[Senate Hearing 111-837]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-837

    THE PROGRESS IN PREVENTING MILITARY SUICIDES AND CHALLENGES IN 
           DETECTION AND CARE OF THE INVISIBLE WOUNDS OF WAR

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

                                HEARING

                               before the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             JUNE 22, 2010

                               __________

         Printed for the use of the Committee on Armed Services




        Available via the World Wide Web: http://www.fdsys.gov/

                               __________







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                      COMMITTEE ON ARMED SERVICES

                     CARL LEVIN, Michigan, Chairman

ROBERT C. BYRD, West Virginia        JOHN McCAIN, Arizona
JOSEPH I. LIEBERMAN, Connecticut     JAMES M. INHOFE, Oklahoma
JACK REED, Rhode Island              JEFF SESSIONS, Alabama
DANIEL K. AKAKA, Hawaii              SAXBY CHAMBLISS, Georgia
BILL NELSON, Florida                 LINDSEY GRAHAM, South Carolina
E. BENJAMIN NELSON, Nebraska         JOHN THUNE, South Dakota
EVAN BAYH, Indiana                   ROGER F. WICKER, Mississippi
JIM WEBB, Virginia                   GEORGE S. LeMIEUX, Florida
CLAIRE McCASKILL, Missouri           SCOTT P. BROWN, Massachusetts
MARK UDALL, Colorado                 RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina         DAVID VITTER, Louisiana
MARK BEGICH, Alaska                  SUSAN M. COLLINS, Maine
ROLAND W. BURRIS, Illinois
JEFF BINGAMAN, New Mexico
EDWARD E. KAUFMAN, Delaware

                   Richard D. DeBobes, Staff Director

               Joseph W. Bowab, Republican Staff Director

                                  (ii)






                            C O N T E N T S

                               __________

                    CHRONOLOGICAL LIST OF WITNESSES

    The Progress in Preventing Military Suicides and Challenges in 
           Detection and Care of the Invisible Wounds of War

                             june 22, 2010

                                                                   Page

Chiarelli, GEN Peter W., USA, Vice Chief of Staff, U.S. Army.....     5
Greenert, ADM Jonathan W., USN, Vice Chief of Naval Operations, 
  U.S. Navy......................................................    13
Amos, Gen. James F., USMC, Assistant Commandant, U.S. Marine 
  Corps..........................................................    20
Chandler, Gen. Carrol H., USAF, Vice Chief of Staff, U.S. Air 
  Force..........................................................    24
Jesse, Robert L., Acting Principal Deputy Under Secretary for 
  Health, Veterans Health Administration, Department of Veterans 
  Affairs........................................................    29

                                 (iii)

 
    THE PROGRESS IN PREVENTING MILITARY SUICIDES AND CHALLENGES IN 
           DETECTION AND CARE OF THE INVISIBLE WOUNDS OF WAR

                              ----------                              


                         TUESDAY, JUNE 22, 2010

                                       U.S. Senate,
                               Committee on Armed Services,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:35 a.m. in room 
SD-G50, Dirksen Senate Office Building, Senator Carl Levin 
(chairman) presiding.
    Committee members present: Senators Levin, Lieberman, 
Akaka, Webb, McCaskill, Udall, Hagan, Begich, Burris, McCain, 
Inhofe, Thune, and Collins.
    Committee staff members present: Richard D. DeBobes, staff 
director; and Leah C. Brewer, nominations and hearings clerk.
    Majority staff members present: Gabriella Eisen, counsel; 
Gerald J. Leeling, counsel; and Jason W. Maroney, counsel.
    Minority staff members present: Michael V. Kostiw, 
professional staff member; Diana G. Tabler, professional staff 
member; and Richard F. Walsh, minority counsel.
    Staff assistants present: Jennifer R. Knowles, Hannah I. 
Lloyd, and Breon N. Wells.
    Committee members' assistants present: James Tuite, 
assistant to Senator Byrd; Nick Ikeda, assistant to Senator 
Akaka; Greta Lundeberg, assistant to Senator Bill Nelson; 
Gordon I. Peterson, assistant to Senator Webb; Tressa Guenov, 
assistant to Senator McCaskill; Roger Pena, assistant to 
Senator Hagan; Lindsay Kavanaugh, assistant to Senator Begich; 
Amanda Fox, assistant to Senator Burris; Anthony J. Lazarski, 
assistant to Senator Inhofe; T. Finch Fulton and Lenwood 
Landrum, assistants to Senator Sessions; Richard Perry, 
assistant to Senator Graham; and Ryan Kaldahl, assistant to 
Senator Collins.

       OPENING STATEMENT OF SENATOR CARL LEVIN, CHAIRMAN

    Chairman Levin. Good morning, everybody.
    The committee meets today to receive testimony on the 
status of our efforts to prevent military suicides and the 
challenges in detection, treatment, and management of the so-
called ``invisible wounds of war,'' which we consider to 
include traumatic brain injury (TBI), and concussive events, 
post-traumatic stress disorder (PTSD), and other combat-related 
psychological health concerns.
    A hearing on military suicides was requested by Senator 
Inhofe several weeks ago, and we all appreciate that request. 
Due to our committee markup schedule, we were unable to 
schedule a hearing until this week. Originally, this hearing 
was meant to focus on Service suicide prevention policies and 
programs. But, given the recent disconcerting reports alleging 
poor diagnosis and treatment of servicemembers suffering from 
TBI and PTSD, I felt it important to broaden the scope of our 
discussion today to include those topics as well, especially 
given the fact that they can often occur concurrently, making 
diagnosis of any or all of these illnesses difficult.
    The increase in suicides by military personnel in the last 
few years is alarming. In 2007, 115 Army soldiers committed 
suicide. In 2008, the number increased to 140, and to 162 in 
2009. Similarly, 33 marines committed suicide in 2007, 42 in 
2008, and 52 in 2009. I understand there are a number of 
additional cases where the Armed Forces medical examiner has 
not yet concluded whether the deaths are by suicide so, the 
2009 numbers will likely be even higher.
    These increases indicate that, despite the Services' 
efforts, there is still much work to be done. We must improve 
our suicide prevention efforts to reverse the number of 
servicemembers taking their own lives.
    I am greatly concerned about the increasing number of 
troops returning from combat with PTSD and TBIs, and the number 
of those troops who may have experienced concussive injuries 
that were never diagnosed.
    Studies indicate that mild TBI, or concussion, is 
associated with PTSD, depression, and anxiety. These 
conditions, in turn, may contribute to the increase in the 
number of suicides.
    One key to suicide prevention is to make greater efforts to 
end the stigma that too many perceive attaches when they 
receive mental health care. Another key, of course, is the 
proper and timely diagnosis and treatment of TBI and PTSD, and 
increasing awareness of, and access to, mental healthcare 
resources, as well as leadership support for those seeking such 
care.
    We hope to hear from our witnesses today the approach that 
each Service and the Department of Veterans' Affairs (VA) is 
taking to help detect, treat, and manage psychological health 
problems, to include PTSD and TBI.
    The numbers of suicides have increased in every Service, 
but significantly more so in the Army and Marine Corps, the two 
Services most heavily engaged in ground combat in Iraq and 
Afghanistan. Congress has recognized the strain on these ground 
forces, and has, over the past several years, authorized 
significant increases in the Active Duty end strengths for the 
Army and Marine Corps. It is our intent that these increases 
will help to relieve the stress on those forces, but we also 
have to make sure that we provide all the assistance that our 
troops need to cope with the stress that they are experiencing.
    The professionals tell us that common issues leading to 
suicide include relationship problems, financial problems, and 
legal problems, as well as mental health issues. I know that 
each of the Services, as well as the VA, have programs to 
address those as part of the suicide prevention efforts. 
Undoubtedly, deployments and lack of dwell time have 
contributed to these underlying problems that are linked with 
suicides.
    The Army is working with the National Institute of Mental 
Health (NIMH) on a 5-year longitudinal study to help identify 
and develop intervention and mitigation strategies to help 
decrease the number of suicides in the Army. While this is an 
important effort, we cannot wait for the full 5 years to occur 
for these results. We must identify actions, and take them now, 
to reduce suicides. General Chiarelli, we look forward to 
hearing about interim findings from the study, and how the Army 
might use those findings now to better target suicide 
prevention efforts.
    We must learn more about TBI and concussive events, and 
their relationship to PTSD and suicide. Unfortunately, these 
brain injuries remain relatively unknown territory in both the 
military and civilian medical environments.
    We look forward to learning more about the policies and 
programs each Service has in place to handle incidences of TBI 
and concussive events, both in theater and at home. We also 
look forward to learning what policies, programs, and 
initiatives each of the Services and the VA has implemented and 
identified to ensure that our servicemembers, in both the 
Active Duty and Reserve components, veterans, and their 
families, receive all of the support that we can provide, and 
that our All-Volunteer Force can continue to perform its 
mission with the health and other services that they need and 
deserve.
    I'm pleased to welcome our witnesses. We have with us 
General Peter Chiarelli, Vice Chief of Staff of the U.S. Army; 
Admiral Jonathan Greenert, the Vice Chief of Naval Operations 
of the U.S. Navy; General James Amos, Assistant Commandant of 
the U.S. Marine Corps; General Carrol Chandler, Vice Chief of 
Staff of the U.S. Air Force; and Dr. Robert Jesse, the Acting 
Principal Deputy Under Secretary for Health for the Veterans 
Health Administration of the VA.
    General Amos, since Secretary Gates has just announced his 
recommendation to the President to nominate you to be the next 
Commandant of the Marine Corps, I know we all offer our 
congratulations and great hopes for you in the future.
    Senator McCain.

                STATEMENT OF SENATOR JOHN McCAIN

    Senator McCain. Thank you, Mr. Chairman.
    Let me thank our witnesses for joining us today.
    I'd like to also acknowledge Senator Inhofe, who initiated 
a request in April for a full committee hearing on the tragic 
and important issue of suicide in our military. Thank you for 
your initiative, Senator Inhofe. I'm pleased that we are having 
this hearing.
    It's our privilege to serve the distinguished men and women 
of our Armed Forces, who, even after more than 9 years of war, 
love their country and risk everything to defend her. We have 
greatest admiration and appreciation for them and for their 
families, and we'll always honor their courage and sacrifice.
    The burdens of our missions in Iraq and Afghanistan are 
tremendous, and so are the consequences for those who serve. 
Many of our servicemembers have answered their country's call, 
with multiple deployments to combat and little time for rest 
and recovery at home.
    The enemy's signature weapon, the improvised explosive 
device (IED), causes multiple injuries to parts of the body and 
brain. As is the case with every war, many of the deepest 
wounds are those that wrack the minds and souls of our citizen 
soldiers, wounds that continue to plague them long after 
they've returned home from the field of battle.
    The Department of Defense (DOD) has documented nearly 2,000 
suicides from 2001 to 2009. Today the Services report more than 
140 during 2010.
    Although the Air Force and Navy have previously experienced 
rates of suicide higher than those reported today, rates for 
the Army and Marine Corps are at historically high levels. 
These are casualties that our Nation cannot accept and that our 
armed services must work to prevent, both among troops who have 
deployed and those who have not. We must erase cultural 
barriers and attitudes from peers and leaders that may cause 
soldiers who need care to turn away from it. We must conquer 
any bureaucracy that stands in the way of compassionate care 
for a man or woman who seeks it.
    Since the attacks of September 11, we have devoted billions 
of dollars to improving care for wounded and ill servicemembers 
and their families provided not just by DOD and the Veterans 
Administration alone, but by many agencies of government and 
the private sector.
    One important example is the National Suicide Prevention 
Lifeline. Crisis counselors who respond to hundreds of calls 
from current and former serving members of the military every 
day. As a Nation, we can be proud of these efforts, but not yet 
content with their results. Teaching our servicemembers and 
their families to navigate complex pathways to care is 
necessary, but leading them there is essential. As in all 
military campaigns, the quality of leadership will determine 
our success or failure.
    Several of our witnesses report that military 
servicemembers continue to distrust informing their chain of 
command that they have a brain injury or that they're 
experiencing stress or considering harm to themselves and 
others, for fear of bringing a sense of shame to themselves and 
their unit. This is unacceptable. There's no shame in admitting 
that you are struggling with the hidden wounds of war, for 
those wounds are every bit as real as those that are visible on 
the surface.
    The Services must increase focus on transforming the 
culture of leadership, and must train more leaders to 
understand that emotional and physical health are critical 
factors in military readiness, and hold them accountable if 
they fail.
    Americans expect that high quality health and mental health 
care, matched by compassionate involvement of military leaders, 
can and will make a difference that is capable of saving lives 
that would be lost to suicide. To meet this rightfully high 
expectation, leaders at every level must exercise their sacred 
obligation to take responsibility for their subordinates, know 
about their lives and families, have conversations with them, 
and listen to their concerns. These powerful human 
interactions, which are the essential character of the core 
military values of trust and cohesion, can save lives. Our 
service men and women and their families deserve nothing less.
    I thank you, and I look forward to hearing the testimony of 
our witnesses.
    Chairman Levin. Thank you very much, Senator McCain.
    We'll start with General Chiarelli, and we'll just go right 
down the table.
    General Chiarelli.

STATEMENT OF GEN PETER W. CHIARELLI, USA, VICE CHIEF OF STAFF, 
                           U.S. ARMY

    General Chiarelli. Chairman Levin, Senator McCain, 
distinguished members of the committee, I thank you for the 
opportunity to appear before you today to provide a status of 
the Army's ongoing efforts to reduce the number of suicides 
across our force, and also detect and care for soldiers 
suffering from PTSD, TBI, and other behavioral health issues.
    I've submitted a statement for the record, and I look 
forward to answering your questions at the conclusion of our 
opening remarks.
    As you are all aware, it remains a very busy time for our 
Nation's military. We're in the ninth year of war being fought 
in two separate theaters. The pace of operations is exceedingly 
high, and will likely remain so for the foreseeable future.
    I'm proud to report that the men and women serving in our 
Army today are doing an absolutely outstanding job. They are 
well trained, highly motivated, and deeply patriotic. Our 
Nation has asked a great deal of them and of their families, 
and they've exceeded expectations by a long shot.
    However, the prolonged demand continues to put a 
significant strain on our force. One of the symptoms of this, 
albeit the most severe, is the historically high number of 
suicides we've experienced in recent years. Fortunately, we've 
seen a fairly significant reduction in suicides among Active 
Duty soldiers this year, as compared to last year. However, 
we've seen an unexpected increase in suicides among our 
Reserve-component soldiers not on Active Duty, in particular, 
the Army National Guard.
    Needless to say, the loss of any soldier, Army civilian, or 
family member to suicide is tragic and unacceptable. Each of 
these suicides represents an individual and a family that has 
suffered an irreparable loss. Over the past 12 months, we've 
learned a great deal about suicides. For example, we now know 
that soldiers with one or no deployments represent 79 percent 
of all suicides. First-termers represent 60 percent of all 
suicides.
    I've worked closely with my colleagues from the Navy and 
Air Force, and particularly with my good friend Jim Amos. Our 
Army and Marine Corps ground forces share a similar mission, 
and we're working together on many of the same issues.
    You have my word that we will continue to work diligently 
to learn even more, in an effort to further reduce suicides in 
our force.
    In the meantime, we've learned a tremendous amount about 
the broader challenge of behavioral health issues affecting 
many of our soldiers, Army civilians, and family members. After 
8-plus years of war and multiple deployments, many are 
suffering from depression, anxiety, TBI, and PTSD, often 
referred to as the ``invisible wounds of war.'' These and other 
highly complex injuries and conditions involving the brain pose 
unique challenges, especially as compared to easily detectable 
wounds, such as an amputation or a burn. In particular, the 
comorbidity of symptoms can make diagnosis especially 
difficult, in many cases, a fact not well understood or 
appreciated by many.
    The reality is, the study of the brain is an emerging 
science, and there is still much to be learned. But, we're 
making progress. Over the past 12 months, the Army's commitment 
to health promotion, risk reduction, and suicide prevention has 
changed Army policy, structure, and processes. We have 
realigned garrison programs, increased care provider services, 
refocused deployment and redeployment integration, and enhanced 
treatment of PTSD and TBI, and promoted tele-behavioral 
medicine.
    Our success notwithstanding, we still have much more to do. 
We face an Army-wide problem that can only solved by the 
coordinated efforts of our commanders, leaders, soldiers, 
program managers, and health providers.
    This is a holistic problem, with holistic solutions, and 
that is how we're approaching it. We remain focused on 
investigating ways to promote resiliency, reduce stressors 
caused by a variety of factors, improve leaders' and soldiers' 
ability and willingness to identify when they or their buddies 
need help, and be able and willing to take advantage of the 
resources and support that are available to them.
    I can assure the esteemed members of the committee there is 
no greater priority for me and the other senior leaders of the 
U.S. Army than the safety and well-being of our soldiers. The 
men and women who wear the uniform of our Nation are the best 
in the world. We owe them and their families a tremendous debt 
of gratitude for their service and many sacrifices.
    Mr. Chairman, Senator McCain, members of the committee, I 
thank you for your continued and generous support and 
demonstrated commitment to the outstanding men and women of the 
U.S. Army and their families. I look forward to your questions.
    [The prepared statement of General Chiarelli follows:]
           Prepared Statement by GEN Peter W. Chiarelli, USA
    Chairman Levin, Senator McCain, distinguished members of the Senate 
Armed Services Committee; I thank you for the opportunity to appear 
here today to provide a status on the U.S. Army's ongoing efforts to 
reduce the number of suicides across our force; and, also detect and 
care for soldiers suffering from post-traumatic stress, traumatic brain 
injury and other behavioral health issues.
    On behalf of our Secretary, the Honorable John McHugh and Chief of 
Staff, General George Casey, I would like to take this opportunity to 
thank you for your continued, strong support and demonstrated 
commitment to our soldiers, Army civilians, and family members.
    As you are well aware, it continues to be a very busy time for our 
Nation's military. We are in the ninth year of war, being fought in two 
separate theaters. The pace of operations is exceedingly high; and, 
will likely remain so for the foreseeable future.
    I will tell you, the men and women serving in the Army today are 
doing an absolutely outstanding job on behalf of our Nation. They are 
well-trained, highly-motivated, and deeply patriotic. Our Nation has 
asked a lot of our soldiers and they have exceeded expectations by a 
long shot.
    However, the prolonged demand on them--and on their families--
continues to put a significant strain on our force. Many individuals 
have deployed multiple times. They are tired. A significant number of 
them suffer physical injuries, such as musculo-skeletal damage, 
amputations, bullet or shrapnel wounds, or burns. Many more suffer from 
behavioral health issues, such as depression, anxiety, traumatic brain 
injury and post-traumatic stress--often referred to as the ``invisible 
wounds of war.'' The Army is continuing to work very, very hard to 
identify ways to address these behavioral health issues by alleviating 
some of the stress on our force while also improving our ability to 
detect, prevent, and treat these and other injuries.
    Our overarching goals are to improve individuals' resiliency; 
eliminate the longstanding, negative stigma associated with seeking and 
receiving help; and, ensure soldiers, Army civilians, and family 
members who may be struggling get the help that they need.
     calendar year 2009 and calendar year 2010 army suicide reports
    Suicides in the United States Army have been on the rise since 
2004. In calendar year 2009, we had 162 active duty suicide deaths 
(including activated members of the National Guard and U.S. Army 
Reserves), with 244 across the total Army. During this same period, we 
had 1,679 known attempted suicides.
    However, so far this year, we've seen a fairly significant 
reduction in suicides among active-duty soldiers. As of 10 June 2010, 
there have been 62 suicides (includes 3 activated USAR soldiers and 3 
activated ARNG soldiers); for the same time period last year there were 
89.
    Unfortunately, we have seen an increase in suicides among Reserve 
component soldiers not on active duty [2010 total (as of 10 June)--53 
(43 ARNG; 10 USAR); 2009 total--42 (same time period)].
    The decrease in active duty suicides would seem to indicate the 
refocused efforts by our Army are beginning to work. Conversely, the 
increase in suicides among Reserve component soldiers not on active 
duty may reflect the Army's more limited ability to influence these 
soldiers once they return home.
    We also track suicides among Department of the Army civilians [2010 
total (as of 10 June) for DA civilians--13; 2009 total--21] and family 
members [2010 total (as of 10 June) for family members--4; 2009 total--
11].
    The loss of any soldier, Army civilian or family member to suicide 
is tragic, incomprehensible, and unacceptable. Each of these suicides 
represents an individual and a family that has suffered an irreparable 
loss. Army leadership is working to better understand the causes of the 
disturbing rise in soldier suicides and we've instituted prevention 
measures that recognize everyone in the Army must be part of the 
solution. You have my word that we will continue to work diligently to 
further reduce suicides across our Force.
                soldiers engaging in high-risk behavior
    Equally alarming to the increase in Army suicides is the growing 
population of soldiers engaging in high-risk behavior. Illicit drug 
use, alcohol abuse, disciplinary infractions, misdemeanors and felony 
crimes are all on the rise. There is a known spike in these behaviors 
as soldiers return from deployments. A so-called ``star burst'' effect 
has been recognized at about the 90 day mark, where an increase in 
these and other high-risk behaviors has been noted. Meanwhile, there is 
a clear link between suicides and these and other high-risk behaviors.
    Of the 160 active duty suicide deaths in fiscal year 2009, 146 were 
related to high-risk behavior (e.g., self-harm, illicit drug use, binge 
drinking and criminal activity); including 74 drug overdoses. Data 
collected since 2005 consistently show that approximately 33 percent of 
suicides included either drug or alcohol use. In addition 32 percent 
had some form of closed or pending misdemeanor or felony investigation.
                        prescription drug abuse
    Meanwhile, recent estimates show that 14 percent--or approximately 
106,000 soldiers--are prescribed some form of pain, depression or 
anxiety medication. This ranges from Percocet for a simple tooth 
extraction to powerful anti-psychotic medications prescribed to an 
individual experiencing a true psychiatric crisis. The potential for 
abuse (or misuse) is obvious. We are working with the legal and medical 
communities to improve transfer of information between commanders, 
medical professionals, and program and service providers, while 
ensuring we protect the privacy rights of patients.
    The office of the Army Surgeon General is also drafting a new 
policy to provide guidance on the prevention and management of 
polypharmacy with psychotropic medications and central nervous system 
depressants. This new policy will assist in reducing adverse clinical 
outcomes among patients receiving care in the military medical system.
    This is one of the major risks associated with suicide: 
polypharmacy, post-concussive syndrome and pain. I have mentioned the 
first two; to address pain management, our medical department recently 
led a task force consisting of subject matter experts from all Services 
and Department of Veterans Affairs (VA). This task force has developed 
a number of recommendations to improve pain management for our 
patients; and, we are currently developing a campaign plan to address 
this important issue. These efforts will improve care for all patients, 
both in and out of uniform.
    The Army is also continuing to conduct and evaluate programs for 
substance abuse self-referral, pre-deployment and post-deployment 
behavioral health screening, and the use of virtual communication 
technology to provide more accessible behavioral health counseling.
    The nationwide shortage of behavioral health care providers and 
substance abuse counselors continues to present a significant 
challenge. The Army is working hard to recruit more in order to meet 
the increased need for these services across our Force.
    For example, one hundred more Medical Corps officers were recruited 
in fiscal year 2009 as compared to fiscal year 2007. One hundred and 
twenty more civilian Behavioral Healthcare personnel were hired in 
fiscal year 2008 compared to fiscal year 2007. Meanwhile, the Army has 
increased funding for use of ``3R'' bonuses (recruiting, relocation and 
retention) in order to hire more substance abuse and family advocacy 
program counselors. The Army has also expanded its civilian force 
structure to include supportive specialties such as Licensed 
Professional Counselors, Licensed Marriage and Family Therapists 
(LMFTs) and Military Family Life Counselors (MFLC).
                   army suicide prevention task force
    After the all-time high of 20 suicides in a single month, January 
2009, the Army mandated an unprecedented Army-wide stand-down followed 
by a deliberate chain teaching program focused on suicide prevention. 
The Secretary of the Army at that time the Honorable Pete Geren, and 
Chief of Staff of the Army, General George Casey appointed me to lead 
the effort to reduce the trend of suicides in the Army.
    I ordered the immediate activation of the Army Suicide Prevention 
Task Force (ASPTF)--a group of multi-disciplinary representatives from 
across the Army staff--in March 2009 to dedicate focused energies and 
resources to tackle all aspects of suicide.
    Over the past year, the ASPTF examined the complexity of suicide, 
taking into account national suicide trends, individual soldier risk 
factors and the Army's institutional approach to suicide prevention. 
The task force identified risk factors and indicators that help 
potentially illuminate correlations to high-risk and suicidal behavior 
in the Army. The task force continues to review over 70 existing Army-
wide programs, identifying those that work, while strengthening the 
most effective programs and streamlining efforts where it makes sense.
    The unique governance, policy, structure and process of the task 
force, together with the Army Suicide Prevention Council (an interim 
HQDA-level organization chartered under my authority and mandated to 
expedite solutions from HQDA through appropriate commands) greatly 
expedited implementation of many strategic changes over the past 12 
months, including:

         June 2009, reduced accessions waivers for adult felony 
        (major misconduct) convictions; and DAT (positive drug and 
        alcohol tests at MEPS); misconduct (misdemeanor/major 
        misconduct) for drug use; possession; or drug paraphernalia, to 
        include marijuana. This translated to nearly 4,300 fewer 
        applicants accepted into the Army as compared to 2008.
         Revised legacy protocols for investigating and 
        reporting suicide.
         Rewrote DA PAM 600-24, Health Promotion, Risk 
        Reduction, and Suicide Prevention (HP/RR/SP) for 
        synchronization of HP/RR/SP Program Portfolio. This policy 
        integrates HP/RR/SP programs and services at the installation 
        level.

                    vcsa suicide senior review group
    In an effort to learn as much as possible from every suicide, in 
March 2009 I also established the monthly VCSA Suicide Senior Review 
Group (SRG). The SRG involves senior commanders from affected commands 
across the Army. We meet in person or via video tele-conference and 
review approximately 15 to 20 suicide cases each month. The cases are 
discussed to glean lessons learned and identify trends and themes in an 
effort to help prevent future suicides. The SRG is the most intense 
2\1/2\ hours I spend each month.
    Also, to aid in gaining as much information as possible from every 
suicide, the task force developed a suicide event collection report, 
comprised of data fields to be filled in by the Field Army. The report 
provides me and Army leadership with instant, actionable information on 
each individual Army suicide within approximately 72 hours of the 
Criminal Investigation Command's initial response.
                 army campaign plan for hp/rr/sp report
    The ASPTF is responsible for the development and publication of the 
Army Campaign Plan for HP/RR/SP, a comprehensive plan outlining 
unprecedented changes in Army doctrine, policy and resource allocation. 
This holistic approach accounts for the many challenges our soldiers, 
Army civilians, and families face. These challenges include, but are 
not limited to: substance abuse; financial and relationship problems; 
and, post-traumatic stress and traumatic brain injury.
    The content of the Campaign Plan was informed and developed by 
three concurrent efforts: (1) the collection of suicide data and 
research; (2) the comprehensive review of existing policy, doctrine and 
all known HP/RR/SP related documents from HQDA and across DOD; and (3) 
the VCSA-led installation level assessment, which obtained input from 
commanders, soldiers and family members and reviewed programs and 
processes at the installation level.
    I also chartered a multi-disciplinary team of experts led by a 
General Officer that is writing a comprehensive report on the Army's 
HP/RR/SP past and future efforts. The team is preparing to release its 
full report as soon as it is completed and reviewed.
    The report represents over a year's worth of work at the direction 
of the Army's Senior Leadership to provide a ``directed telescope'' on 
the alarming rate of suicides in the Army. The report is based on the 
ASPTF's experience, ongoing research; and, presents new concepts and 
modeling for HP/RR/SP governance, policy, structure, and process. It 
represents the most comprehensive HQDA report of its kind, capturing 
both the initial findings of the ASPTF and informing the future of 
suicide prevention within the Army.
    In an effort not to prematurely reveal out of context details on 
findings, I will mention very few in this statement. Prior to the 
formal roll-out, I and the Army's other senior leaders will come back 
and brief the members and their staffs on the full contents of the 
report.
    Bottom line: this report indicates there is a confluence of 
stressors that cause suicides, but no single panacea to prevent them. 
As I have said many times over the past year, there is no one solution 
to this problem.
    Last year, shortly after Secretary Geren and General Casey 
appointed me as lead of this ongoing effort, I visited six 
installations with a team for the sole purpose of looking at suicide 
prevention efforts in the Force. By the time we reached the third 
installation, it was readily apparent to all of us that this challenge 
was not limited specifically to suicides; but, to the overall health 
and well-being of the Force after 8-plus years of war. In other words, 
we quickly determined that suicide is merely a symptom--albeit the most 
severe--of a much larger problem. The focus on suicide prevention was 
too narrow and the aperture needed to widen to a more comprehensive 
review of all soldier and family risk reduction and wellness programs.
    That initial eye-opening experience led to the holistic approach we 
have since adopted to achieve soldier wellness (promoting the physical, 
mental and spiritual health of the force). We remain focused on 
investigating ways to promote resiliency; reduce stressors caused by a 
variety of factors; improve leaders' and soldiers' ability and 
willingness to identify when they or their buddies need help; and be 
able and willing to take advantage of the resources and support that 
are available to them.
                            a team approach
    As I emphasized previously, effectively addressing the challenge of 
soldier suicides will require a team effort across all Army components, 
jurisdictions, and commands, as well as continued cooperation with 
partners outside of our organization, to include VA (has joined the 
Army Suicide Prevention Council) and the National Institute of Mental 
Health (NIMH).
    In October 2008, the Army entered into a 5-year, $50 million joint 
study with NIMH, the Army Study to Assess Risk and Resilience in 
Servicemembers (Army STARRS). This study represents the largest DOD 
longitudinal epidemiologic study of mental health, psychological 
resilience, suicide risk, suicide-related behaviors, and suicide deaths 
in the Army. The goal is to help identify those soldiers most at risk, 
as well as develop intervention and mitigation strategies that will 
help decrease the number of suicides across the Army.
    This is the largest single study on the subject of suicide that 
NIMH has ever undertaken. It includes soldiers from every component of 
the force--Active Army, Army National Guard, and Army Reserve. The 
study will follow willing soldiers as they enter the training base and 
periodically thereafter for the next 5 years. The researchers will 
conduct a variety of interviews, surveys, psychological evaluations, 
etc.
    Intermediate data and emerging results are reported quarterly to 
inform the Army's ongoing intervention strategies. Initial findings 
from preliminary analyses of suicide deaths include:

         Suicide risk is highest for currently deployed 
        soldiers, next highest for previously deployed, and lowest (in 
        relative terms) for never-deployed soldiers;
         Since 2004, suicide risk has been elevated among 
        soldiers with <1 year of service;
         Most (about 53 percent) soldiers who die by suicide do 
        not have a record of an encounter with a behavioral health 
        diagnosis in the military healthcare system;
         Mental disorders, particularly depression, anxiety, 
        and post-traumatic stress are among the most potent risk 
        factors for suicidal behavior; and
         The average period between onset of PTS and an 
        individual seeking help is 12 years; during that period, 
        symptoms can manifest in a variety of ways, including spousal 
        abuse, anger management issues, divorce, drug/alcohol abuse, 
        loss of employment.

    We are confident this study's findings will eventually lead to 
predictive algorithms. Ultimately, we are trying to develop a 
predictive model that accounts for the cumulative effect of transitions 
of all types (accession, PCS, death of family member, TCS, retirement, 
etc.) and stressors across a soldier's entire career. Ideally, this 
would lead to tailored interventions based on known or predictive 
levels of stress. The results will benefit the Army, the other military 
Services, as well as the U.S. population overall, and may lead to more 
effective interventions for both soldiers and civilians.
            traumatic brain injury and post-traumatic stress
    One of the challenges in preventing suicide is recognizing that an 
individual--even someone as close as a family member or good friend--is 
considering taking his or her own life and may need help. Too often 
individuals will suffer in silence. They may be dealing with severe 
depression or anxiety and choose to hide their concerns from family 
members or friends.
    Post-traumatic stress (PTS), traumatic brain injury (TBI), and 
other behavioral health issues can present similar significant 
challenges. I consider these ``invisible injuries'' to be among the 
most common result of the ``signature weapon'' of this war: blast. In 
fact, the majority (60 percent) of the soldiers enrolled in the Army's 
Wounded Warrior program have PTS (43 percent) and/or TBI (17 percent) 
as a primary service disqualifying injury of 30 percent or greater.
    These injuries pose unique challenges, especially as compared to 
easily-detectable wounds such as amputations and burns. PTS and TBI are 
among the most difficult and debilitating in terms of accurate 
diagnosis, treatment, and recovery. The study of the human brain is an 
emerging science; and, there is still much to be learned about these 
and other highly-complex injuries involving the brain. This pertains 
not just within the military community, but throughout the entire 
medical community as a whole, worldwide.
    We are making progress, both in theater and at medical facilities 
around the world. In a concerted effort to minimize the number and 
severity of injuries, the Army implemented a new TBI management 
strategy across the force aimed at prevention, early detection and 
effective treatment of injuries. Additionally, the Army is instituting 
a revised program of instruction for medics and other behavioral health 
providers that includes training specific to TBI and PTS injuries. 
We're also incorporating instruction on this important issue into 
training programs at the National Training Center, Joint Readiness 
Training Center and other locations.
    The new TBI management strategy, ``Educate, Train, Treat, and 
Track,'' is also being successfully implemented downrange. Deploying 
soldiers receive training prior to their arrival in theater; in fact, I 
personally have briefed several units. Last week, I briefed a deploying 
Brigade Combat Team via VTC. This emphasizes to leaders and soldiers 
just how serious I, and the Army's other senior leaders, are when it 
comes to these very serious injuries.
    The new TBI management strategy also includes strict ``event-
based'' protocols that govern exactly what leaders and soldiers must do 
if involved in any type of concussive event. At a minimum, every 
soldier must undergo a medical evaluation followed by a mandatory 24-
hour downtime period and a second exam before returning to duty. We 
cannot permit the proud ``Warrior Spirit'' of our soldiers, which leads 
many of them to ignore their concussions and remain in the fight, to 
dominate the competing need to protect them against another injury 
during the vulnerable period of healing.
    Meanwhile, back at home, since 2002, the Department of Defense has 
opened 52 TBI treatment centers across the country. These centers are 
staffed with multidisciplinary teams of medical providers capable of 
treating the full range of TBI, from mild to severe. The National 
Intrepid Center of Excellence, dedicated to research and treatment of 
military personnel and veterans suffering from TBI and other behavioral 
health issues will open this summer. It is built on the Bethesda, 
Maryland campus of what will become the new Walter Reed National 
Military Medical Center, the DOD's largest and most advanced medical 
complex, and across from the National Institute of Health--a key 
partner in advancing the science and treatment of these injuries and 
illnesses.
    We are making progress, but it remains an incredibly challenging 
endeavor. The reality is some of these neurological injuries or 
conditions cannot be fully healed or repaired even with the most 
advanced medical treatment available. Unlike an amputation, for 
example, there is no standard procedure or prognosis for care for 
moderate or severe TBI. This can understandably add to the frustration 
felt by affected soldiers and family members.
    In the past, individuals suffering from TBI, PTS, or what was 
previously referred to as ``battle fatigue,'' were often told there was 
nothing further that could be done for them. They were discharged from 
the military and left to suffer in silence. This is absolutely 
unacceptable. Next to the prosecution of current and future conflicts, 
our highest priority remains caring for the brave men and women who 
serve and sacrifice on behalf of our Nation.
    In 2007, the Army established Warrior Transition Units (WTU) to 
facilitate the treatment and rehabilitation of soldiers determined to 
require complex medical care for 6 months or longer. Today, there are 
29 WTUs and 9 community-based WTUs located around the world. 
Approximately, 9,300 wounded or injured soldiers are receiving 
treatment at these facilities. Teams comprised of nurse case managers, 
health care providers, and cadre members assist them and their families 
through the full recovery process. The feedback has consistently been 
very positive. We are continually making improvements to the care and 
services provided at these facilities based on lessons learned.
    The Army activated the Warrior Transition Command to oversee the 
WTUs and to guide the ongoing execution and development of the Warrior 
Care and Transition Program. This included accomplishing a paradigm 
shift from simply treating and discharging soldiers to a comprehensive 
program that includes holistically preparing Veterans for a successful 
and productive future in the Army or as a private citizen. The 
overarching goal is to help soldiers and veterans to heal physically 
and mentally while building bridges to positive opportunities that lie 
ahead for them in the future.
    I, and the Army's other senior leaders, are absolutely committed to 
doing anything and everything possible to help these soldiers at all 
stages of care, even after they leave military service.
                       changing the army culture
    Today, there is a wide range of programs and services available to 
soldiers, veterans, Army civilians and family members who need 
assistance. However, individuals are frequently reluctant to seek help. 
We must change the culture of our Army. In the past, there has been a 
stigma associated with seeking help from any kind of mental health 
professional. Soldiers avoided seeking this type of assistance for fear 
that it might adversely affect their careers. However, that is not the 
case; and, we are taking the necessary steps to change this 
misperception across the Army.
               web-based behavioral health care services
    Today, soldiers and family members can access behavioral health 
care services online through the TRICARE Assistance Program (TRIAP). 
The program is open to:

         Active duty servicemembers
         Members eligible for the Transition Assistance 
        Management Program (TAMP) for 6 months after demobilization
         Members enrolled in TRICARE Reserve Select, as well as 
        spouses and family members 18+ years

    Soldiers and family members can access unlimited short-term, 
problem-solving counseling 24/7 with a licensed counselor from home or 
any location with a computer, Internet, required software download, and 
webcam. If more specialized medical care is deemed necessary, an 
immediate warm handoff can/will be made to a medical provider.
    In conjunction with TRIAP, the Army is working to build a network 
of locations and online providers for telemental health services, using 
medically-supervised, secure audio-visual conferencing to link 
beneficiaries with offsite providers. Once in place, this Network will 
be able to provide the full-range of behavioral health care services, 
including psychotherapy and medication management. Our long-term goal 
is to create a network of counselors and certified mental health care 
providers that encompasses the entire United States. Then, when a 
Brigade redeploys, for example, a gymnasium full of stations/computers 
could be put in place allowing every leader and soldier to participate 
in a behavioral health evaluation online upon redeploying.
    From 28 Oct 09 to 18 Nov 09, Tripler Army Medical Center (TAMC), 
Schofield Barracks, HI, conducted a Behavioral Health (BH) virtual 
pilot study with soldiers returning from combat duty to determine 
clinical efficiency of BH screening, comparing face-to-face versus 
webcam versus VTC. A total of 450 soldiers from 25th Infantry Division 
were screened. The results were very positive. Young soldiers indicated 
an overwhelming preference for online counseling versus face-to-face.
    The pilot conducted at TAMC validated the use of virtual BH 
counseling for our returning/redeploying soldiers. In March 2010, we 
conducted a similar pilot for an entire returning Brigade Combat Team 
(4-25 IBCT) at Fort Richardson, AK. Similar satisfaction and increased 
BH referral rates were appreciated; and, we are now implementing this 
virtual BH technology at other locations anticipating returning units. 
These previous efforts will allow us to enhance collaboration with the 
DVA and hopefully expand this capability in the future to include 
TRICARE network BH providers.
                         behavioral health care
    The good news is that soldiers are seeking behavioral health care 
in record numbers with over 236,000 behavioral health contacts in 
fiscal year 2009, indicating that our efforts to emphasize the 
importance of behavioral health are working. In particular, recent 
mental health assessments conducted in theater have shown a marked 
increase in the percentage of soldiers willing to seek mental health 
care without undue concern that it will be perceived as a sign of 
weakness or negatively impact their careers. This is because soldiers 
recognize the importance of individual help-seeking behavior and 
commanders realize the importance of intervention.
    That said, we recognize that we must do more. We must eliminate the 
longstanding, negative stigma associated with seeking and receiving 
help. There is absolutely no reason for an individual to suffer when 
help is available simply because he or she is afraid of how others will 
react.
                                closing
    In my 38-year career in the Army, I have never dealt with a more 
difficult or critical mission than the current charge to reduce the 
number of soldier suicides and properly diagnose and treat individuals 
suffering from TBI, PTS, and other behavioral health issues.
    Over the past year, our commitment to health promotion, risk 
reduction and suicide prevention has changed Army policy, structure and 
processes. We have realigned garrison programs, increased care provider 
services, refocused deployment and redeployment integration, enhanced 
treatment of PTS and TBI, and promoted tele-behavioral medicine. Our 
success notwithstanding, we still have much more to do. We face an 
Army-wide problem that can only be solved by the coordinated efforts of 
our commanders, leaders, program managers and service providers.
    This is a holistic problem with holistic solutions, and that's how 
we are going to continue to approach it with this campaign.
    Again, I can assure the esteemed members of this committee that 
there is no greater priority for me and the other senior leaders of the 
U.S. Army than the safety and well-being of our soldiers. The men and 
women who wear the uniform of our Nation are the best in the world, and 
we owe them and their families a tremendous debt of gratitude for their 
service and for their many sacrifices.
    Chairman, members of the committee, I thank you again for your 
continued and generous support of the outstanding men and women of the 
U.S. Army and their families. I look forward to your questions.

    Chairman Levin. Thank you very much, General.
    Admiral Greenert.

STATEMENT OF ADM JONATHAN W. GREENERT, USN, VICE CHIEF OF NAVAL 
                     OPERATIONS, U.S. NAVY

    Admiral Greenert. Thank you, sir.
    Chairman Levin, Senator McCain, and distinguished members 
of this committee, thank you for the opportunity to testify 
about the ongoing efforts to prevent suicides in our Navy and 
to discuss what has been referred to as the ``invisible wounds 
of war''--namely, PTSD and TBI.
    Each suicide is a tragic loss that can destroy families, 
devastate a community, and impact unit cohesiveness and morale. 
While the contributing factors of suicide are unique to each 
person, a common thread is a personal perceived inability to 
cope with stress.
    Our focus of effort is to better understand the stressors 
that sailors and their families face, and equip them with 
positive methods to cope with stress. We want to foster 
resilience in our sailors and their families, increase unit- 
and family-level vigilance, and encourage early intervention 
and care.
    Our acronym, or our brand, in this, is ACT, A-C-T--to 
``Ask'' about a shipmate, to ``Care'' for the shipmate, and to 
help that shipmate get ``Treatment.'' A first step in this is 
awareness and training of the providers, the sailors, and the 
families. To that end, in fiscal year 2010, training workshops 
for leaders, for first responders, and for suicide prevention 
coordinators, has been conducted at 20 locations in 5 
countries, with 5 more being planned for the end of the fiscal 
year.
    A new training video, called ``Suicide Prevention: A 
Message from Survivors,'' was distributed, just this April. 
Interactive training programs, such as front-line supervisor 
training and peer-to-peer training, have been distributed, 
aimed at strengthening a culture of support. We have trained 
about 120,000 people, so far, in operational stress control.
    A key in all of this is taking control of stressors. Stress 
is a fact of life. We want to reframe the issue, in terms of 
operational stress control, a comprehensive approach to address 
the psychological health of sailors and their families amidst a 
period of high operational tempo, a dynamic work environment, 
and increased deployments. It's a program designed to be 
implemented by leadership at all levels, providing them with 
practical decisionmaking tools for sailors, for leaders, and 
for families to build resilience and improve their awareness of 
stress response, and to take every action to mitigate the 
effects of stress as part of a healthy lifestyle.
    Our sailors deployed to Iraq and Afghanistan face a dynamic 
environment with unique experiences and a preponderance of 
events that could manifest PTSD. Accordingly, we are focused on 
preventing PTSD, building resilience, and eliminating barriers 
or stigma associated with the treatment after deployment.
    Prevention efforts include incorporating operational stress 
control continuum and stress first-aid principles for all our 
sailors, from basic training to flag officer development, Web-
based information resources, and Navy career courses. Our 
Project FOCUS (Families Overcoming Under Stress) is an example 
of a selected intervention for families responding to the 
challenges of deployment and related stresses. It has reaped 
tangible results, and it is being instituted DOD-wide.
    The combat and operational stress first-aid training is 
designed to guide our sailors, our leaders, and caregivers to 
provide support in a manner designed to overcome the stigma of 
requesting help.
    While there are several injury patterns in theater, an 
important area for all of us remains TBI. The diagnosis and 
treatment of TBI is a top priority. There is still much we do 
not know about the injuries and their long-term impacts on the 
lives of our servicemembers. But, through a collaborative 
effort with other Services, Defense Centers of Excellence, 
Defense and Veterans Brain Injury Centers, the VA, and 
academia, we are committed to a full assessment of blast 
injuries, immediate attention to injuries, and ensuring at 
every sailor affected subsequently receives the best medical 
treatment available.
    Surveillance for injuries across the deployment continuum 
is essential to the early identification of TBI. Predeployment 
screening, which will establish a baseline, monitoring and 
treating, in situ, sailors involved in a blast event, and 
instituting tracking mechanisms for followup care are key 
elements.
    I want to thank you for your attention and commitment to 
the critical issue of suicide prevention, and your interest in 
the best possible care for the silent injuries of war: PTSD and 
TBI. By teaching sailors to navigate stress, our Navy will make 
our force more resilient. By assisting in treating those with 
TBI and PTSD, we could eliminate a potential cause of 
depression and suicidal behavior.
    Our Navy is committed to a culture that fosters individual, 
family, and command resilience and well-being. We honor the 
sacrifice and the service of our members and their families, 
and we will do everything possible to support our sailors so 
that they recognize that their lives are truly valued and truly 
worth living.
    On behalf of the men and women of the U.S. Navy and their 
families, thank you for your attention and commitment to these 
issues. I look forward to your questions.
    [The prepared statement of Admiral Greenert follows:]
          Prepared Statement by ADM Jonathan W. Greenert, USN
    Chairman Levin, Senator McCain, and distinguished members of this 
committee, I would like to thank you for this opportunity to discuss 
our efforts to prevent suicides and the treatment of traumatic brain 
injury and post-traumatic stress.
    Suicide loss destroys families, devastates communities, and 
unravels the cohesive social fabric and morale inside our commands. 
Navy has worked at multiple levels to understand and appreciate the 
unique factors that contribute to each loss, and at the same time 
recognize and foster the common factors of the organization and 
environment that help keep people on a path to life.
                              what we know
    In calendar year 2009, 46 Active Duty sailors and 6 Selected 
Reserve sailors took their lives. This translates to an annual suicide 
rate of 13.3 per 100,000. From January through May 2010, there have 
been 13 suspected Active Duty suicides, compared to 20 through May in 
2009; there are 3 suspected Selected Reserve suicides, compared to 2 
through May in 2009.
    Since 1993, Navy suicide rates per 100,000 have ranged from 17.3 in 
1995, to 9.7 in 2005, with an average of 11.6.
    Numbers and rates alone do not describe the entire situation nor 
reveal all the lessons learned to save lives. Each suicide and each 
suicide attempt is investigated. Further a DOD Suicide Event Report, 
and other documents, provides the means to gather case data for 
qualitative and quantitative analysis. Lessons learned are integrated 
into the education and training continuum, communications plans and 
policy changes. Demographic factors, such as age, time-in-service, pay 
grade, and ethnic background have thus far revealed little regarding 
suicide risk; Navy's demographic distribution of suicides largely 
mirrors population demographics. Analyses conducted on deployment cycle 
status, recent deployments, boots-on-ground deployment, and 
``individual augmentee'' status are a relatively proportional to 
suicides among sailors who had deployed (Center for Naval Analysis May 
2010, CNO Executive Panel (CEP) 2010). A deployment experience may 
influence the sequence of events to suicide in some individual cases. 
But, as a whole, deployment history does not appear to affect suicide 
risk.
    Consistent with the last 10 years of analysis, sailors who commit 
suicide tend to have multiple stressors (DONSIR Technical Report, 
DODSER). Recent analysis suggests that as many as half of those who 
committed suicide had transition-related factors, such as: change of 
duty station, deployments, temporary duty or an upcoming separation 
from active duty or retirement (CEP Study: 2010). Periods of duty 
station transition introduce stress, may interrupt social support 
systems, and could result in leadership and organizational systems 
being less available to see some signs of change in a sailor. 
Coincident with their decision to act, many sailors who commit suicide 
had factors or were in situations that affected their judgment: 
including alcohol, anger, high emotion, and/or sleep disruption. We are 
working closely to analyze and understand how work load, operational 
tempo and organizational (unit) factors may contribute to sleep deficit 
and how sleep deficit may link to suicide.
    The 2008 DOD Health Related Behaviors Survey reported that 5 
percent of sailors surveyed had seriously considered suicide in the 
past 12 months. Although that might be a generalization, using the 
force level at that time (340,000), this translates to as many as 
17,000 sailors contemplating suicide in a year. Since the long-term 
annual average of sailors who have died of suicide is 40, it is clear 
that the vast majority of sailors who consider suicide ultimately chose 
a path to life. Factors such as resilience, leadership, peer 
engagement, family bonds, support services, and a sense of purpose can 
compel sailors to not choose suicide.
                              our approach
    Potential solutions to suicide must enhance our ability, as a 
community, to influence one to choose a path of life. That includes the 
ability to recover from traumatic change or misfortune and regain 
physical and emotional stamina. The center of gravity of our policy and 
practice is the combination of resilience of sailors and their 
families, the command's awareness and intervention. We consider it a 
core responsibility to educate, build a resilient force, and provide an 
environment in which sailors and families can thrive in the face of 
dynamic and demanding operations. It is incumbent on every leader to 
build trust and unit cohesion at the command level, and provide a clear 
sense of mission and meaning to what our sailors do. Additionally, 
leaders must identify and assist those faced with significant outside 
stressors, to include relationships, financial and legal matters, 
health and mental health issues, and depression. All of these are 
similar to issues that affect suicide rates in the general U.S. 
population.
                            what we've done
    Navy's suicide prevention efforts focus on leadership, education, 
and awareness. Prevention efforts in the past year have provided policy 
guidance, training, tools, and communication to enable local command 
suicide prevention programs, and strengthen a network of command 
suicide prevention coordinators. Chief of Naval Operations instruction 
(OPNAVINST) 1720.4A, published 4 August 2009, provides updated policy 
for Navy suicide prevention programs centered on local command programs 
supported by a designated suicide prevention coordinator, responsible 
for support of training, intervention, reporting, and response. In 
fiscal year 2010, training workshops for leaders, first responders, and 
suicide prevention coordinators have been conducted at 20 locations in 
5 countries, with 5 more planned by the end of the fiscal year. A new 
training video, ``Suicide Prevention: A Message from Survivors'' was 
distributed in April 2010. Interactive training options such as ``Front 
Line Supervisor Training'' and ``Peer-to-Peer Training'' which include 
skill-building exercises, based on scenarios and role play, have 
further enhanced the command toolkit. Community-specific outreach 
workshops and leadership briefs were provided, upon request, to 
Reserve, Recruiter, and Supply Corps audiences.
    Navy continues a robust communications plan about suicide 
awareness, promoting the core message: ``Life Counts!'' A dedicated 
website (www.suicide.navy.mil), poster series, brochures, videos, 
leadership messages and newsletters communicate Navy's message on 
suicide prevention. Expanded communications have included quarterly 
update messages, public service announcements, and efforts to engage 
sailors in creating innovative options such as our poster contest, in 
which sailors designed the entries and chose the winner with online 
voting. Providing families with information about risk factors, warning 
signs, and support resources has also been a top priority since 
families are the most likely the first to observe sailor distress.
    Our program, ``Operational Stress Control (OSC)'', is an 
increasingly integrated structure of promoting health, family 
preparedness/resilience, and stress prevention. It is aimed at building 
resilience and proactively addressing chronic problems before they 
become acute. OSC \1\ addresses the psychological health needs of 
sailors and their families; it is implemented by operational leadership 
and supported by the naval medical community. OSC provides practical 
decisionmaking tools for sailors, leaders, and families, developing 
their abilities to identify stress responses and mitigate tension. By 
addressing problems early, most individuals should be able to mitigate 
the effects of personal turmoil and acquire the necessary help when 
professional counseling or treatment warrants. The Stress Continuum \2\ 
is an evidence-informed model that highlights the shared responsibility 
of sailors, families, leadership, and caregivers for maintaining 
optimum psychological health. This model has been integrated into our 
behavioral health communications to the Fleet. It includes suicide 
awareness, substance abuse, navigating stress, and leader skills. This 
past year has seen the introduction of a formal OSC curriculum for 
sailors ``from boot camp through War College'', as well as for their 
families. Within a few months, a 1-day, facilitated, skills-based 
course will be available.
---------------------------------------------------------------------------
    \1\ NAVADMIN 332/08 dated 21 November 08 established the Navy's 
Operational Stress Control program.
    \2\  The Navy and Marine Corps utilize the Stress Continuum Model. 
Historically, Navy viewed those under stress as either fit or unfit 
whereas now we understand four distinct stages of stress responses: 
Ready (Green), Reacting (Yellow), Injured (Orange) or Ill (Red). This 
model is used to recognize and intervene when early indicators of 
stress reactions or injuries are present before an individual develops 
a stress illness, such as PTSD or depression.
---------------------------------------------------------------------------
    Recognition of stress related behavior must be followed by 
effective action. We have developed a stress first-aid intervention to 
recognize when a shipmate is in trouble, called Combat and Operational 
Stress First Aid (COSFA). It is being taught to all sailors, to 
intervene and engage that shipmate, and to connect that shipmate to the 
next level of leader and caregiver support. The advantage of this 
integrated approach is that we are training our sailors to look beyond 
stereotypical warning signs, and to recognize changes in behavior and 
initiate helpful actions to save lives, preclude further injury, and 
promote personal growth.
    The Chief of Naval Operations (CNO) directed the establishment of 
the Navy Preparedness Alliance (NPA), represented by Chief of Navy 
Personnel, Commander U.S.. Fleet Forces, Surgeon General, Commander 
Navy Installations Command, and Chief of Navy Reserve, Chief of 
Chaplains, and Master Chief Petty Office of the Navy to address a 
continuum of care covering all aspects of individual medical, physical, 
psychological, spiritual and family readiness across the Navy. The 
``alliance'' has proven valuable in examining the tough readiness 
issues that cross stakeholder boundaries and making informed decisions 
on identified issues. For example, acting on the advice of the 
``alliance,'' Navy placed a limitation on tour lengths for personnel 
assigned to overseas detainee operations, based upon a review of the 
results of the Behavioral Health Needs Assessment Survey (BHNAS) (a 
battery of anonymous self-reports to evaluate psychological well-
being). The Chief of Naval Personnel chairs the NPA and routinely 
reports its findings directly to the CNO. Navy's integrated approach 
continues to rely on leadership monitoring a variety of indicators of 
the ``tone of the force,'' including a comprehensive quarterly review 
of personal and family readiness/preparedness metrics and trends, 
various family readiness polls, and focus groups.
    Support structures and intervention mechanisms initiated in the 
last few years have become more integrated and effective. ``Navy Safe 
Harbor'' \3\ continues its mission to provide nonmedical support for 
all seriously wounded, ill, and injured sailors, and their families, 
with Recovery Care Coordinators and Nonmedical Care Managers covering 
17 locations. The Navy Reserve Psychological Health Outreach (RPHO) 
Program, implemented in fiscal year 2008, provides two RPHO 
Coordinators and three Outreach team members (all licensed clinical 
social workers) to each Navy Reserve Region (five regions) for mental 
health support. The RPHO teams engage in active outreach, clinical 
assessment, referral to care, and follow-up services to ensure the 
mental health and well-being of Reserve sailors and have been actively 
involved in extending tracking and intervention for suicide related 
behaviors in our Reserve community.
---------------------------------------------------------------------------
    \3\ Safe Harbor is a Navy program, established in 2005, for the 
non-medical care management of severely wounded, ill, or injured 
sailors and their families. Safe Harbor sailors have had no suicides.
---------------------------------------------------------------------------
                            what is working
    The 2009 Behavioral Health Quick Poll provided a baseline 
assessment of our suicide prevention and OSC awareness and attitudes. 
This annual poll will be repeated over the next few months to examine 
changes over time. The 2009 poll indicated that 83 percent of sailors 
polled reported receiving required annual training, and 86 percent of 
sailors polled expressed confidence that they know what to do if 
someone talks about suicide or shows warning signs. Over 84 percent of 
enlisted sailors polled and 94 percent of officers polled believed an 
at-risk sailor would get needed help. However, several perceived that 
pursuing treatment would result in some negative impact to their 
careers such as loss of security clearance, or that the individual 
would be treated differently by their peers in the unit. These polls 
have shaped our actions to foster new attitudes and habits, to 
encourage early use of support resources and to provide viable paths to 
unit reintegration and continued Navy service.
                           what we've learned
    There is no conclusive evidence that suicide awareness efforts 
alone reduce suicide rates. Evidence does support the effectiveness of 
comprehensive approaches that include stress reduction, suicide 
awareness, intervention skills, community building, leadership 
engagement, and access to quality treatment. Communities engaged in 
workshop training in 2008-2009 experienced relatively stable or 
declining suicide numbers during this period. A rise in Navy's suicide 
rate in 2009 was, in part, attributable to shore and training units 
that were not systematically included in or utilizing comprehensive 
training workshops, until 2010.
                           where we're going
    Initiatives and areas of expanded focus for fiscal year 2011 
include: providing one-day training workshops for Navy mental health 
providers to improve skills in assessing and managing suicide risk; 
articulation of policies and best-practices regarding communication 
between commands and medical providers related to suicide assessments 
and follow-up care; better communication processes for access to 
support services for civilian personnel; continuing to implement OSC; 
assessing tangible effectiveness of training efforts; expanding post-
intervention support for those affected by suicide loss; and 
researching the means to measure organizational strain in terms of the 
ratio of mission demands to end-strength resources, and how to reduce 
or mitigate strain effects.
                      post-traumatic stress (pts)
What we know
    Combat stress affects each sailor uniquely, falling along a 
physical and emotional stress continuum ranging from stress reactions 
to stress injuries and disorders, to include Acute Stress Disorder and 
Post-Traumatic Stress Disorder. Early identification of symptoms 
enables supervisors and unit leaders to aggressively intervene to 
preclude stress reactions and injuries from becoming stress disorders. 
Navy has channeled our psychological health-related efforts within the 
domains of: reducing stigma through culture change, psychological 
health promotion, surveillance, and clinical care.
What we've done
    Culture Change:
    Using a partnership of Navy line officers and clinicians/
caregivers, Department of the Navy embarked on developing a Maritime 
Combat and Operational Stress Control doctrine that creates a new way 
of thinking and talking about the effects of psychological demands on 
our sailors, marines, and their families. This joint leader and 
caregiver effort created the stress continuum model that provides a 
color-coded paradigm for recognizing and communicating about stress 
injury behaviors. This model has been integrated into our behavioral 
health communications that include: suicide awareness, substance abuse, 
stress management, and leader skills.
    Psychological Health Promotion:
    Psychological health promotion efforts are based on the Institutes 
of Medicine three levels of prevention: universal, selected, and 
indicated. Selected prevention efforts includes stress resilience 
training in operational training, suicide and substance use awareness 
training and leader after action reviews following critical events. 
Project FOCUS (Families Over-Coming Under Stress) is an example of a 
selected intervention for families responding to the challenges of 
deployment. Indicated prevention efforts are those that provide 
critical interventions for those who show stress injury behaviors. The 
combat and operational stress first aid training is designed to guide 
sailors, leaders, and caregivers to provide early non-stigmatizing 
support.
    Surveillance:
    Navy medicine implemented an aggressive in-theater surveillance 
program combining on-site mental health leadership consultation and 
care through the Mobile Care Teams (MCT)--a small team of industrial/
organizational psychologists supported by a clinical mental health 
provider. In conjunction with the consultation and care services, the 
MCT executed the fourth installment of BHNAS. The BHNAS is the most 
comprehensive in-theater mental health assessment conducted by the U.S. 
Navy and provides data relative to critical mental health indices (PTS, 
Depression, Anxiety, Morale, Suicide-Risk, and TBI) as well as 
organizational variables (e.g., living conditions, leadership, unit 
cohesion, family relationships). Data collection for BHNAS IV recently 
concluded in Afghanistan and Kuwait and consisted of over 1,000 sailor 
surveys. Analysis is ongoing.
    Post-Deployment Health Assessments (PDHA) and Post-Deployment 
Health Reassessments (PDHRA) are also utilized to assess the mental 
health of our sailors. Current efforts are underway to expand the 
Mental Health Assessment aspect of these tools to continue surveillance 
for 2 years after redeployment.
    Clinical Care: Beginning in 2007, Navy Medicine established 
Deployment Health Centers (DHCs) as nonstigmatizing portals of care for 
servicemembers staffed with primary care and psychological health 
providers. We now have 17 DHCs operational. Our health care delivery 
model supports early recognition and treatment of deployment-related 
stress reactions and injuries within the primary care setting, enabling 
early and effective interventions to reduce occurrence of post-
traumatic stress disorder and other mental health conditions.
    Navy Medicine emphasizes the importance of evidence-based 
treatments when caring for our wounded sailors and marines with post-
traumatic stress disorder. The Navy Center for Combat Operational 
Stress Control (NCCOSC) has developed the Psychological Health Pathways 
program and is currently pilot testing this program at Naval Medical 
Center San Diego, Naval Hospital Camp Pendleton, and Naval Hospital 
Twentynine Palms. The program is designed to track all patients 
diagnosed with PTSD to ensure that clinical practice guidelines are 
followed and evidence-based care is provided to each patient. It 
involves aggressive mental health case management, standardized 
measures, provider training and comprehensive data tracking.
What we've learned
    Command and shipmate intervention can help prevent stress reactions 
and injuries from developing into stress disorders such as post-
traumatic stress disorder, depression, and other mental health 
conditions that could potentially lead to suicidal behavior. Navy's 
broad array of prevention, early intervention, and treatment programs 
serves to empower shipmates, supervisors, and leaders to identify 
stress symptoms early in the reintegration process and get them the 
level of support they need.
Where we're going
    Navy is constantly assessing the effectiveness of current programs, 
with a priority on increasing access to evidence-based programs with 
proven outcomes. Research efforts are underway to build on the rapidly 
growing body of knowledge regarding the innovative prevention and 
treatment of stress disorders in military populations.
    Navy Medicine is actively engaged in ongoing efforts with the 
Department of Veterans Affairs (VA) and the other Services to implement 
the Integrated Strategy for Mental Health. The goal of this effort is 
to collaborate and coordinate across departments to develop a 
population based continuum of care.
                         traumatic brain injury
What we know
    While there are many significant injury patterns in theater, an 
important focus area remains Traumatic Brain Injury (TBI). Blast is the 
signature source of injury of Operation Enduring Freedom and Operation 
Iraqi Freedom, and blast injury often causes TBI. Sailors are deployed 
in support of operations in Iraq and Afghanistan and, accordingly, 
treatment of TBI is a priority for Navy. The majority of TBI injuries 
are categorized as mild--a concussion. There is much we do not know 
about these injuries and their long-term impacts on the lives of our 
service members.
What we've done
    Education of sailors and medical personnel about the early 
identification and treatment of TBI is critical to the successful 
recovery. Navy medicine is addressing this issue by providing TBI 
training to health care providers from multiple disciplines throughout 
the fleet. This training is designed to educate personnel about TBI/
concussion, ensure all medical personnel are familiar with tools used 
to assist in diagnosis of TBI, and to review guidelines for the 
treatment of TBI.
    Navy Medicine, in partnership with the Center for Deployment 
Psychology at the Uniformed Services University, is providing hands-on 
training on TBI/Concussion management and the Military Acute Concussion 
Evaluation, an in-theater screening test for possible TBI. Initial 
training has been provided to 688 medical officers, physician 
assistants, and Hospital Corpsmen. Plans are underway to expand this 
training.
    Surveillance for injuries across the pre and post deployment 
continuum is essential to early identification of TBI. Pre-deployment 
screening with the Automated Neurological Assessment Metrics (ANAM) 
establishes a baseline, and enables identification of individuals with 
conditions that should preclude deployment. Navy has implemented ANAM 
testing with targeted testing of the highest risk communities, 
including: Navy Military Construction Battalions, Explosive Ordnance 
Detachments, and Weapons Intelligence Units.
    The Navy is standardizing a model for treatment of injured service 
members with Traumatic Brain Injury/Concussion and will implement it 
across the Navy Medicine enterprise. The multidisciplinary model will 
be primary care based with active case management to ensure 
coordination of care. Experts in treatment of TBI are available to all 
individuals with TBI that need care beyond what can be provided in Navy 
Primary Care.
    We are employing a strategy that is both collaborative and 
integrative by actively partnering with the other Services, Defense 
Center of Excellence for Psychological Health and Traumatic Brain 
Injury, Defense and Veterans Brain Injury Center (DVBIC), the VA, and 
leading academic medical and research centers to make the best care 
available to our wounded, ill and injured afflicted with TBI.
What we've learned
    In order to detect TBI cases earlier, event-based reporting is 
required to ensure that all at risk individuals receive proper 
evaluation. Additionally, we have learned that there are other tools 
available to help diagnose TBI that may be more effective than the 
ANAM. Navy will continue to explore new ways to identify individuals 
with TBI so that they can receive the care they need.
Where we are going
    Navy Medicine is working with the Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury and the DVBIC, as well 
as the other Services, to ensure we have a comprehensive TBI 
surveillance program in place for the identification and early 
management of TBI cases in theater. This process again emphasizes the 
importance of collaboration between line and medical leaders. The new 
in-theater TBI surveillance process will be based upon incident event 
tracking and will require that leaders send all service members with 
suspected concussions and those exposed within a set radius of an 
explosive blast to medical for evaluation. This process will cast a 
wider net to further ensure individuals with TBI are identified early.
    Navy Medicine is also working to establish TBI Restoration Centers 
in theater, where servicemembers can receive assessment and short-term 
treatment from a team consisting of a psychologist, physical therapist, 
occupational therapist, and a sports medicine trained family physician.
                               conclusion
    On behalf of the men and women of the U.S. Navy, I thank you for 
your attention and commitment to the critical issue of suicide 
prevention and in your interest in the best possible care for the 
silent injuries of war: PTS and TBI. By teaching sailors to navigate 
stress, Navy will make our force more resilient. By assisting and 
treating those with TBI and PTS, we could eliminate a potential cause 
of depression and suicidal behavior. Navy is committed to a culture 
that fosters individual, family, and command resilience and well-being. 
We honor the service and sacrifice of our members and their families, 
and we will do everything possible to support our sailors, so that they 
recognize that their lives are truly valued and truly worth living.

    Chairman Levin. Thank you so much, Admiral.
    General Amos.

 STATEMENT OF GEN. JAMES F. AMOS, USMC, ASSISTANT COMMANDANT, 
                       U.S. MARINE CORPS

    General Amos. Thank you, Chairman Levin and distinguished 
members of the committee, for inviting me here today to discuss 
the issues of suicide, TBI, and PTSD.
    On behalf of the more than 240,000 Active and Reserve 
marines and their families, I'd like to extend my appreciation 
for the sustained support Congress has faithfully provided its 
Marine Corps.
    As we begin this hearing, I would like to highlight a few 
points from my written statement:
    You have rightfully focused on three of the most difficult 
challenges facing the Marine Corps today. Let me assure you 
that the leadership of the Marine Corps recognizes the 
seriousness of the challenges we face with TBI, PTSD, and 
suicide, and we are doing all that we can to prepare and to 
protect our young men and women.
    We have learned much in the last several years about the 
effects of concussive events and combat stress on our marines 
that we just simply did not know several years earlier in this 
long war. With the knowledge we have gained, we have made 
progress in training to develop resiliency in diagnosing and 
treating TBI and PTS, and at educating our marines to prevent 
suicides.
    We also realize that we have much more to do. With the 
benefit of research coordinated by organizations such as the 
Defense Centers of Excellence for Psychological Health and TBI, 
we will continue to improve our diagnostic tools and treatment 
for these injuries.
    The tragic loss of a single marine to suicide is deeply 
felt by all of us who remain behind. We have experienced about 
the same number or suicides this year as we had last year at 
this same time. We recognize that our considerable efforts to 
prevent suicides must continue if we are to turn the trend of 
the last few years around.
    We are building on the noncommissioned officer (NCO) 
training program that we launched, late last year, to reach the 
rest of our Marine Corps. We continue to examine each suicide 
carefully and forensically, and disseminate the lessons learned 
from that across all Marine Corps leadership.
    I have personally been involved, along with General 
Chiarelli, USA, in the development of theater guidelines for 
the detection and treatment of mild TBI. The newly established 
concussive protocol and regulations we have in place for 
marines deployed in Afghanistan are squarely aimed at the 
leaders and medical personnel, all in an attempt to further 
care for our wounded marines and sailors. It will ensure that 
those exposed to concussive events will be properly diagnosed 
and receive immediate attention, and that this information will 
have been properly recorded for future reference. The long-term 
objective of this protocol is to reduce the chances that a 
marine or sailor will suffer the effects of a blast injury at 
some later date, perhaps even years later.
    PTSD is a real injury that is often difficult to diagnose. 
Many marines are reluctant to recognize the fact that they are 
injured, and even more reluctant to come forward. Our efforts 
to reduce this injury begin early on in our training regimen, 
by training marines to be more resilient to the stresses of 
combat. We have embedded mental health professionals in our 
combat units to reduce the stigma and the barriers to seeking 
help. We are exploring new ways to ensure that marines have 
access to care, including the establishment of a new crisis 
hotline aimed at marines, for marines and their families.
    Partnering with the medical community, we are committed, as 
a Corps, to making sure every marine struggling with stress 
gets the support and, if needed, the treatment they need. While 
there is no single answer that will solve the challenges of 
rising suicides, TBI, and PTSD, we are committed to exploring 
every potential solution and using every resource we have 
available. We will not rest until we have turned this around.
    Thank you again for your concern on these very important 
issues. I thank each of you for your faithfulness to our Nation 
and your confidence in the leadership and commitment of your 
Marine Corps.
    I request that my written testimony be accepted for the 
record. I look forward to your questions.
    [The prepared statement of General Amos follows:]
             Prepared Statement by Gen. James F. Amos, USMC
    Chairman Levin, Senator McCain, and distinguished members of the 
committee; on behalf of your Marine Corps, I would like to thank you 
for inviting me here today to discuss the issues of suicide, traumatic 
brain injury (TBI), and post-traumatic stress (PTS). We are grateful 
for your continued generous and faithful support and for your attention 
to these critical issues.
                                suicide
    With every suicide case there is a unique life to understand. As a 
matter of practice, I am fully briefed on each and every suicide and 
believe that suicide prevention is a leadership issue. We are certain 
of this: there is no single answer that will prevent suicides, and 
solutions must include initiatives that approach the problem from 
multiple angles and from multiple disciplines.
    Central to our efforts, we are educating all marines to be focused 
on this fight. Whenever a Marine is in distress, whether due to a 
relationship problem, mental illness, financial crisis or combat 
experience, it is the responsibility of all marines to get that Marine 
to help. We are working hard to eliminate the stigma that deters some 
marines from seeking care.
    Whether our total suicide numbers trend higher or lower, one 
suicide is still one too many. The Commandant and I, along with other 
Marine Corps leaders, remain actively engaged in this fight.
                      understanding the statistics
    Between 2001 and 2007, the number of suicides in the Marine Corps 
fluctuated between 23 and 34, but in the past 2\1/2\ years we have seen 
a disturbing increase. From a recent low point of 25 suicides in 2006, 
the number increased to 33 in 2007, 42 in 2008, and 52 in 2009. This 
year, from January 1, 2010 through June 8, another 21 Marines have died 
by suicide, which the exact same number of suicides that we had last 
year through the 8th of June. Our suicide rate in 2009 was 24.0 
suicides per 100,000 marines, which exceeded the national civilian rate 
of 20.0 per 100,000 when adjusted to match the demographics of the 
Marine Corps. Attempted suicides have also increased from 103 attempts 
in 2007, to 146 in 2008, and to 164 in 2009. Through June 8 of this 
year, 89 marines have attempted suicide. This is an increase from the 
same time last year.
    Marines who attempt suicide resemble our institutional 
demographics: Caucasian male, 17-25 years old, and between the ranks of 
Private and Sergeant (E1-E5). As with suicides, reported risk factors 
and stressors for suicide attempts also center on mental health issues 
and relationship problems.
    Based on our ongoing assessment, we are also concerned that our 
current surveillance and investigative procedures may be missing 
qualitative data from the final 72 hours prior to a marine's death. As 
a result, we are exploring a forensic psychological autopsy study to 
more fully understand the detailed processes that lead to a marine 
suicide, which we hope will further inform points at which intervention 
may prevent another tragedy from occurring.
    Additional analysis is being conducted to assess the impact that 
operational deployments may have on suicide rates. To date, this data 
suggests that while the continuing stress resulting from overall 
operational tempo may be a factor in our increasing suicide rate, there 
does not appear to be a difference in suicide risk resulting from 
deployment history. Our analyses also suggest that there is no specific 
time period post deployment that is associated with increased risk of 
suicide for marines.
                           suicide reporting
    We review and investigate all non-hostile casualty reports daily to 
track both suicides and suicide attempts and we coordinate weekly with 
the Armed Forces Institute of Pathology, who is the final arbiter on 
the manner of death for the Marine Corps. When a suspected suicide or 
attempt is reported, our Suicide Prevention Program Office makes 
contact with the local command to verify the report and facilitate 
their completion of the Department of Defense Suicide Event Report 
(DODSER). This surveillance tool is standardized for use by all 
Services. Along with the other Services, we initiated use of the DODSER 
in January 2008 for suicides, and in December 2009, we began using it 
for all suicide attempts. We believe that the standard operating 
procedures put into place for reporting suicide attempts will 
facilitate a richer dialogue between medical personnel and marine 
leadership.
    After each suicide, we do an extensive review of the factors 
leading up to the suicide. We seek information from leaders, co-
workers, friends, and medical personnel. We do not require information 
from family members so as not to burden the family at a time of such 
tragic loss and grief, but include it when available in such a manner 
that will not compound their loss.
    In November 2009, I directed all Commanding Generals to personally 
receive investigative information on all suicides under their command 
and to report those deaths directly to me. Lessons learned identified 
in these reviews are analyzed and selected for inclusion in a monthly 
report that is sent to all Marine Corps General Officers, Senior 
Executive Service civilians, and Sergeants Major across the Marine 
Corps.
                       suicide prevention efforts
Training
    We have learned that peer to peer leadership is essential and our 
gradually increasing understanding of this problem over the last 5 
years led directly to the creation of the Non-Commissioned Officer 
(NCO) suicide prevention course, ``Never Leave a Marine Behind.'' The 
course was developed with a targeted process approach to ensure it was 
reality-based, relevant for and about NCO marines. Despite NCOs and the 
marines they lead making up about 75 percent of the Marine Corps, that 
group of Marines has accounted for up to 93 percent of marine suicides. 
Since the implementation of the course, they now account for 81 percent 
of marine suicides. We have directed the development of similarly 
targeted courses for our youngest marines (private to lance corporal), 
staff-NCOs and officers.
    In addition to targeted training approaches, prevention is 
incorporated into our formal education and training at all levels of 
professional development and throughout a Marine's career; from recruit 
training in boot camp and new officer training in The Basic School, to 
the Sergeants Major Symposium and the Commanders Course for senior 
leaders. Training is continuously evaluated and revised to reflect the 
best practice as science knows it today. It is also taught using 
warrior metaphors in the Marine Corps Martial Arts Program, in which 
every Marine participates.
Partnerships
    The complex nature of suicide requires an important balance between 
immediate action and long-term thinking. We are fully engaged in 
research efforts with both Federal and civilian partners to fill in the 
gaps in our understanding and continue to guide our prevention efforts. 
We continue to coordinate our suicide prevention efforts with other 
experts from across the Federal Government, civilian organizations, and 
with international military partners. Some specific examples include:

         The Secretary of the Navy authorized $10 million to 
        fund the Marine Corps' participation in the Army's ground 
        breaking study with the National Institute for Mental Health 
        (NIMH) called the ``Study to Assess Risk and Resilience in 
        Servicemembers'' (STARRS). The Marine Corps and NIMH program 
        managers are currently developing the procedures that will 
        guide the study. The Army STARRS team is providing their full 
        and complete support as we join this unprecedented 5-year 
        longitudinal study on modifiable risk and protective factors 
        related to mental health, suicide and resilience. The study has 
        been specifically designed to return timely information to 
        Marine Corps leadership to inform our evolving prevention 
        strategies and is likely to inform our suicide prevention 
        program this year and for many years to come.
         We actively participate as a member of the DOD Suicide 
        Prevention and Risk Reduction Committee (SPARRC), meeting 
        monthly with our DOD and Veterans Affairs (VA) partners to join 
        efforts in reducing suicides.
         The Marine Corps also chairs the International 
        Association of Suicide Prevention Task Force on Defense and 
        Police Forces. This Task Force includes membership from 15 
        different countries working together to share best practices 
        and develop effective suicide prevention programs, building on 
        shared unique experiences in military culture that crosses 
        national boundaries.
            traumatic brain injury and post-traumatic stress
Traumatic Brain Injury (TBI)
    Naval medicine remains at the forefront of researching and 
implementing pioneering techniques to treat TBI. The Marine Corps is an 
active partner with the medical experts within and outside the 
Department of Defense in continuing to advocate for innovative research 
and best practice dissemination to improve the lives of our marines. We 
are complying fully with the DOD directive for each deploying marine to 
complete the Automated Neuropsychological Assessment Metrics test prior 
to deployment. Along with the Vice Chief of the Army, I have personally 
been involved in the development of theater guidelines for the 
detection and treatment of TBI. These departmental level guidelines are 
aimed at Leaders as well as medical personnel and will ensure that 
marines who are exposed to potentially concussive events will have this 
information recorded for future reference as well as removing the onus 
from the individual to self identify to receive a medical evaluation.
    We have put into effect this new protocol for concussive events 
that will improve our ability to diagnose, track, and treat marines and 
sailors who may suffer mild TBI. This protocol requires all personnel 
in proximity to the blast event to be screened by medical personnel to 
better identify those that might have suffered a concussion. Those that 
show signs of a concussion are required to rest and are treated and 
evaluated prior to being returned to duty. The protocol takes into 
account the severity of the injury as well as whether this is the 
marine's first concussive event or if he has been subject to previous 
events. This new protocol will result in better diagnosis, 
recordkeeping, and treatment of marines and sailors at the time of the 
injury, which in turn will reduce the chances that the marine or sailor 
will suffer effects of the injury at some later date.
Post-Traumatic Stress (PTS)
    We are attentive to the mental health of our warriors and we are 
dedicated to ensuring that all marines and family members who bear the 
invisible wounds caused by stress receive the best help possible. We 
developed the Combat Operational Stress Control (COSC) program to 
prevent, identify, and holistically treat mental injuries caused by 
combat or other operations. Again partnering with the medical community 
we are committed as a Corps to making sure every marine struggling with 
a stress issue gets the support and if needed, treatment, they need.
Resiliency Training
    We have taken steps in our pre-deployment training to improve our 
marines' resiliency and give them the tools to deal with the stresses 
of combat. Realistic training prepares our deploying marines by 
simulating as closely as possible the sights, sounds, smells, and 
sensations of combat. Our Infantry Immersive Trainer at Camp Pendleton, 
CA, is a state-of-the-art facility that seeks to give the experience of 
combat to our marines in training. We are expanding this capability by 
establishing other immersive trainers at locations such as Camp 
Lejeune, NC.
Combat and Operational Stress Control Program
    The COSC program is a program through which Marines and leaders are 
trained to prevent, detect, and manage stress problems in marines as 
early as possible. COSC provides leaders with the resources to 
intervene and manage these stress problems in theater or at home. 
Collaboration between warfighters in the Marine Expeditionary Forces, 
Navy Medicine, and Navy Chaplains resulted in the Combat Stress 
Continuum Model. This tool facilitates the identification of distress 
in marines and offers a decision tree to guide leaders' responses.
    To assist with prevention, rapid identification, and effective 
treatment of combat operational stress, we have expanded our program of 
embedding active duty Navy mental health professionals in operational 
units--the Operational Stress Control and Readiness (OSCAR) Program--to 
directly support all Active and Reserve ground combat elements in 
theater. We are extending OSCAR capabilities down to all of our 
infantry battalions and companies by providing additional training to 
doctors and corpsmen, chaplains, and selected leaders within each unit 
to make expertise more immediately available, and to decrease stigma 
through building relationships.
                               conclusion
    Suicides are a loss that we simply cannot accept. Leaders at all 
levels are personally involved in efforts to address and prevent future 
tragedies. Taking care of marines is fundamental to our ethos and 
serves as the foundation of our resolve to do whatever it takes to help 
those in need at every possible juncture whether it be suicide 
prevention, documenting and tracking concussive events, and assisting 
those with PTSD and combat operational stress. We are aggressively 
acting to increase our prevention activities and follow-on care in 
these areas. The further left of an incident is our best opportunity to 
save lives by connecting Marines to needed help and mentorship. 
Likewise, TBI and PTS are very real injuries that must be diagnosed, 
recorded, and treated. We have taken concrete steps to do just that and 
will continue our efforts to build resilience and reduce the stigma of 
seeking help for these wounds. Thank you again for your concern on 
these very important issues.

    Chairman Levin. Thank you, General.
    The testimony of all of our witnesses will be made part of 
the record, and we thank you for that.
    General Chandler.

   STATEMENT OF GEN. CARROL H. CHANDLER, USAF, VICE CHIEF OF 
                     STAFF, U.S. AIR FORCE

    General Chandler. Thank you, Mr. Chairman, distinguished 
members of the committee. Thank you for the opportunity to 
address suicides in the Air Force, as well as the detection and 
care of our airmen suffering from PTSD and TBI.
    The Air Force is strongly committed to the physical, 
emotional, and mental health of our airmen. We appreciate the 
linkage between health of the force and mission readiness. The 
number of airmen taking their own lives has been rising, 
despite our commitment to prevention. Similarly, PTSD is an 
area of increasing concern. Finally, our ability to detect and 
treat TBI continues to be challenging.
    The mental state of individuals contemplating suicide, and 
the actual condition suffering PTSD and TBI, are similar, in 
that they often do not manifest themselves in visible ways. The 
Air Force suicide rate recently reached slightly more than 14 
suicides per 100,000 total-force airmen. Nearly two-thirds were 
not receiving assistance from mental health professional, 
despite concerted effort to reverse a long-held bias against 
seeking mental health assistance.
    While no segment of the Air Force is immune to suicide, 
there are known high-risk populations and known common risk 
factors, like relationship problems, legal issues, financial 
troubles, and the history of mental health diagnosis. The Air 
Force recognizes suicide as a public health concern that 
requires active and persistent involvement from commanders, 
supervisors, and peers, often referred to as ``wingmen,'' at 
all levels of the organization. Their increased involvement is 
made easier and more effective through more available 
professional counseling service and focused training. All part 
of our improved resiliency program.
    The Air Force initiated the Total Force Resiliency Program 
in February of this year to holistically address the root 
causes of suicide. The Air Force program reflects a broadbased 
approach to supporting airmen and their families, recognizing 
that physical, mental, and emotional health are critical to the 
quality of life and readiness of the force.
    Airmen Resiliency Programs and the Air Force Suicide 
Prevention Program are complementary efforts that rely on 
leadership and engagement, immediate family involvement, and 
wingmen support are key components. In May, the Air Force Chief 
of Staff directed a servicewide Wingman Day to reinforce the 
significance and role of every airman as mutually-supportive 
critical components in suicide prevention and resilience. There 
is no substitute for airmen knowing their subordinates, and 
their coworkers well enough to recognize changes in attitude, 
behavior, and personality, and then intervening when something 
is not right.
    Part and parcel of these programs is an effort to expand 
the availability of professional counseling. The Community 
Action Information Board, which provides a forum for cross-
organizational review and resolution of individual, family, 
installation, and community issues, is now chaired by me, the 
Air Force Vice Chief of Staff, to provide adequate oversight, 
in light of our increasing suicide rates. Also, professional 
counseling is available, now more than ever, through primary 
care clinics, the Airmen Family Readiness Centers, and through 
DOD's Military OneSource Referrals for confidential no-cost 
counseling. Complementing this increased capacity are training 
programs to better prepare our individual airmen.
    Resiliency training is delivered in a tiered fashion, based 
on risk factors. Those most at risk receive the greatest and 
most structured exposure to resiliency and suicide prevention 
training, while basic education and training is made available 
to low-risk audiences, via unit briefings, chaplain services, 
financial classes, and computer-based training. Additionally, 
the Air Force is identifying strategies to ensure all 
accessions are exposed to Total Force Resilience and Suicide 
Preventions Programs early on. Additionally, airmen will get 
additional training and assistance as they deploy from combat.
    A Deployment Transition Center, at Ramstein Airbase in 
Germany, will open next month to provide 2 days of training to 
assist in the transition from deployment to home station for 
airmen regularly exposed to significant risks of combat-related 
death, like convoy operators, explosive ordinance disposal 
personnel, and security forces, and the Office of Special 
Investigations. The goals of the Center include providing 
reconstitution, wingman support, and fostering individual 
resiliency skills for our most vulnerable airmen, those exposed 
to traumatic situations, situations that may lead to PTSD or 
TBI.
    In 2003, more than 600 U.S. Air Force personnel were 
diagnosed with PTSD. In 2008, that number increased to over 
1,500, with over 78 percent of the diagnosis stemming from 
deployment-related events.
    Efforts to prevent, identify, and treat PTSD begin and end 
at home, with screening and education, the use of forums, like 
the Community Action Information Board, and the use of 
traumatic stress response teams at each installation. All aim 
to foster resiliency through focused education and 
psychological first-aid.
    While deployed, combat operational stress control teams 
seek to prevent or minimize adverse effects of combat on our 
airmen. Of note, even nondeployed airmen, like those piloting 
remotely piloted aircraft and some of our intelligence 
personnel, must be monitored for PTSD symptoms as well. They 
too are actively engaged in combat operations.
    Although, where it may not be possible to pinpoint the 
instant PTSD is onset in an individual, this is rarely the case 
with TBI. TBI is recognized in the Air Force as a physical 
condition that can cause lifelong symptoms.
    From 2001 to 2009, 1,008 airmen were diagnosed with TBI, 
accounting for 4 percent of all DOD TBI cases. Baseline testing 
of deployers and education of commanders and medical personnel 
is increasing as we work to apply the best joint practices to 
prevent, identify, and treat TBI. Our goal is simply to provide 
the best possible treatment, minimize the impact on long-term 
health, and maximize rehabilitation, recovery, and 
reintegration.
    In conclusion, airmen are our Air Force's greatest asset, 
the key component of our ability to partner with the joint and 
coalition team to win today's fight. There is a commonality 
among suicide, PTSD, and TBI, beyond their obvious impact on 
individuals and the mission. They all require heightened 
awareness and understanding if we're to identify, prevent, and 
treat them effectively.
    Again, thank you for your continuing support for our 
airmen, and thank you for the opportunity to discuss these 
important issues today. I look forward to your questions.
    [The prepared statement of General Chandler follows:]
          Prepared Statement by Gen. Carrol H. Chandler, USAF
                              introduction
    The Air Force is strongly committed to the physical, emotional, and 
mental health of our airmen, and appreciates the linkage between health 
of the force and mission readiness. The number of airmen taking their 
own lives has been rising, despite our commitment to prevention. 
Similarly, Post-Traumatic Stress Disorder (PTSD) is an area of 
increasing concern. Finally, detection and treatment of Traumatic Brain 
Injury continues to challenge us. All three are similar in that they 
are difficult to detect, and may have significant impact on health and 
mission readiness. We are taking action to reduce risk through measures 
to prevent, identify, and treat each. Efforts to bolster every airman's 
resilience must involve the entire chain of command, commanders, 
supervisors, co-workers, base support agencies, and especially our Air 
Force families throughout the Total Force.
                     suicide in the u.s. air force
    In 2010, 45 airmen--27 Active Duty, 8 Guard, 3 Reserve, and 7 
civilians--have taken their own lives, compared to 33 during the same 
period last year. Currently, the Air Force suicide rate exceeds 14 
suicides per 100,000 Total Force airmen. If these levels persist, the 
Air Force suicide rate by year's end will be a significant deviation 
from the 11.6 per 100,000 the Air Force averaged during the last 6 
years.
    Among our airmen who took their own lives, nearly two-thirds were 
not receiving assistance from a mental health professional. Despite 
concerted efforts to reverse a long-held bias against seeking mental 
health assistance, many airmen continue to resist seeking help when 
they most need it. Even among those who seek counseling, there is a 
marked bias against involving their chain of command in their 
treatment. Based on an anonymous review of more than 1,000 mental 
health records in 2006, approximately 89 percent did not inform their 
chain of command. Additionally, in the 2008 Health Related Behaviors 
Survey 1 out of every 8 airmen responded that they believe that a 
mental health appointment will ``definitely'' hurt their career.
    While no segment of the Air Force is immune to suicide, there are 
known high-risk populations. The most common risk factors associated 
with Air Force suicides are relationship problems, legal issues, 
financial troubles, and history of mental health diagnosis. The Air 
Force seeks to identify these factors prior to enlistment and 
throughout an airman's service. While not directly linked to 
deployments or work-place stress, these factors can be exacerbated by 
demanding military lifestyles. Notably, only approximately 20 percent 
of Air Force suicide victims have deployment experience within the last 
year. Over the past 2 years, the Air Force has had four suicides in the 
U.S. Central Command area of responsibility--three in 2009 and one in 
2010. In 2009, approximately 60 percent of all Air Force suicides were 
committed by airmen in age groups 17-24 and 25-34, accounting for 29 
percent and 31 percent of total Air Force suicides respectively. Thus 
far in 2010, these age groups continue to be at the highest risk for 
suicide, combining for more than 61 percent of Air Force suicides. The 
security forces and intelligence career fields have the highest suicide 
rates; both averaged approximately 24 per 100,000 during the last 
several years. The Air Force recognizes suicide as a public health 
concern that requires active and persistent involvement from 
commanders, supervisors, and wingmen at all levels of the organization.
                         total force resiliency
    In February of this year, the Air Force initiated Total Force 
Resiliency to holistically address the root causes of suicide. Because 
there is significant commonality between the Services, we have studied 
the Army and Navy resiliency programs and shared best practices to 
provide our airmen the skills they require to succeed during potential 
physical and psychological challenges. The Air Force program reflects a 
broad-based approach to supporting airmen and their families. It 
recognizes that physical, mental, and emotional health are critical to 
readiness and optimal performance, and is a comprehensive approach to 
enhance well-being, not merely a safety net. Our resiliency program 
focuses on the ability to withstand, recover and/or grow in the face of 
stressors and changing demands. Airman resiliency and the Air Force 
Suicide Prevention Program are complementary efforts. The key 
components of our suicide prevention program are leadership engagement 
and immediate family involvement. Both are helped by base support 
activities which deliver relevant programs and services.
    To emphasize the imperative of leader and peer participation, the 
Chief of Staff directed a Service-wide ``Wingman Day.'' During the 
month of May, every unit took time out to discuss suicide prevention, 
Total Force Resiliency, and reinforce the significance and role of 
every airman as supportive wingmen in prevention and resilience. This 
effort generated positive momentum and challenged every member of the 
Air Force to recognize his or her role in suicide prevention. There is 
no substitute for airmen knowing their subordinates and coworkers well 
enough to recognize changes in attitude, behavior, and personality--and 
then intervening when something is not right.
                        availability of services
    The Air Force Surgeon General, in collaboration with the Military 
Health System Strategic Communication Group, is working to ensure 
suicide prevention programs and messages receive sufficient breadth and 
depth of exposure. At Headquarters Air Force, Major Commands, and base 
level, the Community Action Information Board (CAIB) provides a forum 
for cross-organizational review and resolution of individual, family, 
installation, and community issues that impact the readiness of the 
force and the quality of life for Air Force members and their families. 
In a recent change, based on our concerns about the increased suicide 
rate, the Air Force Vice Chief of Staff now chairs the HQ USAF CAIB.
    In addition, the Air Force has significantly expanded counseling 
services beyond those traditionally available through chaplains or the 
mental health clinic. Mental health providers are now based in primary 
care clinics across the Air Force. Airman and Family Readiness Centers 
sponsor Military Family Life Counselors that offer counseling to 
individuals or couples without generating documentation. Military 
OneSource, a Department of Defense program that provides resources and 
support to service members and their families, provides free access to 
off-base counselors for as many as six sessions.
                       targeted training programs
    Resiliency training is delivered based on a tiered model. The few 
career fields with the highest risk factors, including those departing 
or returning from deployments, receive the greatest and most structured 
exposure to resiliency training and suicide prevention programs in the 
Tier 1 category. Tier 1 training also ensures that members with acute 
risk of suicide receive clinical care by mental health professionals. 
Tier 2 training tailors and intensifies resiliency and suicide 
prevention messages based on risk factors. Tier 3 training provides 
basic education and training to the widest possible audience via unit 
briefings, chaplain services, financial classes, and computer-based 
training. Additionally, the Air Force is identifying strategies to 
ensure all accessions, beginning with Basic Military Training at 
Lackland AFB, TX, will incorporate resiliency training into their 
curriculum to provide initial exposure. Shortly thereafter, this 
training will be expanded to include commissioning programs and 
technical training. In order to improve the effectiveness of healthcare 
provider interventions, we are also focusing on advanced provider 
training.
                      deployment transition center
    A Deployment Transition Center (DTC) will begin initial operations 
in July 2010 at Ramstein AB, Germany. This organization will provide 2 
days of training to assist in the transition from deployment to home 
station for airmen regularly exposed to significant risk of combat-
related death, and will be initially focused on convoy operators, 
explosive ordinance disposal personnel, and security forces personnel, 
although these services may be extended to other at-risk Air Force 
members as the DTC matures. This overseas center will provide these 
airmen centralized training and facilitate a graduated transition home 
with positive family reintegration. The goals of the center include 
providing reconstitution, utilizing the support of fellow airmen 
returning from deployment, and fostering individual resiliency skills 
and coping mechanisms. The center is part of the overarching resiliency 
education and training program being developed with the goal of 
supporting broader Air Force populations, not merely those airmen 
considered most vulnerable due to high potential of exposure to 
traumatic situations.
 invisible wounds of war: post-traumatic stress disorder and traumatic 
                              brain injury
    In 2003, more than 600 USAF personnel were diagnosed with PTSD, and 
in 2008, that number increased to over 1,500, with over 78 percent of 
the diagnoses stemming from deployment related events. Over the same 
period, there has been an increase in the number of medical visits for 
PTSD, from more than 3,800 in 2003, to more than 14,300 in 2008. The 
increase in medical care can be attributed not only to the increase in 
PTSD cases, but also our increased awareness and treatment efforts. The 
Air Force has taken numerous steps to address this threat to our 
airmen, beyond the standup of the DTC already discussed.
    Efforts to prevent, identify and treat PTSD begin at home, during 
pre-deployment preparation. Prescreening and education at home bases 
now enhance resilience through education on risk factors, symptom 
recognition, benefits, and destigmatization of mental health care, and 
promotion of the wingman culture. Also, the Integrated Delivery System 
and the CAIB provide forums at each installation for cross-
organizational review and resolution of individual, family, 
installation, and community issues associated with PTSD and other 
issues that impact mission readiness. Additionally, mental health 
providers are receiving training focused on prevention, identification, 
and treatment of PTSD. Finally, Traumatic Stress Response teams at each 
installation now foster resiliency through focused preparatory 
education and psychological first-aid for those exposed to potentially 
traumatic events.
    Similarly, Combat Operational Stress Control teams seek to prevent 
or minimize adverse effects of combat on our airmen in theater. In 
addition to airmen deployed to the combat zone, nondeployed airmen, 
like our remotely piloted aircraft crews and intelligence personnel, 
must be monitored for post-traumatic stress symptoms--they too are 
actively engaged in combat operations. Although challenges remain for 
the Air Force to prevent, identify, and treat PTSD, we, along with our 
joint partners, are actively engaged to improve our capability and 
capacity institutionally, for what is often a very individualized need. 
Recognizing PTSD is a challenge--as it often is for Traumatic Brain 
Injury (TBI).
    TBI is recognized in the Air Force as a physical condition that can 
cause life-long symptoms. From 2001 to 2009, 1,008 airmen were 
diagnosed with TBI, accounting for 4 percent of all Department of 
Defense TBI cases reported. Effective early TBI detection is the 
cornerstone of TBI care, and baseline Automated Neuropsychological 
Assessment Metric is now collected on 56 percent of airmen deploying 
into theater. Also, the Air Force will begin educating commanders and 
medical personnel by the end of this calendar year, applying best joint 
practices in prevention, identification, and treatment of TBI. Through 
education that is focused on early detection and prevention, our goal 
is to identify TBI cases and ensure our airmen receive the best 
possible treatment, minimizing the impact on long-term health, and 
maximizing rehabilitation, recovery, and reintegration.
                               conclusion
    Airmen are our Air Force's greatest asset--the key component to our 
ability to partner with the Joint and coalition team to win today's 
fight. We ask for an extraordinary amount of selflessness and sacrifice 
from them and their families. In return, our obligation is to assist 
each of them according to their particular needs. There is commonality 
among suicide, PTSD, and TBI beyond their obvious impact on individuals 
and mission; they all require heightened awareness and understanding if 
we are to prevent, identify, and treat them effectively. Also, although 
it is possible to focus efforts on high-risk categories of people, 
every individual remains vulnerable, valuable, and must be considered. 
The needless loss of an airman and the resultant impact on their 
families and the Air Force is not acceptable.

    Chairman Levin. Thank you so much, General Chandler.
    Dr. Jesse.

  STATEMENT OF ROBERT L. JESSE, ACTING PRINCIPAL DEPUTY UNDER 
     SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Jesse. Good morning, Chairman Levin, Ranking Member 
McCain, and members of the committee. Thank you for inviting me 
here to discuss the VA efforts to respond to, treat, and 
minimize the impacts of TBI, PTSD, and veteran suicide.
    My written testimony provides greater detail about our 
programs and about our cooperation with our partners at DOD and 
the Services, but, in the few minutes I do have now, I'd like 
to highlight a few key factors for the committee.
    Before doing so, I would like to express our gratitude to 
the committee for their insight into the importance of these 
issues, and for their ongoing support of all of the initiatives 
that are intended to mitigate this.
    The VA has developed and implemented a range of innovative 
programs to ensure that it provides world-class rehabilitation 
care for veterans and servicemembers with TBI. We offer 
services at 108 facilities across the country through an 
integrated network that brings together some of the best minds 
in medicine. We deliver comprehensive clinical rehabilitative 
services through interdisciplinary teams of specialists, while 
providing patient and family education and training, 
psychosocial support, and advanced rehabilitation and 
prosthetic technologies.
    VA has placed nurse liaisons in military treatment 
facilities to support coordinated care, patient transfers, and 
shared patients. In terms of the population we treated between 
March 2003 and March 2010, the VA has seen, at our state-of-
the-art Polytrauma Rehabilitation Centers, almost 1,800 
patients, more than half of whom are Active Duty 
servicemembers.
    Second, the Federal Recovery Coordination Program is a 
successful joint VA/DOD initiative that provides severely 
injured veterans and servicemembers with access to the benefits 
and care that they need to recover. Our 20 Federal Recovery 
Coordinators work with military liaisons, member of the 
Services' Wounded Warrior programs, Service Recovery Care 
coordinators, TRICARE coordinators, and various VA staff 
members, to bridge the transition from VA to DOD.
    Each enrolled client has a specially tailored Federal 
Individual Recovery Plan based on the goals and needs of the 
veteran or servicemember, and based upon input from the client 
and his or her family. This plan serves as the basis for 
returning our wounded warriors to the highest level of 
functionality independence they can achieve.
    Third, VA has implemented a robust screening protocols for 
PTSD, TBI, and suicidal tendencies. We screen every veteran 
from Afghanistan and Iraq for brain injuries, and we screen 
every veteran we see for PTSD, depression, and drinking 
problems. If the PTSD or depression screen is positive, we 
require an evaluation for suicidal tendencies. VA repeats the 
screening at consistent intervals, since problems can arise at 
any time. Any positive screen leads to further evaluation in 
the primary care setting, followed by specialty care services 
as needed.
    The VA has established access standards for mental health 
that require prompt contact of new patients, within 24 hours of 
referral, by a clinician, to evaluate the urgency of the 
veteran's needs. If the veteran has an urgent care need, we 
require our staff to make appropriate arrangements, including 
an immediate admission to one of our facilities. If the need is 
not urgent, the patient must be seen for a full mental health 
and diagnostic evaluation and development initiation of an 
appropriate treatment plan within 14 days. Across the system, 
the VA is meeting the standard over 95 percent of the time.
    Finally, VA's suicide prevention efforts are having a 
meaningful and positive impact on those veterans who come to us 
for care. A suicide by a servicemember or veteran is a tragedy 
for the individual, his or her friends and family, and to the 
Nation.
    We have initiated several programs to put VA in the 
forefront of suicide prevention. Chief among these is 
establishing a national suicide prevention hotline, placing 
suicide prevention coordinators at VA Medical Centers, 
significantly expanding mental health services, and integrating 
primary and mental health care to alleviate the stigma of 
seeking mental health assistance.
    The return on investment for these efforts is significant. 
Our suicide prevention hotline has saved the lives of more than 
9,000 veterans and servicemembers since its inception. Other 
data demonstrate that younger veterans who come to the VA for 
healthcare services were 30 percent less likely to die from 
suicide than those who don't come to us for care. More broadly, 
the rate of suicide among veterans receiving healthcare from VA 
has declined steadily since 2001. From a public health 
perspective, this decline is significant, corresponding to 
about 250 fewer lives lost as a result of suicide.
    These are considerable accomplishments that both VA and 
Congress can be proud of. But, it is imperative that we reach 
more of our veterans and servicemembers, and deliver them the 
care that they need.
    In conclusion, VA and DOD maintain a longstanding 
relationship that shares best practices, identifies joint 
solutions, operates centers of excellence, and works to support 
the brave men and women who wear the uniform.
    Thank you again for the opportunity to discuss these 
important issues with you today. I'm prepared to answer your 
questions.
    [The prepared statement of Dr. Jesse follows:]
            Prepared Statement by Robert Jesse, M.D., Ph.D.
    Good morning Chairman Levin, Ranking Member McCain, and members of 
the committee. Thank you for inviting me here to discuss the Department 
of Veterans Affairs (VA) efforts to respond to, treat, and minimize the 
impacts of traumatic brain injury (TBI), post-traumatic stress disorder 
(PTSD), and veteran suicide. My testimony will describe VA's programs 
and initiatives in the areas of TBI and mental health, with a specific 
emphasis on our suicide prevention programs, and highlight the close 
cooperation VA maintains with the Department of Defense (DOD) and the 
Services.
                         traumatic brain injury
Care, Management, and Transition of Veterans and Servicemembers
    Polytrauma is a new word in the medical lexicon that was termed by 
VA to describe the complex, multiple injuries to multiple body parts 
and organs occurring as a result of blast-related injuries seen from 
Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF). 
Polytrauma is defined as two or more injuries to physical regions or 
organ systems, one of which may be life threatening, resulting in 
physical, cognitive, psychological, or psychosocial impairments and 
functional disability. TBI frequently occurs in polytrauma in 
combination with other disabling conditions such as amputation, 
auditory and visual impairments, spinal cord injury (SCI), post-
traumatic stress disorder (PTSD), and other medical problems. Due to 
the severity and complexity of their injuries, servicemembers and 
veterans with polytrauma require an extraordinary level of coordination 
and integration of clinical and other support services.
    VA has developed and implemented numerous programs to ensure it 
provides world-class rehabilitation services for veterans and active 
duty servicemembers with TBI. VA has enhanced its integrated nationwide 
Polytrauma/TBI System of Care. The VA Polytrauma/TBI System of Care 
consists of four levels of facilities, including 4 Polytrauma 
Rehabilitation Centers, 22 Polytrauma Network Sites, 82 Polytrauma 
Support Clinic Teams, and 48 Polytrauma Points of Contact. The system 
offers comprehensive clinical rehabilitative services including: 
treatment by interdisciplinary teams of rehabilitation specialists; 
specialty care management; patient and family education and training; 
psychosocial support; and advanced rehabilitation and prosthetic 
technologies. In 2005, VA expanded the scope of services at existing VA 
TBI Centers, and accordingly renamed them Polytrauma/TBI Rehabilitation 
Centers, to establish an integrated, tiered system of specialized, 
interdisciplinary care for polytrauma injuries and TBI.
    PRCs provide the most intensive specialized care and comprehensive 
rehabilitation care for veterans and servicemembers with complex and 
severe polytrauma. PRCs maintain a full staff of dedicated 
rehabilitation professionals and consultants from other specialties to 
support these patients. Each PRC is accredited by the Commission on 
Accreditation of Rehabilitation Facilities, and each serves as a 
resource to develop educational programs and best practice models for 
other facilities across the system. The four regional centers are 
located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA. 
A fifth center is currently under construction in San Antonio, TX, and 
is expected to open in 2011.
    Since 2007, VA has placed Polytrauma Nurse Liaisons at Walter Reed 
Army Medical Center and National Naval Medical Center (at Bethesda, MD) 
to support coordination of care, patient transfers, and shared patients 
between DOD and VA PRCs. Whenever an injured veteran or servicemember 
requires specialized rehabilitative services and enters VA health care, 
the Polytrauma Nurse Liaison maintains close communication with the 
admissions nurse case manager at the VA PRC, providing current and 
updated medical records. Before transfer, the Center's 
interdisciplinary team meets with the DOD treatment team and family by 
teleconference as another way to ensure a smooth transition.
                           va accomplishments
    A total of 1,792 inpatients with severe injuries have been treated 
at the Polytrauma Rehabilitation Centers from March 2003 through March 
2010; 907 of these patients have been active duty servicemembers, of 
which 754 were injured in OEF or OIF. VA continues following these 
patients after their discharge from a VA PRC to assess their long-term 
outcomes. Data available for 876 former PRC patients indicate:

         781 (89 percent) are living in a private residence;
         642 (73 percent) live alone or independently;
         413 (47 percent) report they are retired due to age, 
        disability or other reasons;
         206 (24 percent) are employed;
         90 (10 percent) are in school part-time or full-time; 
        and
         59 (7 percent) are looking for a job or performing 
        volunteer work.

    Throughout the Polytrauma/TBI System of Care, we have established a 
comprehensive process for coordinating support efforts and providing 
information for each patient and family member. Specialized 
rehabilitation initiatives at the PRCs include:

         In 2007, VA developed and implemented Transitional 
        Rehabilitation Programs at each PRC. These 10-bed residential 
        units provide rehabilitation in a home-like environment to 
        facilitate community reintegration for veterans and their 
        families, focus on developing standardized program measures, 
        and investigate opportunities to collaborate with other 
        entities providing community-based reintegration services. 
        Through December 2009, 188 veterans and servicemembers have 
        participated in this program spending, on average, about 3 
        months in transitional rehabilitation. Almost 90 percent of 
        these individuals return to active duty, or transition to 
        independent living.
         Beginning in 2007, VA implemented a specialized 
        Emerging Consciousness care path at the four PRCs to serve 
        those veterans with severe TBI who are slow to recover 
        consciousness. Patients with disorders of consciousness (e.g., 
        comatose) require high complexity and intensity of medical 
        services and resources in order to improve their level of 
        responsiveness and decrease medical complications. To meet the 
        challenges of caring for these individuals, VA collaboratively 
        developed this care path with subject matter experts from 
        Defense and Veterans Brain Injury Center (DVBIC) and the 
        private sector. VA and DVBIC continue to collaborate on 
        research in this area, and incorporate improvements to the care 
        path in response to advances in science. From January 2007 
        through December 2009, 87 veterans and servicemembers have been 
        admitted in VA Emerging Consciousness care. Approximately 70 
        percent of these patients emerge to consciousness before 
        leaving inpatient rehabilitation.
         In October 2008, all inpatients with TBI at VA PRCs 
        began receiving special ocular health and visual function 
        examinations based upon research conducted at our Palo Alto 
        PRC. To date, 840 inpatients have received these examinations.
         In April 2009, VA began an advanced technology 
        initiative to establish assistive technology laboratories at 
        the four PRCs. These facilities will serve as a resource for VA 
        health care, and provide the most advanced technologies to 
        veterans and servicemembers with ongoing needs related to 
        cognitive impairment, sensory impairment, computer access, 
        communication deficits, wheeled mobility, self-care, and home 
        telehealth.
         The PRCs have been renovated to optimize healing in an 
        environment respectful of military service. Military liaisons 
        located at the centers help to support active duty patients and 
        to coordinate interdepartmental issues for patients and their 
        families. Working with the Fisher House Foundation, we are also 
        able to provide housing and other logistical support for family 
        members staying with a veteran or servicemember during their 
        recovery at one of our facilities.
         In fiscal year 2009, 22,324 unique outpatients had 
        83,794 total clinic visits across the Polytrauma Support Clinic 
        Team sites; an increase of over 30 percent from fiscal year 
        2008.

    In addition to improvements in the Polytrauma/TBI System of Care, 
VA developed and implemented the TBI Screening and Evaluation Program 
for all OEF/OIF veterans who receive care within VA. From April 2007 
through March 2010:

         408,474 OEF/OIF veterans have been screened for 
        possible TBI;
         56,161 who screened positive have been evaluated and 
        received follow-up care and services appropriate for their 
        diagnosis and their symptoms;
         30,368 have been confirmed with a diagnosis of having 
        incurred a mild TBI;
         Over 90 percent of all veterans who are screened are 
        determined not to have TBI, but all who screen positive and 
        complete a comprehensive evaluation are referred for 
        appropriate treatment.

    VA continues to increase collaborations with private sector 
facilities to successfully meet the individualized needs of veterans 
and complement care in cases when VA cannot readily provide the needed 
services, or cases where the required care is geographically 
inaccessible. VA medical facilities have identified private sector 
resources within their catchment area that have expertise in 
neurobehavioral rehabilitation and recovery programs for TBI. In fiscal 
year 2009, 3,708 enrolled veterans with TBI received inpatient and 
outpatient hospital care and medical services from public and private 
entities, with a total disbursement of over $21 million.
VA and DOD Cooperation on Outreach, Transition and Complementary Care
    VA and DOD have shared a longstanding integrated collaboration in 
the area of TBI through the DVBIC. Since 1992, DVBIC staff members have 
been integrated with VA Lead TBI Centers (now Polytrauma Rehabilitation 
Centers) to collect and coordinate surveillance of long-term treatment 
outcomes for patients with TBI. Other significant initiatives that have 
resulted from the ongoing collaboration between VA and DVBIC include: 
developing collaborative clinical research protocols; developing and 
implementing best clinical practices for TBI; developing materials for 
families and caregivers of veterans with TBI; developing integrated 
education and training curriculum on TBI, and joint training of VA and 
DOD heath care providers; and coordinating the development of the best 
strategies and policies regarding TBI for implementation by VA and DOD.
    In addition to the longstanding affiliation with DVBIC, since 2007, 
VA has collaborated with DOD to develop implementation plans for 
Defense Centers of Excellence (DCoE) and the associated injury 
registries, including Centers for Psychological Health and Traumatic 
Brain Injury, Extremity Injuries and Amputation, Hearing Loss and 
Auditory System Injuries, and Vision. VA has assigned personnel at the 
Center for Psychological Health and TBI, and at the Vision Center. VA 
continues to be involved in working groups with DOD representatives to 
assist in developing concepts of operations and plans for the Hearing 
Loss and Auditory System Injuries Center and the Center for Extremity 
Injuries and Amputation.
    VA, in collaboration with DVBIC, developed a uniform training 
curriculum for family members in providing care and assistance to 
servicemembers and veterans with TBI: ``Traumatic Brain Injury: A Guide 
for Caregivers of Servicemembers and Veterans.'' In 2009, VA and DOD 
collaboratively developed clinical practice guidelines for mild TBI and 
deployed this to health care providers, as well as recommendations in 
the areas of cognitive rehabilitation, drivers' training, and managing 
the co-occurrence of TBI, PTSD, and pain.
    In 2009, the VA-led collaboration with DOD and the National Center 
for Health Statistics produced revisions to the International 
Classification of Diseases, Clinical Modification (ICD-9-CM) diagnostic 
codes for TBI, resulting in significant improvements in the 
identification, classification, tracking, and reporting of TBI and its 
associated symptoms.
The Federal Recovery Coordination Program
    The Federal Recovery Coordination Program (FRCP) serves an 
important function in ensuring that severely injured veterans and 
servicemembers receive access to the benefits and care they need to 
recover. Beginning in 2008, FRCP has helped coordinate and access 
Federal, State, and local programs, benefits and services for severely 
wounded, ill, and injured servicemembers, veterans, and their families 
through recovery, rehabilitation, and reintegration into the community. 
The program is a joint program of DOD and VA, with VA serving as the 
administrative home.
    The program has grown since enrolling the first client in February 
2008. Not every individual referred to the program meets enrollment 
criteria or needs the full services of FRCP. Some individuals are 
enrolled for a period of time and then determine that they no longer 
need the program's services. Currently, 538 clients are enrolled and 
another 26 individuals are being evaluated for enrollment; 478 have 
received assistance. Anyone can return for re-enrollment or additional 
assistance if the problems are not resolved or if new problems develop.
    Recovering servicemembers and veterans are referred to FRCP from a 
variety of sources, including from the servicemember's command, members 
of the interdisciplinary treatment team, case managers, families, or 
clients already in the program, Veterans Service Organizations, and 
other nongovernmental organizations. Generally, those individuals whose 
recovery is likely to require a complex array of specialists, transfers 
to multiple facilities, and long periods of rehabilitation are 
referred.
    FRCP outreach efforts include brochures, a presence on VA's OEF/OIF 
Web site, participation and presentations at local, State, and national 
events. Our toll-free number (1-877-732-4456), new in April 2009, 
provides another avenue for referral or assistance. When a referral is 
made, a Federal Recovery Coordinator (FRC) conducts an evaluation that 
serves as the basis for problem identification and determination of the 
appropriate level of service.
    FRCs coordinate benefits and services for their clients through the 
various transitions associated with recovery and return to civilian 
life. FRCs work with military liaisons, members of the Services' 
Wounded Warrior Programs, Service recovery care coordinators, TRICARE 
beneficiary counseling and assistance coordinators, VA vocational and 
rehabilitation counselors, military and VA facility case managers, VA 
Liaisons, VA specialty care managers, Veterans Health Administration 
(VHA) and Veterans Benefits Administration (VBA) OEF/OIF case managers, 
VBA benefits counselors, and others.
    Each enrolled client receives a Federal Individual Recovery Plan 
(FIRP). The FIRP, based on the goals and needs of the servicemember or 
veteran and upon input from their family or caregiver, is designed to 
efficiently and effectively move clients through transitions by 
identifying the appropriate services and benefits. The FRCs, with input 
and assistance from interdisciplinary team members and case managers, 
implement the FIRP by working with existing governmental and 
nongovernmental personnel and resources.
    FRCP staffing has grown to meet the program's needs. Eight FRCs 
were initially hired in January 2008. We are adding 5 additional FRCs 
to the 20 current positions in order to meet the growth and success of 
the program. Most of these new hires will be placed at VA PRCs adding 
additional support for severely wounded, ill, and injured 
servicemembers and veterans. The table below shows the current 
locations, as well as the locations for the new FRCs.

------------------------------------------------------------------------
          Facility Name and Location                   Total FRCs
------------------------------------------------------------------------
Walter Reed Army Medical Center, DC...........                        3
National Naval Medical Center, Bethesda, MD...                        3
Brooke Army Medical Center, San Antonio TX....                        4
Naval Medical Center, San Diego, CA...........                        3
Camp Pendleton, CA............................                        1
Eisenhower Army Medical Center, Augusta, GA...                        2
James A. Haley VAMC, Tampa, FL................                        1
Providence VAMC, Providence, RI...............                        1
Michael E DeBakey VAMC, Houston, TX...........                        1
USSOCOM Care Coalition, Tampa, FL.............                        1
Richmond VAMC Polytrauma, VA..................             2 (new hire)
Palo Alto VAMC Polytrauma, CA.................             2 (new hire)
Navy Safe Harbor, DC..........................             1 (new hire)
                                               -------------------------
  Total (FRC) FTE.............................                       25
------------------------------------------------------------------------

    Administrative staff includes an executive director, two deputies 
(one for benefits and one for health), an executive assistant, an 
administrative officer, and two staff assistants.
    The FRCP is VA's lead for the National Resource Directory (NRD), an 
online partnership of the U.S. Departments of Defense, Labor and 
Veterans Affairs for wounded, ill, or injured servicemembers, veterans, 
their families, caregivers, and supporting providers. The NRD is a 
comprehensive online tool available worldwide with over 11,000 Federal, 
State, and local resources organized into 9 easily searchable topic 
areas including: benefits and compensation, families and caregivers, 
employment, education and training, health care, housing, 
transportation and travel, and homeless assistance. The NRD has an 
average of 1,200 visitors a day where they access approximately 5,000 
page views.
    FRCP's success rests in its extraordinary and well-trained 
problemsolving professional staff. We have learned a great deal over 
the past 2 years and have been able to respond quickly to developing 
needs or problems. We are looking forward to the results from a current 
Government Accountability Office program evaluation and those from our 
satisfaction survey. This input will guide the Program's future 
development and adaptation.
               mental health care and suicide prevention
    VA has responded aggressively to address previously identified gaps 
in mental health care by expanding our mental health budgets 
significantly. In fiscal year 2010, VA's budget for mental health 
services reached $4.8 billion, while the amount included in the 
President's budget for fiscal year 2011 is $5.2 billion. Both of these 
figures represent dramatic increases from the $2.0 billion obligated in 
fiscal year 2001. VA also has increased the number of mental health 
staff in its system by more than 6,000, since 2005 when VHA began 
implementing its Mental Health Strategic Plan. During the past 3 years, 
VA trained over 3,000 staff members to provide psychotherapies with the 
strongest evidence for successful outcomes for PTSD, depression, and 
other conditions. Furthermore, we require that all facilities make 
these therapies available to any eligible veteran who may benefit. In 
fiscal year 2010 and fiscal year 2011, we will continue to expand 
inpatient, residential, and outpatient mental health programs and 
continue our emphasis on integrating mental health services with 
primary and specialty care. We thank Congress for its strong support 
over the past several years, as without its help, none of this would be 
possible.
    VA is working closely with our colleagues at DOD to improve the 
quality of care for veterans and servicemembers alike. Since October 
2009, VA and DOD have held two major conferences related to the mental 
health needs of veterans and servicemembers.
    VA offers mental health services to veterans through medical 
facilities and Community-Based Outpatient Clinics (CBOC), and in 
addition, VA's Vet Centers offer another important component of mental 
health care focused on readjustment counseling. Vet Centers embrace a 
veteran-centric program model that goes beyond formal procedures in 
making a personal and empathic connection that helps combat veterans 
overcome stigma and other barriers to care. Approximately 80 percent of 
all Vet Center staff members are veterans, and 60 percent are combat 
veterans. In addition to 100 Operation Enduring Freedom and Operation 
Iraqi Freedom (OEF/OIF) Veteran Outreach Specialists, more than one-
third of all staff now serving in Vet Centers are OEF/OIF veterans. 
Early access to readjustment counseling in a safe and confidential 
setting can help reduce the risk of suicide and promote recovery among 
servicemembers returning from a combat theater. Through the end of 
December 31, 2009, Vet Centers have made contact with 424,398 (39 
percent) of all separated OEF/OIF veterans, and 317,309 were provided 
outreach services, primarily at demobilization sites, while 107,089 
received substantive readjustment counseling in a VA Vet Center.
    VA has been making significant enhancements to its mental health 
services since 2005, through the VA Comprehensive Mental Health 
Strategic Plan and special purpose funds available through the Mental 
Health Enhancement Initiative from fiscal year 2005 to fiscal year 
2009. In 2007, VA approved the Handbook on Uniform Mental Health 
Services in VA Medical Centers and Clinics to define what mental health 
services should be available to all enrolled veterans who need them, no 
matter where they receive care, and to sustain the enhancements made in 
recent years.
    VA's enhanced mental health activities include outreach to help 
those in need to access services, a comprehensive program of treatment 
and rehabilitation for those with mental health conditions, and 
programs established specifically to care for those at high risk of 
suicide. To reduce the stigma of seeking care and to improve access, VA 
has integrated mental health into primary care settings to provide much 
of the care that is needed for those with the most common mental health 
conditions. In parallel with the implementation of these programs, VA 
has been modifying its specialty mental health care services to 
emphasize psychosocial as well as pharmacological treatments and to 
focus on principles of rehabilitation and recovery. VA is ensuring that 
treatment of mental health conditions includes attention to the 
benefits as well as the risks of the full range of effective 
interventions. Making these treatments available responds to the 
principle that when there is evidence for the effectiveness of a number 
of different treatment strategies, the choice of treatment should be 
based on the veteran's values and preferences, as well as the clinical 
judgment of the provider.
Screening, Treatment, and Access
    Crucial to initiating such care, VA requires that all new patients 
to primary care be screened for PTSD, depression, and problem drinking. 
If the PTSD or depression screen is positive, an evaluation for 
suicidality also is required. VA repeats this screening at consistent 
intervals, since problems can arise at any time, not just on initial 
access to VA care. Any positive screen leads to further evaluation in 
the primary care setting, followed by initiation of mental health 
services, if needed, in the primary care setting or through referral to 
mental health specialty care.
    For patients identified through these screens, or in any other way, 
VA has established access standards that require prompt evaluation of 
new patients (those who have not been seen in a mental health clinic in 
the last 24 months) with mental health concerns. New patients are 
contacted within 24 hours of the referral by a clinician competent to 
evaluate the urgency of the veteran's mental health needs. If it is 
determined that the veteran has an urgent care need, appropriate 
arrangements (e.g., an immediate admission) are required. If the need 
is not urgent, the patient must be seen for a full mental health 
diagnostic evaluation and development and initiation of an appropriate 
treatment plan within 14 days. Across the system, VA is meeting this 
standard 95 percent of the time.
    Screening usually occurs in the primary care setting where most 
veterans initially seek care for mental health as well as physical 
health problems. VA has expanded integrated mental health services in 
primary care throughout the system. To ensure veterans are monitored 
appropriately while they are receiving mental health services, 
including treatment with psychotherapeutic medications, VA requires 
that these integrated care programs include evidence-based care 
management and co-located, collaborative care by a mental health 
professional.
    In addition, research has shown the value of having co-located, 
collaborative mental health staff that can complement the medication-
focused care management programs with psychosocial interventions to 
address depression and other mental health problems. The mental health 
providers co-located in primary care also can engage with family 
members when appropriate to listen to their concerns, ensure they 
understand the care the veteran is receiving, and describe how they can 
contribute to ongoing treatment for the veteran.
    One important set of requirements in the handbook was to ensure 
that evidence-based psychotherapies are available for veterans who 
could benefit from them and that meaningful choices between effective 
alternative treatments are available. VA implemented the broad use of 
evidence-based psychotherapies in response to evidence that for many 
patients, specific forms of psychotherapy are the most effective and 
evidence-based of all treatments. Specifically, the Institute of 
Medicine report on treatment for PTSD emphasized findings that 
exposure-based psychotherapies, including Prolonged Exposure Therapy 
and Cognitive Processing Therapy, were the best-established of all 
treatments for PTSD. Other specific psychotherapies included in VA's 
programs include Cognitive Behavioral Therapy and Acceptance and 
Commitment Therapy for depression; Skills Training, Social Skills 
Training for Veterans with serious mental illness, such as 
schizophrenia; and Family Psycho-Education for schizophrenia. VA is 
adding other treatments such as Problemsolving for Depression, 
Cognitive Behavioral Therapy and Contingency Management for Substance 
Use Disorder, and behavioral strategies for managing both pain and 
insomnia.
    For several years, VA has provided training to clinical mental 
health staff to ensure that there are therapists in each facility able 
to provide evidence-based psychotherapies for the treatment of 
depression and PTSD as alternatives to pharmacological treatment or as 
a course of combined treatment. More recently, VA has begun training 
Vet Center mental health professionals in Cognitive Processing Therapy 
(CPT). To date, 120 Vet Center staff members have participated in 
training courses to develop full competency in this treatment approach. 
Vet Center staff training will also be enhanced this year through 
national training in May commemorating the Vet Center program's 30th 
year in existence. VA is initiating a training academy for all Vet 
Center team leaders.
    VA has expanded care for veterans with Substance Use Disorders 
(SUD), for example, greatly expanding Intensive Outpatient Centers for 
Veterans with Substance Use Disorders. These Centers have the strongest 
evidence base for effective treatment; they provide a team of mental 
health professionals in a comprehensive program format that offers care 
at least 3 days each week for at least 3 hours each day. In addition, 
SUD care also has been integrated in PTSD Clinical Teams by including a 
SUD provider to work with these Teams at each VA facility.
    A central concept for all services is a recovery orientation. For 
those with serious mental illness, the focus on recovery reflects major 
scientific advances in treatment and rehabilitation. Although it is 
still not possible to offer definitive cures for all patients with 
serious mental illness, it is realistic to offer the expectation of 
recovery. Veterans, often with their families, should collaborate with 
their providers in planning treatments based on the goals that will 
help the veteran live the kind of life he or she chooses, in spite of 
any residual signs or symptoms of mental illness. To achieve this 
vision, VA has hired a Local Psychosocial Recovery Coordinator at every 
facility and has hired staff members to provide peer support, trained 
clinicians in evidence-based strategies for treatment and 
rehabilitation, enhanced the care in residential treatment settings, 
developed Psychosocial Rehabilitation and Recovery Centers and 
strengthened programs that involve families.
Suicide Prevention
    Preventing suicides is a top priority for VA. A suicide by a 
servicemember or veteran is a tragedy for the individual, his or her 
friends and family, and the Nation. Data indicate that while civilian 
suicide rates have remained fairly static over the past 30 years, there 
has been a deeply concerning increase in the suicide rate among members 
of the Armed Forces over the last 5 years. Eighteen deaths per day 
among the veteran population are attributable to suicide. More than 60 
percent of suicides among VA health care users are among patients with 
a known mental health diagnosis. We have initiated several programs 
that put VA in the forefront of suicide prevention for the Nation. 
Chief among these are:

         Establishment of a National Suicide Prevention 
        Hotline, including a major advertising campaign to provide this 
        phone number to all veterans and their families;
         Placement of suicide prevention coordinators at all VA 
        medical centers;
         Significant expansion of mental health services; and
         Integration of primary care and mental health services 
        to help alleviate the stigma of seeking mental health 
        assistance.

    In 2007, VA developed its signature program, the Suicide Prevention 
Hotline (1-800-273-TALK (8255)), in partnership with the existing 
Department of Health and Human Services Substance Abuse and Mental 
Health Services Administration (SAMHSA) Suicide Prevention Hotline. At 
the same time, VA provided specific funding and training for each 
facility to have a designated Suicide Prevention Coordinator; it also 
held the first Annual Suicide Awareness and Prevention Day. The same 
year, VA initiated system-wide screening for suicide in primary care 
patients, instituted training for Operation S.A.V.E. (which trains non-
clinicians to recognize the signs of suicidal thinking, to ask veterans 
questions about suicidal thoughts, to validate the veteran's 
experience, and to encourage the veteran to seek treatment), and 
required Suicide Prevention Coordinators to begin tracking and 
reporting suicidal behavior. In addition, VA added more suicide 
prevention coordinators and suicide prevention case mangers in our 
larger medical centers and community-based outpatient clinics, doubling 
the number of dedicated suicide prevention staff in the field. By 2008, 
VA had re-established a monitor for mental health follow-up after 
patients were discharged from inpatient mental health units and held a 
fourth regional conference on evidence-based interventions for suicide. 
In 2009, VA launched the Veterans Chat Program to create an online 
presence for the Suicide Prevention Hotline. Veterans Chat and the 
Hotline are intended to reach out to all veterans, whether they are 
enrolled in VA health care or not. VA also added a flag to patient 
records to notify physicians of patients at risk for suicide. This 
year, VA has already held a Suicide Prevention Coordinator conference 
and co-hosted a conference with DOD to discuss ways VA and DOD can 
reduce the prevalence of suicide among veterans and servicemembers.
    VA has adopted a broad strategy to reduce the incidence of suicide 
among veterans. This strategy is focused on providing ready access to 
high quality mental health and other health care services to veterans 
in need. This effort is complemented by helping individuals and 
families engage in care and addressing suicide prevention in high risk 
patients. VA cannot accomplish this mission alone; instead, it works in 
close collaboration with other local and Federal partners and brings 
together the diverse resources within VA, including individual 
facilities, a Center of Excellence in Canandaigua, New York, a Mental 
Illness Research and Education Clinical Center in Veterans Integrated 
Service Network (VISN) 19, VA's Office of Research and Development, and 
clinicians.
    This evidence clearly demonstrates that once a person has 
manifested suicidal behavior, he or she is more likely to try it again. 
As a result, VA has adopted a comprehensive treatment approach for high 
risk patients. This includes a flag in a patient's chart, necessary 
modifications to the patient's treatment plan, involvement of family 
and friends, close follow up for missed appointments, and a written 
safety plan included in the veteran's medical record. This plan is 
shared with the veteran and includes six steps: (1) a description of 
warning signs; (2) an explanation of internal coping strategies; (3) a 
list of social contacts who may distract the veteran from the crisis; 
(4) a list of family members or friends; (5) a list of professionals 
and agencies to contact for help; and (6) a plan for making the 
physical environment safe for the veteran.
    During 2009, the VA Call Center for the Suicide Prevention Hotline 
(1-800-273-TALK) received approximately 10,000 calls per month, 
approximately 20 percent of all calls to the National Suicide 
Prevention Lifeline. Approximately a third of these calls are from non-
veterans. These calls led to 3,364 rescues of those determined to be at 
imminent risk for suicide and 12,403 referrals to VA Suicide Prevention 
Coordinators at local facilities. In 2009, the VA Call Center received 
calls from 1,429 active duty servicemembers, a little more than 1 
percent of all calls. To address the needs of the active duty 
population, VA worked with SAMHSA to modify the introductory message 
for Lifeline, developed memoranda of understanding with DOD, and 
established processes for facilitating rescues, including 
collaborations with the Armed Services in Iraq. Also during 2009, the 
Hotline services were supplemented with Veterans Chat, which has been 
receiving more than 20 contacts a day.
    The online version of the Hotline, Veterans Chat, enables veterans, 
family members, and friends to chat anonymously with a trained VA 
counselor. If the counselor determines there is an emergent need, the 
counselor can take immediate steps to transfer the visitor to the 
Hotline, where further counseling and referral services can be provided 
and crisis intervention steps can be taken. Since July 2009, when 
Veterans Chat was established, VA has learned many valuable lessons. 
First, it is clear that conversations are powerful and capable of 
saving lives. As a result, opening more avenues for communications by 
offering both an online and phone service is essential to further 
success. Second, training and constant monitoring is very important, 
and VA will continue pursuing both of these efforts aggressively.
    The Lifeline and VA Call Center may be the most visible components 
of VA's suicide prevention programs, but the Suicide Prevention 
Coordinators are equally important. Both the VA Call Center and 
providers at their own facilities notify the Suicide Prevention 
Coordinators about veterans at risk for suicide. The Coordinators then 
work to ensure the identified veterans receive appropriate care, 
coordinate services designed specifically to respond to the needs of 
veterans at high risk, provide education and training about suicide 
prevention to staff at their facilities, and conduct outreach and 
training in their communities. Other components of VA's programs 
include a panel to coordinate messaging to the public, as well as two 
Centers of Excellence charged with conducting research on suicide 
prevention: one, in Canandaigua, focused on public health strategies, 
and one in Denver, focused on clinical approaches. VA also has a Mental 
Health Center of Excellence in Little Rock, AR, focused on health care 
services and systems research.
    Data also support the conclusion that high quality mental health 
care can prevent suicide. The suicide rate for all veterans who used VA 
health care declined significantly from fiscal year 2001 to fiscal year 
2007. Fully understanding these data require some background on VA's 
efforts to track suicide rates for veterans. First, it is important to 
consider who accesses VA health care. For this, it is useful to refer 
to findings on those veterans returning from Afghanistan and Iraq who 
participated in the Post-Deployment Health Re-Assessment (PDHRA) 
program administered by DOD. Between February 2008 and September 2009, 
approximately 119,000 returning veterans completed PDHRA assessments 
using the most recent version of DOD's form. Of the more than 101,000 
who screened negative for PTSD, 43,681 came to VA for health care 
services (43 percent). Among 17,853 who screened positive for PTSD, 
12,674 came to VA for health care services (71 percent). These findings 
demonstrate that veterans screening positive for PTSD were 
substantially more likely to come to VA for care. Findings about 
depression were similar. Both sets of findings support earlier evidence 
that those veterans who come to VA are those who are more likely to 
need care and to be at higher risk for suicide. The increased risk 
factors for suicide among those who came to VA is often referred to as 
a case mix difference.
    Working with the Centers for Disease Control and Prevention's 
National Violent Death Reporting System, VA recently calculated rates 
of suicide for all veterans, including those using VA health care 
services and those who do not. This analysis included data from 16 
states for individuals aged 18-29, 30-64, and 65 and older for the 
years 2005, 2006, and 2007 (during the period of VA's mental health 
enhancement process). The year 2005 marked the beginning of 
enhancement, while the year 2007 is the most recent one for which data 
are available.
    Suicide rates for veterans using VA health care services aged 30-
64, and those 65 and above were higher than rates for non-users, and 
they remained higher from 2005 to 2007, probably a reflection of the 
case mix discussed above. However, findings for those aged 18-29 were 
quite different. In 2005, younger veterans who came to VA for health 
care services were 16 percent more likely to die from suicide than 
those who did not. However, by 2006, those younger veterans who came to 
VA were 27 percent less likely to die from suicide, and by 2007, they 
were 30 percent less likely. This difference appears to reflect a 
benefit of VA's enhancement of its mental health programs, specifically 
for those young veterans who are most likely to have returned from 
deployment and to be new to the system.
    Because the number of veterans from the 16 States in this group is 
relatively low, the rates are, for statistical reasons, variable. 
Nevertheless, they demonstrate important effects. In 2005, 2006, and 
2007, respectively, those who came to VA were 56, 73, and 67 percent 
less likely to die from suicide. Those who utilized VA services were, 
to some extent, protected from suicide with an effect that appeared to 
increase during the time of VA's mental health enhancements. More 
broadly, the rate of suicide among veterans receiving health care from 
VA has declined steadily since fiscal year 2001; specifically, the rate 
declined more than 12 percent during this time. From a public health 
perspective, the decline in rates is significant, corresponding to 
about 250 fewer lives lost as a result of suicide.
                               conclusion
    In conclusion, thank you again for the opportunity to speak about 
VA's efforts to treat and reduce TBI, PTSD, and suicide among 
servicemembers and veterans.

    Chairman Levin. Thank you very much, Dr. Jesse.
    Thanks to the VA also for the important work that they do 
in this area, and the joint work that is being done between the 
VA and DOD.
    We are lucky that the chairman of the Senate Veterans' 
Affairs Committee, Senator Akaka, is also on the Armed Services 
Committee, which has allowed us to do a lot better with 
coordination on these matters. It's a real break for us, and 
more importantly, for our troops and our veterans, that Senator 
Akaka is a member of this committee.
    Let's try a 7-minute first round for questions.
    General Chiarelli, let me start with you. A couple of weeks 
ago, National Public Radio reported that the military is 
failing to diagnose brain injuries in troops who served in Iraq 
and Afghanistan, that the injuries were not documented on the 
battlefield, and that soldiers with TBI don't always get the 
best medical treatment. Interviews of soldiers at Fort Bliss 
revealed that some soldiers with TBI, who were crying out for 
help, still had to wait more than a month to see a neurologist. 
Also, they reported that many military doctors have failed to 
accurately diagnose TBI. Can you give us your response to those 
reports?
    General Chiarelli. Mr. Chairman, I provided a complete 
response to National Public Radio in which I detailed my 
problems with the report. I have three basic problems with the 
report:
    Number one, it criticized the leadership for not caring or 
not doing anything about it. I think that's far from the truth.
    I took great exception with the report stating that our 
doctors don't seem to care, and are not properly diagnosing 
these injuries, without explaining the real issue here. You 
cannot isolate TBI without talking about PTSD.
    As I mentioned in my opening statement, the comorbidity of 
symptoms between these two make it very, very difficult for 
doctors to make that diagnosis. Of my Army wounded warrior 
population--the most severely wounded population I have, with a 
single disqualifying injury of 30 percent or greater--60 
percent have either TBI or PTSD--43 percent PTSD, 17 percent 
TBI. I really believe that when you fail to talk about both 
PTSD and TBI in this issue of comorbidity, you're doing a great 
disservice, because, to state it flatly, our science on the 
brain is just not as great as it is in other parts of our body. 
Researchers are struggling today to find the linkages and to 
learn everything they can about the brain, and because of this, 
we're going to see some misdiagnosis.
    I can tell you, of the folks that the National Public Radio 
talked about, they had over 200 appointments apiece. There's no 
doubt, you could go to any one of our posts and find soldiers 
who are struggling because of our inability to nail down and to 
diagnose exactly what treatment they need for these behavioral 
health issues. But, I promise you, it is not for a lack of 
trying or real care on the part of our doctors. Our leadership 
is totally committed to working these issues.
    Chairman Levin. In terms of the wait one of the soldiers 
claimed it took a month or more to see a neurologist?
    General Chiarelli. I will tell you that a neurologist is 
not the answer, necessarily, to these soldiers' issues. I have 
a total of 52 neurologists in the U.S. Army; 40 of them are 
currently practicing. Forty, and that's when I include my child 
neurologists. The team that will work with somebody on any 
behavioral health issue is a team of a neurologist, possibly a 
psychiatrist, nurse case manager, who will look at the entire 
file or medical record of care given to that soldier, and work 
to provide them the best that they can.
    One of the problems we have here--I get this from talking 
to doctors--is, the medications for PTSD and TBI are totally 
different. So, if we misdiagnose, at the beginning, and provide 
a diagnosis of PTSD, when in reality it's TBI, the medications 
we're going to put that soldier on are going to be different 
than what the real problem is, and may be different from 
another behavioral health issue that that soldier may have, 
because it's not all TBI and PSTD. There's anxiety issues, 
depression issues, other issues that are the product of these 
wars, that are causing us so much difficulty in this area.
    I have 79 percent of the psychiatrists currently assigned 
to the U.S. Army, based on my authorization prior to 2001. I 
know that that authorization is lacking, but I only have 79 
percent. It's not just an Army problem. This, I think you will 
all agree, is a national problem, a shortage of behavioral 
health specialists.
    Chairman Levin. So, there are some areas of professional 
need where we are short. Is this a matter of funding? Is this a 
matter of finding people? Or, what is it?
    General Chiarelli. No, I don't believe it's a matter of 
funding at all. I think it's a matter of finding folks, getting 
them to move to some of the places where the Army is stationed. 
I think a psychiatrist might prefer to be in Nashville than in 
Clarksville, TN. So, we have to rely on the TRICARE network, 
many times, to provide some of the behavioral health 
specialists that we need.
    Chairman Levin. In terms of the delay issue, is the delay 
the result of a lack of resources, in the cases that were 
talked about on National Public Radio, or is that a matter of 
the complexity which you just described?
    General Chiarelli. I would argue it's the case of the 
complexity, I really would. I'm not saying that, in every 
instance, that we're getting soldiers in exactly when we want 
them to be, but when soldiers are assigned to our Wounded 
Warrior Transition Units (WTU), they have a primary care 
manager, at the rate of 1 per 200, a primary care manager, 
where you or I would have a primary care manager at a ratio of 
1 to 1,200 to 1,500. They have a nurse case manager at a ratio 
1 to 20, and they have a squad leader at a ratio to 1 to 10 or 
less.
    So, we've done everything we can to focus our resources, 
our limited resources, in this area. But, I will tell you, we 
are short behavioral health specialists.
    Chairman Levin. But, again, that's not a funding issue?
    General Chiarelli. It is not a funding issue.
    Chairman Levin. All right.
    Dr. Jesse, the VA, as you, I think, testified, screens all 
of our Iraq and Afghan veterans who receive care from the VA 
for TBI. Does that screening for TBI indicate that there is a 
routine failure in the military to properly diagnose TBI before 
you see that veteran, when they're still on Active Duty?
    Dr. Jesse. No, sir. I don't think we can say that. The 
problem with TBI is that there's no hard, fast diagnostic test. 
There's not a lab test that you can send off and get a solid 
answer back. The other one is that of temporal issues--often it 
takes time for it to manifest some of the effects that show up.
    So, I don't think that it's a failure, on DOD side, to find 
these people. I think, it may just be the complexity of 
disease, as you've heard, takes time to manifest in ways that 
we can then identify it.
    Chairman Levin. Thank you.
    My time's up.
    Senator Inhofe.
    Senator Inhofe. Thank you, Mr. Chairman.
    Chairman Levin. Again, thank you, Senator, for your 
initiative in this area.
    Senator Inhofe. Yes, sir.
    Oddly enough, of all of the subcommittees of the Armed 
Services Committee, the one I've never served on is Personnel. 
I don't know a lot about these issues. But, when it was called 
to my attention, the propensity of these suicides, and we 
started looking into it, I made the request, Mr. Chairman--and, 
also the request, which I think you may be doing in another 
hearing, actually bringing in some of the medical experts and 
soldiers, with their experiences.
    General Chiarelli, I know that you have really made a study 
of this thing. It was in your written testimony that on Active 
Duty, you've actually had a reduction in suicides, but an 
increase in the Reserve component. Is this correct?
    General Chiarelli. That's correct, Senator.
    Senator Inhofe. I can remember back during the 1990s, when 
we were downsizing the military. Then, of course, when 
September 11 happened, we have all these deployments--everybody 
up on this side of the table hears from our people back home, 
our Guard and Reserve, the OPTEMPO is just not livable. That 
goes all the way across Services. I would think that, since you 
made that statement, that perhaps the OPTEMPO might be some 
leading cause of these, in that the OPTEMPO for the Reserve and 
the Guard is much higher. Do you see that relationship?
    General Chiarelli. I see that as one of the factors, 
Senator. We've had a decrease of 15 Active component suicides 
this year, compared to last year. When I talk Active, I'm 
talking about the 547,400 we have in the Active component 
force, plus about 200,000 that are mobilized at any one time 
out of the Reserve and National Guard. It's about a 700,000-
person force.
    Once a Reserve soldier is made an Active Duty soldier, he 
is counted in my Active component numbers. We are down 15. We 
are down two with our Reserve component soldiers not on Active 
Duty. We are up 21 in our National Guard soldiers who are not 
on Active Duty, and that concerns me greatly.
    It's three things. I think its multiple deployments for 
them. I don't think we're getting enough time with them at the 
DEMOB station to give them the kind of behavioral health 
checkouts that they need. Third, I think--Senator McCain said 
it in his opening statement--this lack of human interaction, at 
least with other soldiers, that they have when they leave the 
Service within 5 to 7 days after a 12-month deployment, I 
think, is a real issue here.
    Senator Inhofe. OPTEMPO, that's what we're talking about. 
There is an article--and perhaps you had implied that--on the 
public radio thing, that that was not totally accurate. I agree 
with you.
    There's another article, from June 14, in USA Today. It was 
pretty critical because it talked about the law that was passed 
in 2008, and one of the main persons was this Representative 
Bill Pascrell, of New Jersey--which said, there have to be both 
``pre'' and ``post''--and apparently we're short on the 
``post'' end of it. Can you elaborate on that a little bit?
    General Chiarelli. Senator, we followed the law when it was 
passed. The law stated that we were to use the Automated 
Neuropsychological Assessment Metrics (ANAM) as a screening 
tool in pre- and post-deployment. We still use the ANAM in 
predeployment to get a baseline on cognitive skills of our 
soldiers. But, what we found when we used the ANAM in post, was 
that we were getting a number of false positives, a high number 
of false positives, way too high. We were tying up our limited 
behavioral health specialists in working their way through 
these false positives from the ANAM.
    Now, we still use the ANAM in post if a soldier 
demonstrates any of the symptoms of TBI or any cognitive 
issues. So, we are still using it. We're just not making it 
mandatory for every soldier, so we don't take our short 
behavioral health specialists and wade through a whole bunch of 
false positives, which the test tended to produce.
    We have other things that we're using. Virtual behavioral 
health is something I'm very excited about, where we can give 
every soldier a 30- to 40-minute triage session with a 
behavioral health specialist, using the Internet putting 
together a virtual net of providers who can take an entire 
brigade and put everybody, from brigade commander to the 
youngest private in that unit, through a 30- to 40-minute 
screen. I mean, this is the kind of thing I would like to be 
able to provide to Reserve component soldiers when they get 
back, but I don't necessarily have the time necessary to do 
that.
    Senator Inhofe. I really appreciate the attention you've 
given to this issue.
    Do any of the rest of you want to comment on that, in terms 
of how it relates to the provision that was passed in 2008 in 
our authorization bill?
    General Chandler. Senator, if I could, I would say that we 
still use the ANAM, pre and post. We're fortunate, in a way, 
based on the numbers that we're dealing with, that we can do 
that, even with the false positives. Like the Army, we also 
have other tools that we use. We had a fair amount of success 
with a Post-Deployment Health Assessment, which takes place in 
theater, face to face, or shortly after return. One of the 
things that I think is very important is, 6 months later, 
there's a post-deployment health reassessment. That assessment 
has yielded 16 percent of those airmen that we're treating for 
post-deployment stress syndrome. We think that 6-month follow 
up is extremely important, as well.
    Senator Inhofe. All right.
    General Amos. Senator, we're in agreement with the Army and 
the other Services here. We test, using the ANAM test, 100 
percent of our marines, prior to deployment. We are not doing 
that when they come back. It is used occasionally by our mental 
health professionals, if they don't have anything better. But, 
the issue of false positives, and the lack of reliability in 
the ANAM on the post-TBI incident, especially when you come 
home, leads our Navy doctors, our mental health professionals, 
to seek other ways to take a look at our marines. We're doing 
that.
    Much like General Chandler talked about, we screen both 100 
percent of the marines as they're coming out of theater, and 
then, within 90 to 180 days later, we do it again. Just to give 
you some numbers, for PTS, 15 percent of those that are 
screened coming out theater answer some questions positively, 
which would lead you to further screening. Of that further 
screening, 7 percent see mental health professionals. Then, by 
the time you dwindle this thing down, it's about 2 percent of 
the marines actually need mental health care when they come 
out.
    Senator Inhofe. Right.
    General Amos. So, it's just not that reliable on the back 
side, sir.
    Senator Inhofe. That's very helpful. I appreciate that.
    My time has expired, but I wanted to ask you a question 
that could be answered for the record, if that's all right, Mr. 
Chairman.
    Chairman Levin. Yes.
    Senator Inhofe. A January 14 article said, ``When Soldiers 
Deploy, Family Deploys.'' It's talking about tying in the 
OPTEMPO with the families, with the deployments. The New 
England Journal of Medicine did a study. I read this article 
and then did a little bit more research on some of the findings 
that they're having, in terms of the families--the wives, the 
kids--and nothing was really said during the opening statements 
about that.
    So, I'd like to have the four of you address what we might 
be doing, in terms of the wives, the children, that might be 
having the same problem in the same ratio that the troops 
themselves, or the Active and the Reserve components are 
having.
    Thank you, Mr. Chairman.
    [The information referred to follows:]

    General Chiarelli. The Army provides a wide array of services, 
training and support to soldiers, wives, and families in the early 
detection and treatment of psychological problems. The Comprehensive 
Behavioral Health System of Care mitigates the effects that the stress 
of deployment can have on the mental well-being Army families. 
Inpatient and outpatient behavioral health care is available to family 
members through medical treatment facilities at every Army installation 
that hosts families. The Army leverages local healthcare providers in 
the surrounding installation communities through the TRICARE network 
system. TRICARE covers medically and psychologically necessary 
behavioral health care services for family members to include 
individual, family, and group therapies, collateral visits, 
psychoanalysis, psychological testing, inpatient hospitalization, 
partial hospitalization and residential treatment.
    Other programs that provide training and behavioral health services 
to Army families include Army Community Service; Battlemind; Child, 
Adolescent and Family Behavioral Health; Family Assistance for 
Maintaining Excellence; Military OneSource; Psychological Health in 
Schools Programs; and the Warrior Resiliency Program. Through these 
services and programs, family members receive help to deal with 
depression, anxiety, behavioral health symptoms, and reintegration. 
These services also provide crisis intervention, classroom 
intervention, individual therapy, and resilience training.
    Admiral Greenert. Operational Stress Control (OSC) is the Navy's 
comprehensive prevention and awareness initiative to address the 
psychological health needs of sailors and their families and reduce the 
stigma associated with seeking assistance. The initiative is led by 
operational leadership and supported by Navy Medicine. OSC provides 
practical decisionmaking tools for sailors, leaders, and families to 
identify stress responses and mitigate problematic tension. The Stress 
Continuum is an evidence-informed model that highlights shared 
responsibility by sailors, family members, and Navy leadership for 
maintaining optimum psychological health. The model is used to 
recognize and intervene early, when indicators of stress reactions or 
injuries are present, before an individual develops a serious stress 
illness, such as Post-Traumatic Stress Disorder or depression.
    Working in collaboration with Navy Medicine, Fleet and Family 
Support Programs (FFSP) have launched an OSC awareness effort focusing 
on family members. OSC concepts are being incorporated into existing, 
regularly scheduled family support services such as predeployment and 
stress management workshops, Family Readiness Groups, Ombudsmen 
training, transition assistance workshops, parenting classes, and 
clinical counseling sessions, to familiarize family members with the 
concepts and stress continuum language. This information provides 
family members a framework from which they can identify behaviors/
symptoms early and speak to someone about obtaining help for 
themselves, their children, or their military loved one.
    Brief, solution-focused clinical counseling provided in Fleet and 
Family Support Centers (FFSC) is another avenue where military and 
family members can seek consultation and assistance from licensed 
mental health professionals for commonly occurring situations and 
adjustment issues before more significant problems develop that require 
medical or psychiatric intervention. Placement of clinical counselors 
for children in FFSCs and Behavioral Health Consultants in Child 
Development Centers help identify and provide assistance to children 
who are adversely impacted by their parent's deployment.
    General Amos. The Marine Corps does not maintain surveillance of 
the rates of mental illness among Marine dependents. There is no 
evidence to indicate that rates of mental illness are higher among the 
Marine dependent population than in a similar civilian population. 
However, the leadership of the Marine Corps is acutely aware of the 
stresses borne by Marine families as a result of deployments in support 
of military operations overseas and is constantly making improvements 
in the support provided to the physical and psychological health of 
Marine families.
    A full spectrum of mental health care is provided to Marine 
dependents through TRICARE. Direct care, where available, is provided 
by the Navy military treatment facilities which support the Marines. 
Where care is not available through the direct care system, it is 
provided through the TRICARE network.
    Additional resources are available to support military dependents. 
Marine Corps Community Services provides counseling and referral 
services and conducts activities to facilitate return and reintegration 
of families following deployment. Navy chaplains supporting Marine 
Corps can provide spiritual counseling and informal referral to the 
mental health care system. Military OneSource is available to provide 
confidential life skills advice and up to six sessions with a mental 
health counselor. The Exceptional Family Member Program provides a 
spectrum of services and referral to Marine families with members who 
have ongoing physical, psychological and emotional challenges. 
Educational and Developmental Intervention Services are provided by 
BUMED to children with physical or psychological needs related to their 
education. Families Over-Coming Under Stress (FOCUS) is a very 
successful program which provides developmentally appropriate 
education, family-centered skill building and social support for 
families of deployed servicemembers, particularly focused on children 
with deployed, injured, or deceased parents.
    General Chandler. The mental health of families is of significant 
concern to the Air Force (AF) as family support is essential for 
effective functioning of our servicemembers. The AF has had an increase 
in utilization of mental health services over the past 5 years at 
military treatment facilities and the TRICARE network. AF health care 
records show that approximately 16,000 active duty family member 
beneficiaries (approximately 3 percent of all beneficiaries) have a 
primary diagnosis of some form of depression. This compares to an 
estimated national prevalence of depression of approximately 10 
percent.
    AF Airman and Family Readiness Centers (A&FRC) champion the 
resilience of AF families by offering proactive services and programs 
to assist in identifying and resolving concerns brought about by 
personal and familial stress. Those programs include support across the 
entire cycle of deployment; contracted non-medical counseling by 
licensed mental health professionals; emergency financial assistance 
through the AF Aid Society; advocacy for military child education and 
families with special needs; consultations on personal financial 
readiness, spouse employment, relocation and transition assistance; and 
information and referral to other appropriate agencies.
    In addition to the services available through the A&FRC, more 
formal mental health care is also available.
    Mental health visits: Beneficiaries have access to mental health 
treatment in both outpatient and inpatient settings. In the AF, due to 
the primacy of the mission to active duty airmen, most care to family 
members is arranged through the TRICARE network.
    Behavioral Health in primary care: Studies show that half of all 
medical visits for mental health concerns occur in primary care 
clinics. Often this is enough, but over 60 percent of AF medical 
treatment facilities have behavioral health providers embedded within 
them. Seeing a mental health provider in primary care is a lower-stigma 
alternative and typically involves a few visits for a focused 
intervention. No separate mental health charting is necessary.
    The TRICARE Assistance Program (TRIAP): TRIAP offers web-based 
counseling for adult beneficiaries.

    Chairman Levin. Thank you, Senator Inhofe.
    Now, Senator Inhofe, made reference to a bill that has been 
introduced by Congressman Bill Pascrell, who was the cofounder 
and cochair of the Congressional Brain Injury Task Force. We 
have received a statement from him, which we will make part of 
the record.
    [The information referred to follows:]
          Prepared Statement by Congressman Bill Pascrell, Jr.
    Mr. Chairman, in 2001, I cofounded the Congressional Brain Injury 
Task Force with former Congressman Jim Greenwood of Pennsylvania. At 
that time, there was little awareness and understanding of traumatic 
brain injury and the issue was generally seen as problem in the 
civilian realm. In contrast, today this issue has become most pressing 
as roughly 1 of out 5 veterans of Operation Enduring Freedom and 
Operation Iraqi Freedom are estimated to experience a possible 
traumatic brain injury and as traumatic brain injury has been 
recognized as the ``signature injury of the war.''
    This month, the media extensively covered the military's failure to 
identify, diagnose, record, and treat brain injuries. NPR and 
ProPublica found that while millions of dollars have been pumped in the 
system since 2007, there have been few results. Furthermore, USA Today 
found that the Pentagon ``failed to comply with a congressional 
directive to give all troops tests before and after'' combat.
    To give some background, in 2007, through the fiscal year 2007 
supplemental appropriations bill, Public Law 110-28, Congress gave the 
Department of Defense $900 million to increase access, treatment, and 
research for traumatic brain injury and post-traumatic stress disorder. 
In 2008, my colleagues and I put in place protections for the troops in 
the National Defense Authorization Act for Fiscal Year 2008, Public Law 
110-181, requiring cognitive screenings of soldiers pre-deployment and 
post-deployment. Two years later, the law has yet to be fulfilled as 
less than 1 percent of approximately 560,000 members of the Armed 
Forces have been given a post-deployment cognitive screening in order 
to identify any possible brain injury.
    We have let too many soldiers fall through the cracks and we cannot 
continue to wait as our soldiers continue to come home from the 
battlefield, without the proper diagnoses. The Department today uses 
two different tests on soldiers pre-deployment and post-deployment. 
These tests are not comparable and cannot detect changes to a soldier's 
brain. To correct this, I included language in the 2011 Defense 
Authorization bill, H.R. 5136, to require the same cognitive screening 
tool be used pre-deployment and post-deployment to detect any cognitive 
change in our soldiers and also to require the Department of Defense to 
complete the studies necessary to find the best cognitive assessment 
tools for our troops.
    Over the last few years, Congress has continued to emphasize the 
importance of this issue and has made funds available for the 
identification and treatment of brain injuries in our soldiers. I am 
disappointed that after so many Members of Congress weighed in on this 
matter, that we must again push to have this problem addressed. I hope 
that this hearing will help the Department to better understand our 
goals and that they will be willing to demonstrate their desire to put 
strong policies in place to identify, diagnose, record, and treat brain 
injury for not only our troops who are currently still deployed, but 
also for the soldiers that we have missed since the beginning of these 
wars. I thank the Chairman for holding this hearing and look forward to 
working with members as well as the Department of Defense to help our 
soldiers in this area of need.

    Chairman Levin. Senator Akaka.
    Senator Akaka. Thank you very much, Mr. Chairman, for 
scheduling this hearing on these vitally important topics.
    I want to thank my brother and friend Senator Inhofe for 
helping to bring this about.
    I want to welcome our distinguished group of witnesses, and 
thank each of you for your dedicated service to our country. I 
also want to thank the men and women that you lead, and thank 
them for their outstanding service.
    Like you, the topics at hand today are ones that I care 
deeply about. Continuing to work with you and my colleagues, we 
can refine efforts to prevent military suicides and to look for 
better ways to detect, treat, and care for those suffering from 
invisible wounds of war.
    General Chiarelli and General Amos, suicide prevention is 
difficult and challenging. For all of you on our panel, this 
has come about, of course, because of what we call ``combat 
stress.'' As was mentioned, this includes PTSD, TBI, and 
behavioral health issues that we are facing here.
    As was previously stated, the Services have experienced a 
rise in the number of suicides since the wars in Afghanistan 
and Iraq started. There is a need to understand suicide, look 
at the causes, and get a point where we can prevent it.
    Generals Chiarelli and Amos, and also Dr. Jesse, how can 
the DOD and VA better collaborate in the area of suicide 
research and prevention? This has been mentioned, by General 
Chiarelli, as a great need here. I'd like to have the three of 
you give your perspectives on this.
    General Chiarelli?
    General Chiarelli. I will argue, the cooperation between 
the VA and the Services, I believe, has never been better. I 
think the disability evaluation system (DES) pilot that we're 
running at different installations is proving to be a great 
success for the U.S. Army. The wonderful thing about this is, 
is that when a soldier goes through the DES, we ensure, that, 
if they are leaving the Service, that they're in the VA system. 
This is something that has never happened before, as far as I 
know it. It is a wonderful benefit of this system, that when a 
soldier makes the decision to leave the Service, he or she is 
in that VA system. Before, we would, in fact, have soldiers 
separate, and it would be their responsibility to work their 
way through the process to get in to receive both their medical 
benefits and other benefits through the VA system.
    I think that you've hit upon a key piece here, and that is 
stressors. But, it's not only combat stress, it's individual 
soldier stress and family stress. When we look at those across 
a continuum, what we're seeing in the Army, with the high 
OPTEMPO that we're on today, that a soldier, in the first 6 
years he or she spends in the U.S. Army, has the cumulative 
stressors of an average American throughout their entire life. 
That's when you combine high OPTEMPO, individual soldier 
stressors, and family stressors.
    This is an area we're looking at very, very hard. When you 
realize that 79 percent of our suicides last year were 
soldiers, 60 percent in their first term, 79 percent one 
deployment or no deployments, I think, it points to doing 
everything we possibly can to mitigate those stressors, 
whenever possible, and as we're working so hard to do in the 
Army, work to increase the resiliency of our soldiers, 
particularly in their younger years.
    Senator Akaka. Thank you.
    General Amos?
    General Amos. Senator, I'll be happy to talk about, not 
only the relationship, but the handoff between the military 
and, in my backyard, the Marine Corps and the Veterans 
Administration. Like General Chiarelli, I have never seen it 
better. The entire organization is well led, from the top down, 
from VA. They are compassionate. They are passionate about the 
care of our young men and women that enter their system. I've 
never seen it better. I'm fortunate to get to travel around and 
visit a lot of our VA hospitals and our wounded, and I come 
away just completely wowed by what I see.
    There is a systematic handoff. In the Marine Corps, this is 
done through what we call our Recovery Care Coordinators. We 
have them around the Nation, and they are not part of the 
Federal Recovery, but they are linked to it--but, they are U.S. 
marines whose job and life is to know everything they can about 
the VA system. So, when a marine transitions--especially one of 
our wounded marines--out heading into VA-land after a 
disability board, and he's moving on to the next half of his 
life, that Recovery Care Coordinator contacts a Federal 
Recovery Care Coordinator, the District Injured Support Marine 
we have out there, our network of Marine for Life, to put our 
arms around this guy.
    I've seen it firsthand, where the actual handoff for a 
needy marine, in some cases 2 years after the initial injury--I 
just saw this about last month, down in Corpus Christi, TX. A 
young marine, TBI, 2 years ago, his life is unraveled right 
now. Through the Federal Recovery Coordinator and the VA in San 
Antonio, and our Care Coordinator, we were able to plug this 
marine, get him back into a hospital right now for further 
care.
    So, I've never seen it better, Senator.
    Senator Akaka. Yes.
    Let me ask, Admiral Greenert, for your comments, as well as 
General Chandler, after you.
    Admiral Greenert. Thank you, Senator. I think General 
Chiarelli and General Amos hit the nail on the head. The 
cooperation is very good. In fact, we meet monthly with the 
leadership of the VA and leadership of DOD to streamline the 
DES.
    I would say that what we are finding in our study of 
suicides, the transitional period seems to be a spike in 
stressors. This is an area we need to watch very closely, this 
transition period, and be sure that our sailors have the social 
support network that they've had as they've moved through their 
career in the Navy, as long as it is. It's also a focus area, 
to watch out for those stressors.
    Thank you.
    Senator Akaka. General Chandler?
    General Chandler. Senator, we have approximately 700 airmen 
in our Wounded Warrior Program. These are young men and women 
whose lives have been changed forever, and that we are 
dedicated to taking care of, from the time they've been wounded 
until they no longer need our services in the Air Force, and we 
make the transition to the Federal system, if, in fact, that's 
required and we're not able to bring them back to the Air 
Force.
    We use much of the same system that General Amos described, 
with Care Recovery Coordinators that allow us to do that around 
the Nation, to service the young men and women that require 
that kind of treatment and that kind of handling. We're very 
comfortable with our relationship with the VA and the way 
that's working.
    Senator Akaka. I'm glad that we've been working on what we 
call ``seamless transition.'' It appears that we are moving 
along on that.
    Dr. Jesse?
    Dr. Jesse. Thank you, sir. So, as not to reiterate things 
that have already been said, I'd just like to point out a 
couple areas where this level of integration has really become 
manifest. The first is in the post-deployment and health 
reassessment exercises. The VA generally has a presence at 
those exercises, not to administer the exams, but to be present 
to make sure that those servicemembers are aware of all of 
their benefits that the VA can provide. But, also, if there are 
immediate health, and particularly mental health, issues that 
arise, that they are there and can literally make an 
appointment on the spot. They can get them enrolled in the VA, 
make an appointment. If we need to take them into our care at 
that point, we can do that, so that we participate in that.
    The second is the polytrauma networks, which really are--
while the VA has four, and going on five now, Polytrauma 
Centers of Care, are very tightly integrated into the Wounded 
Warrior Programs at Walter Reed and Bethesda. In fact, I had 
the real honor to accompany Deputy Secretary Gould and Dr. 
Stanley on a tour of Walter Reed, and then come directly down 
to Richmond and look at the seamless way that both patients and 
their information move back and forth through those networks, 
including the fact that there are VA representatives stationed 
in the DOD facilities, and DOD clinicians in the VA Polytrauma 
Centers, so that we ensure that any movement of patient is a 
warm handoff and not just being sent to another place.
    Finally, in the mental health area, I think there's just 
been an extraordinary collaboration going on for some time now. 
There was a joint conference, in the fall of 2009, that led to 
an integrated VA/DOD strategic plan. The real goal was to make 
sure that when, for instance there are evidence-based therapies 
for treatment of PTSD, that the VA and the Services agree on 
how we treat those patients so that as treatment begins in the 
Services, and then transitions in the VA, we're not abruptly 
stopping one form of therapy and entering into another. I think 
this is a hugely important point of collaboration, that we've 
gotten that far.
    Senator Akaka. Thank you for your responses.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator Akaka.
    The testimony of our witnesses, saying that the integration 
of planning and diagnosis and treatment of our troops that are 
veterans is going along at a good pace, is important news to 
both of our committees. It's something we put a great focus on, 
both Veterans Affairs and Armed Services. Our wounded warrior 
legislation was aimed at accomplishing that. So, this is 
important testimony, and good to hear.
    Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    General Chiarelli, I want to follow up on a question that 
Senator Inhofe asked you.
    Senator Inhofe, I want to thank you for suggesting this 
hearing, as well as the chairman, for holding this important 
hearing.
    In the past year, I have met with a retired general in my 
State, with returning members of the National Guard, and with a 
whole variety of healthcare professionals, to discuss the 
mental health needs of our troops and the troubling rise in 
suicides. To a person, each of them has told me that it's 
insufficient dwell time between deployments that they believe 
is the biggest factor, that there's not sufficient recovery 
time before deployments occur again. How important do you think 
that factor is to the increase in problems with mental health 
and the suicide rates?
    General Chiarelli. I think, for the National Guard 
soldiers, it may be higher than we're seeing with the Active 
component soldiers. As I indicated, 79 percent of our suicides 
last year were soldiers who had never deployed or only deployed 
one time. So, that would argue that, in that group of 700,000, 
there's a bit of resilience that grows with repeated 
deployments. I'm just giving you the numbers we're seeing out 
of NIMH, and as we start to pull the early results.
    I really believe, though, the real issue here for our 
National Guard soldiers is that, when they come back off of 
multiple deployments, that second or third deployment, that we 
have sufficient time at the DEMOB station to do the kind of 
medical tests, such as a virtual behavioral health counseling 
or other things, to ensure that, number one, we get a good read 
on how they're doing; and, number two, that they fully 
understand the medical benefits that they're going to have when 
they return to their State.
    One of the hardest things for any of us is that the 
benefits for a National Guard soldier differ from State to 
State. We've made great progress with TRICARE Reserve Plus. You 
add that to the Transitional Assistance Management Program, 
which gives you 6 months of care when you come back home. If we 
can get the soldier to enroll in TRICARE Reserve Plus, we can 
provide them continuous medical care to the next deployment. I 
think this is critical.
    I think we have to look at this population a little bit 
differently, and, again, as Senator McCain said, I am able to 
wrap leaders around returning Active component soldiers for the 
entire time that they're back. We take a Reserve component 
soldier today and, within 5 to 7 days, he's back in his 
community, on his own.
    Senator Collins. A related problem, at least in a rural 
State like mine, is an absence of mental health professionals 
in those rural communities. Even though the VA will provide the 
assistance, or the National Guard will provide the assistance, 
it's often many hours away. That's a problem that's in our 
society as a whole, and you've mentioned the shortages that 
you're facing, and that it's difficult to match the mental 
health professionals where bases may be located. But, that's an 
even worse problem when you're talking about National Guard 
members or reservists who are going back to their home 
communities, their regular jobs in small communities that may 
not have any mental health professionals at all.
    General Chiarelli. If I could just quickly comment.
    Senator Collins. Yes.
    General Chiarelli. We started a program, last August, which 
gives counseling, 24-7, without a TRICARE referral, to anyone 
who's authorized for TRICARE. It is done online. It falls short 
of psychotherapy or prescription pain management, so we can't 
do that online. But, where I really see us making up for this 
shortage is to really explore what we can do with tele-
behavioral health.
    Senator Collins. I agree.
    General Chiarelli. Because this gets at the stigma issues, 
it gets at the kind of shortages you're talking about in rural 
areas, Senator. I really think that this is something that will 
fix us now, rather than wait until we grow the necessary 
providers that we need over time. I really think we should be 
exploring this as hard as we possibly can.
    Senator Collins. I completely agree. There's great 
potential, particularly since so many of these young troops 
have access to computers in their own homes, because the stigma 
still is there. Despite all of our efforts, it's still there. 
So, I'm delighted to hear you put an emphasis on that.
    General Amos, even though we've given a lot of attention to 
the Army's rising suicide problem, I was struck to see, in 
2009, that the branch with the highest rate of suicides among 
Active Duty personnel was actually the Marine Corps. The Army's 
clearly done a great deal, is the Marine Corps matching that 
effort, in stepping up your programs and trying to tailor them 
to the culture of the marines?
    General Amos. Senator, that's a great question. The short 
answer is: absolutely, yes. We are joined at the hip with our 
programs that we mutually share cross-boundary. We are aware of 
all that each of the other Services do. We collaborate. We 
share best practices. We steal good ideas from one another. So, 
the answer is yes.
    In 2009, we led the Department of the Defense in suicides, 
percentage-wise. We had 52. That's double what we had in 2005, 
when we had 25. So, you ask yourself, ``What is it that's 
caused this?'' We don't have all the answers on this thing, and 
you wouldn't expect me to, but you would expect me to be trying 
to find out and do something about it.
    Interestingly, the Marine Corps is the youngest Service, 
age-wise, of all the other Services; for instance, 67 percent 
of all of our 202,000 marines, between the ages of 17 and 25. 
If you compare that to the other Services, we are woefully 
more--when I say ``immature,'' I'm just talking about years--as 
a whole-cloth force. So, that, in and of itself, causes some 
issues. Our population, where our marines are killing 
themselves, are between 17 and about 23/24; it's male; it's 
about half married, half single; white. The deployment--for 
instance, this year alone, we've had nine young marines take 
their lives that had never seen their deployment. We have had 
marines come right out of boot camp, and, after having spent 12 
weeks in what is arguably a ``legendary boot camp,'' which 
calls out an awful lot of folks who just can't handle the 
stress, they kill themselves. They go home on leave, and every 
now and then they'll take their life. They've never seen 
deployment one, and they've just completed the most rigorous, 
probably, physical and mental examination that they've ever had 
in their life. So, what causes that?
    We had a young lance corporal just check into his unit, who 
were deployed in Afghanistan 2 weeks ago, his very first day, 
he goes on duty, walks outside the perimeter, and shoots 
himself. He did this--as you, kind of, do the forensics on this 
thing--his girlfriend left him just before he left. He has 
issues with his family at home, his mother and father, and so, 
these are the kind of things that we're seeing.
    So, what are we doing about it? First and foremost, in our 
organization we're focusing on the leadership of the Marine 
Corps. I know that sounds trite, but we're an organization 
that's based on leadership, everything we do. So, we start with 
the very top. The Commandant of the Marine Corps, the Sergeant 
Major of the Marine Corps, are adamant about this, and it's 
flowed all the way down through our senior leadership, that we 
have to absolutely pay attention to this. This is not something 
to be taken lightly, and it is an issue. So, that's the first 
thing, the senior leaders' focus.
    It took us about 6 months to develop--we pioneered it about 
last July, a NCO suicide prevention half-day course. It's film, 
it's in the vernacular of the NCOs, because looking at that 
population of our young marines that are taking their lives, 
it's that 17-to-22/23. That's where the NCOs--they own those 
marines. They know them better than anybody. So, we focused 
this effort on them. High reviews, just great reviews from the 
NCOs. One-hundred percent of our NCOs have gone through this 
thing, and they're taking that training down to the young 
marines below them.
    Interestingly, we've seen a drop in suicides this year, 
even though right now we are on the same plateau as we were 
last year. That's probably not very encouraging, but if you 
consider this vector we've been on since 2005, which has been 
very steeply vertical, the fact that we are even where we were 
last year is an encouraging sign.
    The further piece of news that's encouraging is, this NCO 
course, it is too soon to tell, but last year, 92 percent of 
our suicides were in this age group that I just described, 
about 23 to 17, and a lot of them were NCOs. We've seen a drop 
this year down to 84 percent, as of today. We've said, ``Okay. 
Let's take a look at those real young marines, the privates 
through lance corporals; let's take a look at the staff NCOs; 
and let's take a look at our young officers, lieutenants to 
captains, and let's build a very similar program.'' We're in 
the throes of that right now. It should be published within the 
next 2 to 3 months. We're going to do that whole thing for the 
entire Marine Corps.
    So, we think it's going to work. We think it has worked. 
Too soon to tell. But, ma'am, we have increased our resiliency 
training by--immersion training for our young marines, all that 
predeployment stuff, trying to make our marines more resilient.
    I have a list of things down here that I could go through. 
But, I just want you to know this has our attention. This is 
job one with the Marine Corps.
    Senator Collins. Thank you.
    Chairman Levin. Thank you, Senator Collins.
    Senator Udall is next.
    Senator Udall. Thank you, Mr. Chairman.
    Good morning, to the panel.
    General Chiarelli, I want to, in particular, note the 
attention you've paid to these important issues. I had an 
opportunity to travel with you to Fort Carson earlier this 
year. I know you've immersed yourself in these difficult 
discussions. I know we don't have all the answers yet, and 
that's why we're holding the hearing, in part. I trust my 
questions will be received in that spirit, as well.
    I wasn't here earlier, during the questioning about the 
ANAM test. I think you said that, while the Army uses it, 
predeployment, for a baseline, you don't use it post-
deployment, not usually, because of the false positives that 
often result, or result, to some extent of the time. Here's my 
question. By definition, a baseline is supposed to give us 
something to look back at, in the aftermath, a way to compare. 
So, if we're not using, what is it, close to 600,000 pre-
deployment assessments to compare to the post-deployment 
assessments, what are we doing with them? Why use ANAM at all 
if it's not being used in that post-deployment situation?
    General Chiarelli. Senator, I will tell you, we are using 
the ANAM on post-deployment, but only if the soldier 
demonstrates some kind of a symptom of having cognitive issues. 
That may be cognitive issues that could be caused by TBI or 
some other behavioral health issue.
    So, the baseline is very, very important, because it gives 
the doctor an additional tool that, when symptoms are 
demonstrated, or in a post-deployment screening we have reason 
to believe we should have that soldier go through the ANAM, we 
go ahead and use it. What we're just not doing is doing a post-
deployment ANAM for every soldier irregardless--or regardless 
of--my English teacher would have just been--thank you very 
much.
    Senator Udall. Mine too, General. [Laughter.]
    General Chiarelli. Regardless of whether they show those 
symptoms, because we were getting so many false positives. We 
just don't have the behavioral health specialist folks, to work 
through all those false positives and give the care we need to, 
to the rest of those who need care.
    Senator Udall. That's helpful, and we'll continue that 
conversation. My next question will follow on that. I want to 
talk about the post-deployment health assessment (PDHA). It's 
supposed to catch things that weren't caught in theater, as I 
understand it. A soon-to-be-published study has shown that the 
standard screen on the PDHA fails to catch 40 percent of those 
who sustained a TBI in theater. This comes from research at 
Fort Carson, in my home State of Colorado.
    I've been there, as I've mentioned, on a number of 
occasions, to get briefings on how they're handling TBI 
patients. I think they're doing it right. By using a more 
thorough exam, with clinical interviews to augment the PDHA. 
There's a concern, as I understand it, that individualized 
approach would take too much time, and require scarce personnel 
to administer, and that such an approach can't be replicated 
across the force. But, I'm told that at Fort Carson it only 
takes about 15 to 20 minutes of additional time to do this. 
Could you speak to Fort Carson's approach and whether the 
Army's looking at maybe applying this elsewhere?
    General Chiarelli. I'll tell you, I disagree with Fort 
Carson. I want them to institute the virtual behavioral health 
screening, so that we can ensure that we get everyone. I don't 
want to use any form. I don't want to use any series of 
questions that automatically says that a soldier does not have 
those issues. I think that what we really need to do is to get 
to a standard that says we're going to give everyone a post-
deployment screen; follow that up, 90 days later and 180 days 
later.
    Here's my problem with the Fort Carson approach. The Fort 
Carson approach focuses on soldiers with doctors that they have 
assigned when they come back. They may get through a 15- to 20-
minute screening of a select population who's demonstrated, 
based on a questionnaire, that they may have issues, they may 
be medium to high risk. But, when you do that, you take away 
the doctors that are providing care to those folks that we have 
already found, because you're focusing on this group. That's 
why this virtual network is so important, that you can do an 
actual triage and get the number down to those that you can 
treat with those people you have on base. I've had discussions 
with Fort Carson about this.
    I have to tell you, until I get doctors to use the virtual 
method, many of them push back, and they push back because they 
have never done this before. But what we're finding is that 
those who go through it, the doctors--those doctors are the 
biggest supporters of it, because we find that this generation, 
in many times, opens up much greater using either Skype 
technology or some kind of high-definition video teleconference 
(VTC), even more so than sitting across a room, like you and I 
are right here. They really feel they're able to get at some of 
these issues and do a good evaluation.
    Senator Udall. I respect the passion in your response. 
Let's continue the conversation. Again, it points out General, 
how involved you are, and how much you've paid attention to 
details and soldiers.
    Let me turn to another--perhaps a bit of a difficult 
conversation that's tied to the National Public Radio story. 
They report a term that's used by researchers, ``the miserable 
minority,'' to refer to those who suffer from mild TBI, who 
have long-term repercussions. It's true, from what I learned, 
that most soldiers recover from mild TBI, but some who seem to 
have symptoms persist for months or even years, and if you get 
a repeat of a TBI incident, you can aggravate that mild TBI.
    The National Public Radio story intercepted an email from 
one of General Schoomaker's advisors, Dr. Hogue, who questioned 
the importance of even identifying mild TBI accurately, asking, 
quote, ``What's the harm in missing the diagnosis of mild 
TBI?'' Can you help me understand whether finding ways to 
diagnose and treat mild TBI is important to the Army?
    General Chiarelli. It is extremely important to the Army. 
Dr. Hogue represents a population of psychiatrists and 
psychologists, quite frankly, you can find one who will support 
just about any different way of attacking this. It is not this 
well-developed science that we have in other areas, such as 
heart surgery. I think the dialogue is good. I didn't 
necessarily agree with Dr. Hogue when he wrote in the New 
England Journal of Medicine. But, he did do a peer-reviewed 
study where he talked about this.
    I think the great disservice that National Public Radio did 
to everyone was to try to isolate TBI from PTSD. That is just 
not possible. As I indicated before, the comorbidity of these 
two is what's giving us the difficulty today. I also think that 
they did a disservice when they indicated that PTSD is a 
psychological problem. It is not just a psychological problem. 
It is a physical injury that occurs. If anything, I think could 
be best described as a chemical injury, because that frontal 
cortex doesn't turn on and stop the flow of those things that 
keep a person at this altered state for 4 to 6 hours. So, I 
think we have to look at these two together and realize the 
real difficulty that doctors are having trying to separate and 
understand the symptoms 100 percent in every single case.
    Senator Udall. General, thanks. Let's continue this spirit 
of discussion.
    I want to thank all the members of the panel, as well, and 
I thank you for your service.
    Thank you.
    Chairman Levin. Thank you, Senator Udall.
    Senator McCaskill.
    Senator McCaskill. Thank you, Mr. Chairman.
    I thank all of you for being here.
    There are basically three areas I'd like to try to cover, 
quickly, that I think are important. An overarching concern is 
that of confidentiality. So many of the issues surrounding 
mental health, whether it is brought on by a brain injury or 
whether it's brought on by substance abuse, alcohol abuse, or 
prescription drug abuse, so much of the problem we have in the 
military is the stigma associated with getting help, 
particularly for Active military, Reserves, and National Guard.
    I'm sure you all are aware of the pilot program that is 
ongoing--I know General Chiarelli and I have talked about it--
for the confidentiality of alcohol and substance abuse 
treatment at three different facilities, where these soldiers 
are not being referred to their chain of command after they 
have sought treatment.
    General Chiarelli, could you address how that program is 
going, and whether you think this pilot program shows real 
potential for allowing folks to get help without the negative 
impact to their careers that so many of them fear right now?
    General Chiarelli. Tremendous potential. We've done it at 
three installations. We started in Fort Carson in August 2009. 
We're expanding it to two others. The only thing that's not--
and the secretary of the Army approved this, a month ago--the 
only problem that we're having is trying to recruit the number 
of drug and alcohol counselors that we need in order to ensure 
that, when someone self-refers themselves for this problem, 
that, in fact, they can be seen immediately and not be told, 
``Well, come back 6 weeks from now and we'll take care of 
you.'' But, we're seeing great results from the three 
installations that we have started the pilot at.
    Senator McCaskill. That leads to one of the other areas 
that I wanted to cover today, and that is the availability of 
counselors. In 2009 I was successful at getting a provision 
that required the Institute of Medicine to assess whether 
licensed mental health counselors should be allowed to practice 
without supervision within the military for purposes of this 
kind of counseling. That study was released in January, and 
supported the conclusion that they should be able to practice 
without that extra layer of supervisory personnel. I'm curious 
now, with that, Do you see the ability for us to staff up at 
more appropriate levels to get at this problem that we see, in 
terms of availability of mental health professionals for our 
men and women who need help?
    General Chiarelli. Yes. This is a wonderful provision, and 
we've come to about 92 percent of our pre-2001 authorization. 
We've done an exhaustive study. Just as we reach, or are 
getting close to reaching our goal, because of the increased 
amount of drug and alcohol issues that we have in the Army--and 
I'm not going to paper that over--we need about 225 more. So, 
we have authorization to hire an additional 225, and this is 
going to be a great help to us.
    Senator McCaskill. I think it's so important that we look 
at this as being just as important as so many of the other 
tools we give to our fighting men and women. Our heroes need, 
not just the protective armor of the battlefield, they need the 
availability of help when they need it. I know that you've made 
this a huge priority, I know all of you on this panel have.
    I want to make sure that if there's anything that we can 
do, as members of this committee, to continue to reinforce this 
at the highest levels of leadership in our armed services, that 
you let us know. The idea that we would stand between more help 
for our men and women who are struggling, that we need to get 
more people on board, is very frustrating. I want to make sure 
that you know that there are many of us that want to go to 
battle over this, if necessary.
    That brings me to the final thing. Unfortunately, Missouri 
has had one of the highest rates of suicide in our National 
Guard. That is this notion of embedding, particularly for our 
National Guard and our Reserves--embedding mental health 
counselors within units. As you probably know, this has been 
done in California, at a surprisingly low pricetag, because the 
availability of the embed is for the weekends and for the 2-
week training, as opposed to 365 days, around the clock. That 
help, during those weekends and during those weeks of training, 
I think, it could be a huge assistance to our National Guard 
members, and would want your reaction to that.
    I know that we don't have a member of the Reserves on the 
panel, or National Guard, but if----
    General Chiarelli. No, I look for any way that I can get 
behavioral health specialists down to National Guard units, and 
I think embedding is an outstanding idea. I will work with the 
surgeon generals but they have not brought that program to me. 
We've been trying to expand at the telehealth capabilities to 
our National Guard armories. But, I promise you, Senator, I'll 
look into that and talk to the National Guard surgeon general 
about just that.
    Senator McCaskill. This is really important, because in 
California, which has the largest Guard component in the 
country, it has 40 different Guard units--the cost for 1 year 
of mental health embeds was 820,000. That's a bargain, 
particularly when we see this kind of increase.
    We've lost five members of the National Guard in Missouri 
already this year to suicide. That is something that is 
unacceptable, and something we clearly--and I know the surgeon 
general of the Missouri National Guard, General Danner, is very 
concerned, and wants to move toward some kind of embed program. 
I think the support of the people at this panel this morning 
would be crucial for that to move forward. I think we could 
also, obviously, do it for the Reserve units.
    General Chiarelli. We need to look across the National 
Guard, because as I indicated before, we've had an increase of 
21 suicides across the National Guard, at the same time we're 
down in all other categories. So, this really has my attention 
and, I know, the attention of Ray Carpenter.
    Senator McCaskill. Okay. I'll continue to follow up on 
that.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator McCaskill.
    Senator Begich.
    Senator Begich. Thank you very much, Mr. Chairman.
    I want to follow up, if I can, on just a few of the 
comments and responses to some of the questions that were given 
earlier.
    First, General Chiarelli, I want to, one, thank you for the 
work you're doing. You are definitely passionate about trying 
to resolve this issue, or at least move forward in a positive 
way, and I really appreciate that.
    I appreciated your comments on telemedicine. I know, Dr. 
Jesse, you've been subjected to my conversation before on this 
issue, through the VA, for the Veterans Committee. I do believe 
this is a huge opportunity that both the DOD and the VA can 
really exploit in a positive way. With the new generation of 
young people who--you think, 10 years back, where we were with 
PDAs, telephones, cell phones, and computers, to where we are 
today, is unbelievable. So, I'm curious, because I hear your 
comment about some doctors push back on this new technology. 
How are you getting them to see the value?
    I say this in as polite way as I can. You're the military. 
One thing I've learned about the military is, when you want to 
do something, you just do it and get moving. I understand that 
doctors have to grow into some of these things. But, time is of 
the essence. What are you using to get these doctors to get on 
step with telemedicine? Because that is the future, when it 
comes to mental health services, especially in a State like 
mine, where these folks come back from serving, and they're 
sent back home, to a village--and I'll use the Guard as an 
example--back to a village of 200 people. No medical services 
that they can tap into, from a veteran's perspective. But, what 
are you doing to get those doctors to get on step and get on 
with the program, here?
    General Chiarelli. We're doing exactly what you would 
expect us to do now. We published an overall comprehensive 
behavioral health plan. We're standardizing how we're going to 
treat soldiers when they come back. Part of this time, I 
believe we've seen a thousand flowers blooming, and I think 
it's time----[Laughter.]
    --to move away from that, ensuring that we look for 
innovation and new kinds of treatments, but, at the same time, 
we have standard program for returning soldiers, that not only 
takes them from the day they return home, but at the 90-, 180-
daymark, when so many of us, I think, would agree, we start to 
see many of these problems pop up.
    Senator Begich. Right.
    General Chiarelli. So, we're doing it exactly in the 
military way that you allude to, Senator.
    Senator Begich. Okay.
    General Chiarelli. We're going to make sure that it's 
standardized across our force.
    Senator Begich. I think that's great.
    Dr. Jesse, I know we've talked, but I'd love you to put on 
here--I actually just saw some technology development, done by 
an Alaska native corporation, on utilization of BlackBerrys, 
PDAs, and others, on alcohol screening and alcohol abuse--kind 
of, follow-up for those that decide to move forward. I saw that 
technology, and it was impressive to me, because what it shows 
is, it's reaching into how to get to these young men and women 
in their world of technology, versus what we think is the right 
way, bringing them into the office, sit them down. We're 
touching them in a different way. So, that technology is very 
unique, and I know the VA is starting to look at some of that.
    Can you just put on the record a little bit of what you're 
doing around electronic telemedicine?
    Dr. Jesse. Sure. We have quite a long history in 
telehealth, actually dating back even to the 1980s, with home 
monitoring of pacemakers using TTM technology. We've invested 
heavily in home telehealth by putting, if you will, ``boxes'' 
in patients' home. I think we have 43,000 of them deployed. 
But, as you mention, the new technology is using smart phones, 
where you don't even have to invest in something that ties 
somebody to their home. Anybody who has a kid in their 20s now 
knows you don't even bother to call them, you just text them.
    Senator Begich. That's right.
    Dr. Jesse. They don't answer their phone, but they'll text 
you back.
    Senator Begich. Right.
    Dr. Jesse. Interestingly, as an example, you're all aware 
of the VA's suicide hotline, which people can call in to, but, 
about a year ago, they started a chat line for the younger 
folks are much more used to chat lines on the Web than they are 
to having phone conversations. That's been, I think, an 
important emerging way to contact, for the younger people. So, 
as we deploy that mental health technology, along with all of 
other medical capabilities, using new technologies that the 
people who need it understand and prefer to use, I think, is 
going to be vital.
    General Chiarelli. Could I mention one other thing?
    Senator Begich. Please.
    General Chiarelli. We just signed an MOU with the VA on 
credentialing and privileging, which is a key and critical 
piece, here. We can do that with the VA so their doctors can be 
part of our virtual behavioral health----
    Senator Begich. Excellent. Yes.
    General Chiarelli. But, that is a real issue when you're 
trying to provide the same kind of care across State lines, and 
even within State lines. In the area of behavioral health, I 
think we really need to look at some of those rules, and think 
about, do they need to be the same for this branch of medicine 
as they do, say, for a heart surgeon or someone else?
    Senator Begich. You just got to my next question, so I'm 
going to start with you and then come down the row here. I'll 
leave my friend, Howie Chandler to last.
    My next question is kind of the question that hasn't been 
asked; I think Senator McCaskill started to get to it. What do 
we need to do, here in Congress, to help make it easier for you 
to deliver the services that you know, instinctively and as 
well as data has shown you, to the young men and women? What 
you just made a comment about, delivering these services over 
State lines, or maybe you could elaborate. What are those one 
or two things, each one of you, if you could just expand--
because part of what we should be doing here, honestly, is--
what do we need to do to support you? It's great to have a 
hearing, but what's the next step?
    General Chiarelli. I would mention credentialing and 
privileging. Give you just a quick example. I can go ahead and 
provide a TRICARE referral for a soldier at Fort Campbell, 
Kentucky, to drive 100 miles to Nashville to see a 
psychiatrist. I cannot hook him up over the Internet if he is 
not at military installation, and privileged and credentialed 
from that location. So, I can't hook into his office in 
Nashville, yet I can put a soldier in a car and send him 100 
miles to go see that doctor, as a TRICARE referral.
    Senator Begich. Good example. My time is up, but if each 
one of you can just give a quick one, and then I'll close out.
    Thank you, Mr. Chairman.
    Go ahead.
    Admiral Greenert. Senator, for the Navy, if we could look 
at the age of healthcare professional appointments and 
mandatory retirements, there are a lot of people want to help, 
out there, that may be over the age of 42. That, I think, if I 
understand it right, is the limit for a lot of our healthcare 
providers, particularly mental. That could be helpful.
    Senator Begich. Very good.
    General Amos. For the Marine Corps, your continued support 
for our deployment cycles and in sustainment of our Marine 
Corps while we are in between those deployment cycles, with 
programs like the Yellow Ribbon Program, our Returning Warrior 
Programs, those kinds of things that help our families--that is 
a modest investment that has paid rich dividends. So, your 
continued support on that would be great.
    Senator Begich. General Chandler?
    General Chandler. Senator, I would echo what my 
counterparts have said, and also add to that, thanks for your 
support for the bonuses and special pays. That has allowed us 
to recruit, frankly, almost the numbers we need, in most areas. 
We're suffering, as the Nation is, in a shortage of mental 
health nurses. But, that's really the only shortage that's 
dramatic at this point, and we appreciate your support for 
that.
    We've had some promising research at Lackland Air Force 
Base, in San Antonio, with TBI and hyperbaric treatment. Any 
support that we could receive in that area would also be very 
helpful.
    Thank you.
    Senator Begich. Very good. Thank you very much.
    Dr. Jesse, we've already had our conversation. I'll leave 
that, if I can, because my time is expired. I'll be tapping 
you, don't worry. [Laughter.]
    Mr. Chairman.
    Chairman Levin. Thank you, Senator Begich.
    What kind of support do you need for that hyperbaric 
treatment?
    General Chandler. Sir, we're actually in our infancy, quite 
honestly. If I can take that for the record and get back----
    Chairman Levin. Is it a----
    General Chandler.--in terms of costing.
    But, as most things go, it becomes a personnel and dollar 
issue. But, we've had some fairly promising results with 
hyperbaric chamber treatment.
    Chairman Levin. If you can just give us any example--and 
this goes for all of you--where there is a funding shortfall on 
the appropriations side, we would more than welcome it. We're 
determined we're going to get you whatever funding you need to 
address this issue.
    [The information referred to follows:]

    Congressional support for current Air Force (AF) hyperbaric oxygen 
treatment (HBOT) for Traumatic Brain Injury (TBI) research is 
sufficient and greatly appreciated. Department of Defense (DOD) 
research on HBOT for TBI is in its infancy and is centered on chronic 
mild and moderate TBI. It remains an unproven therapy and is not 
accepted as a standard of care because only anecdotal case reports and 
a small series of trial reports indicate some potential benefit for 
TBI. Several prospective randomized clinical trials are underway within 
DOD and civilian institutions to provide more conclusive evidence 
regarding HBOT's use for TBI. Definitive phase 3 trials, which will 
take 2-3 years and include randomized, multi-center (DOD facilities 
only), double blind, definitive studies under the auspices of the Food 
and Drug Administration with an investigational new drug registration, 
are projected to start in fall 2010. If this research validates the 
efficacy of HBOT for TBI, we will request additional congressional 
support for the sustainment and possible expansion of hyperbaric 
chambers and personnel in addition to presenting the evidence to the 
Undersea and Hyperbaric Medical Society for consideration as an 
accepted indication for use.

    Chairman Levin. Senator Lieberman.
    Senator Lieberman. Thanks, Mr. Chairman.
    Thanks, to all of you. I apologize that I was drawn out to 
another meeting in between.
    I appreciate, very much, the work that all the Services are 
doing on these problems, particularly, obviously, suicide 
prevention programs. I know, for each of you, this is a deeply 
personal issue, and I thank you for the time that you're 
putting into it.
    In my own work on this, I have become familiar with some 
statistics that surprised me. I want to offer them, not to 
diminish the problem that you and we are facing among 
servicemembers, because every suicide is a tragedy, and we want 
to prevent them all. But, what's interesting to me is that--and 
obviously the most significant factor for all of us is the 
extent to which the suicide rate among Active Duty U.S. 
military personnel has increased, over the last decade, from 
9.1 per 100,000 in 2001, to 15.6 per 100,000 in 2009. The 
increase is in comparison to a rate among the civilian 
population of 11.11 per 100,000 population. But, what's really 
striking to me, and shows, really, a broader societal problem--
if you take out the young male population in the country--and 
the military is still disproportionally composed of young 
males, as compared to the overall population--the rate of 
suicide among 18- to 24-year-old males is 17.8 percent.
    This suggests a broader societal problem, which was a total 
surprise to me as I went over the numbers. It doesn't diminish, 
in any way, the importance of the efforts you are making, and 
that we're trying to support you in making. But, what it says 
is that rate of suicide among young males in military was 
actually significantly lower than the general civilian 
population. Certainly, a decade ago, now has come up, but still 
is lower. Obviously, we'd like it to be zero.
    But, I want to suggest, in these statements, no attempt to 
minimize the problem, but to say that this cries out for some 
larger societal response that deals with young males in our 
society.
    I don't know whether any of you want a chance to respond to 
that.
    General Chiarelli. If I could, real quick.
    Senator Lieberman. Yes, General Chiarelli.
    General Chiarelli. Sir, we've run across something that's 
very, very interesting. As I indicated--I threw out some 
numbers--but, when we look at the number of soldiers who are 
first-termers----
    Senator Lieberman. Right.
    General Chiarelli.--who join the Army between the ages of 
28 and 29, they account for three times their expected rate of 
suicide. In other words, they're only 5 percent of the first-
term populations, but they account for 15 percent of the first-
term suicides, which would indicate that not only is it youth, 
but it is also this combination of additional stressors.
    Senator Lieberman. Interesting. Well, those are compelling 
numbers.
    Let me go on to another question. I apologize, I gather, 
from staff, this hasn't been dealt with in depth, so I'll run 
the risk of asking it again. This is the question of how the 
Services diminish the understandable human fear, that anxiety 
in a member of the Service, that going for help will be 
detrimental to that serviceperson's career and advancement. I 
know that the Air Force actually quantified that in their 
study. But, my own sense, from conversations with members of 
other Services, is that this is a pervasive problem. You all, 
obviously, are deeply concerned about this and focused on how 
to make it better. In some sense, my question is, how do you 
transfer that concern down the chain of command so that 
individual members of your Services feel that they can go for 
help for a mental problem, just like you go for help if your 
leg is bothering you?
    General Chandler. Senator, I wouldn't minimize that problem 
for the Air Force, quite frankly. I think it still exists, and 
I think there is a stigma attached to that. I think the basic 
answer to your question is, it becomes a leadership issue, 
directly down to the senior NCOs and officers that look the 
young men and women in the eye every day, that can recognize 
whether or not they have an issue, and then act accordingly.
    We have the same demographic issues that you described 
earlier, in terms of young male airmen that are taking their 
lives. We diverge a little bit from the other Services, in that 
our biggest issue, in terms of suicide, are relationships; 
about 70 percent of Air Force suicides involve relationship 
issues of some kind.
    Senator Lieberman. You mean within the military----
    General Chandler. These are typically personal 
relationships.
    Senator Lieberman. Personal. Yes.
    General Chandler. Second would be legal issues that a 
member might have. Then, third, financial. Only 20 percent of 
our suicide victims have been deployed in the last year. So, we 
deviate, again, a little bit from the Army and the Marine 
Corps, as we do that. But, if you look at the elements of the 
Air Force where that occurs--those specific career fields--
those, in fact, are young male members, primarily in terms of 
security forces, EOD--explosive ordinance disposal--and those 
kinds of duties. But, at the same time, those career fields are 
also under a fair amount of high OPTEMPO. Security forces are 
at 1-to-1, in terms of dwell time.
    So, I wouldn't minimize the way we get at this in the Air 
Force, but we have moved our mental health care providers into 
our primary care clinics, to try to keep people from having to 
necessarily go someplace else, behind a curtain, to see a 
mental health provider. Our airman family and readiness centers 
also provide military health counselors, where you can actually 
go get help with your family members or for yourself. Of 
course, the Military OneSource provides, at no cost--I believe 
the number is six visits that you can arrange for yourself to 
do that. Again, all of these are confidential kinds of ways to 
do this.
    There are ways to get at it, including our Chaplain Corps, 
which are all trained in suicide intervention, as well. We 
approach this from a number of different directions. But, I 
think the stigma issue is one that's going to be very, very 
difficult to overcome.
    Senator Lieberman. Thanks.
    My time's up, but I wonder if any of the others of you want 
to briefly comment on that. Essentially, what you're doing to 
try to remove this----what General Chandler called--I think, 
appropriately called, a stigma.
    General Amos. Senator, you're absolutely right. I think 
this is evolutionary. Just 5 years ago, we wouldn't have even 
been talking about this in a battalion or a squadron or some 
type of deployed unit. We would be sloughing this off. Now, my 
sense in the Marine Corps is, we have the senior leadership of 
the Marine Corps, both the enlisted and the officer side, that 
are believers. They understand that this stigma is real and 
that we have to set the conditions to get around it. I'm not 
convinced that our middle-grade staff NCOs and our young 
officers have the same sense of appreciation. I think it's 
probably because they're younger, there's less----
    Senator Lieberman. Right.
    General Amos.--they've been exposed to it less. But, this 
is a leadership issue that we're working on. To get around this 
and to try to mitigate this, we've put mental health--we call 
them OSCAR teams--we put them in the deploying battalions that 
are forward-deployed. We have gone through--and that has mental 
health providers, corpsmen; we brought our chaplains involved 
in these things. Now we have embedded these units with every 
single forward-deployed unit in Afghanistan right now. So, 
we're trying to get away from that.
    There's just a host of things we're trying to do to deviate 
around this, or sneak around behind the backdoor of this stigma 
thing--but, the last thing is, is that, on the suggestion of 
our young marines, we are establishing, right now, with TRICARE 
West, everything west of the Mississippi, a Marine Distress 
Hotline. It's manned by marines, plugged into the TRICARE West 
Region, 21,000 healthcare--mental health care providers. The 
whole idea behind that, it's completely nonattribution. Family 
members can use it 24 hours a day. You can call and say, ``I'm 
having serious issues with PTSD,'' ``I'm having issues with 
whatever.'' It's all anonymous.
    Senator Lieberman. Right.
    General Amos. So, we're working around it, Senator.
    Senator Lieberman. Mr. Chairman, I know my time's up. I 
leave it to you. I don't want to intrude on Senator Hagan's 
time.
    Chairman Levin. Admiral, that's fine. You can go ahead.
    Admiral Greenert. Real quick, Senator, if I may. We have a, 
kind of, statistically different situation. Our demographics 
for those that committed suicide is sort of spread across the 
age spectrum, and location and rating and seniority. The last 
three suicides--we had a 40-year-old senior enlisted 
individual, right before deployment; a 50-year-old captain 
entering retirement; and an 18-year-old sailor, just out of 
boot camp.
    So, looking across that, our focus has been, no one's 
immune to the stressors, and, if you can't deal with the 
stressors, to a bad choice.
    Senator Lieberman. Right.
    Admiral Greenert. So, to us, as a leadership issue. We 
focus on operational stress control and management. For those 
that still have a stigma--and it does exist--we have what we 
call Deployment Health Centers--there are 17 of them, they're 
spread around where our fleet concentration area is--where 
folks can go and see a clinician or a counselor, without the 
stigma being attached. It's not attached to the hospital, it's 
not attached to the fleet family support center; it's located 
away, where our sailors feel more comfortable. We find that, 
once they go there, then they'll see there's nothing wrong 
seeking treatment, and they tend to migrate to the clinic.
    Thank you.
    Senator Lieberman. Good. Thank you.
    Chairman Levin. Before I call on Senator Hagan, let me 
mention this. I'm going to have to leave. There's a question, 
that I'm going to ask you to answer for the record, about the 
status of our Centers of Excellence for Traumatic Brain Injury.
    [The information referred to follows:]

    General Chiarelli, Admiral Greenert, General Amos, and General 
Chandler, in the Wounded Warrior Act of 2008 (Public Law 110-417), 
Congress mandated the establishment of Centers of Excellence to help 
focus research projects, eliminate duplication of efforts, and to learn 
and share best practices through collaboration with other Federal 
agencies, academia, and the private sector. What is the current 
relationship between each of the Services and the Centers of 
Excellence?
    General Chiarelli. The Suicide Prevention Program Managers from 
each of the Services are represented in the Suicide Prevention and Risk 
Reduction Committee (SPARRC), which is part of the Defense Centers of 
Excellence (DCoE). To support Army family members, we promote and 
utilize DCoE's resources, such as the DCoE Outreach Center, Real 
Warriors Campaign, and Afterdeployment.org.
    Admiral Greenert. Navy Medicine works collaboratively with the DCoE 
for Psychological Health and Traumatic Brain Injury (TBI) and its 
component centers: Defense and Veterans Brain Injury Center (DVBIC); 
Center for the Study of Traumatic Stress (CSTS); Center for Deployment 
Psychology (CDP); Deployment Health Clinical Center (DHCC); and the 
National Center for Telehealth and Technology.
    Navy Medicine also provides staff in support of the DCoE and is 
working to ensure that professionals throughout Navy Medicine--
clinicians, researchers, educators and program managers--are working 
with the DCoE to enhance research, education and outreach efforts.
    Additionally, the Services support the other Centers of Excellence 
by providing lead operational support as assigned by Assistant 
Secretary of Defense for Health Affairs. Navy has the lead of the 
Vision Center of Excellence which is focused on research and treatment 
for improved vision care and restorative innovations for 
servicemembers.
    General Amos. The Marine Corps works collaboratively with the DCoE 
for Psychological Health and TBI and its component centers: DVBIC; 
CSTS; CDP; DHCC; and the National Center for Telehealth and Technology 
(T2) on an ongoing basis. The interface for these interactions is 
through various Headquarters level work centers, but principally Health 
Services and Manpower and Reserve Affairs.
    General Chandler. There is a Quad Services Meeting every week 
between the DCoE, DVBIC, National Intrepid Center of Excellence, the 
TRICARE Management Activity, and the four Services to discuss TBI 
issues. This has been a great collaborative group.

    Chairman Levin. If Senator Lieberman is not able to stay, 
then I would ask Senator Hagan to adjourn the committee after 
she is done.
    Thank you.
    Senator Hagan.
    Senator Hagan. So, that means we might be here a while. No. 
[Laughter.]
    I think this is a very important hearing. I think anytime 
we have one suicide, that's one too many, and certainly, the 
numbers that we've been seeing are certainly unacceptable. So, 
I really appreciate the time that the Services are putting into 
helping address this issue.
    General Chiarelli and General Amos, you have underscored 
the importance of mental resiliency programs, proper and timely 
diagnosis, transferring the culture of leadership with regards 
to the invisible wounds, the strain of our forces, limited 
dwell time; and personal problems, such as financial and 
relationships, are certainly among the many challenges that we 
have to overcome. However, we do have a responsibility to 
effectively institute mental resiliency programs to prepare our 
servicemembers for the combat stresses that they will 
ultimately face. What are the Services doing to 
institutionalize resiliency training at the predeployment and 
the post-deployment stage?
    General Chiarelli. Our program is comprehensive soldier 
fitness. Senator, we've been working with the University of 
Pennsylvania. We have trained over 1,200 master resilience 
trainers, through a very intensive course. Our goal is to get 
them down to every battalion in the U.S. Army. We are focusing 
those trainers, right now, at the basic entry levels of our 
soldiers, because we know we have to build their resiliency 
early on in their career. It is absolutely critical.
    In addition to that, we have the Global Assessment Tool 
(GAT) that is a requirement for every soldier to fill out, to 
understand where they stand when it comes to resiliency. We've 
had, now, over 780,000 folks fill out the GAT. Plus, online 
instruction, based on the results you get on the GAT, that is 
available for a soldier to take, to work resiliency.
    This is something that finally starts to get us to the 
left, and not waiting until we see soldiers with problems, but 
try to attack resiliency as far to the left as we possibly can.
    Senator Hagan. Thank you.
    General Amos.
    General Amos. Senator, we, in the Marine Corps, believe 
it's two-part. Resiliency is both physical and mental. The 
beginning stages of a marines recruit training at Parris Island 
or San Diego begins to build that physical strength. We 
attribute a lot of our ability to be able to do the things the 
Marine Corps does for this Nation as a result of its physical 
strength training. So, it begins there.
    Values-based training was instituted about a year ago in 
the Marine Corp, at boot camp and at schools of infantry--at 
North Carolina, at Camp Geiger, and out in San Diego, at Camp 
Pendleton--which teaches some of these things, along with 
suicide prevention, sexual assault prevention, those behavioral 
health issues. So, that's where it begins.
    When the marine enters his first unit and is preparing to 
deploy, we believe the best thing we can do for them is to not 
only get them physically fit, conditioning-wise, which we have 
a combat fitness regimen we put them through, but the second 
piece is what we call immersion training. In other words, we 
want the marine to experience, back home, before he or she 
leaves, most of what--the fear, the anxiety, the confusion, the 
fog of war. We started on the west coast, we're now migrating 
to Camp Lejeune, going out to Hawaii, and and we'll do the same 
thing in Okinawa. But, an immersion trainer, inside a 
building--it's a huge building--and we have transitioned from 
an Iraqi village to an Afghan village. We have role players, we 
have amputees in there, we have RPGs that fire, we have music, 
well, we have everything in there. You couple that, and you 
rerun the scenario over and over again, so the young marines 
become accustomed to fear, and they become accustomed to the 
uncertainty of warfare. You take that, you put them in an IED 
lane that's as--2\1/2\ miles long, walking through villages, 
IEDs are going off, RPGs, more role players. So, you get the 
idea that our last attempt to build this resiliency is to 
immerse them, as much as we can, and help them know that their 
training is adequate and they will be okay.
    We find that, if we do that, that when they are--when they 
hit their first firefight, their chances of them surviving are 
greatly enhanced. We believe, intuitively, that they'll 
probably have less cases of PTS, down the road.
    So, that's what we're doing to build that resiliency. We 
follow along when they come home.
    Senator Hagan. Thank you.
    Admiral Greenert, you mentioned, in response to Senator 
Begich's question, the last question that he asked, something 
about the age of 42. I didn't quite get that. Could you 
elaborate on that?
    Admiral Greenert. Yes, ma'am. Healthcare providers who 
desire to enter service, there's a maximum age of 42. That 
allows them for a 20-year career, age-of-62 mandatory 
retirement. That was the point. If we could raise that age--
because there are a lot of folks older than 42 that want to 
help.
    Senator Hagan. Okay. That's what I thought. Thank you.
    Many of the burdens associated with the wars in Iraq and 
Afghanistan have been shouldered by the Reserve and the 
National Guard members. When these citizen soldiers redeploy, 
they are almost immediately demobilized and returned to their 
civilian lives. Unfortunately, for many, the lives and the jobs 
that they left are not what they return to, which is compounded 
by the isolation of not having a support structure that's 
comparable to what is available to those on Active Duty.
    One of the questions is, what efforts are being made to 
ensure that our members of the Guard and Reserve have a soft 
landing when they return home?
    General Chandler. Senator, if I could?
    Senator Hagan. Great.
    General Chandler. I would tell you that, in your 
reintegration and redeployment process, you need to go all the 
way back to the beginning, obviously, before you start your 
deployments, to make it successful. Our Guard and Reserve total 
force, if you will, in the Air Force, and that includes Air 
Force civilians, all have access to the same things that our 
Active Duty people do, as well.
    Your point is well taken, in terms of how we reintegrate 
those people once they come home. I would tell you that the 
Yellow Ribbon Reintegration Program, that's been a very good 
part of our Guard and Reserve, has been very successful at, not 
only preparing members and families for deployment, but caring 
for families during deployment, and then giving us the 
opportunity to reintegrate those Guard and Reserve members when 
they return.
    In my discussions with the commander of the Reserve and the 
director of the Guard, they seemed to be very happy. We're 
happy, at this point, with the results that we're getting. 
We're getting the resources to do that, and for that, we 
appreciate your support.
    General Amos. Senator, for the Marine Corps, we will deploy 
almost two types of--we don't have Guard, and two types of 
Reserves. We'll deploy what we call a Selective Marine Corps 
Reserve Unit, which is a whole-cloth unit, a squadron, a 
battalion. It's some type of unit. They actually activate 4 
months or so before they deploy. They go through the entire 
training program, the resiliency training, the immersion, all 
that stuff. When they come back, they do a unit reintegration. 
They have access to the exact same capabilities and helps that 
a regular unit does.
    Where we struggle, and where we have been working hard the 
last year and a half, are what we call ``individual augments.'' 
In other words, that's that young marine, out of the middle of 
North Carolina or Oklahoma or someplace, that is pulled out of 
what we call Individual Ready Reserve. He or she has 
volunteered, perhaps, and come forward and said, ``I'll go to 
Afghanistan. I'll join the staff of General McChrystal.'' That 
individual then comes on Active Duty individually, doesn't have 
access to all these great programs. We do our best, we have a 
training program for them to get them set; but, when they come 
home is where I worry the most about. That's where, just as 
General Chandler talked about, the whole idea of the Returning 
Warrior, or the Yellow Ribbon Program, has been such a huge 
hit, because we reach out, harvest them in, and then plug them 
into that program, along with their spouse, and it gets rave 
reviews. So, that's how we are trying to accommodate those 
onesy-twosies.
    Senator Hagan. All right.
    Thank you. My time is up.
    Senator Lieberman.
    Senator Lieberman [presiding]. Thank you.
    I have no further questions. I thank all the witnesses for 
what you're doing, and also for your responses to our 
questions.
    I know, from Chairman Levin and Senator McCain, for all of 
us, this will be a continuing focus of concern for members of 
the committee. We are so grateful to our military personnel. 
They serve with such honor and capability and sacrifice. It's a 
part of why, of all the great institutions in our country, I 
think the military today remains one that still enjoys broad 
public respect and trust. But, it takes its toll, that service 
and sacrifice, and I think we're getting much more in touch 
with the toll it takes on the minds and spirits of people who 
serve. Therefore, we want to do everything we can to make sure 
that we, one, prevent the most serious problems, such as 
suicide; and, two, we treat problems much before we get to that 
point.
    So, I hope you will understand that you should feel free to 
advocate to us what you think you need from Congress to fulfill 
the goals that you have in this regard, which are the goals 
that we have as well.
    I thank you very much. The hearing is adjourned.
    [Questions for the record with answers supplied follow:]
               Questions Submitted by Senator Carl Levin
     defense centers of excellence for traumatic brain injury and 
                          psychological health
    1. Senator Levin. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, in the Wounded Warrior Act of 2008 (Public 
Law 110-417), Congress mandated the establishment of Centers of 
Excellence to help focus research projects, eliminate duplication of 
efforts, and to learn and share best practices through collaboration 
with other Federal agencies, academia, and the private sector. What is 
the current relationship between each of the Services and the Centers 
of Excellence?
    General Chiarelli. The Suicide Prevention Program Managers from 
each of the Services are represented in the Suicide Prevention and Risk 
Reduction Committee (SPARRC), which is part of the Defense Centers of 
Excellence (DCoE). To support Army family members, we promote and 
utilize DCoE's resources, such as the DCoE Outreach Center, Real 
Warriors Campaign, and Afterdeployment.org.
    Admiral Greenert. Navy Medicine works collaboratively with the DCoE 
for Psychological Health and Traumatic Brain Injury (TBI) and its 
component centers: Defense and Veterans Brain Injury Center (DVBIC); 
Center for the Study of Traumatic Stress (CSTS); Center for Deployment 
Psychology (CDP); Deployment Health Clinical Center (DHCC); and the 
National Center for Telehealth and Technology.
    Navy Medicine also provides staff in support of the DCoE and is 
working to ensure that professionals throughout Navy Medicine--
clinicians, researchers, educators and program managers--are working 
with the DCoE to enhance research, education and outreach efforts.
    Additionally, the Services support the other Centers of Excellence 
by providing lead operational support as assigned by Assistant 
Secretary of Defense for Health Affairs. Navy has the lead of the 
Vision Center of Excellence which is focused on research and treatment 
for improved vision care and restorative innovations for 
servicemembers.
    General Amos. The Marine Corps works collaboratively with the DCoE 
for Psychological Health and TBI and its component centers: DVBIC; 
CSTS; CDP; DHCC; and the National Center for Telehealth and Technology 
(T2) on an ongoing basis. The interface for these interactions is 
through various Headquarters level work centers, but principally Health 
Services and Manpower and Reserve Affairs.
    General Chandler. There is a Quad Services Meeting every week 
between the DCoE, DVBIC, National Intrepid Center of Excellence 
(NICoE), the TRICARE Management Activity, and the four Services to 
discuss TBI issues. This has been a great collaborative group.

    2. Senator Levin. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, have you found the Centers of Excellence to 
be a valuable resource for the military Services?
    General Chiarelli. DCoE is a valuable resource for the Army, 
particularly the Real Warriors Campaign, which promotes the processes 
of building resilience, facilitating recovery and reintegration of 
returning servicemembers and reducing stigma associated with seeking 
help. As previously noted, due to the participation of all the 
Services, the SPARRC facilitates sharing initiatives and best 
practices.
    Admiral Greenert. The Centers of Excellence have been a valuable 
resource in a number of ways:

         The DCoE has served a role in facilitating and 
        increasing collaboration among the Services. This is best 
        demonstrated through the development of the Department of 
        Defense (DOD)/Department of Veterans' Affairs (VA) Integrated 
        Mental Health Strategy and the Directive Type Memorandum (DTM) 
        developed by all of the Services to require event reporting and 
        tracking of individuals exposed to blast and, therefore, at 
        risk for TBI.
         Education and Stigma Reduction as demonstrated by the 
        Real Warrior Campaign.
         Since their establishment they have directed over $50 
        million in funding to further research on psychological health 
        and TBI.

    General Amos. The Centers of Excellence have been valuable in a 
number of ways:

    1.  The DCoE has served a role in facilitating collaboration among 
the services. This is best demonstrated through the development of the 
DOD/VA Integrated Mental Health Strategy and the DTM developed by all 
of the Services to require event reporting and tracking of individuals 
exposed to blast and therefore at risk for TBI.
    2.  Education and Stigma Reduction as demonstrated by the Real 
Warrior Campaign and DCoE educational conferences and monthly webinars.
    3.  Coordination of Research, directing over $50 million in funding 
to further research on psychological health and TBI.

    General Chandler. The Quad Services Meeting every week between the 
DCoE, DVBIC, NICoE, the TRICARE Management Agency and the four Services 
is valuable for the discussion of TBI issues. This has been a great 
collaborative group. Some initiatives from the group include:

    1.  Developed the DTM ``Policy Guidance for Management of 
Concussion/Mild TBI in the Deployed Setting.''
    2.  Educated medical providers on mild to severe TBI (more than 800 
DOD/VA clinicians attended the 2009 DVBIC 3rd Annual Military Training 
Conference).
    3.  Conducted a media roundtable to increase awareness of DOD 
initiatives during TBI awareness month in March 2010.
    4.  Developed education materials for servicemembers on TBI to 
implement the DTM.
    5.  Developed a TBI pocket guide highlighting TBI clinical practice 
guidelines.
    6.  Developed TBI Program Guidance for the Services to standardize 
the treatment of our servicemembers across the DOD.
    7.  Identified Medical Treatment Facilities (MTFs) to participate 
in the DOD Cognitive Rehabilitation Program.

    3. Senator Levin. Dr. Jesse, the Centers of Excellence were 
intended to be joint DOD-VA ventures. What role does the VA currently 
play in the Centers of Excellence?
    Dr. Jesse. Since 2007, VA has collaborated with DOD to establish 
the DCoE and the associated injury registries, including the Centers 
for Psychological Health and Traumatic Brain Injury (TBI), Extremity 
Injuries and Amputation, Hearing Loss and Auditory Injuries, and 
Vision. VA has assigned personnel to the Centers for Psychological 
Health and TBI, including a deputy director for the Centers, and two 
subject matter experts--one for TBI, and one for psychological health-
related disorders. VA has also assigned personnel at the Defense Vision 
Center of Excellence, including: a deputy director, chief of staff, and 
a vision rehabilitation specialist. VA is completing selections for 
three additional staff positions (research optometrist, administrative 
assistant, and a biostatistician) to be posted at the Vision Center of 
Excellence.
    VA continues to work with DOD representatives to finalize the 
implementation plan to jointly establish the Center for Extremity 
Injuries and Amputation. VA also continues to assist DOD 
representatives with developing the concept of operation and 
implementation plan for the Center for Hearing Loss and Auditory 
Injuries. After the implementation plans for these two centers are 
finalized by DOD and forwarded for review, VA will determine its level 
of support for both of these centers.
                                 ______
                                 
                Questions Submitted by Senator Jack Reed
                      later development of wounds
    4. Senator Reed. General Chiarelli, Admiral Greenert, General Amos, 
and General Chandler, acknowledging the imminent need to treat 
invisible wounds today, we also have to prepare to care for the 
conditions that may not manifest for 5, 10, or 15 years after a 
deployment. How are the Services working to address the long-term 
effects of invisible wounds on our Active Duty and Reserve component 
servicemembers?
    General Chiarelli. Timely detection and identification of a 
soldier's behavioral health issues or TBI is the goal of the Army's 
Comprehensive Behavioral Health System of Care. Long-term support of 
our troops is a continuous process. Soldiers undergo screening for 
behavioral health issues as they enter the Army, during periodic health 
assessments (PHAs) mandated for soldiers throughout their military 
service, and upon discharge from the Service. During pre-deployment 
readiness processing, soldiers undergo extensive screening for medical 
and behavioral health issues, including family problems, in order to 
document baseline soldier well-being, and to detect/treat conditions 
that may interfere with meaningful military service. Upon redeployment, 
soldiers are promptly screened in Post-Deployment Health Assessment 
(PDHA) for Post-Traumatic Stress, major depression, and TBI, as well as 
for concerns about family issues and drug and alcohol abuse. Soldiers 
who screen positive undergo further clinical assessment as needed, and 
are provided definitive treatment as clinically indicated.
    All medical encounters and care are recorded in the soldier's 
electronic health record. This information is available to healthcare 
providers throughout the Military Health System. It is also available 
to providers in the VA health system through the Bidirectional Health 
Information Exchange (BHIE). The BHIE allows providers at DOD Military 
Treatment Facilities and VA health facilities to view clinical data 
when a shared patient presents for care. The capture of a soldier's 
health information electronically and the ability to share a soldier's 
health information with the VA ensures continuity of care even if the 
soldier presents for behavioral health care in future years in either 
the Military Health System or the VA.
    Admiral Greenert. Tracking sailors with increased risk for the 
invisible wounds of this conflict will help us to follow them into the 
future to learn about the long term effects and to offer treatment as 
new discoveries occur. This tracking currently is accomplished in a 
number of ways:

         The Combat Trauma Registry, located at the Naval 
        Health Research Center, tracks all combat injuries which allows 
        for inquiries into injury patterns and casualty management that 
        are helpful in guiding prevention and treatment efforts both 
        now and in the future.
         Additionally, the new requirement, established by the 
        Directives Type Memorandum, for tracking individuals exposed to 
        blast, regardless of symptoms, will allow for enhanced follow 
        up care and evaluation.
         The Centers of Excellence are also developing 
        registries that will track individuals with various conditions 
        specific to their mission. As an example, the Vision Center of 
        Excellence, led by Navy, is developing a registry that will 
        allow all individuals with eye injuries to be tracked and 
        followed.

    Research also continues help to redefine how we care for wounded 
warriors today and in the future. Navy Medicine is coordinating with 
organizations such as the DVBIC, the NICoE, and the Center for 
Neuroregenerative Medicine at the Uniformed Services University of the 
Health Sciences to complete and publish clinical research about the 
clinical outcomes of individuals diagnosed with TBI as a result of 
combat. We hope these efforts allow us to be better able to detect the 
long-term effects of concussions/mild TBI resulting from combat 
deployment or blast exposure.
    General Amos. Tracking patients with increased risk for the 
invisible wounds will help us to follow them into the future to learn 
about the long term effects and to offer treatment as new discoveries 
occur. This tracking currently is accomplished in a number of ways:

    1.  The Combat Trauma Registry, located at the Naval Health 
Research Center, allows for tracking of all combat injuries which 
allows for inquiries into injury patterns and casualty management that 
is helpful in guiding prevention and treatment efforts both now and in 
the future.
    2.  Additionally, The new requirement for tracking individuals 
exposed to blast, regardless of symptoms will allow for enhanced follow 
up care and evaluation.
    3.  The Centers of Excellence are developing registries that will 
track individuals with various conditions specific to their mission.

    Research will also help to define how we care for wounded warriors 
in the future. Navy Medicine is coordinating with organizations such as 
the DVBIC, the NICoE, and the Center for Neuroregenerative Medicine at 
the Uniformed Services University of the Health Services to complete 
and publish clinical research regarding the clinical outcomes of 
individuals diagnosed with TBI from combat. In this manner we hope to 
be better able to detect the long-term cognitive sequelae of 
concussions/mTBI resulting from combat deployment or blast exposure.
    General Chandler. While airmen are offered pre- and post-deployment 
education that encourages them to get help for problems early, 
surveillance for mild TBI or post-traumatic symptoms is primarily 
through periodic mandatory assessments.
    Airmen undergo a PDHA upon return from deployment, which is a face-
to-face assessment that asks specifically about symptoms related to 
Post-Traumatic Stress Disorder (PTSD) and TBI. Positive responses are 
assessed and treatment is offered. Later, between 90 to 180 days post-
deployment, the airman completes a Post-Deployment Health Reassessment 
(PDHRA) questionnaire, again screening for PTSD and TBI symptoms in 
addition to other physical/psychological symptoms. If airmen respond 
positively to critical items, they are contacted by a provider and an 
appointment is arranged for further assessment. In addition to the 
PDHRA, members undergo an annual PHA that assesses physical and 
psychological symptoms. The airman sees their Primary Care Manager 
(PCM) for further evaluation if they report symptoms related to TBI/
PTSD. In the event that there are still undisclosed symptoms at the end 
of an airman's career, these can be identified during the separation 
physical examination occurring upon discharge from the Air Force.

                      timing of treatment received
    5. Senator Reed. General Chiarelli, Admiral Greenert, General Amos, 
and General Chandler, how long, on average, does it take for a 
servicemember to begin receiving mental health treatment once a need is 
identified?
    General Chiarelli. A soldier may begin receiving mental health 
treatment at the time the need is identified if the medical situation 
dictates. The Army is committed to meeting the mental health needs of 
our soldiers by providing quality care, at the appropriate level, and 
in a timely manner. Timely treatment is of particular importance since 
mental health diagnoses are treatable, and treatment delay has been 
shown to be an important factor associated with response to functional 
outcomes. The Army offers an extensive array of mental health referral 
and program options that promote early detection and treatment.
    Admiral Greenert. In-theater services are typically provided by 
embedded medical and mental health providers. This allows for immediate 
evaluation, treatment and medical evacuation for emergent conditions is 
available as required.
    In response to the recommendations by the DOD Mental Health Task 
Force, the Assistant Secretary of Defense for Health Affairs (9 Oct 07) 
issued a memorandum making the initial, non-urgent/emergent mental 
health assessments be booked similar to routine primary care 
appointments for which the TRICARE access standard is 7 days. Since 15 
Jan 08, Navy Medicine military treatment facilities have been directed 
to operate under this new access standard. Data, provided via the 
TRICARE Operations Center (Health Affairs/TRICARE Management Activity), 
allows Navy Medicine to monitor our ability to meet this standard. 
Current data indicates that across Navy Medicine: (1) acute mental 
health care appointments occur within the 24-hour standard 89 percent 
of the time; and (2) routine mental health appointments occur within 
the 7-day standard 85 percent of the time.
    General Amos. In-theater services are typically provided by 
embedded medical and mental health providers. This allows for immediate 
evaluation, treatment and emergent medical evacuation available as 
required.
    In response to the recommendations of the DOD Mental Health Task 
Force, ASD (HA) (9 Oct 07) issued a memorandum requiring initial, non-
urgent/emergent MH assessments be booked similar to routine primary 
care appointments for which the TRICARE access standard is 7 days.
    The Marine Corps works closely with Navy Medicine on issues 
concerning in-garrison medical care. As of 15 Jan 08, Navy Medicine 
MTFs have been directed to operate under this new access standard. 
Data, provided via the TRICARE Operations Center (Health Affairs/
TRICARE Management Activity), has been available since September 2009 
allowing Navy Medicine to monitor the percentage of time the mental 
health access to care standards are being met. Current data indicates 
that across Navy Medicine: (1) acute mental health care appointments 
occur within the 24-hour standard 89 percent of the time; and (2) 
routine mental health appointments occur within the 7 day standard 85 
percent of the time.
    General Chandler. Mental health issues identified by servicemembers 
as emergent or urgent in nature are addressed on an immediate or same 
day walk-in basis with access to care in the military treatment 
facilities or through civilian network partnerships. Routine or non-
urgent mental health concerns identified by servicemembers are 
addressed by referral to either behavioral health optimization program 
mental health providers embedded in primary care or by referral to 
mental health providers in specialty mental health clinics. Over 76 
percent of beneficiaries seeking mental health treatment for routine, 
non-urgent concerns are seen in the military treatment facilities 
within the routine access to care standard of 7 days of identifying 
their need. An additional small percentage of servicemembers that 
identify a mental health concern either decline the option for mental 
health services or decline offered evaluation within the access to care 
timeframe, opting for a later appointment at their discretion. 
Additionally, many servicemembers are opting to utilize the available 
mental health resources offered through TRICARE and Military OneSource 
to address stress and other psychological health concerns.

                           guard and reserve
    6. Senator Reed. General Chiarelli, Admiral Greenert, General Amos, 
and General Chandler, in what ways do you coordinate with your Reserve 
component counterparts to ensure that our guardsmen and reservists are 
receiving the mental health treatment they may need following their 
demobilization?
    General Chiarelli. The Army is implementing improvements in letting 
demobilizing guardsmen and reservists know what services are available 
and how they can receive them before they leave the mobilization 
platform. These services include use of the Department of Veterans 
Affairs (VA) medical system, TRICARE resources and the Yellow Ribbon 
Reintegration Program (YRRP).
    The Army coordinates healthcare delivery for Reserve component 
soldiers coming off active duty with the VA. The VA routinely provides 
direct care for Reserve and other remote or geographically dispersed 
soldiers. An Army and VA partnership embeds VA Liaison Case Managers in 
14 prioritized Army MTFs under an initiative called VA Liaison and Care 
Management Program, which ensures soldiers receive seamless continuity 
of care as they migrate from active duty to veteran status in the VA 
Healthcare System.
    TRICARE also has programs that assist Guard and Reserve soldiers 
and families. A National Guard or Reserve member separating from a 
period of active duty that was more than 30 consecutive days in support 
of a contingency operation is eligible for Transitional Assistance 
Management Program (TAMP). The TAMP provides 180 days of transitional 
health care benefits to help certain uniformed services members and 
their families transition to civilian life.
    Additionally, Guard and Reserve members who are experiencing common 
psychological health concerns like combat stress and family separation 
may use a new initiative called TRICARE Assistance Program (TRIAP), 
which provides video chat and instant messaging to give quick and easy 
access to counseling services. This program is also available to 
spouses, and other family members 18 years or older.
    Further post-demobilization support is provided through the The 
YRRP. The YRRP provides deployment support, reintegration programs, 
services and training for National Guard and Reserve members throughout 
all phases of deployment to include demobilization. It provides 
soldiers with transition information on available resources and 
connects them with providers who can assist in overcoming the 
challenges of reintegration.
    Admiral Greenert. Commander, Navy Reserve Forces Command has 
assumed responsibility for overseeing implementation of the PDHRA 
program for the Navy Reserve. With strong leadership support they are 
actively engaged in program execution and because of this increased 
focus, Servicemember compliance rates have improved.
    Providing mental health support to Reserve sailors is an integral 
component of Navy mental health care. To meet this need, the Navy 
implemented the Navy Reserve Psychological Health Outreach (NRPHO) 
program in fiscal year 2008. The NRPHO program has a team of 25 social 
workers who provide initial mental health clinical assessment of 
Reserve component servicemembers and provide appropriate health care 
referral if needed. They are also making visits to two to three Navy 
Operational Support Centers (NOSC) per month in each of the five Navy 
Reserve Regions where they provide psychological health education 
including the Operational Stress Control (OSC) Awareness brief to NOSC 
staff and Reserve unit members.
    As June 2010, the NRPHO Teams have clinically assessed and referred 
almost 2400 reservists to appropriate sources of mental health care; 
have made outreach calls to an additional 1860 reservists; and have 
made 281 visits to the NOSCs, providing the OSC Awareness brief to over 
29,400 RC members and NOSC staff. In addition, Navy Medicine has hired 
a full-time Director of Psychological Health (DPH) for Navy Reserve to 
oversee and expand Reserve Navy Reserve psychological health programs.
    General Amos. A primary tool to discover unmet needs of Reserve 
marines, like all marines who deploy, is the PDHRA instrument. 
reservists should be completing these surveys post-deployment just like 
their active duty counterparts. reservists have access to TRICARE 
health care benefits for 180 days following their separation from 
Active Duty.
    While I defer to my military medicine colleagues on the actual 
delivery of care, our Wounded Warrior Regiment (WWR) and battalions 
stay connected to marines in need of services even after they leave 
active duty. I believe that our Wounded Warrior construct is a superb 
model and we will continue to leverage its successes moving forward.
    General Chandler. In-theater services are typically provided by 
embedded medical and mental health providers. This allows for immediate 
evaluation, treatment and medical evacuation for emergent conditions is 
available as required.
    In response to the recommendations by the DOD Mental Health Task 
Force, the Assistant Secretary of Defense for Health Affairs (9 Oct 07) 
issued a memorandum making the initial, non-urgent/emergent mental 
health assessments be booked similar to routine primary care 
appointments for which the TRICARE access standard is 7 days. Since 15 
Jan 08, Navy Medicine military treatment facilities have been directed 
to operate under this new access standard. Data, provided via the 
TRICARE Operations Center (Health Affairs/TRICARE Management Activity), 
allows Navy Medicine to monitor our ability to meet this standard. 
Current data indicates that across Navy Medicine: (1) acute mental 
health care appointments occur within the 24-hour standard 89 percent 
of the time; and (2) routine mental health appointments occur within 
the seven day standard 85 percent of the time.
                                 ______
                                 
           Questions Submitted by Senator E. Benjamin Nelson
centers of excellence's suicide prevention and risk reduction committee 
                             annual report
    7. Senator Ben Nelson. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, a vital and significant component of our 
force is the operational Reserve. Last year, as Chairman of the 
Personnel Subcommittee of the Senate Armed Services Committee, I held a 
hearing on DOD suicide prevention programs and raised a concern that 
Services were not collecting information on Guard and Reserve members 
who commit suicide, while not on active status. Statistics show that 
servicemembers are more likely to commit suicide while not deployed, 
when they are removed from their support structure. I expressed that 
concern to Secretary Gates, and following 7 months of engagement with 
the Department, DOD established a policy to begin reporting suicides of 
Guard and Reserves in civilian status. The policy letter went into 
effect October 22, 2009, and was a critical step in understanding how 
the whole-of-Reserve Forces are being affected by suicides. If we don't 
collect data on our Reserve and Guard forces, we have no ability to 
know whether we are providing appropriate support and programs for our 
Guard and Reserve Forces. Those statistics were to be reported in the 
DCoE's SPARRC Calendar Year 2009 Annual Report--has this report been 
completed?
    General Chiarelli. The Army Suicide Prevention Task Force (ASPTF) 
provides the Armed Forces Medical Examiner (AFME) with quarterly 
suicide statistics for Active Duty, Reserve component on active duty, 
and Reserve component not on active duty. AFME provides this data to 
DCoE, which then provides service-wide statistics that are shared among 
DOD officials. DCoE prepared the 2009 DODSER annual report, which 
included data on active duty suicides, including Guard and Reserve 
soldiers in an active-duty status. The report has been completed and is 
with the Office of the Assistant Secretary of Defense for Health 
Affairs for review/approval. A release date has not been established at 
this time.
    Admiral Greenert. Navy provided Selected Reserve (SELRES) sailor 
suicide information to the DOD SPARRC Calendar Year 2009 Annual Report 
which has not yet been published. Navy began collecting DOD Suicide 
Event Reports (DODSERs) for suspected suicides and suicide attempts of 
SELRES sailors beginning in April 2009 to better understand the factors 
affecting this population and identify needs and prevention 
opportunities. Suicide numbers based on death certificates for SELRES 
sailors were available before that date. In 2008, there were nine 
suicides of Navy SELRES personnel not on drill or duty status at the 
time of death; there were six in 2009; and, there have been four to 
date in 2010.
    General Amos. The DOD Task Force on the Prevention of Suicide by 
Members of the Armed Forces has completed its study, with delivery of 
the report to the Secretary of Defense (SecDef) expected in early 
August. The Marine Corps is in full compliance with the Reserve 
tracking policy. We collect data using the DODSER on all Select Marine 
Corps Reserve members and report those numbers throughout the Marine 
Corps leadership in an attempt to identify lessons learned. We also 
submit the numbers quarterly to DOD leadership in accord with policy, 
through the DCoE on Psychological Health and TBI, SPARRC.
    General Chandler. The 2009 DOD SPARRC 2009 annual report is 
currently being reviewed within the Defense Center of Excellence prior 
to release to Congress. The Air Force is very concerned with suicides 
throughout our total force. The Air Force has collected and monitored 
Guard and Reserve suicide events that occur while not on active status 
and reporting this to the SPARRC since 2009. The suicide prevention 
program manager has provided Air Force senior leaders weekly reports on 
total force suicides since December of 2009.

    8. Senator Ben Nelson. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, two reporting periods have passed since the 
Under Secretary for Personnel and Readiness established this new 
reporting requirement. I would like to know how the numbers compare for 
that population and what we are doing to understand and assess the new 
information. Can anyone speak to this change in reporting and what we 
are finding?
    General Chiarelli. For calendar year 2010, suicides for the Reserve 
component not on Active Duty year-to-date exceeds last year's number 
for the same timeframe. The ARNG suicide cases also exceed the number 
of suicides for the same timeframe last year; USAR suicide cases are 
the same as this timeframe last year.
    A Senior Review Group (SRG) briefing is conducted on a monthly 
basis by the Vice Chief of Staff of the Army (VCSA). A designated 
general officer from each reporting unit/command briefs the VCSA on 
circumstances related to the specific suicide cases that are presented. 
The ultimate goal of the SRG briefing is to develop solutions that the 
Army can implement to prevent or mitigate future suicides. These 
solutions are captured through lessons learned and themes and trends, 
which are then published for distribution to Army senior leaders.
    Admiral Greenert. Navy provided SELRES suicide information to the 
DOD SPARRC Calendar Year 2009 Annual Report, which has not yet been 
published. The Navy began collecting DODSERs for suspected suicides and 
suicide attempts of Selective Reserve sailors beginning in April 2009 
to better understand the factors affecting this population and identify 
needs and prevention opportunities. Suicide numbers based on death 
certificates for SELRES sailors were available before that date. In 
2008, there were nine suicides of Navy Selective Reserve personnel not 
on drill or duty status at the time of death; there were six in 2009; 
and, there have been four to date in 2010.
    Population denominators for Selective Reserve not on active duty 
have not been standardized for exact rate calculation and rates tend to 
have considerable variance with relatively small numerator numbers; 
but, approximate suicide rates for Navy SELRES are very comparable to 
the active component suicide rate.
    The Navy Reserve Psychological Health Outreach (NRPHO) Program has 
made significant strides in extending the suicide prevention training, 
surveillance, outreach, and follow-up provided to our Reserve 
population and, based on success of the approach, has served as the 
model that the U.S. Marine Corps is now implementing.
    General Amos. Suicides and attempts while a reservist is on active 
duty are captured within the Marine Corps Total Force System and 
reported in our annual active duty statistics. We also track inactive 
Select Marine Corps Reserve suicides and attempts, and report those 
numbers separately. We have not found any risk factors or 
characteristics unique to inactive reservists in our data, but continue 
to analyze for any actionable information to prevent suicides and get 
help to all marines.
    Suicide data for Active Duty reservist and Inactive Select Marine 
Corps reservists:

                         Active Duty Reservists
------------------------------------------------------------------------
                    Year                        Suicides      Attempts
------------------------------------------------------------------------
2005........................................            3
2006........................................            0
2007........................................            0
2008........................................            2
2009........................................            1             4
2010 (through 19 July)......................            0            3
------------------------------------------------------------------------
 USMC began tracking in 2009.
 Calendar Year 2009 data through 19 July, for comparison, were
  zero suicides and four attempts.


                 Inactive Select Marine Corps Reservists
------------------------------------------------------------------------
                    Year                        Suicides      Attempts
------------------------------------------------------------------------
2009........................................           12
2010 (through 19 July)......................            4            0
------------------------------------------------------------------------
 USMC began tracking in 2009.
 Inactive SMCR Suicide Reporting required effective 1 January
  2009.
 Calendar Year 2009 data through 19 July, for comparison, were
  five suicides and four attempts.

    General Chandler. The Air Force Guard and Reserve have established 
processes to identify suicides by not-in-status members and the Air 
Force is tracking this data as part of our Total Force Suicide 
Prevention efforts. These numbers are reported weekly to Air Force 
senior leaders. The smaller populations of these groups result in 
greater year-to-year variability in their overall rates. Over the past 
several years, the rates of suicide in the Air Force Guard and Reserve 
have been comparable to that of our active duty servicemembers.
2007
    AD: 34 suicides (10.3 per 100,000)
    ANG: 17 suicides (16.9 per 100,000); 15 not-in-status/2 AGR
    AFR: 10 suicides (14.1 per 100,000) 9 not-in-status, 1 active
2008
    AD: 40 suicides (12.1 per 100,000)
    ANG: 9 suicides (8.4 per 100,000); 7 not-in-status/2 AGR
    AFR: 5 suicides (7.4 per 100,000); 4 not-in-status, 1 active
2009
    AD: 41 suicides (12.4 per 100,000)
    ANG: 15 suicides (13.9 per 100,000); 13 not-in-status/2 AGR
    AFR: 8 suicides (11.8 per 100,000); 5 not-in-status, 3 active

    On average, the age of both Air Force Guard and Reserve suicides is 
higher than the average age of active duty suicides, and this 
demographic difference is consistent with the higher average age of Air 
Force Reserve component personnel compared with active duty personnel. 
We continue to analyze the data developed by these efforts to better 
focus our suicide prevention efforts.

    9. Senator Ben Nelson. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, I am interested in how the Guard and 
Reserve population is being supported and if the report has highlighted 
any challenges or concerns that the Reserve components face. How are 
our prevention programs working for them and what else must be done?
    General Chiarelli. The Army National Guard and the Army Reserve 
have implemented the Army's Campaign Plan for Health Promotion, Risk 
Reduction and Suicide Prevention. This multi-level, holistic approach 
takes into account the many challenges our Army National Guard and Army 
Reserve soldiers, Department of the Army civilians and family members 
are confronted with. The Centers of Excellence's SPARRC Annual Report 
further highlighted the issues faced by this same population. These 
concerns include substance abuse; financial and relationship problems; 
post-traumatic stress and TBI. The Army National Guard and Army Reserve 
have revised their internal policies, programs and support in order to 
leverage enhanced health promotion and suicide prevention support for 
soldiers, civilians, and family members who are located far away from 
our installations and garrisons. Despite significant efforts to address 
these challenges in the last year, it is too early to tell whether they 
will have the desired outcome in reducing the rate of suicide across 
the Force. The Army National Guard and the Army Reserve prevention 
program efforts are constant, evolving efforts to provide our Army 
family with the resources they need. Challenges remain with access to 
medical and behavioral health services for non-active duty soldiers who 
do not qualify for VA benefits, along with the lack of case managers to 
support medical issues within the same community.
    Admiral Greenert. The Navy Reserve has been completely integrated 
in Navy Suicide Prevention activities. The Chief of Navy Reserve 
attends weekly updates provided to the Chief of Naval Operations on 
suicide trends and prevention activities. Reserve commands have suicide 
prevention coordinators, leaders participate in program informational 
briefings, and Reserve component sailors receive the same spectrum of 
training in OSC and suicide prevention as their Active component 
counterparts. Additionally, the Navy Reserve PHOP conducts 
consultations, referrals, and support and follow-up for commands, 
sailors, and family members.
    General Amos. The Calendar Year 2009 DCoE on Psychological Health 
and TBI report has not been released. All Marine Corps suicide 
prevention policies apply equally to our Active and Reserve marines. In 
addition to our regular suicide prevention initiatives, the Marine 
Corps has a number of programs designated specifically to meet the 
needs of our Reserve marines. One such program is the PHOP. There are 
30 Marine Corps Reserve Psychological Health Outreach staff members 
available to assist all returning units. We have also called upon the 
Military Family Life Consultants (MFLCs), a program sponsored by the 
DOD, that is available to support returning units, whenever need is 
identified by the command. In addition, the Marine Corps Mobilization 
Command has a Family Readiness Team that helps track those in the 
Inactive Ready Reserve (IRR) in need of support. There are several 
initiatives already underway within Navy Medicine to provide support to 
the IRRs to include family readiness days.
    Further, we support many reservists and Veterans through our WWR 
with liaison officers at the VA polytrauma centers and headquarters. 
The WWR's Call Center regularly coordinates with the VA by referring 
Veteran wounded, ill, and injured marines to appropriate VA divisions 
for assistance. The WWR participates in the VA's Return Integration 
Location process whereby demobilizing reservists at various post-
deployment reassessment sites receive information on VA entitlements. 
To support remote and isolated reservists, the WWR has District Injured 
Support Cells (DISCs), who are geographically dispersed mobilized 
marine reservists who conduct face-to-face visits and telephonic 
outreach to Reserve and veteran marines and families located throughout 
the country. The WWR's DISCs and the marines from the Reserve Training 
Centers have immediate access to the WWR's Medical Cell and Clinical 
Services Staff for psychological health and TBI issues.
    General Chandler. The data suggests the Air Force suicide 
prevention program results in the Guard and Reserve are roughly 
comparable to those in the Active-Duty Force. Data on suicides by 
Reserve and Guard members not in active status is drawn from local 
medical examiner determinations and may not be as consistent as death 
determinations made by the Armed Forces Medical Examiner for our active 
duty personnel. It is more challenging to collect accurate data on all 
Guard and Reserve members as much of their medical care is provided in 
the civilian system. There is also less visibility regarding the 
details of day-to-day activities and potential risk factors or 
stressors leading up to suicide events for these personnel.
    Air Reserve Component (ARC) members participated in the recent Air 
Force Chief of Staff directed Wingman Day stand-down and have the same 
suicide prevention training requirements as active duty members. 
Current and future efforts are focused on clear communication and 
coordination between active duty component personnel and their ARC 
counterparts throughout the entire process from working on projects, 
initiatives and working groups, through the final coordination process.

              department of defense oversight of services
    10. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, what is DOD doing to understand 
what programs related to suicide the Services are undertaking and what 
works?
    General Chiarelli. The DOD Task Force, formed in August 2009, was 
directed to address trends and causal factors, methods to update 
prevention and education programs, suicide assessment by occupation, 
suicide incident investigations, and protective measures for 
confidential information derived from investigations for all the 
Services. Their findings are due to be released in the third quarter, 
calendar year 2010.
    In addition, DOD contracted with RAND Corporation to evaluate 
suicide prevention efforts within DOD. The report assessed programs 
within each of the Services to identify strengths and weaknesses in our 
suicide prevention efforts. The information collected will be used to 
improve development of future suicide prevention programs.
    Admiral Greenert. Navy supports the efforts of the Defense Center 
of Excellence, the DOD SPARRC, and the DOD Task Force on Prevention of 
Suicide by Members of the Armed Forces in understanding Navy's suicide 
prevention initiatives and assessing effectiveness.
    Navy efforts to assess effectiveness of programs have included an 
annual Behavioral Health Quick Poll (to assess perceived stress, 
attitudes, and suicide prevention knowledge and confidence) and an 
upcoming study, in conjunction with the Uniformed Services University 
of the Health Sciences (USUHS), on the effectiveness of the latest 
suicide prevention training. Navy OSC includes assessment and analysis 
as a centerpiece of the program. OSC has used various polls and 
questionnaires, focus groups, and studies to establish baseline 
measures of stress, knowledge, and the use of stress navigation 
strategies. This feedback helps to develop and assess leadership tools, 
communication efforts, and program goals, and is integral to continual 
process and program improvement.
    General Amos. The Marine Corps shares all of our programs, both 
implemented and under development, with our sister Services and DOD 
through our active membership in the SPARRC, chaired by DCoE on 
Psychological Health and TBI, in the Office of the Assistant Secretary 
of Defense (Health Affairs). However, the Marine Corps has contracted 
with both the Uniformed Services University of the Health Sciences and 
the American Association of Suicidology to ensure best practices are 
applied and that our efforts are studied for effectiveness.
    General Chandler. DOD has established the SPARRC, which provides 
oversight of the annual DOD suicide prevention conference. This 
conference provides a forum for sharing of best practices across the 
Services, the Department of Veteran Affairs and civilian agencies. The 
SPARRC has been instrumental in establishing consistent data collection 
processes across the Services, as well as standardizing the reporting 
of suicides. The SPARCC meets on a monthly basis to facilitate 
communication across DOD agencies and the Services regarding efforts 
underway in suicide prevention programs. The DOD recently took part in 
a Congressional Task Force on Suicide Prevention. This task force will 
provide a comprehensive review of suicide prevention efforts in DOD. 
The Air Force suicide prevention program and the SPARRC stand ready to 
respond to findings and recommendations from this task force.

    11. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, is DOD overseeing a best practices 
model, taking into account the differences of the Services and 
incorporating those things and treatments that could work Service-wide?
    General Chiarelli. Through the Services' collaborative efforts, the 
SPARRC evaluates policy and best practices among the Services in order 
to provide input to DCoE for policy/procedural changes at the DOD 
level. Specifically, the DCoE, with input from the Services through the 
SPARRC, is working on formalizing these changes through a new DOD 
Instruction.
    Admiral Greenert. Navy supports the efforts of the Defense Center 
of Excellence, the DOD SPARRC, and the DOD Task Force on Prevention of 
Suicide by Members of the Armed Forces to understand Navy's suicide 
prevention initiatives and best practices. The annual DOD/VA Suicide 
Prevention Conference is a forum that brings together researchers, 
treatment providers, and policy makers for understanding and sharing of 
the latest information as applied to various populations and 
circumstances.
    General Amos. The Marine Corps shares all of our resources, plans 
and findings with our sister Services through the SPARRC, chaired by 
DCoE on Psychological Health and TBI, in the Office of the Assistant 
Secretary of Defense (Health Affairs). We regularly compare our 
initiatives to the best practices registry sponsored by the Department 
of Health and Human Services through the federally funded Suicide 
Prevention Resource Center.
    General Chandler. DOD is overseeing the collection of best practice 
models through the DCoE. The DOD has established the SPARRC, which 
provides a forum for sharing of practices across the Services. The 
SPARRC has been instrumental in establishing consistent data collection 
processes across the Services through use of the DODSER, as well as 
standardizing the reporting of suicides across the Services, which 
allows a better comparison of suicide rates across DOD. The SPAARC 
provides oversight of the annual DOD suicide prevention conference. 
This conference provides a forum for sharing of best practices across 
the Services, the Department of Veteran Affairs and civilian agencies.

    12. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, if we are not doing this, how can 
we do this and who should oversee the overall mental health and 
wellness of our armed services?
    General Chiarelli. We are doing this through the efforts of the 
SPARRC.
    Admiral Greenert. Responsibility for administering chapter 55 
(Medical and Dental Care) of title 10, U.S.C., is vested in the 
Secretary of Defense. The purpose of the chapter is to create and 
maintain high morale in the uniformed services by providing an improved 
and uniform program of medical and dental care for members and certain 
former members of those services, and for their dependents.
    Navy Medicine is an active participant in the VA and DOD Integrated 
Mental Health Strategy which aims to improve access, quality, 
effectiveness, and efficiency of mental health services for all active 
duty and Reserve sailors and their families.
    Navy Medicine works collaboratively with the DCoE for Psychological 
Health and TBI and its component centers: DVBIC; CSTS; CDP; DHCC; and 
the National Center for Telehealth and Technology.
    General Amos. The Marine Corps is responsible for the overall 
mental health and wellness of your marines and it is a responsibility 
that is our foremost priority. Along with our partners in Navy Medicine 
and Chaplaincy, we strive to improve our understanding of mental health 
and wellness, stressors, barriers to care, and breaking stigma.
    General Chandler. The Assistant Secretary of Defense (Health 
Affairs) (ASD(HA)) has oversight of health and wellness of our armed 
services as administrator of the Military Health System. While each 
Service's surgeon general tailors the delivery of care to the specific 
mission under the direction of the respective service chief, there is 
also extensive coordination both between the VA and the Services and 
between each of the Services. This coordination and integration has 
been on a course of steady improvement over the last 15 years.
Assistant Secretary of Defense (Health Affairs)
    Since 1994, the ASD(HA) has been the principal advisor to the 
Secretary of Defense on DOD health policies, programs and activities 
and is responsible for a number of the organizations that directly 
affect the health care of servicemembers and their dependents including 
the TRICARE Management Activity.
The DOD/VA Joint Executive Council
    The DOD/VA Joint Executive Council (JEC) was established in 2003 to 
oversee and guide the joint health and benefits activities of the 
Departments. The JEC links three supporting councils: the Health 
Executive Council (HEC); the Benefits Executive Council (BEC); and the 
Interagency Program Office (IPO). Under this structure, the DOD and VA 
work closely with one another across departmental lines to improve 
access, quality and efficiency.
The Wounded, Ill, and Injured Senior Oversight Committee
    In May 2007, the Wounded, Ill, and Injured Senior Oversight 
Committee (SOC) was created by VA and DOD, and co-chaired by their 
Deputy Secretaries. The SOC was established as a means to bring high-
level Department attention to addressing the recommendations and issues 
associated with the care and services for returning servicemembers.

                  yellow ribbon reintegration program
    13. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, the goal of the YRRP is to prepare 
members of the National Guard and Reserves and their families for 
mobilization, sustain their families during mobilization, and 
reintegrate the servicemembers with their families, employers, and 
communities after deployment. How is the YRRP working for your Service?
    General Chiarelli. The YRRP works extremely well for the Army 
National Guard. Through May 2009, the National Guard had conducted 619 
events involving 47,182 servicemembers and 58,350 family members. 
Attendees were provided information on available services to help 
prepare soldiers and their family members for mobilization, sustain 
families during mobilization and reintegrate soldiers with their 
families after mobilization. The YRRP is a proactive outreach to 
servicemembers, families, and employers throughout deployment cycle.
    Admiral Greenert. The Navy Reserve provides three specific 
activities that have been designated as YRRP events: Pre-Deployment 
Family Readiness Conferences (PDFRCs), the Returning Warrior Workshop 
(RWW), and the PDHRA.
    PDFRCs are conducted every 12 to 18 months at 128 NOSCs across the 
country and are the Navy Reserve's largest pre-deployment event. 
Designed to build resilience, the PDFRC provides education, resources, 
and the opportunity for sailors and families to resolve a broad 
spectrum of issues prior to the rigors of a deployment and the 
challenges of family separation.
    The RWW is a reintegration program sailors and their guests 
normally attend between 30 and 60 days following demobilization. This 
2-day weekend retreat provides a safe, relaxed atmosphere to help 
sailors and families with post-deployment reintegration. In 2009, more 
than 1,800 servicemembers and 1,400 family members attended one of 27 
RWWs held in every region of the country. In 2010, 13 workshops were 
attended by 832 servicemembers and 699 family members with an 
additional 38 workshops scheduled through July 2012.
    The PDHRA is the 90-day YRRP event and occurs between 90 and 180 
days after demobilization. The Navy Reserve has sustained a 98 percent 
rate for PDHRA compliance. Sailors complete the PDHRA online and a 
qualified health care provider follows up with each sailor by phone. 
Further follow-up in person is conducted if and when warranted. The 
PDHRA process is also used to provide information about VA health 
benefits, Military OneSource, etc.
    Since program inception, the response from our Navy reservists and 
their families has been overwhelmingly positive in regards to all three 
aspects of the Yellow Ribbon Program. It has proven to be a Navy force 
multiplier and a vital part of preparedness, sustainment and 
reintegration.
    General Amos. The YRRP is working well for Marine Forces Reserve, 
our mobilizing units, small detachments, and individual augmentee 
servicemembers and their families. We are aggressively implementing the 
YRRP program to ensure servicemembers and their families are properly 
informed of and have access to myriad programs, resources, and services 
to minimize stress before, during, and after deployments. The Office of 
the Secretary of Defense is engaging on our behalf on logistical 
challenges, such as a proposed change to the Joint Federal Travel 
Regulations to permit non-dependent family members--or any designated 
representative chosen by the servicemember--funded travel and per diem 
to YRRP events. Language to address this issue is also included in the 
proposed National Defense Authorization Act (NDAA) for Fiscal Year 
2011.
    General Chandler. The YRRP for members and families has proven to 
be highly successful for the Air Force Reserves and Air National Guard. 
Deployment support and reintegration programs are provided in all 
phases of deployment, including, but not limited to, pre-deployment, 
deployment, demobilization, and post-deployment and reconstitution 
phases. Reconstitution activities are held at approximately 30, 60, and 
90-day intervals following deployment or demobilization. These 
activities focus on reconnecting servicemembers and their families with 
providers to ensure they understand their benefits and entitlements as 
well as the resources available to help overcome the challenges of 
reintegration. Best practices from the most successful programs are 
collected and shared. Positive survey input from servicemembers and 
families have validated this program.

    14. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, is the YRRP available to all 
members of your component when they deploy?
    General Chiarelli. Yes, the YRRP is made available to all members 
of the Army National Guard when they deploy. Additionally, the National 
Guard makes every attempt to ensure that all Service branches within 
our States, Territories and the District are included, whenever 
possible, in our YRRP process throughout all phases of the deployment 
cycle.
    Admiral Greenert. Although YRRP legislation addresses only the 
Reserve components, similar programs are available to all members of 
the Navy. Predeployment assistance is provided to Active component 
sailors through their local commands, and PDFRC are available to all 
reservists and their family members. RWWs are available to all 
redeploying Navy sailors, Active and Reserve component, and their 
families.
    General Amos. The YRRP is available to all members of the Marine 
Corps Reserve component.
    General Chandler. Yes, the YRRP is made available to all members of 
the Army and Air National Guard when they deploy. Additionally, the 
National Guard makes every attempt to ensure that all Service branches 
within our States, territories, and the district are included, whenever 
possible, in our YRRP process throughout all phases of the deployment 
cycle.

    15. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, could the YRRP be modified to help 
further extend support services to members and families to help address 
suicide prevention?
    General Chiarelli. Section 595 of NDAA for Fiscal Year 2010 has 
already expanded the YRRP to include a more enhanced suicide 
prevention, community healing and response training provision. In 
complying with this expansion, the National Guard ensures that suicide 
prevention, education and training are provided throughout all phases 
of deployment. However, the National Guard is moving towards placing 
this critical area within our Behavioral Health programs and has 
already started a Warrior Care Initiative that encompasses programs 
like Buddy-to-Buddy, Flash Forward, and Peer-to-Peer.
    Admiral Greenert. Suicide prevention education is provided annually 
to all Navy reservists as part of the Navy's Total Force policy and 
program.
    The RWW provides the ideal opportunity to reinforce this important 
issue with redeploying sailors and their families. Considered a YRRP 
event, sailors and their guests normally attend a workshop between 30 
and 60 days following demobilization. Mental health screening and 
suicide prevention education are provided as part of the workshop.
    In addition Navy Medicine has funded the Navy Reserve PHOP (further 
discussed in the answer to question 18), which also provides outreach 
and education services to reservists and their family members to help 
address suicide prevention in addition to other stressors.
    General Amos. The NDAA for Fiscal Year 2010 directed DOD to develop 
suicide prevention awareness and training in the Reserve community. As 
such, the Marine Corps is an active member of the Yellow Ribbon Suicide 
Prevention Working Group. Training includes describing the warning 
signs for suicide teaching effective strategies for prevention and 
intervention; examining the influence of military culture on risk and 
protective factors for suicide; and engaging in interactive case 
scenarios and role plays to practice effective intervention and 
strategies. Additionally, the program provides the families and 
communities of National Guard and Reserve members with training that 
promotes individual and community healing in response to a suicide. We 
are happy with the YRRP authorities that exist today. As we fine-tune 
our efforts and gather data and lessons learned, we can recommend 
changes or extension of the YRRP program Office of the Secretary of 
Defense, Office of Reintegration Programs.
    General Chandler. Section 595 of the 2010 NDAA has already expanded 
the YRRP legislation to include a more enhanced suicide prevention and 
community healing and response training provision. In complying with 
this expansion, the National Guard (NG) ensures that suicide prevention 
education and training are provided throughout all the phases of 
deployment. However, the NG is moving towards placing this critical 
area within our Behavioral Health programs and has begun a Warrior Care 
Initiative that encompasses programs like Buddy-to-Buddy, Flash 
Forward, and Peer-to-Peer, all of which embrace more of the Behavioral 
Health aspect of suicide prevention.

    16. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, have you found that the YRRP varies 
significantly among States?
    General Chiarelli. The YRRP implementation requirements are 
standardized throughout the States. However, while we provide policy 
and guidance on what needs to be accomplished/presented during an event 
or activity throughout the deployment cycle, we do not tell our States, 
Territories, or the District how this information should be presented. 
For example, if you attend a National Guard YRRP post deployment event, 
Veterans Administration, Employer Support of the Guard and Reserve, and 
financial briefs will be presented, but how they are being presented is 
entirely up to the State.
    Admiral Greenert. YRRP events have been standardized throughout all 
Navy regions. In particular, the Navy has developed policy and 
execution guidance governing its three Yellow Ribbon events: PDFRCs, 
the RWW, and the PDHRA. Every effort is made to ensure the agenda, 
content, and messages delivered via PDFRCs and RWWs are consistent in 
every Navy region. The Bureau of Medicine and Surgery has developed 
standard procedures for conducting the PDHRA nationwide.
    General Amos. No. The Marine Forces Reserve executes the program 
consistently throughout the Nation.
    General Chandler. The YRRP implementation requirements within the 
National Guard (NG) are standardized throughout our States. However, 
while we provide policy and guidance on what needs to be accomplished/
presented during an event or activity throughout the deployment cycle, 
the States/territories and district determine how the information is 
presented. For example, if you attend a NG YRRP post-deployment event, 
you will receive information on VA, Employee Support to Guard and 
Reserves (ESGR), and a financial brief, but the presentations may vary 
based on need.

    17. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, is there an effort to standardize 
the approach to provide guidance of what works to Guard and Reserve 
units across the country?
    General Chiarelli. Yes, and it's going very well. The Army Reserve 
shares after-action reports and best practices with the DOD's Center 
for Excellence. In evaluating the YRRP, the Army Reserve is working to 
provide sequential, progressive, and interactive approaches for all 
topics, to include suicide prevention. Pre-deployment suicide 
prevention training focuses on coping with the difficulties of extended 
separation and deployment. It then shifts to ensuring that family 
members get connected and remain connected with their unit's rear 
detachment and family programs staff during the soldier's deployment. 
The initial post-deployment focus is on reuniting, reconnecting, and 
reintegrating the soldier with their family members. Finally, the Army 
Reserve attends to each soldier's physical, behavioral, and mental 
health concerns through the PDHRA and other discussions approximately 
90 days following the soldier's release from active duty.
    Every 2 weeks the Army Reserve uses feedback to provide informal 
guidance to the field through teleconferences for all Yellow Ribbon 
points of contact in the Regional Support Commands and Operational and 
Functional Commands. Each quarter, the program managers provide 
informational meetings and workshops where issues are discussed and 
disseminated to all for incorporation into local/regional events. The 
Army Reserve is projected to publish new guidance for program 
implementation at the start of fiscal year 2011 based on the first 2 
years of feedback from commanders, Yellow Ribbon points of contact, and 
event participants.
    For the National Guard, there is policy and implementation guidance 
published on what topics and issues that should be covered during a 
particular YRRP event. Additionally, in coordination with the Army and 
Air Guard, we are also developing a ``Best Practices Toolkit,'' which 
will be available on our Joint Services Support website that all of our 
State event coordinators, as well as the other Reserve components, can 
access. As we continue to work with our Services within our States, the 
toolkit will be updated to ensure that the guidance being provided is 
relevant and up to date.
    Admiral Greenert. Following each Yellow Ribbon event, the 
responsible command, either a regional Reserve Component Command or 
NOSC, provides a detailed after-action report to Commander Navy Reserve 
Forces Command (CNRFC) to document attendance, money spent, and 
identify lessons learned, best practices, and potential improvements. 
CNRFC then evaluates this after-action report and forwards it to the 
Office of the Secretary of Defense for Reserve Affairs' Yellow Ribbon 
office. The most significant lessons learned, best practices, and 
program modifications and improvements are provided to the NOSCs so 
they can be shared with Reserve unit leaders and sailors, induce 
greater participation in Yellow Ribbon events, and convince sailors of 
the enduring value of these programs. In addition, the Yellow Ribbon 
Center for Excellence has established an online tool to capture best 
practices, termed ``Golden Nuggets,'' for Yellow Ribbon events.
    General Amos. Promising practices identified in Marine Forces 
Reserve are shared with the Office of the Secretary of Defense (OSD) 
Office of Reintegration Programs to be offered to all Services for 
their edification. All of the Service Program Managers converse with 
the OSD Office and each other at least monthly to share challenges and 
solutions. In addition, regional and State partnerships between Service 
representatives ensure solutions to common challenges are shared and 
benefit all.
    General Chandler. The Air Force Reserve YRRP is not managed by 
State, but rather by Air Force Reserve Command, which extends to all 
Air Force Reserve units. When planning a joint event (between Air Force 
components or between Services) a standardized agenda is used which 
includes presentations from the VA and TRICARE. The Office of the 
Secretary of Defense YRRP Working Group is developing a standardized 
curriculum for all YRRP events. The National Guard (NG) has made an 
effort to standardize the guidance for the program. The NG's Policy and 
Implementation Guidance provides guidance on topics and issues that 
should be presented/covered during a particular YRRP event. 
Additionally, in coordination with the Army and Air Guard, we are 
developing a ``Best Practices Toolkit'' that will be available on our 
Joint Services support website and is available to all State YRRP event 
coordinators and Reserve components. This information will be updated 
periodically to ensure the guidance is accurate and relevant.

    18. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, Guard and Reserve members who do 
not live in close proximity to a military installation, or who live in 
very remote locations, can experience their own set of issues when it 
comes to access to health care and family support programs that may be 
needed following a deployment. Are there any specific programs, 
including Yellow Ribbon, in place in each of the Services to address 
the unique needs of Guard and Reserve members and their families, to 
ensure that there are no gaps in access to help and support for the 
Guard and Reserve when it comes to suicide prevention?
    General Chiarelli. In addition to the Yellow Ribbon program, which 
provides support both before and after a soldier deploys, many States 
and Territories have developed local programs to promote soldier health 
in the National Guard, such as Michigan's Buddy-to-Buddy peer program, 
California's embedded psychologist program, and Kansas' resiliency 
program. The Army National Guard's resilience, risk reduction, and 
suicide prevention efforts would be greatly improved with additional 
funding to sustain Army Family Covenant type services, provide 
behavioral health/emergent care/substance abuse treatment for soldiers 
and families regardless of status, and additional behavioral health 
providers for clinical and administrative case management.
    Admiral Greenert. The Navy Reserve has been completely integrated 
in Navy Suicide Prevention policy, programs, and activities. The Chief 
of Navy Reserve attends weekly updates provided to the Chief of Naval 
Operations on suicide trends and activities. Reserve commands have 
suicide prevention coordinators, leaders participate in program 
informational briefings, and sailors receive the same spectrum of 
training in OSC and suicide prevention as their active duty 
counterparts.
    While lack of day to day observation and contact can be a challenge 
to supporting SELRES between monthly drill periods, the Navy PHOP has 
provided a very helpful resource in extending the reach for 
consultation and referral, support, and follow-up for commands, 
sailors, and family members in the area of psychological health. As of 
30 June, the PHOP teams had reached out to more than 1,860 Navy Reserve 
members, clinically assessed and referred 2,376 reservists to 
appropriate sources of mental health care, and conducted 281 visits to 
NOSCs nationwide, providing the OSC awareness and suicide prevention 
briefs to 29,400 SELRES and full-time support staff.
    The Navy began collecting DODSERs for suspected suicides and 
suicide attempts of SELRES sailors beginning in April 2009 to better 
understand the factors affecting this population and identify needs and 
prevention opportunities.
    General Amos. As an active member of the Yellow Ribbon Suicide 
Prevention Working Group, the Marine Corps is working with its sister 
Services to identify and remove gaps which may limit access to help and 
support for its Reserve component. The Marine Corps Reserves' efforts 
mirror those of the total force and include noncommissioned officer 
peer-to-peer training along with annual suicide prevention training. We 
are expanding efforts to reach family members as key partners in the 
effort to prevent suicides. In addition to our regular suicide 
prevention initiatives, the Marine Corps has a number of programs 
designated specifically to meet the needs of our Reserve marines. One 
such program is the PHOP. There are 30 Marine Corps Reserve 
Psychological Health Outreach staff members available to assist all 
returning units. We have also called upon the MFLCs, a program 
sponsored by DOD, that is available to support returning units whenever 
need is identified by the command. In addition, the Marine Corps 
Mobilization Command has a Family Readiness Team that helps track those 
in the IRR in need of support, and Navy Medicine has several 
initiatives underway to provide support to the IRRs to include family 
readiness days.
    General Chandler. For the Air Force Reserves (AFR), the Office of 
the Secretary of Defense recently authorized one adult MFLC, one child 
and youth MFLC and one Military OneSource coordinator to work at 
Headquarters, Air Force Reserve Command (AFRC). Some of their roles and 
responsibilities will be to coordinate with State-level Joint Family 
Assistance Program offices and assist in ensuring reservists and their 
families are aware of benefits to which they are entitled. AFR and Air 
National Guard (ANG) airmen and Family Readiness offices assist 
commanders and first sergeants with their responsibility of contacting 
families of deployed personnel to keep them abreast of their benefits 
and direct them to support services such as Military OneSource, which 
has been a tremendous asset for geographically dispersed families. When 
it comes to suicide prevention, the YRRP provides needed resources and 
support by means of a Chaplain presence and State Directors of 
Psychological Health at Yellow Ribbon events. We work with the 
servicemembers and their families, as well as commanders that may need 
guidance. We also realize that monitoring and providing support doesn't 
end after completed Yellow Ribbon events. We must train and educate the 
servicemember, families, and commanders and units on suicide 
prevention.

    19. Senator Ben Nelson. General Chiarelli, Admiral Greenert, 
General Amos, and General Chandler, how are these programs reviewed and 
managed to ensure that Reserve and Guard soldiers in Nebraska have the 
same benefits and support as those in other States?
    General Chiarelli. The Yellow Ribbon program is a standardized and 
funded program and each State individually requests the funding it 
needs to meet its annual requirements. The ARNG has developed a 
synchronization matrix to set overall standards while providing States 
the flexibility to meet their Yellow Ribbon goals.
    Admiral Greenert. DOD has an instruction which establishes a core 
curriculum for the Services' YRRP events.
    Additionally, YRRP events have been standardized throughout the 
Navy Reserve. In particular, the Navy has developed policy and 
execution guidance governing its three Yellow Ribbon events: PDFRC, the 
RWW, and the PDHRA. Every effort is made to ensure the agenda, content, 
and messages delivered via PDFRCs and RWWs are consistent in every Navy 
region. The Bureau of Medicine and Surgery has developed standard 
procedures for conducting the PDHRA nationwide.
    General Amos. There is one Reserve company based in Nebraska. 
Marine Forces Reserve executes the YRRP consistently across the country 
regardless of where they reside. Each battalion and squadron-level unit 
and above has a full-time, nondeploying Family Readiness Officer (FRO), 
whose responsibility it is to educate that unit's marines and family 
members on methods and resources to employ for attaining and 
maintaining a continual state of readiness for any exigency of the 
military lifestyle, including mobilization and deployment. FROs 
encourage socialization of the unit families through hosting of 
periodic family day and recreational events. They also schedule 
educational sessions to support the resiliency needs of families 
associated  with  welcome  aboard;  indoctrination  into  the  Marine  
Corps  lifestyle;  pre-, during, and post-deployments; and life skills 
that cover a broad array of support to build knowledge, skills, and 
critical identification abilities in the areas of combat and 
operational stress, suicides, casualty assistance, elder care, and 
deployment impacts on children.
    General Chandler. The Air Force Reserve YRRP is not managed by 
State but rather by Air Force Reserve Command (AFRC), which extends to 
all Air Force Reserve (AFR) units. As such, all AFR members receive the 
same benefits and support regardless of the State in which they reside. 
For the Air National Guard (ANG), the guidance set by the Office of the 
Secretary of Defense (OSD) as well as the policy memorandum (dated 20 
July 2009) signed by General McKinley, Chief, National Guard Bureau 
(NGB), gives specific instruction as to what topics should be covered 
during each phase of the YRRP. In addition, the NGB Joint Staff Yellow 
Ribbon Office and the ANG Yellow Ribbon program managers work 
collaboratively to collect best practices, attend events and review 
policy and guidance to ensure each member eligible for the YRRP 
receives the necessary resources and information. Each State may 
orchestrate the events differently, but standards and guidelines are 
set by OSD as well as the Chief of the National Guard Bureau.
                                 ______
                                 
                Questions Submitted by Senator Jim Webb
                           prescription drugs
    20. Senator Webb. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, in response to a question for the record 
for the military departments' surgeons general following a March 10, 
2010, Personnel Subcommittee hearing on the military health system, DOD 
responded that the Services do not have the capability to track 
prescription medication use in theater, and that ``the Military Health 
System Pharmacy Data Transaction Service (PDTS) has no visibility of 
pharmacy data for prescriptions dispensed in forward operating areas.'' 
It is my understanding that the PDTS serves to track the administration 
of medications to enhance patient safety and avoid medication 
contradictions. However, in-theater doctors and medics are not linked 
to the PDTS; therefore, not only are prescriptions themselves not being 
tracked, but doctors and medics in-theater are required to treat 
patients without complete medical case histories. What policies and 
processes are the military departments instituting to ensure proper 
data collection and record keeping for the prescription of psychotropic 
and other drugs administered to forward-deployed servicemembers?
    General Chiarelli. Providers document theater-generated outpatient 
prescriptions in the Armed Forces Health Longitudinal Technology 
Application-Theater (AHLTA-T). This is the deployed version of the 
Military Health System's electronic medical record. Currently U.S. Army 
Medical Command (MEDCOM) is working with U.S. Central Command (CENTCOM) 
to develop a policy to ensure theater systems training requires 
entering all medications within the Medications Orders menu in AHLTA-T. 
This will improve standardization of documentation and ease in 
reviewing medications by the deployed provider. All prescriptions 
appear in the consolidated medications list within the Theater Medical 
Data Store (TMDS), which will comply with the current policy of 
electronic health record reach back capability via AHLTA-Warrior and 
TMDS.
    Additionally, MEDCOM is developing training for providers on their 
responsibility to advise Commanders, as appropriate, about medications 
prescribed to a soldier if the medication affects mission readiness or 
fitness for duty.
    Admiral Greenert. It is not a completely accurate assumption that 
the Services do not have the capability to track prescription 
medication use in theater. Theater generated prescriptions are 
documented and viewable through TMDS and this information can be 
accessed by garrison providers via a web interface. Deployed health 
care providers have full reach back capability to the servicemember's 
garrison prescription history via TMDS, Armed Forces Health 
Longitudinal Technology Application (AHLTA)-Warrior, or by Enterprise 
Remote Access (ERA) web based AHLTA virtualized access.
    PDTS is a pharmacy claims service used to prevent drug-drug 
interactions, duplications, fraud, and assist with billing in the 
military MTF, retail pharmacy and mail order points of service and 
while the data forms a fairly solid picture of outpatient pharmacy use 
in DOD in the 3 points of service, it is not designed to answer 
questions about medications being prescribed in theater.
    PDTS is currently not available in a deployed setting, however 
there are two electronic health records in theater: AHLTA-T (theater) 
(outpatient) and TC2 (inpatient). Each is a stand-alone system with the 
information entered into it uploaded to TMDS. This can be accessed via 
the web by other locations although internet connectivity in theater is 
a limiting factor. TMDS is currently the most comprehensive and best 
organized application to view theater health history (individual 
patient issues). TMDS is also available via AHLTA.
    TMDS is not ideal for viewing medication history and does not 
perform drug checks against the greater enterprise. Drug interactions 
can also be checked utilizing Lexi-Comp medication resource electronic 
clinical reference that is available through the Navy Medicine Online 
telelibrary and downloadable.
    The ASD/HA memo Policy on Worldwide Use of Theater Medical 
Information Program-Joint 03 November 2008, signed by Assistant 
Secretary of Defense for Health Affairs addressed the collection and 
storage of theater health related data on servicemembers. Navy Medicine 
is in compliance with this memorandum, with all outpatient care in 
theater being documented in AHLTA-T and inpatient care documented in 
TC2. Both systems feed data into TMDS. The provider notes are also 
visible to any provider anywhere in the world via TMDS or viewable as 
previous encounters in AHLTA.
    General Amos. PDTS is a pharmacy claims service used to prevent 
drug-drug interactions, duplications, fraud, and assist with billing in 
the military MTF, retail pharmacy and mail order points of service. The 
system was not designed for individual patient medication management 
and is a poor tool to accomplish this task. PDTS is useful in providing 
data to answer population based inquiries.
    While leaders in Washington, DC may not have direct view of 
theater-generated prescriptions, patient encounters are documented and 
viewable through TMDS and this information can be accessed by garrison 
providers via a web interface to TMDS. Deployed health care providers 
have full reach back capability to SM's garrison prescription history 
via TMDS, AHLTA-Warrior, or by Enterprise Remote Access (ERA) web based 
AHLTA virtualized access.
    The ASD/HA memo Policy on Worldwide Use of Theater Medical 
Information Program-Joint 03 November 2008, signed by Assistant 
Secretary of Defense for Health Affairs, S. Ward Casscells, M.D., 
addresses the collection and storage of theater health related data on 
SMs.
    General Chandler. There are two electronic health records in 
theater: Armed Forces Health Longitudinal Technology Application-
Tactical (AHLTA-T) for out-patient and emergency room records and 
Theater Medical Information Program Composite Health Care System Cache 
(TC2) for in-patient records. Each is a stand-alone system with the 
capability to upload information to the TMDS. This can be accessed via 
the internet; however, connectivity is often a limiting factor. 
Medication data is not transferred from AHLTA-T to PDTS, so reports 
cannot be run to evaluate medication usage. In the near term, DOD is 
testing the ability to run ad hoc reports through TMDS and is 
considering options for passing medication data from TMDS to PDTS for 
use in running reports. To address this in the long-term, TRICARE 
Management Activity's Defense Health Information Management System 
(DHIMS) personnel are working to identify data requirements for PDTS to 
be able to fully interface with theater systems (TMDS, AHLTA-T, and 
TC2). This information could be used for clinical decision support 
(e.g., screening for drug-drug interactions) and for analysis and 
reporting purposes. Requirements are being built into the next PDTS 
contract to transfer theater data to PDTS; however, the estimated 
completion date is unknown.

    21. Senator Webb. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, when will comprehensive data be available 
from the Services for prescription drug use for the Active-Duty, Guard, 
and Reserve components?
    General Chiarelli. Providers can view all medications prescribed to 
deployed soldiers.
    Providers document and view all medications prescribed in garrison 
through the Armed Forces Health Longitudinal Technology Application 
(AHLTA), the Military Health System's electronic medical record. The 
system includes both inpatient and outpatient prescribed medications. 
This provides ready visibility of these medications without requiring 
additional information systems. Deployed healthcare providers have full 
reach back capability to a soldier's garrison prescription history via 
AHLTA-Warrior, a web-based AHLTA view only interface, or by Enterprise 
Remote Access, a web-based AHLTA virtualized access.
    Providers document theater-generated outpatient prescriptions in 
AHLTA-Theater. These prescriptions are then viewable through the TMDS, 
which is the data repository and a web-based program to access theater-
generated electronic medical records. Garrison providers can access 
Theater outpatient information via a web interface to TMDS and via 
AHLTA. The Assistant Secretary of Defense (Health Affairs)/DHIMS is 
currently working to simplify the process of reviewing all prescribed 
medications within AHLTA with an implementation timeline of 
approximately September 2010.
    Admiral Greenert. CENTCOM submitted a requirement requesting a new 
capability to: track patients deployed in theater who are being 
prescribed medications that by themselves may require follow-up; track 
patients who are being prescribed medications in theater that may 
disqualify them from being in a deployed status; and identification of 
patients who may be going to multiple providers and/or clinics in the 
pursuit of multiple prescriptions for drugs that are prone to patient 
abuse. This capability is targeted for release, by the Office of 
Assistant Secretary of Defense for Health Affairs, in late September or 
early October 2010. DOD is testing the ability to run adhoc reports for 
medication data through TMDS.
    Also, the TRICARE Management Activity has developed requirements 
that would allow PDTS to receive medication information from in 
theater. This information could be used as clinical decision support 
(screening for drug-drug interactions) and reporting purposes. The 
Office of Assistant Secretary of Defense for Health Affairs anticipates 
that software development work should begin in early fiscal year 2011.
    General Amos. CENTCOM submitted a requirement requesting a new 
capability to: track patients deployed in theater who are being 
prescribed medications that by themselves may require follow-up; track 
patients who are being prescribed medications in theater that may 
disqualify them from being in a deployed status; and identification of 
patients who may be going to multiple providers and/or clinics in the 
pursuit of multiple prescriptions for drugs that are prone to patient 
abuse. This capability is targeted for release in late September or 
early October 2010.
    DOD is testing the ability to run ADHOC reports for medication data 
through TMDS. DHIMS is working to improve the reporting capabilities.
    TRICARE Management Activity has developed requirements that would 
allow PDTS to receive medications from theater systems. This 
information could be used as clinical decision support (screening for 
drug-drug interactions) and reporting purposes. It is anticipated work 
should begin in early fiscal year 2011.
    General Chandler. DHIMS personnel are currently working to identify 
data requirements for the PDTS to be able to fully interface with 
theater systems. These theater systems include the TMDS, Armed Forces 
Health Longitudinal Technology Application-Theater (AHLTA-T) and 
Theater Medical Information Program Composite Health Care System Cache 
(TC2). The estimated completion date of this interface is unknown.

    22. Senator Webb. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, what is being done to review the policies 
governing the prescription of psychotropic medications in general, 
including their prescription in combination with other drugs 
(polypharmacy)?
    General Chiarelli. In June 2009, Office of the Surgeon General/U.S. 
Army MEDCOM issued guidance to providers caring for patients who 
receive treatment with multiple medications. This policy was revised in 
September 2009, and is currently being updated further to fully address 
the problem of polypharmacy among soldiers receiving treatment, 
especially when psychotropic agents or central nervous system 
depressants are involved. The purpose of this policy is to provide 
guidance on the prevention and management of polypharmacy with 
psychotropic medications and central nervous system depressants to 
reduce adverse events and optimize clinical outcomes among soldiers 
receiving care in the military medical system. This policy mandates 
that care providers carefully monitor soldiers with complex or multiple 
medical and/or behavioral health problems to reduce the risk of serious 
drug interactions and polypharmacy. Providers will review the 
medication profile at each visit, assess for ongoing clinical 
indications for medication treatment, screen for the potential side 
effects, including the effects of drug-drug interactions, and refer to 
a clinical pharmacist for further review and reconciliation if the 
number and nature of the patient's medications triggers a pharmacy 
referral.
    Risk has been greatly reduced for Warrior Transition Unit (WTU) 
soldiers, who are at the highest risk among our troops, by implementing 
intensive monitoring by primary care physicians in close collaboration 
with pharmacists assigned to the WTUs. Consequently, soldiers' 
medications are reviewed within 24 hours of arrival in the WTU, 
reviewed thereafter at least weekly, and more often if changes in 
dosage or medication are made in the course of treatment. High risk 
soldiers are assigned to only one health care provider to access 
controlled medications that may put them at greater risk. Soldiers who 
have demonstrated difficulties in complying with treatment on opioid 
analgesics and other controlled medications are enrolled in the Sole 
Provider Program for more intense monitoring and control.
    Admiral Greenert. Medication reconciliation, a National Patient 
Safety Goal of the Joint Commission accreditation agency, is a complete 
review of all patient medications and any potential interactions with 
other drugs. Today, medication reconciliation is performed by the 
medical provider at each patient encounter, both in and out of theater.
    The WTU Pharmacy Prescription Medication Analysis and Reporting 
Tool is a DOD-consolidated medication screening tool containing 
medication from all points of service (MTF, retail and mail order). 
This tool also provides reports on four targeted categories (sedative 
hypnotics, narcotics, antidepressants, and antipsychotics) and can be 
used to identify at-risk patients prior to deployment.
    Current pre-deployment screening procedures address all medication 
usage including psychotropics as documented on the NAVMED 1300/4, which 
was revised April 2010.
    General Amos. While I defer to the military medicine professionals 
regarding appropriate management of all medical conditions, the Marine 
Corps adheres to all current directives regarding medications usage and 
deployment. Specifically, the Marine Corps is well aware of and 
adherent to the guidance contained in the CENTCOM ``Individual 
Protection and Individual/Unit Deployment Policy'' Mod 10 released 05 
March 2010 and DOD DTM dated November 7, 2006 ``Policy Guidance for 
Deployment-Limiting Psychiatric Conditions and Medications.''
    General Chandler. Several processes, programs, and directives are 
in place at Air Force MTFs to closely monitor and manage medication 
therapy, including the prescribing of psychotropics and the monitoring 
of polypharmacy:
Medication Reconciliation
    This is a National Patient Safety Goal of the Joint Commission on 
Accreditation of Healthcare Organizations. The objective is for 
providers to review and evaluate all medications with each patient at 
each encounter. The patient leaves each encounter with a list of 
current medications from all providers, all pharmacies and any over the 
counter medications or vitamins.
Composite Health Care System (CHCS) Profile Review
    All prescriptions filled through CHCS are screened for drug 
interactions, overlaps, duplications, and early fills. Prescriptions 
filled at network pharmacies are also screened through the Prescription 
Data Transaction Service. When potential problems are identified (e.g., 
duplications/overlaps, drug-drug interactions, etc.), pharmacy 
personnel follow-up with the patient and, when appropriate, with the 
patient's provider.
Prescription Restriction Program
    This is a program available through the Pharmacy Operations Center 
that can be used to limit patients to one pharmacy and one provider. It 
is usually used for controlled substances, but can also be used as a 
patient safety tool to prevent patients from receiving prescriptions 
from multiple providers or pharmacies for the same or similar 
medications.
Pre-Deployment Screening
    Pre-deployment screening addresses all medications including 
psychotropics. It is directed in Air Force Instruction (AFI) 48-120 (in 
coordination), which will implement DOD Directive (DODD) 6490.02E, 
Comprehensive Health Surveillance; DOD Instruction (DODI) 6490.03, 
Deployment Health, Joint Chiefs of Staff (JCS) Memorandum, 2 Nov 07, 
Procedures for Deployment Health Surveillance; and, Headquarters United 
States Air Force (HQ USAF)/Assistant Vice Chief of Staff (CVA) 
Memorandum, 23 Feb 06, PDHRA. The AFI provides guidance for all Air 
Force and Air Reserve component (ARC) installations in meeting the 
requirements of the deployment health and medical surveillance program. 
When published, it will supersede Air Force Surgeon General's 
Memorandum, dated 22 May 03, ``Medical Procedures for Deployment Health 
Surveillance.'' Additionally, a tool available to assist in the pre-
deployment screening process is the Prescription Medication Analysis 
and Reporting Tool (P-MART), which is a consolidated medication 
screening tool that displays medications from all points of service 
(MTF, retail, and mail order). This tool provides reports on four 
targeted categories (sedative hypnotics, narcotics, antidepressants, 
and anti-psychotics), and can identify at-risk patients.
                                 ______
                                 
                Question Submitted by Senator Mark Udall
               npr and propublica investigation interview
    23. Senator Udall. General Chiarelli, you mentioned in your 
testimony that you provided to National Public Radio a complete 
response to its recent report on brain injuries in the Army, in which 
you detailed your problems with the report. Would you please provide me 
your complete response for the record?
    General Chiarelli. A copy of my letter to NPR is attached.
      
      
    
    
      
                                 ______
                                 
            Questions Submitted by Senator Roland W. Burris
                       families of servicemembers
    24. Senator Burris. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, as you know, war wounds and mental trauma 
do not only affect the injured veteran, dealing with these conditions 
is also very hard on the family members. Are there any statistics 
available about the incidence of suicide and depression of the families 
of servicemembers?
    General Chiarelli. The ASPTF has tracked family member suicides 
since calendar year 2009. Army Criminal Investigation Division (CID) 
investigates the death of all Army family members that occur on post. 
When the death of a family member occurs off-post, CID coordinates with 
the local law enforcement agency on the investigation. If the death 
appears to be the result of a suicide, CID notifies the ASPTF liaison 
officer. ASPTF does not track the incidence of depression in family 
members. However, this data may be obtained from medical channels if 
the family member was seen at one of the Army's medical facilities, or 
a TRICARE provider. Tracking Reserve component (not on Active Duty) 
family member suicides has proven to be problematic.
    Admiral Greenert. It is difficult to accurately quantify because 
dependents often access mental health services outside of the Military 
Health System. Additionally, psychiatric disorders are diagnosed by a 
cluster of symptoms rather than the presence of measurable physical 
findings. This leads to a disparity in the reported incidence rates and 
other epidemiologic statistics for the majority of psychiatric 
disorders calling into question their reliability.
    We are however, able to infer a change in the psychological health 
status of our servicemembers' family members by their utilization of 
mental health services. For example, between 2007 and 2009 there was an 
increase of more than 14 percent in the number of family members under 
the age of 18 who received mental health treatment; 95 percent of this 
increase was in the diagnoses of conduct, adjustment and anxiety 
disorders as well as developmental disorders from increased learning 
problems in school. This supports the fact that children, when 
stressed, typically become anxious or act out their stress through 
behavioral problems rather than complain of sadness or depression. From 
these findings we can conclude that family members are also having 
difficulties with managing the impact of the war on the family unit of 
our veterans' and servicemembers.
    Programs are in place to support the family; assist in building on 
the baseline resilience that family members bring with them; and treat 
mental health conditions once they are identified.
    General Amos. The Marine Corps tracks family member suicides that 
are reported through the personnel casualty reporting system. Over the 
last 5 years, there have been 0 to 2 Marine dependent suicides per 
year. We do not have detailed information on these deaths as they have 
occurred in the civilian area of responsibility with minimal military 
opportunity to investigate. This is below the National civilian suicide 
rate. the Marine Corps do not track statistics on the incidence of 
depression in families of servicemembers.
    General Chandler. The mental health of families is of significant 
concern to the Air Force as family support is essential for effective 
functioning of our servicemembers. Air Force health care records show 
that approximately 16,000 active duty family member beneficiaries 
(approximately 3 percent of all beneficiaries) have a primary diagnosis 
of some type of depression. This compares to estimated national 
prevalence of depression of approximately 10 percent. The Air Force has 
had an increase in utilization of mental health services over the past 
5 years both at military treatment facilities and through the TRICARE 
network.
    There is currently no requirement for local authorities to report 
family members' cause of death to the Air Force. The Air Force suicide 
prevention program is working with Air Force Manpower and Personnel to 
develop a process for collecting this data and tracking Air Force 
family member suicides by obtaining data on Servicemembers Group Life 
Insurance claims. We will share this process with our Sister Services 
to ensure future tracking of this important issue across DOD.

    25. Senator Burris. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, what types of mental health services are 
available to family members and caregivers?
    General Chiarelli. Inpatient and outpatient behavioral health care 
is available to family members through MTFs at every Army installation 
hosting families. The Army additionally leverages local healthcare 
providers in the surrounding installation communities through the 
TRICARE Network system. TRICARE covers medically and psychologically 
necessary behavioral health care services for family members to include 
individual, family, and group therapies, collateral visits, 
psychoanalysis, psychological testing, inpatient hospitalization, 
partial hospitalization and residential treatment.
    There are also numerous programs that provide training and 
assistance for families experiencing stressors related to military 
service and deployments. These programs include an extensive array of 
behavioral health services that address symptoms of depression, 
anxiety, and other psychological health issues, and specifically 
provide training to assist families with identification of symptoms 
that may indicate depression, anxiety and other psychological health 
issues. These support programs for soldiers and their families include 
the following:

         Army Community Service. Army Community Service 
        programs offer real-world solutions to problems commonly 
        encountered by soldiers and their families. The program equips 
        people with the skills and education that they need to face the 
        challenges of military life today and tomorrow.
         Battlemind. Numerous Battlemind products have been 
        developed and implemented to train soldiers and families to 
        cope with the rigors of deployment and redeployment. These 
        training products are designed to enhance the recovery and 
        resiliency of soldiers before, during, and after deployment. 
        Battlemind resources include training programs and videos 
        focusing on post-deployment recovery, marital relationships, 
        and supporting children from pre-school to teen.
         Child and Adolescent Center of Excellence. This COE 
        works to characterize the effects of belonging to a military 
        family; focuses on the impact of being a child with a parent 
        who deploys, is wounded or killed in action; follows them over 
        time; focuses on interventions, programs, and policies to 
        assist families in relation to these unique stressors; and 
        provides targeted healthcare solutions, support products, and 
        services to military dependent children and adolescents and 
        exports them DOD-wide.
         Family Assistance for Maintaining Excellence. Formerly 
        known as Families Adapting to Military Experience, Family 
        Assistance for Maintaining Excellence provides standardized, 
        evidence-based behavioral health assessments; services include 
        education, prevention, screening, and/or treatment for Spouses.
         Military OneSource. A free 24-hour, 7-days-a-week 
        information center and website where soldiers can seek 
        assistance. Counseling is provided by phone or in person by 
        Masters-level consultants on issues such as family support, 
        emotional stress, debt management, and legal concerns at no 
        cost to the soldier or family member for up to twelve sessions.
         Psychological Health School Programs. A preventive 
        approach intended to strengthen individual servicemembers, 
        their families, their units, and communities, enhancing their 
        ability to cope with stress. Resilience promotion involves a 
        continuum of care from non-clinical to clinical settings.
         Warrior Resiliency Program. Focuses on the prevention 
        and treatment of combat and deployment stressors impacting on 
        warriors and their families. This is a preventive approach 
        intended to strengthen individual soldiers, their families, 
        their units, and communities, enhancing their ability to cope 
        with stress. Resilience promotion involves a continuum of care 
        from non-clinical to clinical settings.

    Caregivers who are not eligible beneficiaries can receive education 
counseling, research and referrals through Military OneSource 
(www.MilitaryOneSource.com) when the mental health concern is related 
to or on behalf of a servicemember. For mental health issues unrelated 
to the servicemember, Military OneSource will work with the non-
dependent or parent to refer them to the appropriate behavioral health 
resource in the community. While there are no costs associated with 
using Military OneSource, the non-dependent is responsible for any 
resource other than the assistance provided by Military OneSource.
    Admiral Greenert.
For Families--
    Project FOCUS (Families Over-Coming Under Stress) addresses 
difficulties that children and families face during the challenges of 
multiple deployments and parental operational stress. FOCUS works in 
coordination with Navy's Fleet and Family Support Centers as well as 
the Marine Corps Community Service's programs to provide a thorough 
continuum of care to servicemembers and their families.
    Navy Fleet and Family Support Centers (FFSCs) offer a wide-range of 
services to families to include pre- and post-deployment programs, 
including counseling services. They have incorporated the OSC concepts 
into their programs as appropriate.
Medical Care for Dependents--
    Eligible beneficiaries can access a wide range of mental health 
services in the Military Health Service. TRICARE covers medically and 
psychologically necessary behavioral health care services including 
outpatient psychotherapy, psychological testing and medication 
management; acute inpatient psychiatric care, psychiatric partial 
hospitalization program, residential treatment center care (limited to 
beneficiaries under age 21), and substance use disorder services. The 
web-based TRIAP provides online access (chat, web-based video) to 
counseling for short-term, non-clinical issues. The Telemental Health 
Program is available at participating TRICARE facilities where 
beneficiaries can use secure audio-visual conferencing to connect with 
offsite TRICARE network providers for clinical counseling.
    Respite care services are available to injured servicemembers and 
are provided by a home health agency authorized by TRICARE and approved 
by the servicemember's case manager. Respite care provides rest and 
change for the primary caregiver who has been caring for the patient at 
home and assisting with activities of daily living.
For Caregivers--
    The Caregiver Occupational Stress Control (COSC) Project provides 
training and materials to educate caregivers on compassion fatigue and 
secondary trauma. COSC enhances the resilience of caregivers to the 
psychological demands of exposure to trauma, wear and tear, loss, and 
inner conflict associated with providing care.
    General Amos.
For Families--
    Project FOCUS (Families Over-Coming Under Stress) addresses 
difficulties that children and families face during the challenges of 
multiple deployments and parental operational stress. FOCUS works in 
coordination with Navy's Fleet and Family Support Centers as well as 
the Marine Corps Community Service's programs to provide a thorough 
continuum of care to servicemembers and their families.
    Marine Corps Community Services (MCCS) offer a wide-range of 
services to families to include pre- and post-deployment programs. They 
have incorporated the OSC concepts into their programs as appropriate.
For Caregivers--
    The COSC project provides training and materials to educate 
caregivers on compassion fatigue and secondary trauma. Caregiver OSC 
enhances the resilience of caregivers to the psychological demands of 
exposure to trauma, wear and tear, loss, and inner conflict associated 
with the therapeutic use of self.
    Respite care services are available to injured servicemembers and 
are provided by a Home Health Agency authorized by TRICARE and approved 
by the servicemember's case manager. Respite care provides rest and 
change for the primary caregiver who has been caring for the patient at 
home and assisting with activities of daily living.
Medical Care for Dependents--
    Eligible beneficiaries can access a wide range of mental health 
services in the Military Health Service. TRICARE covers medically and 
psychologically necessary behavioral health care services including 
outpatient psychotherapy, psychological testing and medication 
management; acute inpatient psychiatric care, psychiatric partial 
hospitalization program, residential treatment center care (limited to 
beneficiaries under age 21), and substance use disorder services.
    The web-based TRIAP provides online access to counseling for short-
term, non-medical issues.
    The Telemental Health Program is available at participating TRICARE 
facilities where beneficiaries can use secure audio-visual conferencing 
to connect with offsite TRICARE network providers.
    General Chandler. There is a comprehensive spectrum of mental 
health care and support available to family members and beneficiaries 
who may also be care-givers of the wounded, ill, and injured.
    The following types of treatments are available to family members:
Formal mental health visits:
    In the Air Force, due to the primacy of the mission to active duty 
airmen, most care to family members is arranged through the TRICARE 
network.
    Behavioral Health in primary care:
    Studies show half of all medical visits for mental health concerns 
occur in primary care clinics. More than 60 percent of Air Force MTFs 
have behavioral health providers embedded within them. Seeing a mental 
health provider in primary care is a lower-stigma alternative and 
typically involves a few visits for a focused intervention.
    The TRICARE Assistance Program:
    TRIAP offers web-based counseling for adult beneficiaries.
Nonmedical counseling
    Military OneSource offers nonmedical counseling with licensed 
providers for family members and is easily accessed through a toll-free 
telephone number by self-referral. MFLCs and licensed mental health 
providers offer confidential support to military members and family 
members through base Airman and Family Readiness Centers.
Support and referral
    Recovery Care Coordinators (RCCs) and Family Liaison Officers 
working with wounded, ill, and injured airmen also help support family 
members and caretakers and refer them to any needed services. 
Additionally, our chaplains are active in supporting family members and 
caretakers and are trained in suicide prevention strategies.
    In summary, there is a broad spectrum of mental health services 
available to beneficiaries who need mental health services.

    26. Senator Burris. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, is it only military dependents that qualify 
for these services, or are there resources available to affected non-
dependents such as parents?
    General Chiarelli. Army Behavioral Health services are not 
available to non-dependents such as parents. However, parents and non-
dependents are eligible to receive education counseling, research and 
referrals through Military OneSource (www.MilitaryOneSource.com) when 
the mental health concern is related to or on behalf of a 
servicemember.
    For mental health issues unrelated to the servicemember, Military 
OneSource will work with the non-dependent or parent to refer them to 
the appropriate behavioral health resource in the civilian sector. 
While there are no costs associated with using Military OneSource, the 
non-dependent is responsible for any resource other than the assistance 
provided by Military OneSource.
    Admiral Greenert. Section 1672 of the NDAA for Fiscal Year 2008 
authorizes a family member who is not otherwise eligible for medical 
care at a Military Treatment Facility (MTF), and who is caring for a 
member of the Armed Forces recovering from serious injuries or 
illnesses, to receive medical care at the MTF on a space-available and 
reimbursable basis. Such care includes available mental health services 
in the MTF. Earlier this year, the Deputy Secretary of Defense signed 
out a memorandum on April 1, 2010 expanding eligibility of care to non-
family members.
    Additional help is available to primary caregivers of homebound 
injured active duty servicemembers. Respite care services are available 
to the family members of injured servicemembers and are provided by a 
home health agency authorized by TRICARE and approved by the 
servicemember's case manager. Respite care provides rest and change for 
the primary caregiver who has been caring for the patient at home and 
assisting with activities of daily living.
    General Amos. Section 1672 of the NDAA for Fiscal Year 2008 
authorizes a family member who is not otherwise eligible for medical 
care at a Military Treatment Facility (MTF), and who is caring for a 
member of the Armed Forces recovering from serious injuries or 
illnesses, to receive medical care at a MTF on a space-available and 
reimbursable basis. Such care includes available mental health services 
in the MTF. Deputy Secretary of Defense Memorandum of April 1, 2010 
expanded eligibility for this care to non-family members.
    Additional help is available to primary caregivers of homebound 
injured active duty servicemembers. Respite care services are available 
to injured servicemembers and are provided by a Home Health Agency 
authorized by TRICARE and approved by the servicemember's case manager. 
Respite care provides rest and change for the primary caregiver who has 
been caring for the patient at home and assisting with activities of 
daily living.
    General Chandler. Current policy does not provide these services to 
non-dependents such as parents unless they are designated as the 
caregiver by the servicemember. Caregivers must be certified by medical 
personnel prior to designation. Those designated as caregivers are 
authorized inpatient and outpatient care at a military treatment 
facility on a space-available basis.

                  differences in services' statistics
    27. Senator Burris. General Chiarelli and General Amos, all of the 
Services have seen an increase in their suicide rates. However, the 
Army and Marine Corps have seen a much higher rate of suicides than the 
Navy and the Air Force. For example, in 2008, the Army and Marine Corps 
had suicide rates of 18.5 and 19.5 per 100,000 servicemembers, 
respectively. However, the Navy and the Air Force had rates of 11.6 and 
12.1 per 100,000 servicemembers, respectively. Why do you believe 
suicide rates in the Army and Marine Corps are so much higher?
    General Chiarelli. The U.S. Army Public Health Command (Prov) 
technical paper dated 29 April 2010, based on an overall assessment 
over the study period from 2003-2009, indicates that the primary high 
risk population for suicide among Army soldiers is young males with a 
behavioral health (BH) condition, which is consistent with data on 
civilian risk factors. Other than having a BH diagnosis, other factors, 
such as participation on first deployment, levels of combat exposure, 
and personal and work-related stressors likely contribute to suicide 
risk. On the latter, they did indicate ``further analysis is required 
to understand their relative impact and to prioritize areas for 
prevention and intervention.''
    According to the Army suicide reports used for the VCSA's Senior 
Review Group meetings, the leading factor associated with a completed 
suicide event involves a relationship problem (55.8 percent of 520 
cases), with military/work stress being the second leading factor (49.6 
percent of the 520 cases). In most cases, there are multiple 
contributing factors.
    General Amos. The Marine Corps consists of an overwhelmingly young, 
male and mostly single population whose life-skills and resilience are 
still developing. Impulsivity is known to play a role in suicide-
related behavior and we believe that our young marines are at increased 
risk. In addition, we believe that high sustained operational tempo is 
a stressor that may be experienced uniquely in the different Services.

    28. Senator Burris. Admiral Greenert and General Chandler, do you 
believe there are any components of your suicide prevention programs 
that can account for your lower numbers?
    Admiral Greenert. We believe that a sustained, multi-faceted 
strategy that includes introducing and sustaining OSC training 
throughout the career continuum, local level leadership engagement, 
education, and outreach has reduced variability in Navy suicide rates 
over the years. We are committed to a systematic approach with 
continuous process improvement. We are glad to see lower numbers but 
hesitate to draw premature conclusions, and recognize the need to 
maintain vigilance regardless of the direction of the numbers.
    General Chandler. Given the different missions and cultures of the 
Services, it is difficult to directly compare suicide prevention 
efforts between the Services. The Air Force is concerned with the 
health and resilience of all servicemembers and extends great effort to 
reduce the risk of loss of a single servicemember to the tragedy of 
suicide. The Air Force Suicide Prevention Program is founded upon 11 
enduring elements as a community-based prevention program. The first, 
and key, element to this program is senior leader involvement. 
Messaging from senior leadership regarding the importance of seeking 
help when needed has been a critical factor in the success of the Air 
Force Suicide Prevention Program. The Air Force Suicide Prevention 
Program is also based on a strong research foundation. The prevention 
program is engaged in a number of studies with researchers at the USUHS 
to examine case data on past suicides, including data collected through 
our Suicide Event Surveillance System, and the DODSER and Personal 
Health Assessment data, to look for factors that may allow us to better 
identify those at risk for suicide. Recent efforts in this area have 
allowed us to identify career fields that appear to be at greater risk 
for suicide, allowing leadership to target additional prevention 
efforts at these groups.
    The Air Force is also collecting data on new recruits entering the 
Air Force regarding past behavioral history. This data collection 
appears to show promise in allowing us to identify, from a recruit's 
earliest days in the Air Force, those airmen who may be at higher risk 
for a variety of problems. The Air Force is now exploring ways to reach 
out to these airmen to improve their ability to cope with the rigors of 
military life and improve resiliency.

                        warrior transition units
    29. Senator Burris. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, numerous Warrior Transition Units (WTU) 
have been established to assist wounded servicemembers in their 
recovery. What types of programs are in place in the WTUs to assist 
servicemembers who are struggling with TBI and PTSD?
    General Chiarelli. Soldiers in WTUs are assigned to a healthcare 
team that includes a PCM, a case manager, and a social worker. This 
team conducts extensive screening for TBI and PTSD during their initial 
and ongoing visits with the soldier. If a soldier screens positive for 
either TBI or PTSD, the team has access to referral resources within 
the Military Health System and in the civilian community. The DCoE for 
Psychological Health and TBI provide resources to healthcare 
professionals through their outreach center and through monthly video 
conferences.
    There are a number of resources available to soldiers and families. 
U.S. Army MEDCOM has developed a number of TBI clinics and specialty 
programs located at Military Treatment Facilities at installations 
throughout the United States and Europe. The VA and DOD have 
collaborated on and published a TBI clinical practice guideline fact 
sheet. Similarly, soldiers diagnosed with PTSD have access to 
Behavioral Health specialists who are experts in the treatment of PTSD. 
The DOD DHCC, a component of the DCoE for Psychological Health and TBI, 
offers a specialized care program for patients experiencing PTSD. 
Soldiers and family members also have access to Behavior Health 
Specialists through Military OneSource.
    Admiral Greenert. Safe Harbor is the Navy's Wounded Warrior Program 
for non-medical care management of recovering servicemembers. Safe 
Harbor does not operate WTUs. The Navy's model for warrior care is to 
transition sailors enrolled in the program close to their original 
homeport or command or wherever they can receive top quality medical 
care and be close to their support network of family members and 
Shipmates. While the Army and Marine Corps wounded warrior population 
tends to be younger, unwed and living in a barracks environment prior 
to injury, Navy has an older population. The average Navy wounded 
warrior is 34 years of age, married and no longer a barracks resident. 
These factors make the Navy model of not garrisoning wounded, ill, and 
injured a good choice for our sailors and coastguardsmen and optimize 
the success of their recovery, rehabilitation and reintegration 
activities.
    Safe Harbor works closely with Navy Medicine and other agencies/
organizations both in the government and private sectors to ensure that 
sailors and coastguardsmen who are struggling with TBI and post-
traumatic stress receive the care and assistance necessary to meet all 
their needs and those of their families. All Navy Wounded Warriors have 
access to TBI and PTSD care offered within DOD and VA Health Systems, 
including the Navy's Comprehensive Combat and Complex Casualty Care 
(C5) at Naval Medical Center San Diego, the NICoE and the DVA 
Polytrauma Centers. Examples of other programs that Safe Harbor assists 
in facilitating access to include DOD Computer/Electronic 
Accommodations Program, the Bob Woodruff Foundation initiatives, Navy 
Marine Corp Relief Society Visiting Nurse, and many more.
    General Amos. In its non-medical care capacity, the Marine Corps' 
WWR has different programs in place to assist our marines and their 
families struggling with TBI and PTSD. Licensed clinical consultants, 
who are located at the WWR's headquarters in Quantico, VA, and its 
battalions at Camp Lejeune, NC, and Camp Pendleton, CA, provide 
resources and coordinate referrals to military, VA and community 
treatment facilities. The WWR's TBI program coordinator screens marines 
with blast exposures for entry into Hyperbaric Oxygen Treatment (HBOT) 
research studies. RCCs assist Active Duty and Reserve marines with TBI 
and PTSD through coordination of a marine's non-medical and medical 
care providers and the completion of a comprehensive transition plan 
(CTP) that helps marines define their personal goals for recovery, 
rehabilitation and reintegration. The WWR's Warrior Athletic 
Rehabilitation Program and its involvement in DOD's Warrior Games give 
marines an outlet to overcome TBI and PTSD through physical activity 
and competition. The Families OverComing Under Stress Program is a 
resiliency program designed to assist and promote strong Marine Corps 
families so they are better equipped to contend with the stressors 
associated with military life and injuries such as TBI and PTSD.
    General Chandler. While the Air Force does not operate WTUs, we 
provide close support to our wounded, ill, and injured airmen through 
our medical staffs and the Air Force Warrior and Survivor Care program. 
Our RCC provide close personalized support to our airmen, monitor those 
with signs of post-traumatic stress and make referrals to the 
appropriate medical specialist. The team approach of clinical case 
manager, RCC, and the unit command works in concert to identify and 
treat airmen with PTSD or TBI. Additionally, our Air Force Wounded 
Warrior Program provides long-term outreach support and referral to 
medical specialists as needed. Since we have experienced excellent 
success with our RCC program, we are expanding that program this year 
by adding 14 additional RCCs throughout the country. Our goal is to 
provide improved coverage, especially for Reserve component units in an 
effort to ensure we are supporting all of our wounded, ill, and injured 
airmen.
    The Air Force works in conjunction with the DCoE for Psychological 
Health and TBI in development of protocols, education and training, 
prevention, patient, family and community outreach. The DVBIC is the 
DOD point of evaluation, treatment and clinical research on TBI. It 
provides treatment and follow-up TBI care to active duty 
servicemembers, veterans and their family members.
    Air Force mental health providers deliver evidence-based treatments 
for PTSD, including prolonged exposure therapy and cognitive processing 
therapy. In addition, eight Air Force sites conduct virtual reality 
treatment for PTSD patients. The Air Force operates a TBI clinic at 
Elmendorf Air Force Base (AFB).
    Through joint collaboration with the Centers for Deployment 
Psychology (CDP) at the USUHS, psychology and social work residents 
attend a two week training that focuses on identification and treatment 
of TBI and PTSD. In addition, CDP also offers training on evidence-
based treatments for PTSD to Air Force providers. DVBIC offers similar 
education on TBI which Air Force providers have attended.

    30. Senator Burris. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, by the very nature of the population in the 
WTUs, is it reasonable to conclude that there is a higher instance of 
substance abuse in these units?
    General Chiarelli. While it certainly is true that soldiers in WTUs 
represent a concentration of those with behavioral health issues such 
as depression and PTSD, as well as TBIs, it is not accurate to 
characterize these conditions, in and of themselves as predisposing 
these soldiers to greater risk of substance abuse behavior than other 
soldiers. There is no data to suggest soldiers in a WTU have a higher 
incidence of substance abuse or are at a higher risk than the general 
Army population. Substance abuse is as much a social phenomenon as it 
is related to behavioral issues. This is why the Army has made such a 
considerable investment in cultivating resilient soldiers and families 
so that they adopt alternative means for coping and dealing with 
anxiety and stress and maintain healthy lifestyles. Any soldier in a 
WTU who exhibits substance abuse problems is immediately referred to 
the Army Substance Abuse Program. For those warriors in transition who 
are determined to be at risk, the PCM will enter that soldier into the 
Sole Provider Program. This program limits access to prescriptions, 
requires weekly medication reconciliation by the WTU pharmacist and 
close monitoring by the PCM of all prescribed medication.
    Admiral Greenert. Navy's equivalent of the WTU is Safe Harbor, 
which has not noted any major substance abuse problems. While the other 
Services' average wounded warrior population is 19-20 years old, unwed 
and live in a barracks environment, Navy has an older population. The 
average Navy wounded warrior is 34 years of age. Sixty-one percent of 
the Safe Harbor population is married. Navy transitions sailors in this 
program close to their homeport or command, whichever is more 
convenient for the servicemember. Both of these factors, older average 
age and environmental stability, may tend to reduce substance abuse.
    General Amos. By virtue of their wounds, illnesses or injuries and 
subsequent treatment, our Wounded Warriors are an at-risk population 
for substance abuse. Wounded, ill or injured servicemembers utilize 
prescribed pain medications at a higher rate than the general military 
population because of their medical conditions. We are aware that 
servicemembers, in particular, with PTSD may use alcohol as a way to 
try to relieve PTSD symptoms. With this heightened awareness, our 
wounded warrior battalion staff screens new admissions, reconciles 
their medication use, and refers marines in need to appropriate 
treatment programs. The WWR also supports alternatives to pain 
medication such as acupuncture, yoga, electrical stimulation and 
biofeedback to decrease the need for traditional pain medications.
    General Chandler. The Air Force does not have WTUs. Based upon 
information from PDHAs and PDHRAs, there is no current evidence of a 
significant trend in substance abuse issues for deploying personnel in 
the Air Force.

                        psychotherapeutic drugs
    31. Senator Burris. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, in light of recent concerns that some 
psychotherapeutic drugs could actually increase the risk of suicide, 
what controls are in place to ensure that patients taking multiple 
drugs are receiving proper clinical review?
    General Chiarelli. The increasing rate of soldier suicide in the 
past 5 years has received the proactive attention of senior Army 
leadership and has led to an unprecedented effort to comprehensively 
address all known domains of risk reduction, to include recent policies 
directing more in-depth oversight of medication prescribing. The intent 
is to minimize iatrogenic risks e.g., overdosing on respiratory drive 
depressants such as narcotics, particularly in combination with alcohol 
and/or other central nervous system depressants, etc.
    In June 2009 the Office of the Surgeon General/U.S. Army MEDCOM 
issued guidance to providers caring for patients who receive treatment 
with multiple medications. This policy was revised in September 2009, 
and is currently being updated further to fully address the concerns of 
polypharmacy among soldiers receiving treatment, especially when 
psychotropic agents or central nervous system depressants are involved. 
The purpose of this policy is to provide guidance on the prevention and 
management of polypharmacy with psychotropic medications and central 
nervous system depressants to reduce adverse events and optimize 
clinical outcomes among soldiers. This policy mandates that care 
providers carefully monitor soldiers with complex or multiple medical 
and/or behavioral health problems to reduce the risk of serious drug 
interactions and polypharmacy. Providers will review the medication 
profile at each visit, assess for ongoing clinical indications for 
medication treatment, screen for the potential side effects, including 
the effects of drug-drug interactions, and refer to a clinical 
pharmacist for further review and reconciliation if the number and 
nature of the patient's medications triggers a pharmacy referral.
    Risk has been greatly reduced for WTU soldiers, who are at the 
highest risk among our troops, by implementing intensive monitoring by 
primary care physicians in close collaboration with pharmacists 
assigned to the WTUs. Consequently, soldiers' medications are reviewed 
within 24 hours of arrival in the WTU, reviewed thereafter at least 
weekly, and more often if changes in dosage or medication are made in 
the course of treatment. High risk soldiers are assigned to only one 
health care provider to access controlled medications that may put them 
at greater risk. Soldiers who have demonstrated difficulties in 
complying with treatment on opioid analgesics and other controlled 
medications are enrolled in the Sole Provider Program for more intense 
monitoring and control.
    Admiral Greenert. National Patient Safety Goals of the Joint 
Commission of Hospital Accreditation regarding medication requires 
medication reconciliation at each patient encounter which includes a 
full review of all medications a patient is currently taking. The 
review is performed not only by the provider, but also the pharmacist 
dispensing the medication.
    The local Military Treatment Facility (MTF) Pharmacy and 
Therapeutics Committees also review all adverse drug reactions and 
report those of significance to the FDA via a MEDWATCH form. The FDA 
also requires a Risk Evaluation and Mitigation Strategy (REMS) on 
certain drugs (many psychotropics and opiates are included) to ensure 
the benefits outweigh the risks. As part of the REM a Medication Guide 
is required to be dispensed to the patient to help avoid serious 
adverse events and warn the patient of any risks.
    Additionally, Case Management works closely with the behavioral 
health providers to ensure that members receive the correct medications 
and understand the instructions for use. Case managers perform 
medication review/reconciliation in AHLTA (electronic records system) 
and provide education and drug interaction information for those 
patients taking multiple drugs.
    General Amos. While I defer to the military medicine professionals 
regarding appropriate management of all medical conditions, the Marine 
Corps is committed to engaged leadership. We are attentive to the 
mental health of our warriors and we are dedicated to ensuring that all 
marines and family members who bear the invisible wounds caused by 
stress receive the best help possible. We developed the Combat 
Operational Stress Control (COSC) program to prevent, identify, and 
holistically treat mental injuries caused by combat or other 
operations.
    General Chandler. Proper clinical review is assured through 
education, policy, and process.
    It is correct that psychotropic medications such as antidepressants 
and anticonvulsants may cause a small increase in suicidal risk in 
patients. Air Force providers have received education on this risk from 
multiple sources including professional organizations, their medical 
treatment center leadership, pharmaceutical companies, and the DOD 
Patient Safety Center.
    AF MTF pharmacy and therapeutics committees review medication 
safety information and medication alerts from agencies such as the Food 
and Drug Administration (FDA) and educate providers at professional 
staff meetings on new safety information on medications.
    By Air Force Surgeon General policy, the Chief of the Medical Staff 
at each MTF is charged with assuring the proper education of providers 
on medications and their effect on suitability for continued service 
and deployment. Deploying airmen are required to demonstrate more than 
90 consecutive days of stability on psychotherapeutic medications 
before deployment. In the case of suicidal risk, airmen at higher risk 
are tracked weekly by the mental health clinic, which communicates with 
the command and the patient's primary care physician.
    Overuse of pain medications can pose a larger risk. In January 2009 
the Surgeon General instructed ongoing review of patients with chronic 
pain by MTFs via pharmacy and therapeutics committees, a staff 
communication log or multidisciplinary review forum. These venues help 
assure that individuals at risk for overuse of opiate medications are 
prevented from engaging in dangerous use of the medication.
    Finally, pharmacy staff are trained to check for therapeutic 
duplications, drug-drug interactions, and that the patient is taking 
medications as prescribed (e.g., not receiving early prescription 
refills).
    In summary, adverse effects from medication or misuse of 
medications do occur, but through education, policy and procedure, the 
Air Force works to minimize these risks.

                          prevention programs
    32. Senator Burris. General Chiarelli, Admiral Greenert, General 
Amos, General Chandler, and Dr. Jesse, DOD and VA, as well as each of 
the individual Services, have numerous programs and initiatives in 
place to put emphasis on suicide prevention. However, as the statistics 
show, the success of these programs is questionable. Are there any 
independent oversight entities at DOD and VA to monitor these programs?
    General Chiarelli. At this time there are no independent oversight 
entities within DOD to monitor the programs and initiatives in place. 
However, the SPARRC meets regularly to share and discuss the numerous 
programs and initiatives in place across DOD. In addition, the SPARRC 
has representation from the VA to ensure interagency collaboration on 
suicide prevention efforts.
    The congressionally mandated DOD Suicide Prevention Task Force has 
spent the past year conducting a comprehensive analysis of the numerous 
programs and initiatives currently being used within DOD. Their 
findings will highlight areas of strength and identify areas for 
improvement for DOD's suicide prevention programs.
    Admiral Greenert. The DCoE for Psychological Health and TBI chairs 
the SPARRC, which was formed to establish standard definitions, 
standardize reporting requirements, track suicide rates, collaborate 
with other experts in the field, and advise and coordinate future DOD 
prevention initiatives. The DCOE and the SPARRC consult numerous 
entities, such as the RAND Corporation, for program evaluation and 
feedback.
    Members of the SPARRC include non-service entities such as VA, 
Substance Abuse and Mental Health Association, the USUHS, and 
recognized civil sector experts.
    The Annual DOD/VA Suicide Prevention Conference is a collaborative 
body for sharing best practices.
    The Joint Commission provides oversight to MTFs.
    Navy efforts to assess effectiveness of programs have included an 
upcoming study, in conjunction with USUHS, on the effectiveness of the 
latest suicide prevention training.
    General Amos. I defer to DOD and VA.
    General Chandler. The DOD SPARRC serves as an important forum for 
sharing Service initiatives and has established standardized data 
collection and reporting processes. This data standardization is 
essential for evaluating the ultimate effectiveness of Service suicide 
prevention programs. The forum for sharing initiatives allows the 
Services to benchmark the practices reviewed at the SPARRC. The SPARRC 
also leads the annual DOD/VA Suicide Prevention Conference, which 
provides a review of military and civilian programs from around the 
country. The Surgeons General and Assistant Secretary of Defense for 
Health Affairs monitor and discuss suicide prevention efforts through 
the Senior Military Medicine Advisory Council. There is also strategic 
planning for provision of mental health services, including suicide 
prevention, between the DOD and VA under the DOD/VA Senior Oversight 
Council. Within the Air Force, suicide prevention data is monitored 
weekly by the Chief of Staff. Additionally, the Air Force had its 
suicide prevention program evaluated by outside experts and the Air 
Force Suicide Prevention Program has been identified as a best practice 
on the U.S. Department of Health and Human Services Substance Abuse and 
Mental Health Services Administration list of evidence-based programs 
for the prevention of suicide.
    Dr. Jesse. Oversight of VA's Suicide Prevention Program is managed 
by internal administrative structures as well as the VA Suicide 
Prevention Steering Committee, a group composed of members representing 
various and relevant VA groups. The member list follows:

          Ira Katz, MD, PhD, Senior Consultant for Mental Health 
        Program Analysis, Co-Chair
          Kerry Knox, PhD, Director, Center of Excellence at 
        Canandaigua, Co-Chair
          Robert Bossarte, PhD, Acting Chief, Epidemiology and Health 
        Services Research, Center of Excellence
          Charles Clancy, MSW, Chief, Social Work Service, Louisville 
        VAMC
          Susan G. Cooley, PhD, Chief, Geriatric Research and 
        Evaluation, Chief, Dementia Initiatives, Office of Geriatrics 
        and Extended Care
          Charles Flora, Associate Director, Readjustment Counseling 
        Services (RCS)
          Theresa Gleason, PhD, Program Specialist, Office of Research 
        and Development, VACO
          Kim Hamlett-Berry, PhD, Director, Office of Public Health 
        Policy and Prevention, VACO
          Terri Huh, PhD, Associate Director for Education and 
        Evaluation, VA Palo Alto GRECC
          Mark Ilgen, PhD, VA Serious Mental Illness Treatment Research 
        and Evaluation Center (SMITREC)
          Bradley Karlin, PhD, Director, Psychotherapy Programs, Office 
        of Mental Health Services, VACO
          Janet Kemp, PhD, Mental Health Program Director, Suicide 
        Prevention and Chief Education, Training and Dissemination, 
        VISN 2 Center of Excellence
          Laurent Lehman, MD, Coordinator, Mental Health Disaster 
        Response, VACO
          Peter Mills, PhD, Director, Field Office, VA National Center 
        for Patient Safety, White River Junction VAMC
          Edward Post, MD, PhD, VA Health Service Research and 
        Development (HSR&D), SMITREC
          Todd Semla, MS, PharmD, Pharmacist Specialist, Hines VAMC
          Suzanne Thorne-Odem, RN, MS, Mental Health Clinical Nurse 
        Advisor, Office of Nursing Services
          Gary Tyndall, MD, Emergency Department Medical Director, 
        Syracuse VAMC
          Marcia Valenstein, MD, VA HSR&D, SMITREC
          Antonette Zeiss, PhD, Acting Deputy Chief, Mental Health 
        Services, VACO

    VA is beginning to see some level of success since the inception of 
our comprehensive suicide prevention programs. Although the trends are 
promising, it is still too early to determine if they are sustainable. 
There has been a decrease in suicide rates among Veterans who receive 
care in the VA from 2001 through 2007 (the last year for which national 
data are available). We will continue to monitor these rates. In 
addition, there are numerous anecdotal stories and documented 
information concerning callers to the Hotline and referrals to the 
Suicide Prevention Coordinators that indicate that the numbers would be 
much higher without these programs. We will continue to implement new 
programs as the evidence builds for specific interventions and 
strategies, but in the meantime we will maintain the programs we have 
in place with continued emphasis on the identification of those 
Veterans at risk in order to provide enhanced levels of care.

                   traumatic brain injury treatments
    33. Senator Burris. General Chiarelli, Admiral Greenert, General 
Amos, General Chandler, and Dr. Jesse, a recent study at Louisiana 
State University's School of Medicine used hyperbaric oxygen therapy on 
blast-injured veterans to repair brain injuries. The results were 
rather impressive, with treated veterans showing a 15-point IQ 
increase, a 40 percent reduction in post-concussion syndrome symptoms, 
a 30 percent reduction in post-TBI symptoms, and a 51 percent reduction 
in concussive depression. Is this a treatment option that is currently 
being examined by DOD or by VA?
    General Chiarelli. Yes, in the next few weeks the U.S. Army Medical 
Research and Materiel Command and the DCoE for Psychological Health and 
TBI will be initiating a pilot study of hyperbaric oxygen for traumatic 
brain injured patients. We are aware that the Navy and Air Force are 
also conducting or participating in research involving oxygen 
therapies. The results of all of these DOD trials will solidify the 
pivotal, larger, multicenter clinical trial scheduled to begin early 
2011.
    We believe the military studies by design will further answer 
definitive questions where other studies anecdotally report results 
without adequate controls to distinguish real treatment safety and 
effectiveness from other confounding factors such as the placebo 
effect, the Hawthorne effect and the practice effect from repeated 
testing. The Louisiana work mentioned above are initial results from a 
pilot study that has not been published in the peer-reviewed medical 
literature at this time, so details of this study are limited and the 
strength of inferences about the effect of hyperbaric treatment are 
limited because this study lacked a non-hyperbaric oxygen control 
group.
    Admiral Greenert. Navy Medicine is committed to providing all 
available therapies to servicemembers and their families as soon as 
there is sufficient evidence to ensure safety and efficacy of the 
therapy. DOD has three placebo-controlled clinical trials planned or in 
progress on the use of hyperbaric oxygen. Two of these are feasibility 
studies which will provide information on appropriate selection of 
hyperbaric oxygen doses and pressures as well as efficacy of procedures 
utilized in providing exposure to affected individuals. One of these is 
a large prospective, efficacy study to assess the effects of hyperbaric 
oxygen therapy on the symptoms of mild and moderate TBI. One of the 
feasibility studies is expected to have data available in early 2011 
and the other in late 2011. The large efficacy study will have data 
available in 2014. Navy Medicine is funding travel for active duty 
servicemembers to participate in these studies and, in partnership with 
the VA, is the lead for one feasibility study.
    The study which is referred to in this question does not appear to 
have been published in a peer-reviewed journal; the results, however, 
are encouraging and it is hoped the DOD trials will provide 
confirmation as to efficacy and safety, as this would allow our wounded 
servicemembers and their physicians to have another therapeutic option 
available.
    General Amos. DOD has three placebo-controlled clinical trials 
planned or in progress. Marines who desire to participate in these 
studies, after appropriate informed consent, will have leadership 
support in doing so. In fact, in one study currently underway 90 
percent of the subjects are marines or former marines.
    General Chandler. Congressional support for current Air Force HBOT 
for TBI research is sufficient and greatly appreciated. DOD research on 
HBOT for TBI is in its infancy and is centered on chronic mild and 
moderate TBI. It remains an unproven therapy and is not accepted as a 
standard of care because only anecdotal case reports and a small series 
of trial reports indicate some potential benefit for TBI. Several 
prospective randomized clinical trials are underway within DOD and 
civilian institutions to provide more conclusive evidence regarding 
HBOT's use for TBI. Definitive phase 3 trials, which will take 2-3 
years and include randomized, multi-center (DOD facilities only), 
double blind, definitive studies under the auspices of the FDA with an 
investigational new drug registration, are projected to start in the 
fall of 2010. If this research validates the efficacy of HBOT for TBI, 
we will request additional congressional support for the sustainment 
and possible expansion of hyperbaric chambers and personnel in addition 
to presenting the evidence to the Undersea and Hyperbaric Medical 
Society for consideration as an accepted indication for use.
    Dr. Jesse. Yes. DOD and VA are actively collaborating on the 
development and implementation of a portfolio of research projects 
focused on understanding the benefits of hyperbaric oxygen therapy 
(HBOT) on the efficacy and utilization of HBOT for treating mild 
traumatic brain injury (TBI) and post-concussive symptoms. This 
collaboration has three pilot trials and one large definitive trial. A 
joint VA, DOD, and academic task force recommended the research 
designs, implementation and outcome measures for all of the trials.
    A VA clinical researcher is participating in the clinical trial 
that has begun recruiting subjects at Quantico Marine Base, and VA 
neuropsychologists are coordinating the data collection and analysis of 
the definitive trial. The full definitive trial in Salt Lake City, UT, 
is projected to begin in late 2010.
    While HBOT demonstrates effectiveness in treating certain 
disorders, there are presently only clinical reports but no 
demonstrated double-blinded, controlled, scientific evidence that 
supports using HBOT to treat mild TBI. Presently, neither the Food and 
Drug Administration (FDA) nor the Undersea and Hyperbaric Medical 
Society--the medical specialty society and authority that provides 
guidance to Centers for Medicare and Medicaid Services (CMS) for use of 
HBOT--recognize use of HBOT as a primary or adjunctive therapy for TBI.
                                 ______
                                 
             Questions Submitted by Senator James M. Inhofe
               npr and propublica investigation interview
    34. Senator Inhofe. General Chiarelli, please provide your 
interview responses to the NPR and ProPublica for the record.
    General Chiarelli. A copy of my letter to NPR is attached. There 
are no other recorded responses. David Zwerdling of NPR spent 6 hours 
with me at Fort Carson, CO, touring the WTU, but there was no formal 
recorded interview.
      
      
    
    
      

                    health and quality of the force
    35. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, the strength of our military is in its 
people--our service men and women, their families, and our civilians 
who support them. We know the deployments over the past decade have 
astronomically increased the strain and stress on the force, presenting 
specific indicators such as an increase in suicide rates, divorces, 
substance abuse, and in some instances, murders and other serious 
criminal activity. This committee is aware of shortfalls in the manning 
of our medical units in certain medical specialty areas such as mental 
health care specialists and providers. What is being done to get after 
the mental health care provider issue?
    General Chiarelli. Since 2007, the Army has added 1,265 civilian, 
military and contract behavioral health (BH) providers to help meet the 
needs of a stressed and growing force. This represents a 69 percent 
increase in BH assets. The Army currently has approximately 89 percent 
of its current BH provider requirements. The Army Medical Department 
continuously monitors the need for BH providers based on the reliant 
population's ongoing and changing demand. While access to BH care 
providers is critical, it is just one aspect of the holistic approach 
the Army is implementing to address the mental fitness and resilience 
of our soldiers.
    Behavioral Health (BH) hiring difficulties are not due to lack of 
funding. Hiring difficulties continue to stem from the National 
shortage of qualified providers, the need for these providers in remote 
locations, and compensation limitations inherent to government 
employment. The Army is using numerous mechanisms to recruit and retain 
both civilian and military providers including bonuses, scholarships, 
and an expansion in training programs. The U.S. Army MEDCOM has 
increased funding for scholarships and bonuses to support expansion of 
our provider inventory.
    The Army expanded the use of the Active Duty Health Professions 
Loan Repayment Program and offers a $20,000 accessions bonus for 
Medical and Dental Corps Health Professions Scholarship Program (HPSP) 
applicants. MEDCOM increased the number of HPSP allocations dedicated 
to Clinical Psychology and significantly increased the annual number of 
graduate students admitted to its Clinical Psychology Internship 
Program. Prior to 2004 the Army historically trained 12 interns per 
year and has progressively increased that number, admitting 33 interns 
in 2009. In addition, the Army is attempting to hire or contract an 
additional 146 psychologists.
    MEDCOM provided centrally funded reimbursement of recruiting, 
relocation, and retention bonuses for civilian BH providers to enhance 
recruitment of potential candidates and retention of staff. The Army 
used a one-time Critical Skills Retention Bonus (CSRB) for social 
workers and BH nurses and the Army Medicine CSRB for clinical 
psychologists. The Army also implemented an officer accessions pilot 
program that allows older healthcare providers to enter the Army, serve 
2 years, and return to their communities.
    In partnership with Fayetteville State University, MEDCOM developed 
a Masters of Social Work program which graduated 19 in the first class 
in 2009. The program has a current capacity of 30 candidates.
    Admiral Greenert. The current Navy mental health workforce 
(including uniformed, government service and contract personnel) are 
trained to address combat, operational, developmental, and occupational 
mental health needs and meet the access to care standard for an initial 
assessment.
    Navy Medicine is expanding its medical end-strength that is organic 
to the Marine Corps, including mental health providers. Further, Navy 
has met the fiscal year 2010 NDAA Section 714 requirement to grow 
mental health by 25 percent, which has been programmed to begin in 
fiscal year 2011. This would be additive to the figures identified 
below. The resulting increase in our beneficiary mission is currently 
planned and funded to be handled through direct and private sector 
care.
    Despite outstanding efforts to aggressively recruit and retain 
qualified medical personnel, manning remains below authorized levels.
    As of June 2010 uniformed Mental Health manning percent (Inventory/
Billets) is as follows:

         Psychiatry - 83 percent (93/112)
         Clinical Psychology - 81 percent (105/127)
         Social Work - 69 percent (24/35)
         Mental Health Nurse Practitioners - 60 percent (12/20)

    Navy Recruiting Command is addressing these shortages through 
aggressive recruiting/accession programs. Incentives are a key 
component of recruiting. fiscal year 2010 incentives include:

         Psychiatrists - eligible for critical wartime 
        specialty bonus of $272,000
         Clinical Psychologists - eligible for $37,000 (with 3 
        year contract) or $60,000 (with 4 year contract)
         Social Workers - eligible for $18,750 (with 3 yr 
        contract) or $30,000 (with 4 year contract)
         Mental Health Nurse Practitioners - All nurses are 
        eligible for the standard bonus of $20,000 (with 3 year 
        contract) or $30,000 (with 4 year contract).
    General Amos. First off, the billets within the Marine Corps for 
psychological health care providers are a priority fill for Navy 
Medicine. To date, all of these billets have been successfully filled. 
I defer to Navy Medicine to answer their manning issues for the medical 
enterprise in its entirety.
    General Chandler. The Air Force continues to face challenges to 
recruit and retain fully qualified mental health specialists as we 
compete with the private sector and other Federal agencies where 
multiple deployments are not an issue. There are significant pay 
disparities, increasing sign-on bonuses, annual compensation packages, 
and retirement packages offering similar benefits as the military.
    To address these issues, the Air Force has an aggressive three-
pronged approach to enhance recruitment and retention of mental health 
care providers.
    The first is to offer educational scholarships and ``grow our own'' 
specialists over time. This includes training through the Uniformed 
Services University of the Health Sciences and through civilian or 
military-sponsored psychiatry and psychology residency and subspecialty 
programs. We have also optimized our enlisted commissioning programs, 
such as the Nurse Enlisted Commissioning Program as a pipeline into the 
mental health specialties of mental health nurse and psychiatric nurse 
practitioner. Additionally, the Air Force gains new health 
professionals through other training venues, such as the Airman 
Education Commissioning Program, Reserve Officer Training Corps, and 
United States Air Force Academy. The Nurse Transition Program is a 
robust recruiting tool that also feeds the mental health nurse 
pipeline. It provides an incentive for new nursing graduates to 
consider Air Force nursing as a career option upon graduation. Other 
educational opportunities include aggressive use of subspecialty 
training and post-baccalaureate-awarding degree programs for our Nurse 
Corps officers to go into specialties such as the mental health field. 
Our optimization project partners mental health specialties with 
Veteran Affairs hospitals and other non-Federal facilities. ``Growing 
our own'' encompasses accessing new recruits, developing their skills 
and specialties, and maintaining and expanding on those capabilities 
for use in both state-of-the-art medical centers and to the deployed 
and austere environments of wartime and humanitarian missions.
    The second is enhanced recruiting and retention of mental health 
professionals is through direct compensation with associated service 
obligations to encourage mental health specialists to a make the Air 
Force their career. The Air Force has funded accession and multiyear 
bonuses, and incentive pay to recruit and retain selected fully 
qualified mental health specialists. These have a positive effect on 
recruiting and retention. Each bonus has caps and the larger bonuses 
have multiyear contractual requirements. Although it does not reach 
parity, the contractual incentive packages help offset some of the pay 
disparities between the military and private sector compensation 
packages. The ability to recruit and retain fully qualified specialists 
without bonuses is extremely limited.
    Lastly, our members grapple with decisions to remain in the service 
and we understand the family is greatly involved in this decision. 
Quality of life issues concerning the availability of schools, 
frequency of moves and deployments, and general base services are at 
the forefront of any discussion. We have addressed many of these issues 
both for the new member and the 20-plus year veteran. For those mental 
health specialties with increasing wartime deployments, we are able to 
spread the deployment load more evenly among our bases and members. By 
keeping our deployments at 6 months in duration, we can maintain 
predictability, stabilize our force and retain more of our skilled 
assets. The Family Health Initiative with embedded Behavioral Health is 
a medical model that better leverages our personnel. We are partnering 
to build force sustainment models and being more proactive in managing 
the numbers of professionals in each mental health specialty.
    While recruiting and retention of the mental health professions 
remains a challenge, we remain committed to exercise all available 
authorities in concert with the other Services and under Health Affairs 
to obtain the best value in mental health care for our Nation's 
military and their family members through enhanced recruiting and 
retention efforts maximizing the tools provided for education, 
compensation, and quality of life efforts for our mental health 
professionals.

             pre- and post-deployment cognitive assessments
    36. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, the NDAA for Fiscal Year 2008 (Public Law 
110-181) required capability to conduct both pre- and post-deployment 
cognitive assessments of the same type for a comprehensive, comparable 
process. Recent reports by the Army Surgeon General state that data 
from an in-theater study of cognitive assessment technology selected by 
DOD for pre- and post-deployment assessment was no better than a 
``coin-toss''. However, a recent study of more than 10,000 pre- and 
post-deployment assessments collected at Fort Campbell, KY, indicates 
that cognitive assessment accurately reported cognitive change 
associated with TBI and even differentiated levels of cognitive change 
associated with mild TBI incidents. Why are cognitive assessments good 
enough for the pre-deployment assessments but not for the post-
deployment assessments?
    General Chiarelli. The intent of Army medicine is to use the best 
available evidence-based tools to identify, evaluate, and treat our 
soldiers. The Automated Neuropsychological Assessment Metrics (ANAM) is 
administered prior to deployment in order to obtain a baseline of 
cognitive functioning. This is necessary because there is a wide range 
of individual differences in cognitive function. The ANAM baseline can 
be compared to post-injury assessments and help guide decisions about 
further assessments and intervention. Follow-up cognitive assessment is 
conducted if a soldier experiences any event that results in potential 
decreased cognitive functioning. The results of the ANAM test may help 
healthcare staff compare a soldier's speed and accuracy of attention, 
memory, and thinking ability before and after an injury.
    Screening for mild TBI, also known as concussion, is intended to 
capture those soldiers who may have sustained a TBI while deployed and 
perhaps have symptoms that require further assessment and treatment. 
Positive screens are not diagnostic of TBI but do trigger a clinician 
interview for further evaluation. Screening for TBI now takes place 
proximate to the time of the injury event, similar to how medical 
clearance is required after aviation incidents. The Army implemented 
the ``Educate, Train, Treat, and Track'' mTBI/concussive injury 
management strategy in late 2009. This management strategy was 
reinforced by DTM 09-033 dated 21 June 2010, titled ``Policy Guidance 
for Management of Concussion/Mild Traumatic Brain Injury in the 
Deployed Setting''. This DTM directs that that any soldier who sustains 
a direct blow to the head, or is dismounted within 50 meters of a 
blast, or is in a building or vehicle damaged by a blast/accident must 
undergo a medical evaluation. This early identification of concussion 
and immediate intervention with 24 hours rest and medical clearance 
prior to return to duty should go a long way to improve the health of 
our soldiers.
    Since May 2008 all soldiers returning from deployment answer a 
series of questions on the PDHA that report exposure to injury event, 
presence of subsequent loss of consciousness or alterations in 
consciousness, presence of symptoms at time of injury, and presence of 
current symptoms. The third post-deployment screen occurs during the 
PDHRA conducted 90-180 days after return from deployment. These tools 
reveal whether an event occurred and whether any symptoms have 
resulted. Detailed cognitive assessments, which the ANAM is a 
component, can then be performed as part of a larger medical workup as 
necessary.
    Admiral Greenert. The NDAA for Fiscal Year 2008 required pre-
deployment testing but did not specify that post-deployment testing be 
done with the same instrument as for pre-deployment testing. The 
Automated Neurocognitive Assessment Metrics (ANAM) assesses only 
cognition, but in the pre-deployment window serves adequately to 
establish a baseline for comparison later on if an individual is 
exposed to blast or suffers a concussion. It sets a baseline, but does 
not serve as a screening test.
    The goal of the post-deployment screening is to identify all 
servicemembers who may be having persistent symptoms from a concussion/
TBI and thus need further evaluation. This is accomplished through the 
PDHA and PDHRA. The most common clinical symptom following concussion 
is headache. Concussion can produce a variety of symptoms (with or 
without cognitive dysfunction) such as headache, dizziness, insomnia, 
irritability, mood and anxiety disturbances, in addition to isolated 
cognitive disturbances. Navy Medicine is focused on evaluating and 
treating all aspects of post-concussion symptoms.
    Navy Medicine providers using their clinical judgment, request 
detailed neurocognitive testing in the post-deployment period as 
warranted. Neurocognitive assessments are focused exclusively on 
assessing cognition and the ANAM measures only select areas of global 
cognition. Comprehensive neuropsychological testing is indicated when 
servicemembers are being seen for comprehensive evaluation. The recent 
Ft. Campbell study uses ANAM for pre- and post-deployment screening and 
reports (although not yet in a peer-reviewed journal) significant 
improvement in minimizing false-positive test results. However, this 
study did not examine the false-negative rate (where servicemember is 
re-assured that testing is normal yet has cognitive impairment); this 
is a significant omission and would have implications on the utility of 
ANAM for routine post-deployment testing.
    General Amos. The recent Fort Campbell study uses ANAM for pre- and 
post-deployment screening and reports (although not yet in a peer-
reviewed journal) significant improvement in minimizing false-positive 
test results. However, this study did not examine the false-negative 
rate (where servicemember is re-assured that testing is normal yet has 
cognitive impairment); this is a significant omission and would have 
implications on the utility of ANAM for routine post-deployment 
testing.
    The NDAA required pre-deployment testing but did not specify that 
post-deployment testing be done with the same instrument as for pre-
deployment testing.
    The Automated Neurocognitive Assessment Metrics (ANAM) serves 
adequately to establish a baseline for comparison later on if an 
individual is exposed to blast or suffers a concussion. It sets a 
baseline, but does not function well as a population screening test.
    DOD is actively researching a variety of cognitive assessments that 
will efficiently and accurately sort out servicemembers who have or at 
high risk for persistent TBI signs or symptoms from those who do not.
    The recent publication of the DTM 09-033 that mandates tracking of 
servicemembers exposed to potentially concussive events will 
significantly improve defining the highest risk marines that require 
close follow up.
    General Chandler. The Air Force agrees with the Army Surgeon 
General that the Automated Neuropsychological Assessment Metric (ANAM) 
is poor at detecting TBI. The broad scientific consensus is that ANAM 
is not a useful tool for pre- and post-deployment assessment of 
cognitive impairment due to lack of specificity about impaired scores 
on testing. Neurocognitive assessments are very sensitive to external 
factors such as sleep disturbances (which are common in post-deployment 
servicemembers due to extended travel and time zone changes), as well 
as testing environments (rooms filled with multiple people taking tests 
simultaneously). Also, since cognitive performance patterns for 
uninjured post-deployed servicemembers are not known; the clinical 
utility of these test results from all post-deploying servicemembers 
would be minimal. Given high false positive rates, retesting everyone 
on redeployment would result in a prohibitive number of unnecessary 
referrals. Currently, using ANAM only when clinically indicated (after 
concussive event) together with neurocognitive assessments, is useful 
to assist in clarifying the extent of cognitive impairments in those 
who may subjectively complain of cognitive symptoms.

    37. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, why aren't post-deployment assessments 
being conducted by the Services?
    General Chiarelli. Post-deployment assessments are currently 
underway by all Services. The PDHA and the PDHRA solicits any history 
of TBI and any symptoms resulting from TBI. Based on a review of all 
PDHA responses from 2004 as reported in the Journal of the American 
Medical Association in 2006, the PDHA detects a 19.1 percent positive 
screening rate. These symptom questionnaires are a proven reliable and 
valid method of determining if servicemembers require or desire further 
evaluation/treatment. Both the PDHA and PDHRA are constantly being 
improved, and are now entering their third generation of development. 
In addition, the Army is fielding an Automated Behavioral Health system 
to enhance screening for PTSD and other behavioral health problems.
    Admiral Greenert. Post-deployment assessments are being conducted 
by the Navy and include screening for TBI. Post-deployment assessment 
of individuals follows Institute of Medicine recommendations to 
evaluate the spectrum of concussion symptoms (cognitive, behavioral, 
and physical) and then to complete neurocognitive testing on 
individuals who have a positive TBI screen when the clinical assessment 
requires it. The current method to complete this TBI screen is through 
the PDHA and PDHRA, which all returning deployers are required to 
complete. Navy reports overall Navy PDHRA compliance at 90 percent (87 
percent Active component and 96 percent Reserve component).
    General Amos. Post-deployment assessments are being conducted. 
Post-deployment Assessment of individuals follows Institute of Medicine 
recommendations to evaluate the spectrum of concussion symptoms 
(Cognitive, Behavioral, and Physical) and then to complete 
neurocognitive testing on individuals who have a positive TBI screen 
when the clinical assessment requires it. The current method to 
complete this TBI screen is through the PDHA and PDHRA, which all 
returning deployers are required to complete.
    General Chandler. The Services are conducting post-deployment 
assessment by asking about concussive events during deployment and TBI 
symptoms the patient is experiencing. If the patient reports a 
concussive event or cognitive symptoms they are referred to a provider 
for assessment. The broad scientific consensus is that the ANAM is not 
a useful tool for post-deployment assessment of cognitive impairment 
due to lack of specificity about impaired scores on testing. In 
addition, given a high false positive rate, retesting everyone on 
redeployment would result in a prohibitive number of unnecessary 
referrals. Current retest using ANAM only when clinically indicated 
(after concussive event) is preferred. In addition, patients with 
continued cognitive complaints are referred to a neuropsychologist for 
a series of cognitive tests able to diagnose the specific problems 
better than the ANAM. The Air Force is conducting post-deployment 
assessments via the PDHA and Post-Deployment Health Risk Assessment 
(PHDRA) and TBI questions were added to the PDHRA Questionnaire in Jan 
2008.

    38. Senator Inhofe. General Chiarelli, is there an official version 
of the in-theater study by the Army available? If so, can we be 
provided with the details of the study to include the study design, the 
data, and the study summary?
    General Chiarelli. Yes, the National Academy of Neuropsychology has 
the in-theater results available at: http://www.nanonline.org/NAN/
Conference/Handouts.aspx under Course 51, Russell et al.

    39. Senator Inhofe. General Chiarelli, the ANAM pre-deployment/
post-deployment study at Fort Campbell showed the following results 
regarding false positives:

        - 2 percent when a post-deployment assessment was compared with 
        a baseline pre-deployment assessment
        - 20 percent when a post-deployment assessment was not compared 
        with a baseline pre-deployment assessment

    Are you aware of the study at Fort Campbell and can you provide 
comment to the results, to include clarification on false positives?
    General Chiarelli. The official results of the Fort Campbell study, 
conducted by researchers from the Walter Reed Army Institute for 
Research, have not been completed nor published. I will provide you 
with a copy of the results when they are published.

                         traumatic brain injury
    40. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, General Chandler, and Dr. Jesse, I am glad that both General 
Chiarelli and Dr. Jesse made mention of the VA led collaboration with 
DOD and National Center for Health Statistics regarding the effort to 
revise methods for identifying, classifying, tracking, and reporting of 
TBI, PTSD, depression, substance abuse, and other combat related 
injuries. However, reporting from multiple open sources have stated 
that DOD does not have full accountability of how many servicemembers 
have TBI and that even with millions of dollars spent on programs since 
2005, positive results have been marginal. Additional reporting 
indicates that the information share between DOD (all Services, Active, 
Guard, and Reserve components) and the VA has not improved accordingly 
and that there is still a backlog of cases in the medical board process 
and that information transference remains a significant issue. A major 
concern is that a disconnect exists between DOD and the VA for the 
transference of servicemember data. In some instances, new veterans 
have to start over, due to the loss of their medical information. Is 
this a valid assessment and, if so, what needs to be done to correct 
this?
    General Chiarelli. Information sharing between DOD and VA has 
improved significantly since the 2004 implementation of the DHIMS BHIE. 
This system permits providers at DOD Military Treatment Facilities and 
VA health facilities to view, in real time, electronic clinical data 
from each other's systems when a shared patient presents for care. BHIE 
currently covers clinical data between DOD and VA on over 3.66 million 
correlated patients.
    Currently, there is not a disconnect between the Army and VA in the 
transfer of medical records for servicemembers participating in the 
Disability Evaluation System (DES) pilot. On average medical record 
transfer in the DES Pilot occurs within 7 calendar days, exceeding the 
standard of 10 calendar days and allowing servicemembers an opportunity 
to start the claim development phase. The DES Pilot sites meet current 
DOD standard of 290 days total processing time, from initiation to 
transition and receipt of VA benefits. For sites not participating in 
the DES Pilot, transfer of medical records is not as rapid, but 
continuous efforts are underway to migrate all Army sites to the DES 
pilot process.
    Admiral Greenert. There is a strong connection between DOD and the 
VA for the transference of servicemembers' health information. The 
Federal Health Information Exchange is a DOD/VA Information Technology 
health care initiative by which DOD health information on separated 
servicemembers is electronically transferred to a secure joint 
repository accessible by VA. This bi-directional information exchange 
was established in 2002, and provides Electronic Health Record data to 
VA clinicians who are able to view all clinically pertinent, historical 
health information. There are issues pertaining to controlling access 
to health information and is related to safeguarding the privacy of the 
information, not the data sharing capability.
    General Amos. I defer to DOD and VA.
    General Chandler. The Air Force recognizes the importance of 
closing perceived gaps in medical care provided to patients with TBI. 
The Air Force concurs with DOD and VA diagnostic criteria for mild, 
moderate, severe and penetrating TBI as defined by the DVBIC. DOD has 
identified, classified, and compiled the number of servicemembers 
diagnosed with TBI and determined the severity of the injury using 
electronic medical records data on an annual basis dating back to 2000. 
We remain committed to providing the most accurate and available 
medical information to the (VA) for all of our airmen transitioning 
from the Military Health System to the VA or private-sector based 
health care.
    Achieving a seamless, bi-directional healthcare information 
exchange (BHIE) process between the DOD and VA electronic health record 
systems remains an important Information Management/Information 
Technology (IM/IT) goal. Although limited BHIE is currently available, 
existing capabilities do not offer the ability for providers to review 
comprehensive medical information at either the DOD or VA user 
interface points. DOD and VA IM/IT officials continue to improve 
existing mechanisms and develop and evaluate potential automated 
solutions to achieve a more robust BHIE process.
    Over the last 18 months, the Air Force has implemented a new 
process that more efficiently transfers the Service Treatment Record 
(the paper medical and dental records) for each retiring or separating 
airman from his or her active duty military treatment facility (MTF) or 
Reserve component medical unit to the VA. This new process requires all 
entries from the DOD electronic health record be printed and added to 
the paper record(s) before the records are transferred to one central 
Air Force health records disposition center located at Randolph AFB, 
TX. The central records disposition center verifies all required 
medical and dental records (if available) have been obtained, 
documented as received, and mailed to either the VA regional office 
processing the airman's VA disability claim or to the VA's Records 
Management Center in St Louis, MO. VA records managers now only have to 
interact with one central Air Force medical records center instead of 
almost 130 Air Force active duty MTFs and Reserve component medical 
units. Performance metrics indicate the new process is working.
    Through the DOD-VA DES Pilot program, servicemembers receive a 
single disability exam from the VA and a single VA disability rating. 
The VA disability exam takes place prior to the beginning of a Medical 
Evaluation Board (MEB). Before the VA exam, the participating military 
treatment facility (MTF) is required to provide the VA with a copy of 
the member's complete health record. This new program offers a unique 
opportunity for the VA to medically evaluate members and determine 
their disability ratings. If the servicemember is determined to not 
meet retentions standards by the Informal Physical Evaluation Board (I-
PEB), the VA exam results are rated by the VA Disability Rating Office. 
In this way, the Board's findings and the VA ratings can be provided to 
the servicemember at the same time.
    Dr. Jesse. VA, in collaboration with DOD, continues to strive to 
improve communication and coordination across Departments in our 
Service to injured veterans and servicemembers. Since 2005, VA has 
supported over 2,200 Post-Deployment Health Reassessment (PDHRA) events 
for Reserve and National Guard units.
    VA and DOD currently share considerable health information through 
the Bi-Directional Health Information Exchange (BHIE) framework. In 
addition, there are specific data exchange capabilities between major 
DOD centers and the VA Polytrauma Centers to facilitate the exchange of 
information including scanned documents. VA and DOD are working 
together to expand the types of data exchanged to include additional 
reports from procedures and items such as Audiology Reports and Neuro-
Cognitive Assessments. This is the list of data types that can be 
shared from the most recent BHIE Fact Sheet:
    BHIE data includes:

         Clinical theater data
         Drug and food allergy data
         Inpatient discharge summaries from DOD's major 
        military treatment facilities
         Laboratory orders
         Laboratory results
         Outpatient pharmacy data
         Pre- and Post-Deployment Health Assessments and Post-
        Deployment Health Reassessments
         Ambulatory clinical encounter notes
         Radiology text reports
         Vital sign data

    Response to Comment: BHIE is fully deployed across the VA 
enterprise so that clinicians at every VA Medical Center and clinic 
have access to DOD data shared through BHIE. At VA facilities, 
clinicians view BHIE data by using Remote Data Views within the VistA 
Computerized Patient Record System (CPRS); VA clinicians may also 
choose to view BHIE data through Vista Web. Both applications are 
implemented at every VA facility. To the extent that some hospital 
staff believe they cannot view BHIE data, VA is working to improve 
clinician awareness as well as clinician training on how to use the 
system. VA has identified some of the factors that contribute to 
clinician confusion about the availability of DOD data. For example, 
the term ``BHIE'' refers to the technical framework that supports data 
sharing; however, the names of the VA applications used to access DOD 
data that are known to VA clinicians are ``Remote Data Views'' or 
``Vista Web.'' When clinicians are asked about BHIE, they may not be 
familiar with the term although they do have the tools that are used to 
view DOD data. Additionally, at times, technical issues within the BHIE 
framework may prevent the viewing of specific types of data, such as 
DOD clinical progress notes; however, this does not preclude access to 
all other DOD health data shared over the framework. There are ongoing 
efforts to resolve all technical issues with BHIE. These efforts are 
closely managed by both VA and DOD leadership and involve the 
development of software and hardware enhancements that are being 
jointly implemented and tested by VA and DOD.
    In 2009, VA launched a VA-wide BHIE awareness initiative. The 
purpose was to improve clinician awareness of the availability of DOD 
data. As part of this effort, VA sent awareness materials, such as 
brochures, videos, and pamphlets, to every VA Medical Center through 
the facility Chiefs of Staff and Public Affairs Officers. Additional 
ongoing efforts include briefings and participation at National 
Veterans Health Administration face-to face and phone conferences 
attended by VA clinicians, including clinical leadership from each 
facility. At some of these conferences, such as the recent Veterans e-
Health University (VeHU) held in August 2010, a number of classroom 
``how to access DOD information'' seminars were provided to VA clinical 
staff. Finally, to ensure that the clinicians treating our most 
severely wounded patients are trained on the availability of DOD data, 
VA technical and implementation staff make routine site visits to our 
four level one polytrauma rehabilitation centers to conduct clinician 
training and provide onsite support.

    41. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, General Chandler, and Dr. Jesse, what does the screening portion 
of this joint venture consist of?
    General Chiarelli. Screening for mild Traumatic Brian Injury (TBI), 
also known as concussion, is intended to capture those servicemembers 
who may have sustained a TBI while deployed and perhaps have symptoms 
that require further assessment and treatment. Positive screens are not 
diagnostic of TBI but do trigger a clinician interview for further 
evaluation. Screening for TBI now takes place proximate to the time of 
the injury event, similar to how medical clearance is required after 
aviation incidents. The Army implemented the ``Educate, Train, Treat, 
and Track'' mTBI/concussive injury management strategy in late 2009. 
This management strategy was reinforced by DTM 09-033 dated 21 June 
2010, titled: ``Policy Guidance for Management of Concussion/Mild 
Traumatic Brain Injury in the Deployed Setting''. This DTM directs that 
that any servicemember who sustains a direct blow to the head, or is 
dismounted within 50 meters of a blast, or is in a building or vehicle 
damaged by a blast/accident must undergo a medical evaluation. This 
early identification of concussion and immediate intervention with 24 
hours rest and medical clearance prior to return to duty should go a 
long way to improve the health of our soldiers. Additionally, TBI 
screening occurs at several intervals and locations once a soldier 
leaves theater. Soldiers aeroevacuated from theater will receive their 
first screen when they arrive at Landstuhl Regional Medical Center 
(LRMC) in Germany. Since May 2006, all servicemembers evacuated from 
theater for battle or non-battle injuries and illnesses are screened 
for TBI upon arrival to LRMC. The main purpose of this screen is to 
identify co-morbid TBI in the context of polytrauma and to ensure 
proper evacuation to an appropriate facility in the Continental United 
States. Second, since May 2008 all servicemembers returning from 
deployment answer a series of questions on the PDHA that report 
exposure to injury event, presence of subsequent loss of consciousness 
or alterations in consciousness, presence of symptoms at time of 
injury, and presence of current symptoms. The third post-deployment 
screen occurs during the PDHRA conducted 90-180 days after return from 
deployment. Finally, since April 2007 any servicemember entering the VA 
medical facility for any clinical care undergoes TBI screening 
identical to that of the PDHA with an instrument called the ``TBI 
Clinical Reminder''.
    The questions used in the PDHA, PDHRA, and VA's TBI Clinical 
Reminder are an adaptation of an instrument called the ``Brief TBI 
Screen (BTBIS)''. This instrument has had preliminary validation 
published in peer-reviewed medical literature. These reviews were 
utilized by the White-House-appointed TBI External Advisory Committee 
to the Defense Health Board and the Institute of Medicine. These panels 
both recommended the use of the BTBIS. In December 2008, the Defense 
Health Board recommended continued use with minor modifications.
    Admiral Greenert. TBI is screened for by questions in the PDHA and 
PDHRA. If a servicemember has clinical symptoms, the unit's medical 
personnel evaluate and then refer for specialty care as needed. 
Servicemembers with clinical symptoms are also encouraged to seek 
medical care independent of post-deployment screenings.
    General Amos. I defer to DOD and VA.
    General Chandler. Screening for mild Traumatic Brian Injury (TBI) 
is intended to ensure those servicemembers who may have sustained a TBI 
while deployed and have symptoms receive further assessment and 
treatment. Positive screens are not diagnostic of TBI but do trigger a 
clinician interview for further evaluation. TBI screening occurs at 
several time points and locations once an airman leaves theater. For 
airmen air evacuated from theater the first screen occurs when they 
arrive at LRMC in Germany. Since May 2006, all servicemembers evacuated 
from theater for battle or non-battle injuries and illnesses are 
screened for TBI upon arrival to LRMC. The main purpose of this screen 
is to identify co-morbid TBI in the context of polytrauma and to ensure 
proper evacuation to an appropriate facility in the Continental United 
States. Second, since May 2008 all servicemembers returning from 
deployment answer a series of questions on the PDHA that reports 
exposure to injury event, presence of subsequent loss of consciousness 
or alterations in consciousness, presence of symptoms at time of 
injury, and presence of current symptoms. The third post-deployment 
screen occurs during the PDHRA conducted 90-180 days after return from 
deployment. Finally, since April 2007 any servicemember entering the VA 
medical facility for any clinical care undergoes TBI screening 
identical to that of the PDHA with an instrument called the ``TBI 
Clinical Reminder.''
    The questions used in the PDHA, PDHRA, and VA's TBI Clinical 
Reminder are an adaptation of an instrument called the BTBIS. This 
instrument has had preliminary validation published in peer-reviewed 
medical literature. These reviews were utilized by the White House-
appointed TBI External Advisory Committee to the Defense Health Board 
and the Institute of Medicine. These panels both recommended the use of 
the BTBIS. In December 2008, the Defense Health Board recommended 
continued use with minor modifications.
    In addition to TBI screening, the VA and DOD have expanded the bi-
directional healthcare information exchange capability to make the 
following information viewable by the VA from the PHA: patient answered 
questions for general health, tobacco use, alcohol use, injury 
prevention, chronic diseases or conditions, dental health, reproductive 
health issues and mental health concerns.
    Dr. Jesse. VA requires that all new patients presenting to VA for 
the first time be screened for the presence of PTSD, depression, and 
alcohol misuse. If the Veteran screens positive for any of these 
problems, they are further evaluated by a primary care provider or by 
referral to a mental health clinic for confirmation of the diagnosis. 
This may be followed by initiation of mental health services, if 
needed, in the primary care setting or through referral to mental 
health specialty care. Veterans who screen positive for PTSD or 
depression are also assessed for suicide risk. Veterans who screen 
positive for alcohol misuse are provided with alcohol counseling, as 
well. Veterans are screened for PTSD every year for the first 5 years 
the Veteran is in VA care and every 5 years thereafter, unless there is 
a clinical need to screen earlier. Veterans are screened for depression 
and alcohol misuse annually.
    New patients with mental health concerns (those who have not been 
seen in a mental health clinic in the last 24 months) or have a 
positive screening for PTSD, depression or alcohol misuse, are 
contacted within 24 hours of the referral by a clinician competent to 
evaluate the urgency of the Veteran's mental health needs. If it is 
determined that the Veteran has an urgent care need, appropriate 
arrangements (e.g., an immediate admission) are required. If the need 
is not urgent, the patient must be seen for a full mental health 
diagnostic evaluation and development and initiation of an appropriate 
treatment plan within 14 days.
    VA also developed and implemented the TBI Screening and Evaluation 
Program for all Veterans who have served in Iraq or Afghanistan, upon 
their initial entry into VA for health care. Veterans who screen 
positively for possible mild TBI are referred for a comprehensive 
evaluation by an interdisciplinary rehabilitation team, and receive 
follow-up care and services appropriate for their diagnosis and their 
symptoms.
    For patients identified through these screens, VA has established 
access standards that require prompt evaluation of new patients. For 
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans 
who have a positive TBI Screening, the VA standard is that: (1) timely 
contact is made to schedule an appointment for comprehensive evaluation 
(contact within 5 days of a positive screening); and (2) that a 
comprehensive evaluation is completed in a timely manner (within 30 
days of having a positive screening).

    42. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, General Chandler, and Dr. Jesse, is data available to healthcare 
providers in the VA, TRICARE, and private practice for those providing 
care for members of all components of the armed services?
    General Chiarelli. Yes. The results of the TBI screening performed 
at LRMC and in the Veteran's Affairs health facilities using the VA's 
TBI Clinical Reminder are part of the soldier/veteran's medical record 
and is available to VA, TRICARE, and private practice healthcare 
providers. The PDHA and PDHRA for soldiers of all components can be 
accessed either in the paper medical record or in AHLTA if scanned or 
soldiers can print out copies of their completed Deployment Health 
Assessments via AKO and release this information to their providers. 
More importantly, servicemembers of all components who screen positive 
on the PDHA and PDHRA are sent for a clinical confirmation evaluation 
and that care is documented as part of their medical record.
    Admiral Greenert. Yes. There are a number of instances in which 
medical information is provided to the VA by the Services. Specifically 
regarding TBI patients undergoing care through the VA, the following 
directly applies:
    ``VA and DOD Memorandum of Agreement (MOA) Regarding Referral of 
Active Duty Military Personnel Who Sustain Spinal Cord Injury, TBI, or 
Blindness to Veterans Affairs Medical Facilities for Health Care and 
Rehabilitation Services''
    This MOA was effective 1 Jan 2007. It specifies that ``The 
referring MTF will provide a copy of all pertinent patient medical 
record documentation requested by the VA health care facility needed to 
make a medical decision.'' Therefore, if a patient is transferred to 
the VA for treatment, their medical information should be provided to 
facilitate their care and reduce duplication of effort and delays in 
care.
    In addition to providing medical records, the care teams ensure 
that the servicemembers have a smooth transition of care in a number of 
other ways including:

         Navy Military Treatment Facilities and VA Poly Trauma 
        Facilities hold multidisciplinary clinical case management 
        video teleconferences to discuss patient transition and care 
        needs and to provide follow up information on previously 
        transferred patients.
         Transition support within the Navy consists of medical 
        care case managers and non-medical care managers working 
        collaboratively and with RCCs and VA Federal Recovery 
        Coordinators and Case Managers. This close cooperation ensures 
        a smooth and seamless handoff of each patient's recovery needs 
        as a member transitions between DOD care locations, or from DOD 
        to the VA and/or into the civilian sector.
         Navy Medicine and Safe Harbor are involved in a DOD-VA 
        Information Sharing Initiative that is linked to a larger 
        effort called Virtual Lifetime Electronic Record. This effort 
        shares medical and non-medical (benefits, service records, pay, 
        etc.) data in electronic means, allowing for ``one-stop 
        shopping'' of information on an individual.

    General Amos. Yes. There are a number of instances in which medical 
information is provided to the VA by the Services. Specifically 
regarding TBI patients undergoing care through the VA, the following 
directly applies:
    ``VA and DOD Memorandum of Agreement (MOA) Regarding Referral of 
Active Duty Military Personnel Who Sustain Spinal Cord Injury, TBI, or 
Blindness to Veterans Affairs Medical Facilities for Health Care and 
Rehabilitation Services''
    This MOA was effective 1 Jan 2007. It specifies that ``The 
referring MTF will provide a copy of all pertinent patient medical 
record documentation requested by the VA health care facility needed to 
make a medical decision.'' Therefore, if a patient is transferred to 
the VA for treatment, their medical information should be provided to 
facilitate their care and reduce duplication of effort and delays in 
care.
    In addition to providing medical records, the care teams ensure 
that the servicemembers have a smooth transition of care in a number of 
other ways including:

    1.  Navy Military Treatment Facilities and VA Poly Trauma 
Facilities hold multidisciplinary clinical case video teleconferences 
to discuss patient transition and care needs and to provide follow up 
information on previously transferred patients.
    2.  Transition support within the Navy consists of medical care 
case managers and non-medical care managers working collaboratively and 
with RCC and VA Federal Recovery Coordinators and Case Managers. This 
close cooperation ensures a smooth and seamless handoff of each 
patient's recovery needs as a member transitions between DOD care 
locations, or from DOD to the VA and/or into the civilian sector.

    General Chandler. For patients being treated by both DOD and VA, 
the Departments continue to maintain the jointly developed Bi-
directional Health Information Exchange (BHIE) system. Using BHIE, DOD 
and VA clinicians are able to access each other's health data in real-
time, including the following types of information: allergy, outpatient 
pharmacy, inpatient and outpatient laboratory and radiology reports, 
demographic data, diagnoses, vital signs, problem lists, family 
history, social history, other history, questionnaires, and theater 
clinical data, including inpatient notes, outpatient encounters, and 
ancillary clinical data, such as pharmacy data, allergies, laboratory 
results, and radiology reports. To increase the availability of 
clinical information on a shared patient population, VA and DOD 
collaborated to further leverage BHIE functionality to allow bi-
directional access to inpatient discharge summaries from DOD's 
inpatient documentation system. Access to DOD discharge summaries is 
operational at some of DOD's largest inpatient facilities representing 
approximately 71 percent of total DOD inpatient beds. In addition to 
sharing viewable text data, VA and DOD have expanded the BHIE 
capability to make the following information viewable by the VA from 
the PHA: patient answered questions for general health, tobacco use, 
alcohol use, injury prevention, chronic diseases or conditions, dental 
health, reproductive health issues and mental health concerns.
    The Federal Health Information Exchange provides the VA with a one-
way transfer of medical data from the DOD on servicemembers who have 
separated the military. Information supplied to the VA includes: 
outpatient pharmacy data, lab and radiology results, inpatient 
laboratory and radiology results, allergy data, consult reports, 
admission, disposition and transfer data, standard ambulatory data 
record elements including diagnosis and treating physician, pre/post-
deployment health assessments (PPDHA), and PDHRA. As of June 2010, over 
2.8 million PPDHA and PDHRA forms on more than 1.2 million individuals 
have been sent from DOD to VA.
    Data exchange between the DOD and non-VA providers is limited to 
transferring copies of paper records to the civilian provider. The 
National Health Information Network (NHIN) is in its infancy and at 
present is being developed and tested via pilot programs. As the NHIN 
is built out, it will allow information to be exchanged between private 
practices, the VA and the DOD using standards-based data elements. The 
information that can be exchanged at this stage is very limited and 
available in only a few geographical locations.
    Dr. Jesse. VA data sharing with private practices or health care 
systems is still in a very early stage with active National Health 
Information Network Pilots in place in San Diego, CA, and Hampton 
Roads, VA.

    43. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, General Chandler, and Dr. Jesse, are all personnel who are 
diagnosed with TBI having that information entered into their medical 
records or only those who have received Purple Hearts?
    General Chiarelli. All personnel diagnosed with TBI have their 
medical care documented in the medical record.
    Admiral Greenert. Any servicemember undergoing care for any type of 
medical condition should have their information entered into the 
medical record. Their receipt of a medal has no impact on the medical 
care provided, nor the requirement to properly document care in the 
medical record.
    General Amos. Any servicemember undergoing care of any type should 
have their information entered into the medical record. Their receipt 
of a medal has no impact on the medical care provided or the 
requirement to properly document care in the medical record.
    General Chandler. Yes, all airmen with a diagnosis related to TBI 
have those diagnoses entered in their medical charts. This is done at 
the time of diagnosis and is part of the process of the medical 
appointment. It occurs regardless of whether the airman receives a 
Purple Heart.
    Dr. Jesse. All Veterans who are diagnosed with TBI have information 
entered into their medical record regarding their evaluation, 
diagnosis, and treatment. In addition, VA developed and implemented a 
national template to ensure that it provides every Veteran receiving 
inpatient or outpatient treatment for TBI, who requires ongoing 
rehabilitation care, an individualized rehabilitation and community 
reintegration plan. VA integrates this national template into the 
electronic medical record, and includes results of the comprehensive 
assessment, measureable goals, and recommendations for specific 
rehabilitative treatments.

          alternative treatments for traumatic brain injuries
    44. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, General Chandler, and Dr. Jesse, alternative treatments for TBI 
have been a significant focus of many members in Congress, specifically 
the use of HBOT. In conjunction with oxygen carrier drugs, such as 
Oxycyte, the positive impacts of the HBOT treatment may be magnified. 
In the fiscal year 2011 markup, the House passed language that will 
continue support for HBOT research and development. What are your 
thoughts on alternative treatments for TBI and specifically HBOT, and 
the associated TBI drugs and what needs to be done to expedite the 
research and development process?
    General Chiarelli. It is very important that we evaluate safety and 
effectiveness of all therapeutic and alternative medicine options 
through controlled trials for TBI prevention, treatment, and 
rehabilitation. Currently DOD is examining hyperbaric oxygen for those 
with persistent brain-related sequelae. The U.S. Army Medical Research 
and Materiel Command and the DCoE for Psychological Health and TBI and 
will be initiating a pilot study of hyperbaric oxygen for traumatic 
brain injured patients in the next few weeks with a goal completion by 
December. We are aware that the Navy and Air Force are also conducting 
or participating in research involving oxygen therapies.
    The results of all of these DOD trials will solidify the pivotal, 
larger, multicenter clinical trial scheduled to begin early 2011.
    The military has funded Oxygen Biotherapeutics research using the 
fiscal year 2007 PH/TBI war supplemental funding to conduct clinical 
trials using Oxycyte with the ultimate goal of improving brain oxygen 
delivery, and patient outcome, after severe TBI. After seeing good 
results in nine patients, the FDA put the Phase II trial on clinical 
hold because of transient platelet suppression, which did not have any 
documented clinical adverse effect, until the mechanism of that 
transient suppression is determined. The U.S. Army Medical Research and 
Materiel Command has just funded a number of projects that are designed 
to answer that mechanism question with the intent to restart the 
clinical trial in the near future.
    To expedite the research and development process it is necessary to 
conduct programs, not projects. It is most efficient to develop a 
programmatic approach rather than conduct a multitude of disconnected 
studies. A programmatic approach will utilize goals, milestones, 
timelines and future funding projected over several years to maximize 
the potential of selecting and advancing products or new technologies 
through FDA approval into the hands of health care providers. To 
minimize the loss of data, research time and risk to the human research 
subjects, it is imperative that studies be conducted as well controlled 
clinical trials. Data repositories and data sharing allow a far greater 
number of researchers to analyze existing pieces of information 
therefore increasing the size of the research base. It is also very 
important to engage the FDA in clinical trials research early and often 
to focus the research efforts on questions and issues that will need to 
be addressed for FDA review and approval.
    Admiral Greenert. Navy Medicine continually seeks to identify and 
implement the best methods to evaluate and treat servicemembers who 
sustain a TBI. Prior to implementing therapies for our servicemembers 
Navy Medicine, in adhering to nationally and internationally recognized 
standards of good clinical practice, require that any treatment 
provided to our servicemembers has demonstrated safety and 
effectiveness. In those cases where the treatment fulfills these 
critical criteria, Navy Medicine will expedite use. Conversely, if a 
treatment does not have scientific merit or is found to be more 
detrimental than beneficial, Navy Medicine will not make it available 
until further research demonstrates a benefit.
    DOD has three placebo-controlled clinical trials planned or in 
progress on the use of hyperbaric oxygen. Two of these are feasibility 
studies which will provide information on appropriate selection of 
hyperbaric oxygen doses and pressures as well as efficacy of procedures 
utilized in providing exposure to affected individuals. One of these is 
a large prospective, efficacy study to assess the effects of hyperbaric 
oxygen therapy on the symptoms of mild and moderate TBI. One of the 
feasibility studies is expected to have data available in early 2011 
and the other in late 2011. The large efficacy study will have data 
available in 2014. Navy Medicine is funding travel for active duty 
servicemembers to participate in these studies and, in partnership with 
the VA, is the lead for one feasibility study.
    The drug, Oxycyte, is currently undergoing evaluation in a clinical 
trial to treat severe TBI. The initial results are promising but this 
larger study will allow us to better gauge its efficacy and 
appropriateness for our population. Of note, examining the categories 
of Navy TBI numbers from 2000-2009 (provided by the Defense Veteran and 
Brain Injury Center), an estimated 76 percent are mild, 20 percent are 
moderate, 2 percent are penetrating, and only 1 percent are severe. 
Navy Medicine actively supports and engages in clinical investigation 
to determine better methods of detecting and treating TBI.
    General Amos. DOD has three placebo-controlled clinical trials 
planned or in progress. Marines who desire to participate in these 
studies, after appropriate informed consent, will have leadership 
support in doing so. In fact, in one study currently underway 90 
percent of the subjects are marines or former marines.
    Moving forward I expect to continue to collaborate with and 
challenge the medical community for ever better tools for the diagnosis 
and treatment of all the wounds of war, both visible and invisible.
    General Chandler. I do not believe there are any current studies 
looking at the use of oxygen carrier drugs.
    There are ongoing studies to validate the efficacy of HBOT in TBI 
patients and we are eagerly awaiting the results. The use of associated 
TBI drugs will be undertaken as further information about them evolves. 
The continued support from Congress for research and development is 
appreciated.
    Dr. Jesse. DOD and VA are actively investigating the efficacy and 
utilization of hyperbaric oxygen therapy (HBOT) for treating mild 
traumatic brain injury (TBI) and post-concussive symptoms. While HBOT 
demonstrates effectiveness in treating certain disorders, there are 
presently only clinical reports but no demonstrated double-blinded, 
controlled, scientific evidence that supports using HBOT to treat mild 
TBI. Presently, neither the Food and Drug Administration nor the 
Undersea and Hyperbaric Medical Society--the medical specialty society 
and authority that provides guidance to Centers for Medicare and 
Medicaid Services (CMS) for use of HBOT--recognize use of HBOT as a 
primary or adjunctive therapy for TBI.
    There is presently no rigorous research evidence to support usage 
of alternative therapies on a clinical level for TBI of any severity; 
e.g., HBOT, vibratory treatments, acupuncture, herbals and supplements, 
yoga and other movement therapy, music therapy, oxygen carrying drugs, 
or any experimental drugs. VA stringently supports the need for 
additional research to design and execute randomized controlled trials 
of all of these agents to better understand their potential for TBI 
care. Currently, the potential risks of all these treatments must be 
considered higher than their potential for benefit and therefore they 
should not be recommended.
    In order to expedite research and development related to TBI, VA 
strongly advocates collaborative research and joint research 
initiatives across all federal agencies. VA is currently engaged in 
collaborative TBI-related research efforts with DOD, academia, the 
National Center for Disability and Rehabilitation Research, and other 
agencies.

                              medications
    45. Senator Inhofe. General Chiarelli, the Army is the only Service 
I have heard directly address the topic of prevention and management of 
polypharmacy with psychotropic medications and central nervous system 
depressants. This could have a significant impact on our suicide 
numbers and the extended suffering by our servicemembers. Can you 
elaborate on your statement of how this new policy will assist in 
reducing adverse clinical outcomes?
    General Chiarelli. The ASPTF has identified polypharmacy as one of 
the risk factors involved in some suicides and accidental fatalities 
among soldiers in treatment. To address these concerns, the U.S. Army 
MEDCOM and the Office of the Surgeon General has published policies for 
the WTUs in particular and for the Army Medical System in general to 
reduce the risks of polypharmacy.
    In April 2009 the MEDCOM published a policy for the Warriors in 
Transition High Risk Medication Review and Sole Provider Program. This 
program is in part a medication reconciliation program for our Wounded 
Warriors assigned to the WTUs. Components of this program include the 
assignment of clinical pharmacists to the WTUs to monitor and support 
safe and effective medication of soldiers in treatment; they review 
medication profiles of their cases at least weekly. The Primary Care 
providers in the WTUs perform medication reconciliation for each 
soldier in treatment within 24 hours of arrival at the WTU and each 
time the soldier's medication regimen is changed to identify and 
prevent potential adverse medication interactions, side effects, or 
potentially lethal medication combinations. Additionally, case managers 
in the WTUs perform clinical risk assessments on each soldier assigned 
to the unit to identify soldiers who may be at risk of intentionally or 
accidentally harming themselves. Soldiers at risk are closely monitored 
as well as immediately referred to the appropriate behavioral health 
resources. Soldiers identified to be at risk of abusing their 
medications are closely monitored and dispensed small amounts of 
medication (1-week supply) with frequent clinical visits, and can be 
restricted to one prescriber and one pharmacy for their medications. 
Soldiers identified to be at risk of abusing drugs or alcohol while on 
their medications are educated regarding the risks and referred to the 
Army Substance Abuse Program, and routinely undergo screening with 
random urine drug testing.
    In September 2009 the MEDCOM published Guidance for Enhancing Risk 
Reduction and Patient Safety via Appropriate Behavioral Health Referral 
and the Conservative Use of Central Nervous System Depressants. This 
policy guides the conservative use of medications to reduce the 
occurrence of harmful polypharmacy for our troops in general. 
Healthcare providers are strongly encouraged to refer soldiers to 
specialty care (e.g. behavioral health resources) for non-medication 
therapies to augment medication therapy and obtain the best clinical 
outcomes. Additionally, medication reconciliation is a requirement of 
the joint commission to reduce the risks of polypharmacy. Medication 
profiles are reviewed and reconciled upon initial contact and 
periodically thereafter by each prescribing healthcare provider, 
especially as they transition from one care setting to another 
(admission or discharge from hospital). Finally, the MEDCOM has 
deployed electronic measures system-wide that automatically screen 
medications each time healthcare providers order them for our soldiers. 
This screen identifies and flags duplicate orders for the same 
medication, duplicate orders for the same class of medication, and 
potential interactions among medications prescribed to the soldier that 
may put them at risk.

         total force health care and transition to veteran care
    46. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, how are each of the Services dealing with 
Reserve components--providing care once they are off Active Duty, 
following up on mental health care, and ensuring their families are 
cared for?
    General Chiarelli. The Army routinely coordinates healthcare 
delivery for Reserve component soldiers coming off active duty with the 
VA. At the local installations, VA representatives attend many PDHRA 
sessions and provide follow-up appointments as necessary within their 
system. The VA provides direct care for Reserve component and other 
remote/geographically dispersed soldiers. Soldiers, both Active and 
Reserve component, have routinely utilized VA PTSD treatment programs, 
such as the one at the Palo Alto VA Medical Center. Additionally, the 
Army utilizes VA liaisons to coordinate healthcare. Through the Army 
and VA partnership, VA Liaison Case Managers are embedded in 14 
prioritized Army MTFs under an initiative called VA Liaison and Care 
Management Program. This ensures soldiers receive seamless continuity 
of care as they migrate from active duty to veteran status in the VA 
Healthcare System.
    TRICARE also has programs that assist Guard and Reserve soldiers 
and families. A National Guard or Reserve member separating from a 
period of active duty that was more than 30 consecutive days in support 
of a contingency operation is eligible for TAMP. The TAMP provides 180 
days of transitional health care benefits to help certain uniformed 
services members and their families transition to civilian life. 
TRICARE Reserve Select is a premium-based health plan that qualified 
National Guard and Reserve members may purchase to receive care in 
their local area. TRICARE Reserve Select requires a monthly premium and 
offers coverage similar to TRICARE Extra and Standard.
    Additionally, Guard and Reserve members who are experiencing common 
psychological health concerns like combat stress and family separation, 
may use a new initiative called TRIAP which provides video chat and 
instant messaging to give quick and easy access to counseling services. 
This program is also available to all spouses and other family members 
that are 18 years or older.
    Admiral Greenert. reservists and their families have access to 
TRICARE health care benefits for 180 days following their separation 
from Active Duty.
    Commander, Navy Reserve Forces Command has assumed responsibility 
for overseeing implementation of the PDHRA program for the Navy 
Reserve. With strong leadership support they are actively engaged in 
program execution and because of this increased focus, servicemember 
compliance rates have improved. Providing mental health support to 
Reserve sailors is an integral component of Navy mental health care. To 
meet this need, the Navy implemented the NRPHO program in fiscal year 
2008. The NRPHO program has a team of 25 Social Workers who provide 
initial mental health clinical assessment of Reserve component 
servicemembers and provide appropriate health care referral if needed. 
They are also making visits to two to three NOSCs per month in each of 
the five Navy Reserve Regions where they provide psychological health 
education including the OSC awareness brief to NOSC staff and Reserve 
unit members.
    As of June 2010, the NRPHO Teams have clinically assessed and 
referred almost 2,400 reservists to appropriate sources of mental 
health care; have made outreach calls to an additional 1,860 
reservists; and have made 281 visits to the NOSCs, providing the OSC 
awareness brief to over 29,400 RC members and NOSC staff. In addition, 
Navy Medicine has hired a full-time DPH for Navy Reserve to oversee and 
expand Reserve Navy Reserve psychological health programs.
    The RWW has become the keynote Reintegration event, as this program 
has become available to RC and AC sailors, marines, and their spouses 
throughout the country. The Navy Reserve has led the way in crafting a 
standardized RWW that represents the ideals of DOD's YRRP, serving the 
RC and AC, and fulfilling the full spirit and intent of the Total Force 
initiatives. In 2009, more than 1,800 servicemembers and 1,400 family 
members attended one of 27 RWWs throughout the country. An additional 
13 have been held in 2010, attended by 832 servicemembers and 699 
family members and 2 more are scheduled through the end of the current 
contract (30 July 2010). 38 more RWWs are planned for the next contract 
through July 2012.
    General Amos. Reservists and their families have access to TRICARE 
health care benefits for 180 days following their separation from 
Active Duty.
    While I defer to my military medicine colleagues on the actual 
delivery of care, our WWR and battalions stay connected to marines in 
need of services even after they leave active duty. I believe that our 
Wounded Warrior construct is a superb model and we will continue to 
leverage its successes moving forward.
    General Chandler. The Air Force, regardless of component, regularly 
screens servicemembers for psychological conditions using the PHA, 
PDHA, and PDHRA. These tools ask questions to help screen for mental 
health conditions related to deployment. The Air National Guard (ANG) 
tracks combat injuries to include mental health conditions through the 
daily casualty reports. ANG members with mental health conditions are 
tracked through the ANG Medical Group (MDG) in coordination with the 
ANG DPH and the servicemember's home State/territory for follow-up 
care. The DPH is available to ANG members and families throughout their 
care and the remainder of their service.
    ANG members may retain health benefits following deployment for 
deployment related conditions to include mental health. The Air Force 
offers Deployment Transition Centers (DTC) for airmen (including Guard 
and Reserve components) returning from combat theaters. The 2-day DTC 
readjustment agenda assists airmen with their return and provides 
mental health resource information. The ANG offers the federally-
mandated YRRP to provide psychosocial and mental health education and 
referral resources for Guard members throughout the deployment cycle.

    47. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, do all the Services follow the same process 
for transitioning your servicemembers from DOD control to VA control as 
part of the medical board process?
    General Chiarelli. Yes, the transition process is the DES consists 
of a MEB phase and a PEB phase. In the traditional or Legacy system 
there were minor differences in how MEB and PEB cases were processed. 
In the DOD/VA DES pilot process the phases are similar across all 
Services.
    Admiral Greenert. Yes, the transition process is the DES and it 
consists of a MEB phase and a PEB phase. In the traditional or Legacy 
DES system there were minor differences in how MEBs and PEBs were 
processed. In the DOD/VA DES pilot the phases are similar across all 
Services.
    General Amos. Yes, the transition process is the DES and it 
consists of a MEB phase and a PEB phase. In the traditional or legacy 
DES there were minor differences in how MEBs and PEBs were processed. 
In the DOD/VA DES pilot process the phases are similar across all 
Services.
    General Chandler. An Air Force member who separates or retires, 
regardless of whether it is through the DES or not, is provided 
counseling on VA benefits and application procedures as part of 
transition assistance counseling. In a medical board process, the 
Integrated DES Program (formerly referred to as the DES Pilot) being 
implemented across DOD prescribes that servicemembers are evaluated for 
VA disability rating as part of their DES evaluation, saving 
servicemembers time in applying for VA benefits upon separation or 
retirement. The process includes a single physical examination 
conducted by the VA in the MED phase. The VA then provides a draft 
rating decision for all conditions claimed by the servicemember. The 
Service conducts a PEB to determine which medical conditions, if any, 
make the servicemember unfit for continued military service. The 
Service PEB uses the VA-determined disability ratings for fitting 
conditions to determine the servicemember's disposition (medical 
separation or retirement). This process is prescribed by DOD.

    48. Senator Inhofe. General Chiarelli, Admiral Greenert, General 
Amos, and General Chandler, what are your observations on the process 
by which servicemembers are assessed, diagnosed, treated, and 
transitioned either back to Active Duty or onward to the VA?
    General Chiarelli. When a soldier is assigned to a WTU, he or she 
develops a CTP in consultation with his or her family, unit leaders, 
and health professionals. The CTP is designed to be a roadmap for 
recovery and transition, with personal and professional milestones, 
such as passing a physical fitness test, taking college courses, or 
participating in internships and job training. The goal is to keep each 
soldier goal-oriented and constantly striving to recover. This helps 
focus his or her attention and energies on healing and the future, 
which produces a positive mental outlook.
    The Warrior Care and Transition Plan includes developing a 
comprehensive and responsive network of available facilities to treat 
Warriors in Transition that include military treatment facilities, VA 
facilities, civilian facilities, and the TRICARE network of providers. 
The Triad of Care (Squad Leader, Nurse Case Manager, and PCM) manages 
each soldier's progress closely and coordinates care through this 
network of resources to ensure comprehensive coverage of care and 
support requirements.
    In WTUs, pharmacists and medical providers collaborate to ensure 
appropriate medication use for each Warrior in Transition. Members of 
the health care team are trained to first consider utilizing treatment 
methodologies other than medicating soldiers as the best approach to 
ensuring appropriate care and treatment.
    VBA counselors work on-site with Warriors in Transition to ensure 
coordination of all necessary services prior to a soldier leaving the 
Army. The Army established liaison teams at VA polytrauma centers to 
ensure appropriate care and support when soldiers enter VA health care 
programs. The Army and the VHA continually develop ways to ensure that 
the CTP follows each soldier into VA care and that the soldier's 
continuity of care is ongoing and consistent.
    Admiral Greenert. Challenges remain with stigma and other barriers 
to care, such as the desire of a sailor to not go to medical after an 
exposure to a blast because they are motivated to ``stay in the 
fight.'' We must continue to work to reduce or eliminate these 
barriers. We need to encourage leaders to get their people to the 
medical experts who can assist them in getting the care they need.
    Once our sailors get into the medical system they receive expert 
medical care throughout the continuum of care from assessment and 
diagnosis to recovery and return to duty or reintegration.
    Case managers work with the care team to ensure that our wounded 
warriors receive the care they need and transition between DOD, VA, and 
civilian facilities smoothly. The DES Pilot, that is now being expanded 
across DOD, has been beneficial in ensuring that those members who must 
transition out of the military do so with their Military and VA 
benefits established prior to discharge. The medical care, coordination 
of care, and transition assistance, has improved and continues to 
improve to meet the needs of our wounded warriors.
    To assist seriously wounded, ill, and injured sailors, 
coastguardsmen, and their families in their transition and 
reintegration back into their communities, Safe Harbor provides support 
through its Anchor Program. The Safe Harbor Anchor Program partners 
with 128 NOSCs across the country as well as Navy Retired Activities 
Offices, American Legion, Navy League, Fleet Reserve Association, and 
other community-based organizations to provide mentor volunteers to 
assist recovering servicemembers (RSM) and their families reintegrate 
back into the community. The mentors, whether a near-peer Navy 
reservists or a senior mentor from our partner organizations provide 
local professional, social and spiritual assistance to RSMs and their 
families solidifying the ``lifetime of support'' provided by Safe 
Harbor.
    General Amos. While I am not a medical expert, I believe there is 
more to be done to meet the needs of all Wounded Warriors. However, my 
lack of satisfaction with the status quo should not be construed to 
mean that I feel that the Marine Corps has failed to make significant 
strides in this area.
    As a Marine leader, I believe the centerpiece of any successful 
Marine Corps effort in this arena, and especially in the areas of TBI 
and PTSD, is Engaged Leadership. No individual is better positioned to 
notice a change in a marine's behavior or apparent well-being than 
another marine.
    Building on this understanding, we have already developed training 
and awareness programs for leaders at all levels of the Corps on these 
subjects with the goal of intervening at the earliest possible 
opportunity before a small problem balloons into an overwhelming 
problem.
    After successful treatment of their condition, successful re-
integration of a marine into the business of being a marine is critical 
for our force and for the individual. I am committed to seeing all of 
our leaders embrace this re-integration process. For those marines with 
medical conditions that prevent them from continuing on active duty, 
the process of transitioning to the VA must be as seamless as possible.
    For over 200 years we have prided ourselves on the fact that 
marines take care of marines. I am committed to seeing that tradition 
hold true far into the future.
    General Chandler. The Air Force DES evaluates all cases where a 
member is found to have a duty limiting condition that is disqualifying 
for worldwide duty in accordance with Air Force Instruction (AFI) 48-
123, Medical Examinations and Standards, and completes a fitness for 
duty determination. The complexity of the system depends greatly on the 
participant and the medical conditions they have. The goal in all cases 
is to complete a thorough medical evaluation and provide an appropriate 
disposition.
    The simplest cases are processed through the Assignment Limitation 
Code Fast Track Program (ALC Fast Track). Such cases are Air Force 
members who present with conditions which, while limiting for worldwide 
duty, are stable, have a low risk of sudden incapacitation and 
minimally impact the ability to perform primary military duties. 
Approximately 60 percent of all cases fit these criteria. In these 
cases, the PCM reviews the condition, conducts the appropriate 
evaluations and, where appropriate, begins treatment. She/he then 
initiates a MEB which is referred to the profile officer for review. If 
the diagnosis is felt to be suitable for ALC Fast Track, the PCM is 
notified and completes a robust medical note outlining all current 
information regarding the condition, the severity and the associated 
sequellae. This is forwarded to Air Force Personnel Center (AFPC) 
medical standards branch where disposition is made. They may return the 
member to full duty, provide an assignment limitation code, or 
determine that the case is not compatible with the ALC Fast Track 
limitations and refer it for full MEB/PEB processing. These 
determinations can be completed usually within 7 days and greatly 
expedites the process.
    Cases referred for full MEB/PEB processing are those which do not 
meet the criteria for inclusion in the ALC Fast Track Program. These 
cases undergo full MEB/PEB processing, and go through a similar 
evaluation by the PCM to determine the exact diagnosis, potential 
treatment and impact on the ability to perform future military duties. 
These cases are sent to the AFPC medical standards branch and go 
through the steps of the MEB, the I-PEB and the formal PEB as required. 
Similar to the ALC-Fast Track, the disposition may be return to duty, 
provision of an assignment limitation code, or recommendation for 
medical discharge.
    In cases where a medical discharge is recommended (or down the road 
for individuals who are retained but later separate or retire), the 
disability rating is provided by the VA. The new DES-Pilot system (also 
being referred to as the Integrated DES) allows veterans to undergo a 
single rating physical exam and receive one disability rating.
                                 ______
                                 
              Question Submitted by Senator Susan Collins
                          information sharing
    49. Senator Collins. Dr. Jesse, I have been contacted by officials 
from the Maine Office of Substance Abuse regarding their concern that 
the VA is preventing VA hospitals, such as Togus Medical Center, from 
participating in the State's Prescription Monitoring Program. The 
Prescription Monitoring Program shares prescription drug information 
among physicians to prevent drug abuse by ensuring that doctors know 
what prescriptions have already been provided to a patient. Without 
access to the prescription drug data from VA medical centers, 
physicians in Maine are concerned that they may inadvertently provide 
duplicative prescriptions to veterans, including prescriptions for 
particularly strong drugs, such as narcotics. Understanding that there 
are privacy consideration, is the VA committed to working with each 
State to ensure that necessary medical information is shared, while 
protecting the privacy rights of patients?
    Dr. Jesse. Patient safety is always a major concern within VA. 
Within our internal national system we have mechanisms to monitor and 
evaluate prescription drug use. Currently, there are statutory barriers 
that prevent VA's participation with the States. VA is, however, 
evaluating possible remedies that may allow participation in these 
programs.

    [Whereupon, at 11:40 a.m., the committee adjourned.]

                                 
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