers who are here to discuss with you today the 
mental health resources available to military members and their 
families. I completed service several months ago as the co-chair of the 
Department of Defense Task Force on Mental Health, and I am very 
pleased to be here with my co-chair Admiral Arthur today.
    The full report of the Task Force on Mental Health is being 
submitted for the record. The report presented an achievable vision for 
supporting the psychological health of military members and their 
families. The task force recommended building a culture of support for 
psychological health throughout DOD in order to combat stigma, 
shortages in staff and training, and procedural and policy barriers 
that were interfering with access to quality care. The task force also 
made recommendations aimed at ensuring a full continuum of excellent 
care for servicemembers and their families, because of significant gaps 
that were found during its investigations. Third, the task force 
recommended increases in resources and staff, and changes in staff 
allocations in order to address shortages that were impeding adequate 
care. Finally, the task force recommended that leadership be created 
and empowered to ensure consistent attention to and advocacy for the 
psychological health of military members and their families.
    The task force made 95 recommendations, almost all of which were 
endorsed by the Secretary of Defense, who submitted a detailed 
implementation plan to Congress in September 2007, several months ahead 
of its statutory deadline. I know that many dedicated individuals 
within DOD and the military services have been working very hard to 
improve supports for mental health, and several of the recommendations 
already have been fully implemented. Many remaining recommendations are 
targeted for complete implementation by May 2008, a few short weeks 
from now. You have many experts here today who can tell you about what 
is being and has been done, so all that I will do in my remaining 
remarks is to identify three areas where I am eager to hear about 
positive progress.
    The first issue I would like to address is TRICARE. The task force 
recommended several specific changes needed to ensure that the TRICARE 
system could provide adequate care for the psychological health of 
military members and their families who cannot receive their care at 
military treatment facilities (MTFs). Some of these changes have been 
made, For example, TRICARE Reserve Select has been simplified to be 
more accessible, and efforts have been made to make it easier to find 
mental health providers. I am aware of little progress, however, on 
many of the other recommended changes.
    Let me give you one example, which pertains to intensive outpatient 
services, a highly utilized benefit in most health plans, and a cost-
effective treatment of choice for many patients with substance abuse or 
other serious psychological problems. Eighteen months ago the task 
force heard public testimony from staff in the TRICARE Management 
Activity and representatives of the TRICARE contractors that cumbersome 
TRICARE rules resulted in intensive outpatient care NOT being covered 
under TRICARE. They asked us for change. We made a recommendation to 
immediately correct this deficiency, yet little progress appears to 
have been made. These services are offered and used heavily in VA, 
available at many MTFs, and are a frequently utilized service in 
Medicaid and Medicare. Thus, military members and their families whose 
primary source of health care is the TRICARE system have no access to 
care that is available to the poor, the elderly, veterans, and their 
military brothers and sisters who are fortunate enough to receive care 
at MTFs. On its face, this seems quite inequitable.
    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 
family members who require care. The task force made several 
recommendations aimed at increasing the number of such providers within 
the military, and I think several efforts are underway in this area.
    I am especially eager to learn about progress in the area of 
recruiting and retaining mental health professionals. The task force 
received numerous indications that it is difficult to get and keep 
highly qualified mental health professionals, especially when there are 
already shortages in the civilian community and DOD must compete with 
the Department of Veterans' Affairs and others for staff. But as the 
cumulative load of deployments on the force mounts, there is no 
question that the need to support psychological health is only becoming 
more urgent. I hope that the importance of the individuals who do that 
work is being recognized by very strong efforts to recruit and retain 
them.
    Also in the area of staffing, I am eager to here 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. Temporary staff already in place often 
could not be retained because it was impossible to give them timely 
information about whether their contract would be extended. Hiring and 
processing procedures for new temporary staff took so long that the 
funds were gone before the person could begin work. Critical GS 
positions lay empty for long periods even when a qualified and willing 
person had already been identified. These procedural problems were 
significant hurdles in the race to meet the needs of servicemembers and 
their families--I am eager to hear how they have been addressed.
    While Congress has been helpful in allocating funds, I am eager to 
hear whether the right mix has been provided. For example, substantial 
funds have been allocated on a non-recurring basis, which makes it 
difficult to address infrastructure issues, and makes it difficult to 
hire the best staff. The task force report emphasized that the 
shortcomings we observed in the military mental health system were not 
caused by the protracted conflicts in which the United States is now 
engaged, and are unlikely to disappear when the conflicts end. Non-
recurring 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 learn how services for family members have been improved since 
the task force submitted its report. We made several specific 
recommendations in this area. For example, we wanted to be sure that 
parents or others caring for wounded or injured servicemembers could 
easily get access to installations, care managers, and other services. 
Because they have no official status as family members within military 
systems, parents sometimes faced barriers which systematically 
disadvantaged young unmarried servicemembers. 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 could receive treatment at MTFs 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, Mr. Chairman and distinguished members, I appreciate 
your sustained attention to these issues. I also very much appreciated 
the prompt and detailed plan 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 families dealing 
with depression, substance abuse, children's disorders, or post-
traumatic stress disorder. I am very much looking forward to the day 
the plan is fully implemented. That concludes my remarks, and I thank 
you for your attention.

    [The Report of the Department of Defense Task Force on 
Mental Health dated June 2007 follows:]

[GRAPHIC] [TIFF OMITTED] T2634.001

[GRAPHIC] [TIFF OMITTED] T2634.002

[GRAPHIC] [TIFF OMITTED] T2634.003

[GRAPHIC] [TIFF OMITTED] T2634.004

[GRAPHIC] [TIFF OMITTED] T2634.005

[GRAPHIC] [TIFF OMITTED] T2634.006

[GRAPHIC] [TIFF OMITTED] T2634.007

[GRAPHIC] [TIFF OMITTED] T2634.008

[GRAPHIC] [TIFF OMITTED] T2634.009

[GRAPHIC] [TIFF OMITTED] T2634.010

[GRAPHIC] [TIFF OMITTED] T2634.011

[GRAPHIC] [TIFF OMITTED] T2634.012

[GRAPHIC] [TIFF OMITTED] T2634.013

[GRAPHIC] [TIFF OMITTED] T2634.014

[GRAPHIC] [TIFF OMITTED] T2634.015

[GRAPHIC] [TIFF OMITTED] T2634.016

[GRAPHIC] [TIFF OMITTED] T2634.017

[GRAPHIC] [TIFF OMITTED] T2634.018

[GRAPHIC] [TIFF OMITTED] T2634.019

[GRAPHIC] [TIFF OMITTED] T2634.020

[GRAPHIC] [TIFF OMITTED] T2634.021

[GRAPHIC] [TIFF OMITTED] T2634.022

[GRAPHIC] [TIFF OMITTED] T2634.023

[GRAPHIC] [TIFF OMITTED] T2634.024

[GRAPHIC] [TIFF OMITTED] T2634.025

[GRAPHIC] [TIFF OMITTED] T2634.026

[GRAPHIC] [TIFF OMITTED] T2634.027

[GRAPHIC] [TIFF OMITTED] T2634.028

[GRAPHIC] [TIFF OMITTED] T2634.029

[GRAPHIC] [TIFF OMITTED] T2634.030

[GRAPHIC] [TIFF OMITTED] T2634.031

[GRAPHIC] [TIFF OMITTED] T2634.032

[GRAPHIC] [TIFF OMITTED] T2634.033

[GRAPHIC] [TIFF OMITTED] T2634.034

[GRAPHIC] [TIFF OMITTED] T2634.035

[GRAPHIC] [TIFF OMITTED] T2634.036

[GRAPHIC] [TIFF OMITTED] T2634.037

[GRAPHIC] [TIFF OMITTED] T2634.038

[GRAPHIC] [TIFF OMITTED] T2634.039

[GRAPHIC] [TIFF OMITTED] T2634.040

[GRAPHIC] [TIFF OMITTED] T2634.041

[GRAPHIC] [TIFF OMITTED] T2634.042

[GRAPHIC] [TIFF OMITTED] T2634.043

[GRAPHIC] [TIFF OMITTED] T2634.044

[GRAPHIC] [TIFF OMITTED] T2634.045

[GRAPHIC] [TIFF OMITTED] T2634.046

[GRAPHIC] [TIFF OMITTED] T2634.047

[GRAPHIC] [TIFF OMITTED] T2634.048

[GRAPHIC] [TIFF OMITTED] T2634.049

[GRAPHIC] [TIFF OMITTED] T2634.050

[GRAPHIC] [TIFF OMITTED] T2634.051

[GRAPHIC] [TIFF OMITTED] T2634.052

[GRAPHIC] [TIFF OMITTED] T2634.053

[GRAPHIC] [TIFF OMITTED] T2634.054

[GRAPHIC] [TIFF OMITTED] T2634.055

[GRAPHIC] [TIFF OMITTED] T2634.056

[GRAPHIC] [TIFF OMITTED] T2634.057

[GRAPHIC] [TIFF OMITTED] T2634.058

[GRAPHIC] [TIFF OMITTED] T2634.059

[GRAPHIC] [TIFF OMITTED] T2634.060

[GRAPHIC] [TIFF OMITTED] T2634.061

[GRAPHIC] [TIFF OMITTED] T2634.062

[GRAPHIC] [TIFF OMITTED] T2634.063

[GRAPHIC] [TIFF OMITTED] T2634.064

[GRAPHIC] [TIFF OMITTED] T2634.065

[GRAPHIC] [TIFF OMITTED] T2634.066

[GRAPHIC] [TIFF OMITTED] T2634.067

[GRAPHIC] [TIFF OMITTED] T2634.068

[GRAPHIC] [TIFF OMITTED] T2634.069

[GRAPHIC] [TIFF OMITTED] T2634.070

[GRAPHIC] [TIFF OMITTED] T2634.071

[GRAPHIC] [TIFF OMITTED] T2634.072

[GRAPHIC] [TIFF OMITTED] T2634.073

[GRAPHIC] [TIFF OMITTED] T2634.074

[GRAPHIC] [TIFF OMITTED] T2634.075

[GRAPHIC] [TIFF OMITTED] T2634.076

[GRAPHIC] [TIFF OMITTED] T2634.077

[GRAPHIC] [TIFF OMITTED] T2634.078

[GRAPHIC] [TIFF OMITTED] T2634.079

[GRAPHIC] [TIFF OMITTED] T2634.080

[GRAPHIC] [TIFF OMITTED] T2634.081

[GRAPHIC] [TIFF OMITTED] T2634.082

[GRAPHIC] [TIFF OMITTED] T2634.083

[GRAPHIC] [TIFF OMITTED] T2634.084

[GRAPHIC] [TIFF OMITTED] T2634.085

[GRAPHIC] [TIFF OMITTED] T2634.086

[GRAPHIC] [TIFF OMITTED] T2634.087

[GRAPHIC] [TIFF OMITTED] T2634.088

[GRAPHIC] [TIFF OMITTED] T2634.089

[GRAPHIC] [TIFF OMITTED] T2634.090

[GRAPHIC] [TIFF OMITTED] T2634.091

[GRAPHIC] [TIFF OMITTED] T2634.092

[GRAPHIC] [TIFF OMITTED] T2634.093

    Senator Ben Nelson. Thank you, Admiral. Thank you, Dr. 
MacDermid.
    Colonel Hoge?

 STATEMENT OF COL CHARLES W. HOGE, USA, DIRECTOR, DIVISION OF 
  PSYCHIATRY AND NEUROSCIENCE, WALTER REED ARMY INSTITUTE OF 
RESEARCH; ACCOMPANIED BY COL CARL A. CASTRO, USA, RESEARCH AREA 
    DIRECTOR, MILITARY OPERATIONAL MEDICINE RESEARCH PROGRAM

    Colonel Hoge. Senator Nelson, Senator Graham: I have a very 
brief statement for both Colonel Castro and myself regarding 
the MHAT assessments that we've conducted annually in Iraq, 
also called MHATs. So I may use that acronym.
    The MHAT missions were established by the Army Surgeon 
General at the request of the Commanding General, Multinational 
Force-Iraq and U.S. Central Command. They've been conducted 
annually in Iraq since the start of Operation Iraqi Freedom, 
and we've also conducted two assessments in Afghanistan in 2005 
and 2007. The MHATs are part of an ongoing scientific effort to 
understand the mental health impact of deployment to Iraq and 
Afghanistan and then utilize this knowledge to improve the care 
that we deliver to the servicemembers in the deployed 
environment and post-deployment.
    This effort is unparalleled compared with previous wars, 
where mental health issues really weren't addressed until years 
and sometimes decades after servicemembers came home.
    The MHATs have maintained a consistent focus on soldiers 
and brigade combat teams or, in the case of Marine units, 
regimental combat teams. We've looked at both Active and 
National Guard units and units that have directly supported 
those brigade combat teams. The in-theater MHAT assessments 
have utilized the same methodology that we've utilized in some 
of our studies post-deployment that we published in the New 
England Journal of Medicine and other top-tier journals.
    The results of these investigations have shown that 15 to 
20 percent of combat troops deployed to Iraq experience 
significant symptoms of acute stress, PTSD, or depression, and 
15 to 20 percent of married servicemembers experience serious 
marital concerns. The MHATs have shown that longer deployments, 
multiple deployments, greater time away from the base camps, 
and combat frequency and intensity all contributed to higher 
rates of mental health problems.
    The most recent MHAT V report is in the process of being 
released, but one of the key findings concerns the cumulative 
effects of deployment, because this was the first time we were 
able to look at servicemembers who were on their third rotation 
to Iraq, compared with two rotations or their first rotation. 
What we found was that mental health problems rose with each 
cumulative deployment, reaching nearly 30 percent among those 
soldiers on their third deployment to Iraq.
    The MHAT V effort also showed that soldiers deployed to 
Afghanistan are now experiencing levels of combat exposure and 
mental health rates equivalent to levels in Iraq and 
substantially higher than they were experiencing in 2005 during 
our last assessment.
    The data from the MHAT missions have led to a number of 
important policy changes. Most importantly, the findings have 
led to revised doctrine and combat stress control procedures 
that we use in the theater, an improved training and 
distribution of behavioral health personnel. They've assured 
that there's sufficient mental health personnel deployed in 
theater and are providing support to soldiers at remote 
locations.
    The MHATs have demonstrated the critical role of strong 
leadership in maintaining the mental health of combat units, 
and it's led to the development and testing of new 
interventions, such as the training program called Battlemind, 
which is now being implemented Army-wide.
    Thank you very much for your continued interest in our 
research and your support for our servicemembers. We look 
forward to answering your questions.
    [The prepared statement of Colonel Hoge follows:]

             Prepared Statement by COL Charles W. Hoge, USA

    Chairman Nelson and distinguished members of the committee, thank 
you for the opportunity to discuss the Army's Mental Health Advisory 
Team (MHAT) assessments. I am Colonel Charles W. Hoge, M.D., Director 
of Psychiatric Research at Walter Reed Army Institute of Research. 
Accompanying me today is Colonel Carl A. Castro, who is Director of the 
Military Operational Medicine Research Program, Medical Research and 
Materiel Command. We have both participated in and supervised elements 
of all five of the MHATs.
    The MHAT missions were established by the Army Surgeon General at 
the request of the Commanding General, Multinational Force-Iraq, and 
U.S. Central Command. The MHATs have been conducted annually in Iraq 
since the start of Operation Iraqi Freedom and twice in Afghanistan in 
2005 and 2007. The mission of the MHATs has been to assess the mental 
health and well-being of deployed forces, examine the delivery of 
behavioral health care in theater, and provide recommendations for 
sustained and improved mental health services to theater commanders. 
Some of the MHATs have also included assessments of morale, the effect 
of multiple deployments, the status of training in behavioral health, 
and battlefield ethics.
    The MHATs are not representative of all soldiers deployed 
throughout Iraq or Afghanistan, but have maintained a consistent focus 
on soldiers in brigade combat teams (BCTs), to include Active and 
National Guard BCTs, as well as units that directly support these BCTs. 
Marine Regimental Combat Teams were studied 2 years ago. The assessment 
methods have included surveys of soldiers, focus group interviews, and 
surveys of behavioral health providers, unit chaplains, and primary 
care professionals.
    The results of these investigations have shown that rates of mental 
health have remained consistent from year to year among soldiers in 
Iraq; 15-20 percent of combat troops deployed to Iraq experience 
significant symptoms of acute stress, post-traumatic stress disorder 
(PTSD), or depression, and 15-20 percent of married servicemembers 
experience serious marital concerns. The MHATs have shown that longer 
deployments, multiple deployments, greater time away from the base 
camps, and combat frequency and intensity all contribute to higher 
rates of PTSD, depression, and marital problems. The full report on the 
findings of MHAT V will be released soon. However the initial review 
shows that rates of mental health problems rose significantly with each 
deployment, reaching nearly 30 percent among soldiers on their third 
deployment to Iraq. The 2007 effort also showed that soldiers in 
brigade combat teams deployed to Afghanistan are now experiencing 
levels of combat exposure equivalent to levels in Iraq, and that mental 
health rates are now comparable between Iraq and Afghanistan. Suicide 
rates have increased compared with baseline rates prior to Operation 
Iraqi Freedom. The data collected from the MHAT missions have also been 
compared with data obtained in the post-deployment period. These 
studies have shown that 12 months is insufficient to reset the mental 
health of soldiers, and that rates of mental health, particularly PTSD, 
remain elevated and even increase somewhat during the first 12 months 
after return from deployment.
    The last two MHAT missions have shown that combat experiences, such 
as losing a team member, and mental health problems are associated with 
approximately a two-fold elevated risk of reporting ethical 
mistreatment of non-combatants, such as damaging Iraqi property when it 
was not necessary or hitting or kicking an Iraqi non-combatant when it 
was not necessary. All of the MHATs have shown that good unit 
leadership is vital in sustaining mental health and well-being among 
combat troops, as well as reducing the likelihood of ethical 
mistreatment of non-combatants.
    The data from all the MHAT missions have led to a number of 
important policy changes. The data have been used to improve the 
training and distribution of behavioral health personnel in theater. 
They have assured that sufficient mental health personnel (credentialed 
providers and mental health technicians) are deployed in theater and 
are providing support to soldiers at remote locations. The MHAT 
findings were the impetus for revising the Combat and Operational 
Stress Control doctrine and training that behavioral health personnel 
receive. All behavioral health professionals deploying to theater are 
now mandated to take the new Army Medical Department Combat and 
Operational Stress Control Course. The MHAT assessments have also led 
to the implementation of new Army-wide mental health training, called 
Battlemind, for all soldiers and leaders, as well as improved training 
in battlefield ethics and suicide prevention. When the findings of the 
most recent MHAT are released, we will further refine our policies to 
meet the mental health needs of soldiers.
    Thank you very much for your continued interest in our research and 
your continued support for our servicemembers. We look forward to 
answering your questions.

    Senator Ben Nelson. Colonel Castro, do you have anything to 
add?
    Colonel Casto. No, I do not, sir.
    Senator Ben Nelson. Thank you very much for your testimony 
here today.
    I'm going to ask a question about what we can do for mental 
health care in the rural areas that are not in close proximity 
to a base or may not even have a large city within a certain 
distance. Dr. MacDermid, did you find any protocols in place or 
that could be put in place to ensure that you could still have 
adequate mental health services? I'm thinking primarily of 
national guardsmen and reservists, who are by comparison 
stranded in other areas, not necessarily close to a base or 
other location for an operation.
    Dr. MacDermid. Thank you for your question. We made a 
number of recommendations about ways to reach National Guard 
and Reserve folks, one of which was to simply increase the 
infrastructure within those organizations, because, for 
example, in each State there's not necessarily someone who has 
the responsibility to oversee and monitor and take action about 
psychological health issues.
    I think it is also the case that the TRICARE system has to 
be functional for Guard and Reserve members, and the VA has 
also been increasing resources in that area. I think it doesn't 
make sense in my mind to try to create something new when there 
are services already out there, but it's not clear that those 
services are working effectively. We recognized, for example, 
that we were told on many installations that even in those 
areas the TRICARE network records did not appear to be very 
accurate, and that is likely to be similar and even more 
problematic in areas where there is not an installation.
    Senator Ben Nelson. Did you encounter anything having to do 
with confidentiality, or were you able to look at all of the 
records?
    Dr. MacDermid. We did not look at medical records, sir. 
That was not something that we had the authority to do. Our 
conversations were with leaders of health care facilities, with 
patients, and with community providers.
    Admiral Arthur. Senator, may I add. There's an even more 
vulnerable population. That's the people who come back and are 
no longer affiliated with the Active, Reserve, or Guard 
component, those people who've gotten out of the Service. They 
go back to work and back in their community, where people 
really don't understand what they have been through and don't 
have any context for some of their mental health issues.
    One of the programs that I think is very successful is the 
Marine for Life program, where the marines have people all over 
the country who are retired or who have just done one or two 
tours in the Marine Corps and feel it is their obligation, 
their responsibility, to take care of marines who have gotten 
out. I think that population really is the unseen population 
for us.
    Senator Ben Nelson. In terms of the family that would be 
experiencing this vicariously, what have your thoughts been 
about how we might deal with the family members, particularly 
if they're in a stranded location far away from a base or 
another provider?
    Dr. MacDermid. There are substantial shortages in the 
civilian community for a variety of medical specialties, and it 
is a problem. That's true for Active folks as well. When they 
have to go to communities to find specialists, they have 
trouble, too, which is one of the reasons why we put as much 
emphasis as we did on uniformed providers.
    I think in many cases the solutions for families are the 
same as the solutions for reaching National Guard and Reserve 
members, because it's families that are out there in 
communities and that is where they have to get most of their 
care, and there's a lot we could still do to try to make sure 
those communities are well prepared to receive them.
    These policy issues we identify that have the effect of 
impeding access to care I think might be low-hanging fruit. 
There probably are things I don't understand. I'm sure that 
there are. But on their face, when it's a matter of changing a 
policy that looks to be a good target for something that might 
open up quite a bit of access fairly quickly; I'm happy to be 
told that I'm wrong about that, but I think it's certainly 
worth a look.
    Admiral Arthur. We also need to provide access for the 
families where they can receive the assistance, the social 
assistance, not just where it's convenient for us. One of the 
things we talked about in the report is even going down to 
school counselors and teachers to educate school counselors and 
teachers about the particular stresses of the military and 
allow them to assist the children right in their schools.
    So there are a lot of things that we can do, but we 
shouldn't make the families necessarily come to us when they 
have a problem. We should be accessible to them before they 
have a problem.
    Senator Ben Nelson. If you were to identify as a percentage 
of shortage, percentage shortage of the providers, the care 
providers that would be available to help, do you think we're 
50 percent below where we should be, or are we more than that, 
or do you have an opinion?
    Dr. MacDermid. This is Admiral Arthur's favorite question, 
sir.
    Admiral Arthur. I mentioned the population-based risk-
adjusted model, and that speaks to assessing what the risks 
are. The risk for a deploying combat battalion might be more 
than for a non-deploying motor transportation battalion, for 
example. So I think we have to assess what the risks are, the 
number of people, and then provide an appropriate number of 
resources and the appropriate kinds of personnel. It is not 
just psychiatrists. We tend to focus on the physician issues, 
but it's really the sociologists, the social workers, the 
psychologist, the mental health practice nurses--anyone who can 
be involved, at the lowest level possible.
    Senator Ben Nelson. So do you have an opinion about how 
adequate we are in terms of numbers? Is it say 50 percent, 40 
percent? Any estimate of that sort?
    Admiral Arthur. I would like to leave that up to my Service 
colleagues, because I think they've done a lot more assessments 
recently, and I actually don't know where we are in the full 
contracting and the supplying of people for battalion support, 
particularly in the field. So if I may I would leave that for 
my Active Duty colleagues.
    Senator Ben Nelson. There have been a lot of questions 
raised about the length of deployment and then how much time 
should lapse between deployment number one and deployment 
number two; in other words, how much time back home should 
there be. I think we're looking at trying to make the number 
the same or something similar to that. I think the longer the 
time at home that a soldier has or an airman or a marine 
probably the better. But I don't know that statistically I can 
prove that.
    It seems self-evident that that time back would be very 
helpful and be required. But is that an assumption on our part 
that is founded on anything that you've been able to determine 
in your studies?
    Admiral Arthur. I think that's a very valid conclusion. It 
also matters greatly where you are in the combat arena. If 
you're right up front in combat operations day after day, or 
you're in convoys day after day with the threat of adverse 
combat action, then you're much more stressed and need more 
time back at home.
    If you're in a rear echelon or a headquarters element in 
some place like Bahrain or other rear locations, then you may 
not need as much rest.
    The greatest concern I have are for the Special Forces 
people in the Army, the SEALS in the Navy, and the recon people 
in the Marine Corps, who have an incredibly high operational 
tempo and a very high degree of mental health issues in 
themselves and their families when they return.
    Colonel Hoge. Sir, if I may answer that question as well. 
We have good data that after a 12-month deployment, 12 months 
back home is not sufficient to reset. We actually see rates of 
mental health concerns rise slightly during that 12-month 
period. They certainly don't go down.
    Senator Ben Nelson. Would it be fair to say, though, that 
the shorter the time in between, it wouldn't be better; it 
would be worse? In other words, is there an optimum time, or is 
each case an individual case? Or have you been able to 
establish what would be an optimal timeframe in between?
    Colonel Castro. Sir, it is important to also keep in mind 
the length of deployment. For example, the Army deploys much 
longer and probably then it would require much longer in-
between deployments. For the Marine Corps, which deploys the 
shorter amount of time, 7 months, then their recovery time 
probably doesn't need to be as long. But as Admiral Arthur 
points out, it's very critical to look at what exactly is 
happening to the servicemember, the warrior, while they're over 
there.
    One of the key findings from the MHAT IV is that those 
soldiers and marines who are in day-to-day combat operations 
day-in and day-out, their mental health rates were two to three 
times higher than the overall force. So it's very important to 
look at all of the variables that we know are related to and 
impacting on the psychological health of the servicemember. But 
we certainly know, as Colonel Hoge points out, a year is not 
long enough if you're deployed for a year or longer. But 
perhaps if you deployed shorter, it's not as long.
    But the bottom line is we don't know because our soldiers 
deploy so frequently we have never been able to give you an 
exact time.
    Senator Ben Nelson. That raises some obvious questions 
about the dwell time, as you say, depending upon whether you 
were forward deployed or where you were in the deployment. It's 
hard enough to try to get something that is uniform across the 
board for each branch the way it is. I imagine it gets a little 
byzantine if you try to make it a pattern or tailor it to each 
individual case.
    So 15 months may not be long enough. Do you have a 
recommendation just overall, a one-size-fits-all type of dwell-
time recommendation?
    Colonel Casto. One of the recommendations we made in the 
MHAT IV report was 18 to 24 months dwell time. But that was 
quite a controversial recommendation.
    Senator Ben Nelson. I imagine it was, yes.
    Senator Graham?
    Senator Graham. Thank you, sir. Mr. Chairman, thanks for 
having the hearing. This has been fascinating. When it seems on 
the money front you expand TRICARE to include mental health 
services available in the civilian community, that would be a 
great start. It seems we're going down that road.
    The investment in technology to understand the brain injury 
situation better--I am fascinated by some of the ideas out 
there and we will follow up and see where this monitoring 
device is at. I know I just want America to know we do spend a 
lot of money trying to find out what is the best equipment, 
what's the best way to prepare our folks for war, and it's 
always an ongoing endeavor.
    You said about 30 percent, I think, Colonel Hoge, of people 
who have gone back for the second or third time are having some 
mental health-related problems, is that right?
    Colonel Hoge. Yes, sir.
    Senator Graham. Is it affecting retention rates?
    Colonel Hoge. I can't answer that. I don't have access to 
that. I haven't looked at that particular outcome.
    Senator Graham. Is it affecting the ability to go back to 
duty? Are these incapacitating problems?
    Colonel Hoge. They aren't necessarily incapacitating to the 
point of not being able to do their duty. But that 30 percent 
rate is based on self-report survey data, where we ask a series 
of questions about what types of mental health problems the 
soldier is experiencing, and they have to report a substantial 
number of symptoms to meet that threshold. So it is not just a 
few symptoms. They have to report a fair number of symptoms.
    Senator Graham. I guess what I'm asking is what kind of 
impact does it have on retention? What kind of impact does it 
have on being able to go back to duty? If you could maybe 
explore that a little bit and get back with us.
    Colonel Hoge. Yes, sir, I'd be happy to do that.
    [The information referred to follows:]

    The Army's retention database does not include any data that may 
indicate if a soldier has a mental health issue. Consequently, we do 
not have retention data that can be used to assess the impact of mental 
health problems. However, the Walter Reed Army Institute of Research 
(WRAIR) proactively approached this issue by looking at Post-Deployment 
Health Assessments (PDHA). Researchers from WRAIR conducted population-
based analyses of over 300,000 Army soldiers and marines who completed 
a PDHA between May 2003 and April 2004. Operation Iraqi Freedom (OIF) 
and Operation Enduring Freedom (OEF) deployers with a mental health 
problem who self-identified on the PDHA were over 30 percent more 
likely to leave military service within 1 year than OIF and OEF 
veterans who did not report a mental health problem on the PDHA. These 
findings have been published in the March 2006 edition of the Journal 
of the American Medical Association.

    Senator Graham. Civilian contractors--we have 130,000 folks 
over there. Has anybody looked at the civilian contracting 
force? I see some heads nod. To be asked later, I guess, in the 
next panel.
    We will do what money can do. We will try to grow the Army. 
I think that's one of the goals, is to grow the Army to make 
sure the rotation schedules are not so onerous.
    Admiral, you had something?
    Admiral Arthur. Sir, I'd like to make a comment about the 
money. We've talked about money and TRICARE and modifying the 
TRICARE benefit. I'd just like to put a plug in that the reason 
we have such a wonderful save rate or resuscitation rate of 
combat injuries and so much attention that can be paid to our 
veterans in the field is because we have maintained an Army, 
Navy, and Air Force medical system that has not only taken care 
of our servicemembers and their families, but has maintained a 
state of readiness over so many decades and is ready to do 
whatever the Nation calls on it, and that requires that the 
Services and their medical functions be properly funded to 
train and equip for their combat role as well as their normal 
health care role.
    Senator Graham. That's well said. I think some of the 
unsung heroes of this war are the men and women in the medical 
services. If you could make it through the door of a hospital 
in Iraq, they say you have about a 90 percent survival rate, 
which is phenomenal. But these injuries are solid. They have to 
be detected, having your buddies understand what to look for, 
having commanders be sensitive.
    What you're doing is good work for the country. War is a 
terrible thing. Just listening to this--my dad went off to 
World War II before I was born, but a lot of people went away 
for 4 years, never saw their family.
    Admiral Arthur. For the duration.
    Senator Graham. For the duration. So America's been through 
these tough times before. But this war is unique and we need to 
make sure that we're stepping up to the plate and providing all 
of the services possible, and retention and recruitment are 
amazingly good to me. The one thing I hear from these beds in 
hospitals when I go visit, like Senator Nelson, is the number 
one comment I get is: ``I want to go back to be with my 
buddies,'' which just astonishes me.
    So I think our force needs to be protected and nurtured. 
But we're blessed to have them. So thank you.
    Senator Ben Nelson. We certainly don't have to work that 
much harder on creating a team concept in the military, because 
that is the reaction that you pick up from a wounded warrior, a 
feeling of guilt that they're no longer able to be there with 
their comrades. If we can establish stronger mental health care 
and recognition of challenges at the time for prevention or 
intervention, it seems to me that we'll be doing what needs to 
be done.
    The suicide rate, is there any comment that any of you 
would like to make about what is an alarming suicide rate for 
our military personnel today?
    We can take that up with the next panel. But I'm also 
thinking perhaps from your standpoint you may have some 
thoughts about it from the reports that you've been involved 
with.
    Colonel Hoge. Yes, sir. We've looked at suicide rates in 
theater with every one of the MHATs and we have seen 
consistently for the last couple of years a higher rate than 
the expected baseline rate of suicides. I think the factors 
that generally drive suicides, there's an element of 
impulsivity. The soldier may, in an impulsive moment, make a 
decision that he wouldn't make when he's back home.
    Then a lot of times these things are precipitated by 
relationship problems that the soldier is having, that type of 
thing.
    Senator Ben Nelson. Any connection that you could draw 
between the length of deployment or the number of deployments 
or the short timeframe for dwell-time tied to suicide?
    Colonel Hoge. Sir, we haven't been able to make a direct 
link because suicides are still quite rare events. We can make 
that kind of link for overall mental health concerns, mental 
health problems. We know there's a relationship between mental 
health problems and suicide, and so we could make the link in 
that way. But we haven't been able to make it in a direct way.
    Senator Ben Nelson. Thank you very much. We appreciate what 
you're doing and thanks for being here today. [Pause.]
    Last, but certainly not least, on our third panel we 
welcome: Lieutenant General Eric Schoomaker, United States 
Army, Surgeon General of the Army and Commanding General, 
United States Army Medical Command; Vice Admiral Adam M. 
Robinson, Jr., United States Navy, Surgeon General of the Navy 
and Chief, Bureau of Medicine and Surgery; Lieutenant General 
James G. Roudebush, United States Air Force, Surgeon General of 
the Air Force, and a resident of Gearing, NE. We appreciate 
that connection, General. Also with her is Colonel Loree K. 
Sutton, United States Army, Special Assistant to the Assistant 
Secretary of Defense for Health Affairs on Psychological Health 
and TBI.
    Colonel Sutton, we congratulate you on your recent 
selection for promotion to brigadier general. Colonel Sutton is 
responsible for, among other things, implementation of the DOD 
Centers of Excellence for PTSD and TBI, which were mandated by 
the Wounded Warrior Act in the National Defense Authorization 
Act for Fiscal Year 2008.
    General Roudebush, I understand you received both your 
bachelor of medicine and doctor of medicine degrees from the 
University of Nebraska, another fine institution. So we have 
high expectations for you as a result of your stellar 
education.
    I know that, General Schoomaker, you have a brother living 
in Omaha, NE. As your brother, the other general, has told me 
on so many occasions, he's had more than one good steak in 
Omaha.
    So we look forward to hearing your assessments today of 
Service and DOD-wide plans to implement all of the findings and 
recommendations we've just heard about in great detail. So with 
that, General Schoomaker, the platform is yours.

 STATEMENT OF LTG ERIC B. SCHOOMAKER, USA, SURGEON GENERAL OF 
 THE UNITED STATES ARMY AND COMMANDING GENERAL, UNITED STATES 
                      ARMY MEDICAL COMMAND

    General Schoomaker. Chairman Nelson, Senator Graham, 
distinguished members of the Personnel Subcommittee: Thank you 
for this opportunity to discuss the Army's efforts to improve 
mental health care for soldiers and family members. Our Army 
Secretary, Pete Geren, our Chief of Staff of the Army, General 
George Casey, and the rest of Army leadership strongly support 
our efforts to improve the quality and access to mental health 
services and are also actively leading and remain engaged in 
our efforts to eliminate the stigma associated with seeking 
mental health care.
    The stigma is not just found in the military community. It 
is a national concern and should really be addressed in all 
communities.
    Our soldiers and our Army are doing amazing work in an Army 
that is demanding and has an extremely high operational tempo 
that you have heard spoken about by our previous two panels. 
But our soldiers and families are stressed. The global war on 
terror has placed increased operational demands on our military 
force. We know that repeated and extended deployments, as 
you've heard from the group that has performed our MHAT 
surveys, are experiencing increased stress, family 
difficulties, other psychological effects of war, such as 
depression, anxiety, withdrawal, and social isolation, and 
symptoms of post-traumatic stress, which, if not identified and 
treated promptly, may evolve into a more resistant 
psychological injury known as PTSD.
    The Army is absolutely committed to ensuring all soldiers 
and families are healthy both physically and psychologically. 
We have embraced the recommendations of the DOD Task Force on 
Mental Health and commend its authors. We are striving to 
provide the best mental health care for our soldiers and 
families. From the time a soldier enters the Army to the time 
that they depart, they are assessed, trained, and offered 
treatment for mental health care should they need it. This 
includes their families as well.
    Much of our efforts are concentrated on the activities 
associated with deployments, whether that's building resiliency 
through training and awareness prior to deployment or 
assessing, training, and treating while being deployed. We then 
follow soldiers very closely upon redeployment and several 
months after redeployment to ensure that the mental health 
needs are assessed and are being met.
    I'll only touch on a few of the many programs that we have 
that address the recommendations of the Task Force on Mental 
Health. I hope it shows that we are taking significant action 
in line with each of these six key objectives that are 
described in the task force report and in their testimony. Let 
me just expand on a few.
    As described by Colonels Hoge and Castro just a moment ago, 
the MHATs are a groundbreaking achievement. Never before has a 
military force studied the psychological strains of combat as 
intensely during the conflict. This work of our best and 
brightest minds is published year after year in the world's 
leading medical journals, like the New England Journal of 
Medicine and the Journal of the American Medical Association.
    I was pleased to hear Senator Boxer in her comments 
actually refer to one of those published studies. The authors 
of that study were sitting here in front of you a moment ago.
    Based on these assessments, we make changes, some 
immediately, to make our work and things work better. Sometimes 
it is not pleasant to hear what they found. Self-assessment is 
often not pleasant, but it is important we hear their 
unvarnished feedback so we can take the necessary steps to 
improve.
    The Army's unprecedented Leader Chain Teach was a powerful 
initiative started at the top of the Army by the Secretary and 
by the Chief, that simultaneously and powerfully addressed 
leadership culture and advocacy. The program has now trained 
over 800,000 soldiers in a massive education effort in the 
summer and fall of last year, and has now been incorporated 
into various soldier and leader training programs throughout 
the Army.
    Our Battlemind training program, which is the brand that we 
essentially call all of our resiliency and recognition and 
prevention programs in the Army, is an outgrowth directly of 
the MHAT assessments. It focuses on building fitness and 
resilience, which Admiral Arthur talked about. MHAT V findings 
indicate that Battlemind training is hitting the target and 
making soldiers less susceptible to combat stress.
    The Chief of Staff of the Army and Secretary of the Army 
have challenged us to incorporate all of this training and 
prevention and early recognition of the psychological 
consequences of deployment and family separation and combat. 
We're doing so throughout the career of every soldier and every 
leader. Excellent quality care is being addressed throughout 
through improved and expanded training courses, like the new 
combat operational stress control course which is now mandatory 
for all deployed behavioral mental health providers.
    Under my predecessor, Major General Gale Pollock, we have 
launched an initiative to hire over 300 behavioral health 
providers, of which we have now hired 149 in the United States. 
These will have direct and lasting impact on access.
    Finally, we've taken the recommendation of the task force 
to heart and have incorporated access and enhancing skills 
through primary care providers through a program called 
RESPECT-MIL. This program had a pilot at Fort Bragg and was so 
successful we have now expanded this to 15 other installations.
    I enumerate these initiatives, not to assert that we are 
100 percent or that we have a 100 percent solution here, but to 
make the point that the Army takes reasoned, focused action 
everywhere we see the opportunity to make a difference.
    I applaud Senator Boxer and Congress for standing up the 
Task Force on Mental Health in 2006. I applaud Congress in 2007 
for directing the establishment of the Centers for Excellence 
for Psychological Health and TBI being directed by my 
colleague, Dr. Loree Sutton. She is absolutely the right 
person, as I think you will see, to lead that organization and 
generate the kind of results that you, Congress, are seeking.
    This committee, along with the leaders of the DOD and the 
Army, is troubled by some of the negative trends that are 
related to the psychological health of our force. I'm very 
conscious of these reports. I know we will address some of 
these issues in these hearings. But I'm also heartened to see 
the terrific effort and the energy being applied to reverse 
these trends, and I am confident that with continued strong 
support from this committee and from Congress, we will provide 
the care and support that our warriors and their families 
deserve.
    Thank you again for holding this hearing. Thank you for the 
privilege of being here and responding to your questions.
    [The prepared statement of General Schoomaker follows:]

     Prepared Statement by LTG Eric B. Schoomaker, M.D., Ph.D., USA

    Chairman Nelson, Senator Graham, and distinguished members of the 
Personnel Subcommittee: thank you for the opportunity to discuss the 
Army's efforts in improving the mental health care for our soldiers and 
their family members. We are committed to getting this right and 
providing a level of care and support to our warriors and families that 
is equal to the quality of their service. Secretary Geren, General 
Casey, General Cody, and the rest of the Army leadership actively 
support our efforts in improving the access to and quality of mental 
health care services. They are also actively engaged in changing the 
culture and eliminating the stigma associated with seeking mental 
health care that not only our Army, but our Nation, experiences.
    We all recognize that the increased operational demand of our 
military force to fight the global war on terror has stressed our Army 
and our families. The Department of Defense (DOD) and the Army have 
made a concerted effort to proactively research the effects of this 
conflict through the DOD's Mental Health Task Force as well as the 
Mental Health Advisory Team's annual assessments. We know from this 
research that repeated and extended deployments have led to increased 
distress, family difficulties, and other psychological effects of war, 
such as symptoms of post-traumatic stress as well as post-traumatic 
stress disorder (PTSD). The Army is absolutely committed to ensuring 
all soldiers and their families are healthy, both physically and 
psychologically. We have made a concerted effort to mitigate risks and 
enhance mental health care services through various programs and 
initiatives which directly align with the DOD's Mental Health Task 
Force Report's four major recommendations: 1) Build a culture of 
support for psychological health; 2) Ensure a full continuum of 
excellent care for servicemembers and their families; 3) Provide 
sufficient resources and allocate them according to requirements; 4) 
Empower leadership.
    Enhancing, protecting, and improving the mental health for our 
soldiers and families starts from the time a soldier enters the Army, 
through various stages of their service, which includes getting ready 
for deployment, being deployed, and returning from deployment (often 
referred to as the Army Force Generation (ARFORGEN) cycle) as well as 
departure from Service.
    From the moment they start Basic Combat Training and at every 
successive assignment, soldiers and their families have access to a 
wide range of support services--the Installation's Army Community 
Service program, the Chaplain's network, Leadership and Family 
Readiness Groups, and of course health care at either the military 
facilities on post or the extensive TRICARE network of providers in the 
civilian community.
    During a soldier's service it is very likely that he or she can be 
called to deploy to a remote location of the world away from their 
families for various and sometimes extensive lengths of time. The Army 
has wisely recognized that building soldier and family resiliency to 
this stressor is key to maintaining their health and welfare. We 
developed ``Battlemind'' products to increase this resiliency and have 
several different training programs available for pre, during and post-
deployment. These programs are designed for soldiers and their 
families, including children as young as pre-school aged to teens, and 
they are distributed throughout the force. These programs are also 
available online anytime at www.behavioralhealth.army.mil.
    In a parallel effort to both raise awareness and reduce the stigma 
associated with mental health care, the Secretary of the Army and Chief 
of Staff of the Army initiated a leader chain teaching program to 
educate all soldiers and leaders about post-traumatic stress and signs 
and symptoms of concussive brain injury. This was intended to help us 
all recognize symptoms and encourage seeking treatment for these 
conditions. All soldiers were mandated to receive this training between 
July and October 2007, during which time we trained over 800,000 
soldiers. We are now institutionalizing this training within our Army 
education and training systems to continue to share the information 
with our new soldiers and leaders and to continue to emphasize that 
these signs and symptoms are a normal reaction to a stressful situation 
and it is absolutely acceptable to seek assistance to cope with these 
issues.
    During deployments, the Army found tremendous value in providing 
mental health treatment far forward in the operational areas. Our 
primary method of providing both preventive and required mental health 
treatment was through Combat Stress Control Teams. From the beginning 
of combat operations, there has been a robust Combat Stress Control 
presence in theater, with approximately 200 deployed behavioral health 
providers to Iraq alone. These combat stress control assets are heavily 
utilized to monitor and mitigate the effects of multiple and extended 
deployments. This is now a joint effort, with the Air Force assisting 
us in Iraq and Afghanistan and the Navy in Kuwait. The Army has also 
done unprecedented work in surveillance of soldiers, both in the combat 
theater and back home. The Mental Health Advisory Teams (MHATs) have 
gone to theater every fall since 2003 and surveyed soldiers, care 
providers, chaplains, and others. Their findings on epidemiology of 
symptoms, access to care, and stigma, have led to direct and immediate 
improvements in the way that we deliver care. The fifth MHAT report is 
due to be released soon.
    Upon redeployment, we continue to gather information about physical 
and psychological health symptoms on the Post-Deployment Health 
Assessment. Through our use of scientific studies to drive evidence-
based practices, such as the work of the MHATs, we developed the Post-
Deployment Health Reassessment to screen soldiers again during a later 
stage of the reintegration and post-redeployment period. Typically we 
find the signs and symptoms of post-traumatic stress are not fully 
apparent until after a 60-90 day readjustment period. In addition to 
these two event driven assessments, we have also implemented an annual 
screening tool, the Periodic Health Assessment, to further supplement 
our information.
    As expected, through our efforts to reduce stigma, raise awareness, 
and assess the health, to include mental health, of our soldiers, the 
need for behavioral health care is increasing. We do have gaps at some 
locations in meeting behavioral health care demand, but we are 
diligently working on solutions. The Army developed a program titled 
the Army Family Covenant, which formally commits us to improving access 
to high quality behavioral health for soldiers and families. Through 
Congressional Supplemental Funding targeted at caring for psychological 
health, we have been able to focus resources on hiring behavioral 
health providers. So far, we have been able to hire and put in place 
138 providers of about 340 identified requirements in a very 
competitive hiring environment. We are also pursuing the hire of an 
additional 40 substance abuse counselors and over 50 marriage and 
family therapists and have added about 90 social workers to our Warrior 
Transition Units (WTUs). My medical treatment facility commanders tell 
me that these hires are making a difference. We also have numerous 
long-term efforts to enhance recruitment and retention of uniformed 
behavioral health providers.
    This committee is familiar with RESPECT-MIL, a program designed to 
decrease stigma and improve access to care by providing behavioral 
health care in primary care settings. Because of the success of this 
program, we have initiated further efforts to train primary care 
providers and integrate behavioral health with primary care. The 
combination of ongoing education and improved access to care through 
numerous portals should again help encourage soldiers to seek care 
early.
    As part of the Army Medical Action Plan, we've developed a program 
for our warriors in transition called the Comprehensive Care Plan which 
is implemented across our 35 WTUs. The continuum of care that a soldier 
receives while in the WTU culminates in a care plan which integrates 
the more conventional medical and surgical interventions we administer 
to our wounded, ill, and injured warriors with efforts to optimize the 
soldiers' return to uniformed service or transition into successful 
life as a veteran. These insights were derived from our experiences 
over the last year and have now been institutionalized under the 
direction of my Assistant Surgeon General for Warrior Care and 
Transition, Brigadier General Mike Tucker. Soldiers in the WTUs are 
expected to be physically, mentally, socially, and spiritually 
strengthened. They are vocationally enabled and a life-care plan is 
established for each of them. This program sets the conditions for a 
successful transition to the VA or society.
    As the Army Surgeon General, I am compelled to remain extremely 
cognizant of the toll that this demand has placed on my health care 
providers. The Army's uniformed behavioral health providers are among 
the most highly deployed of any of our specialties. We use numerous 
recruitment and retention initiatives to encourage them to join and 
stay in the Army, including increased bonuses for psychologists and 
increased educational opportunities for social workers. As part of our 
detailed force management review being led by Major General Gale 
Pollock, we are assessing our manpower requirements and will recommend 
changes to the force structure as needed. We also developed Provider 
Resiliency Training to mitigate burn-out for not only our medical 
providers, but also for Army Chaplains and other specialists who are in 
the business of serving our soldiers and families.
    Although we have had many successes, there are also areas of 
concern. These include the increasing suicide rate, accidental deaths 
due to overdose, and public perceptions that soldiers are being 
inappropriately discharged from the Army for personality disorder when 
in fact they may actually have PTSD or mild traumatic brain injury 
(TBI).
    Unfortunately, Active Army suicide rates have increased over the 
last 7 years. Although the Active Army suicide rate is comparable to 
the demographically-adjusted civilian population rate, it is at an all-
time Army high and we are taking action to address it. Over the last 2 
years, there has been a concerted effort to improve suicide prevention. 
The Army G-1 is leading this effort with support from the medical and 
chaplain communities. The Army Medical Department's Army Suicide Event 
Report continues to offer surveillance and perform analysis. Recent 
analyses of suicides have resulted in concrete recommendations, which 
are currently being implemented, both in theater and on our 
installations.
    We have also chartered a General Officer Steering Committee to 
address suicide prevention. We will develop an action plan focused on 
five areas of emphasis: 1) develop life-coping skills; 2) maintain 
constant vigilance; 3) encourage help-seeking behaviors and reduce 
stigma; 4) maintain constant surveillance of behavioral health data, 
and 5) integrate and synchronize unit and community programs. We must 
develop actionable intelligence that provides our leaders an analysis 
of each suicide or attempted suicide that includes lessons learned, 
trend data, and potential factors to monitor. The intent is to modify 
leader behavior towards soldiers who are impacted by stressors and are 
at risk of harming themselves.
    On the issue of accidental overdoses, I recently chartered a multi-
disciplinary team of 17 dedicated professionals (psychologists, 
psychiatrists, physicians, nurses, unit commanders, first sergeants, 
and sergeants major) to analyze and develop risk mitigation strategies 
to reduce the number of accidental deaths and accidental drug overdoses 
within our WTUs. This team recommended 71 risk mitigation strategies to 
focus on improving identification, training, and monitoring systems. We 
have already adopted 26 of those recommendations. The Army will improve 
its capability to identify high-risk soldiers. We will also improve the 
training of our clinical staff, leaders and soldiers on risk reduction 
measures. We have changed policies and procedures to facilitate these 
risk-reduction measures and we will improve our capability to monitor 
and track accidental deaths, and accidental drug overdoses.
    Finally, there has been a perception that soldiers are being 
inappropriately discharged for personality disorder. All soldiers 
discharged for personality disorder are required to receive a mental 
status evaluation as per Army Regulation 635-200. A new policy was 
implemented in August 2007, requiring a review by the installation's 
behavioral health chief of all personality disorder discharge 
recommendations. We are implementing an update to this policy mandating 
PTSD and mild TBI screenings for any soldier being discharged for 
misconduct. This change in policy will mitigate the risk of discharging 
soldiers with a health condition that was acquired while serving their 
country.
    I greatly appreciate the privilege to command the United States 
Army Medical Command and the opportunity to report on the progress we 
have been making on providing quality mental health care to our 
soldiers and families. We appreciate your support as you interact with 
service men and women and their families in your states in 
communicating our strategic successes in this area. We also appreciate 
your help in influencing the mental health care providers in your areas 
to accept TRICARE patients which will expand our behavioral health care 
capacity.
    In closing, I'd like to share with you a quote from the DOD Mental 
Health Task Force Report: ``In the history of warfare, no other nation 
or its leadership has invested such an intensive or sophisticated 
effort across all echelons to support the psychological health of its 
military servicemembers and families as DOD has invested during the 
global war on terrorism.'' Thank you for holding this hearing and 
giving us the opportunity to share our accomplishments and to reaffirm 
our unyielding commitment to provide the best care to all our soldiers 
and their families.

    Senator Ben Nelson. We thank you, General.
    Admiral Robinson?

 STATEMENT OF VADM ADAM M. ROBINSON, JR., USN, SURGEON GENERAL 
  OF THE UNITED STATES NAVY AND CHIEF, BUREAU OF MEDICINE AND 
                            SURGERY

    Admiral Robinson. Good afternoon, Chairman Nelson. Thank 
you very much. 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, marines, and their families. As the provider 
of medical services for both the Navy and the Marine Corps, we 
have to be prepared to meet the needs of these similar and yet 
unique military populations. Navy medicine is continuously 
adapting to meet the short- and long-term psychological health 
needs of servicemembers and their families before, during, and 
after deployments.
    We are well aware of the fact that the number and length of 
deployments have the potential to impact the mental health of 
servicemembers, as well as the well-being of their families. 
The Navy and Marine Corps operational tempo in support of the 
global war on terror is unprecedented. We need to 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.
    To accomplish this, Navy medicine engages at several levels 
along the continuum of care, from commanding officers to small 
unit leaders to individual servicemembers, and of course with 
their families. Our goal is for psychological health services 
to be available to all who need them, when they need them.
    The same way physical conditioning prepares sailors and 
marines for the rigors and challenges of high tempo operational 
deployments, we are psychologically preparing servicemembers 
and their leaders to build resiliency, which will help manage 
the physical and psychological stresses of battle. We do this 
by preventive education programs introduced at every career 
training point, which help educate servicemembers on the 
importance of psychological health, in an effort to decrease 
the stigma often associated with being given a mental health 
diagnosis and receiving mental health services.
    Command involvement, together with dedicated and embedded 
stress management teams comprised of mental health providers 
and other professionals, are critical in helping sailors and 
marines become comfortable with the concept of building 
resiliency and decreasing stigma.
    Our experiences in previous conflicts, most notably 
Vietnam, suggest that delays in seeking mental health services 
increase the risk of developing mental illness and may 
exacerbate physiological symptoms.
    We are attacking the stigma in a variety of ways to ensure 
servicemembers receive full and timely treatment. This also is 
a critical component in our efforts to decrease the number of 
suicides among sailors and marines. Although suicide rates in 
the Navy and Marine Corps have not significantly fluctuated in 
recent years, our efforts to improve leadership's understanding 
and acceptance of the importance of treating mental health 
conditions is as important as preparing servicemembers to deal 
with the stresses of military life.
    Both the Navy and the Marine Corps have published leaders' 
guides for managing marines/sailors in distress. These products 
are available in various formats and are part of a greater 
effort to ensure front-line supervisors, including junior 
leaders, are able to identify when others in their unit may 
need help. The Marine Corps' Marine Operational Stress 
Surveillance and Training (MOSST) program 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.
    Navy medicine, in coordination with the line leaders in the 
Navy and the Marine Corps, is building on current training 
programs for leaders and our own caregivers. The curriculum 
focuses on combat stress identification and developing coping 
skills. Our goal is for members dealing with combat stress to 
be as comfortable in dealing with it as any other medical 
issue.
    For the servicemember, the predeployment health assessment 
is one way to become aware of potential psychological health 
needs and the health care services available. The symptoms of a 
mental health condition may not necessarily make an individual 
nondeployable, but this assessment helps emphasize the 
importance of psychological health as part of physical health 
and may decrease any delay in seeking treatment.
    Since the late 1990s, Navy medicine has embedded mental 
health professionals with operational components of the Navy 
and 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 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 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 cost.
    For the Marines, Navy medicine division psychiatrists 
stationed with the Marines developed Operational Stress Control 
and Readiness (OSCAR) teams 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 units, 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, and currently there is strong support for making these 
programs permanent and ensuring they are resourced with the 
right staff and funding.
    Before returning from the operational theater, sailors and 
marines are typically provided a series of briefings that 
familiarize them with issues related to combat stress, as well 
as how to manage their expectations after returning home.
    The post-deployment health assessment measures the health 
status of returning servicemembers and must be completed within 
30 days before or after redeployment. Navy and Marine Corps 
post-deployment health assessments are being accomplished in 
theater, during warrior transition, and at Navy Mobilization 
Processing Sites.
    Warrior transition, initiated during OIF and expanded each 
year, has now become an inherent part of the sailor's 
redeployment process home. Recognizing the hardest part of 
going to war is reconciling the experience inclusive of one's 
losses, mental health professionals and chaplains assist 
servicemembers to reflect, recall, and reconcile the enormity 
of their deployment before returning home. Warrior transition 
is now mandatory for all seabees, individual augmentees, and 
soon our SEALs.
    Since 2005 Navy medicine has been administering the post-
deployment health reassessment (PDHRA), as directed by Health 
Affairs. Implementing this program was a joint effort between 
the Navy 's Bureau of Medicine and Surgery, the Bureau of Navy 
Personnel, Headquarters Marine Corps, and the Deputy Commandant 
of the Marine Corps for Manpower and Reserve Affairs.
    The PDHRA extends the continuum of care, targeting 
servicemembers for screening at 3 to 6 months post-deployment. 
Navy medicine played a critical role from the program's 
inception to sustainment and coordinated implementation in line 
units. Beginning in 2006, Navy medicine established deployment 
health centers to serve as non-stigmatizing portals of entry in 
high fleet and Marine Corps concentration areas, and to augment 
primary care services offered at the 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 and their 
communities by deploying Special Psychiatric Rapid Intervention 
Response Teams (SPRIRT). These teams have been in existence 
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 solutions. 
Never before has the mental health and well-being of sailors 
and marines deployed to a war zone been as intensely studied. 
In order to establish comprehensive psychological health 
services throughout Navy and Marine Corps and to evaluate and 
provide recommendations on the needs of deployed sailors and 
marines, Navy medicine has developed the Behavioral Health 
Needs Assessment Survey (BHNAS).
    The BHNAS was adapted from the Army's series of MHAT 
surveys. Recently, Navy received funding for creation of a 
Navy-Marine Corps Center for the Study of Combat Stress, to be 
located at the Naval Medical Center in San Diego. This center 
is strategically located to work closely with our new 
comprehensive combat casualty center, our C-5, to better 
understand the impact upon Navy and Marine Corps families.
    I have commissioned the Center for Naval Analyses to 
conduct a wide-ranging study of combat and operational stress 
control, impact and attitudes.
    This survey, unlike the anonymous BHNAS, will target over 
15,000 randomly selected families and provide the most 
comprehensive determination as to the cumulative effect of the 
global war on terror.
    Reinforcing a culture which values psychological health 
will require an enduring commitment to the mental health needs 
of servicemembers, their families, and those who provide their 
care. It requires a commitment to ensuring psychological health 
services are available and accessible in the operational 
environment. Expanding surveillance and detection capabilities, 
equipping our providers with the best possible training, and 
minimizing the stigma associated with seeking treatment, we 
will underscore a culture that recognizes and embraces the 
value of enhancing our resilience to deal with the increasing 
stresses of military life and understands that in the end it 
may be less a question for medical science than a challenge for 
every leader to accept.
    Chairman Nelson, Navy medicine continues to rise to the 
challenge of meeting the psychological needs of our brave 
sailors and marines and their families. I thank you very much 
for your support to Navy medicine and look forward to answering 
your questions.
    [The prepared statement of Admiral Robinson follows:]

       Prepared Statement by VADM Adam M. Robinson, Jr., MC, USN

    Chairman Nelson, Ranking Member Graham, 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 Navy and the 
Marine Corps, we have to be prepared to meet the needs of these 
similar, and yet unique military populations. Sailors and marines often 
serve side-by-side, and they also serve under very different 
conditions--aboard ships, as boots on the ground, or as individual 
augmentees (IAs). As a result, these servicemembers face different 
physical and mental stressors and challenges during deployments. At the 
same time, their families may be also impacted by the unique stresses 
and demands of military life in slightly different ways. Navy Medicine 
is continuously adapting to meet the short- and long-term psychological 
health needs of servicemembers and their families before, during, and 
after deployments.
    We are well aware of the fact that the number and length of 
deployments have the potential to impact the mental health of 
servicemembers, as well as the well-being of their families. The Navy 
and Marine Corps operational tempo in support of the global war on 
terror is unprecedented. At the same time, Navy Medicine is playing an 
increasing role in Humanitarian Assistance and Disaster Relief 
missions. We need to remain vigilant of the potential long term impact 
our mission requirements--past, present, and future--will have on the 
physical and mental health of our sailors and marines.

                           CONTINUUM OF CARE

    Navy Medicine ensures a continuum of psychological health care is 
available to servicemembers throughout the deployment cycle--pre-
deployment, during deployment, and post-deployment. We are also making 
more mental health services available to eligible family members who 
may be affected by the psychological consequences of combat and 
deployment.
    To accomplish this continuum of care, Navy Medicine engages at 
several levels--from Commanding Officers, to small unit leaders, to 
individual servicemembers, and of course, with their families. Our goal 
is that necessary psychological health services will be available to 
all who need them--when they need them.

                    PREVENTION AND STIGMA REDUCTION

    The same way physical conditioning prepares sailors and marines for 
the rigors and challenges of high tempo operational deployments, we are 
working to psychologically prepare servicemembers and their leaders to 
build resiliency, which will help sailors and marines manage the 
physical and psychological stresses of battle and deployments. 
Preventive education programs introduced at each career training point 
help educate servicemembers on the importance of psychological health 
in an effort to decrease the stigma often associated with being given a 
mental health diagnosis and receiving psychiatric care.
    Command involvement, together with dedicated stress management 
teams comprised of health care providers and other professionals, are 
critical in helping sailors and marines become comfortable with the 
concept of building resiliency and seeking mental health support and 
care when necessary. 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. These delays can have a negative effect on the 
health of the servicemember, jeopardize a servicemember's career and 
permanently alter their family situation. That is why we are attacking 
the stigma associated with getting help for mental health and stress-
related conditions in a variety of ways to ensure servicemembers 
receive full and timely treatment--before deployment, in theater or 
after returning from deployment.
    The reduction of stigma to seeking mental health services is a 
critical component in our efforts to decrease the number of suicides 
among sailors and marines. Although suicide rates in the Navy and 
Marine Corps have not significantly fluctuated in recent years, our 
efforts to improve leadership's understanding and acceptance of the 
importance of treating psychiatric conditions is as important as 
preparing servicemembers to deal with the stresses of military life. 
Both the Navy and the Marine Corps have published Leaders Guides for 
Managing Marines/Sailors in Distress. These products available in 
various formats are part of a greater effort to ensure frontline 
supervisors, including junior leaders, are able to identify when others 
in their unit may need help.
    The Marine Corps created the Marine Operational Stress Surveillance 
and Training (MOSST) Program, which 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. Warrior resetting, the final phase of the 
program includes medical screenings and briefings about the prevention 
of drug and alcohol abuse, anger management, and handling financial 
difficulties.

                           BEFORE DEPLOYMENT

    Navy Medicine, in coordination with line leaders in the Navy and 
the Marine Corps, is building on current training programs for leaders 
and our own caregivers. The curriculum focuses on combat stress 
identification and developing coping skills. From the Navy's ``A'' 
Schools, to the Marine Corps Sergeant's course, and in officer 
indoctrination programs, we are ensuring that dealing with combat 
stress becomes as comfortable as dealing with any other medical issue.
    Before a unit deploys, there are several opportunities for sailors, 
marines, and their families to become acquainted with the types of 
resources available to help them cope with the stresses of deployment. 
Pre-deployment briefs include information about everything from legal 
services, pay fluctuations, chaplain services, as well as family 
support assets available in the military community organizations, and 
the medical facilities at the base. Representatives from each of these 
organizations detail when and how to access these services.
    For the servicemember, the Pre-Deployment Health Assessment is one 
way to become aware of potential psychological health needs and the 
health care services available. The symptoms of a mental health 
condition may not necessarily make an individual nondeployable, but 
this assessment helps emphasize the importance of psychological health 
as part of physical health and may decrease any delay in seeking 
treatment.
    Because IAs do not deploy as part of a larger unit, providing them 
with information presents unique challenges for Navy Medicine. There is 
an increasing number of sailors who are serving as IAs and the Navy 
Expeditionary Combat Readiness Center's IA Family Readiness Program has 
been a step in the right direction in reaching out to these 
servicemembers and their families. These centers have proven to be a 
critical asset in assessing the health of returning IAs, as well as in 
coordinating their transition for additional care at the Department of 
Veterans Affairs (VA), or out into the community. Reserve component and 
IAs also receive debriefings, medical assessments, and information on 
access to care as they mobilize and demobilize through the Navy 
Mobilization Processing Sites.

             DURING DEPLOYMENT--ABOARD SHIPS AND IN-THEATER

    In 1999, the Department of Defense directed the establishment of 
Combat Stress Operational Control programs within the services and the 
combatant commands to ensure appropriate management of combat and 
operational stress and to preserve mission effectiveness and war 
fighting capabilities.
    Before 1999, the Marines relied upon chaplains and a very small 
organic mental health footprint for prevention and early intervention 
of operational stress with more definitive care provided by the nearest 
Navy Medical Treatment Facilities. Hospital medical services were not 
always well coordinated with commands and during large-scale 
deployments medical battalions relied upon the use of mental health 
augmentees who had limited orientation and connections to the units 
they were called upon to support.
    Since the late 1990s Navy Medicine has embedded mental health 
professionals with operational components of the Navy and the Marine 
Corps. Since 1998, 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 (e.g., personality 
disorders), fell precipitously. Tight quarters, long work hours, and 
the fact that many of the staff may be away from home for the first 
time, present a situation where the stresses of ``daily'' Navy life 
aboard ship may prove detrimental to a sailor's ability to cope. Having 
a mental health professional who is easily accessible and going through 
many of the same challenges has increased operational and battle 
readiness aboard these floating platforms, saving lives as, well, 
hundreds of thousands of dollars in operational costs.
    For the marines, Navy Medicine division psychiatrists stationed 
with marines developed Operational Stress Control and Readiness (OSCAR) 
Teams which embed mental health professional teams 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 units, which 
improves cohesion and helps to minimize stigma. These teams provide 
education and consultation to commanders, entire units and individual 
marines. Battlefield debriefings address the topic of combat and 
operational stress and provide units and individual servicemembers with 
the skills to recognize and cope with the unique stressors of combat. 
Types of stress-related injuries are discussed, as well as how these 
injuries may manifest physically and mentally. The briefings also 
provide an opportunity to prevent combat stress situations from 
deteriorating into disabling conditions. Since the beginning of 
Operations Enduring Freedom and Iraqi Freedom (OEF/OIF), mental health 
related medical evacuations for marines have been significantly lower 
among units supported by OSCAR and currently, there is strong support 
for making these programs permanent and ensuring they are resourced 
with the right staff and funding.

                            AFTER DEPLOYMENT

    Before returning from the operational theater, sailors and marines 
are typically provided a series of briefings that familiarize them with 
issues related to combat stress, as well as how to manage their 
expectations about returning home. The presentations focus on whatever 
experiences the sailors and marines have encountered while in theater 
and how these may affect their daily lives post deployment. In 
addition, since 2001, Navy Medicine has been providing Post-Deployment 
Health Assessments (PDHAs) to measure the health status of returning 
servicemembers. This global screening must be completed within 30 days 
before or after redeployment. The criteria for a PDHA vary and depend 
on where an individual deployed and for how long. Current guidance 
states that a PDHA is required if the servicemember was involved in 
land based operations for 30 continuous days to overseas locations 
without a fixed Military Treatment Facility (MTF) or by Command 
decision based on health risk. Navy and Marine Corps PDHAs are being 
accomplished in theatre, during Warrior Transition, and at Navy 
Mobilization Processing Sites. Warrior Transition, initiated during OIF 
and expanded each year, has now become an inherent part of a sailor's 
redeployment process home. Recognizing that truly the hardest part of 
going to war is reconciling the experience--inclusive of one's losses--
mental health professionals and chaplains located in Kuwait assist 
servicemembers to reflect, recall and reconcile the enormity of their 
deployment before returning home. Warrior Transition accomplishes this 
by providing 3 days of facilitated decompressing; This preparation 
being the psychological equivalent of the ``long boat ride home''. 
Warrior Transition is now mandatory for all Seabees, IAs, and soon 
SEALs.
    Of the PDHAs completed in the Navy, there is an overall referral 
rate for additional health care services of 10 percent, with a 2 
percent referral rate for mental health issues. The rate is currently 
the same for Active or Reserve component (AC/RC) sailors. For the 
marines, the overall referral rate following the assessment is 16 
percent, with a mental health referral rate of 3 percent. This rate is 
also the same among Active and Reserve component marines.
    Since 2005, Navy Medicine has been administering the Post-
Deployment Health Reassessment (PDHRA) as directed by the Office of the 
Assistant Secretary of Defense for Health Affairs (ASD(HA)). 
Implementing this program was a joint effort between the Navy's Bureau 
of Medicine and Surgery (BUMED), the Bureau of Naval Personnel 
(BUPERS), Headquarters Marine Corps (Health Services), and the Deputy 
Commandant of the Marine Corps for Manpower and Reserve Affairs 
(USMC(M&RA)). The PDHRA extends the continuum of care, targeting 
servicemembers for screening at 3 to 6 months post-deployment.
    Currently, BUMED provides PDHRA program management and oversight 
and management of global war on terrorism funds. In addition, in 
consultation with ASD(HA), BUMED develops directives, procedures and 
protocols for supporting program implementation. Navy Medicine also 
serves as the liaison with the Navy and Marine Corps Public Health 
Center to provide technology and training for the electronic 
completion, storing and reporting of PDHRA data. Navy Medicine played a 
critical role from the program's inception to sustainment and 
coordinated implementation in line units.
    Beginning in 2006, Navy Medicine established Deployment Health 
Centers (DHCs) to serve as non-stigmatizing portals of entry in high 
fleet and Marine Corps concentration areas and to augment primary care 
services offered at the 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 Health Assessment and Reassessment. The centers 
provide treatment for other servicemembers as well. We now have 17 such 
clinics, up from 14 since last year. From 2006 through January 2008, 
DHCs had over 46,400 visits, 28 percent of which were for mental health 
issues.
    The Navy and Marine Corps are working to improve their PDHRA 
completion rates. To date, for sailors who have completed their PDHRAs, 
the follow-on medical care referral rate is 26 percent (AC 21 percent, 
RC 34 percent). Of the 26 percent of referrals, 6 percent are for 
mental health issues. For the Marines, of the PDHRAs completed, the 
overall Marine Corps referral rate is 28 percent (AC 24 percent, RC 48 
percent) with a 7 percent referral rate for mental health (AC 6 
percent, RC 9 percent).
    Since February 2007, Command Navy Reserve Forces assumed 
responsibility for overseeing implementation of the PDHRA program in 
the Navy Reserve component. With strong leadership support they are 
actively engaged in program execution, as reflected in their high 
compliance rate. For the AC, BUMED is still working with line 
leadership on the transition of program oversight and execution to the 
appropriate line organizations. In addition, we are advocating on 
behalf of a single integrated database and reporting system for 
identification, notification and documentation of compliance by 
eligible members.
    Since April 2007, USMC(M&RA) assumed management oversight for 
program execution for the marines. With BUMED support, USMC(M&RA) 
developed and implemented an aggressive plan to contract $4.5 million 
for mobile surge teams to complete 50,000 PDHRAs.

                    ACCESSING MENTAL HEALTH SERVICES

    Whether a servicemember is identified as needing mental health 
services through a health assessment tool or through self-referral, our 
personnel at Navy MTFs are prepared to provide high quality mental 
health services. In addition, sailors, marines and eligible 
beneficiaries seeking services can access a wider range of providers to 
meet their needs through various organizations such as Military 
OneSource, Navy's Family Support Centers, Marines' Corps Community 
Services, and the Navy's Chaplains Corps. All of these of entry points 
allow beneficiaries to select the type of mental health services they 
feel most comfortable to help them deal with their situation.
    While Navy Medicine is making a concerted effort to ensure 
psychological health care for active duty members is available in the 
direct care system whenever possible, personnel shortages in 
psychological specialties make that a challenge. TRICARE network 
resources may be available; however, there is some concern that those 
providers may be less familiar with the unique demands placed upon 
active duty members.
    There are significant shortfalls in our Active Duty mental health 
community. Navy uniformed psychiatry and psychology communities 
continue to experience manning shortfalls. Our psychiatry community is 
at 90 percent manning, our clinical psychology community is at only 
77.5 percent manning. The roles of the Navy social work community are 
being expanded and increases in the Psychiatric Nurse Practitioner 
community are also being explored to meet the growing needs for mental 
health services, both in theater and in garrison. Uniformed mental 
health providers are critical in our efforts to provide preventive and 
clinical services to marines and sailors. We must continue to develop 
mechanisms, including changes to accession and retention bonuses and 
special pays, to ensure an adequate complement of uniformed mental 
health providers.
    Providing services to Reserve sailors and marines is a continuous 
challenge as mental health problems may not emerge until the end of 
their benefit period. Furthermore, other problems, such as substance 
abuse, family discord or vocational dysfunction, may not present until 
after their benefits expire. Another challenge in meeting the needs of 
reservists is that many of them, unlike the Active-Duty Forces, do not 
reside in large fleet or military concentration areas and return from 
deployments to sites where they lack access to medical services or 
support networks. We will continue to strengthen our partnership with 
the Department of Veterans Affairs so that these servicemembers will be 
able to access psychological health services as close to their homes 
and families as possible.
    Coordination of care is being provided by a myriad of agencies and 
our commitment to ensure quality health care for reservists and their 
families remain in the forefront. The demands of providing services to 
these veterans, particularly in high fleet and Marine Corps 
concentration areas, is closely monitored to ensure sufficient capacity 
is available in our system. Our goal is to establish comprehensive and 
effective psychological health services throughout the Navy and Marine 
Corps. This effort requires seamless programmatic coordination across 
the existing line functions (e.g., Wounded Warrior Regiment, Safe 
Harbor), and we are working to achieve long-term solutions to provide 
the necessary care.
    Navy Medicine is also paying particular attention to de-
stigmatizing psychological health services, the continuity of care 
between episodes and the hand-off between the direct care system and 
the private sector. We are developing a process to continuously assess 
our patient and their families perspectives so that we cam make 
improvements when and where necessary.

   CONTINUING EFFORTS TO MEET THE MENTAL HEALTH NEEDS OF SAILORS AND 
                                MARINES

    In order to evaluate and provide recommendations on the needs of 
deployed sailors and marines, Navy Medicine has developed the 
Behavioral Health Needs Assessment Survey (BHNAS). BHNAS was adopted 
from the Army's series of Mental Health Advisory Team surveys, which 
started in 2003, of land warfighters.
    Preliminary results of the BHNAS show that Navy's contributions to 
the global war on terrorism are diverse and substantial. The impact of 
OIF-related deployments appears to vary according to type of assignment 
and degree of exposure to direct combat. Sailors who had seen the most 
combat were more likely to screen for a mental health problem. As a 
matter of fact, Navy corpsmen showed the highest incidence of mental 
health problems among Navy personnel surveyed. Sailors reporting a 
strong sense of unit cohesion and leadership were half as likely to 
report mental health issues as those in less-stable command 
environments. These findings highlight an additional burden on the IA 
population because IAs do not enjoy the same level of command 
integrity, ethos and camaraderie. Phase II analysis of our BHNAS which 
focuses exclusively on our IAs, a study now which now has evaluated 
more than two thousand Sailors, is near completion.
    Recently Navy Medicine received funding for creation of a Navy/
Marine Corps Center for the Study of Combat Stress to be located at the 
Medical Center San Diego. This center is strategically located to work 
closely with our new Comprehensive Combat Casualty Care Center (C5). 
The concept of operations for this first-of-its-kind capability is 
underway, as is the selection of an executive staff to lead the Center. 
The primary role of this Center is to identify best Combat and 
Operational Stress Consultants (COSC) practices; develop combat stress 
training and resiliency programs specifically geared to the broad and 
diverse power projection platforms and Naval Type Commands; establish 
provider ``Caring for the Caregiver'' initiatives; and coordinate 
collaboration with other academic, clinical, and research activities. 
As the concept for a DOD Center of Excellence develops, we will 
integrate, as appropriate, the work of this center. The program also 
hopes to reflect recent advancements in the prevention and treatment of 
stress reactions, injuries, and disorders.
    Never before has the mental health and well-being of sailors and 
marines deployed to a war zone been as intensely studied. To better 
understand the impact upon Navy and Marine Corps families, I have 
commissioned the Center for Naval Analysis to conduct a sweeping study 
of Combat and Operational Stress Control impact and attitudes. This 
survey, unlike the anonymous BHNAS, will target over 15,000 randomly 
selected families and provide the most comprehensive determination as 
to the cumulative effect of global war on terrorism. Navy Medicine will 
continue to build upon and expand our efforts of assessing their mental 
health needs as a result of their service. Among the recommendations by 
the first BHNAS are to: continue developing stress resiliency programs; 
adopt a consistent ``Caring for the Caregiver'' program; fully 
implement the Psychological First Aid (self-aid and buddy-aid); and 
assess differential COSC burden on RC and IAs and their families.
    Implementing the recommendations of the BHNAS is the responsibility 
of Navy Medicine's COSC. These two individuals are dedicated to 
addressing mental health stigma, training for combat stress control, 
and the development of non-stigmatizing care for returning deployers 
and support services for Navy Caregivers. The COSC assigned to Navy 
Medicine serves as the Director of Deployment Health, and he and his 
staff oversee Pre- and Post-Deployment Health Assessments, as well as 
the PDHRA. In addition, this position oversees Substance Abuse 
Prevention and Treatment, Traumatic Brain Injury diagnosis and 
treatment, and a newly created position for Psychological Health 
Outreach for Reserve Component Sailors. Navy Medicine is also 
establishing psychological outreach programs at the Navy Operational 
Support Centers (NOSC) throughout fiscal years 2008 and 2009. These 
programs will provide outreach to Reserve servicemembers and their 
families for psychological health, including high risk concerns such as 
PTSD and TBI, as well as post-deployment reintegration issues. 
Psychological Outreach Coordinators will work directly with Reserve 
servicemembers and their families as a liaison to the NOSCs and 
Military Treatment Facilities, the Department of Veterans Affairs, and 
other Service organizations.
    As Navy Medicine champions multi-disciplinary efforts in 
preventing, identifying, and managing stress, we continue to expand and 
strengthen our collaboration with a variety of community resources such 
as Navy Chaplains, the Navy Fleet and Family Support Centers and Marine 
Corps Community Services. Another example of strategy to create 
solutions for pressing problems is the implementation of Project 
Families Overcoming and Coping Under Stress (FOCUS). Project FOCUS is a 
prevention/very early intervention program consisting of 10 to 12 
sessions with a team of specially trained counselors. In the initial 
pilot, this service--which can be arranged by direct contact from the 
family at risk--will positively impact 1,200 families.
    Reinforcing a culture that values psychological health will require 
an enduring commitment to the mental health needs of servicemembers, 
their families, and those who provide their care. It requires a 
commitment to: ensuring psychological health services are available and 
accessible in the operational environment; expanding surveillance and 
detection capabilities; equipping our providers with the best possible 
training, and minimizing the stigma associated with seeking treatment. 
We need to underscore a culture that recognizes and embraces the value 
of enhancing our resilience to deal with the increasing stressors of 
military life, and a culture that understands that in the end, it may 
be less a question for medical science than a challenge for every 
leader to accept.
    Chairman Nelson, Ranking Member Graham, distinguished members of 
the committee, Navy Medicine continues to rise to the challenge of 
meeting the psychological health needs or our brave sailors and 
marines, and their families. I thank you for your support to Navy 
Medicine and look forward to answering any of your questions.

    Senator Ben Nelson. Thank you, Admiral.
    General Roudebush?

STATEMENT OF LT. GEN. JAMES G. ROUDEBUSH, USAF, SURGEON GENERAL 
                 OF THE UNITED STATES AIR FORCE

    General Roudebush. Yes, sir. First, Chairman Nelson, thank 
you. I know you are the driving force that brings us here today 
to discuss this and the information that has been shared 
already, that will be shared, and the questions that have been 
asked. The concerns raised I think underscore the importance of 
this. So thank you for giving us the opportunity to come at 
this in a way that I think is very meaningful for us all within 
the Air Force.
    I would first like to lay out the challenge and the 
opportunity, and then I will talk a bit about how we in the Air 
Force are approaching this. We clearly have airmen in harm's 
way, as do our sister Services, perhaps not in the magnitude, 
but certainly within the intensity. We have airmen serving in 
the battlefield that are out there in the joint warfight, doing 
that mission every day, and we must take care of them.
    In addition to that, we have an incredibly high operational 
tempo. As I believe you would agree, we've been at war 18 
years. We did not come home after the Gulf War. We continued 
operations, and that has caused stress, strain, and wear on our 
forces and our equipment that we simply must attend to.
    Now, we in the Air Force come at this in a way that is very 
coherent and resonant with our Air Force culture of 
accountability, caring for each other, a wingman culture, if 
you will. You always take care of your wingman. You protect 
their six. You make sure that nothing is below or behind that 
could be injurious, and that's how we succeed. We succeed as a 
team very much the same in the way that we approach the 
challenges for our airmen. We medics support our line directly 
in doing this.
    We are accountable for a fit, healthy force that's able to 
do the mission in some very demanding circumstances, both at 
home station and deployed, because every Air Force base is an 
operational platform whether we're providing global deterrence 
from F.E. Warren in Cheyenne, WY, or global strike from Knob 
Noster, MO, or global mobility from Charleston. Every base is 
an operational platform, and we medics support our line in 
doing that, first by providing a healthy, fit force, but also 
by taking care of families, providing resilience and families 
that are able to support these warriors as they go in harm's 
way and take on these intense and very demanding missions.
    In addition to that, we provide constant surveillance, 
understanding, and attending to the health of our forces, so 
that rotationally and repeatedly and heroically we can deploy 
and do the mission, wherever that mission is found. When 
illness or injury occurs, we are there with the right care, to 
take care of those injuries and illnesses and, in support of 
our joint warfighters, to take care of those injuries and 
illnesses forward, stabilize them, and bring them home safely 
for definitive care here in the States.
    The best care that we can provide, though, we believe is 
often preventive. If there is not an injury or an illness, that 
is the best outcome. That's economy of force. That's preserving 
health, and we think that is the best outcome right up front. 
But again, if illness or injury occurs, we're there to take 
care of it.
    Now, we support the line in doing this. Within our Air 
Force culture, the line is very much accountable and 
responsible for the health and well-being of the forces. I 
mentioned the wingman culture. The wingman program, if you 
will, wherein we take care of each other and we work to reduce 
the stigma--there is no stigma in needing help or asking for 
help. Certainly it can be uncomfortable, but sometimes that 
very uncomfortable conversation is the one that needs to 
happen: I need help or you need help. That's the best place for 
it to begin.
    In addition to that, we have a suicide prevention program 
which is very much a line program. This was initiated in 1996 
and serves as a model both for the military and for the Nation. 
During that time we've reduced our suicide--the incident of 
suicides, 28 percent. Any suicide is too many. However, to the 
full extent that we can prevent suicide we believe that that's 
very important to do. That's a community-based program, but it 
requires attention every day. It requires training, and it 
requires buy-in that in fact we do take care of each other and 
there is no stigma in seeking or needing help.
    Lastly, for those who are significantly wounded we have the 
Air Force Wounded Warrior Program, wherein a family liaison 
officer is assigned to every severely injured airman to 
administratively assist the family, and to assure that all 
medical issues are attended to as well, and that injured or ill 
individual is properly taken care of.
    So through this constellation of programs, both the medical 
and line, we are every day attending to our airmen to assure 
that we can repeatedly, heroically be there to support the 
mission, accomplish the mission, to dominate the domains, air 
space and cyber space, in support of our sovereign options, and 
do it without fail.
    Sir, I appreciate this opportunity to talk to you about Air 
Force medicine and I look forward to your questions.
    [The prepared statement of General Roudebush follows:]

     Prepared Statement by Lt. Gen. (Dr.) James G. Roudebush, USAF

    Mr. Chairman and esteemed members of the committee, it is my honor 
and privilege to be here today to talk with you about the Air Force 
Medical Service (AFMS). The AFMS exists and operates within the Air 
Force culture of accountability wherein medics work directly for the 
line of the Air Force. Within this framework we support the 
expeditionary Air Force both at home and deployed. We align with the 
Air Force's top priorities: Win Today's Fight, Take Care of our People, 
and Prepare for Tomorrow's Challenges. We are the Nation's Guardian--
America's force of first and last resort. We get there quickly and we 
bring everyone home. That's our pledge to our military and their 
families.

                           WIN TODAY'S FIGHT

    It is important to understand that every Air Force Base is an 
operational platform and Air Force medicine supports the war fighting 
capabilities at each one of our bases. Our home station military 
treatment facilities form the foundation from which the Air Force 
provides combatant commanders a fit and healthy force, capable of 
withstanding the physical and mental rigors associated with combat and 
other military missions. Our emphasis on fitness, disease prevention 
and surveillance has led to the lowest disease and non-battle injury 
rate in history.
    Unmistakably, it is the daily delivery of health care which allows 
us to maintain critical skills that guarantee our readiness capability 
and success. The superior care delivered daily by Air Force medics 
builds the competency and currency necessary to fulfill our deployed 
mission. Our care is the product of preeminent medical training 
programs, groundbreaking research, and a culture of personal and 
professional accountability fostered by the Air Force's core values.
    The AFMS is central to the most effective joint casualty care and 
management system in military history. The effectiveness of forward 
stabilization followed by rapid Air Force aeromedical evacuation has 
been repeatedly proven. We have safely and rapidly transferred more 
than 48,000 patients from overseas theaters to stateside hospitals 
during Operations Enduring Freedom and Iraqi Freedom. Today, the 
average patient arrives from the battlefield to stateside care in 3 
days. This is remarkable given the severity and complexity of the 
wounds our forces are sustaining. It certainly contributes to the 
lowest died of wounds rate in history.

                        TAKE CARE OF OUR PEOPLE

    We are in the midst of a long war and continually assess and 
improve health services we provide to airmen, their families, and our 
joint brothers and sisters. We ensure high standards are met and 
sustained. Our Air Force chain of command fully understands their 
accountability for the health and welfare of our airmen and their 
families. When our warfighters are ill or injured, we provide a wrap-
around system of medical care and support for them and their families--
always with an eye towards rehabilitation and continued service.
    The Air Force is in lock-step with our sister Services and Federal 
agencies to implement the recommendations from the President's 
Commission on the Care for America's Returning Wounded Warriors. The 
AFMS will deliver on all provisions set forth in the National Defense 
Authorization Act (NDAA) for Fiscal Year 2008 and provide our 
warfighters and their families help in getting through the challenges 
they face. As we will discuss today, the AFMS is committed to meeting 
the mental health needs of all our airmen, whether deployed or at home, 
and we are very grateful for your support in these areas.
Psychological Health
    Psychological health means much more than just the delivery of 
traditional mental health care. It is a broad concept that covers the 
entire spectrum of well-being, prevention, treatment, health 
maintenance and resilience training. To that end, I have made it a 
priority to ensure that the AFMS focus on the psychological needs of 
our airmen and identify the effects of operational stress.
Prevention
    The Air Force has enhanced mental health assessment programs and 
services for airmen. We identify mental health effects of operational 
stress and other mental health conditions, before, during and following 
deployments through periodic health assessments (PHAs). We begin with 
the annual PHA of all personnel to identify and manage overall 
personnel readiness and health, including assessment for post-traumatic 
stress disorder (PTSD) and traumatic brain injury (TBI).
    Before deployment, our airmen receive a pre-deployment health 
assessment. This survey includes questions to determine whether 
individuals sought assistance or received care for mental health 
problems in the last year. It also documents any current questions or 
concerns about their health as they prepare to deploy. The responses to 
these questions are combined with a review of military medical records 
to identify individuals who may not be medically appropriate to deploy.
    The Post-Deployment Health Assessment (PDHA) and Post-Deployment 
Health Reassessment (PDHRA) contain questions to identify symptoms of 
possible mental health conditions, including depression, PTSD, or 
alcohol abuse. Each individual is asked if he or she would like to 
speak with a health care provider, counselor, or chaplain to discuss 
stress, emotional, alcohol, or relationship issues and concerns. New 
questions were added to the PDHA and PDHRA to screen for TBI. Quality 
assurance and programs evaluations are conducted to assess 
implementation effectiveness and program success. Treatment and follow-
up are arranged to ensure continuity of care by building on Department 
of Defense (DOD) and Veterans Affairs (VA) partnerships.
    The Air Force integrates these prevention services through the 
Integrated Delivery System (IDS). The IDS is a multidisciplinary team 
that identifies and corrects gaps in the community safety net. Leaders 
from the chapel programs, mental health services, family support 
centers, child and youth programs, family advocacy and health and 
wellness center are involved at each installation. They promote 
spiritual growth, mental, and physical health, and strong individuals, 
families, and communities.
Post Traumatic Stress Disorder
    The incidence of PTSD is low in the Air Force, diagnosed in less 
than 1 percent of our deployers (at 6 month post-deployment). For every 
airman affected, we provide the most current, effective, and 
empirically validated treatment for PTSD. We have trained our 
behavioral health personnel to recognize and treat PTSD in accordance 
with the VA/DOD PTSD Clinical Practice Guidelines. Using nationally 
recognized civilian and military experts, we trained more than 200 
psychiatrists, psychologists, and social workers to equip every 
behavioral health provider with the latest research, assessment 
modalities, and treatment techniques. We hired an additional 32 mental 
health professionals for the locations with the highest operational 
tempo to ensure we had the personnel in place to care for our airmen 
and their families.
Traumatic Brain Injury
    We recognize that TBI may be the ``signature injury'' of the Iraq 
war and is becoming more prevalent among servicemembers. Research in 
TBI prevention, assessment, and treatment is ongoing and the AF is an 
active partner with the Defense and Veterans Brain Injury Center 
(DVBIC), the VA, the CDC, industry and universities. The AF has very 
low positive screening for TBI--approximately 1 percent from Operation 
Iraqi Freedom and Operation Enduring Freedom.
    Screening for TBI occurs locally in theater, before transport of 
wounded servicemembers stateside, and again at stateside hospitals as 
indicated. The Military Acute Concussive Evaluation tool is 
administered in accordance with the Joint Theater Trauma System TBI 
Clinical Practice Guideline. U.S. Transportation Command policy 
dictates that all servicemembers be screened for the signs and symptoms 
of TBI prior to transportation out of theater at either Landstuhl 
Regional Medical Center or at U.S. Air Forces Europe Aeromedical 
Staging Facilities. Follow up care for those with positive screens is 
conducted at U.S. military treatment facilities and/or DVBICs. The 59th 
Medical Group, Lackland Air Force Base, TX, is one of three DOD DVBIC 
Regional Centers that cares for TBI patients.
    The Air Force is involved in several cutting edge research 
initiatives involving TBI. One in particular is the collaboration 
between the Air Force Research Laboratory and the University of 
Florida's Brain Institute. This research is focusing on the presence of 
biochemical markers in spinal fluid that is associated with TBI. 
Another is the Brain Acoustic Monitor, which detects mild TBI injuries 
and replaces invasive pressure monitors used to measure brain pressure 
for severe TBI cases.
    TBI is an expanding area of study requiring close cooperation among 
the Services, the Department of Veterans Affairs, academic institutions 
and industry. It is vital that we better understand this disorder and 
clarify the long-term implications for our airmen, soldiers, sailors, 
and marines.
Suicide Prevention
    The Air Force suicide prevention program is a commander's program. 
It has received a great deal of national acclaim and has achieved a 28 
percent decrease in Air Force suicides since the program's inception in 
1996. We continue to aggressively work our 11 suicide prevention 
initiatives using a community approach, and this year released 
Frontline Supervisor's Course. The course further educates those with 
the most contact and greatest opportunity to intervene when airmen are 
under stress. We conducted suicide risk assessment training for mental 
health providers at 45 Air Force installations throughout 2007 to 
ensure Air Force mental health providers are highly proficient in 
evaluating and managing suicide risk.
    Air Force prevention efforts are centered on effective detection 
and treatment. Recurring suicide prevention training for all airmen is 
a central component of this risk recognition. As part of our Chief of 
Staff's and Secretary's new Total Force Awareness Training initiative, 
we recently released revamped computer-based training. This effort 
incorporates suicide prevention education into the CSAF's core training 
priorities, ensuring suicide prevention will continue to receive the 
appropriate priority and attention.
    In 2008, the Air Force Suicide Prevention Program will monitor the 
Frontline Supervisors Training and the new computer-based suicide 
prevention training to ensure these initiatives effectively meet the 
training needs of airmen. Every Air Force suicide will be studied for 
lessons learned to prevent future suicides. These lessons will be 
shared in the annual Air Force Suicide Lessons Learned Report that is 
distributed Air Force-wide.
    The best approach to preventing Air Force suicides is continued 
emphasis on the data-proven Air Force Suicide Prevention Program. Each 
of the 11 initiatives in the Air Force Suicide Prevention Program 
represents an important tool for commanders. These initiatives focus on 
leadership involvement; suicide prevention in professional military 
education; community preventive services; community education and 
training; Critical Incident Stress Management and others. Since 
September 2006, every base commander must ensure all 11 initiatives are 
fully implemented on their installation using the annual Air Force 
Suicide Prevention Program Assessment Process and Checklist. There is 
no single, easy solution to preventing suicide. It requires a total 
community effort using the full range of tools.
    The Air Force Suicide Prevention Program was added to the National 
Registry of Evidence-based Programs and Practices (NREPP) in 2007, and 
is currently 1 of only 10 suicide prevention programs listed on the 
registry. NREPP is a searchable database of interventions for the 
prevention and treatment of mental and substance use disorders. 
Operated by the Substance Abuse and Mental Health Services 
Administration, NREPP was developed to help people, agencies, and 
organizations implement effective mental health programs and practices 
in their communities. This listing demonstrates the military's ongoing 
pivotal leadership role in suicide prevention within the United States 
and around the world.

                   PREPARE FOR TOMORROW'S CHALLENGES

    We're looking forward to the fiscal year 2009 deployment of our 
Tele-mental Health Project, which will provide video teleconference 
units at every mental health clinic for live patient consultation. This 
will allow increased access to, and use of, mental health treatment to 
our beneficiary population. Virtual reality equipment will also be 
installed at six Air Force sites as a pilot project to help treat 
patients with post traumatic stress disorder. Using this equipment will 
facilitate desensitization therapy by recreating sight, sound and smell 
in a controlled environment. We are excited about these initiatives, 
not only for our returning deployers, but for all of our servicemembers 
and their families.
    In the months ahead, we will continue to implement enhanced AFMS 
psychological health and TBI programs made possible by fiscal year 2007 
supplemental funding. These programs promote greater focus on access to 
care, quality of care, resilience, and surveillance. The funding will 
allow us to hire 97 additional mental health specialists over the next 
several months. We are indebted to Congress for your support.
    We will continue to work closely with the Office of the Secretary 
of Defense and our sister Services to implement the recommendations of 
the DOD Mental Health Task Force and the wounded, ill, and injured 
provisions of the NDAA for Fiscal Year 2008.

                               CONCLUSION

    In closing, Mr. Chairman, I am intensely proud of the daily 
accomplishments of the men and women of the United States AFMS. Our 
future strategic environment is extremely complex, dynamic and 
uncertain, and therefore we will not rest on our success. We are 
committed to staying on the leading edge and anticipating the future. 
With your help and the help of the committee, the AFMS will continue to 
improve the health of our servicemembers and their families. We will 
win today's fight, and be ready for tomorrow's challenges. Thank you 
for your enduring support.

    Senator Ben Nelson. Thank you very much, General.
    Colonel, General-to-be?

STATEMENT OF COL LOREE K. SUTTON, USA, SPECIAL ASSISTANT TO THE 
ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS), PSYCHOLOGICAL 
               HEALTH AND TRAUMATIC BRAIN INJURY

    Colonel Sutton. Good afternoon, Chairman Nelson. Thank you 
so much for inviting me. We thank you also for your kind 
remarks in your introduction.
    Let me just say for the record, sir, that my grandmother, 
Volga Bell Ward, graduated from Union College in Lincoln, NE. I 
just wanted to establish that. [Laughter.]
    Senator Ben Nelson. Great connection.
    Colonel Sutton. Today, Mr. Chairman, I'm here to provide an 
update on the military health system improvements in 
psychological health and TBI, with a particular emphasis on 
what is happening with the Defense Center of Excellence for 
Psychological Health and TBI. Let me start out by saying I'm 
heartened by the optimism expressed by Senator Boxer and 
certainly shared by yourself and members of your committee, and 
Admiral Arthur and Dr. MacDermid.
    I'm deeply indebted to the Mental Health Task Force and to 
their emphasis on culture, on leadership, on the continuum of 
care, as well as the resources needed, particularly to reach 
those very tough populations that are particularly at risk, 
such as our Reserve components.
    I would also like to share with you some of my excitement, 
sir, in terms of what's going on with the Defense Center of 
Excellence. We are becoming the front door for the Department 
for all matters of concern related to psychological health and 
TBI. I am pleased to report to you, sir, that we are on the 
verge of requiring a name change already, because Secretary 
Peake at my first meeting with him in January, he said: 
``Loree, what you really need is you need a deputy for your 
center from the VA.'' I assured him that such an addition would 
be welcome, at which point we'll need to change our name from 
the ``Defense Center of Excellence'' to, I would propose, the 
``National Centers of Excellence.''
    We opened our doors for initial operations on November 30, 
2007, which meant that on December 1, we had a phone number, we 
had a receptionist, and we had a dugout in Rosslyn with a part-
time chief of staff, a couple of contractors, and, fortunately, 
we are harnessing also the power, the momentum, and the 
achievements of a number of centers.
    So I would think of the Center of Excellence at this point, 
sir, as a center of centers. We are so pleased to be able to 
bring in the efforts and the track record, the achievements, of 
the Defense and Veterans Brain Injury Center with their 16 
years of research, education, and treatment. They were named in 
fact as the number one treatment and research network for TBI 
in the country in 2005.
    We're also bringing in, led by David Riggs, the Center for 
Deployment Psychology, which will really help boost our 
efforts, not just to reach out to psychologists, but to mental 
health professionals, health professionals within our direct 
care system, as well as throughout the country, because we 
realize those 800,000 soldiers, sailors, airmen, and marines 
who've already served are out there as veterans in various 
areas of the country.
    We're bringing in the efforts of the Deployment Health 
Clinical Center, led by Colonel Chuck Engel, as well as working 
very closely with the Center for the Study of Traumatic Stress 
at the Uniformed Services University, led by Dr. Bob Ursano.
    Sir, we are also so blessed to be working with Mr. Arnold 
Fisher and the Intrepid Fallen Heroes Fund. Mr. Fisher has 
pledged to do for psychological health and TBI what he and his 
fund have already done for the care of amputees with the Center 
for the Intrepid.
    We just recently convened our first strategic planning 
conference last week, sir. We had 160 folks that came together, 
a combination of military, VA, and advocacy groups. We had 
folks such as Meredith Beck from the Wounded Warrior Project, 
Ted and Sarah Wade, Barbara Cohoon from the National Military 
Family Association. It was just a tremendous effort coming 
together to really get our first initial traction. This will be 
a quarterly conference and I'll look forward to reporting to 
you our ongoing results.
    We are in the process of launching a national awareness 
campaign, building upon the efforts that the National Institute 
for Mental Health had several years ago: Real Men, Real 
Depression. We are now looking to harness the power of stories 
that come from real warriors, real battles, and real strength.
    Sir, having said all of that, yes, we have done a lot. We 
are working on the issues of concern that were earlier 
addressed. I can certainly provide more details on that, and we 
have much more work ahead of us. We must continue to fully 
implement the Mental Health Task Force recommendations, 
redouble our efforts for suicide prevention, build that global 
network that will include not only DOD and the Services, but 
also the VA, our civilian colleagues. Yes, we've already been 
contacted and are in collaboration with folks in Israel, Great 
Britain, Australia, Canada, and we seek to add to that global 
network.
    We're opening a clearinghouse and a call center which will 
really facilitate that communication between us and those that 
we serve. We want it to be two-way. The 18th of March this 
month we will initiate what will become a monthly video 
teleconference that will reach out to not only our folks within 
the Services, but to anyone who wants to join our regular 
communication, followed by a newsletter coming out in April. 
We're also looking for ways to harness the power of not just 
800 numbers and websites and newsletters, but YouTube and 
MySpace and podcasting and all of the ways that our generation 
of warriors and their families communicate.
    Sir, we are also very, very interested in working on what 
really was emphasized first and foremost by the task force and 
has been mentioned by so many others this afternoon. That is 
the importance of culture. We can work the implementing of all 
of the task force recommendations. We can come up with the best 
strategy, plans, programs, and policies. But unless and until 
we transform the culture that undergirds our efforts, we will 
fall flat.
    So that is a particular area of focus coming out the gate. 
We are partnering with the National Institutes of Health. We 
have the CDC, the Institutes of Medicine, the Substance Abuse 
and Mental Health Services Administration. We are working with 
a group of founding Federal partners, working with the Federal 
Steering Group to initiate a priority working group to address 
the reintegration needs of our veterans, servicemembers, and 
families that will be co-chaired by Toni Zeiss who is also on 
the task force. So clearly it's time for us to do a little less 
talking and a whole lot more action here, sir, and we're after 
it.
    We thank you so much for your support. We thank you for 
your sustained collaboration. We have a lot of work ahead, but 
I assure you, sir, we'll keep after it.
    [The prepared statement of Colonel Sutton follows:]

             Prepared Statement by COL Loree K. Sutton, USA

    Mr. Chairman, distinguished members of the committee, thank you for 
inviting me. Today, I will provide an update on the Military Health 
System (MHS) improvements in Psychological Health and Traumatic Brain 
Injury (TBI). You asked that I address implementation of the Mental 
Health Task Force recommendations, implementation of the Department of 
Defense Center of Excellence (DCoE) for Psychological Health and TBI, 
and information on suicide rates and risk factors.
    The Psychological Health programs in the MHS continuum of care 
encompass:

         Resilience, prevention, and community support 
        services;
         Early intervention to reduce the incidence of 
        potential health concerns;
         Deployment-related clinical care before, during, and 
        after deployment;
         Access to care coordination and transition within the 
        Department of Defense (DOD)/Department of Veterans Affairs (VA) 
        systems of care; and
         Robust epidemiological, clinical, and field research.

                      DOD MENTAL HEALTH TASK FORCE

    The Department is grateful for the hard work and dedication of the 
members of the DOD Mental Health Task Force (MHTF). In September 2007, 
DOD responded to the Task Force's report accepting 94 of the 95 
recommendations for implementation.
    As of today we have completed five of the recommendations offered 
by the MHTF. We have initiated actions on all other recommendations. 
Some will be completed by May of this year and others will be completed 
at a later date, due to longer term implementation requirements. 
Finally, some will continue, based on the requirement of the 
recommendation. We will conduct a broad evaluation of our progress in 
May to gauge our status and reprioritize as needed to maintain our 
momentum.
    The one recommendation that DOD did not accept recommended actions 
that are taking place through programs that are currently operating, 
such as Military OneSource. Further initiatives could serve to confuse 
our warriors and their families as well as duplicate successful 
programs.

                      DEFENSE CENTER OF EXCELLENCE

    Our approach in developing a culture of leadership and advocacy 
began with the creation of the DCoE. The Assistant Secretary of Defense 
for Health Affairs appointed me as the DCoE Director in September 2007 
and the DCoE opened its doors on November 30, 2007. The Center serves 
as the Department's ``front door'' for all issues pertaining to 
Psychological Health and TBI.
    This Center will lead clinical efforts toward developing excellence 
in practice standards, training, outreach, and direct care for our 
military community with Psychological Health and TBI concerns. It will 
also provide research planning and monitoring in these important areas 
of knowledge.
    The DCoE will provide intensive outpatient care for wounded 
Warriors in the National Capital Region and importantly, it will 
instill that same quality of care across the country and around the 
world. We will accomplish this by establishing clinical standards, 
conducting clinical training, developing education and outreach 
resources for leaders, Families and communities, along with 
researching, refining and distributing lessons learned and best 
practices to our military treatment facilities (MTFs) and to the 
TRICARE provider networks. We will work together with our colleagues at 
the VA, National Institutes of Health (NIH) and elsewhere to create 
these clinical standards.
    The DCoE staff will build and orchestrate a national network of 
research, training, and clinical expertise. It will leverage existing 
expertise by integrating functions currently housed within the Defense 
Veterans Brain Injury Center (DVBIC), the Center for Deployment 
Psychology (CDP), and Deployment Health Clinical Center (DHCC).
    To date, the DCoE is engaged in multiple projects that respond to 
the recommendations of the MHTF, including:

          (1) Mounting an anti-stigma campaign projected to begin this 
        spring using input from the Uniformed Services University of 
        the Health Sciences, NIH, VA, the Substance Abuse and Mental 
        Health Services Administration, our coalition partners, and 
        others in the public and private sectors;
          (2) Establishing effective outreach and educational 
        initiatives, including an Information Clearinghouse, a public 
        Web site, a wide-reaching newsletter, and a 24/7 call center 
        for servicemembers, family members, and also for clinicians;
          (3) Promulgating a Telehealth Network for clinical care, 
        monitoring, support, and follow-up;
          (4) Conducting an overarching program of research relevant to 
        the needs of servicemembers in cooperation with other DOD 
        organizations, VA, NIH, academic medical centers, and other 
        partners--both national and international;
          (5) Providing training programs for providers, line leaders, 
        families and community leaders; and
          (6) Designing and planning for the National Intrepid Center 
        of Excellence (anticipated completion in fall 2009), a building 
        funded by the Intrepid Fallen Heroes Fund that will be located 
        in Bethesda adjacent to the future Walter Reed National 
        Military Medical Center.

    The Department has allocated more than $83 million toward DCoE 
functions. That total includes amounts allocated specifically to 
telehealth infrastructure, Automated Behavioral Health Clinic, Defense 
Suicide Event Registry and DVBIC functions. An additional $45 million 
was allocated to research and development projects.
    A vital responsibility of the DCoE is quality of care. The quality 
of care initiative relies on developing and disseminating clinical 
guidance and standards, as well as training clinicians in clinical 
practice guidelines (CPGs) and effective evidence-based methods of 
care.
    DCoE is moving forward on these projects, as it continues the 
relentless momentum to reach full operational capability in October 
2009. Each of the Services has initiated quality of care functions, 
including essential clinician training. For mental health, each Service 
is training mental health providers in CPGs and evidence-based 
treatment for Post Traumatic Stress Disorder (PTSD). The Services are 
training primary care providers in mental health CPGs. Regarding TBI, 
we sponsored a TBI training course attended by more than 800 providers, 
including VA providers from over 30 disciplines. We will repeat this 
training in 2008 to provide a basic level of understanding of mild TBI 
to as many health care providers as possible. Over the coming months, 
the DCoE will consolidate and standardize these training efforts.
    Severe TBI is easily observed. Similar to other severe trauma 
conditions, severe TBI is treated using well-established procedures. 
Usually, moderate TBI is clearly recognizable with an event-related 
period of loss of consciousness and observable neurocognitive, 
behavioral, or physical deficits. On the other hand, mild TBI, while 
more prevalent, is more difficult to identify and diagnose on the 
battlefield, just as it is in civilian scenarios. Our index of 
suspicion must be high to ensure that we appropriately evaluate, treat, 
and protect those who have suffered mild TBI. Military medicine has 
established a strategy to improve the entire continuum of care for TBI 
and published a DOD policy on the definition and reporting of TBI. This 
policy guidance serves as a foundation for shaping a more mature TBI 
program across the continuum of care and sets the stage for the mild 
TBI CPG to follow.
    The Army Quality Management Office--the DOD executive agent for 
Clinical Practice Guidelines--is creating a formal CPG for mild TBI. 
Guidelines generally require 2 years to develop; however, we have 
expedited that process and will have the CPG completed in 1 year. The 
Department will collaborate with VA on the development of this CPG to 
assure a standard approach to identification and treatment of mild TBI.
    Having standard guidelines and trained staff represent only part of 
the quality requirement. Equally important is proper equipment for the 
provision of care. Operations Iraqi Freedom and Enduring Freedom have 
placed our servicemembers at highest risk for potential brain trauma. 
Therefore, DOD acquired equipment to enhance screening, diagnosis, and 
recovery support for these warriors.

                                 ACCESS

    Our ability to deliver quality care depends, in part, on timely 
access. Access, in turn, depends on the adequacy of staff to meet the 
demand in line with acceptable standards for appointment wait times. We 
also must provide the services in a location or manner in which the 
service or family member can meet with the provider or interface with 
the system without undue hardship or long travel times and distances.
    In October 2007, the Department issued a new policy stating that 
patients should have initial primary psychological evaluations 
scheduled within 7 days of their request, with treatment to follow 
within normal access standards. Emergency evaluations are addressed 
right away.
    In addition to this enhanced access, we have begun moving 
Psychological Health functions into primary care settings. The Services 
will hire Psychological Health personnel for both mental health clinics 
and primary care clinics. In the primary care setting, Psychological 
Health providers can consult with primary care providers to identify 
mental health conditions and to make appropriate referrals for 
treatment. Alternately, behavioral health providers can manage the 
patient's care in the primary care setting when appropriate. This 
arrangement also enables us to provide care for behavioral aspects of 
more traditionally physical health problems, such as pain and sleep 
problems that cause patients to seek care.
    To ensure ready access to mental health and TBI care in our MTFs, 
we are increasing staff using a number of approaches.

         For TBI, we developed a standard capabilities model of 
        multi-disciplinary staffing and management; capabilities we are 
        now assessing for use across the military Services. This model 
        offers the basis for a site certification pilot program that 
        the Army has undertaken to ensure that soldiers with TBI 
        receive care only at those facilities with established 
        capability to care for them.
         Deployment-related health care has proven most 
        effective when integrated with total health care. The Institute 
        of Medicine advocated this position and the Department codified 
        it in the DOD/VA Post-Deployment Health Evaluation and 
        Management Clinical Practice Guideline. Telehealth technology 
        will help to integrate this care particularly in the more 
        remote locations. The DCoE will coordinate and integrate 
        telehealth activities and capabilities across the Department; 
        meanwhile, the Services have begun demonstration projects to 
        assess how best to leverage telehealth technology to increase 
        care for TBI patients in remote or underserved locations.
         For mental health, we developed a population-based, 
        risk-adjusted staffing model to more clearly inform us of the 
        required number of mental health providers. The Department 
        contracted with the Center for Naval Analysis to validate the 
        model and expects results later this year. Using that validated 
        model, the Department will adjust the requirements and 
        disposition of mental health providers in the next fiscal year.

                 United States Public Health Service (USPHS). 
                Mental health providers are in short supply across the 
                country--complicated by hard-to-serve areas, such as 
                remote rural locations. To increase providers in these 
                areas, we have initiated a partnership with USPHS, 
                which will provide uniformed mental health providers to 
                the MHS. The USPHS has committed to sending us 200 
                mental health providers of all disciplines. The 
                military Services will place those providers in 
                locations with the greatest needs.
                 Civilian and contract. We will employ civilian 
                and contract providers to increase our mental health 
                staff by more than 750 providers and approximately 95 
                support personnel. Additionally, the MTF commanders 
                have hiring authority and may increase their staffs to 
                meet unique demands.
                 TRICARE network. In the past few months, our 
                managed care support contractors have added more than 
                3,000 new mental health providers to our TRICARE 
                network across the three regions. In addition, they 
                have reached out to thousands of non-network providers 
                to identify clinicians who would be available to take 
                on new patients if a network provider could not be 
                identified within the established access times.
                 Military. As always, we must recruit and 
                retain military providers. These men and women serve 
                critical missions as an integral part of our deploying 
                force.

                               RESILIENCE

    Our vision for building resilience incorporates psychological, 
physical, and spiritual fitness. When health concerns present, we must 
strive to break down the barriers so that those seeking care receive it 
at the earliest possible time and in the least restrictive setting, 
including nonmedical settings, such as chaplains, first sergeants, and 
counselors.
    I mentioned our anti-stigma campaign earlier. An important part of 
reducing stigma is education. The DCoE proposes a standardized 
curriculum for Psychological Health and TBI education for leaders, 
servicemembers, and family members. In the interim, each Service will 
implement training across its leadership spectrum that adheres to our 
overarching principles and is adaptable to the culture of its own 
Service.
    For families, we have implemented and expanded a number of 
education and outreach initiatives.

         The Mental Health Self-Assessment Program is 
        accessible at health fairs as well as in a Web-based format. We 
        expanded this program to include our school-aged family 
        members.
         The Signs of Suicide Program, an evidence-based 
        prevention and mental health education program in our DOD 
        Educational Activity schools, will expand to public middle and 
        high schools in areas with high concentrations of deployed 
        forces.
         For our younger children, the proven-successful Sesame 
        Street Workshop will expand with our cooperation to address the 
        impact of having a deployed parent come home with an injury or 
        illness. This program will be added to the original Workshop 
        educational program and distributed widely across the 
        Department. It is scheduled for completion and kickoff in April 
        2008 to coincide with the Month of the Military Child.

    For our servicemembers, we have taken a number of steps to prevent 
and identify early psychological issues.

         We will incorporate baseline neurocognitive 
        assessments into our lifecycle health assessment procedures 
        from entering the service through retirement. As we progress in 
        that objective, we will continue to provide pre-deployment 
        baseline assessments.
         We added questions to both the Post-Deployment Health 
        Assessment and Post-Deployment Health Reassessment to 
        facilitate TBI screening. We also support initial 
        identification teams at high-density deployment locations to 
        ensure consistent screening and to further evaluate and treat 
        those who screen positive.
         Screening and surveillance will promote the use of 
        consistent and effective assessment practices along with 
        accelerated development of electronic tracking, monitoring, and 
        management of Psychological Health and TBI conditions and 
        concerns. We will incorporate screening and surveillance into 
        the lifecycle of all servicemembers.
         We must remember that our health care and community 
        support caregivers may develop compassion fatigue. To help with 
        that, the DCoE will develop a new curriculum of training or 
        validate existing training to alleviate and mitigate compassion 
        fatigue.

                           DOD-VA TRANSITION

    We must effectively establish a patient- and family-centered system 
that manages care and ensures a coordinated transition among phases of 
care and between health care systems. Transition and coordination of 
care programs help Wounded Warriors and their families make the 
transition between clinical and other support resources in a single 
location, as well as across different medical systems, across 
geographic locations, and across functional support systems, which 
often can include nonmedical systems.
    In terms of transition, we seek better methods to ensure provider-
to-provider referrals when patients move from one location to another 
or one health care system to another, such as between DOD and VA or the 
TRICARE network. This is relevant most especially for our Reserve 
component members.
    Care coordination is essential for TBI patients who may have 
multiple health concerns, multiple health providers, and various other 
support providers. Frequently, they are unsure of where to turn for 
help. Proactively, the DCoE Clearinghouse, Library, and Outreach staff 
will offer accurate and timely information on benefits and resources 
available. Meanwhile, Army and the Marines have established enhanced 
care coordination functions for their warriors.
    Newly hired care managers will support and improve transition 
activities. The Marine Corps created a comprehensive call center within 
its Wounded Warrior Regiment to follow up on Marines diagnosed with TBI 
and Psychological Health conditions to ensure they successfully 
maneuver the health care system until their full recovery or transition 
to the VA. The Navy is hiring Psychological Health coordinators to work 
with their returning reservists, and the National Guard is hiring 
Directors of Psychological Health for each State headquarters to help 
coordinate the care of Guardsmen who have TBI or Psychological Health 
injuries or illnesses related to their mobilization. The other Reserve 
components are looking closely at these programs to obtain lessons 
learned as they set up their own programs.
    Information sharing is a critical part of care coordination. DOD 
and VA Information Management Offices are working to ensure that 
information can be passed smoothly and quickly to facilitate effective 
transition and coordination of care.

                                RESEARCH

    Research and development provide a foundation upon which other 
programs are built. Our intent is to rely on evidence-based programs; 
our assessment identifies the need to develop a systematic program of 
research that will identify and remedy the gaps in Psychological Health 
and TBI knowledge. To that end, we have established integrated 
individual and multi-agency research efforts that will lead to improved 
prevention, detection, diagnosis, and treatment of deployment-related 
Psychological Health issues and TBI.
    We will fund scientifically meritorious research to prevent, 
mitigate, and treat the effects of traumatic stress and TBI on 
function, wellness, and overall quality of life for servicemembers and 
their caregivers and families. Our program strives to establish, fund, 
and integrate both individual and multi-agency research efforts that 
will lead to improved prevention, detection, diagnosis, and treatment 
of deployment-related Psychological Health and TBI.

                                SUICIDES

    Let me now offer you an update on our suicide rates and risk 
factors.
    The DOD's confirmed and suspected suicide rates increased in 2006 
and 2007. Even with these increases, the aggregate suicide rates for 
DOD remain comparable to the demographically-adjusted civilian 
population rates. Risk factors for suicide remain unchanged:

         Failing relationships
         Legal/occupational/financial problems
         Alcohol abuse

    Early intervention and prevention programs include pre-deployment 
education and training, suicide prevention training, Military 
OneSource, the Mental Health Self Assessment Program, National 
Depression and Alcohol Day Screening, and health fairs. To increase the 
awareness of DOD's outreach and prevention programs available to the 
Reserve component members, DOD formed a partnership with the VA and 
other Federal agencies as well as professional advocacy groups.
    DOD also provides a broad array of support systems and services to 
the military community. Services available at military installations 
include health and wellness programs, stress management, family 
readiness and community support centers, family readiness groups, 
ombudsmen, volunteer programs, legal and educational programs, and 
chaplains, among many other community programs.

                               CONCLUSION

    Mr. Chairman, distinguished members, thank you for caring and for 
understanding the needs of our warriors and their families. Thank you 
also for providing the resources and support to design and implement 
programs to meet these needs. I look forward to working with you as we 
continue to build the Center of Excellence and implement the MHTF 
recommendations for Psychological Health and TBI. I am honored to serve 
with you in support of our warriors and families. There simply is no 
greater privilege!

    Senator Ben Nelson. Thank you very much, and I believe you 
will.
    I'm concerned about how you transform the culture and how 
you identify the condition in such a way that it doesn't have 
stigma associated with it. Now, General Schoomaker, we were 
talking the other day. You made it clear, and I think most 
everybody would recognize this, that the stress associated with 
the warriors is not something brand new; from the beginning of 
time stress has been associated with conflict. Perhaps our 
knowledge of it is more refined today, and we're working to 
refine it even more as we move forward.
    As we do that, is there really an expectation that we can 
somehow move from what is a macho attitude toward a recognition 
that we're really trying to build people's resiliency? Are 
there softer ways to talk about the situation, or does that 
even help?
    General Schoomaker. Sir, I think it goes without saying 
that the U.S. military is a microcosm--a subset of the American 
society as a whole, and reflects the attitudes of society as a 
whole. The problems that we encounter in stigma within the 
uniformed Services is reflected in society at large. As I said 
in my opening comments, I think that this is an issue that 
needs to be addressed by all communities.
    Having said that, I think that this is done not by medics, 
it's not done by people sitting at this table, but, as I think 
all my colleagues have emphasized, this is a problem for line 
leadership right down to the smallest unit leader and fellow 
soldiers, sailors, airmen, marine, coast-guardsmen, who in a 
sense give license to the view that the human dimension of 
combat and the human dimension of deployment and separation 
from families involves stressors that are going to be 
manifesting symptoms that may make them--as you said in your 
opening comments and as Senator Graham said--less than 
completely engaged warriors.
    That's how we have to look at this. I think that our 
leadership has taken a very assertive role in doing exactly 
what you describe.
    Senator Ben Nelson. Colonel, maybe I can ask you in terms 
of that, the cultural change in the way we think of this. In 
the training, basic training, building people into warriors 
requires building up self-confidence, teamwork, everything that 
we want to have somebody be combat prepared. How far can we go 
at the beginning to build up that resiliency to, if not 
eliminate the possibility, which is unlikely, but reduce the 
impact of the stress?
    Is there some tie to that where people would be less 
stressed with more training, more specific training, more 
directed training toward that, so that maybe we can get ahead 
of it rather than have to treat it after the fact?
    Colonel Sutton. I couldn't agree more with you, Mr. 
Chairman. In fact, I would say that the process of building 
resiliency for soldiers, sailors, airmen, marines, coasties, 
and their families has to start at day one. It starts not only 
with the tough training that challenges our young folks to go 
beyond that which they believe or know about themselves. Of 
course, it's always fun to go to a basic training graduation 
where, after 12 weeks, when the buses come in it looks like 
they've scooped up folks from the shopping malls of America, 
with purple hair and rings and all of the rest. Twelve weeks 
later, the parents walk right by them and don't even know who 
they're seeing.
    It's a transformation, and it starts with day one. I think 
we also need to look toward baseline cognitive screening when 
folks come in at accession, as well as perhaps imaging. We're 
looking at that right now because, although we're currently 
focused on the deployment cycle, we know that we need to 
prolong that. We need to extend that over the life cycle of a 
young troop and her family member being with us.
    It also has to do with the tough training that you 
mentioned. I would take issue with your comment earlier as to 
whether we need a softer approach. In fact, I would go back to 
a couple of weeks ago in the Washington Post newspaper; there 
was an article with a young female, as it turns out, Cobra 
pilot. When she was asked at the end, how do you cope with the 
stress of doing your job and engaging in combat, and she says: 
``Don't ask me, how do I cope. That makes it sound like I have 
to get over something. Because when somebody's shooting at my 
marines, this is my job; this is what I'm trained to do and I'm 
proud to do it.''
    I think it's that kind of pride, buttressed by the 
confidence that can only come from tough training, as well as 
the framework of education to help folks understand what are 
the normal consequences of exposure to trauma, to killing, to 
losing one's buddy, and what are the support systems; what are 
the tools.
    This generation wants tools. They don't see themselves as 
disabled or weak or needing help. They want tools to be able to 
keep themselves going and performing. So I think that's part of 
it.
    Two other examples I would point to, sir, as already 
positive signs of this transformation in culture that we're 
aiming for. Several weeks ago in Tom Rick's Inbox in the 
Washington Post once again, he gave the story of a young marine 
staff sergeant; and Staff Sergeant Travis Twigg, who came back 
from his third deployment and had a tough time, lost several of 
his men, and was not readjusting well.
    His sergeant major brought him in and said: ``Sit down, 
Twigg; do you know why you're here?'' No, Sergeant Major. 
``You're here because you have PTSD. Do you know why I know? 
Because I have it, and you're going to get help.''
    He got Staff Sergeant Twigg to Bethesda, where he was 
hospitalized. He had a tough course of treatment, but did very 
well. He's back in the Corps today, and in the article Staff 
Sergeant Twigg says: ``Listen, here's my phone number, here's 
my email; I want to help anyone else who has these problems.'' 
I'm going to be contacting young Staff Sergeant Twigg here and 
bringing him on our team.
    But think of what that says. The chain of command saw a 
problem, and didn't say: ``Ah, Twigg's weak; he's messed up; he 
can't hang.'' No. They recognized that this young staff 
sergeant needs help, and said I'm going to get it to him, and 
he's going to be back in the force. That expectation of 
recovery, of performance, of resilience, whether it's in the 
classroom or the battlefield, it's paramount for our leaders to 
understand that we must prepare our troops; we must give them 
the tools that will allow them to gain the confidence and the 
expectation of recovery.
    Lastly, sir, I would point to as another sign of this 
transformation in culture that is just really getting started, 
has to do with Secretary of Defense Gates, his leadership in 
saying that, question 21 on the security clearance 
questionnaire, we need to change that. I'm proud to say that 
there's been a lot of interagency work on that, but that is 
nearing fruition, and I think that's going to be a real 
improvement that will help our troops understand that the 
Department's stance toward seeking help, whether it be for 
mental or for physical health issues, is absolutely a sign of 
strength and we want folks to feel like they can go forward 
without fear for their careers.
    Senator Ben Nelson. Now, we as a society at large have 
stigmatized seeking help by the very question about have you 
ever had this. People get over appendicitis, I guess, when the 
appendix is removed and other conditions, but there isn't 
necessarily an indication that that condition has been removed 
with or without treatment. So we've probably done society as a 
whole a great disservice. We have to move beyond that.
    General Roudebush, maybe you can give us your perspective 
from the Air Force.
    General Roudebush. Yes, sir, and I think it does go that 
form follows function. We train individually. We select people 
for their capabilities and we train them in a particular area 
of expertise, and we expect them to execute in that particular 
area. But in reality we execute as a team. We very seldom ever 
execute individually. You're always reliant on a team member 
for some portion. We execute as a team, but quite literally, we 
take care of each other as a family. Now, we have the family 
that the good Lord gave us, but we have the family that we're 
issued, and they're both really good families. I think that is 
at the essence of taking care of each other.
    Stigma is both self-perceived and outwardly or externally 
perceived. The individual may feel some reticence to say, ``I 
need help,'' and may suspect or assume that the others in the 
unit will think less of them because they did in fact need some 
assistance. But if you break down those barriers and say, yes, 
we execute and we succeed as a team and we take care of each 
other as a family, those barriers become less noticeable and 
less onerous.
    Now, I will tell you, it is far from perfect. I think the 
recommendations that the task force made are right on target, 
both in terms of assisting us in positioning the right 
resources and in prioritizing the right activities, policies, 
and issues. So I think we must do it better.
    But at the end of the day it's going to be that 
accountability to each other and the willingness not to inflict 
stigma or assume stigma that I think will allow us to get to 
the other side. Once we get by that, and if you can get to a 
problem sooner, when it's this big, as opposed to later when 
it's this big, the whole process is enhanced. A better result, 
less time out; and frankly, it helps us deal with some very 
trying and demanding circumstances.
    In our theater of operations, everyone has PTS. There is 
nothing normal about that circumstance. It's preventing that 
from becoming PTSD that we need to concentrate on.
    Senator Ben Nelson. We don't have to establish the disorder 
associated with every PTS. It's the extent of the PTS, I 
assume, that then establishes whether it's a disorder or not.
    General Roudebush. Yes, sir, and getting to it sooner, in a 
proactive fashion, mitigating it early, is clearly the 
preferred way to do this. But it does take a team to do that.
    Senator Ben Nelson. In the case of Active Duty, when 
following the deployment the unit comes back and it stays 
pretty much intact. When you get to Guard and Reserve in 
stranded situations, where a reservist comes back from a 
deployment and goes back into society, which probably does not 
have him or her associated with the team that they were with 
during the deployment, is there a greater risk of PTS becoming 
a disorder as time goes by if they don't get some care for that 
up front? Is there a greater risk with that group, and is the 
probability higher that they will have a greater problem than 
somebody that will stay with the unit?
    General Roudebush. Sir, I can give you the Air Force 
statistics. Our statistics as we have gathered them, and they 
are far from as complete as we would rather or they need to be, 
but we continue to make progress in that regard. Our findings 
for our Guard and Reserve members are not significantly 
different than our Active Duty.
    Now, the challenges for us is getting to those folks in a 
way in terms of both surveilling and screening to assure that 
that happens. To that end, certainly their line and their unit 
counterparts are instrumental in assuring that we don't lose 
track of them, as are their families; and sensitizing the 
families that if something does not seem right, if something is 
amiss, to ask the question much sooner than later, as both an 
ally and a resource, is helpful in that regard.
    But it is more challenging with the Guard and Reserve, 
there is no doubt about that.
    Now, when we find it we very aggressively go after it and 
treat it, either using uniformed capabilities or using our 
TRICARE networks if that's more appropriate, because keeping 
these folks close to their home of record and at home with 
their families we believe is an important part of reintegrating 
them and successfully taking care of these folks.
    But yes, sir, it is a challenge.
    General Schoomaker. Sir, this is a great question and it's 
one that all of us are very concerned about, and I'm going to 
lean on what we've learned from the MHAT studies. I think I 
could say without fear of contradiction that we know there are 
several factors that contribute to raising the risk of post-
traumatic stress symptoms and other stress-related symptoms, 
like isolation and depression.
    First is intensity of combat. The variability of combat 
teams, marine and soldier teams, the variability in their self-
reported symptoms is a function of the intensity of combat.
    Second is the coexistence of concussive or mild TBI or 
severe injury. We think there is now some work done by Dr. Hoge 
that was recently published that suggested it might be the 
context in which that concussive injury occurred. In contrast 
to the sport field, when it's in combat concussive injury is 
often associated with a life-threatening event, maybe 
associated with the loss of friends and the like.
    The third is deployment length and frequency of deployment. 
These are all associated with a higher risk of stress.
    Let me say one other thing that I think is very important 
that you've touched on in your last series of questions, and 
that has to do with stigma. I think one of the very positive 
effects of reexamining and rescreening soldiers, sailors, 
airmen, and marines, anyone who's been deployed, not just at 
reintegration, because we've learned through the MHAT studies 
that the excitement of reintegration, the desire to get home 
and to be fully incorporated into home and family and job if 
you're a reservist or a national guardsman overwhelms what may 
be symptoms.
    The MHAT studies have very closely shown us that you need 
to go back and reexamine at the 90- to 180-day period, and that 
is a challenge for the distributed Reserve and National Guard.
    Finally, I'd say in regard to stigma, and this is Eric 
Schoomaker's opinion, the assumption of a stigma to oneself I 
think is attributed in part to fear. Part of that fear is that 
I am self-identifying a serious illness, a mysterious illness, 
one that may never end. One of the things that can be 
reassuring about our studies is that, with screening and 
identification of the early symptoms of post-traumatic stress, 
we can do things symptomatically that improve the individual 
soldier or marine's state and eliminate, as you said, their 
emergence into or maturation into a disorder, especially if we 
can keep them away from alcohol and drugs and family discord 
and violence and all the other things that may characterize the 
establishment of a well-established PTSD.
    So I think one of the clues and one of the keys to removing 
stigma for that individual is improved education about the fact 
that your having these symptoms does not label you with a 
permanent disability, that in fact we can treat these and we 
can prevent a much more long-lasting disability.
    Admiral Robinson. Mr. Chairman, I would also like to add, 
just to the stigma question, I agree with what General 
Schoomaker said and also what General Roudebush said. Stigma is 
going to be a factor because it's a factor in our country. The 
keys to success that I think the Navy and Marine Corps have 
shown are leadership, number one, education number two, 
education from boot camp all the way through War College. It's 
a continuous process and there has to be education amongst the 
buddies that are caring for one another, the shipmates that are 
there, the leaders that are there, the small units that are 
there.
    Additionally--and this is very important, and I think this 
may be one of the keys--to embed mental health resources in the 
units means that when you go see the chaplain, who could be 
part of that, but when you go see the psychologist, the 
psychiatrist, or the social worker who is a part of your unit 
and who has been living with you day-in and day-out, it becomes 
less of an issue of stigma; it becomes more an issue of, that's 
one of my shipmates, that's one of my buddies, I have to go see 
him, I have some issues.
    So that together helps from the culture point of view. If 
at the same time families are given the opportunity to have 
deployment counseling, to have ombudsmen, to have different 
people who are available and units who are available to provide 
that mental health or that support that they need, so that they 
can in fact understand what their loved one's going through 
while away on the deployment and they can also build up their 
resiliency and psychological health, it becomes a synergistic 
effect and it becomes very effective in terms of not only 
reducing the stigma, but also realizing that mental health and 
mental illnesses are as real as physical illnesses.
    You said it yourself: If I break my leg, no one cares that 
I come in with a cane and have a limp. But if I've had some 
sort of mental issue, then everyone looks at me as if I'm not 
capable of ever functioning again, which is completely untrue.
    Senator Ben Nelson. General?
    General Roudebush. Chairman Nelson, if I might add one 
thing. We've been focusing a great deal on mental health 
capabilities, psychiatrists, psychologists, social workers, and 
all the technical support that surrounds that. But as a family 
physician I can tell you that I was trained to anticipate and 
expect that upwards of two-thirds to perhaps even more of the 
issues that I would face as a family physician will have an 
emotional aspect to it or a psychological aspect to it.
    So I think it's important, while we focus on the pure 
mental health resources or the more specifically focused, that 
we also pay very close attention to the whole constellation of 
care capabilities that we have, both primary care as well as 
specialty and subspecialty, to provide them training, as in 
fact we all have, to focus on getting the right kinds of 
diagnostic training and sensitization, if you will, to look for 
TBI, to look for PTSD, while you may be treating something that 
is a very visible issue relative to an injury or an illness, to 
look for those things that may not be quite so visible.
    So we can really leverage the entire care capability that 
we have to further focus on this and assure that we're not 
overlooking those injuries that we ought to be paying attention 
to.
    General Schoomaker. General Roudebush is right on target. 
In fact, I think that that is the main thrust of the military's 
respect-military effort. It's to further arm primary care 
providers of all kinds--nurse practitioners, physician 
assistants, general internists, family medicine doctors, 
whoever that primary care provider is--with the tools and 
skills necessary to screen and do first-line treatment.
    Admiral Robinson. That's the plan for the deployment health 
centers that the Navy now has, so agreed.
    Senator Ben Nelson. The screening that you do I suppose 
prior to somebody's joining one of the branches is important in 
trying to ferret out existing conditions of some sort of mental 
condition or perhaps identifying people that might have a 
greater potential for stress, as I think was indicated, put 
somebody as a mechanic as opposed to out in the front line if 
there's something that could be identified that might be 
predisposed to stress.
    Then before they're sent to theater there's another 
screening. Do the screenings take it up to where you can really 
catch the people, somebody that might be more predisposed than 
someone else? Or can the person being screened hide it from the 
screening process? Colonel Sutton, do you have a thought?
    Colonel Sutton. Sir, this is an important area. I think 
screening does play a role both at accession and certainly 
predeployment and ongoing during deployment and after they 
return, as well as the post-deployment reassessment of health. 
I would say, though, that rather than thinking of, for example, 
at accession this being a process designed to screen out, I 
would argue that this ought to be a process designed to screen 
in, that is to identify strengths as well as areas of potential 
vulnerability, and then to customize our leadership and our 
approach to help that troop really reach his or her potential.
    When 3 out of 10 of our 18- to 25-year-olds qualify for 
military service, I would argue that we already have an elite 
force, and so I would argue to screen at the beginning and then 
as we go through the process--and this, by the way, is 
something that in light of Colonel Hoge's recent article and 
other emerging reports in the last year that have come out, we 
are relooking our screening process right now. We want to make 
sure that we are absolutely asking the right questions to 
elicit the information that we're after.
    To do that, we're bringing in not only experts from DOD and 
the VA, but we're also going to bring in civilian experts from 
around the country, in fact around the world. We will be coming 
forward with recommendations to the senior leadership within 
the next 6 to 8 weeks. But the screening process, the one that 
we had in place now, is a good one. I think that, armed with 
our latest knowledge, we can improve it even further.
    General Schoomaker. But sir, with respect, I would say that 
the present state of what we have still centers around self-
identification.
    General Roudebush. Exactly.
    General Schoomaker. This dovetails very clearly with your 
earlier line of questioning around stigma, that in a society 
that stigmatizes a mental health or behavioral health problem, 
it is the tendency for some of our soldiers to obscure or to 
withhold information that is sensitive.
    I failed to mention one other stressor, one other factor 
that predisposes to post-traumatic stress, and I defer to my 
colleague the psychiatrist at the other end of the table to 
validate this. That is preexisting experiences prior to coming 
into the Service. Severe trauma prior to coming into the 
Service represents another predisposing element to development 
of symptoms while in service. If that's obscured or withheld, 
then it does become a challenge to us.
    Senator Ben Nelson. Thank you for what you're doing. It 
seems just even gratuitous for me to say how important it is, 
but I think we all recognize the mental well-being of our men 
and women in uniform is critical, not only to performance, but 
to quality of life and to our society. So I really do 
appreciate what you're doing and I hope that we'll continue to 
learn more about what will help us in not only identifying but 
treating these different areas.
    I'm encouraged by the fact that there's not just one 
category that everything falls into. The more that we're able 
to distinguish between various different degrees of post-
traumatic stress is, I think, critically important to being 
able to do the job right and get the best result for our 
servicemembers and their families. So I commend you for what 
you're doing.
    Colonel, thank you for taking the leap into a new area. We 
wish you the very best. Of course, we want to be responsive to 
the needs in terms of what financial resources and other 
resources will be necessary for us to be able to do this.
    Working to have the VA together with DOD, with a new name, 
in your area and in so many other situations, such as 
retirement, and disability determination, is extremely 
important to our members as well. So I hope that we'll be able 
to cross the lines to VA and DOD generously and not get blocked 
in that process.
    Of course, General Schoomaker, we all appreciate your 
stepping into the breach with the Walter Reed situation and 
your willingness to take that, make that an opportunity and 
give us more confidence that, as you have, that the military 
really does care from the top down about the people who have 
the need for care of any kind. Our wounded warriors deserve no 
less than the best, and we thank you for providing it.
    The hearing is adjourned.
    [The following appendices will be retained in committee 
files:]

    Appendix A: Mental Health Advisory Team (MHAT-I) Report, Operation 
Iraqi Freedom, 16 December 2003
    Appendix B: Mental Health Advisory Team (MHAT-II) Report, Operation 
Iraqi Freedom, 30 January 2005
    Appendix C: Mental Health Advisory Team (MHAT-III) Report, 
Operation Iraqi Freedom, 29 May 2006
    Appendix D: Mental Health Advisory Team (MHAT-IV) Report, Operation 
Iraqi Freedom, 17 November 2006
    Appendix E: Mental Health Advisory Team (MHAT-V) Report, Operation 
Iraqi Freedom/Operation Enduring Freedom, 14 February 2008

    [Questions for the record with answers supplied follow:]

           Questions Submitted by Senator Joseph I. Lieberman

                    MENTAL HEALTH TASK FORCE REPORT

    1. Senator Lieberman. Vice Admiral Arthur and Dr. MacDermid, I 
thank you both again for your work on the Mental Health Task Force. 
Your report issued critical findings and recommendations that provide a 
blueprint for the Department to build a true continuum of care for 
psychological health (PH). In fact, your report issued over 90 
findings, many of which can be accomplished administratively and others 
which will require statutory changes. If you can, please provide 
specific recommendations you regard as priorities that you feel our 
committee should act on in the National Defense Authorization Act 
(NDAA) for Fiscal Year 2009.
    Vice Admiral Arthur and Dr. MacDermid. The Task Force made 95 
recommendations, 94 of which were endorsed by the Secretary of Defense. 
The testimony by the other panelists made it clear that many actions 
are being undertaken to respond to the recommendations. I am not a 
legislative expert, so there may have been progress of which I am 
unaware, but my impression is that there may be action yet required 
related to the recommendations of the Task Force regarding TRICARE. I 
list four specific recommendations below. The background and 
justification for each of these recommendations is provided in the task 
force report, which was submitted for the record.


5.3.4.6...................................  DOD should modify TRICARE
                                             regulations to permit
                                             updates as new treatment
                                             approaches for
                                             psychological disorders
                                             emerge (e.g., intensive
                                             outpatient services).
                                             Policies should parallel
                                             those currently in place
                                             for medical conditions.
5.3.4.7...................................  TRICARE should accept
                                             accreditation of
                                             residential treatment
                                             facilities for children by
                                             any nationally-recognized
                                             accrediting body, as is the
                                             norm in the civilian
                                             sector.
5.3.4.8...................................  TRICARE should allow
                                             outpatient substance abuse
                                             care to be provided by
                                             qualified professionals,
                                             regardless of whether they
                                             are affiliated with a day
                                             hospital or residential
                                             treatment program,
                                             including standard
                                             individual or group
                                             outpatient care.
5.3.4.5...................................  DOD should ensure TRICARE
                                             reimbursement rates for
                                             mental health services are
                                             competitive with local
                                             rates paid by other major
                                             payors to ensure military
                                             families are given priority
                                             by area providers.


    As I indicated in my testimony, the shortcomings in the PH system 
identified in the task force report were revealed but not caused by the 
current war. A long period of relatively constrained conflicts (though 
their frequency was increasing rapidly) led to the development of a 
system that been streamlined, downsized, and civilianized to the point 
that it has been very difficult during this large sustained conflict to 
adequately serve the needs of Active and Reserve, deployed and at-home, 
members and their families. While substantial funds have been 
allocated, my impression is that most of these funds are non-recurring, 
and not permitted to be used to increase the infrastructure of 
positions to support PH. Without recurring funds, we are at risk of 
coming out of this war with an infrastructure no better prepared for 
the next war than it was prior to September 11. Thus, I suggest that 
the following recommendation may deserve further legislative attention.


5.3.1.1...................................  Congress should provide, and
                                             the military Services
                                             should allocate, sufficient
                                             and continuing funding to
                                             fully implement and
                                             properly staff an effective
                                             system supporting the PH of
                                             servicemembers and their
                                             families.


    I know that Members of Congress are deeply concerned about the PH 
of servicemembers and their families, and deeply committed to making 
long-lasting change. For that reason, I suggest that the following 
recommendation be considered for legislative action.


5.4.1.5...................................  Each Service Surgeon
                                             General's annual report to
                                             Congress should include
                                             data about the PH of
                                             servicemembers and their
                                             families, and on the
                                             efforts to improve PH.



                 UNIFORMED BEHAVIORAL HEALTH PROVIDERS

    2. Senator Lieberman. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, I hope that we all agree 
that Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury 
(TBI), and other mental health issues are significant health challenges 
facing the Department and our servicemembers in this conflict. I 
believe that now we must move beyond simply recognizing that PTSD, TBI, 
and other mental health issues are a problem and find long-term 
solutions. In order for the immediate mental health needs of 
servicemembers to be met, and to build the continuum of care for PH 
called for by the Department of Defense (DOD) Mental Health Task Force, 
we must have significantly more uniformed behavioral health providers. 
Growing our uniformed behavioral health workforce is critical to a 
long-term solution to our mental health crisis and also to inoculate 
our forces against such injuries in the future. What plans do each of 
the Services have to increase the number of uniformed behavioral health 
providers?
    Lieutenant General Schoomaker. The Army offers several programs to 
increase and train mental health professionals in uniform. The Clinical 
Psychology Internship Program is a postdoctoral program which trains up 
to 30 interns per year. Participants are on Active Duty during this 
program and incur an additional Active Duty service obligation. The 
Health Professions Scholarship Program is available for students 
pursuing a doctorate in Clinical Psychology in exchange for an Active 
Duty service obligation. The newly-established Masters in Social Work 
program at the U.S. Army Medical Department Center and School will send 
up to 25 students per year to Fayetteville State University starting in 
Academic Year 2008. The Uniformed Services University of the Health 
Sciences offers a Clinical Psychology Training Program, and has 
introduced a new Adult Psychiatric Mental Health Nurse Practitioner 
(PMH-NP) program. The PMH-NP program is a 24-month, full-time program, 
that will begin in Academic Year 2008.
    Vice Admiral Robinson. The Navy will increase authorized 
endstrength by 14 Psychiatrists, 4 Clinical Psychologists, and 3 Mental 
Health Nurse Practitioners. In addition there will be increased 
uniformed mental health assets bought by the Marine Corps to support 
the Combat Stress Control and Readiness Program (OSCAR). The numbers 
have not been finalized by the Marine Corps but the Navy has already 
taken steps to increase the accession and retention of our mental 
health practitioners.
    The Psychiatry multi-year special pay has increased $8,000 each of 
the past 2 fiscal years and will be evaluated again for fiscal year 
2009 by OSD/HA. NDAA for Fiscal Year 2007 authorized a Critical Wartime 
Skills Accession Bonus (CWSAB). As a result, the DOD initiated a 
$175,000 CWSAB for Psychiatrists for a 4-year commitment in fiscal year 
2008. This rate will be revaluated for fiscal year 2009 by OSD/HA. The 
CWSAB has been fully funded for 50 physician direct accessions in 
fiscal year 2009.
    Clinical Psychologists with 3 to 8 years of service are now 
eligible for $60,000 Critical Skills Retention Bonus (CSRB) for a 4-
year commitment. Navy and OSD are also reviewing an accession bonus for 
Clinical Psychologists and the OSD/HA and the three Services are 
evaluating the NDAA for Fiscal Year 2008 Special Pay authority to pay 
Clinical Psychologists a multi-year retention bonus.
    The Navy has also established six new Mental Health Nurse 
Practitioner billets in fiscal year 2008 with plans to grow this 
community in the near future.
    Lieutenant General Roudebush. We agree that meeting the mental 
health needs of our airmen is a priority that requires a comprehensive 
integrated mental health structure. The Air Force has taken a two-
pronged approach to growing mental health providers. In the short-term, 
we have hired 32 mental health professionals at the locations with the 
highest operational tempo and are hiring 75 contract personnel to 
provide direct patient care and support the establishment of Active 
Duty Directors of Psychological Health at every Air Force installation 
worldwide. We have also assigned an Air Force Active Duty mental health 
clinician to my staff as a consultant on PH.
    In the long-term, Active Duty authorizations for mental health 
providers require an AFMS-wide evaluation of our medical services and 
potential offsets to live within our budgetary constraints. The Air 
Force plans to recruit an additional 71 psychologists (68 AD/3 GS), 44 
social workers (25 AD/19 GS), 6 psychiatrists (6 AD), and 6 mental 
health nurses (6 GS) in fiscal year 2008.
    Our goal is to improve the continuity of mental health care by 
collaborating with the Department of Veterans Affairs (VA) and Public 
Health Service, and by shoring up our access to the civilian network of 
medical providers. The directors of PH will help facilitate these 
relationships.

    3. Senator Lieberman. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, would additional 
authorizations for bonus and special pays assist in recruiting and 
retaining uniformed behavioral health providers?
    Lieutenant General Schoomaker. Yes, the Army competes within a 
market that suffers from shortages of qualified mental health 
professionals. Additional incentives specific to mental health are 
needed to recruit and retain these professionals in the Army. Current 
bonuses and special pays include the following:

         1. Psychiatrists who execute a multi-year special pay contract 
        that extends their Active Duty service obligation are paid 
        $17,000 per year for a 2-year contract, $25,000 per year for a 
        3-year contract, and $33,000 per year for a 4-year contract.
         2. Licensed Clinical Psychologists are offered the Critical 
        Skills Retention Bonus (CSRB) at a rate of $13,000 per year for 
        2 years or $25,000 per year for 3 years. In addition, the 
        Health Professions Loan Repayment Program (HPLRP) is available 
        for the accession of 5 Clinical Psychologists and the retention 
        of 20 Clinical Psychologists per year at the rate of $38,000 
        per year. Finally, the Health Professions Scholarship Program 
        is available to students pursuing a doctorate in Clinical 
        Psychology in exchange for an Active Duty service obligation.
         3. Social Workers in the grade of Captain are offered the CSRB 
        at the rate of $25,000 for a 3-year Active Duty service 
        obligation. The HPLRP is also available for the accession of 5 
        Social Workers and the retention of 20 Clinical Psychologists 
        per year at the rate of $38,437 per year. Finally, a Masters of 
        Social Work program has been established at the U.S. Army 
        Medical Department Center and School to send up to 25 students 
        per year to Fayetteville State University starting in Academic 
        Year 2008.
         4. Psychiatric Nurses and Psychiatric Nurse Practitioners are 
        authorized to receive Registered Nurse Incentive Special Pay at 
        a rate of $5,000 per year for 1 year, $10,000 per year for 2 
        years, $15,000 per year for 3 years, and $20,000 per year for 4 
        years. The Uniformed Services University of the Health Sciences 
        has also introduced a new Adult Psychiatric Mental Health Nurse 
        Practitioner (PMH-NP) program. The PMH-NP program is a 24-
        month, full-time program beginning in Academic Year 2008, with 
        Army allocations to be determined.

    Vice Admiral Robinson. The recruiting and retention tools provided 
by the NDAAs for Fiscal Year 2007 and Fiscal Year 2008 have been very 
helpful. These, coupled with proposals for fiscal year 2009, should go 
a long way to help us meet our goals. However, we constantly review the 
efficiency of our tools and if it is deemed that these tools are 
insufficient, then more will be requested.
    The military-civilian pay differential and current OPTEMPO to 
support the global war on terrorism has affected the retention of many 
of our health care providers, especially our mental health providers.
    Navy continues to work with the Tri-service Health Professions 
Incentive Working Group (HPIWG) to address Special and Incentive pays 
based on inventory needs by specialty including behavioral health 
providers. In the proposed NDAA for Fiscal Year 2009, there is an 
accession bonus for fully trained clinical psychologists to address 
recruiting challenges.
    The following describes the current incentives to attract and 
retain behavioral health specialists. Some have been recently enacted 
from the 2007 and 2008 NDAAs and we are monitoring the effects on 
recruiting and retention.

         1. Psychiatry (Medical Corps)

                 a. Eligible for the following entitlements: Variable 
                Special Pay, Additional Special Pay, and Board 
                Certified Pay.

                 b. Eligible for the following discretionary special 
                pays: Incentive Special Pay (ISP) $15,000/year and 
                Multiyear Special Pay (MSP) 2 year-$17,000/year, 3 
                year-$25,000/year, and 4 year-$33,000/year. The 4 year 
                MSP for Psychiatrist has increased from $17,000/year in 
                fiscal year 2006 to $25,000/year in fiscal year 2007 to 
                $33,000 in fiscal year 2008.

    The NDAA 2008 allows up to $400,000 CWSAB for board certified 
direct accessions. DOD/HA has authorized $175,000 accession bonus for 
psychiatrists who accept a 4-year commitment. During the discharge of 
this Active Duty Service Obligation, individuals are not be eligible 
for the Multi-year Incentive Special Pay or Multi-year Special Pay. The 
number of psychiatrists Navy medicine can directly access is limited by 
our accession goal in fiscal year 2008. The proposed fiscal year 2009 
goal has been increased to support this bonus and an increase in 
accessing psychiatrists.

                 c. Psychiatrists are eligible for the Health 
                Profession Loan Repayment Program (HPLRP) if they meet 
                eligibility requirements. HPLRP can be used as an 
                accession incentive and as a retention incentive. This 
                program provides up to $38,300 per year to repay 
                qualified school loans. HPLRP obligation runs 
                consecutively with other obligations.

         2. Clinical Psychologists (Medical Service Corps)

                 a. The Navy recently implimemented a Critical Skills 
                Retention Bonus for Clinical Psychologists. The 
                incentive pays $60,000 ($15,000/year) for 4-year 
                contract at MSR. Clinical Psychology Officers with 3-8 
                years of commissioned service are eligible.
                 b. Psychologists are eligible for the HPLRP if they 
                meet eligibility requirements. HPLRP can be used as an 
                accession incentive and as a retention incentive. This 
                program provides up to $38,300 per year to repay 
                qualified school loans. HPLRP obligation runs 
                consecutively with other obligations.
                 c. Clinical Psychologists are eligible for Board 
                Certified Pay.
                 d. A fiscal year 2009 ULB for a $70,000 Clinical 
                Psychology Accession Bonus of was submitted and 
                forwarded by DOD. This is in the proposed 2009 NDAA.

         3. Social Workers

                 a. Social Workers are also eligible for HPLRP as an 
                accession and retention tool.
                 b. Social Workers are eligible for Board Certified 
                Pay.

         4. Mental Health Nurse Practitioners

                 a. Nurse Corps recently recognized Registered Nurse 
                Mental Health Nurse Practitioners with subspecialty 
                code.
                 b. Once approved by Assistant Secretary of Health 
                Affairs Mental Health Nurse Practitioners will be 
                eligible for board certified pay.

    Lieutenant General Roudebush. Increases to current authorizations 
and implementation of new bonuses and special pays among uniformed 
behavioral health providers may have an impact on some aspects of 
recruiting. Larger bonuses and special pays might encourage more 
psychiatry residents and newly graduated providers to consider the 
military as a viable place to start their careers. However, it may be 
difficult to offer a large enough accession bonus to entice an 
established behavioral health professional in civilian practice to 
leave and enter the military. Fully trained and qualified providers who 
come onto Active Duty service usually do so for reasons other than 
monetary gain.
    Increases to current authorizations and implementation of new 
bonuses and special pays would likely benefit retention. Uniformed 
behavioral health providers who are ambivalent about staying in the 
military because of increased demands and stresses might be persuaded 
to remain if their pay was closer to or slightly above the pay of their 
civilian counterparts.

    4. Senator Lieberman. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, what has the impact of 
military to civilian conversions over the last several years been on 
the ability to provide behavioral health services in a time of war?
    Lieutenant General Schoomaker. Within the Army, we programmed 107 
military behavioral health specialties for civilian conversion in 
fiscal year 2006 and fiscal year 2007 combined. We found, however, that 
in some local markets we were unable to replace military providers with 
civilians in a timely manner and so only executed 51 conversions and 
restored the military requirement to 56 of those billets. The 
conversion of those 51 billets decreased the depth of the pool we can 
draw from to support deployment needs.
    Our increasing understanding of the scope of this challenge has led 
us to significantly increase the number of uniformed providers as we 
reshape our behavioral health structure. MEDCOM has the full support of 
Army leadership in this restructuring. We have been allowed complete 
flexibility to change the grade and skill of military positions as we 
see fit to best meet our growing behavioral health needs. Among the 
increases in fiscal year 2008 and fiscal year 2009 are 100 enlisted 
mental health specialists, 18 psychiatrists, 6 child psychiatrists, 8 
psychiatric nurses, 19 social workers, and 12 clinical psychologists.
    Vice Admiral Robinson. Military-to-civilian conversions have not 
impacted Navy's ability to provide behavioral health services. Although 
some billets were targeted for conversion in the early years, those 
were quickly restored. There has been no reduction in mental health 
capability associated with military to civilian conversions.
    Lieutenant General Roudebush. The impact of military to civilian 
conversions has been minimal for the Air Force Medical Service. A total 
of 3 psychologist positions and 19 social worker positions have been 
converted in the past 3 years. Two of the psychologist positions have 
been filled, and 10 social workers have been hired. The social worker 
positions converted are Family Advocacy Officers (FAO), who work 
outside of the medical treatment facilities, rather than in clinical 
behavioral health care.

    5. Senator Lieberman. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, what models are the 
Services using in determining current and future uniformed provider 
staffing requirements, especially in light of new initiatives such as 
the Navy/Marine Corps Combat Stress Control and Readiness Program 
(OSCAR)?
    Lieutenant General Schoomaker. The Army uses MEDCOM's Automated 
Staffing Assessment Model (ASAM) to determine current and projected 
uniformed provider and ancillary support staffing requirements within 
Army fixed medical treatment facilities. Additionally, MEDCOM recently 
concluded an in-depth study of behavioral health staffing that will be 
used in concert with the ASAM to increase requirements for 
psychiatrists, social workers, clinical psychologists, mental health 
nurse practitioners, and behavioral health specialists. Finally, the 
Army Medical Department has adjusted its basis for allocating mental 
health support to the warfighter. In 2006, we assigned 1 behavioral 
health professional to support every 1,000 warfighters. Currently, our 
target is 1 behavioral health provider for every 700 soldiers.
    Vice Admiral Robinson. Operational medical requirements for the 
Marine Corps, to include the OSCAR teams, are set by Headquarters 
Marine Corps. As a new requirement, additional ``Blue in Support of 
Green'' (BISOG) billets for the OSCAR program are to be established in 
a phased manner starting in fiscal year 2010. Beginning with the Active 
divisions and Marine Forces Reserve, the Marine Corps will eventually 
staff enough OSCAR teams to support all of the Marine Corps operational 
forces, to include air and logistics units, down to the regimental 
level or equivalent.
    Navy Medicine will support the BISOG requirements through accession 
and retention initiatives and increased BSO 18 staffing to support the 
rotation base of the OSCAR billets. Navy Medicine determines the mental 
health staffing at their Medical Treatment Facilities using workload 
models and the rotation requirements needed to support operational 
staffing requirements.
    Lieutenant General Roudebush. The Air Force has historically used a 
patient population-based product line medical manpower standard to 
formulate requirements for specific health care product lines, to 
include mental health. This population-based product line medical 
manpower standard methodology is what is used to formulate future 
requirements during programmatic/execution processes.
    In addition to the established mental health standards, the Air 
Force added a Director, PH, at each of its Air Force Bases and has 
enhanced the Behavioral Health Outpatient Program (BHOP) at 20-25 bases 
that did not have a dedicated BHOP provider. The BHOP integrates 
behavioral health consultants (BHCs) into the primary care setting to 
help provide early recognition and intervention for those patients with 
psychosocial issues or behavioral health issues that may require more 
intensive specialty mental health care.

                           SUICIDE PREVENTION

    6. Senator Lieberman. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, our greatest resources in 
the Armed Forces are our personnel and we must implement measures that 
prevent suicides and assure those in uniform and their families that 
even one life lost is one too many. Too much of our current debate on 
suicide has focused on whether or not there are statistically 
significant differences in suicides rates from 1 year to the next or 
when in comparison to those in the general population. Instead, I urge 
the DOD and the committee to focus efforts on establishing protocols to 
investigate all suicides to determine causes and contributing factors, 
procedures to take immediate corrective action when necessary, and 
track the implementation of all Service-wide and force-wide 
recommendations emerging from such investigations. I believe that 
suicide prevention is critical to the health and future of our forces. 
What measures have the Services taken to date to prevent any increases 
in suicide rates given the physical and mental strain many 
servicemembers and their families are experiencing?
    Lieutenant General Schoomaker. On March 20, 2008, the Deputy Chief 
of Staff, G-1 and the Surgeon General hosted a Suicide Prevention 
General Officer Steering Committee (GOSC). The GOSC's efforts will be 
ongoing, with a focus on targeting the root causes of suicide, while 
engaging all levels of the chain-of-command. The GOSC approved the 
following: (1) conducting suicide prevention chain teaching for the 
entire force between June 1, 2008, and August 31, 2008; (2) 
establishing a suicide prevention analysis and reporting cell that has 
epidemiological consultation-like capabilities; and (3) developing the 
GOSC charter and expanding its membership. The GOSC also reaffirmed the 
Army Suicide Prevention overarching strategies and expanded them. They 
include: (1) raising soldier and leader awareness of the signs and 
symptoms of suicide and improving intervention skills; (2) providing 
actionable intelligence to leaders regarding suicides and attempted 
suicides; (3) improving soldiers' access to comprehensive care; (4) 
reducing the stigma associated with seeking mental health care; and (5) 
improving soldiers' and their families' life skills.
    Vice Admiral Robinson. Navy's suicide prevention program goes 
beyond statistical baselines to focus on root causes that may lead to 
suicidal thinking. Navy programs and leadership training are designed 
to facilitate early recognition of sailors and marines who may be 
experiencing stress reactions for any reason, and to intervene with an 
appropriate level of support. Navy maintains an active suicide 
prevention program at each command, which include:

         Mandatory annual training on suicide awareness, including 
        risk factors, protective factors, warning signs and how to 
        obtain assistance for self and shipmate.
         Life-skills/health promotions training (on such topics as 
        alcohol abuse avoidance, skills for managing finances, stress, 
        conflict, and relationships) to enhance coping skills and 
        reduce incidence of problems that increase suicide risk.
         Crisis intervention plans that outline the process for 
        identification, referral, access to treatment, and follow-up 
        for personnel who indicate a heightened risk of suicide.
         Support for those who seek help with personal problems 
        including access to prevention, counseling, and treatment 
        programs and services supporting the early resolution of mental 
        health, family and personal problems that underlie suicidal 
        behavior.
         Reporting of suicides and collection of data to inform 
        prevention efforts and policy decisions.
         Providing supportive response to sailors and family members 
        affected by suicide loss.
         All sailors have a duty to take care of each other and seek 
        help for another sailor in distress.

    The Manual of the Judge Advocate General (JAG Instruction 5800.7E) 
requires a command investigation to be conducted with deaths of 
military personnel apparently caused by suicide or under other unusual 
circumstances. Also, the Article 1770-030 of the Naval Military 
Personnel Manual (NAVPERS 15560D), directs completion of a Personnel 
Casualty Report (PCR), which provides visibility throughout Navy senior 
leadership, including the Bureau of Medicine and Surgery. Beginning in 
January 2008, PCR submission initiates the DOD Suicide Event Report 
(DODSER) reporting process by which gathering of standardized 
information occurs across DOD. The DODSER collects information on the 
decedent's demographics, circumstances of death, medical and 
performance history, recent stressors and behaviors, deployment 
history, combat experiences, substance use/abuse, and other 
information, to enable informed assessment of the causes of suicide to 
better develop mitigation and prevention strategies. Navy reports are 
individually reviewed by a licensed mental health provider and 
collective data are analyzed for trends. While Navy suicide rates have 
remained relatively steady given increasing demands and stress on our 
sailors, even the loss of just one sailor or family member to suicide 
is one too many. We are continuously working to improve mental health 
initiatives and intervention focused on reducing the number of suicides 
in the Navy, as well as initiatives to enhance leadership's ability to 
recognize and understand depression and stress injuries, and the impact 
they have on sailor and family resilience.
    Lieutenant General Roudebush. The loss of any airman to suicide is 
a tragedy of great concern to Air Force senior leaders. The Air Force 
has taken a multi-faceted, commander-driven and community wide approach 
to suicide prevention. Prevention of such events requires a culture of 
mutual responsibility, devotion and commitment. Our suicide data 
tracking systems are in place to monitor the effectiveness of these 
concerted prevention efforts.
    I would like to ensure the committee those discussions related to 
the reduction of suicides from year to year, and the metrics to 
demonstrate change, are not reflective of our attempt to dehumanize the 
tragedy, but represent our pursuit of programs and initiatives that are 
successful at guiding our efforts to reach those in need of help and 
support.
    Every Air Force suicide is investigated by the Air Force Office of 
Special Investigations and reviewed in detail by installation and Major 
Command leadership to identify lessons learned that might inform our 
efforts to identify and intervene with those at risk. Additionally, 
when there has been recent involvement of medical or mental health 
services, a Medical Incident Investigation (MII) is commissioned to 
review the chain of events leading up the death in terms of the 
standard of care provided and potential missed opportunities or systems 
failures that were contributory. This MII is briefed to the major 
command commander and up to the Office of the Air Force Surgeon 
General. The lessons learned from these various investigations are 
briefed to our most senior Air Force leaders and aggregated into an 
annual report which is disseminated to commanders throughout the Air 
Force.
Background:
    The Air Force has achieved a 28 percent decrease in Air Force 
suicide rates since the program's inception in 1996. The Air Force 
Suicide Prevention Program was added to the Substance Abuse and Mental 
Health Services Administration's National Registry of Evidence-based 
Programs and Practices (NREPP) in 2007, and is currently 1 of 10 
suicide prevention programs listed on the registry. This listing is not 
about chest thumping, it is about a successful program that makes a 
difference.
    Air Force prevention efforts are centered on effective detection 
and treatment. A central component of this risk recognition and 
referral process is the recurring suicide prevention training for all 
airmen. To better standardize Air Force suicide prevention training, a 
revamped computer-based training was released on 15 Oct 07 as part of 
the Chief of Staff, U.S. Air Force's (CSAF) new Total Force Awareness 
Training initiative. This effort incorporates suicide prevention 
education into the CSAF's core training priorities, ensuring suicide 
prevention will continue to receive prioritized focus and attention.
    Air Force Suicide Prevention Program (AFSPP) introduced the 
Frontline Supervisors Training in 2008. This interactive training 
provides a powerful vehicle for educating those with the most contact 
and greatest opportunity to intervene with airmen under stress. Lastly, 
suicide risk assessment training for mental health providers was 
conducted at 45 installations throughout 2007 to ensure Air Force 
mental health providers are highly proficient in evaluating and 
managing suicide risk. Throughout the next year, the Air Force Suicide 
Prevention Program will monitor the Frontline Supervisors Training and 
the new computer-based suicide prevention training to ensure these 
initiatives are effectively meeting the training needs of airmen.

    7. Senator Lieberman. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, would the Services support 
measures to initiate investigations on all suicides and establish 
Department-wide standards and protocols for taking necessary corrective 
actions?
    Lieutenant General Schoomaker. The Army supports measures to 
initiate investigations on all suicides and to establish Department-
wide standards and protocols. The Army currently investigates all 
suicides through the Criminal Investigation Command. Additionally, 
units are required to conduct a Commander's Inquiry (known as a 15-6 
investigation) on all suspected suicides. The Army currently uses a 
standardized instrument for reporting suicides and attempted suicides, 
the Army Suicide Event Report. Army behavioral health providers compile 
this report. This instrument has been adopted recently by the other 
Services and is now known as the DODSER. Finally, the Army is planning 
to develop a multi-disciplinary suicide prevention analysis and 
reporting cell that has epidemiological consultation-like capabilities. 
This cell will integrate all of the above data.
    Vice Admiral Robinson. The Navy fully supports the standardization 
for data collection/investigation into every suicide, which commenced 
at the beginning of CY 2008 with the implementation of the DODSER. The 
DODSER provides detailed insight into the circumstances, both personal 
and professional, surrounding the decedent at the time of the suicide. 
As the data is compiled we now have the ability to perform trend 
analysis and use the results to revise suicide prevention policy as 
needed. However, standardizing protocols for taking necessary 
corrective actions would likely be counterproductive. Every suicide 
presents unique circumstances and a standard protocol may not address 
the prevention efforts that would be the best course of action in that 
specific incident. Commanders in the field should be able to draw on 
multiple resources to take the most appropriate course of action when a 
suicide occurs. Standardizing protocols would tie leader's hands in 
making the right decisions for their command.
    Lieutenant General Roudebush. The Air Force would support such 
proposals. In fact, the Air Force and DOD have already taken steps to 
implement similar activities. The Air Force tracks and analyzes suicide 
and suicide attempt data using the Air Force Suicide Event Surveillance 
System. In early 2008, the DOD Suicide Prevention and Risk Reduction 
Committee (composed of the Suicide Prevention Program Managers from 
each Service) launched the DOD Suicide Event Reporting System to track 
data on suicides and suicide attempts across all the Services.
    Every Air Force suicide is investigated by the Air Force Office of 
Special Investigations and reviewed in detail by installation and Major 
Command leadership to identify lessons learned that might inform our 
efforts to identify and intervene with those at risk. Additionally, 
when there has been recent involvement of medical or mental health 
services, a Medical Incident Investigation (MII) is commissioned to 
review the chain of events leading up the death in terms of the 
standard of care provided and potential missed opportunities or systems 
failures that were contributory. This MII is briefed to the major 
command commander and up to the Office of the Air Force Surgeon 
General. Suicides related to domestic or child abuse are examined in 
the DOD-mandated Annual Fatality Review. The lessons learned from these 
various investigations are briefed to our most senior Air Force leaders 
and aggregated into an annual report which is disseminated to 
commanders throughout the Air Force.

                      DEFENSE CENTER OF EXCELLENCE

    8. Senator Lieberman. Colonel Sutton, last year, Senator Boxer and 
I introduced S.1196, the Mental Health Care for Our Wounded Warriors 
Act, which was incorporated, into the NDAA for Fiscal Year 2008. In 
addition to the mandates laid out in those provisions, the Defense 
Center of Excellence (DCoE) has also been charged with implementing 
many of the recommendations of the Mental Health Task Force Report. I 
believe that adequate resourcing of the Center is critical for its 
early and long-term utility and success. What resources do you need at 
this time to carry out the directives for the DCoE outlined in the NDAA 
for Fiscal Year 2008 and to implement the numerous recommendations of 
the Mental Health Task Force Report?
    Colonel Sutton. Congress has generously provided funding for the 
Department and the Center for fiscal year 2008 and fiscal year 2009. 
Our greatest challenge at present is the ability to use that funding 
effectively and efficiently to immediately staff the Center and to 
begin the programs necessary to fulfill the recommendations of the 
MHTF. Within the military health system, our clinical staffs are busy 
on the front lines both at home and in deployed status. The Department 
has initiated several actions to increase the numbers of mental health 
professionals to support our wounded warriors and their family members.

                      STRAINS OF MILITARY FAMILIES

    9. Senator Lieberman. Lieutenant General Schoomaker, we have been 
reading an increasing number of reports on the strain that military 
families are experiencing. Last summer, an article published in the 
Journal of the American Medical Association cited rising rates of child 
maltreatment in military families, primarily attributed to spouses 
alone during deployments. My staff has also been visiting a number of 
military bases across the country and they have heard reports at bases 
of increasing reports of domestic violence, substance abuse in 
families, and mental health issues in spouses and children. What 
initiatives is the Army undertaking to assess the needs of military 
families and to direct resources to meet those needs?
    Lieutenant General Schoomaker. In July 2007, the Army Surgeon 
General's Office informed all Army Medical Department providers of the 
observed increases in child neglect rates during deployments and 
directed them to increase the screening of the spouses of deployed 
soldiers for depression and any signs of poor coping capacity. 
Additionally, 16 hours of free child care at child development centers 
has been made available for each child of deployed soldiers and wounded 
warriors. In November 2007, the Secretary of the Army teamed with the 
Gallup organization to initiate quarterly surveys of Army families as a 
part of the Army Family Covenant. The intent is to assess Army family 
health through satisfaction surveys of all Army families, including 
those who live away from Army installations. The survey includes 
questions that will help us evaluate services provided to families 
during deployments.
    The article published last August in the Journal of the American 
Medical Association, ``Child Maltreatment in Enlisted Soldiers' 
Families During Combat-Related Deployments,'' did not cite rising rates 
of child abuse overall. However, it did demonstrate that children were 
at 4 times greater risk of neglect by the civilian spouse during 
deployments. The rate of physical abuse was actually less during 
deployments. Similarly, the observed rates of domestic violence have 
not increased overall since the deployments began--rates have gone 
down. We have found that rates decrease during deployments and rise 
again after reunion, but rates do not rise above pre-deployment levels.

    10. Senator Lieberman. Lieutenant General Schoomaker, what 
additional resources or authorities does the DOD require to accomplish 
these objectives?
    Lieutenant General Schoomaker. The Army plans to more than double 
the number of marriage and family therapists that will be available to 
our soldiers and families this summer. We are using funding 
appropriated in the fiscal year 2007 Supplemental Appropriations Act to 
hire an additional 35 marriage and family therapists, bringing our 
total across the Army to 60. Based on our experience from the past few 
years, we determined that the ratio of one therapist for each brigade 
size element would best support our families. We have had 25 marriage 
and family therapists at select locations since 2003 and have observed 
more positive outcomes of family maltreatment cases when such services 
have been available. After the staffing increases this summer, we will 
continue to monitor outcomes to see if further adjustments are 
necessary.

                         REALLOCATION OF FUNDS

    11. Senator Lieberman. Lieutenant General Schoomaker, the Base 
Realignment and Closure process will lead to a greater concentration of 
military families at a smaller number of bases across the United 
States. How will funding be reallocated to ensure that resources will 
be available for families as they relocate?
    Lieutenant General Schoomaker. We are performing detailed planning 
to align health care capability with demand for services across time. 
Resources will be realigned to support both soldiers and their families 
using a resourcing model based on population timelines to ensure 
adequate health care continues at all of our medical treatment 
facilities. In areas where there is a potential for a lapse in care due 
to the difficulty in hiring providers or the timing of new construction 
or the expansion of existing health care facilities, we are developing 
mitigation strategies, such as the increased use of the TRICARE 
network.

                            SUBSTANCE ABUSE

    12. Senator Lieberman. Colonel Castro, substance abuse appears to 
be on the rise on military bases. Many of these individuals abusing 
substances also have PTSD, TBI, depression, or another mental health 
condition. I am growing increasingly concerned that we must not only 
focus on the psychological and brain injuries, but also on 
understanding how better to assess and treat substance abuse. Is 
substance abuse on the rise on our military bases and among those that 
have deployed to Iraq and Afghanistan?
    Colonel Castro. The most recent data from the fifth Mental Health 
Advisory Team (MHAT V) conducted in 2007 found that 8 percent of 
soldiers deployed to Iraq reported using alcohol in theater and 1.4 
percent reported using illegal drugs/substances. These reports of 
alcohol and substance abuse do not differ statistically from rates in 
2006 (6.8 percent and 1.6 percent). The Army maintains a formal drug 
testing program in theater, and the drug positive results have remained 
significantly lower than 1 percent for the last 3 years. Our drug 
positive rates across the Army have also remained relatively stable 
since the beginning of global war on terrorism. We have seen an 
increase in positive tests for pain killers, but the vast majority of 
those positives are found to be legitimate use. We have seen an 
increase in self-reports of alcohol abuse from 28 percent pre-global 
war on terrorism to 32 percent for those soldiers returning from 
deployment. We have also seen an increase in the numbers of soldiers 
being diagnosed with alcohol abuse or dependence. We have initiated use 
of more early intervention programs that are used with soldiers at the 
first sign of trouble. We are in the process of developing mediated 
versions of our best prevention/intervention programs to expand our 
reach and we have accelerated the hiring of substance abuse treatment 
professionals. We understand the importance of meeting soldiers' needs 
regarding substance abuse and we are responding accordingly.

    13. Senator Lieberman. Colonel Castro, how integrated are substance 
abuse programs with behavioral health services in military treatment 
facilities? Is the level of integration sufficient? If not, what 
integrated models of care is DOD examining and are there plans to 
export those models to military treatment facilities?
    Colonel Castro. The level of integration is sufficient, because we 
are able to maintain the necessary communication and coordination to 
take care of soldiers while adhering to Federal law concerning privacy. 
We are looking at the feasibility of integrating records. The Army 
Substance Abuse Program (ASAP) is a command program in which the 
commanders and providers collaborate in our prevention efforts and 
assist soldiers who abuse alcohol or drugs. If soldiers have a 
substance abuse problem, they are referred to ASAP substance abuse 
counselors who are part of the behavioral health network, but are 
located in separate clinics. The regulation requires the soldier be 
mandated into treatment and that the commander be a part of the 
treatment planning; commanders are required to attend rehabilitation 
meetings with the servicemember and provider. The program also outlines 
commander's requirements if soldiers test positive for drugs or fail at 
attempts for rehabilitation. Specific laws (42 U.S.C., Sec 290dd-2) 
govern the privacy of soldiers who are in substance abuse treatment. 
This law is more stringent than those applied to other behavioral 
health programs or records. That being said, there is continuous 
cooperation and collaboration between the substance abuse clinics and 
other behavioral health providers. An example is dealing with or 
treating PTSD. Behavioral health and substance abuse clinics cross-
check with each other to ensure that soldiers presenting with PTSD 
symptoms or substance abuse are also evaluated for the other since many 
patients suffering from PTSD self-medicate with alcohol.

              MENTAL HEALTH NEEDS OF FEMALE SERVICEMEMBERS

    14. Senator Lieberman. Colonel Sutton, last year, Senator Boxer and 
I had included a provision in the NDAA for Fiscal Year 2008 for DOD to 
conduct a study on the potentially unique mental health needs of female 
servicemembers. Determining whether or not psychological injuries and 
brain injuries manifest differently in men and women will be important, 
especially when developing long-term research and treatment 
infrastructures across DOD. Will the DCoE be involved in this study?
    Colonel Sutton. The DCoE recognizes and supports the unique needs 
of women servicemembers and veterans. One of the eight directorates of 
the DCoE, Research, Program Evaluation, Quality and Surveillance, has 
identified women's health issues as a priority research area. To 
emphasize the importance of this focus, the Research Directorate now 
actively includes statements encouraging examination of gender-specific 
issues in its request for proposals and broad agency announcements.
    The DCoE encourages meritorious research on the mental health needs 
of female servicemembers. Basic, translational, behavioral and clinical 
research in women servicemembers' health, especially applied to sex/
gender differences, are of particular interest. Studies considering the 
health disparities/differences and diversity are also important.

    15. Senator Lieberman. Colonel Sutton, what other initiatives will 
the Center be undertaking to examine the possibility that female 
servicemembers may process stress, trauma, and TBI differently than 
male counterparts?
    Colonel Sutton. The DCoE is collaborating with the scientific, 
health professionals and advocacy communities to fully address the 
unique gender-specific needs of recovering servicemembers and veterans 
with PH and TBI concerns/needs. In early March, the DCoE will hold an 
interagency initial planning meeting on women's issues related to PH 
and TBI by inviting its prospective collaborative partners from the VA, 
the Defense Health Board, and the National Institute of Health Office 
of Research on Women's Health. Ongoing research is examining the short- 
and long-term effects and outcomes of PH issues and TBI in women. These 
findings will be used to inform best practices. The DCoE will take the 
lead in creating best practices workshops in addressing the PH and TBI 
needs and concerns of servicemembers.
                                 ______
                                 
            Questions Submitted by Senator Claire McCaskill

                    PERSONALITY DISORDER DISCHARGES

    16. Senator McCaskill. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, I am concerned with the 
continuing use of administrative personality disorder discharges in the 
Services, especially in instances involving combat veterans. A 
personality disorder discharge results in a servicemember being 
dismissed from service without medical or personnel benefits because 
his or her behavioral issues are determined to be pre-existing. I am 
concerned with the frequency that these highly prejudicial discharges 
are occurring--particularly in cases involving combat veterans. I am 
also especially concerned because these discharges are processed by 
unit commanders in concert with the personnel commands, not by medical 
professionals and the medical command, although I understand that it is 
a diagnosis from a medical professional that enables the discharge. Are 
you concerned that administrative personality disorder discharges are 
being misused in the DOD/your Service?
    Lieutenant General Schoomaker. No, we do not believe personality 
disorder discharges are being or have been misused. We recently 
completed a project to gather available data regarding the personality 
disorder separations of Army soldiers who have been deployed and were 
separated between 2001 and 2006. The data is currently being reviewed 
by Army leadership; however, initial assessments did not reveal 
evidence of systematic misuse in the Army. While gathering the data, 
however, issues were identified with the manner in which diagnoses are 
documented. Therefore, we took immediate steps to improve the level of 
medical review for personality disorder discharges to address this 
issue. The Army Medical Department implemented a new policy in August 
2007, requiring all recommendations for personality disorder 
separations be reviewed by the installation's Chief of Behavioral 
Health. This will add an additional layer of experienced medical review 
to the separation process.
    Vice Admiral Robinson. I believe that administrative personality 
disorder discharges are being properly used by the Navy. We have a 
valid process for determining if a personality disorder discharge is 
warranted with significant safeguards. A convenience of the Government 
separation as detailed in the Navy's Military Personnel Manual (MPM) 
1910-122, clearly states the requirements for personality disorder 
separation as:

         Clinical diagnosis required, i.e., psychiatrist or clinical 
        psychologist (Ph.D.-level)
         Disorder must be so severe that the member's ability to 
        function in the Navy environment is significantly impaired
         Impairment interferes with the member's performance of duty, 
        or poses a threat to the safety or well-being of the member or 
        others

    Furthermore, MPM 1910-122 requires various safeguards to protect an 
individual being separated by reason of convenience of the government. 
It specifically requires written notification to an individual 
requesting a mental health evaluation and clearly states the right of 
an individual to a second, independent mental health professional 
opinion. Additionally, an individual is reminded of their right to an 
Inspector General investigation if they feel their referral is a 
reprisal from the command.
    Lieutenant General Roudebush. Air Force policy is clear that airmen 
will not be discharged for personality disorders when other psychiatric 
disorders that warrant medical disability processing are present. Units 
and personnel offices cannot discharge airmen for personality disorders 
without the recommendation of an Air Force mental health provider. Air 
Force mental health providers are trained in the careful assessment and 
diagnosis of airmen with mental health problems, and render a diagnosis 
of a personality disorder only when a lifelong pattern of maladaptive 
behavior is clearly present. If other psychiatric disorders are 
present, including combat-related conditions, Air Force mental health 
providers refer those individuals for a Medical Evaluation Board.
    I have full confidence that our medical and mental health providers 
maintain high standards of competence and adhere to their ethical 
obligation to provide the best possible care to every patient, and have 
not seen anything that has suggested that administrative personality 
disorder discharges are being misused in the Air Force.

    17. Senator McCaskill. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, do you believe these 
discharges should continue to be handled as administrative discharges 
or should there be a more extensive medical process, like a Medical 
Evaluation Board?
    Lieutenant General Schoomaker. I do not believe personality 
disorder discharges should require a Medical Evaluation Board. In the 
Army, the diagnosis of a personality disorder is made by a psychiatrist 
or a doctoral-level clinical psychologist with necessary and 
appropriate professional credentials who is privileged to conduct 
mental health evaluations for the DOD. In addition, all recommended 
separations for personality disorder are now reviewed by the 
installation's Chief of Behavioral Health. Finally, all soldiers 
recommended for a personality disorder separation receive a mental 
status evaluation. Based on the findings of the evaluation, a soldier 
may be referred for a Medical Evaluation Board. With these procedures 
in place, a more extensive medical process is not required.
    Vice Admiral Robinson. I believe that these discharges should 
continue to be handled as administrative discharges. The process for 
identifying and evaluating a personality disorder is fair to the 
individual and a reasonable method to separate someone, honorably and 
without undo delay or expense to the government. It is important to 
note that personality disorder is not a mental illness but, rather, a 
disorder and in this case simply a disorder which makes one 
incompatible for military service. The Navy uses the Diagnostic and 
Statistical Manual of Mental Disorders, 4th Ed., (DSM IV), which 
requires that all other mental illnesses and disorders must be 
eliminated before a valid diagnosis of personality disorder can be 
made. DSM IV is the basic reference followed by Navy Medical 
professionals in examining for mental illness and disorders. If during 
the evaluation the mental health professional (psychiatrist or Ph.D. 
clinical psychologist) recommends a Medical Evaluation Board, that 
process is initiated.
    Lieutenant General Roudebush. Currently, both the administrative 
separation of airmen for conditions unsuited to service and the medical 
discharge of personnel unfit for service require thorough medical 
evaluations.
    It is appropriate for psychological conditions as outlined in the 
American Psychiatric Association's Diagnostic and Statistical Manual 
for Psychiatric Conditions, 4th Edition, and defined by regulations as 
unsuitable for service to be processed for administrative separation 
after the thorough evaluation by an Air Force mental health provider. 
This group of conditions includes personality disorders, a diagnosis 
that reflects a lifelong pattern of maladaptive behavior. Other 
examples include sleepwalking, dyslexia, airsickness, flying phobia, 
claustrophobia, and adjustment disorders.
    All psychiatric disorders not explicitly defined as unsuited to 
service are processed through the medical evaluation board system. 
Medical evaluation boards are initiated when an Air Force mental health 
provider identifies concerns about an airman's fitness for continued 
service. Disorders warranting a medical evaluation board are explicitly 
excluded from the administrative separation process.

    18. Senator McCaskill. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, would you support a 
moratorium on the personality disorder discharges?
    Lieutenant General Schoomaker. I do not support a moratorium on all 
personality disorder discharges. Based on the review of data that is 
underway, we anticipate a need to tighten the criteria under which this 
separation may be applied, and improve enforcement of procedures 
already in place.
    Vice Admiral Robinson. I believe that a moratorium on personality 
disorder discharges would put an undue burden on our already stressed 
forces and potentially add to the number of considerable hazards 
associated with military service. A servicemember is only separated for 
a personality disorder if a mental health professional determines the 
disorder is so severe that the member's ability to function effectively 
in the Navy environment is significantly impaired to the point where it 
interferes with the performance of their duties or poses a threat to 
the safety or well being of the member or others.
    Lieutenant General Roudebush. Air Force mental health personnel 
exhibit high standards of professional and ethical conduct, and when an 
airmen displays a lifelong pattern of maladaptive behavior the 
diagnosis of a personality disorder is appropriate. In these cases, the 
successful adaptation to the military environment is unlikely. When an 
airman is failing to adapt because of a personality disorder, 
administrative separation is in the best interests of the airman and 
the Air Force. A moratorium on personality discharges will force 
commanders to address these airmen through other measures, such as 
punitive discharges. This would be unfair to airmen with personality 
disorders, because the failure to adapt is secondary to the disorder 
and not misconduct.
    We must also appreciate that further restriction on a Commander's 
ability to separate personnel who are not a good fit to our force, is a 
drain on leaders, stresses our health care system, and may well impact 
spill over to other areas of culture (i.e. like suicide rates, AWOL).

    19. Senator McCaskill. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, do you believe the 1982 DOD 
directive on personality disorder discharges needs to be updated?
    Lieutenant General Schoomaker. I believe all of our policies and 
directives should be routinely reviewed and updated to reflect the 
realities of a Nation at war in a persistent conflict.
    Vice Admiral Robinson. DOD Directive 1332.14, Enlisted 
Administrative Separations, outlines policy for personality disorder 
discharges. This directive was originally issued in January, 1982 and 
updated in December, 1993 and March, 1994 and presently meets our 
needs. Navy policies regarding enlisted separations are in accordance 
with this directive and I do not believe it needs updating at this 
time.
    Lieutenant General Roudebush. It is reasonable that a document last 
published in 1982 be reviewed for currency and updated as appropriate.

    20. Senator McCaskill. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, do you believe new 
safeguards should be applied to personality disorder discharges, 
especially in light of the heavy combat activity of most of today's 
servicemembers?
    Lieutenant General Schoomaker. Yes, some additional safeguards 
should be applied to personality disorder discharges. For example, the 
Army implemented a new policy in August 2007, where all recommendations 
for separation for a personality disorder require review by the 
installation's Chief of Behavioral Health. The Army Staff is currently 
reviewing additional safeguards for soldiers based on length of service 
and combat experience.
    Vice Admiral Robinson. I believe that the current DOD and Navy 
policies regarding personality disorder discharges are sufficient to 
meet the needs of our servicemembers. I certainly recognize that the 
global war on terrorism has placed our sailors in harm's way and some 
may suffer from anxiety disorders like PTSD or other problems like TBI. 
In order for an individual to be discharged for a personality disorder 
they must receive a mental health evaluation by a psychiatrist or Navy 
clinical psychologist (Ph.D.). Our mental health professionals are 
sensitized to the special needs of our sailors returning from a combat 
zone and are able to distinguish between PTSD and a personality 
disorder. Additionally, the Navy will add a requirement to the Military 
Personnel Manual 1910-122 to include the statement in all personality 
disorder diagnoses that the examination included survey for symptoms of 
PTSD and TBI, and that none were found.
    Lieutenant General Roudebush. I agree that existing safeguards must 
be strictly adhered to, and by and large, we do. These safeguards 
include the following: 1) involvement of Air Force mental health 
providers; 2) the use of diagnostic criteria for personality disorders 
as published in the American Psychiatric Association's Diagnostic and 
Statistical Manual for Psychiatric Conditions, 4th Edition; and 3) the 
requirement in DOD Directive 6490.1 that a member with a personality 
disorder must have an impairment ``so severe so as to preclude 
satisfactory performance of duty'' before administrative separation can 
be considered. A key feature of personality disorders involves 
persistent and pervasive patterns of behavior which are distinguishable 
by professionals from transient or emergent psychological issues, such 
as post-traumatic stress, insomnia, and adjustment disorders.
    If the implication is that we are missing diagnoses and there is 
evidence to support that, it would make sense to ensure our mental 
health experts have current training on developing conditions and the 
literature related to it.
    We must also appreciate that further restriction on a commander's 
ability to separate personnel who are not a good fit to our force may 
have other impacts, such as negatively affecting unit morale and 
stressing health care resources, and may well spill over to other areas 
(e.g. suicide rates, AWOL).
    The table below shows Air Force data for personality disorder 
discharges; the number of airmen administratively separated for this 
reason has not gone up during Operation Enduring Freedom (OEF)/
Operation Iraqi Freedom (OIF).
      
    
    

    21. Senator McCaskill. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, do you believe a review 
board should be established to review past personality disorder 
discharges of combat veterans, as I have joined Senator Bond and others 
in calling for?
    Lieutenant General Schoomaker. Soldiers and veterans currently have 
the right to appeal their discharges to the Army Board for Correction 
of Military Records, as created by Congress. I do not believe a 
separate review board is needed.
    Vice Admiral Robinson. To date, there is no evidence there is a 
problem in the Navy with personality disorder discharges and combat 
veterans. However, the NDAA for Fiscal Year 2008 requires DOD to report 
to Congress by 1 Apr 08 on all cases of administrative separation of 
any servicemember who had served in Iraq or Afghanistan since October 
2001 for personality disorder. Before the establishment of a review 
board, I believe it would be prudent to await the results of this 
report.
    Lieutenant General Roudebush. I do not believe an across-the-board 
review is necessary. I am confident in the professional and ethical 
conduct of Air Force mental health providers in these cases, and this 
contention is supported by recent data from the Air Force Personnel 
Center. Trends indicate no increase in personality disorder discharges 
since the start of the war. Of those separated for a personality 
disorder, more than 60 percent are discharged during their first 6 
months on Active Duty and less than 5 percent have deployed. These data 
suggest that the Air Force uses administrative discharges to 
appropriately discharge airmen with longstanding personality issues 
that render them unsuitable for military service.

                        FEMALE WOUNDED WARRIORS

    22. Senator McCaskill. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, I am interested in the 
physical and mental health needs of our female wounded warriors. Many 
studies have shown that women have particularly unique needs when it 
comes to mental health and that PTSD and TBI can sometimes be more 
difficult to diagnose in women. I was pleased that the NDAA for Fiscal 
Year 2008 included language that addressed potential unique needs of 
female wounded warriors. Are you confident that we are doing enough to 
recognize where there are differing needs for treatment of female 
wounded warriors?
    Lieutenant General Schoomaker. No, but we are using a variety of 
treatment interventions to address the unique needs of our female 
soldiers. When clinically appropriate, we will have female-only groups. 
We are attempting to hire 330 more civilian contract mental health 
providers (266 in the United States and 64 at our overseas locations), 
who will treat all soldiers. Our educational products, such as the 
Battlemind training programs and suicide prevention products, consider 
women as part of their target audience. More research is needed to 
assess the gender difference in the military population, specifically 
as related to global war on terrorism operations.
    Vice Admiral Robinson. Navy has long recognized the importance of 
women's health issues and established a women's health program office 
in the Bureau of Medicine and Surgery many years before the onset of 
the global war on terrorism. I am confident that Navy health care 
providers are intimately familiar with the varying needs of our 
heterogeneous beneficiary population, including those of our female 
wounded warriors. Through supplemental appropriations recently enacted 
to address PH and TBI diagnosis and treatment requirements among 
servicemembers, we have expanded access to care for all wounded 
warriors, which, in turn, allows us to more effectively address the 
unique needs of uniformed servicemembers, whether female or male.
    Lieutenant General Roudebush. Since OEF/OIF are the first U.S. 
engagements where women have been exposed to combat stress in large 
numbers, we clearly have lessons to learn.
    Trauma theory and treatment models fortunately have been developed 
through the study of responses to combat, disasters, motor vehicle 
accidents, sexual assault, and abuse trauma. Our current evidence-based 
trauma treatments have been used effectively with both men and women 
across the spectrum of exposures and trauma types. We are confident 
that our models of trauma adequately account for female trauma in terms 
of both assessment and treatment.
    Nonetheless, the study of combat-related trauma and mild TBI in 
women remains in its infancy, and our Air Force and joint Service 
subject matter experts, in conjunction with experts from the Centers of 
Excellence and from academia, are now beginning to establish a body of 
literature that will help to improve our understanding in these areas.

    23. Senator McCaskill. Lieutenant General Schoomaker, Vice Admiral 
Robinson, and Lieutenant General Roudebush, are we doing enough to 
train our mental health and medical professionals to recognize 
differing symptom patterns? For example, do you have separate group 
counseling session for women when treating PTSD?
    Lieutenant General Schoomaker. We consider the uniqueness of every 
patient and provide the best possible treatment available, based on the 
individual patient's symptoms. In some of our facilities, however, we 
do offer separate counseling groups for women diagnosed with PTSD, when 
clinically appropriate. There is no centralized data base that allows 
us to track which facilities offer female only groups. We examine the 
specific needs of our female soldiers and strive to use treatment 
approaches that best meet their needs. We also partner with the VA and 
make use of their specialized programs for women experiencing PTSD. We 
will further review our training curriculum to ensure that we are 
offering adequate training to recognize differing symptom patterns in 
our women patients.
    Vice Admiral Robinson. Using the congressional TBI and PH 
supplemental funds the Navy is implementing enhanced training to 
facilitate early recognition of stress injuries and appropriate 
initiation of clinical intervention at initial point of service. To 
achieve this goal we are using a two-tiered training approach. First, 
we are teaching the early recognition of stress injuries to a broad 
range of Navy caregivers; for example, physicians, nurses, corpsmen, 
chaplains, fleet and family service personnel. The stress injury 
continuum training that was started in September 2007 teaches awareness 
and intervention skills for stress reactions and those with stress 
injuries. Sailors and marines who show potential stress illness 
behaviors are referred to mental health for assessment. The second tier 
consists of enhanced training for the assessment and treatment of PTSD 
and mild TBI to primary care physicians and nurse practitioners. The 
goal is to initiate appropriate therapy for mild-PTSD and mild-TBI 
where sailors and marines receive their routine health care. The goals 
of this training are to enhance early recognition of problems that 
interfere with daily life, begin appropriate treatment in a non-
stigmatizing care environment, and facilitate better use of limited 
mental health clinician services for more complex patients.
    The treatment of PTSD uses a combination of cognitive behavioral 
therapy strategies, medications, individual, and group therapies based 
on a comprehensive assessment of individual symptoms and treatment 
goals. Specific decisions about what type of PTSD group therapy is most 
appropriate are dependent more on trauma exposure rather than gender. 
Decisions about participation in group therapy are made by the patient 
and their primary care provider. The trauma experiences of both women 
and men who have been sexually assaulted tend to have common issues 
around violation, powerlessness, and vulnerability and both genders can 
relate to those issues. Similarly, those exposed to violent crime and 
motor vehicle accidents have different trauma themes than those with 
combat stress injuries. It is also important to note that mixed trauma 
group therapy can be very effective for all participants regardless of 
gender or trauma if the individual is ready for group therapy and the 
clinicians address the diversity of trauma, commonality of post-trauma 
symptoms, and the effectiveness of recovery strategies.
    Lieutenant General Roudebush. We know from the scientific 
literature on PTSD that women are at higher risk to develop PTSD than 
men and that they report twice the lifetime prevalence of the disorder 
in the U.S. population. In the Air Force, female deployers are offered 
a comprehensive range of medical and mental health services to meet 
their needs as identified through our screening procedures. The Post-
Deployment Health Assessment (PDHA) and Post-Deployment Health 
Reassessment (PDHRA) employ the Primary Care PTSD Screen (PC-PTSD). The 
PDHRA also employs the PTSD Checklist-Military Version (PCL-M) for 
assessment of both male and female respondents who screen positive on 
the PC-PTSD. The choice of therapeutic modalities including individual, 
marital, or group therapy are generally determined collaboratively by 
the mental health provider and the patient to accommodate the needs of 
the patient. We are taking the mental health of our female deployers 
extremely seriously and are eager to incorporate the lessons learned 
from the Air Force, other Services, and the growing body of research in 
this area.

                    TRICARE AND MENTAL HEALTH ISSUES

    24. Senator McCaskill. Vice Admiral Arthur, Dr. MacDermid, 
Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant 
General Roudebush, should we expand TRICARE coverage to nonclinical 
mental health counseling? Isn't routine counseling a great way to 
prevent mental health issues from elevating and becoming more urgent 
and clinical in nature?
    Vice Admiral Arthur and Dr. MacDermid. The task force strongly 
supported access to routine counseling for servicemembers and their 
families. In recommendation 5.3.4.10, we recommended that TRICARE 
services be expanded to include treatment for `V-codes,' such as 
partner relational problems, physical/sexual abuse, bereavement, 
parent-child relational problems, and other appropriate services. This 
was the single task force recommendation not endorsed by the Secretary 
of Defense. I believe the reason is that Military OneSource provides 
access to short-term non-medical counseling at no charge for all 
military members and their families.
    Lieutenant General Schoomaker. The Senior Army Leadership has 
identified a vital need to address nonclinical mental health counseling 
for soldiers and their families challenged by frequent and long 
overseas deployments. Ensuring the availability of comprehensive and 
sufficient nonclinical counseling services is a top Army priority. In 
partnership with the TRICARE Management Activity, we are seeking ways 
to deliver better and more comprehensive nonclinical mental health 
counseling for soldiers and their families. Army leadership is 
addressing this priority with the Assistant Secretary of Defense for 
Health Affairs.
    Vice Admiral Robinson. Implementing guidelines of 32 CFR  199.6, 
reflected in the TRICARE Policy Manual, already provide the necessary 
flexibility and support to leverage non-clinical mental health 
counseling and support to beneficiaries while supporting access to a 
higher level of care if symptoms worsen.
    The issue of promoting mental health versus waiting to treat mental 
illness is crucial. The Navy and Marine Corps Operational Stress 
Control program teaches a form of stress first-aid that increases 
shipmate awareness of stress reactions, appropriate responses and 
helping those experience such stress reactions to seek further help. 
Providing, peers, family members, and unit leaders with the tools to 
help others deal with the stresses associated with daily life and 
crisis stressors will strengthen the most important factors for 
ensuring good mental health-social support and group cohesion. The next 
level of resources are the life-skills counseling services to help 
build enhanced coping options. If good social support and enhanced 
coping skills do not help to improve a servicemember's quality of life, 
clinical counseling and augmented social supports should be used.
    Lieutenant General Roudebush. Non-clinical mental health counseling 
is widely available to Air Force members and their families, through 
Military OneSource and Military Family Life Consultants in our Airmen 
and Family Readiness Centers.
    However, I do not support expanding TRICARE coverage to include 
non-clinical services. Maintaining a high degree of confidence in the 
Air Force Medical Service and TRICARE is best accomplished by covering 
the delivery of evidence-based mental health services by licensed 
mental health professionals. To maintain the highest standards of 
professional medical care, we must resist the temptation to consider 
the full range of needs and services that might benefit military 
members and families to be clinical in nature. We cannot maintain 
appropriate standards of care and practice fiscal responsibility if we 
expand our medical services in this manner. I submit that there are 
appropriate mechanisms to meet these needs as previously discussed and 
I support their continued availability as services distinct from 
medical care.

    25. Senator McCaskill. Vice Admiral Arthur, Dr. MacDermid, 
Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant 
General Roudebush, have you looked at the mental health professions and 
determined if we have professionals out there who could be providing 
care to our servicemembers that are currently being left out of the 
TRICARE system? Please discuss both clinical and non-clinical mental 
health professionals.
    Vice Admiral Arthur and Dr. MacDermid. In recommendation 5.3.3.3, 
the task force recommended that a full spectrum of mental health 
professions be used to support the PH of servicemembers and their 
families. A companion recommendation is 5.2.3.3., which recommends that 
mental health professionals apply evidence-based clinical practice 
guidelines.
    The task force received testimony from several practitioner 
organizations seeking greater inclusion in the TRICARE system. We 
believe that TRICARE should constantly be monitoring the development of 
mental health professions, and when a profession has matured to the 
point that its training and certification procedures are such that 
there can be adequate confidence in the quality of care the members of 
that profession are likely to provide, then that profession should be 
included in TRICARE spectrum.
    Lieutenant General Schoomaker. Currently, we are making extensive 
use of clinical and non-clinical mental health providers. Clinical 
personnel include psychiatrists, psychologists, social workers and 
psychiatric social workers. Our clinical personnel need to be licensed 
and credentialed, so that we can be assured we have the best quality 
providers. We also provide nonclinical mental health support through 
the Military and Family Life Consultant (MFLC) Program which provides 
short-term, nonmedical counseling services to military families. MFLCs 
can help people who are having trouble coping with concerns and issues 
of daily life. Counselors and other nonclinical mental health 
professionals often provide support and counseling at our schools. In 
addition, Military OneSource (MOS) is staffed by both clinical and 
nonclinical mental health professionals. Military OneSource supplements 
existing family programs by providing a website and a worldwide, 24-
hour, 7-day-a-week information and referral telephone service to all 
Active, Guard, and Reserve soldiers, deployed civilians and their 
families. Military OneSource services are provided at no-cost to the 
soldier.
    There are many clinicians who have not signed up to be TRICARE 
providers. Anecdotally, providers claim difficulties with paperwork, 
reimbursement, and interference in medical decisions. The TRICARE 
Management Activity (TMA) is working to resolve these issues and urging 
more providers to sign up. Since May 2007, an additional 2,800 
behavioral health providers have joined the TRICARE network. In 
addition, TMA recently required the Managed Care Support Contractor 
(MCSC) to establish toll-free Behavioral Health Provider Locators and 
Appointment Assistance Services. This service allows soldiers and their 
families to call the MCSC to receive assistance with locating a network 
mental health provider.
    Vice Admiral Robinson. The MCSCs have developed and continue to 
refine comprehensive provider networks supporting the MHS including 
nonclinical mental health professionals (Counselors, Pastoral 
Counselors, and Licensed Clinical Social Workers). Although there is 
variability with the reporting format from three contractors, it 
appears that the majority of the networks include nonclinical mental 
health professionals. Although the capacity exists in the majority of 
the networks, the overall use of nonclinical mental health care support 
may be impacted due to referral patterns and the level of knowledge 
required of the health plan by network providers (primary care managers 
(PCMs)). The PCMs may not be leveraging the support from nonclinical 
mental health professionals in their efforts to provide care. This 
presents an education and marketing opportunity for TMA to ensure that 
existing capabilities within the health care plan are clearly 
articulated to network PCMs.
    Lieutenant General Roudebush. There will always be a certain 
percentage of providers who make a choice not to participate in the 
TRICARE program, just as they make that same choice for other health 
plans. The real issue is not whether all providers accept TRICARE but 
if there are adequate numbers of providers accepting it in the areas 
where our servicemembers and families live. The provider's choice to 
participate in TRICARE is contingent upon a whole list of variables. 
There are undoubtedly methods by which TRICARE could increase its 
attractiveness to potential providers, including simplicity of claims 
filing, increased responsiveness to questions, and reimbursement rates. 
As the TRICARE program is not a Service program but in fact a DOD 
program, none of these changes are within the Services' ability to 
implement. We work closely with the TMA to identify locations that 
appear to have issues with access to medical care. They in turn work 
through the Managed Care Support contractor to contact providers in 
that area to encourage them to participate in the TRICARE program.

    26. Senator McCaskill. Vice Admiral Arthur, Dr. MacDermid, 
Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant 
General Roudebush, how are reimbursement rates in TRICARE affecting 
access to mental health care for our servicemembers?
    Vice Admiral Arthur and Dr. MacDermid. The task force was 
repeatedly told during its site visits that low TRICARE reimbursement 
rates are a disincentive to participation in the system. Of course, 
many practitioners would say the same about reimbursement rates for 
other government programs, so TRICARE is not unique. Military families 
are unique, however, in their service to the country in times of war 
and thus may merit special treatment. According to what we were told, 
slow reimbursement and cumbersome application processes are additional 
barriers.
    Lieutenant General Schoomaker. The Supplemental Health Care Program 
(SHCP) is the process for providing soldiers health care services from 
civilian providers. TRICARE reimbursement under SHCP uses the same 
reimbursement rate system as the rest of the TRICARE program. There is 
also a reimbursement waiver system in place to pay higher reimbursement 
amounts to ensure appropriate access to care for soldiers. This system 
allows the Managed Care Support Contractors (MCSCs) to increase rates 
up to 115 percent of the maximum allowable charge. If this increase 
does not improve access, the MCSC will determine the lowest rate the 
provider will accept. The MCSC will request approval of this higher 
reimbursement amount from the TMA.
    Additionally, TMA continues to assess civilian provider acceptance 
of TRICARE patients. The results of TMA's 2007 survey of civilian 
providers show that only 55 percent of psychiatrists accepting new 
patients will accept TRICARE new patients. Approximately 25 percent of 
providers noted reimbursement rates as the main reason they will not 
accept TRICARE patients. Fortunately, title 10 provides the DOD the 
flexibility to approve higher reimbursement amounts in order to obtain 
adequate access to health care services. TMA is currently performing a 
nationwide analysis of access to mental health services. This analysis 
will evaluate the impact of reimbursement rates on mental health 
access. Where appropriate, TMA will have the ability to increase rates 
to improve access.
    Vice Admiral Robinson. The Managed Care Support Contractors (MCSCs) 
monitor network adequacy and provide monthly Network Status/Inadequacy 
Reports--Network Management Activities. Reports are forwarded to the 
Regional TMA with copies provided by the Regions for Service review and 
comment.
    Recent reports provide the following information related 
specifically to mental health:

         Shortage of Psychiatrists in Brunswick, ME--Naval Air Station 
        [Require four Psychiatrists and we have two]
         Shortage of Psychiatrists and Psychologists in the area 
        around Naval Hospital Cherry Point
         Shortage of Psychiatrist in the area around Naval Air Station 
        Springfield, Missouri [require one more Psychiatrist]
         The contractors have not indicated that the above shortages 
        are attributed to low reimbursement rates
         Shortage of Psychologists in the area around Yuma USMC/El 
        Centro area [four Psychologist refusing to contract because 
        they do not need additional business]

                 Two factors may attribute to the above shortage:

                         Anecdotally, this may be attributed to low 
                        reimbursement rates: the reimbursement rate may 
                        not be enough for the local psychologists to 
                        increase their availability
                         Or, it may be attributed to the fact that 
                        there are limited qualified behavioral health 
                        providers within this area and the demand is 
                        beyond the local capacity.

    We have and continue to experience shortages of ENT, 
Anesthesiology, and Plastic Surgery in the area around Twentynine 
Palms. The MCSC (TriWest) continues to pursue these specialties despite 
the reluctance of providers to contract due to low reimbursement rates.
    Although we have seen other surgical and medical specialties refuse 
to join the TRICARE network due to low reimbursement rates, we are not 
attributing shortages with mental health providers to reimbursement 
rates; other than the anecdotal information on the providers in Yuma 
USMC/El Centro. Standard reimbursement rates in areas that have high 
demand and low mental health resources may not be sufficient to entice 
or reward providers to offer preferred access to TRICARE beneficiaries.
    Lieutenant General Roudebush. According to the DOD/HA survey, 
Civilian Physician Acceptance of New Patients Under TRICARE Standard, 
conducted from fiscal years 2004-2007, of those physicians not 
accepting new patients, the number one reason was reimbursement. This 
ranged, as the number one reason, from 23.6 percent to 28 percent for 
the 4 years of the survey. The second highest reason for not taking new 
TRICARE Standard patients was the physician was not available or was 
too busy.
    The specialty least likely to accept any new patients, regardless 
of whether they were TRICARE, was psychiatry with only 89.4 percent 
accepting any new patients. Psychiatry is also the least likely 
specialty to accept new TRICARE Standard patients, with only 48.8 
percent stating they would take new TRICARE Standard patients.
    Taking those two survey results into consideration, it could be 
deduced that reimbursement rates are in fact affecting the decision of 
providers to accept new TRICARE patients.

    27. Senator McCaskill. Vice Admiral Arthur, Dr. MacDermid, 
Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant 
General Roudebush, do we have a problem getting mental health 
professions to enroll in and participate in the TRICARE network?
    Vice Admiral Arthur and Dr. MacDermid. During site visits, the task 
force was not told of difficulties getting professions to accept 
TRICARE, but was told that professionals are sometimes reluctant, for 
the reasons outlined above. Or professionals might accept TRICARE but 
severely limit the number of TRICARE patients that will be seen, in 
order to minimize negative financial impact on their practice.
    Lieutenant General Schoomaker. Participation in the TRICARE network 
by mental health providers varies from market to market. The 2007 TMA 
nationwide survey shows that psychiatrists have the lowest acceptance 
of TRICARE patients when compared to all other provider types. The 
Managed Care Support Contractors are aware of the increased demand for 
mental health services and are actively engaged in the recruitment of 
mental health providers.
    Vice Admiral Robinson. The TRICARE Program is managed by OSD(HA). 
While some Navy Medicine beneficiaries utilize TRICARE, we do not have 
any direct oversight over the mental health manning issues that TRICARE 
may have. We do however, monitor network adequacy reports provided by 
the Managed Care Support Contractors.
    Lieutenant General Roudebush. Getting mental health professionals 
to enroll in and participate in the TRICARE network is challenging. 
Currently there is a nationwide shortage of mental health 
professionals. Several task forces, including the recent Mental Health 
Task Force, identified several critical shortfalls within this 
specialty area. As we generate additional requirements in an 
environment where there is no unused capacity, Alaska for example, we 
will find these shortages increasing.

    28. Senator McCaskill. Vice Admiral Arthur, Dr. MacDermid, 
Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant 
General Roudebush, what do you think we need to do to get more mental 
health professionals accepting TRICARE?
    Vice Admiral Arthur and Dr. MacDermid. According to what we were 
told on site visits, raise reimbursement rates, speed processing of 
claims, and reduce administrative burden.
    Lieutenant General Schoomaker. The DOD has the authority to adjust 
TRICARE reimbursement rates in specific markets for specific 
specialties. The TMA is currently performing a nationwide analysis of 
access to mental health services. The nationwide review by TMA will 
indicate which areas are having problems with mental health access and 
which area may be candidates for an increase in reimbursement rates.
    Vice Admiral Robinson. The TRICARE Program is managed by OSD(HA). 
While some Navy Medicine beneficiaries utilize TRICARE, we do not 
control general contract terms and other conditions that are set by 
OSD(HA).
    Lieutenant General Roudebush. The DOD/HA survey, Civilian Physician 
Acceptance of New Patients Under TRICARE Standard, conducted from 
fiscal years 2004-2007, indicated that the number one reason physicians 
were not accepting new patients was reimbursement. This answer ranged 
from 23.6 percent to 28 percent for the 4 years of the survey. The 
second highest reason for not taking new TRICARE Standard patients was 
their practices were full. This answer ranged from 3 percent to 18 
percent for the 4 years of the survey. A few other reasons were listed 
but were significantly less likely to result in a physician not taking 
new TRICARE patients.
    Based on this data, it appears the area that would most likely 
result in increased provider acceptance of TRICARE would be in the 
reimbursement arena.

    29. Senator McCaskill. Vice Admiral Arthur, Dr. MacDermid, 
Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant 
General Roudebush, what are we doing or should we be doing, in 
particular, to ensure mental health care access to servicemembers 
living in rural and remote areas, such as Guard members who demobilize 
in rural parts of Missouri?
    Vice Admiral Arthur and Dr. MacDermid. Like their civilian 
counterparts, military families living in rural areas face several 
problems in accessing care for PH. There is a well-known shortage of 
providers, such as psychologists and psychiatrists, in such areas. 
There are now fewer military installations than in the past. Another 
problem is that the civilian providers who are present in these areas 
may be whom they come in contact.
    Many advocacy, professional and government organizations are 
working on the problem of reaching rural families, and it seems clear 
that a multi-pronged strategy is required. Elements of such a strategy 
likely include: a) increasing the number of military professionals who 
can be assigned to military installations as needed; b) creating 
incentives for civilian professionals to locate in underserved areas; 
c) increasing the number of DOD family assistance centers and VA vet 
centers; and d) increasing use of technology, such as web-based self-
assessment and education, telephone-based counseling, telemedicine, and 
other emerging strategies.
    Lieutenant General Schoomaker. Military OneSource now offers six 
telephonic mental health counseling sessions which U.S. Army Reserve 
and National Guard soldiers can use in remote areas. Additionally, in 
December 2007, the TMA required the Managed Care Support Contractors 
(MCSC) to establish toll-free Behavioral Health Provider Locators and 
Appointment Assistance Services. This service allows soldiers and their 
families to call the MCSC and receive assistance locating a network 
mental health provider. The provider locator and assistance staff have 
assisted more than 1,500 beneficiaries successfully locate and make 
mental health appointments. This often requires the locator staff to 
conference call with the beneficiary and provider to ensure a 
satisfactory appointment.
    Since October 2006, the Army Wounded Warrior Program has placed 
approximately 35 staff at VA Medical Centers around the country to 
assist wounded warriors, veterans, and their families access needed 
health care and social support services. Additionally, Warrior 
Transition Unit Forward Teams, formerly called AMEDD VA Liaisons, are 
assigned to VA Polytrauma Rehabilitation Centers. These uniformed 
personnel are strengthening the links between Army Medical Treatment 
Facilities, Warrior Transition Units, VA medical facilities, and 
civilian facilities. Some of their outreach efforts are directed at 
Army National Guard and U.S. Army Reserve soldiers.
    Family support is also part of the Army Family Covenant Initiative 
and the Army Campaign Plan. The Army Family Covenant Initiative is an 
approach to standardize and fully fund family programs and services to 
support an expeditionary Army. The Army Integrated Family Support 
Network (AIFSN) is a service delivery system that is part of this 
initiative and will integrate all the programs and services currently 
operational in a State or region, like the Beyond the Yellow Ribbon 
Program, which is a program built specifically for National Guard 
soldiers and their families. The purpose of the Beyond the Yellow 
Ribbon Program is to provide concise, coordinated, and unified support 
to our citizen-soldier and their families to ensure a safe, healthy, 
and successful reintegration following deployments. Connecting 
programs, like Beyond the Yellow Ribbon, to AIFSN will provide a 
conduit for the Army to better prepare and care for all of its 
soldiers.
    Vice Admiral Robinson. We have implemented several programs and 
initiatives to ensure that sailors and marines are provided mental 
health support during and after demobilization. Each of the Uniformed 
Services promote and participate in ``Military OneSource''--a DOD web-
based program providing comprehensive information and assistance 
(including guidance for obtaining counseling) for servicemembers. It 
also offers 24-hour/7-day-per-week toll free telephone access for 
assistance and support. During demobilization, sailors and marines 
receive briefings on post-deployment medical and dental benefits 
including those available through the Transitional Assistance 
Management Program (TAMP), TRICARE Reserve Select (TRS), as well as 
information and resources available at Navy and Marine Corps Reserve 
Centers.
    TAMP offers transitional TRICARE coverage for up to 180 days 
following separation for eligible members and their families. National 
Guard and Reserve members separated from Active Duty after having been 
ordered to Active Duty for more than 30 days in support of a 
contingency operation are eligible for this coverage. Eligible members 
and family members include those who are:

         Involuntarily separated from Active Duty
         Separated from Active Duty after being involuntarily retained 
        in support of a contingency operation.
         Separated from Active Duty following a voluntary agreement to 
        stay on Active Duty for less than 1 year in support of a 
        contingency mission.

    To retain coverage, members must reenroll in TRICARE Prime during 
their transition period. This enables servicemembers and their families 
to access support through the Behavioral Health Provider Locater and 
Appointment Assistance Program, provided by all three Management Care 
Support Contractors. This program offers 24-hour/7-day-per-week 
assistance in locating and obtaining behavioral health care.
    In addition to service described above, Navy Medicine ensures that 
Post-Deployment Health Centers actively support completion of PDHAs, 
for Active and Reserve component members, to monitor the needs of 
servicemembers.
    Navy medicine has used a portion of the TBI and PH Supplemental to 
fund additional support for Naval Reserve personnel. The Navy Reserve 
has received $2.64 million worth of support to establish the Navy 
Reserve Psychological Health Outreach Program. The goals for this pilot 
program are to:

         Create a PH ``safety net'' for Navy reservists and their 
        families, who are at risk for not having their stress injuries 
        identified and treated in an expeditious manner;
         Improve the overall PH of Navy reservists and their families; 
        and
         Identify long-term strategies to improve PH support services 
        for reservists and their families.

    Outreach Coordinators will also be responsible for:

         Coordinating ``Returning Warrior Workshop'' presentations in 
        conjunction with Navy Reserve Component Command Family 
        Readiness Coordinators and members of the Chaplain Corps;
         Working with the Navy Reserve PDHRA program manager to ensure 
        reservists follow through with recommended or requested 
        referrals to mental health care providers; and
         Facilitating access to PH support resources for Navy Reserve 
        family members.

    With respect to specific concerns you expressed regarding rural 
Missouri, I would offer that, while there have been some difficulties 
in maintaining a robust network at Naval Air Station Springfield, and 
the surrounding area, the Managed Care Support Contractor (TriWest) is 
proactively addressing the shortage (one provider) with psychiatrists. 
TriWest has contracted 11 Mental Health Counselors to improve mental 
health access within this area. We are also exploring partnering with 
the University of Missouri in using their curriculum for the Training 
Enhancement in Rural Mental Health program to expand the capabilities 
of our primary care providers, both Active and Reserve component, to 
care for patients with higher level behavioral health problems.
    Lieutenant General Roudebush. The Military Medical Support Office 
(MMSO) serves as the centralized Tri-Service point of contact to 
coordinate health care outside the cognizance of a Military Treatment 
Facility for TRICARE Prime Remote-eligible Active Duty military and 
Reserve component servicemembers within the 50 United States and 
District of Columbia. The MMSO assists the member in finding providers 
and ensuring smooth claims processing. The Air Force has three full-
time military members at the MMSO ensuring these members receive timely 
assistance.

    [Whereupon, at 4:46 p.m., the subcommittee adjourned.]

                                 
