[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




                         [H.A.S.C. No. 113-24]
===================================================================
 
                         MENTAL HEALTH RESEARCH

                               __________

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON MILITARY PERSONNEL

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                             APRIL 10, 2013


                                     
[GRAPHIC] [TIFF OMITTED]

                                     




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20402-0001


                   SUBCOMMITTEE ON MILITARY PERSONNEL

                  JOE WILSON, South Carolina, Chairman

WALTER B. JONES, North Carolina      SUSAN A. DAVIS, California
JOSEPH J. HECK, Nevada               ROBERT A. BRADY, Pennsylvania
AUSTIN SCOTT, Georgia                MADELEINE Z. BORDALLO, Guam
BRAD R. WENSTRUP, Ohio               DAVID LOEBSACK, Iowa
JACKIE WALORSKI, Indiana             NIKI TSONGAS, Massachusetts
CHRISTOPHER P. GIBSON, New York      CAROL SHEA-PORTER, New Hampshire
KRISTI L. NOEM, South Dakota
               Jeanette James, Professional Staff Member
                 Debra Wada, Professional Staff Member
                      Colin Bosse, Staff Assistant
                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2013

                                                                   Page

Hearing:

Wednesday, April 10, 2013, Mental Health Research................     1

Appendix:

Wednesday, April 10, 2013........................................    25
                              ----------                              

                       WEDNESDAY, APRIL 10, 2013
                         MENTAL HEALTH RESEARCH
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Ranking 
  Member, Subcommittee on Military Personnel.....................     2
Wilson, Hon. Joe, a Representative from South Carolina, Chairman, 
  Subcommittee on Military Personnel.............................     1

                               WITNESSES

Carr, CDR Russell B., M.D., USN, Service Chief, Adult Behavioral 
  Health Clinic, U.S. Navy, Walter Reed National Military Medical 
  Center at Bethesda.............................................    10
Horoho, LTG Patricia D., USA, Surgeon General, U.S. Army.........     6
Nathan, VADM Matthew L., USN, Surgeon General, U.S. Navy.........     7
Travis, Lt Gen Thomas W., USAF, Surgeon General, U.S. Air Force..     9
Woodson, Dr. Jonathan, Assistant Secretary of Defense for Health 
  Affairs, U.S. Department of Defense............................     4

                                APPENDIX

Prepared Statements:

    Horoho, LTG Patricia D.......................................    45
    Nathan, VADM Matthew L., joint with CDR Russell B. Carr......    61
    Travis, Lt Gen Thomas W......................................    71
    Wilson, Hon. Joe.............................................    31
    Woodson, Dr. Jonathan........................................    32

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Mrs. Noem....................................................    85

Questions Submitted by Members Post Hearing:

    Ms. Shea-Porter..............................................    89
                         MENTAL HEALTH RESEARCH

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                         Washington, DC, Wednesday, April 10, 2013.
    The subcommittee met, pursuant to call, at 3:47 p.m., in 
room 2118, Rayburn House Office Building, Hon. Joe Wilson 
(chairman of the subcommittee) presiding.

  OPENING STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM 
  SOUTH CAROLINA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mr. Wilson. Good afternoon. And, ladies and gentlemen, 
thank you for attending a meeting of the Military Personnel 
Subcommittee Hearing on Mental Health Research--very important 
to the military and the young people who make possible for us 
to have the freedoms to be here today.
    Today the subcommittee will hear testimony on the research 
conducted by the Department of Defense and the military 
services to address deployment-related psychological health 
needs of service members particularly traumatic brain injury, 
TBI, and post-traumatic stress disorder, PTSD.
    Before I begin I would like to thank Ranking Member Susan 
Davis from California for suggesting that we hold this hearing. 
I would also like to recognize her leadership in this role 
while both--when she was chairwoman of the committee and now as 
ranking member.
    Today, we continue to address the signature wounds of the 
wars in Iraq and Afghanistan, PTSD and TBI. Our unwavering 
commitment is to our service members who are experiencing the 
challenge of multiple deployments.
    Collectively, the Department of Defense and in particular 
the leaders of the military health system who appear before us 
today have done tremendous work responding to the mental health 
needs of our service members and families. This has not been an 
easy task. I want to thank you for your efforts.
    Since 2007, Congress has appropriated close to $1.5 billion 
for scientific and clinical research for the Department to 
improve the prevention, screening, diagnosis, and treatment of 
PTSD and TBI.
    This investment has funded nearly 1,000 studies in 
collaboration with Federal, academic, and public/private 
partnerships. How have these studies increased the 
understanding of these conditions and how has this new 
knowledge translated into more effective methods of preventing 
and treating TBI and PTSD?
    I am also anxious to hear about the future of these 
research efforts. How has sequestration and the Continuing 
Resolution affected both ongoing studies and those that are yet 
to be begun? We must not lose the momentum we have gained 
through this research.
    We must continue to build on the hard work that has already 
been done to fill in any remaining gaps in scientific 
knowledge. I am committed to supporting the Department of 
Defense's goal to prevent and treat these devastating 
conditions. Our service members deserve no less.
    With that, I want to welcome our witnesses and I look 
forward to their testimony.
    Before I would introduce our panel, let me offer 
Congresswoman Susan Davis of San Diego an opportunity to make 
her opening remarks.
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 31.]

    STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
 CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mrs. Davis. Thank you. Thank you, Mr. Chairman. Let me join 
you in welcoming our witnesses.
    Dr. Woodson, General Horoho and Admiral Nathan, we want to 
welcome you back.
    General Travis, I understand that this will be your first 
testimony, and we certainly welcome you as well.
    Commander Carr, thank you for coming to testify and to 
share your expertise as a clinician with the subcommittee.
    We appreciate your service to the Nation, all of you, to 
our Nation, and appreciate your being here.
    Mr. Chairman, I want to thank you as well for your interest 
and for holding this hearing on mental health research.
    Over the past decade, the press has continued to 
characterize post-traumatic stress disorder and traumatic brain 
injuries as the signature wounds of the current conflicts. And 
I prefer to mention PTSD as PTS, post-traumatic stress, because 
I think what we know about that is not necessarily a disorder--
obviously, some normal activity in many, many ways, a normal 
response to the situation that people find themselves in, but 
one of course that we must work with and we must work with it 
as it reflects the way in which it is amplified in the people 
who suffer from it.
    As a result of over the last several years Congress has 
responded by increasing the resources and the requirements for 
mental health prevention, treatment, and research.
    And what is important is that members of this subcommittee 
I believe understand where the mental health research is today 
and how we should move forward in the area of mental health 
especially given the fact that increasing fiscal constraints of 
the Department will be felt over time.
    As PTS and TBI begin to emerge as prominent injuries from 
the conflicts in Afghanistan and Iraq and stories of service 
members facing difficulty to obtain appropriate care begin to 
increase, Congress began its efforts to push the Services and 
the Department of Defense to be more proactive in this area.
    And efforts by Congress to address the issues that were 
being raised began back in 2004 actually when the Secretary of 
Defense was directed to conduct a study of the mental health 
services available to service members at that time.
    Since then, Congress has imposed a number of requirements, 
a number of policies and programs in an effort to improve the 
prevention, the treatment, and the research of PTS and TBI.
    Congressional action also included providing nearly $2 
billion in funding for PTS- and TBI-related research. To date, 
the DOD [Department of Defense] has invested over $710 million 
in over 500 research projects related to the prevention, 
screening, diagnose, and treatment of TBI.
    More than $717 million has been provided for over 400 
research project relations to the research of psychological 
health of service members including PTS, suicide prevention, 
military substance abuse resilience, prevention of violence 
within the military, and family related research.
    I certainly understand that science and research, 
particularly treatment research and pharmaceutical development, 
takes a significant amount of time before we can see concrete 
results. I think we all understand that. But it has been nearly 
6 years since we began to significantly increase the funding 
that has been provided specifically for mental health research.
    It would help members to better understand how that money 
has been used. What, if any, are the results that have come 
from the research? Where are the potential breakthroughs? What 
areas in fact may not be as productive, what gaps may exist 
that should be addressed, and how should we begin to prioritize 
the demands that continue to grow in this area?
    I look forward to your testimony to hear from all of you 
especially on where we need to focus our attention to 
complement the ongoing activities of mental health research, 
prevention, and treatment.
    As the budget continues to shrink, of course greater 
pressure to reduce research and development funding will grow, 
and we need to ensure that our limited resources are being used 
in the most efficient manner.
    Thank you, Mr. Chairman, for the hearing today.
    Mr. Wilson. Thank you, Mrs. Davis.
    Even before we begin I would like to also welcome, 
additional members of Congress here because what you are doing 
and what you are saying is so important. And we have 
Congressman Bill Young who has been chairman of the House 
Appropriations Committee and as a veteran himself, a champion 
on behalf of service members and he is backed up by an 
extraordinary lady, his wife, Beverly, who is here today. And 
if you ever wonder where she is coming from, it says ``Support 
the Troops,'' and she means it, and she does. So both of you, 
thank you for being here.
    Additionally, we have Congressman Tim Murphy. Tim is 
actually a member of the Navy Reserve and he, with his medical 
background, has just been such a resource for all of us in 
Congress. So Congressman Murphy of Pennsylvania, thank you for 
being here today, too.
    We are joined today by an outstanding panel. Given the size 
of our panel, the desire to give each witness the opportunity 
to present his or her testimony, each member an opportunity to 
question the witnesses, I would respectfully remind the 
witnesses to summarize, to the greatest extent possible, the 
high points of your written testimony in 3 minutes.
    I assure you your written comments and statements will be 
made part of the record. Let me welcome the panel.
    A longtime person who we can count on to be at virtually 
every hearing, Dr. Jonathan Woodson, the Assistant Secretary of 
Defense for Health Affairs, Department of Defense.
    I would like to welcome Lieutenant General Patricia D. 
Horoho, U.S. Army, the Surgeon General of the U.S. Army, United 
States Army.
    And we have Vice Admiral Matthew L. Nathan, who I am just 
so grateful, the Medical Corps, United States Navy, the Surgeon 
General, United States Navy.
    Additionally, we have Lieutenant General Thomas W. Travis, 
U.S. Air Force, the Surgeon General and of the U.S. Air Force. 
This is his first appearance. I want to welcome you.
    I also appreciate that we have a shared Virginia heritage 
and also as a graduate of Uniformed Services University of 
Health Sciences, I have a son who is a fellow graduate and I 
know what a great institution that is.
    Commander Russell B. Carr, M.D., United States Navy Service 
Chief, the Adult Behavioral Health Clinic of Walter Reed 
National Military Medical Center, U.S. Navy.
    So thank all of you for being here today. We will begin 
with Dr. Woodson and proceed, and again, thank all of you for 
being here.

   STATEMENT OF DR. JONATHAN WOODSON, ASSISTANT SECRETARY OF 
     DEFENSE FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE

    Dr. Woodson. Chairman Wilson, Ranking Member Davis, 
distinguished members of the committee, thank you for the 
opportunity to be here today.
    Our Armed Forces have been engaged in combat operations for 
over 11 years. Our service members have performed selflessly 
and courageously. Their experiences have been unique in the 
history of warfare.
    They have survived injuries that 15 to 20 years ago would 
not be survivable and while this survivability rate is a 
reflection of our investments in medical research, it also 
brings with it new challenges in recovery and reintegration. 
They have returned to the war zones on multiple deployments 
placing exceptional stressors on their lives and on those of 
their families.
    While our investments in medical research are focused on 
both the visible and invisible wounds of war, today I will 
focus mainly on our research efforts surrounding the invisible 
wounds, TBI, PTSD, depression, and other mental illnesses and 
suicidal thoughts and behaviors.
    Our research extends through a broad spectrum of 
activities. Foundational science, epidemiology, and ideology, 
how we can better prevent these illnesses and injuries, when 
someone is injured or ill how we can more rapidly and 
accurately diagnose their condition, when we have identified 
their condition how we can most effectively treat the 
individuals, how we can improve the opportunities for in the 
timeliness of recovery and recuperation including follow-up 
care and services research, and what the long-term needs of our 
wounded, ill, and injured will be in the decades ahead.
    In many cases over the past decade, we have been able to 
rapidly transfer our research findings to practical 
applications on the field, yet it is always--as is always, in 
the case of science, there are gaps that remain particularly in 
the neural and behavioral sciences.
    I will not cite each study we have under way today, but I 
will make several points about the nature of our research. 
First, the Department is not doing this work alone. We are 
working closely with our colleagues in the Department of 
Veterans Affairs, the Department of Health and Human Services 
to include the National Institutes of Health, the Center for 
Disease Control and Prevention, the Substance Abuse and Mental 
Health Services Administration, and we have engaged the 
Department of Education. In addition, we have extensive 
collaborative efforts with private and public universities in 
industry.
    Second, we also are effectively leveraging the impressive 
scientific capabilities of our partner organizations by sharing 
clinical data that will benefit not just our service members 
but all Americans.
    For instance, the DOD, NIH [National Institutes of Health] 
Federal TBI Research Informatics System links TBI clinical 
research from the Department of Defense, VA [Department of 
Veterans Affairs], and NIH. In addition to the tremendous value 
it provides, shared data repositories decrease costs of 
research of standardized collection of research data and allow 
access for researchers outside of the original study creating 
opportunities for faster advancement in science through 
collaboration.
    Finally, we are intently focused on continuing to move from 
our research from the laboratory to the bench, from the bench 
to the bedside, of those who are ill and injured by more 
aggressively managing the portfolio of research, reducing the 
duplication and closing gaps by rigorous joint program and 
interagency scientific reviews.
    Scientific understanding and progress does not occur 
overnight as has been noted, yet we all recognize the urgency 
surrounding the work that we do. I want to express my great 
appreciation to this committee for the longstanding support and 
advocacy for our medical research agenda. It has made a 
difference in lives saved, in the prevention of illness and 
injury, and in the acceleration of recovery for so many of our 
service members.
    With your continued support and engagement, I am confident 
that we will continue to make progress in this important work 
and meet both our medical and moral obligation to those who 
have served and sacrificed. Thank you for the opportunity to 
speak to you today on these important matters, and I look 
forward to your questions.
    [The prepared statement of Dr. Woodson can be found in the 
Appendix on page 32.]
    Mr. Wilson. Thank you very much, Mr. Secretary.
    General Horoho.

STATEMENT OF LTG PATRICIA D. HOROHO, USA, SURGEON GENERAL, U.S. 
                              ARMY

    General Horoho. Thank you, sir.
    Chairman Wilson, Ranking Member Davis, and distinguished 
members of the subcommittee, thank you for the opportunity to 
appear to you today to discuss the Army's mental health 
research initiatives and to highlight the incredible work of 
dedicated men and women with which I have the honor to serve 
with.
    I would like to begin today with a story which illustrates 
the miracles which are possible from the investment in research 
and medical innovation.
    On June 2, 2009, during Staff Sergeant Paul Roberts' 
deployment to Afghanistan his unit was performing a combat 
patrol when his vehicle was hit with an improvised explosive 
device. The impact of the IED [improvised explosive device] 
destroyed the vehicle, killed the driver, the gunner, and the 
interpreter.
    Staff Sergeant Roberts was the only survivor. He sustained 
severe injuries from the explosion including third-degree burns 
to his wrists and legs, second-degree burns to his arms and 
face, and traumatic brain injury.
    Due to the tremendous research investments made in combat 
trauma, psychological health, and TBI, Staff Sergeant Roberts 
recovered from both his visible and invisible wounds. He was 
medically retired and has successfully transitioned from 
military to civilian life.
    His survival and recovery from these horrific injuries and 
successful transition to the civilian life is a direct result 
of the fruit borne by years of medical research.
    Traumatic brain injury and post-traumatic stress and post-
traumatic stress disorder have been characterized in the public 
as the signature wounds of Operation Enduring Freedom and 
Operation Iraqi Freedom.
    From 2001 to 2006, funding for research and psychological 
health, traumatic brain injury, and suicides totaled $83 
million. As the impact of the invisible wounds of the war 
became increasingly evident, Congress significantly increased 
funding for critical research, and as was stated earlier, a 
total of $1.4 billion of research and over 900 research 
projects have been supported over the last several years.
    And I would like to highlight a few of the policies and 
programs which were guided by the past decade's medical 
research efforts. TBI research findings have directly affected 
policy and changed the way the military acute concussion 
evaluation is used and administered in the deployment 
environment which has resulted in a 98-percent return-to-duty 
rate.
    The immediate goal in TBI diagnostics have been able to 
identify the unique biological effects of TBI. We are working 
on a capability for medics in austere combat environments to 
administer a simple test to detect TBI.
    Similar to our approach to concussive injuries, Army 
medicine has harvested research findings to inform the 
identification in the treatment of combat stress and PTSD. The 
mental health advisory team examinations of in-theater 
behavioral health issues have impacted policy, improved 
distribution of mental health resources and services throughout 
theater, and modified the doctrine of our combat operational 
stress teams.
    Research has informed the development of new clinical 
practice guidelines. Army medicine has developed the embedded 
behavior health program to put care where the soldiers are. 
Embedded behavior health moves behavior health personnel out of 
our large hospitals, forms them into teams, and places them in 
smaller clinics much closer to where the soldiers live.
    This creates working relationships between behavior health 
providers and unit leaders to better understand the specific 
challenges soldiers face and then tailors their clinical 
services to serve them. This care model has demonstrated 
significant reductions in key behavior health measures while 
knocking down access barriers and stigma.
    Military medicine is at an important crossroads. We owe it 
to this generation of our soldiers and our families to help 
them deal with the consequences of war long after the last 
soldier departs Afghanistan.
    Our commitment to support wounded warriors and their 
families must never waver, and our programs of support must be 
built and sustained for the long road.
    In closing, a strong decisive Army will be, as it has 
always been, the strength of our Nation. In partnership with 
the Department of Defense, my colleagues on the panel today, 
the Department of Veterans Affairs, and civilian partners in 
Congress, we will be prepared for tomorrow's challenges.
    Thank you again for the opportunity to testify in front of 
this committee today, and more importantly, thank you for the 
support you have given over the last 12 years. Thank you.
    [The prepared statement of General Horoho can be found in 
the Appendix on page 45.]
    Mr. Wilson. Thank you, General, for your very positive 
message.
    Admiral Nathan.

STATEMENT OF VADM MATTHEW L. NATHAN, USN, SURGEON GENERAL, U.S. 
                              NAVY

    Admiral Nathan. Chairman Wilson, Ranking Member Davis, 
distinguished members of the subcommittee, thank you for this 
opportunity to discuss mental health research including our 
progress, opportunities, and our challenges. We are sincerely 
grateful for your leadership and for the support you have shown 
in this area over the years.
    All of us in military medicine are dedicated to ensuring 
that the resources you've provided translate into effective 
treatment modalities and advances in caring for our service 
members.
    Navy Medicine Research, Development, Testing, and 
Evaluation is foundational to our mission of force health 
protection. Cutting-edge RDT&E [Research, Development, Test, 
and Evaluation] programs bolster both our current and future 
capabilities and help sustain a culture of excellence.
    Our 2013 Navy Medicine Chartered Course reflects the 
strategic goals of readiness, value, and jointness, and these 
key priorities are fully synchronized with our translational 
research efforts, particularly those focused on post-traumatic 
stress, traumatic brain injury, and suicide prevention.
    Our clinical investigation programs are the core of the 
Navy Medicine PH-TBI [Psychological Health and Traumatic Brain 
Injury] translational research efforts.
    CIPs [Clinical Investigations Programs] result in 
actionable intelligence for our providers on resilience 
building, stress reduction, prevention efforts, and 
psychological treatment interventions.
    Our priority remains translating our investments, your 
investments, into advancements in caring for our sailors, our 
marines, and their families. Collectively, military medicine 
has done this exceptionally well in the combat casualty arena 
as evidenced by the unprecedented battlefield survival rates in 
our recent conflicts.
    We have leveraged research, advances, and point-of-injury 
treatment, evacuation and clinical practices as well as a 
registry of trauma throughout the continuum of care to save 
lives. Our commitment remains to realize the same level of 
progress and success in caring for our personnel with post-
traumatic stress, traumatic brain injury, and other related 
mental health injuries.
    Our work continues to demonstrate progress and we see 
progress in several key areas including: identifying new 
therapies and strengthening the evidence for existing 
prevention and treatment interventions; utilizing surveillance 
practices to enhance communication, coordination, and 
detection; integrating innovative technologies and alternative 
therapies with treatment and prevention efforts; developing and 
validating risk and resilient screening tools to guide 
interventions and mitigate negative behavioral health outcomes 
following traumatic exposures; providing clinical and 
operational leaders, information, and strategies to facilitate 
early detection and improve outcomes; and capitalizing on data 
signals and surveillance outcomes to optimize effective 
decisionmaking and guide future mental health operations.
    Careful monitoring and assessment is inherent in our 
ongoing evaluation process. We are applying critical reviews 
through each phase and milestone to help ensure that our funded 
projects meet the intended objectives and provide the potential 
for long-term value to both our clinicians, our patients, and 
their families.
    Sound partnerships and collaborations have been critical to 
our research efforts. We are working in close collaboration 
with the Army, the Air Force, DOD, The Centers of Excellence, 
as well as the VA, other Federal agencies, and leading academic 
and private institutions.
    I believe military medicine can lead the way forward in 
this area; however, as I have said previously we will not solve 
this alone. The issues associated with mental health are 
presenting a national challenge and requires the expertise and 
commitment of our civilian colleagues from medical and nursing 
schools to leading research centers to private practice 
providers.
    We must continue to undertake these efforts with a renewed 
sense of urgency. It is our obligation to those entrusted to 
our care.
    In summary, deriving best value from our research 
investments requires careful planning, sharp execution, and 
good stewardship of our resources. We are committed to finding 
solutions and providing innovations to enhance clinical 
diagnostics and therapies to improve the outcomes of our 
injured service members.
    On behalf of the men and women of Navy Medicine, I thank 
you for your support, your confidence, your leadership, and I 
look forward to your questions. Thank you.
    [The joint prepared statement of Admiral Nathan and 
Commander Carr can be found in the Appendix on page 61.]
    Mr. Wilson. Thank you very much, Admiral.
    General Travis.

 STATEMENT OF LT GEN THOMAS W. TRAVIS, USAF, SURGEON GENERAL, 
                         U.S. AIR FORCE

    General Travis. Mr. Chairman, thank you for your kind 
welcome, my first experience here and I am looking forward to 
it.
    Ranking Member Davis, distinguished members of the 
committee, thank you for providing this forum to address 
something that is important not only to the military but also 
to this Nation and that is mental health and mental health 
research.
    The Air Force Medical Services made meaningful progress 
towards translating mental health research into clinical, and I 
would add, operational practice to improve behavioral health 
prevention, treatment outcomes, ensuring better health, 
operational performance, and of course quality of life for our 
airmen wherever they serve and after they serve.
    Fortunately, the rates for PTSD, PTS, and traumatic brain 
injury in airmen have remained relatively low, but we have 
joined with DOD in participating in research in these areas and 
of course benefit from the results as we treat our airmen and 
their families.
    While the Medical Research Materiel Command Structure and 
the Defense Centers of Excellence in Psychological Health and 
TBI, DCoE [Defense Centers of Excellence], have primary 
responsibility for the oversight of these areas of research for 
the DOD, our Air Force research teams focus their efforts on 
specific operational Air Force issues where needed while also 
participating in many joint and interagency research 
activities.
    Much of our mental health research is conducted at the 59th 
Medical Wing at Lackland Air Force Base in Texas and the 711th 
Human Performance Wing at Wright-Patterson Air Force Base in 
Ohio. We are very excited and encouraged by these research 
successes that have already translated into the clinical 
operational practice.
    As an example of the latter, as a result of our study on 
the stressors experienced by remotely piloted aircraft mission 
unit members, we are now embedding psychologists with the right 
clearances in remote warfare units to provide early 
intervention and care and have convinced commanders to improve 
staffing and change work shift cycles to align with the 
recommendations of the study. They have paid attention and the 
changes have been made and we are seeing some promising results 
in these new remote warfare career fields.
    We are of course closely following our deployed airmen to 
understand the impact of war on psychological health to 
mitigate future battlefield mental health stressors. We have 
studies in place to examine secondary mental health effects 
when moving brain-injured patients in our air-vac system, best 
practices for psychiatric evacuees, and two studies 
particularly examining the stresses in para-rescue, combat 
rescue, and special ops forces that may result in improved 
clinical practice guidelines and prevention.
    And while the Air Force suicide rate remains below the DOD 
average and age-adjusted civilian rates, we strive to make 
continuous improvements in that very important program as well.
    The Air Force is partnered with various universities but 
specifically the University of Rochester in 2004 to 2010 to 
evaluate the effectiveness of the suicide prevention program 
and we found out that in years when that program is more fully 
implemented Air Force suicide rates have been lower and we 
continue now to partner with various universities to learn more 
and then of course we share that information through the DOD 
suicide prevention office.
    In summary, these mental health research programs will help 
us prepare for tomorrow's challenges while addressing long-term 
issues experienced by returning warriors.
    Thank you for your support of Air Force medicine, military 
medicine, and I hope today's discussion is useful for all of us 
and I do look forward to your questions.
    [The prepared statement of General Travis can be found in 
the Appendix on page 71.]
    Mr. Wilson. Thank you very much, General.
    And we proceed with Commander Carr.

  STATEMENT OF CDR RUSSELL B. CARR, M.D., USN, SERVICE CHIEF, 
ADULT BEHAVIORAL HEALTH CLINIC, U.S. NAVY, WALTER REED NATIONAL 
              MILITARY MEDICAL CENTER AT BETHESDA

    Commander Carr. Chairman Wilson, Ranking Member Davis, 
distinguished members of the subcommittee, I am honored to be 
with you today as a mental health clinician representing my 
colleagues throughout the Department of Defense.
    I am a board-certified psychiatrist and a psychoanalyst. I 
have also deployed to Iraq with the Army where I experienced 
firsthand both the blast of IEDs and the deaths of fellow 
Americans.
    Over the past decade, I have also heard the horrors of 
combat from my patients. From these experiences, I understand 
why some combat veterans feel they deserve to die while others 
feel more at ease sleeping under a bridge than rejoining the 
communities they fought to defend. I also understand why we 
must fight for them every day to help all of them.
    Currently, I run the Adult Outpatient Mental Health Clinic 
at Walter Reed. The wars continue in our offices just like in 
every mental health clinic in the DOD. Almost everyone we see 
is suicidal. We use all of the approaches at our disposal both 
evidence-based and innovative ones to keep them alive and to 
help them reconnect with the rest of America.
    Since the wars in Iraq and Afghanistan began, our knowledge 
about comment related PTSD or PTS has grown exponentially. 
Research must continue. It is not quick and it is not easy but 
we must continue it.
    Here are a few examples of recent research that has 
directly impacted military mental health care. The PTSD 
checklist, also called the PCL, is a rating scale developed 
through research to help clinicians identify service members 
with PTSD and to track their symptoms over time.
    Recent research has also found that the benzodiazepine 
class of medications typically used for anxiety actually worsen 
many PTSD symptoms. They are no longer a standard treatment for 
PTSD.
    The last example is the blood pressure medication named 
Prazosin or Minipress. It has been found in an off-label use to 
reduce the nightmares and excessive alertness that many people 
with PTSD experience.
    In closing, we have made tremendous strides in 
understanding PTSD but there is still much to do. We are 
leveraging the best available technologies including talk 
therapies and treating it, but even the best treatments do not 
work for 30 to 40 percent of patients. In my opinion as a 
clinical expert, we need talk therapies created specifically 
for combat-related PTSD.
    As reflected in Admiral Nathan's written testimony, 
military clinicians will continue to collaborate with their 
civilian counterparts to create life-changing treatments for 
those who continue to suffer.
    What I hope you take from my comments is that we cannot 
settle for success with only some of our service members and 
leave the rest behind allowing them to return to their 
hometowns as broken, tormented souls. The battle for our 
veterans' lives is one we cannot lose. We fight it through 
continued research.
    It is my pleasure to testify before you today and I look 
forward to your questions.
    [The joint prepared statement of Commander Carr and Admiral 
Nathan can be found in the Appendix on page 61.]
    Mr. Wilson. Thank you very much, Commander Carr.
    Each of you has, have come across as so sincere and caring 
about our personnel and their families, military families. I 
want to thank each of you.
    We want to proceed to have a 5-minute questions with each 
person of the subcommittee and I am very grateful that Jeanette 
James who has served as an Army nurse, we are very fortunate, 
she will be maintaining the time. She is above reproach and I 
am just really proud of her resource on the professional staff 
and you know and we want the American people to know what 
extraordinary staff people we have who are available on issues 
such as we have today.
    As we begin, and the 5 minutes applies particularly to me, 
I want to ask our first four witnesses, and I have a keen 
interest in this. I was the past president of Mid-Carolina 
Mental Health Association and so as you were presenting 
different points, I--this is an issue that I have worked on for 
many years with a very personal interest and knowing what can 
be done. It is my understanding though that DOD will stop 
funding medical research for the rest of fiscal year 2013 and 
use the funds to pay TRICARE providers instead.
    Please explain what impact resource constraints such as of 
the continuing resolution and sequestration have had on PTSD 
and TBI research. How will your constrained budgets affect your 
ability to continue studies beyond the fiscal year 2013 and 
beginning with Mr. Secretary on and then I have got another 
question, Commander Carr, for you.
    Dr. Woodson. Thank you so much for that question. And no 
doubt 2013 is a difficult year from a budget point of view. Not 
only because of the actual cuts that are imposed by 
sequestration but cuts late in the year, the CR [Continuing 
Resolution], we have had to manage almost month by month in 
terms of our strategy.
    But to answer your question specifically, our intent is not 
to stop funding for research. In fact, most of the research for 
2013 has already been funded. So those projects are ongoing, 
but really to drill down into your question, we are not going 
to wholesale shift money out of research on these important 
areas to solve other budgetary problems. We are going to have 
to find creative ways of solving the budgetary problems but 
that is not going to be what happens.
    Mr. Wilson. That is great news. Thank you.
    General Horoho. --excuse me--tremendous challenges across 
Army medicine with sequestration and then medical research 
materiel command is one of my subordinate commands that oversee 
many of these research projects.
    And so as I look at the overall funding for Army medicine, 
I have made decisions that will protect behavioral health, 
warrior care as well as primary care and made the decision in 
primary care because part of what we have learned out of 
research is the positive impact of embedding behavioral health 
in our primary care clinics as a touch point. So that is why we 
have looked at that area.
    The impact that it is having on Medical Research Materiel 
Command is that we will be focusing on ensuring that we keep 
our top researchers in some of the projects that we can't fund 
this year that they won't stop but we want to maintain the 
talent because you can't raise that up quickly and so that is a 
concern of mine is how do we make sure we maintain the 
capabilities for future research that needs to be done.
    So were still--I can't give you a direct answer because we 
are literally monitoring the budget monthly as things change 
and looking at how we move money from the direct care over to 
the research.
    Mr. Wilson. But it does not----
    General Horoho. But we are committed.
    Mr. Wilson. But it does not appear to be a precipitous 
cutoff?
    General Horoho. No, sir. There is nothing that we have cut 
off at all across the board.
    Mr. Wilson. Okay. Excellent. Thank you.
    Admiral Nathan. Mr. Chairman, there are two prongs to it. 
One is the dollars for funding the programs themselves and then 
the other would be the personnel piece that might be sensitive 
to furlough.
    We have received no indication that we have to remove 
monies from research and/or development to pay for the 
operating and maintenance funding of our medical centers. So we 
are proceeding until apprehended with all research in 
behavioral health and in wounded warrior programs.
    There are research programs and there are research grants 
that are heavily laden with civilian personnel, Federal 
employees, and the Department of the Navy has been so far 
fairly flexible in allowing exemptions to furlough where 
possible to protect any programs that are prioritized as 
wounded warrior and or recovering warrior programs.
    So at this point in time, I am fairly comfortable and 
confident that we are going to be able to continue the inertia 
that we have in these research programs for mental health, 
behavioral health, post-traumatic stress, suicide prevention.
    Mr. Wilson. Thank you so much. That is very positive.
    General Travis.
    General Travis. Yes sir, I would echo what everyone else at 
the table has said. The Air Force DHP [Defense Health Program] 
funded R&D [Research and Development] and O&M [Operations and 
Maintenance] fund mental health research represent about 10 
percent of the research portfolio and we have not impacted 
those whatsoever.
    We don't know yet what the impact of sequestration on what 
we are going to be able to do this year but at this point, my 
intent is to keep R&D going and we will see as the years go by 
and budgets come down the impact of that.
    Very worrisome, because we are just now I think learning so 
much and I think to cut off the funding at this part, at this 
time as this war comes down would be really a shame.
    Mr. Wilson. And thank you all and following the 5-minute 
rule, I proceed to Congresswoman Susan Davis.
    Mrs. Davis. Thank you very much, Mr. Chairman.
    And I wanted to come back with a few other questions, but 
Commander Carr, I just wonder from something you had said about 
the importance of talk therapies and the fact that we still 
don't know a lot about which have the desired effect perhaps. I 
am not sure if I am saying that correctly.
    What I actually wondered from your statements, we are here 
because we want to talk about research and we want to maintain 
that, but at the same time sometimes when we are spending a lot 
of money I know that we hear out in the field essentially that 
some of that money might be better spent with making certain 
that we have the clinicians that we need that are well trained 
and perhaps have even had some experience in theater 
themselves.
    Is that something that you feel as well that sometimes we 
perhaps don't do as good a job in making sure that we have all 
the available help necessary especially in communities that 
have a more difficult time accessing that kind of help?
    Commander Carr. Ma'am, trying to understand your question 
in terms of do we need more staffing, is that----
    Mrs. Davis. Well I think we always need more staffing, but 
I think that there is also sometimes a feeling that we are 
spending money and time on research which I happen to believe 
is a good thing, but on the other hand that sometimes maybe 
that has a higher priority than having the clinicians in the 
field that we need.
    I am just wondering from your experience if you wanted to 
comment on that. We always can't do it 100-percent correct. I 
am just wondering if you sense some of that feeling and you get 
it from the clinicians that are in the field.
    Commander Carr. Yes ma'am, I--you know, I think we have 
spent much of the last several years to really standardizing a 
lot of the therapies that we use for particularly PTSD was what 
I was referring and I think we have a lot of--I would say all 
of our providers involved at this point had a lot of skills and 
a lot of experience but we are always trying to treat everyone 
that we can. I think that was part of what I am trying to say 
that not all of our patients responded to the same standardized 
treatments. And so we are always needing more--you know when I 
mention talk therapies in particular, I really believe the PTS, 
PTSD, the major treatment for this therapy, different forms of 
psychotherapy and medications can help with controlling 
symptoms, but we really need therapies specifically for combat 
trauma and of course, as you are saying, people who have been 
there, as some of my patients say to me. And they see the 
ribbons on my uniform and they say you will get it--you will 
understand because you have been there. You know, it is 
really--I don't see it as necessarily exclusionary when they 
say that, but one of hope. They are wanting to be understood 
and wanting to feel understood by the person with them. And 
they think that someone who has been there can maybe do that.
    Mrs. Davis. I think it is interesting that we haven't 
talked too much about stigma and we have spoken of that so many 
times in the past and it may be that we are overcoming that 
issue and working to look at the kinds of research, the kinds 
of therapies that are really the most helpful.
    Dr. Woodson, in your written testimony you mention the need 
to establish a coordinated military veterans and civilian brain 
donor registry and tissue banking system. And I am wondering, 
does that require any legislative authority to do that and is 
DOD now working to establish a system like that?
    Dr. Woodson. Thank you very much for that question. 
Actually, we have established one. What we are learning is that 
we need to assist with some administrative changes so that 
service men and women and others who would choose at the time 
of their death to donate their brain can do so more easily and 
we can identify them.
    This is actually very important going forward in our 
collaborative efforts with the NIH and many of the civilian 
academic partners and will add I think a great deal to our 
understanding of the pathobiology of these diseases.
    So at this time I don't think we need legislation, but we 
do need is some changes in administrative process.
    Mrs. Davis. And do you see that--in collaboration with the 
initiative that the president has mentioned as well----
    Dr. Woodson. Absolutely, yes.
    Mrs. Davis [continuing]. And the money would be--I 
understand about, what, $50 million or so will be going to 
DARPA [Defense Advanced Research Projects Agency].
    Dr. Woodson. Yes.
    Mrs. Davis. Okay, great. Thank you very much.
    My time is up, but I hope we have another round, thank you.
    Mr. Wilson. Thank you Mrs. Davis, and we now proceed to Dr. 
Wenstrup, of Ohio.
    Dr. Wenstrup. Thank you, and I am not sure who to address 
this to specifically so whoever feels they have the answer, if 
there is an answer, let me know. But I was wondering if there 
has been any look at risk factors before deployment such as--we 
all know the risk factor of going to war. I understand that 
part, but are there other risk factors that pertain to some of 
the troops before they deploy?
    General Horoho. Thank you, sir.
    A couple things that we have looked at in the predeployment 
is looking at the stress factors of stress on the family, prior 
deployments, the number of deployments, any behavioral health 
history, and so we now have a behavior health data portal which 
is a Web-enabled that asks consistent questions across the 
board and kind of tease out those risk factors that then is 
shared when we are looking at our treatment protocol and then 
it also can be shared with the provider that is in theater so 
that as we work on that care coordination and treatment plan.
    And we are also working with fusion cell of information. So 
there are many risk factors that are out there and sometimes 
commanders see one piece of that, behavior health sees another 
piece of it, primary care, so we have been working with 
developing a database, a commander's dashboard, that will fuse 
all of that information together as we look at the health of 
the force.
    Dr. Wenstrup. Are there ever any struggles between 
commanders who certainly don't want to lose a troop but someone 
may be having too many risk factors to deploy?
    General Horoho. I don't think it is so much that, as we 
have seen with embedding behavior health, what it has done, it 
has actually I think brought our leaders closer with our 
soldiers and the behavior health community.
    We have seen a 58-percent reduction in risky behaviors just 
by having embedded behavior health in the units and so 
commanders are actually embracing this. And I think it is more 
and why we haven't talked about stigma is because we have got 
five touch points now. And I think people are being much more 
comfortable, but this is part of our battle rhythm and the way 
that we need to take care of our soldiers and their family 
members. So I think that communication is helping.
    Dr. Wenstrup. I thank you very much, ma'am.
    Dr. Woodson, did you want to add something to that?
    Dr. Woodson. Just a couple of quick points. Clearly, if 
someone has a prior history of PTSD and particularly if it is 
undiagnosed or untreated, that is going to be a problem.
    Now as it relates to a previous history of PTSD, I think as 
we are dissecting through the data, one of the things that we 
are finding is that there are service men and women who come 
into the service with undiagnosed and unreported prior 
psychological trauma that is made worse perhaps by their 
military deployment experience.
    We are just getting through that data, but being able to 
dissect into the lives of the young people who come into the 
service and understanding what kinds of trauma they might have 
been exposed to is really going to be important for the future.
    Dr. Wenstrup. Thank you.
    I have a question for you, General Travis. You mentioned 
something about the reduction of the suicide rate within the 
Air Force. Is that within the Air Force or is that military 
wide?
    General Travis. Well, we are all struggling with this and 
of course we now coordinate many of our strategies together to 
the DOD suicide prevention program, but the Air Force has had 
some success with an 11 element program that focuses mainly on 
leadership community, education, and of course special 
protection for folks under investigation.
    We have also targeted suicide prevention efforts at our 
most at risk career fields such as security police and 
maintenance, believe it or not because they have had some 
special problems. So our outreach to their supervisors and to 
those members were very specific in educating those folks and 
we have seen great results so far.
    I mean, everybody's rates are slowly going up, but our 
program seems to be working and as with anything, it does take 
a while year-to-year to show the response.
    And one other just a comment to add to your last question, 
we have several studies going on our frequent deployers such as 
special ops and security forces as well and we look at family 
resilience, we look at relationships, we look at their social 
context, their psychosocial context on these frequent 
deployers, and because we do embed or dedicate, EOD [Explosive 
Ordnance Disposal] is another community that we are very 
tightly connected with, we actually know the families, they 
know us.
    That builds a trust that I think as Congresswoman Davis 
mentioned, the stigma issue is starting to become a little bit 
less of a problem. So we are learning a lot, and I think we 
will learn a lot more as we continue.
    Dr. Wenstrup. Thank you all very much.
    I yield back my time.
    Mr. Wilson. Thank you very much and we have Congresswoman 
Noem, of South Dakota.
    Mrs. Noem. Well, thank you, Mr. Chairman. I appreciate it 
and I want to thank everyone on the panel for being here today 
as well. It has been a great conversation and great discussion 
for me to hear.
    I have a couple of questions and I believe that it was 
Lieutenant General Horoho who has discussed the 900 different 
research projects that are going on throughout the DOD when it 
comes to acceleration of improvement, when it comes to not only 
our active military. And I might ask you to speculate a little 
bit into veterans as well after they come back from deployment 
and maybe aren't in engagement anymore, but I am curious about 
environment.
    If some of these research programs have looked at 
surroundings and environment during the treatment process of 
PTSD or TBI if being in a calm or more peaceful situation 
accelerates that type of improvement. If you would speak to 
that.
    I would also like Commander Carr to speak to that as well 
if he notices because I think when you have specialized 
programs for treatment that they can engage in we may see that 
acceleration much quicker and I would like to know if different 
programs, where they are located, how the facilities are 
arranged if that can make a big difference for military men and 
women.
    General Horoho. Yes, ma'am. Thank you very much for that 
question and I can talk about it from firsthand experience in 
Afghanistan.
    We have 11 concussive care centers in Afghanistan and what 
we did at those centers we actually took our concussive care 
coordinators as well as our behavioral health and married those 
together in a very healing environment, so darkened rooms, 
small little lights, calm music, sleep tapes, and really 
looking at alternative medicine, how do you use that when 
someone is exposed to concussions, IED blasts, or other 
behavior health issues.
    Very, very positive feedback and that has actually led to 
our 98-percent return-to-duty rate in theater. We have also 
taken that same concept when--which has really driven the pain 
management task force is looking at how do you take alternative 
medicine therapies, or yoga, which also talks about the healing 
environment, relaxation, mindfulness, virtual reality, all of 
those are being incorporated into the communities in which we 
provide behavior healthcare.
    Mrs. Noem. Okay, great.
    Commander Carr, if you could speak to that as well and then 
even talk about specific facilities or programs that may be 
available throughout the country that our men and women can 
participate in.
    Commander Carr. Well, I can talk about, ma'am, what I see 
as the importance of when you say peaceful environment, I 
actually think of the relationship between the--their therapist 
and the soldier or marine person coming in for treatment that--
by peace I mean feeling gotten--feeling understood and being 
able to feel they have a safe place to--to process to talk 
about what they have experienced.
    You know, how I understand that, how I understand trauma is 
that it comes from feeling--people feeling--that no one else 
gets what they have experienced. They can't tell it to anyone. 
They cannot process it with anyone and they are left alone.
    So it may mean that their battle buddies, their unit that 
they are with may help them--may feel in that sense peaceful to 
them, you know versus a place they may go home and no one else 
gets it and understands or someone who comes to see me, it is 
the relationship that I try and build with them.
    So I don't think in terms of facilities, I you know, I 
think, unfortunately I--you know, my knowledge is much more 
local. I would have to take for the record any information on 
specific treatment facilities.
    [The information referred to can be found in the Appendix 
on page 85.]
    Mrs. Noem. Okay.
    Dr. Woodson, could you refer to that? Another portion may 
be a way to describe this question is, is it often that our men 
and women have the opportunity to withdraw to a facility for a 
treatment program that helps them go back to Active Duty or 
service quicker, and what about that would possibly make that 
acceleration of improvement happen?
    Dr. Woodson. It is an excellent question and let me try to 
answer it two ways. I think we are learning out of the National 
Intrepid Center of Excellence that number one, you need to give 
special environments to some service members suffering from 
PTSD and TBI. And you need to give them a multidisciplinary 
evaluation because it may be a number of factors that are 
contributing to persistence of symptoms. You need to dissect 
them out and treat them appropriately.
    But the other part of the question is that as it were, 
looking through the research and learning more about this, one 
size is not going to fit all. And that what promotes a positive 
response and improvement in one individual of PTSD is not what 
is going to be in the other.
    And so if you look at the literature there is everything 
from service dogs that are helpful and it might be this issue 
of a service dog allowing a service member to reconnect with 
feelings and emotion and the world to equestrian therapy to 
golf lessons. And what I am saying to you is that one of the 
individualized approaches in the future probably is to figure 
out how to get that service member to reconnect.
    Mrs. Noem. So with these research programs, are those of 
some of the things that we are researching and doing studies on 
so that we have different types of programs available 
throughout the country?
    Dr. Woodson. So in our portfolio, we are looking at these 
alternative therapies and within the portfolio of PTSD we are 
really trying to get a better understanding of who is at risk, 
what are the triggers, and then what are the therapeutic 
options.
    Now I say that with the understanding and hope that you 
have the understanding that there is so much that is not known 
yet about this specific----
    Mrs. Noem. Well I have had some tell me that even it can 
make a difference for many to be in a rural area compared to an 
urban area, a larger facility versus a smaller facility, that 
even those types of changes can be beneficial for some over 
others.
    Dr. Woodson. Now, I would agree with that. The issue is 
again I think it is going to--we are going to have to figure 
out how to predict an individual response to different 
therapies.
    I would say that as a last note that much of what we are 
doing is resonating in the civilian community. We are 
understanding that many more people suffer from this problem in 
the civilian community and some of the very same things that we 
are trying to deal with need to be discussed, dissected out, 
and we need to gain knowledge on the better. Combat-related 
PTSD may be a subclass.
    Mrs. Noem. Thank you.
    I apologize. I am over my time, Mr. Chairman.
    Mr. Wilson. Thank you, Mrs. Noem.
    We will proceed to Congressman Austin Scott, of Georgia.
    Mr. Scott. Ma'am, gentlemen, thank you so much for being 
here.
    And Dr. Woodson, you spoke to an issue, very briefly about 
an issue that I want to talk about a little bit. We are all 
obviously all concerned about the mental health issues of our 
soldiers when they come back and our citizens as a whole. And I 
think we are--we have got beyond I think the stigma of it, 
which I think was maybe the first issue at least for moving 
beyond that. And I think that, you know, the progress that is 
being made is pretty encouraging.
    I guess I get back to the challenge and commander you 
mentioned this and several of you have about the fact that what 
works for one doesn't necessarily work for one person doesn't 
necessarily work for the next person.
    But General Horoho, I am from Georgia, Fort Benning's right 
down the road, not in my district but obviously a lot of our 
soldiers that are in combat are based there and many of our 
other bases. As far as equestrian therapy goes, we have a 
facility close to Benning called Hopes and Dreams. It is in 
Quitman. They have got some innovative ways that they have 
worked with members who have come back with problems.
    They have had a lot of successes and I guess my question is 
when we talk about the equestrian facilities and other things, 
what ongoing research is there with these alternative 
treatments and what are the opportunities for organizations 
like Hopes and Dreams to expand their reach, if you will, and 
their support of our soldiers when they come back?
    General Horoho. Thank you, sir. We have with looking at 
equine therapy were actually doing more of that in the Western 
region and looking to see whether or not that is beneficial. So 
Fort Riley is one of the areas where we have been using that 
therapy to look at and evaluate. So that is kind of where we 
have focused it.
    The opportunity is there with collaborative partnerships so 
if those--if there is an area near Fort Benning and that 
organization would like to partner, that is something that can 
be done with the local commanders and the commander of the 
facility there.
    Mr. Scott. Okay. I will get you some information on that 
and I appreciate that.
    One of the other areas that I have questions about is the 
hyperbaric chambers and the studies that were done with the use 
of hyperbaric chambers. What would--and it doesn't matter to me 
whichever one--Dr. Woodson, maybe start with you since you 
are--what--the research that came from those tests, what 
opportunities are there, what challenges are there? What are 
the beliefs of the DOD right now with the use of hyperbaric 
treatments?
    Dr. Woodson. That is a great question. As you know, we took 
on a rigorous evaluation of hyperbaric oxygen therapy a few 
years back. The literature had a lot of anecdotal reports, 
uncontrolled reports of benefit in TBI and other diseases to 
tell you the truth.
    We have four trials. The first--and the Surgeon Generals 
can speak to specific trials--was reported out I think in the 
September timeframe and that showed that while it wasn't 
detrimental to the individual, it did not show any clear 
benefit. We have another trial that is due out either this 
month or next month and another I believe due out in the fall.
    What we hope to do is after these trials are completed and 
some are placebo-controlled trials is then convene a consensus 
panel to make final recommendations around this particular 
therapy.
    Mr. Scott. I have talked to soldiers that have been 
involved in it and some of them of feel like it helps and some 
of them don't. Again, it might be one of those issues where it 
works for one and doesn't necessarily work for the other. And I 
hope that that when the decision is made that we are doing 
whatever we can to make sure that we are opening that 
opportunity for people who do want to try it.
    With that said, Mr. Chairman, I will turn the remainder of 
my time back in, and thank you for being here.
    Mr. Wilson. Thank you, Congressman Scott, and in 
consultation with the ranking member, we will proceed with a 
second round of questions.
    Commander Carr, I am interested in how PTSD and TBI 
research has improved medical care for service members. Please 
give us examples of improvements from your own practice.
    Commander Carr. Thank you, sir. I can think of a couple of 
applications of what I--of examples that I described in my 
opening remarks. Prazosin, it is a medication that was found--
it is actually a high blood pressure medication and it was 
discovered several years ago that it would decrease nightmares, 
decrease arousal symptoms; treating right now a Army physician 
who has had severe PTSD from being in Fallujah for about a 
year, the battalion aid station.
    She saw horrific casualties, she has attempted suicide 
three times. She has made it clear, there will not be a fourth 
that is not successful. I inherited her as a patient when I got 
more--she was struggling with other therapies and I tried her 
on this medication, and it has worked. It has reduced a lot of 
her ``on edge'' all the time, feeling like--as she puts it--
being ``over there'' all the time.
    She can start to reengage a little bit more and feel 
connected again and we still have to process a lot in therapy. 
Again, talk therapy is really where the work is done with 
improving PTSD, but it has really been a gamechanger for her.
    You know, I can think of other in terms of specific 
examples of other treatments. You know we have a--I think of a 
patient right now that you know had struggled with some of the 
standard treatments that have been tried before.
    As I mentioned before, they are not all the--not everyone, 
as you have heard from other panel members, not everyone 
responds to standard treatments and part of that is some of the 
main therapies that we use were actually originally developed 
for one-time sexual assault trauma and transferred over into 
combat trauma which is much more--much more extensive going 
over several years, many incidents, and it is a different--as I 
argued before, combat trauma is a different experience. As Dr. 
Woodson said it is a subset in many ways of forms of PTSD and 
the standard treatments may work very well, but others it 
doesn't work for and the--they need something that focuses more 
on the state that they are in, that they are left versus 
specific incidents that they are trying to overcome or process 
in their mind.
    And you know I have been working with at least several in 
you know, much more of what are called psychodynamic approaches 
or other more innovative approaches that have started--you know 
that are basically trying to help reach them where they are. 
And you know, there is ongoing research in those fields as well 
that I am learning from, I take in information from. I am 
continuing to try to seek the latest research and learn more 
about them.
    Mr. Wilson. Thank you very much. And I can tell you you are 
really putting your heart into what you are doing too, so thank 
you.
    And General Horoho, I have a--it is a hypothetical and it 
would be advice to a commander and that is if a soldier is in 
theater and has killed the enemy while deployed and feels that 
he can't do it anymore but tells his command this, what does 
the command--how do they react? What do they do?
    General Horoho. Okay. Sir, thank you. As we look at that, 
that commander looking at that has several options.
    Right now we have 90 sites for telebehavior health in 
Afghanistan. So some of the most remote combat outposts for 
exactly what you are talking about. So we have our combat 
stress control teams that are far forward on the battlefield so 
they would be able to turn to someone that has a habitual 
relationship with the unit and say, ``I need you to please talk 
to the soldier.'' A lot of times it is done after-hours, so 
that soldier is--you know, if they want their privacy they will 
do it after-hours because they don't want their peers to 
sometimes to know that they are going.
    They can have telebehavior health so that we are trying to 
get in front of something so that you are not waiting until you 
read a playback or having to go to either Bagram or Kandahar. 
We can get that capability far forward in being able to deal 
with it and then we have our chaplains that are there as well.
    And we also have the resiliency centers and if I could just 
really focus on that because we talked so much about treatment, 
diagnosis and treatment but really a tremendous amount of work 
is being done on resiliency and trying to get far forward of 
the left of the boom.
    And the comprehensive soldier family fitness of looking at 
what are the strengths that an individual has, what are the 
stressors in their lives, and what are the right coping skills 
so that we can equip those individuals with that.
    That is now a standard across the entire army and we are 
trying to put as much capabilities either through telehealth 
which we have had about a 780-percent increase, which is 
tremendous and so we have had over 7,700 behavior health 
appointments a day.
    So we have seen a huge increase and I think that is 
helping. And part of that is used from this telehealth that we 
have in theater.
    So he has many resources to be able to reach out to and 
then if they feel like they need to be taken back to the 
Resiliency Center and have several days of rest, they are doing 
that. From 7 to sometimes 14 days of rest.
    Mr. Wilson. That is extraordinarily encouraging, and I have 
seen domestically the success of telemedicine. So this is as a 
parent of four members of the--serving in the military today, 
what you said is just incredibly encouraging. Thank you very 
much.
    And I proceed now to Mrs. Davis.
    Mrs. Davis. Thank you, Mr. Chairman. I think it is really 
obvious listening to you that we have deployed many different 
modalities, really tried to respond as quickly as possible. 
What we know about scientific research and I think you 
mentioned this, General, that it takes about 16 years sometimes 
to be able to translate that into real practice and policies 
and yet it feels as if we have tried to shorten that.
    What is helping that process along? Can we do it even 
faster in some cases? And is it a financial problem that we 
face in terms of trying to do that or is it more the nature of 
what you are working with?
    Dr. Woodson.
    Dr. Woodson. Maybe perhaps I can take that question on. You 
have asked two very good questions. One had to do with what 
have you done that has translated into making a practice better 
for the physician at the front line? What is the value of the 
research?
    Well, what we have done actually is we have in some sense 
reengineered the way we call what is the best evidence in 
medical science and then get it out to the field.
    And if I could, we have published a series of guidelines 
that we get out to the field that are readily available to 
clinicians so that they don't have to plow through all of the 
literature and the like.
    We, DCoE's, one of DCoE's main benefit has been to get the 
experts together, decide what is the best evidence about what 
works and get it out to the field. This strategy has reduced 
our death rates from trauma and it is reducing I think the 
impact of these nonvisible wounds of war and allowing us to 
treat them more effectively.
    Now having said that, there is a sort of a ying and a yang 
circle. We can look at the outcomes of the best evidence and 
say it is not good enough and feed that back into research 
design to improve protocol.
    The other thing is with this design, we can--and the 
collaborations we have set up--we can move through the science 
and the process of investigation a lot more quickly to generate 
new knowledge and then to get it back into practice.
    So we are trying to reengineer the way we do research as 
much as we are trying to make sure that the clinicians have the 
latest and greatest and best-evidence treatments available to 
them.
    Admiral Nathan. If I could just give you a tactical example 
of what is happening at Camp Pendleton in San Diego----
    Mrs. Davis. Right. I was going to ask you about that, but I 
am running out of time.
    Admiral Nathan. So the question is, you go into a large 
clinic where lots of people are being seen by lots of providers 
and perhaps one provider has stumbled onto something that works 
pretty well and how do we distribute that, how do we 
disseminate that quickly and rapidly?
    So that program, every patient--there are over 3,000 that 
have been enrolled so far--are given iPads when they come in 
and go through a series of standardized questions about how 
they are doing.
    This is before they see the provider and they go through a 
standard where they can enter in the kind of treatments they 
have been receiving. That is all correlated in real-time as to 
how this large cohort of patient populations seen at these 
mental health clinics are doing in San Diego and Camp 
Pendleton.
    That then immediately feeds back to the clinicians through 
the electronic medical record telling them what the general 
number of people are who are experiencing the symptom, what 
treatment they have been on so far, and has it worked or not. 
And all of a sudden, in real-time, you can change your therapy 
based on how the herd is sort of running. And we have seen 
great results with that. Already that has changed the paradigm 
out there of how we are treating sleep disturbances because 
what the doctors and the providers thought was the right answer 
turned out to be wrong.
    And these patients are also salvoed through email at home 
and their families are salvoed through emails at home. And so 
all this is collected and this is real-time information now 
that you have at your fingertips that tells you the providers 
in my clinic are trying this. It is not working. Why would I 
try it? Let me try something else. And then it catches on much 
more quickly.
    Mrs. Davis. That is a very good to know. It--so--because I 
think the other thing that is happening at Pendleton is people 
are getting a lot of attention and--in an organized way that 
doesn't enhance stigma--that really----
    One other quick question, Dr. Woodson, was just about the--
you know, the Defense Centers of Excellence and coming under 
the Army now as the executive agent essentially. Is there 
anything about that that members of Congress should be 
concerned about because obviously we wanted to be certain that 
the centers were able to help all of us with that kind of 
information that you mention.
    Dr. Woodson. So rather than concern I would greet it as 
good news and here is the reason why. The generals and admirals 
to my left I couldn't be more proud of in terms of working 
together in a collaborative way to make improvements.
    MRMC [Medical Research and Materiel Command] is becoming 
more of a joint research asset. As we move to the defense 
health agency standup you are going to see part of that process 
formalize. So in moving DCoE under MRMC it gives it sort of 
administrative support that it couldn't have out on its own and 
because it needed to generate protocols, distribute funds, take 
care of personnel, it frees it up from those activities in some 
sense and gives it appropriate support and oversight.
    It becomes a much more efficient process. return on 
investment is greater. So this is good news, and I will let the 
distinguished panel here talk to the benefits of joint research 
programs but again, I think we get answers faster, at lower 
cost, when we approach it collaboratively.
    Mrs. Davis. Thank you.
    Mr. Wilson. Thank you, Mrs. Davis.
    Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    You know, often, PTS is recognized sometimes long after the 
deployment and that is why we do the follow-up surveys and 
questions and find out how people are doing. Certainly often it 
is a recognized after that honeymoon period when someone comes 
home and just thrilled to be home.
    You know, what we have had other wars in our history and 
there have been various levels of combat stress or whatever it 
was deemed at those times and you know we have had some wars 
where people came home to parades to meet headquarters where 
people came home and were spit upon.
    And I wonder if there is any effect from our society. In 
other words, is the way that society is approaching our troops, 
does that have any effect in your opinions on the high rise of 
PTS.
    In other words, coming home to an ambivalent nation. It is 
not really recognizing the sacrifices that are being made or in 
many people's minds don't feel it is important or many say we 
shouldn't be there and you come home to that and you have given 
another year of your life and people are saying, what a waste.
    I am just wondering if that has any effect on some of the 
troops and maybe Commander Carr, you can address that first or 
whoever would like to.
    Dr. Woodson. Let me just make an opening comment that I 
can't answer your question specifically because I don't know if 
we have dissected out all of those factors, but I would perhaps 
challenge one premise that PTSD is more prevalent now then it 
was in other wars.
    We just ignored it in other wars. Remember, PTSD wasn't 
coded as a diagnosis until 1981 after--well after Vietnam. So I 
can remember just to give your personal story of hearing 
stories about my uncles when they came back from the wars and 
how the family talked about them being different. And so the 
point being is that it occurred in the other wars, we just 
ignored it at that point. We didn't have a diagnosis for it.
    Commander Carr. Yes, sir. I agree with Dr. Woodson. I mean, 
there is World War II and the medical evacuations from the 
Pacific were--about a third of them were psychiatric and that 
is not really discussed very much from that war.
    Partly it is generational and there is a lot of silence, 
but there is definitely--there is definitely--it was called 
``combat fatigue'' back then, but there was definitely what we 
would call PTSD now and you can hear it described of children 
whose say father fought in World War II and it may just not 
have been called that, but they were--they were seen as 
different.
    You know their spouse may say, ``Well, they were never the 
same after the war.'' And you know, ``They have been abusive at 
times,'' or ``They may have drank a lot more,'' and it is 
present with all wars, sir.
    Dr. Wenstrup. My question though is do we as a society have 
any effect on the patients as they return or is this all due to 
their experience in theater or how we welcome them home.
    There may not be an answer but I am just curious and I 
recognize what you are saying that a lot of times we just 
didn't talk about it in the other wars as we are now.
    Commander Carr. Sir, the only thing I would add is I think 
the expression of it is probably different. As an example, you 
know, someone that I treated described his father. He had three 
purple hearts from the African Campaign in World War II; 
campaign in North Africa rather and you know he came back--you 
know he came back a hero, but he still had PTSD but he was 
described as being different from the war.
    You know whereas patients now may--maybe--they may react 
differently. People who have PTSD may talk in a much more 
negative way about their situation, about the wars, was it 
worth it. I have had patients who will say well, there is going 
to be no unconditional surrender on a battleship at the end of 
this and it does impact how they perceive themselves.
    Now both sets of those have PTSD but they just--it is just 
expressed differently I would say, sir.
    Dr. Wenstrup. Thank you very much. I appreciate it.
    I yield back my time.
    Mr. Wilson. Thank you, Dr. Wenstrup.
    And we will be concluding with Congressman Austin Scott, of 
Georgia.
    Mr. Scott. Thank you. Thank you, Mr. Chairman.
    I have one quick question, Dr. Woodson, or any of you can 
address this. What about the spouses? When our soldiers come 
home obviously if the soldier is going through these things 
then obviously the spouse is sharing--in those areas--are we 
making therapy available for them?
    Dr. Woodson. Yes. Absolutely. We have certainly increased 
our focus on families understanding that families are enablers. 
They are an important contributor and they suffer from the 
deployment both while the service member is away and when they 
come back the reintegration process and then if they come back 
having been harmed by their wartime experience, it becomes even 
more of a stress.
    We are looking for ways actually to do even good research 
on families. We are a little bit encumbered because not being 
in the military of course we can't require them to participate 
in certain surveys and the like, but we are engaging more and 
more partners to look at what the effects of this stress is on 
the family and then what specifically we need to do about it.
    I am particularly concerned about children of service 
members who have been overseas and the fact that we don't know 
enough about how to manage deployments, reintegration, and 
issues within families as a result of service to this Nation.
    Mr. Scott. Thank you.
    Mr. Chairman, I yield the remainder of my time.
    Mr. Wilson. Thank you very much.
    And as we conclude, again, on behalf of the entire 
subcommittee, I would like to thank all of you for being here. 
We appreciate your genuine concern for service members, 
military families.
    Secretary Woodson, thank you for concluding on that.
    Again, it is really reassuring as a veteran, as a part of a 
military family today, to know what you are providing and what 
this means to our country.
    With there being no further, we shall be adjourned.
    [Whereupon, at 5:12 p.m., the subcommittee was adjourned.]


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                            A P P E N D I X

                             April 10, 2013

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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                             April 10, 2013

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


                      Statement of Hon. Joe Wilson

           Chairman, House Subcommittee on Military Personnel

                               Hearing on

                         Mental Health Research

                             April 10, 2013

    Today the Subcommittee will hear testimony on the research 
conducted by the Department of Defense and the military 
services to address deployment-related psychological health 
needs of service members, particularly Traumatic Brain Injury 
(TBI) and Post-traumatic Stress Disorder (PTSD). Before I 
begin, I'd like to thank Ranking Member Susan Davis from 
California for suggesting that we hold this hearing. I'd also 
like to recognize her leadership in this area both while she 
was the Chairwoman of the committee and now as the Ranking 
Member.
    Today, we continue to address the signature wounds of the 
wars in Iraq and Afghanistan, PTSD and TBI. Our unwavering 
commitment is to our service members who are experiencing the 
challenge of multiple deployments. Collectively the Department 
of Defense and, in particular, the leaders of the military 
health system who appear before us today, have done tremendous 
work responding to the mental health needs of our service 
members and their families. This has not been an easy task. I 
want to thank you for your
efforts.
    Since 2007, Congress has appropriated close to $1.5 billion 
for scientific and clinical research for the Department to 
improve the prevention, screening, diagnosis and treatment of 
PTSD and TBI. This investment has funded nearly one thousand 
studies in collaboration with Federal, academic, and public-
private partnerships. How have these studies increased the 
understanding of these conditions and how has this new 
knowledge translated into more effective methods of preventing 
and treating TBI and PTSD?
    I am also anxious to hear about the future of these 
research efforts. How has sequestration and the Continuing 
Resolution affected both ongoing studies and those that are yet 
to begin? We must not lose the momentum we have gained through 
this research. We must continue to build on the hard work 
that's already been done to fill any remaining gaps in 
scientific knowledge. I am committed to support DOD's goal to 
prevent and treat these devastating conditions. Our service 
members deserve no less.


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?

      
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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                             April 10, 2013

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

      
              RESPONSE TO QUESTION SUBMITTED BY MRS. NOEM

    Commander Carr. While the relationship between provider and patient 
is probably the most important factor in the treatment of psychological 
health issues, it is also true that a tranquil, non-threatening 
environment is a vital aspect of psychotherapy, perhaps particularly 
for PTSD. There are two outstanding programs that serve as examples of 
the type of calm, peaceful environment that is important for PTSD care. 
One is the NICoE, or the National Intrepid Center of Excellence, 
located in Bethesda on the same campus as Walter Reed National Military 
Medical Center. NICoE has been developed as a place for innovative 
assessment and treatment for service members who have not responded to 
standard treatments for TBI and psychological health concerns. It has a 
beautiful architecture and a soothing environment that creates a unique 
experience for wounded warriors who are treated there. The second 
program is called OASIS, or Overcoming Adversity and Stress Injury 
Support, which is located at Naval Medical Center San Diego. OASIS 
offers a comprehensive program of evidence-based treatments for the 
mind and body. It also has beautiful oceanfront views that are integral 
to its peaceful treatment environment. [See page 17.]
?

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


              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                             April 10, 2013

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

      
                 QUESTIONS SUBMITTED BY MS. SHEA-PORTER

    Ms. Shea-Porter. 1) In your testimony you've noted new drugs that 
can help with PTSD. I'm interested in what progress you've made using 
canine therapy for PTSD or TBI. Please tell me about your research and 
results using canine therapy for treatment or mitigation of PTSD or TBI 
symptoms.
    Dr. Woodson. At this time, the DOD has no results to provide from 
canine studies of therapy for treatment or mitigation of PTSD or TBI 
symptoms. We included a request for studies to evaluate the role of 
service animals in PTSD recovery in a recent Program Announcement and 
received some research submissions in response. However, review of 
those submissions is not complete.

    Ms. Shea-Porter. 2) In your testimony you've noted new drugs that 
can help with PTSD. I'm interested in what progress you've made using 
canine therapy for PTSD or TBI. Please tell me about your research and 
results using canine therapy for treatment or mitigation of PTSD or TBI 
symptoms.
    General Horoho. The Army supports complementary integrative 
medicine in appropriate circumstances and is open to alternative 
therapies. Canine assisted therapy for PTSD is an emerging area of 
alternative therapy. While some Service Members who received dogs from 
sources outside the Army have reported that the dogs have helped 
mitigate their symptoms, the medical benefit of canine assisted therapy 
for PTSD or TBI symptoms has not been validated by any formal studies.
    Neither USAMEDCOM nor USAMRMC has any currently funded studies 
involving canine therapy for treatment or mitigation of PTSD or TBI 
symptoms; however, the Army has an interest in pursuing such a study. 
USAMRMC included a request for studies to evaluate the role of service 
animals in PTSD recovery in a recent Program Announcement. Some 
research proposals have been received, they are currently in the review 
process.

    Ms. Shea-Porter. 3) In your testimony you've noted new drugs that 
can help with PTSD. I'm interested in what progress you've made using 
canine therapy for PTSD or TBI. Please tell me about your research and 
results using canine therapy for treatment or mitigation of PTSD or TBI 
symptoms.
    Admiral Nathan. Therapy dogs are used in a variety of Navy Medicine 
settings to help reduce anxiety, lower emotional reactivity, and 
provide a sense of security to our patients.
    While Animal Assisted Therapy (AAT) remains experimental (i.e., 
more research is required), it has been shown to be effective in 
helping to treat a number of psychological disorders exhibited by many 
types of patients. These include hospitalized psychiatric patients, 
children with developmental disorders, patients with substance abuse 
problems, and victims of trauma. Therapy dogs have frequently been used 
overseas to help service members cope with the stressors of living in a 
deployed environment. They are also used in several of our facilities 
to help patients cope with the challenges associated with their medical 
condition. There is substantial anecdotal data suggesting that therapy 
dogs can be beneficial to service members with PTSD.
    At the National Intrepid Center of Excellence (NICoE), therapy dogs 
have proven to be an extremely useful part of the therapy regimen. One 
reason for this is therapy dogs help facilitate positive social 
interactions between service member-trainers and the public. With the 
dogs at their side, service members can begin to rebuild their sense of 
trust in others and their sense of self-worth. NICoE utilizes a 
contracted service, Warrior Canine Connection (WCC), to teach service 
members with PTSD and TBI how these dogs can be used to help manage 
their symptoms. Additionally, in collaboration with both the Uniformed 
Services University of the Health Sciences (USUHS) and NICoE's Research 
Directorate, WCC is striving to gain scientifically-based evidence to 
demonstrate the benefits of the warrior-canine bond in reducing the 
symptoms of TBI and PTSD. They are also exploring the bio-mechanisms 
triggered during this human-animal interaction, which may correlate 
with the observed reduction in symptoms.
    Ms. Shea-Porter. 4) In your testimony you've noted new drugs that 
can help with PTSD. I'm interested in what progress you've made using 
canine therapy for PTSD or TBI. Please tell me about your research and 
results using canine therapy for treatment or mitigation of PTSD or TBI 
symptoms.
    General Travis. Research has demonstrated that the use of canine 
therapy is beneficial in the support of people with either physical or 
mental health diagnoses. Canine-assisted therapies can reduce anxiety 
[Barker and Dawson (1998)] \1\ and complement other therapies for Post-
Traumatic Stress Disorder (PTSD) like Prolonged Exposure treatment 
[Lefkowitz, et al, 2005]. \2\ While there is a research project in 
canine therapy approved through Walter Reed National Medical Center, 
the Air Force does not have any mental health research specifically 
addressing canine therapy. However, with the support of Womack Army 
Medical Center, Pope Air Force Base (AFB) has implemented a service dog 
training program. Pope AFB's program began June 2012 as a complementary 
treatment intervention for complex PTSD/Traumatic Brain Injury cases 
and expects to expand to include a total of 8 service animals within 
the next several months. Although Pope AFB's canine program is not 
research, reports are that those service members in the program 
typically show a decrease in suicidal thoughts, an increased sense of 
safety, independence, motivation and self-efficacy.
---------------------------------------------------------------------------
    \1\ Barker, S. B., & Dawson, K. S. (1998). The effects of animal-
assisted therapy on anxiety ratings of hospitalized psychiatric 
patients. Psychiatric Services, 49(6), 797-802.
    \2\ Lefkowitz, C., Prout, M., Bleiberg, J., Paharia, I., & Debiak, 
D. (2005). Animal-assisted prolonged exposure: A treatment for 
survivors of sexual assault suffering posttraumatic stress disorder. 
Society and Animals, 13(4), 275-296.

    Ms. Shea-Porter. 5) In your testimony you've noted new drugs that 
can help with PTSD. I'm interested in what progress you've made using 
canine therapy for PTSD or TBI. Please tell me about your research and 
results using canine therapy for treatment or mitigation of PTSD or TBI 
symptoms.
    Commander Carr. [The information was not available at the time of 
printing.]

                                  
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