[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
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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\
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\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
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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.
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\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
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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
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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:]
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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.]