[Senate Hearing 114-620]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 114-620

               THE CURRENT STATE OF RESEARCH, DIAGNOSIS,
 AND TREATMENT FOR POST	TRAUMATIC STRESS DISORDER AND TRAUMATIC BRAIN 
                                 INJURY

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

                                HEARING

                               before the

                    SUBCOMMITTEE ON STRATEGIC FORCES

                                 of the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 20, 2016

                               __________

         Printed for the use of the Committee on Armed Services



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                      COMMITTEE ON ARMED SERVICES

  JOHN McCAIN, Arizona, Chairman      JACK REED, Rhode Island
JAMES M. INHOFE, Oklahoma             BILL NELSON, Florida
JEFF SESSIONS, Alabama                CLAIRE McCASKILL, Missouri
ROGER F. WICKER, Mississippi          JOE MANCHIN III, West Virginia
KELLY AYOTTE, New Hampshire           JEANNE SHAHEEN, New Hampshire
DEB FISCHER, Nebraska                 KIRSTEN E. GILLIBRAND, New York
TOM COTTON, Arkansas                  RICHARD BLUMENTHAL, Connecticut
MIKE ROUNDS, South Dakota             JOE DONNELLY, Indiana  
JONI ERNST, Iowa                      MAZIE K. HIRONO, Hawaii
THOM TILLIS, North Carolina           TIM KAINE, Virginia
DAN SULLIVAN, Alaska                  ANGUS S. KING, JR., Maine 
MIKE LEE, Utah                        MARTIN HEINRICH, New Mexico 
LINDSEY GRAHAM, South Carolina          
TED CRUZ, Texas                         
                                     
                 Christian D. Brose, Staff Director
                Elizabeth L. King, Minority Staff Director
             

_________________________________________________________________

                       Subcommittee on Personnel

 LINDSEY GRAHAM, South Carolina,      KIRSTEN E. GILLIBRAND, New York
             Chairman                 CLAIRE McCASKILL, Missouri
ROGER F. WICKER, Mississippi          RICHARD BLUMENTHAL, Connecticut
TOM COTTON, Arkansas                  ANGUS S. KING, JR., Maine
THOM TILLIS, North Carolina
DAN SULLIVAN, Alaska                 



                                  (ii)





















                           C O N T E N T S

_________________________________________________________________

                             April 20, 2016

                                                                   Page

The Current State of Research, Diagnosis, and Treatment for Post-     1
  Traumatic Stress Disorder and Traumatic Brain Injury.

Greenhalgh, Captain Walter M., MC, USN, Director for the National     3
  Intrepid Center of Excellence Directorate, Walter Reed National 
  Military Medical Center.
Colston, Captain Michael J., MC, USN, Director, Defense Centers       7
  of Excellence for Psychological Health and Traumatic Brain 
  Injury.
Street, Amy E., Deputy Director, Women's Health Sciences              8
  Division, National Center for Posttraumatic Stress Disorder.

Questions for the Record.........................................    32

                                 (iii)

 
                     THE CURRENT STATE OF RESEARCH,
    DIAGNOSIS, AND TREATMENT FOR POST-TRAUMATIC STRESS DISORDER AND 
                         TRAUMATIC BRAIN INJURY

                              ----------                              


                       WEDNESDAY, APRIL 20, 2016

                           U.S. Senate,    
                         Subcommittee on Personnel,
                               Committee on Armed Services,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:36 p.m. in 
Room SR-222, Russell Senate Office Building, Senator Lindsey O. 
Graham (chairman of the subcommittee) presiding.
    Committee members present: Senators Graham, Cotton, Tillis, 
Sullivan, Gillibrand, Blumenthal, and King.

          OPENING STATEMENT OF SENATOR LINDSEY GRAHAM

    Senator Graham. The hearing will come to order.
    We're here to receive testimony on research, diagnosis, and 
treatment of post-traumatic stress and traumatic brain injury 
in the Department of Defense and Department of Veterans 
Affairs.
    The committee meets this afternoon to receive testimony 
from the Department of Defense and Department of Veterans 
Affairs on research, diagnosis, and treatment of post-traumatic 
stress and traumatic brain injury. This is an important 
hearing. We must do everything we can to help servicemen and 
women and veterans suffering from PTS [post-traumatic stress] 
and TBI [Traumatic Brain Injury].
    We're fortunate to have a distinguished panel of witnesses 
joining us today: Captain Walter Green--say it----
    Captain Greenhalgh. Greenhalgh.
    Senator Gillibrand.--Greenhalgh, sorry about that--Medical 
Corps, United States Navy, Director for the National Intrepid 
Center of Excellence at Walter Reed National Military Medical 
Center; Captain Mike Colston, Medical Corps, United States 
Navy, Director of the Defense Center of Excellence for 
Psychological Health and Traumatic Brain Injury; and Dr. Amy 
Street, Deputy Director of the Women's Health Division, 
National Center for Post-Traumatic Stress, Department of 
Veterans Affairs.
    Post-traumatic stress and traumatic brain injury have been 
called the signature wounds of the Afghan and Iraq conflict. 
Since 2001, about 5 percent of the over 2.7 million 
servicemembers deployed in support of the wars in Afghanistan 
and Iraq were diagnosed with PTS. And from 2000 through 
September 2015, there are over 339,000 TBI cases diagnosed, 
with most of these being mild TBI diagnosed in garrison 
locations. With the significant impacts that both PTS and TBI 
have made on our servicemembers and veterans, it is vitally 
important that we better understand, through well-developed 
medical research, the causes of PTS and TBI, and develop 
appropriate measures to treat and eventually prevent PTS and 
TBI. While both DOD [Department of Defense] and VA [Veterans 
Affairs] have made significant research investments to learn 
more about PTS and TBI leading to major advancements in 
diagnosis and treatments, more work must be done on prevention.
    Today, I want our witnesses to tell us what DOD and the VA 
are doing to prevent, diagnose, and treat PTS and TBI, and to 
give us an overview of promising treatments, therapies, and 
technologies that may be available in the near future. Finally, 
tell us what this subcommittee can do to help your department 
provide better care for servicemen and women and veterans who 
may suffer from PTS and TBI.
    Senator Gillibrand.

           STATEMENT OF SENATOR KIRSTEN E. GILLIBRAND

    Senator Gillibrand. Thank you so much, Chairman Graham, for 
your leadership. I'm so grateful I get to serve on this 
subcommittee with you.
    Senator Graham. Thank you.
    Senator Gillibrand. It's extremely meaningful, the work 
that we do.
    I want to welcome our witnesses. Thank you for your 
service, and thank you for the focus you have on the state of 
research, diagnosis, and treatment for post-traumatic stress 
disorder and traumatic brain injury.
    I'm pleased we have witnesses here, both from the DOD and 
the Department of Veterans Affairs. Both of these agencies are 
addressing significant caseloads of PTSD and TBI. I look 
forward to learning about how each agency responds to the 
challenges of research treating these conditions, and if there 
are different approaches in how to do this. Although PTSD and 
TBI are widely recognized as signature wounds of our recent 
conflict in Iraq and Afghanistan, we know that these conditions 
are more than just war injuries. We know that PTSD is triggered 
by a traumatic event. That traumatic event can be combat-
related, but all too frequently, the trigger event can be 
military sexual assault. While we continue our efforts to rid 
the military of this scourge, we must provide world-class 
treatment to the survivors of this horrendous crime.
    I am particularly interested in learning more about PTSD 
that is caused by sexual assaults. Specifically, I would like 
to know if PTSD presents itself differently in male survivors 
versus female survivors, and how treatment for PTSD meets the 
unique needs of male survivors of sexual assault.
    I'd also like to hear more about the state of the art in 
diagnosing and treating PTSD and TBI, the interaction between 
the two, and the ongoing research to improve diagnosis and 
treatment of these conditions. Over the years, our 
understanding of PTSD and TBI has grown substantially; however, 
there remains much more to be learned.
    Furthermore, we need to ensure that those who suffer from 
PTSD and TBI related to military service have access to a 
healthcare system that is able to meet their physical and 
mental healthcare needs. Our servicemembers, retirees, and 
their families deserve the highest-quality care.
    So, thank you each to our witnesses for the time and effort 
they've put into this important issue.
    Thank you.
    Senator Graham. Well, one, thank you for the compliment, 
Senator Gillibrand. It's been a pleasure working with you and 
your staff.
    Captain, please.

 STATEMENT OF CAPTAIN WALTER M. GREENHALGH, MC, USN, DIRECTOR 
  FOR THE NATIONAL INTREPID CENTER OF EXCELLENCE DIRECTORATE, 
          WALTER REED NATIONAL MILITARY MEDICAL CENTER

    Captain Greenhalgh. Well, good afternoon, sir. Thank you.
    Well, good afternoon, Chairman Graham, Ranking Member 
Gillibrand, and members of the subcommittee. Thank you all for 
the opportunity to discuss with you the Department of Defense's 
efforts to prevent, diagnose, treat, and research traumatic 
brain injury, or TBI, and its associated psychological health 
comorbidities.
    As the Director for the National Intrepid Center of 
Excellence, or NICoE, at the Walter Reed National Military 
Medical Center in Bethesda, I lead a team of exceptional 
professionals whose mission is to improve the lives of patients 
and families impacted by TBI and psychological health issues.
    Through the generosity of the American people and the 
Intrepid Fallen Heroes Fund, NICoE opened in 2010 on the Walter 
Reed Bethesda campus, followed by five of the proposed nine 
Intrepid Spirit Centers, or NICoE satellites, to be build on 
military installations around the country. Together, we've 
created an integrated TBI care network. It's a very important 
component of the military health system's TBI pathway of care, 
as managed by the Defense and Veterans Brain Injury Center.
    This past year, NICoE officially transitioned into the 
Walter Reed National Military Medical Center command structure, 
becoming a directorate within the flagship of military medicine 
and formalizing research support and collaboration from the 
Uniformed Services University of the Health Sciences, also on 
the Bethesda campus.
    This completely integrated approach to our work, leveraging 
the expertise and resources of Walter Reed's outpatient TBI 
programs, inpatient consultation service, and Uniformed 
Services University's research capabilities allows us to serve 
our unique patient population in a seamless fashion, using the 
entire TBI care portfolio available on America's Academic 
Health Campus in Bethesda.
    An important part of the Federal TBI continuum of care in 
the TBI research mission--is the TBI research mission. NICoE 
and the network of military health system TBI Care Centers, in 
collaboration with partners, including the Veterans 
Administration, National Institutes of Health, Uniformed 
Services University, and other Federal academic and private 
institutions, continue to push the boundaries of innovation 
with cutting-edge translational research.
    One signature collaborative project is the congressionally 
mandated longitudinal 15-year study to comprehensively 
categorize servicemembers and their caregivers affected by TBI. 
Another example is the neuroimaging core research project, with 
over 1,000 servicemembers affected by TBR thus far evaluated 
clinically and with state-of-the-art neuroimaging capability, 
collecting over 40,000 imaging and clinical datapoints for 
study per patient.
    In addition to our high-tech research, NICoE is actively 
engaged in clinical research on our high-touch aspects of our 
program, such as our National Endowment for the Arts-supported 
Therapeutic Arts Program and our congressionally supported 
research on Kindergarten-9 assisted therapy. And by tracking 
both the short- and long-term outcomes of our programs, we are 
also able to rapidly assess and accelerate discovery more 
effectively using every taxpayer dollar by putting the research 
and its findings immediately to use at the deckplates amongst 
our patients.
    So, I'm grateful for the opportunity to represent the men 
and women working at NICoE, as well as the patients we're 
honored to serve. I look forward to answering your questions 
today.
    Thank you.
    [The joint prepared statement of Captain Greenhalgh and 
Captain Colston follows:]

  Joint Prepared Statement by Captain Mike Colston, M.D. and Captain 
                        Walter Greenhalgh, M.D.
    Chairman Graham, Ranking Member Gillibrand and members of the 
Committee, we are pleased to discuss the Department of Defense's (DOD) 
efforts to promote psychological health (PH) and prevent, diagnose, and 
treat traumatic brain injury (TBI) and behavioral health conditions. We 
are honored to be joined by Dr. Amy Street, the Deputy Director of the 
Department of Veteran Affairs' (VA) National Center for Post-Traumatic 
Stress Disorder's (PTSD) Women's Health Sciences Division.
    We want to thank the Committee for its sustained leadership and 
support for the work we perform in the Military Health System (MHS) to 
care for our Nation's Service members, veterans, and their families--
especially those dealing with the complex issues of PH and TBI. Your 
investments in medical research have led to important advancements in 
care and a greater understanding of where future research should be 
targeted.
    Advances in combat medicine and protective equipment have saved the 
lives of countless Service men and women who would have died from their 
injuries in conflicts of the past. With that welcome increase in 
survival rates, however, comes a lifelong obligation to Service members 
whose road to recovery, both physical and mental, is long. By their 
nature, the signature invisible wounds of our recent wars--PTSD and 
TBI--demand greater sensitivity in identification of the injury or 
illness, as well as an ability to coordinate treatment with other 
injuries.
    Over the last 15 years over 300,000 Service members have suffered a 
TBI and over one million have been treated for behavioral health 
conditions. To meet these challenges, we have expanded the ability of 
our military hospitals, military clinics and network of civilian 
providers to treat these conditions, introduced new therapies to 
improve recovery, and generated a comprehensive portfolio of research 
efforts to advance the state of the science and drive evolution of 
care.
    Although our recent conflicts have added greater awareness and 
urgency to understanding PH and TBI, these medical conditions are not 
confined to military personnel alone. That is why the DOD has partnered 
with other government agencies, academic research institutions, and the 
private sector to share what we know and what we have learned, address 
our gaps in knowledge, and increase our collaboration on research. Many 
of the efforts and milestones that will be discussed today are a result 
of this ongoing collaborative work.
       current state of tbi/ph research, treatment, and therapies
    TBI and PH research represent complex undertakings, as these 
conditions are heterogeneous and often associated with other medical 
conditions. Our research often involves differentiating comorbidities 
like PTSD, depression, substance abuse, and chronic pain--all factors 
which can complicate the prevention and treatment of other PH 
conditions and TBI. The best way to account for these comorbidities, 
and effectively identify treatments and therapies, is through the kinds 
of comprehensive and longitudinal research efforts we have undertaken. 
What we've learned about the brain over the past decade of PH and TBI 
research outpaces any advancement of knowledge to date--and only 
through continued effort will we reap the benefits of the research we 
have begun.
    The President's Executive Order in 2012 directed Federal agencies 
to develop a coordinated National Research Action Plan (NRAP). This 
directive has accelerated the knowledge we have gained and strengthened 
inter-agency cooperation and coordination. The DOD, VA, and Department 
of Health and Human Services (HHS), responded to the Executive Order 
with a wide-reaching plan to improve scientific understanding, develop 
effective treatment, and reduce occurrences of PTSD, PH conditions, TBI 
and suicide. The NRAP represents the ten-year strategic blueprint for 
interagency research to identify and develop more effective diagnostic 
and treatment methodologies to improve outcomes for TBI and PH and we 
are eager to continue working with our inter-government partners to 
advance our understanding of these conditions.
    Specifically, two jointly funded VA and DOD consortiums are focused 
on priorities outlined in the NRAP: The Consortium to Alleviate PTSD 
(CAP), and the Chronic Effects of Neurotrauma Consortium (CENC). The 
CAP seeks to improve the psychological and physical health and well-
being of Operation Enduring Freedom, Iraqi Freedom, and New Dawn 
Service members and veterans by developing and evaluating the most 
effective preventive, diagnostic, prognostic, treatment and 
rehabilitative strategies for combat-related PH issues and comorbid 
conditions. The CENC is dedicated to establishing a comprehensive 
understanding of the chronic sequelae that may be associated with mild 
TBI. Together, CAP and CENC ensure that high priority research areas 
are being addressed and efforts are not being duplicated across or 
within agencies. This collaboration supports a more unified vision for 
research within the federal community to better anticipate and respond 
to emerging medical requirements.
    In 2012, DOD funded an independent study to assess access to mental 
health providers for more than 1.3 million Service Members and their 
families who reside in rural and remote locations. Initial results of 
the study were released in January 2015 and included a geospatial 
development tool to monitor locations of US military members, their 
families, and their distance from mental health care. Recommendations 
emerging from these findings included the increased use of telehealth 
and other technologies to improve access to care for remote 
populations. The Department is pursuing the study's recommendations, 
including incorporating the increased use of telehealth and other 
technologies to improve access to care for remote populations. We 
recently updated our policies on telehealth and telemedicine to 
encourage greater adoption by both providers and patients and continue 
work to expand utilization of telemedicine capabilities.
    The Department has taken other steps to increase access to needed 
behavioral health services, and we monitor our performance in access 
and quality. We have eliminated the limit on inpatient behavioral 
health bed days in our TRICARE program, and we are finalizing our 
policies to ensure alignment with the Mental Health Parity Act in 2016. 
The MHS is a leader among US health systems in achieving high rates of 
timely outpatient follow-up visits for patients with PTSD or depression 
after psychiatric hospitalization for PTSD: 86 percent of patients who 
were hospitalized were seen as an outpatient within 7 days of 
discharge; 95 percent were seen within 30 days. Additionally, 91 
percent of patients diagnosed with PTSD and 82 percent of patients with 
depression received psychotherapy.
    The Department has also introduced new approaches to how we screen 
for TBI in Service Members returning from deployment. Improvements in 
TBI screening, including screening in theater, and changes in the post-
deployment health assessment and re-assessment were based, in part, on 
evidence derived from DOD-funded studies.
    The use of integrated interdisciplinary treatment programs has also 
increased since 2007 due to evidence from DOD studies for management of 
severe TBI and a number of DOD-funded studies are cited by the Joint 
Theater Trauma System Clinical Practice Guideline Management of 
Patients with Severe Head Trauma. This highly practical guidance is 
revised annually and directs care for severe and penetrating TBI 
sustained in theater.
    DOD continues to develop innovative technologies in areas of TBI 
care that improve recovery and reintegration. Examples of novel 
interventions for TBI under study include neurofeedback, biofeedback, 
the interactive metronome, computer-based cognitive rehabilitation, and 
non-invasive electrical stimulation devices. To identify objective TBI 
screening, diagnostic, and assessment tools, the DOD is studying the 
effectiveness of innovative technologies such as portable devices to 
measure the brain's electrical activity, environmental sensors and 
other concussion detection systems, and neurocognitive assessment 
tools.
    Current progress in the upstream treatment of PH and TBI is 
exemplified by the inTransition program established in response to 
Executive Order 13625. The inTransition program pairs trained mental 
health professionals with Service members transitioning to new care 
teams in VA or in the local community. It has wide utilization--with 
over 10,000 calls per month and more than 15,000 extended coaching 
cases since its inception in February 2010. This number will continue 
to grow as all Service Members who are receiving mental health care and 
leaving military service are now automatically enrolled into the 
inTransition program. By enhancing coordination between referring and 
gaining providers, inTransition reduced the number of Service Members 
who disengage from mental health care during a period of change.
    In addition to the progress in PH and TBI treatment practices, our 
physical infrastructure has been expanded and improved over the past 
five years. The Defense and Veterans Brain Injury Center (DVBIC), 
National Intrepid Center of Excellence (NICoE), and other Intrepid 
Sites make up a network of treatment facilities across the world that 
focus on TBI care for Service members and their families. Located on 
military installations, providers at these facilities diagnose and 
initiate the treatment for patients referred with complex, comorbid PH/
TBI conditions; conduct focused research, and deliver expert treatments 
to improve TBI and PH outcomes. These centers leverage their collective 
reach and provide comprehensive TBI care throughout the MHS.. 
Additional DVBIC sites located in VA Polytrauma Rehabilitation Centers 
extend the scope of members and their families. Located on military 
installations, providers at these facilities diagnose and initiate the 
treatment for patients referred with complex, comorbid PH/TBI 
conditions; conduct focused research, and deliver expert treatments to 
improve TBI and PH outcomes. These centers leverage their collective 
reach and provide comprehensive TBI care throughout the MHS.. 
Additional DVBIC sites located in VA Polytrauma Rehabilitation Centers 
extend the scope of members and their families. Located on military 
installations, providers at these facilities diagnose and initiate the 
treatment for patients referred with complex, comorbid PH/TBI 
conditions; conduct focused research, and deliver expert treatments to 
improve TBI and PH outcomes. These centers leverage their collective 
reach and provide comprehensive TBI care throughout the MHS.. 
Additional DVBIC sites located in VA Polytrauma Rehabilitation Centers 
extend the scope of
          future of tbi/ph research, treatment, and therapies
    Research has provided many answers and influenced improvements to 
care--however, gaps remain in the nation's scientific knowledge about 
PH and TBI, gaps that we are working diligently to address.
    Coordinated research efforts to accelerate discovery of the 
mechanisms underlying behavioral health conditions, TBI, and other 
comorbidities remain a top priority. Understanding pathophysiology 
allows researchers to target treatment more efficiently and identify 
new targets for treatment. Our research plan outlines a timeline to 
work towards developing effective biomarkers that detect disorders 
early and accurately. Additionally, the NRAP work group is 
orchestrating better coordination of federal research strategies and 
investments. Major efforts include the Federal Interagency TBI Research 
(FITBIR) Registry to share research data, use of Federal RePORTER and 
other interagency databases to share research portfolio information, 
and a Joint Strategic Portfolio Reviews and Analyses to discuss current 
activities, priorities, and remaining gaps.
    In 2001 the DOD initiated the largest longitudinal study of Service 
Members, Veterans, and their families in US military history--the 
Millennium Cohort Study. This epidemiological study includes more than 
200,000 participants across the globe, with a planned follow-up for 21+ 
years to evaluate the long-term impact of military experiences during 
and after the time of military service. The Millennium Cohort Study 
offers a unique opportunity to define the challenges that Service 
Members, Veterans and military families experience. This will serve to 
advance the understanding of protective and vulnerability factors that 
can then be used to design training and treatment programs into the 
future.
    Our partnership programs also provide us with important insights. 
Working with the National Collegiate Athletic Association (NCAA), DOD 
created the Concussion Assessment, Research and Education (CARE) 
Consortium to conduct a large-scale, multi-site study of the natural 
history of concussion in both sexes across multiple sports. The aim of 
the study is to address current gaps in our knowledge, and shed light 
on the neurobiological mechanisms of concussion symptoms and the 
trajectory of recovery. It will provide information on a cohort of 
individuals with SRC, and contribute to other datasets for public use 
and drive a more informed public discussion about concussion care and 
policy.
    In addition to these advancements made in research, treatment, and 
therapies--the MHS is working internally to make PH and TBI efforts 
more effective, cost-efficient, and beneficial to Service Members, 
Veterans, and their families. DCoE estimates there are more than 200 
programs receiving DOD funding to provide both clinical and non-
clinical psychological health or TBI services for Service Members and 
family members. Such services account for more than $1 billion 
annually. DOD has begun a multifaceted approach to examine program 
effectiveness to review the value of these programs, ensuring they both 
are non-duplicative and informed by clinical evidence.
    Beginning in fiscal year 2015, DCoE implemented onsite program 
evaluations with current DOD-funded PH and TBI programs to measure 
program effectiveness and meet the intent of NDAA [National Defense 
Authorization Act] directives. DCoE's program evaluation efforts are 
DOD's primary mechanism to comprehensively document program efficacy 
within the MHS.
                               conclusion
    Scientific progress is incremental and takes time, but Service 
Members and their families need solutions. The progress the 
Department--and the Nation--has made in the past 10 years has led to an 
expanded knowledge base and cutting-edge treatments that have improved 
the lives of our Service Members, Veterans, their families, and all 
Americans. Yet, we are neither complacent nor satisfied with our 
achievements. Our mission is urgent. We have a long-term plan to 
continue to improve our treatment of these very complex medical 
conditions. We are honored to represent the Department of Defense today 
on behalf of the men and women who conduct such vital research, and 
deliver care in support of such a special population. We are grateful 
for the ongoing support of this Committee and the Congress in 
supporting our efforts, and we look forward to answering your 
questions.

  STATEMENT OF CAPTAIN MICHAEL J. COLSTON, MC, USN, DIRECTOR, 
  DEFENSE CENTERS OF EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND 
                     TRAUMATIC BRAIN INJURY

    Captain Colston. Chairman Graham, Ranking Member 
Gillibrand, members of the subcommittee, thank you for support 
of our Nation's servicemembers, veterans, and their families.
    I'm pleased to share DOD's efforts to foster research for 
PTSD and other psychological health conditions, TBI, and 
comorbidities, including substance-use disorders, pain 
disorders, and suicide.
    Last year, over a quarter of our servicemembers were 
treated for these conditions, so please allow me to discuss how 
we evolved to support the need. We reduced barriers to care, 
including stigma. We expanded access to care by tripling the 
size of our mental health infrastructure. We improved 
transition points in the continuum of care. And we improved our 
system's ability to treat the sickest patients. All the while, 
we developed a comprehensive research portfolio to study PTSD, 
TBI, and suicide.
    DOD partners with other government agencies, academia, and 
the private sector in research. The centerpiece of our 
collaborative efforts is the National Research Action Plan, or 
NRAP. NRAP brings together DOD, VA, the Department of Health 
and Human Services, and the Department of Education, improving 
our understanding of TBI and PTSD. But, there are challenges. 
One challenge is ascertaining why PTSD, TBI, depression, 
substance-use disorders, and chronic pain all present together. 
Longitudinal research efforts, like the Millennium Cohort Study 
and the 15-year study on TBI, will aid our understanding, just 
as the Framingham Study helped elucidate factors in 
cardiovascular disease.
    PTSD treatment has a wide evidence base, with A-level 
evidence supporting the use of therapy and medications for PTSD 
survivors, irrespective of trauma, be it developmental, be it 
sexual, or be it from the ravages of war. We, nonetheless, face 
challenges in how best to structure our health system to 
support those interventions.
    Health systems research is imperative. Answering mandates 
from Congress in NDAAs '13 and '15, agency priority goals, and 
DOD's Cost Analysis and Program Evaluation Office, my center, 
the Defense Centers of Excellence for Psychological Health and 
TBI, is halfway through a 5-year effort to evaluate 
psychological health in TBI programs for effectiveness, 
including outcomes and fiscal granularity. Cooperation with 
academia and federally funded research and development centers 
aids us in this effort, leading to analyses focused on results.
    With your continued support, I'm confident our discoveries 
will bear fruit in the years ahead. And I look forward to 
answering your questions.

  STATEMENT OF AMY E. STREET, DEPUTY DIRECTOR, WOMEN'S HEALTH 
  SCIENCES DIVISION, NATIONAL CENTER FOR POSTTRAUMATIC STRESS 
                            DISORDER

    Dr. Street. Good afternoon, Chairman Graham, Ranking Member 
Gillibrand, and members of the subcommittee.
    As a researcher whose work is focused on military sexual 
trauma, MST, and a psychologist with the Department of Veterans 
Affairs who works with veterans who have experienced MST, I am 
grateful for the opportunity to speak about the current state 
of research related to MST and the diagnosis and treatment of 
conditions associated with MST, with a particular focus on 
post-traumatic stress disorder. I'm also honored to be seated 
with my colleagues representing the Department of Defense.
    Research indicates that experiences of sexual harassment 
and sexual assault during military service are far too common. 
Data from the 2014 RAND [Research and Development] Military 
Workplace Study indicated that 1 percent of servicemen and 5 
percent of servicewomen were sexually assaulted in the past 
year, impacting an estimated 20,300 Active Duty servicemembers. 
The majority of these assaults occurred in military settings or 
were perpetrated by military personnel.
    Experiences that constitute sexual harassment are even more 
common, with 7 percent of servicemen and 22 percent of 
servicewomen experiencing sexual harassment in the past year. 
My own research demonstrates that experiences of sexual 
harassment and sexual assault are common among troops deployed 
in support of military operations in Afghanistan and Iraq, 
raising the possibility that servicemembers may have been 
exposed to multiple types of severe traumatic stress during 
military operations in these countries.
    MST is an experience, not a diagnosis. And servicemembers 
and veterans will vary in their reactions to MST. Our men and 
women in uniform are remarkably resilient after being exposed 
to traumatic events, but, sadly, many will go on to face long-
term difficulties with mental health after experiencing MST.
    MST is strongly associated with a range of mental health 
conditions, but MST has a particularly strong association with 
PTSD. Research data from veteran samples indicates that 
experiences of MST are an equal or stronger predictor of PTSD, 
as compared to other military-related stressors, including 
exposure to combat.
    In my clinical experience, veterans who have experienced 
MST often struggle with feelings of betrayal, either by 
perpetrators whom they believed to be comrades in arms or by 
the military system that they believed should have protected 
them. MST survivors may also struggle to integrate a victim 
identity with the value they place on their own strength and 
self-sufficiency as former or current servicemembers. Others 
who felt that they had to leave military service prematurely 
may experience grief or anger at losing a military career due 
to the tangible and intangible injuries caused by their alleged 
perpetrators, or, in their view, inadequate action taken by 
their leadership to protect them from such harm.
    Many still think that only servicewomen experience MST, but 
servicemen do, too. Although the rates of sexual assault are 
lower among military men than among military women, in absolute 
numbers, more servicemen than servicewomen experienced sexual 
assault in the past year.
    Research on the mental health consequences of sexual trauma 
among men has lagged behind similar research among women, but, 
increasingly, the data suggests that the mental health 
consequences of MST may be more significant for male veterans 
than for female veterans.
    Fortunately, recovery is possible after experiences of MST. 
And VHA [Veterans Health Administration] has services spanning 
the full continuum of counseling, care, and services to assist 
eligible veterans in these efforts. Recognizing that many 
survivors of sexual trauma do not disclose their experiences 
unless asked directly, it is VA policy that all veterans 
receiving healthcare be screened for experiences of MST. 
Veterans who disclose MST experiences are offered a referral 
for mental health services. All VA counseling, care, and 
services determined to be necessary to overcome the 
psychological trauma of MST is provided free of charge. A 
veteran's eligibility for MST-related care is entirely separate 
from the veteran's entitlement to VA disability compensation 
for the same conditions. Every VA Medical Center provides MST-
related counseling, care, and services. MST coordinators are 
available at every VA Medical Center to assist veterans in 
accessing these services.
    Issues related to brain health and head trauma transcend 
the veteran and military community, impacting all Americans. 
Today, Secretary Bob McDonald is participating in VA's 
groundbreaking 2-day event focused on brain health, Brain Trust 
Pathways to Innovation. This first annual public-private 
partnership event is convening many of the most influential 
voices in the field of brain health, to include the Department 
of Defense, the sports industry, private sector, Federal 
Government, veterans, and community partners, to identify and 
advance solutions for mild traumatic brain injury and post-
traumatic stress disorder. The event will also serve as a 
showcase for many of the advancements that VA is pioneering to 
improve brain health for veterans, the military, and for the 
American public.
    Mr. Chairman, I appreciate the opportunity to appear before 
you today. And I'm prepared to answer any questions you or the 
committee may have.
    [The prepared statement of Dr. Street follows:]

                  Prepared Statement by Dr. Amy Street
    Good afternoon, Chairman Graham, Ranking Member Gillibrand, and 
Members of the Subcommittee. Thank you for the opportunity to speak 
about the VA current state of research related to military sexual 
trauma (MST), and the diagnosis and treatment of mental health 
disorders associated with MST, with a particular focus on posttraumatic 
stress disorder (PTSD).
    VA uses the term ``Military Sexual Trauma'' to refer to 
psychological trauma, which in the judgment of a mental health 
professional employed by the Department, results from a physical 
assault of a sexual nature; battery of a sexual nature; or sexual 
harassment, which occurred while the Veteran was serving on active 
duty, active duty for training, or inactive duty training. For purposes 
of this program, sexual harassment means repeated, unsolicited verbal 
or physical contact of a sexual nature which is threatening in 
character. MST is an experience--not a diagnosis--and Servicemembers' 
and Veterans' will vary in their reactions to MST. Our men and women in 
uniform are remarkably resilient after being exposed to traumatic 
events; but, sadly, many will go on to experience long-term 
difficulties with mental health after experiencing MST.
    We know that experiences of sexual harassment and sexual assault 
during military service are far too common. Data from the 2014 RAND 
Military Workplace Study, using questionnaires that assessed incidents 
consistent with sex crimes under the Uniform Code of Military Justice, 
Article 120, indicated that 1 percent of Servicemen and 5 percent of 
Servicewomen were sexually assaulted in the past year, impacting an 
estimated 20,300 active component Servicemembers. The majority of these 
assaults occurred in military settings or were perpetrated by military 
personnel. Experiences that constitute sexual harassment are even more 
common. Using questionnaires that assessed incidents consistent with 
sex-based military equal opportunity (MEO) definitions of these 
offenses, seven percent of Servicemen and 22 percent of Servicewomen 
experienced sexual harassment in the past year. My own research 
demonstrates that experiences of sexual harassment and sexual assault 
are common among troops deployed in support of military operations in 
Afghanistan and Iraq, raising the possibility that Servicemembers may 
have been exposed to multiple types of severe traumatic stress during 
military operations in these countries.
    Experiences of MST are strongly associated with a range of mental 
health conditions. These mental health disorders can include depression 
and substance use disorders, but experiences of MST have a particularly 
strong association with PTSD. In fact, research data from civilian 
samples demonstrates that rape is the traumatic experience with the 
strongest predictive probability of PTSD. Research data from Veteran 
samples indicates that experiences of MST are an equal or stronger 
predictor of PTSD as compared to other military-related stressors, 
including exposure to combat. In addition, experiences of MST may be a 
stronger predictor of PTSD than experiences of sexual assault that 
occurred during childhood or occur during adult civilian life. In my 
clinical experience, Veterans who have experienced MST often struggle 
with feelings of betrayal, either by perpetrators whom they believed to 
be ``comrades in arms'' or by the military system that they believe 
should have protected them. MST survivors may also struggle to 
integrate a ``victim identity'' with the value they place on their own 
strength and self-sufficiency as a former or current Servicemember. 
Others who felt that they had to leave military service prematurely 
(for instance, because of actual or perceived health or safety issues 
related to their MST experience) may experience grief or anger at 
losing a military career due to the tangible and intangible injuries 
caused them by their alleged perpetrators or, in their view, inadequate 
action taken by their leadership to protect them from such harm.
    Many still think that only Servicewomen experience MST, but 
Servicemen do, too. Although the rates (percentages) of sexual assault 
are lower among military men than among military women, more Servicemen 
in absolute numbers than Servicewomen experienced sexual assaulted in 
the past year. Further, men who are sexually assaulted are more likely 
than women to have been physically injured or to have been threatened 
with physical injury during the assault, and men's experiences are more 
likely to involve multiple assailants. Research on the mental health 
consequences of sexual trauma among men has lagged behind similar 
research among women. However, the data increasingly suggest that the 
associations between experiences of MST and mental health disorders, 
while substantial for female Veterans, appear to be even stronger for 
male Veterans. \1\
---------------------------------------------------------------------------
    \1\ Gender differences in experiences of sexual harassment: data 
from a male-dominated environment.
    AE Street, JL Gradus, J Stafford, K Kelly--Journal of consulting 
and clinical psychology, 2007
    Ann Epidemiol. 2005 Mar;15(3):191-5.
    The role of sexual assault on the risk of PTSD among Gulf War 
Veterans.
    Kang H \1\, Dalager N, Mahan C, Ishii E.
    J Trauma Stress. 2005 Jun;18(3):272-84.
    Deployment stressors, gender, and mental health outcomes among Gulf 
War I Veterans.
    Vogt DS\1\, Pless AP, King LA, King DW.
---------------------------------------------------------------------------
               military sexual trauma-related care in vha
    Fortunately, recovery is possible after experiences of MST, and VHA 
has services spanning the full continuum of counseling, care, and 
services to assist eligible Veterans in these efforts. Recognizing that 
many survivors of sexual trauma do not disclose their experiences 
unless asked directly, it is VA policy that all Veterans receiving 
healthcare be screened for experiences of MST. Veterans who disclose 
MST experiences are offered a referral for mental health services. All 
VA counseling, care, and services determined to be necessary to 
overcome the psychological trauma of MST, including the clinical 
manifestation of related PTSD, is provided free of charge. A Veteran's 
eligibility for MST-related counseling, care, and services is entirely 
separate from the Veteran's entitlement to VA disability compensation 
for the same mental health disorder(s). That is, a Veteran's 
eligibility for MST-related counseling and care is not conditioned on 
the Veterans Benefits Administration having adjudicated the MST-related 
mental health disorder to be service-connected. In addition, Veterans 
who meet the eligibility criteria of 38 U.S.C. section 1720D(a)(1) are 
able to receive MST-related counseling, care, and services, even if 
they are not eligible to be enrolled in VA's health care system or 
receive other VA health care. Every VA medical center provides MST-
related counseling, care, and services; MST Coordinators are available 
at every VA medical center to assist Veterans in accessing these 
services. Many community-based Vet Centers also have specially-trained 
MST counselors.
                      effective treatment of ptsd
    VA is strongly committed to delivering quality care to all Veterans 
with PTSD, including those whose PTSD results from MST. Advances in 
research have led to a range of effective treatments for PTSD that 
reduce symptoms and increase functioning and well-being. The VA/DOD 
Clinical Practice Guidelines, titled Management of Post-Traumatic 
Stress Disorder and Acute Stress Reaction (2010)), recommend trauma-
focused cognitive behavioral therapy [such as Prolonged Exposure (PE), 
and Cognitive Processing Therapy (CPT)], Eye Movement Desensitization 
and Reprocessing, stress inoculation, selective serotonin reuptake 
inhibitors, and venlafaxine, a serotonin norepinephrine reuptake 
inhibitor, as primary treatments for PTSD. PE and CPT are among the 
most widely studied types of trauma-focused cognitive behavioral 
therapy. Evidence demonstrating their effectiveness is particularly 
strong. These treatments have great relevance for MST survivors as much 
of the early work developing and testing both PE and CPT occurred among 
sexual assault survivors in the civilian population.
    VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical 
Centers and Clinics, requires that all VA medical centers provide 
access to either PE or CPT. VA has supported this requirement by 
training upwards of 7,000 therapists in these treatments as part of a 
broader initiative to disseminate evidence-based psychotherapy for 
mental health disorders. Uptake of PE and CPT across the VA health care 
system was rapid; by 2009, 96 percent of VA facilities were providing 
PE or CPT and 72 percent were providing both. VA also offers a range of 
treatment options to treat PTSD and associated symptoms and is using 
telehealth technologies to increase the availability of treatment for 
PTSD. VA remains open to new and innovative treatments for PTSD and 
supports research on these treatments as part of its portfolio on PTSD 
and related mental health disorders.
                               conclusion
    Mr. Chairman, I appreciate the opportunity to appear before you 
today. I am prepared to answer any questions you or other Members of 
the Committee may have.

    Senator Graham. Well, thank you all very much.
    I'll start. And it was a excellent----
    Dr. Street, if someone is a victim of sexual assault in the 
military, can they get a disability rating because of the PTS 
[Post-traumatic Stress]?
    Dr. Street. So, a disability rating would be provided for 
PTSD. So, because military sexual trauma is the experience and 
not the diagnosis, it would be the diagnosis related to the 
experience--in this case, PTSD--that the disability rating 
would come from. And yes, they can.
    Senator Graham. So, if someone has been assaulted, and they 
get PTSD, they qualify.
    Dr. Street. That's right. They would then go through the 
same process that a veteran who experienced PTSD related to 
combat----
    Senator Graham. Okay.
    Dr. Street.--that same disability assessment process.
    Senator Graham. Captain Greenhalgh, when--what's the 
process we use when people return from the battle theater, in 
terms of evaluating them to make sure that we're catching 
things that they may have experienced?
    Captain Greenhalgh. Yes, sir. Well, the--you know, if we're 
talking about traumatic brain injury, for example, it actually 
doesn't start after they leave the battlefield; it starts on 
the battlefield, with--not necessarily symptom-related 
evaluations and screening, but event-related. So, if a 
servicemember, for example, is involved in a--an IED 
[improvised explosive device]--if they're within 50 meters of 
an IED blast, for example, or a rollover accident, it's not up 
to, necessarily, the medical leadership to say they need to get 
screened; the line leadership, the battle buddy, will ensure 
that that person is screened on the battlefield or at the 
local, you know, forward medical unit. So, that's when the 
screening does begin.
    Now, certainly if somebody falls through that crack or is 
not, you know, involved in a significant----
    Senator Graham. Right.
    Captain Greenhalgh.--injury or event, when they return from 
the battlefield, there is immediate post-deployment health risk 
assessments that are performed. Actually, a cycle of three of 
them are performed within--shortly after return, then 90 days 
later, 180 days later.
    Senator Graham. What have we--how old is this system?
    Captain Greenhalgh. Excuse me, sir?
    Senator Graham. How old is this system that you've just 
described?
    Captain Greenhalgh. Well, I, myself, deployed about 4 years 
ago, and it had already been in effect several years before 
that. Now, it's been modified, I think, you know, at----
    Senator Graham. Do you think it's working?
    Captain Greenhalgh. I think it's as good as it can be right 
now, because we are--you know, we're basically not waiting for 
the patients to come to us with----
    Senator Graham. Right.
    Captain Greenhalgh.--symptoms; we're basically asking them 
about symptoms that maybe others wouldn't necessarily associate 
with a traumatic brain injury, and they're----
    Senator Graham. When it comes to prevention--I'm sure there 
are all kind of technical things we're trying to do to protect 
the brain in a IED attack, but when it comes to PTS or--what 
kind of preventive measures are we employing?
    Captain Greenhalgh. With regards to the psychological 
health, sir?
    Senator Graham. Yes.
    Captain Greenhalgh. I mean, I think that prevention begins 
long before they deploy, and it has to do with training and--
being adequately trained and knowing their--you know, kind of 
knowing their algorithms. You know, we don't want to overtrain 
people. You want--you know, when they're in training, you would 
say, you know, ``train like you fight,'' but you want them to 
have adequate rest, let--to allow, you know, brain rest, as 
well. But, you know, sort of----
    Senator Graham. Are we teaching people what to watch out 
for in their buddies?
    Captain Greenhalgh. No, absolutely. I think there's--just 
from the psychological health perspective, certainly, and from 
the traumatic brain injury perspective, as well, there's a lot 
of training that goes on before they deploy. And then, 
depending on how long a servicemember is in theater, there's 
mandatory screening that occurs if they're there for more than 
6 months, even if they're not involved in any sort of any 
specific event.
    Senator Graham. Do you feel you have adequate resources at 
the moment to do your job?
    Captain Greenhalgh. Well, sir, you know, we'd always love 
to have more.
    Senator Graham. Right.
    Captain Greenhalgh. But, I think that, especially with a 
drawdown in commitments overseas, what we're finding is that 
the resources aren't necessarily needed for the Active, you 
know, returning-off-the-battlefield servicemember as much as 
they were just 3 or 4 years ago. I think it's more for the 
long-term commitment that we have to these servicemembers, some 
of whom were injured years ago, understanding that it's not a, 
you know, patch 'em up and send 'em back out to the real world. 
Some of these----
    Senator Graham. Right.
    Captain Greenhalgh.--people suffer for years. And along 
with our, you know, VA colleagues, this is a long-term 
commitment, and that's where I think the nature of the type of 
support that we need definitely changes.
    Senator Graham. Do you think the handoff between DOD and 
the VA is working?
    Captain Greenhalgh. I think it's working better than it 
ever has, sir.
    Senator Graham. Do you agree with that, Ms. Street--Dr. 
Street?
    Dr. Street. I do.
    Senator Graham. Captain Colston, you said that 25 percent 
of the force has been treated for--for what?
    Captain Colston. Yes, sir. So, one of the things that we 
actually do is, in transition, where we--when we do handoffs 
from DOD to VA, we look at who's been treated in the last year. 
And it's at about 20 percent for psychological health 
conditions, and then, for other conditions, such as substance-
use disorders, pain disorders, depression, that kicks it over 
25 percent. So, we have a large cohort of treated people right 
now, sir.
    Senator Graham. So, from a DOD perspective, this is a 
problem.
    Captain Colston. Oh, absolutely, sir. And it's one, 
certainly, that we've devoted a lot of resources to, that we 
have really made a number of turnarounds for.
    Senator Graham. Well, just to stay within time, here--do 
you see any promising therapies in the future? Hyperbaric 
oxygen treatment, I've heard a lot about that. There's a 
program, I think, in Myrtle Beach. People really believe in it. 
There are all kind of ideas out there. Could you tell me a 
little bit about that treatment and what you see coming in the 
future?
    Captain Colston. Well, I think hyperbaric oxygen treatment, 
we've done about seven studies on that right now. None of them 
failed to show any effect beyond a placebo effect. But, we have 
all kinds of innovative strategies, and we also have a number 
of A-level evidence-based strategies for PTSD. I think 
innovations in the future are going to include biomarkers, 
neuroimaging, and, really, better ascertainment of the disease 
states of PTSD and TBI and the other things that run with it.
    Senator Graham. Okay. Well, we'll let the hyperbaric 
people--you'll have your say. You can write us a report about 
it.
    Senator Gillibrand.
    Senator Gillibrand. Thank you, Mr. Chairman.
    Victims and experts have stated that the response to 
military sexual trauma is more similar to that of incest than 
other forms of sexual assault. How many survivors of MST go on 
to develop PTSD, is the first question? And for MST survivors 
who develop PTSD, how do they present differently from those 
with PTSD stemming from other kinds of traumatic events?
    Doctor?
    Dr. Street. We know that experiences of sexual assault, 
including experiences of sexual assault during military 
service, are one of the strongest predictors of PTSD. It's the 
type of event that's associated with PTSD symptoms among both 
women and men, as I mentioned, even more strongly for men than 
for women.
    And the symptoms of PTSD related to MST look really quite 
similar than the symptoms of PTSD related to other forms of 
traumatic stress, although survivors of MST may report certain 
kinds of issues more frequently than other types of trauma 
survivors. So, for example, issues around intimacy and 
sexuality, issues around interpersonal relationships and 
boundaries, certainly issues around trust, issues around self-
blame. Those are issues that come up, I think, much more 
frequently in--when working with sexual trauma survivors.
    Senator Gillibrand. In the last report we got, 62 percent 
of the people who reported that they were sexually assaulted 
were retaliated against--from their perspective, some form of 
retaliation. How does the experience of not being believed or 
being retaliated against affect PTSD symptoms?
    Dr. Street. It worsens it. I've done research indicating 
that a victim's experiences in reporting, in the system, and 
how they feel about that experience--if they feel positively 
about it, if they feel like they were believed--that is a 
strong predictor above and beyond the traumatic experience of 
how they're doing, years later, in terms of PTSD and depression 
symptoms.
    Senator Gillibrand. Last December, there was a study 
completed by the VA researchers that was published in the 
American Journal of Preventive Medicine on the link between 
military sexual trauma and death by suicide. The study found 
that MST was a significant risk factor for suicide among men 
and women, even controlling for other psychiatric disorders. 
What implications do these findings have for screening and 
treating patients with MST?
    And then, to Captain Colston, how do these findings inform 
screenings and treatment of servicemembers? And what kind of 
outreach do you encourage survivors of MST to seek care?
    Dr. Street. So, we do, as I mentioned, screen every veteran 
for experiences of MST, in the VA, which that study would 
suggest is particularly important, because, unlike other types 
of traumatic events, the risk associated with MST for suicide 
doesn't run fully through PTSD or depression; it exists 
separate from that. So, it's just why it's so important that we 
screen specifically for experiences of military sexual trauma, 
so that those patients can be followed up with, in terms of 
suicide risk, directly.
    Senator Gillibrand. Captain?
    Captain Colston. Yes, ma'am. I'd agree with--yes, ma'am, 
I'd agree with Dr. Street. Suicide risk is increased from 
sexual assaults, aside from PTSD. PTSD itself is not 
necessarily a robust risk factor for suicide. It does have a 
hazard ratio that suggests that it's associated with suicide, 
but certainly sexual trauma is a really big factor.
    Developmental trauma, especially developmental sexual 
trauma, stuff that I've seen as a child psychiatrist, that's a 
huge risk factor and something that actually affects the brain 
as it develops, makes you kind of check the horizon for if 
you're safe all the time.
    Senator Gillibrand. Although the prevalence for military 
sexual trauma is higher among women, given the significantly 
larger portion of men in the Armed Forces, there are similar 
numbers of men and women who have survived sexual trauma. How 
do men differ in their response to MST? And how do VA services 
meet the unique needs of men who have survived MST? And are 
treatments for PTSD related to MST different for men and women? 
And, if so, how? And is there a detectable difference in male 
suicide rates?
    Dr. Street. So, male and female survivors of MST look more 
similar than they do different, although men's experiences may 
be exacerbated, in terms of symptomatology, although the 
symptoms themselves are the same. Men--male survivors do 
struggle uniquely with concerns about their masculinity, 
understanding what this says about their sexual orientation, a 
lot of self-blame, ``Why was I targeted for this?'' This isn't 
something that men usually experience.
    In terms of treatments, the treatments look very similar. I 
think differences, in terms of male and female survivors, 
really comes in when we think about our social marketing and 
our outreach. We're very careful to have outreach materials 
that are specifically targeted to male survivors, to include 
pictures of men on all of our outreach materials about MST, in 
addition to pictures of women, so that men can understand that 
our MST treatment services are there for them as well as those 
for women.
    Captain Colston. I'd say one of the things that we struggle 
with, the prevalence of sexual assault in women compared to men 
is probably about five to one. And Dr. Street's data and Nate 
Galbreath's data at SAPRO, and some of Ron Kessler's data from 
Harvard, support that.
    One of the things that we struggle with is getting men into 
care. Men are less apt to engage in care for sexual assault. 
And, in fact, in therapy, that's something that you may address 
way downstream. It's not an initial or presenting problem.
    Senator Gillibrand. It's why I have a concern that the 
suicide rate might be higher, because if----
    Captain Colston. Well, I----
    Senator Gillibrand.--male survivors won't report, they 
don't get any care. And, just anecdotally, I met a male 
survivor who attempted suicide, was not successful, paralyzed 
himself in his--shooting himself in the spine, and was 
paralyzed for the rest of his life. But, he couldn't face his 
life, he couldn't face his wife, he couldn't face anything 
after it. And instead of seeking treatment--or, actually--he 
actually did, but, for many survivors, instead of seeking 
treatment, they just commit suicide.
    Captain Colston. There's no question that it's a trauma 
that's very hard to overcome. And it's very hard for us to get 
granular exactly about what the problem is. There's----
    Senator Gillibrand. Yeah.
    Captain Colston.--on the order of 300 risk factors 
associated with suicide. Certainly, sexual assault is one of 
them. PTSD is one of them.
    One thing is, I think, you know, with regard to VA care and 
some of the promising things, we see that veterans who have 
PTSD have lower suicide rates than other veterans. So, I think 
there are some promising developments in the treatment and in 
the turnover from DOD to VA.
    Senator Gillibrand. Thank you.
    Senator Graham. For the record, Senator Cotton served a 
tour of duty in combat in Iraq. I think you were a platoon 
leader and--is that correct?
    So, Senator Cotton.
    Senator Cotton. Thank you, Chairman Graham.
    And I can say that the system that Captain Greenhalgh 
described has been in effect for at least 10 years, at least in 
the Army.
    I want to talk briefly about the relationship between 
traumatic brain injury and post-traumatic stress. Does--one 
does not necessarily presume or infer the other. Is that 
correct?
    Captain Greenhalgh. Not necessarily, sir. I think, 
certainly, if someone has been exposed in a traumatic event 
downrange that resulted in a traumatic brain injury, I think 
the possibility is greater that they will also have comorbid 
post-traumatic stress along with that. I do believe that a 
history of TBI sort of predisposes someone to be more 
vulnerable to psychological health issues downrange, or down 
the road. And some of that has to do with the chronic effects, 
if that is a servicemember who has chronic effects of the TBI, 
developing some symptoms that are very suggestive also of 
psychological health issues. There's a lot of overlap there, as 
well.
    Captain Colston. And I'd say patients often present to us 
in an undifferentiated state. They'll present, maybe, with 
their--with a problem with suicidality, maybe a substance-use 
disorder, maybe a pain disorder. Sometimes it's very hard for 
us to discern what the precipitant was.
    Dr. Street. I have nothing to add.
    Senator Cotton. Is one easier to diagnose than the other?
    Captain Greenhalgh. From a----
    Senator Cotton. To the extent that you can separate the 
comorbidity of the two.
    Captain Greenhalgh. Well--so, my background, sir, is 
primary care, so I would say, certainly, we see a lot of 
behavioral health in the primary care setting. But, given that, 
we have very strong CPGs for a lot of things that we take care 
of in the--you know, in military medicine and just medicine in 
general.
    When I see a patient who has a history that sort of fits 
within the clinical practice guideline description for certain 
kind of diagnosis, I find that, from the primary care 
perspective, the TBI is certainly an easy one to try and fit 
into that, you know, diagnostic realm.
    Captain Colston. Some of it has to do with the patients 
that present in front of us. For Walt, in a primary care 
setting, he's going to see a different patient population than 
I'll see in a psychiatric setting. One of the things that 
occurs to me is, the science for PTSD is probably more 
developed than the science is for TBI. Science for TBI is 
really in a nascent stage, so PTSD is a little easier to 
discern. It's a little easier to discern from a child 
psychiatry standpoint with regard to developmental trauma, just 
because the prevalence of that is so high.
    Dr. Street. And just to add, I concur that the research 
base on PTSD is a bit further along. And, as part of that, we 
have existing well-validated instruments for the screening and 
diagnosis of PTSD. And I think those instruments are being 
developed for TBI, but are not as far along, haven't undergone 
as rigorous tests.
    Captain Greenhalgh. If I----
    Senator Cotton. So, the science for PTS is further along 
than TBI. Is that simply because of the volume of patients that 
the medical world has seen with post-traumatic stress, as 
opposed to TBI?
    Captain Colston. I think it's a number of factors. The 
science of TBI is--has been really hard to get a handle on, 
just from the standpoint of--you know, it took--I'll give you 
an example, sir--it took 20 years and $50 billion to get on top 
of HIV [Human Immunodeficiency Virus]. HIV has about a dozen 
genes and two serotypes. The brain uses about 20,000 of the 
30,000 genes in the human genome. Understanding the way the 
brain works, especially a brain that's traumatized, is 
extremely hard.
    With regard to PTSD, we at least have a long history of 
looking at people who were traumatized, and a long history of 
treatment interventions, so I think the science is more 
developed for that reason. The prevalences of both of those--in 
DOD, the prevalence of TB--of PTSD is about 2 percent; TBI, 
slightly lower.
    Dr. Street. I think, from a historical perspective, we 
really became aware of PTSD, following the Vietnam War. And so, 
we've had that span of history to really think about the 
disorder, the diagnosis, and the treatment of the disorder. TBI 
is something that we've become so much more aware of, due to 
the recent conflicts in Iraq and Afghanistan.
    Captain Greenhalgh. And, if I could just add, sir. Again, 
from the primary care perspective, there have been versions of 
PTS, it seems, from conflicts centuries ago, as well, this--the 
idea of shell-shock and things like that. I think we've gotten 
more of a handle on it after the Vietnam conflict. But, as 
Captain Colston alluded to, with technology, neuroimaging 
capacity, that really has just been a phenomenon of our 
generation. And so, I think there's a lot of potential there. 
And again, from the primary care perspective, having 
neuroimaging support certain diagnostic criteria for traumatic 
brain injury, I think that's where there's a lot of potential 
for the science. But, I agree, I think we've been describing 
things like PTS for quite a lot longer than we have traumatic 
brain injury.
    Senator Cotton. One word I think I heard you use twice, 
maybe three times, was ``longitudinal.'' The root of that is 
``long,'' which is a little worsened, given the number of 
people who suffer from PTS or TBI. Obviously, when you're 
conducting a longitudinal study, it takes many years to get 
results. Is that something about which we should be concerned?
    Captain Colston. Yes, sir, but it's the only way that we 
can do it, because these things don't present in silos. PTS 
doesn't present in a silo. TBI doesn't present in a silo. So, 
we've got to get a handle on where the patients are. And we 
have a lot of efforts. We've got the millennium cohort study, 
we've got the 15-year TBI study. We have the STARRS [Study to 
Assess Risk and Resilience in Servicemembers] longitudinal 
study on suicide. So, we're looking at several hundred-thousand 
patients now to get an idea of where patients are coming from.
    Captain Greenhalgh. And if I can add onto that, 
``longitudinal'' doesn't mean that we have to wait until the 
study is over to start gathering data, so the 15-year study, 
for example, has report-outs every 4 years. The next one is due 
next year. Not to mention the constant stream of data and 
research that is being formulated into papers and publications 
along the way. That's just a small example.
    So, longitudinal really, I think, if anything, connotes a 
commitment to a long-term study of this, not to say that we're 
going to not give you any answers for 15 more years, sir.
    Senator Cotton. Can--do you, can you, would it be 
productive to expand the dataset to look at other occupations 
that might have similar risk factors, like, say, professional 
football, professional hockey, boxing? There may be others.
    Dr. Street. Certainly, the brain trust meeting that I 
described that's happening today and tomorrow is doing exactly 
that, and it's bringing in a researcher from my institution who 
was one of the first to identify this issue among professional 
football players, and taking that information and then applying 
it to the military and veteran community. So, for sure, these 
public-private partnerships in which you can identify knowledge 
that's been gathered in other places and applied to this 
population, I think are very promising.
    Senator Graham. Senator Blumenthal.
    Senator Blumenthal. Thanks, Mr. Chairman.
    Dr. Street, I think you've touched briefly on the 
transition from Active Duty out of service or into the Reserves 
or care of the Veterans Administration. How well do you think 
that transition is going these days, in terms of the computer 
compatibility, not only in records, but also in transition on 
pharmaceutical drugs, the prescriptions, and so forth? Maybe 
you can give us an overview, because I think you're--you really 
are in a position to comment on that issue.
    Dr. Street. Well, I'm happy to comment from my perspective, 
although my perspective may be a bit limited, so you may choose 
to hear from my colleagues, as well. But, in my perspective as 
a practicing clinician, that transition is going well. I think 
Captain Greenhalgh, earlier, said it's going better than it 
ever has. And I know that there's a lot of attention to this 
issue, a lot of new initiatives. And, in my experience as a 
practicing clinician, I haven't encountered problems with that.
    Captain Colston. Sir, I'd say it's DOD policy right now 
that we do a warm handoff from DOD to VA. And it's really 
important, those transitions. One of the things that we've done 
is, we've established coaching, an in-transition program, where 
we actually look at people's medical data and then go in and 
say, ``Hey, can we help you with your follow-on appointments?'' 
And I think that's been used to good effect in the last year.
    Senator Blumenthal. Well, it's always been the policy. It's 
not always been the executed policy. And so, for example, on 
the interoperability of computer programs, I don't know whether 
you can give us an up-to-date perspective on how well that's 
going. It's been a continuing struggle, as you know.
    Dr. Street. I don't have an update on the status of that. 
I'm--but, I'm happy to take that question for the record, and 
we could get back to you with a more thorough answer on the 
updated status of that integration process.
    Senator Blumenthal. I would appreciate that. And, as well, 
on the pharmaceutical drug issue, the transition there has been 
an issue for some time.
    Senator Blumenthal. Let me shift to, again, the post-
traumatic stress, military sexual assault trauma. Is that an 
area where you think more research, as well as clinical 
treatment, is necessary?
    Dr. Street. I'm a researcher. I'll always say that I think 
more research is necessary. But, I do think this is a case 
where understanding things that are unique about experiences of 
military sexual assault, ways in which those experiences differ 
when they're in the military context from when they're in a 
civilian context, and better understanding that has a lot of 
implications for recovery. So, I think our--research that helps 
us understand that process, as well as research more generally 
targeted to the disorder and treatment of the disorder, is 
extremely valuable.
    Senator Blumenthal. And it may seem obvious--the answer may 
seem obvious. I think I have an idea about what the answer is, 
but maybe you can talk a little bit about what the differences 
are in the civilian-versus-military sexual assault trauma.
    Dr. Street. Sure. Senator Gillibrand, earlier, referred to 
the fact that survivors of military sexual assault in some ways 
looked clinically more like survivors of childhood sexual abuse 
than they look like survivors of adult sexual assault in the 
civilian world. And I think there's some truth to that, 
certainly in terms of the fact that survivors from military 
sexual trauma often talk about the experience of ongoing abuse 
in which they feel trapped and unable to escape because they're 
not able to, sort of, leave their position, although there have 
been policy improvements to make that more possible. They're 
also dependent, often, on their perpetrators for meeting their 
basic health needs or for this feeling that their perpetrators 
are those who are supposed to be watching their back and 
looking out for them. And I think those kinds of differences 
gives the survivor, sometimes, a little bit of a flavor for--
that looks more like ongoing childhood abuse.
    Of course, also, we know that survivors of traumatic stress 
are often repeatedly traumatized over a lifespan. So, that 
earlier trauma increases risk for later trauma. So, many women 
and men who are survivors of sexual trauma in the military are 
also survivors of childhood sexual trauma or other 
interpersonal trauma, as well. So, then those experiences can 
exacerbate each other, in terms of the severity of the symptom 
presentation.
    Senator Blumenthal. Thank you.
    My time is expired. But, I appreciate your taking my 
earlier questions for the record. Thank you very much.
    And thank you all for your service.
    Thank you.
    Senator Graham. Thank you. I think Senator Tillis is on the 
way, but I--Senator Gillibrand, if you have any follow-up.
    Senator Gillibrand. One of the issues that some of us work 
on is rescheduling marijuana to become a Schedule 2 drug so 
more research can be done and so patients that have been 
prescribed the medication can get access to it more regularly. 
One of the concerns we've had is, because it's a Schedule 1 
drug, it, therefore, prohibits the VA from being able to 
prescribe it, even though that individual might have been 
prescribed in their State, where their State's already passed a 
law. We've heard, anecdotally, from many veterans that 
marijuana can often be a very useful treatment for PTSD 
symptoms. Have you studied that issue? Do you have any insight 
into that issue that you'd like to share?
    Captain Colston. Ma'am, I can say DOD hasn't ascertained 
the answer to that question, for the reason that you----
    Senator Gillibrand. For the Schedule 1.
    Captain Colston.--just asked earlier.
    One thing that I have seen, as a child psychiatrist, is, 
there's risks and benefits to any intervention. And with regard 
to marijuana, one of the things that we struggle with is, it 
can precipitate psychosis in some people, especially younger 
people, people of a military age. So, that would be a concern 
that I would have as we press forward on this.
    Dr. Street. I know that VA has ongoing studies looking at 
the effectiveness of marijuana for a treatment of PTSD, but I 
know that there have been issues that have come up related to 
the quality of the marijuana, the consistency of the marijuana, 
the strength of the marijuana, that's made it--there are unique 
challenges, in terms of studying the effectiveness of that 
substance on the disorder.
    Senator Gillibrand. Would you recommend further study of it 
so that we could actually have drug companies study it and drug 
companies produce medicines that then can be tested?
    Dr. Street. I'd like to see the results of the early 
studies, in terms of addressing the, sort of, cost-benefit 
analysis. If early studies looked promising, then I would make 
that recommendation. But, if early studies showed a lot of 
negotiate, unexpected effects, then I would be more cautious in 
that recommendation.
    Senator Gillibrand. Thank you.
    Senator Graham. Senator Sullivan.
    Senator Sullivan. Thank you, Mr. Chair. And I appreciate 
you and the Ranking Member calling this hearing. It's a very 
important topic.
    You know, appreciate the witnesses being here. One of the 
things I really like about this committee, it's very 
bipartisan. And this topic comes up a lot in a very bipartisan 
way. You see members who actually really, really care about 
this. I certainly happen to be one of them. I think most people 
who have served in the military can recall more than one 
instances where a troop member of their squad or unit or--has 
succumbed to the--to depression and suicide. And I think it--
it's a searing experience, of course, for families, but for the 
troops and the leadership and everybody else who goes through 
that. So, it's a topic that we need to do a better job at.
    I'm sure that's probably already been covered to some 
degree, but--What authorities would you view, from our 
perspective, that you need from this committee or the Congress 
to do more to address some of the issues of the stigma PTSD or 
reducing the rates of suicide among our Active Duty and veteran 
populations? Is there anything more you need from us?
    Captain Greenhalgh. Well, sir, I think you talk about two 
things that are very closely related, which is reducing the 
rate--reducing the stigma and then attacking the problem, 
itself, which is suicide. And I think, with regards to reducing 
the stigma, we've made great strides over the last decade, I 
think, at least, in making it not just a, again, symptom-drive 
approach, the patient coming to the medical provider, looking 
for help. With our screening efforts, certainly everybody is 
asked whether they're symptomatic or not. When we go through 
our annual health maintenance examinations, that comes up as a 
very prominent topic, that and TBI history, as well as a lot of 
the technology and, sort of, the apps that are available, a lot 
of, you know, IT solutions, where the servicemember doesn't--
and their family--doesn't necessarily have to go to a clinician 
to ask the question. They can get a lot of the information they 
need online. And I think that goes a long way towards 
destigmatizing, if they can at least get the answer to some of 
their preliminary questions in, sort of, a non-sort-of-clinical 
environment. I think that's certainly one step.
    Captain Colston?
    Captain Colston. With regard to resources, I wouldn't 
necessarily have anything to say about that. I would say that 
there is a robust relationship between suicide and depression. 
And certainly identification and management of depression, 
especially in a primary care setting, is a very important 
strategy, and one that we really want to focus on, really in 
public health.
    Senator Sullivan. Let me ask another question that relates 
to, kind of, my first one on authorities. There is a bill--and 
I'm having my team take a look at it--that I've been looking 
at. I believe it might be Senator Peters who has put this bill 
forward, that--and I don't want to butcher it here, so we can 
make sure you get it for the record--but that is concerned 
about claims that there's been thousands, maybe tens of 
thousands, of members of the military who have received 
discharges that are less-than-honorable discharges related to 
PTSD or brain-injury type of issues. And are you familiar with 
this bill, or are you familiar with--and the bill would ask the 
military to have a presumption, maybe, in favor of a honorable 
discharge. In my military career, have not really seen that 
issue, but I may have been missing something. Are you familiar 
with this bill? Are you familiar with the problem? And what's 
your advice? Do you think there's thousands, or even more, 
members of the military who have been discharged with other-
than-honorable designation because of activities of undiagnosed 
PTSD, and that their discharge designation should be relooked 
at? And do you need authority to do that, from the Congress?
    Captain Colston. Sir, on the bright side, we've already had 
that authority, and we've used it. So, we've--we did a mental 
health review, where we looked at over 200,000 boards. We did a 
physical disability board review, where we looked at a number 
of boards for just that problem. And since 2007, patients that 
you are going to separate for means, be they disciplinary, be 
they for lack of performance, they need to be--PTSD issues and 
TBI issues need to be addressed before that can be done.
    And when we look at the numbers, we look at--we used to 
separate about 4,000 folks a year for personality disorder 
separations. That number is down to 300. So, that number is 
about 7 percent of what it was. There's been a lot of attention 
to this issue. And certainly--about 3 years ago, I think we 
spent on the order of $10 million looking at boards. And 
certainly, as Senator Blumenthal's brought up in some previous 
correspondence with DOD, sometimes we're going all the way 
back, so the boards of correction for military records have 
looked at cases from Vietnam veterans, cases even where PTSD 
didn't exist as a clinical diagnosis. Of course, it's hard to 
ascertain, you know, exactly what the circumstances were around 
something that happened a long time ago without records.
    Senator Sullivan. So, you----
    Sorry, Mr. Chairman. Just a follow-up.
    If you--so, you already have that authority. Have you seen 
this bill? And have you weighed in on it? And--it would be very 
useful. It's, like I said, something that I've--I'm very 
sympathetic to. I don't know what DOD thinks about the bill. At 
the same time, it sounds like you're already--you already have 
the authority to do what the bill does. I don't know if it has 
a presumption in favor of a honorable discharge or--again, I 
don't know the specifics. I'm sorry, I should have brought it 
with me. But, have you weighed in, or do you need the 
authorities, or you think you're good to go in addressing 
this--what you're obviously saying is a problem?
    Captain Greenhalgh. Well, sir, I mean, I haven't seen the 
bill. I haven't been asked to weigh in. But, I echo what 
Captain Colston said, is that I don't think it's an issue of 
the type of discharge that a patient gets. I think it's a 
matter of ensuring that they get the correct kind of care that 
they need prior to discharge, or even after discharge, with 
that warm handoff to our VA colleagues. Whether it's honorable 
or dishonorable, I think, is--isn't necessarily the driving 
point.
    Senator Sullivan. Mr. Chairman, if I may, maybe we can 
submit that bill. And if they had a view on it----
    Senator Graham. Yeah. Well, it sort of is the driving 
point, because you don't want someone to have a UOTHC, other-
than-honorable-conditions discharge, who had a medical 
condition that may have resulted in it.
    Senator Sullivan. Right.
    Senator Graham. That's the whole point.
    Dr. Street. And this was particularly relevant or military 
sexual trauma survivors. They were often diagnosed with a 
personality disorder as part of their discharge after they had 
suffered a sexual assault. And with that discharge, they 
weren't entitled to VA benefits. So, it was a huge problem for 
them----
    Senator Graham. Yeah.
    Dr. Street.--because they have trauma, they've been--
they're a survivor, they need mental health care, and they 
don't even have access to the VA anymore. So, that--we wanted 
those cases to be looked at again to say, Can we get this 
right?
    Senator Graham. Yeah, we--we'll upgrade the discharge if 
there's a medical reason that was missed, or PTS suffering.
    Captain Colston, the reviews you're familiar with, did you 
all actually change discharge designations?
    Captain Colston. Yes, sir. So, several servicemembers have 
had discharge determinations changed over the years. And 
several servicemembers have had their benefits changed. So, 
especially the Physical Disability Board of Review----
    Senator Graham. Could you do this? Could you have that 
group--and I applaud your efforts--give us the results? I 
mean--of the 200,000 reviewed, how many discharges were 
upgraded and how many benefits were restored?
    Captain Colston. Yes, sir. The executive agent for that was 
the Air Force and the Physical Disability Board of Review is 
right here----
    Senator Graham. Our crack staff----
    Captain Colston.--inside the Beltway.
    Senator Graham.--will get on that, won't you, crack staff? 
Absolutely.
    Senator King.
    Senator King. Thank you, Mr. Chairman.
    [The information referred to follows:]

    DOD has undertaken three coordinated efforts to upgrade discharge 
characterizations, dating back to the Vietnam-era, from other than 
honorable characterizations, change administrative separations to 
military retirements, and otherwise scrub all disability boards started 
under a mental health claim since 2001, for a potential increase in 
benefits. These efforts are carried out by the Boards of Correction for 
Military Records (BCMRs).
    The results that you are inquiring about were from the review 
initiated in October 2012, by order of the then-Secretary of Defense, 
Leon Panetta, requiring the existing Physical Disability Board of 
Review (PDBR) to conduct a comprehensive review of mental health 
diagnoses from September 11, 2001 to April 30, 2012, for Service 
members who completed a disability evaluation process and whose mental 
health diagnoses were changed during that process. The PDBR completed a 
review of 200,000 cases where a disability board was started and then 
changed or stopped, for reasons such as change in diagnoses of post-
traumatic stress disorder (PTSD), adjustment disorders, depression, 
anxiety or possible removal of diagnoses stemming from other factors, 
such as disciplinary proceedings. This effort was undertaken to audit 
the system in an analytically sound, non-bureaucratic, and action-
oriented manner to mitigate the risk of bias toward diverting Service 
members away from compensable disabilities.
    No evidence of bias was found. Of the 200,000 cases processed by 
the Services for eligibility, about 5 percent (11,000) were found 
eligible for reconsideration using a permissive administrative filter. 
All eligible individuals received at least two, and most times three, 
mailings, with return receipts requested, that invited them to apply to 
the PDBR for consideration for changes to the military record. About 
1000 were returned by applicants. 100 of the cases either met the 
eligibility criteria for consideration (66 cases resulting in 10 
medical retirements) or contained other discrepancies that accrued to 
the benefit of the applicants (34 cases). Those 34 cases, processed 
under the rationale that the PDBR application was nested within a 
Boards of Correction for Military Review (BCMR) application, resulted 
in 7 additional findings for medical retirements by the BCMRs.
    Subsequent to the above review, then-Secretary of Defense Chuck 
Hagel, issued a memorandum focused upon the petitions of Vietnam 
veterans to Military Department Boards for Correction of Military/Naval 
Records for the purpose of upgrading their discharges based on claims 
of previously unrecognized PTSD, as PTSD was not yet recognized as a 
diagnosis during this period of history. Thirty-eight percent of 
Vietnam-era petitioners have been granted relief, a figure that is 
significantly higher than that for standard discharge upgrade requests. 
The latest numbers indicate the Department has received 759 qualifying 
petitions, 273 of which have been adjudicated and 486 of which are 
still pending resolution. Of those that have been adjudicated, 103 were 
granted upgrades.
    Another effort currently underway by the DOD's Physical Disability 
Board of Review (PDBR), is looking at 77,000 medical boards where 
combined disability ratings of 20 percent or less were assigned to 
Service members who were discharged between September 11, 2001 and 
December 31, 2009. Many of these cases stemmed from decrements in 
disability findings stemming from existence of non-compensable mental 
health conditions, such as personality disorders or adjustment 
disorders. In almost 25 percent of the cases reviewed by the PDBR, an 
applicant became eligible for a disability retirement. Members who 
prevailed in this forum were awarded monthly disability retirement pay 
and TRICARE eligibility for themselves and eligible dependents 
retroactive to the day of original disability separation.
    To ensure that mental health conditions are rightfully considered, 
the DOD has implemented section 521 of the Carl Levin and Howard P. 
``Buck'' McKeon National Defense Authorization Act for Fiscal Year 
2015, P .L. 113-291, by: 1) including the opinion of a clinical 
psychologist or psychiatrist if the review for correction of records 
includes a mental health disorder; and 2) including on the board a 
clinical psychologist, psychiatrist, or physician with training on 
mental health issues pertaining to post-traumatic stress disorder 
(PTSD) and traumatic brain injury (TBI) when there is a request for 
review by a Service member diagnosed with PTSD or TBI while deployed or 
with a mental health disorder while serving in the military.

    Thank you all for your work in what is a really important 
area. We see it daily in Maine.
    Dr. Street, one of the issues we have in our State--it's a 
very rural State, it's large--large, long distances. How do we 
deal with the unique challenges facing veterans in PTSD and 
other mental issues who--it's just almost impossible to drive a 
whole day, and drive back, and to have effective treatment. 
Talk to me about treating this problem in rural areas, and 
particularly about the possibility of using online resources, 
telemedicine, those kinds of things.
    Dr. Street. Well, you're--the things you suggest are 
exactly the kinds of things that we've been working with, 
really figuring out how we can harness technology to take what 
we know are effective treatments, but have used--been, 
historically, in a sort of face-to-face setting in an office 
situation, and use technology to make those more widely 
available. So, certainly telehealth. But, increasingly now, 
we've also been developing and testing online technologies. So, 
for an example, a colleague of mine in Boston recently 
developed a online intervention for comorbid PTSD and alcohol 
abuse that's--that, in early stages, is showing--shown to be 
quite effective. We are also harnessing the use of mobile apps 
that veterans can use, if they have infrequent appointments, in 
between appointments to help manage their symptoms and improve 
their process of recovery. So, we're hoping that use of 
technologies, and really harnessing those technologies, can 
help address some of the issues with treatment among rural 
veterans.
    Senator King. Just as sort of a parenthetical question, 
then I'll get back to the technology. Do we know what works? 
Is--are there proven treatments to deal with this issue?
    Dr. Street. There are. And it's, I think, such an important 
message to get out there. So--because I think it provides hope 
for veterans. But, we have well-established, rigorously-tested 
treatments for PTSD, primarily psychotherapies in the cognitive 
behavioral realm that have been shown, in multiple settings, in 
multiple populations, to be very effective in reducing the 
incidence of PTSD.
    Senator King. I think that's important news out of this 
hearing----
    Dr. Street. Absolutely.
    Senator King.--that this is not a hopeless situation, that 
there are----
    Dr. Street. Absolutely.
    Senator King.--successful treatments.
    Dr. Street. Absolutely.
    Senator King. Well, I want to encourage you, in the 
strongest possible terms, to pursue these technological 
advances, because time is not on our side. And again, in many 
places in this country, people are in very rural areas--in 
Alaska--and they just don't--they just don't have access to a 
clinic or to a group. It's very difficult.
    Dr. Colston, talk--let's talk about substance abuse as it 
relates to this issue. Do you--I'm--from my anecdotal data from 
my staff in Maine, there's a lot of overlap. A lot of people 
that have PTSD end up in a substance-abuse situation, either 
alcohol or drugs. Is that true? And how do we deal with that 
issue?
    Captain Colston. Yes, sir. There's about a 30-percent 
overlap between PTSD and substance-use disorders. And one of 
the really scary things that we're facing right now is the 
scourge of opiate overdose deaths in this country. So, as 
people transition----
    Senator King. 47,000 a year.
    Captain Colston. Yes, sir. Just horrible. And certainly, as 
people have transitioned into heroin use, more heroin 
overdoses----
    Senator King. Do you think part of it is self-medication?
    Captain Colston. Yes, sir, no question. And we've seen that 
with alcohol. We've seen it with all kinds of illicit drugs. 
And, you know, certainly now, the drugs that are out there are 
just scary. They're drugs that you can take once and end up 
dead. And that's really where the change has been. We recognize 
that there is an overlap between those systems, so we have a 
lot of stepdown care in DOD, a lot of intensive outpatient 
treatment, where we great both your mental health issues, 
which--PTSD runs with other things. It runs with TBI, it runs 
with depression, it runs with substance-use disorders, it runs 
with pain. And we also treat your substance-use disorders. With 
regard to opiate-use disorders, we've got medication-assisted 
therapy. With regard to alcohol-use disorders, lots of new 
science that supports the use of things like acamprosate, which 
is a medication-assisted therapy for alcoholism, or other drugs 
that work really well, like naltrexone.
    Senator King. So, you see this as an important area, that 
the comorbidity is a significant issue.
    Captain Colston. Oh, absolutely, sir. Dual-diagnosis work 
is really where most of our stepdown work is right now. And 
Walt, over at the NICoE, sees a fair amount of folks who are 
struggling in that regard, too.
    Senator King. Dr. Street, are there any VA rules that, if 
you--if you're suffering from PTSD, but you also have an--a 
drug-abuse problem, you can't get treatment, or you're 
excluded? There's no--there are no barriers on----
    Dr. Street. No, no barriers. And, in fact, increasingly, 
we're looking at treatments that can treat both of the 
disorders simultaneously, because we know that they are so 
interrelated.
    Senator King. A final question. I know that a program was 
created in 2010 to help people moving out of the service into--
called In Transition, I think it's called. My question is, Is 
it working? And how do we know?
    Captain Colston. So, we're collecting--that's run out of my 
office, sir--we're collecting data on it. We ramped up the 
program tenfold about a year ago.
    Senator King. Good.
    Captain Colston. One of the things that we're trying to do 
throughout DOD is get outcome measures. And, luckily, there 
hasn't been, in this short period that we've been running the 
program, a suicide in any person who's been coached in the 
program. Nonetheless, we want outcome measures with regard to 
things like, How depressed is this patient? What kind of PTSD 
symptoms does this patient have? How much healthcare is this 
patient utilizing? And I think, as our health systems evolve, 
and as we develop registry data, the ability to get a better 
idea of where patients are as they move between DOD and VA, 
we'll get much better answers with regard to outcomes.
    Senator King. I think we should be applying the same level 
of resources, money and personnel, to transition out of the 
service that we put into recruiting in, because that's where a 
lot of the slippage occurs, in that sometimes very difficult 
transition. And that's been something I've--I just think that's 
a--that's a rule of thumb. Let's spend as much helping people 
when they come out as we spend bringing them in, in the first 
place.
    Thank you very much for your testimony and for your work.
    Senator Graham. Senator Tillis.
    Senator Tillis. Thank you, Mr. Chair.
    Thank you all for being here.
    First off, I understand--I'm sorry I'm late. I had a 
competing--actually, I was just following Senator Sullivan 
through the committee, the concurrent committee circuit. So, I 
apologize for being late. If you've already answered these 
questions, I can just refer back to the record.
    One thing I wanted to underscore, I think that Senator 
Sullivan covered. It's a bill that I support, the Fairness for 
Vets Act. I think you all got into a discussion here, so I 
won't ask you to repeat it, but just underscore, I think it--I 
think it's important, and I think it provides value. And I 
believe there's at least consensus among the Department that 
you do, as well? Thank you. Any problems with it?
    Captain Colston. I haven't looked at it yet, sir.
    Senator Tillis. Okay. Okay.
    And I think Senator Cotton may have mentioned something 
about public-private partnerships. We go to the easy--the easy 
one to identify, which would be the NFL [National Football 
League]. Based on where I come from, I could argue NASCAR 
[National Association for Stock Car Auto Racing]. But, what 
other sort of network of private partners are out there? And 
what, specifically, are we doing to really bring in and 
collaborate, use their expertise, not reinventing the wheel? 
And, Dr. Street, maybe I should direct that to you.
    Dr. Street. Yeah, there's actually a 2-day summit going on 
today and tomorrow that's really--the focus of it is public-
private partnerships around the issue of TBI, and bringing in 
folks from VA, from DOD, the NFL, certainly researchers from 
the private sector who are familiar with those issues, to try 
to really garner innovative technologies from different sectors 
and apply them to this population.
    I think that's a good general--this idea of public-private 
partnerships is a good general model, and one that VA is trying 
to do more and more of.
    Senator Tillis. Have we gone into any of the, maybe, 
research universities that do a lot of work there, and found 
partnership opportunities with them? Is that another area 
you're casting a net?
    Dr. Street. Yeah, absolutely. I mean, where I hale from, in 
Boston, we have very close connections with Boston University. 
They've done a lot of work around chronic encephalopathy. And 
many of those investigators actually hold dual appointments in 
the academic institution and in VA so that we can really 
harness some of the power of the best scientists in the country 
who are doing this kind of work.
    Senator Tillis. Okay, thank you.
    Senator King mentioned the transition piece. I'm on 
Veterans Affairs Committee. And, obviously, a lot of the 
challenges we have after a man or woman comes out, they may 
have undiagnosed TBI, PTSD. And I'm trying to figure out how we 
do a better job of--there's this handoff, and, you know, 
sometimes if you go in transition, you've got the younger 
soldiers that are in the back of the room with their headphones 
on, doing their duty, and then moving out there. They may be, 
in fact, people that should be listening. And what they're 
thinking about is moving on. To what extent is the DOD--it 
necessarily becomes a VA role, but to what extent is the DOD 
making sure that--particularly for ones where you may have 
evidence to suggest that someone does have something that has 
not yet been effectively treated--make sure that those veterans 
get vectored into the care that they may need through the VA? 
Does that handoff actually occur, or is it a--just because of 
the finite nature of the transition--I'm trying to get some 
sense of how we do a better job of making--the VA may not know 
that there is someone out there that may--they may need to 
help. So, it's--how do you kind of create an alert system--or 
does it already exist--to make sure there's a good handoff?
    Captain Colston. Well, really, three things. First, there's 
a separation health assessment, where we try to cover all of 
these issues. For patients who present with any kind of 
condition, we have an Integrated Disability Evaluation System 
with the VA. And then we have an in-transition system to coach 
folks who--and it's an opt-out system, and it's not an opt-in 
system--to help folks get that next appointment.
    I'd also say, for the sickest patients, we go all the way 
to--when I was at Great Lakes, if I had a 18-year-old patient 
with schizophrenia who was going to end up at the VA, one of my 
techs would get on the plane and bring him to Alabama or bring 
him to Texas. I mean, that's the level of transition support 
that's expected.
    Senator Tillis. Do you think that we're doing that 
consistently?
    Captain Colston. Sir, I can say we're measuring it right 
now.
    Senator Tillis. Okay.
    Captain Colston. And I could certainly take that question 
for the record as--with regard to how we're doing.
    Senator Tillis. Yeah, I would appreciate that. I mean, just 
to get some sense.
    [The information referred to follows:]

    In addition, August 2012, the Presidential Executive Order 13625 
established the Interagency Task Force on Military and Veterans Mental 
Health (ITF) to implement mental health initiatives across the DOD, the 
Department of Health and Human Services, the VA, and other Federal 
agencies for Veterans, Service members, and their families. 
Specifically for Service members transitioning from the DOD to the VA 
system, one notable action has been the expansion of the DOD's 
inTransition program from ``opt-in'' participation, typically at the 
Separation Health Assessment, to ``opt-out'' or automatic enrollment. 
This program provides specialized coaching and assistance to all 
Service members seen for a mental health concern during the 12 months 
preceding their separation from military service. From inception in 
January 2010 and through March 2016, the inTransition program opened 
16,484 new coaching cases and closed 13,821 coaching cases. Survey 
respondents continue to express high levels of satisfaction with 
inTransition, as 95 percent indicated the service met their needs, and 
95 percent of the respondents indicated the assistance received from 
the program increased the likelihood of continuing treatment at the VA 
or with another clinical provider.
    The DOD/VA Interagency Care Coordination Committee (IC3) addresses 
the needs of the most seriously wounded, ill, and injured Service 
members/Veterans and their families or caregivers. IC3, established in 
2012, is improving the way DOD and VA care coordinators collaborate to 
provide more synchronized care, benefits, and services to those who 
require complex care coordination. IC3's synchronized efforts are 
supported by official policy in both Departments. Care coordination 
always includes point to point travel arrangements and by-name 
handoffs. This type of care is especially critical for the unfortunate 
Service members who develop serious life-long mental illnesses, such as 
schizophrenia or bipolar disorder. This high-needs population will 
require ongoing care regardless of the nation's war footing, as about 3 
percent of the population develops these illnesses, with first 
presentations coinciding with typical age of military accession (18-25 
years old).
    Finally, an Integrated Disability Evaluation System has markedly 
increased the ability of DOD and VA to meet patients where they are, 
shortening wait times for disability determinations, and giving 
veterans options regarding where to access their follow-on care.

    Senator Tillis. You know, I'm from North Carolina. We've 
got a million veterans and a lot of folks who either serve at 
Fort Bragg or Lejeune that end up staying in North Carolina. 
And just want to make sure we're getting them to the care that 
we think can help avoid other problems and complications. I 
work a lot with a drug treatment facility down in Raleigh-
Durham that's--about 60 percent of their clients are people who 
now have substance-abuse problems, but it's not clear how they 
got there, what caused them. Some of them are rooted in PTSD. 
So, I'm very sensitive to this issue to make sure we're 
capturing as many as possible and getting them in--into the 
appropriate sort of care setting. So, I would appreciate that.
    Thank you, Mr. Chair.
    Senator Graham. Thank you.
    This has been a excellent panel. I think you've all 
acquitted yourselves well.
    Just to kind of summarize, one in four military members are 
affected by what we've been talking about today--trauma, PTS, 
drug abuse, alcohol-abuse problems. They've been treated for 
these problems. Is that correct?
    Captain Colston. Yes, sir. We do a DMDC data run, so--a 
Defense Management Data Center data run--for everyone that's 
getting out, and look and say, ``Have you been treated?"
    Now, one thing I can say is, we're--we do a really good job 
with screening. And certainly, we've evolved to identify more 
of the illness that's out there. I think, you know, we now have 
probably the most treated cohort in human history. So----
    Senator Graham. Yeah, I would think so.
    Captain Colston.--I think we're doing a good job in that 
regard.
    Senator Graham. Well, and that's the whole point. We want--
you know, somebody asked this, but, you know, as I wrap up here 
and let other people ask additional questions, please tell us 
what we can do. Because, you know, we're trusting y'all guys. 
Everybody seems to be very focused that the veterans and those 
serving deserve this. About 80 percent of the cases are 
unrelated to being in combat. TBI--one thing about the movie--I 
haven't seen it, but Senator Gillibrand was telling me--that 
you can't look at a TBI injury on a MRI [Magnetic Resonance 
Imaging]. It's not like looking at a broken bone, right?
    Captain Colston. No, sir. There's no neural imaging, no 
correlation.
    Senator Graham. Only God knows how much of this we missed 
in past conflicts.
    Captain Greenhalgh. For the mild TBI, yes, sir.
    Senator Graham. Okay.
    And I'll just add with this and let members wrap up what 
they would like to ask.
    I've been to a bunch of refugee camps. And I'd bet most of 
us have. I can only imagine what the people in these refugee 
camps are going through. From Syria--I was one in Turkey not 
long ago--the children, the women, particularly, victims of 
sexual assault. So, one thing, as a Nation, as a world, we need 
to--there's a--not a whole lot of treatment, the people who 
have been through conflict. And I just think they're ticking 
timebombs if we don't get ahead of this. So, one thing I'd like 
the Senate to understand is that, when we provide aid to the 
refugees, it's more than just food and water and clothing. If 
we don't have a mental health component, I think we're making a 
huge mistake.
    So, anybody else?
    Yes, Senator Sullivan.
    Senator Sullivan. Just had a follow-up question.
    So, the bill is actually S. 1567, Fairness to Veterans 
Erroneously Discharged from the Military. That's the name of 
the bill. So, if you could take a look at that to see if that's 
providing you additional authorities that you think you need, 
which is obviously a issue that seems to be a pretty big issue 
if you're looking at 200,000 cases.
    I just had another question. Like Senator Tillis, I'm on 
the Veterans Affairs Committee, and I asked the questions of 
some of our service organizations when they were testifying 
recently. On the designation PTSD, there's been some discussion 
of--you know, we talk about the stigma, the ``post-traumatic 
stress disorder.'' And so, a ``disorder'' kind of comes with a 
little bit of, you know, implications. And so, some people have 
mentioned to me, ``Well, maybe we--this should be referred to 
as post-traumatic stress injury.'' So, if you receive this in 
combat and you were injured, obviously, that it's like, you 
know, getting shot. Nobody calls a gut wound or a--getting shot 
a ``disorder"; they call it a ``injury.'' So--in some veterans 
groups think that might be a good idea; others don't, for 
reasons that might have to do with benefits and how things are 
actually categorized in the VA. And if you don't call it a 
``disorder,'' you might lose a certain amount of----
    Do you have any thoughts on that, Dr. Street? Any of you? 
Just on the--just the title, itself, which does have certain 
implications. I was just wondering what your thoughts are on 
that.
    Dr. Street. I'm in favor of retaining the ``post-traumatic 
stress disorder'' title. I appreciate the concern about stigma, 
but I--I don't believe that changing the title is the way to 
most effectively combat the stigma.
    Senator Sullivan. No, I don't think it would at--I mean, 
I'm not saying it would, but it--you know, it might be--might 
help, right?
    Dr. Street. I mean, I think certainly--just to outline my 
specific concerns--I mean, there is--we've made so much 
progress, in terms of our ability to diagnose and effective 
treat the disorder. And, in part, that's due to the fact that 
the symptoms of PTSD look so similar, regardless of the source 
of traumatic stress exposure, be that something associated with 
military service or something from the civilian sector. And I'm 
concerned that changing the name would introduce confusion that 
might negatively impact functioning. But, I agree that the 
issue of stigma is a concern and needs to be addressed. I'm 
just not sure that this is the most effective way to do it.
    Captain Colston. There is a good point to the use of that 
term, inasmuch as the normal course of being exposed to trauma 
is toward health, and a vast majority of people who are exposed 
do get healthy. Sebastian Younger, in Vanity Fair, about a year 
ago, wrote a very beautiful article about some of his exposures 
and, you know, the subsequent course, and some of the things 
that we've seen in the military. It's tough to weather the 
vicissitudes of military life, especially when you're coming 
out of combat, especially when you're dealing with austere 
environments. But, I think that, you know, going back to where 
General Chiarelli was 5 years ago or so, when he used the term 
PTS as opposed to PTSD, there's arguments on both sides of the 
ledger.
    I very much agree with Dr. Street's assertion that we've 
got to call it a ``disorder,'' because we've got to get people 
services, we've got to get people support, and we've got to 
make diagnoses, to get paid, in the medical record.
    Senator Sullivan. Thank you.
    Senator Graham. Yes, sir.
    Senator Tillis. This is really just to reinforce what the 
Chair said. One of the things that I'm really intent on is 
challenging you all to tell us where past congressional 
decisions at the time may have made sense; they may not have 
made sense, they just had the votes; or times have changed. 
But, the sorts of things that we place on you, particularly in 
dealing with this--you know, may end--well-intentioned policies 
that do not add value, they add cost or constraints. We need 
your feedback so that we're not only adding some new good ideas 
that maybe take the edge off of some of the old ones that are 
still in place, but really help us do reforms of any--you've 
got a very--you've got a changing environment. Your 
understanding of PTSD, how to treat it, how to transition, how 
to keep track of our vets and take care of them change over 
time. And I really want a committee where they come in here and 
you tell us, ``You need to change this, this"--or call my 
office, or call the Chair's office, and give us an opportunity 
to look at some of the things that you're currently doing that 
are no longer value-added and could deploy resources to a 
better and higher use, in your professional opinion.
    Senator Graham. Thank you.
    Anything else?
    [No response.]
    Senator Graham. I move that all outside statements for the 
record received in advance of the hearing should be included in 
the official record. Without objection.
    Senator Graham. The hearing is adjourned. Well done. Thank 
you.
    [Whereupon, at 3:47 p.m., the hearing was adjourned.]

    [Questions for the record with answers supplied follow:]

           Questions Submitted by Senator Richard Blumenthal
                  transition from dod to va healthcare
    1. Senator Blumenthal. Captain Greenhalgh and Captain Colston: You 
state that the current policy of the Department of Defense (DOD) and 
Department of Veteran's Affairs (VA) is to conduct a ``warm hand-off'' 
for servicemembers' healthcare when they transition out of active duty 
service. What is the current status and effectiveness of the hand-off 
between the DOD and VA for servicemembers' healthcare, particularly 
concerning electronic records and pharmaceutical prescriptions?
    Captain Greenhalgh and Captain Colston. Collaboration between DOD 
and the VA during the transition from DOD to VA health care has never 
been greater, and the two Departments are continuing their efforts to 
improve transition services. These services are mandated in policy and 
executed through intensive case management services, including an 
``InTransition'' program to help Service members during the transition 
period.
    Regarding electronic records, the Departments have collaborated on 
two complimentary mechanisms--a file transfer system and an electronic 
viewer--together they ensure all of the essential information of the 
DOD Health Record is available for both benefits adjudication and 
continuity of care in the VA. In 2010 the Departments agreed on the 
definition of the Service Treatment Records (STR)--it is the composite 
of all digital information and paper documentation necessary for 
continuity of care and benefits determinations. The STR includes the 
Armed Forces Health Longitudinal Technology Application (AHLTA), the 
Military Health System (MHS) electronic medical record that was 
implemented in 2004, and the older information that was created or is 
still printed on paper. To better enable claims processors in the VA to 
request and receive an official electronic archive version of the STR, 
DOD accelerated fielding of the DOD Health Artifact and Image 
Management Solution (HAIMS), and established an automated interface 
with systems supporting the Veterans Benefits Administration (VBA). 
Since January 1, 2014, the record transfer has occurred electronically. 
The Services compile and scan all the paper documentation and upload 
the files into HAIMS. In addition, everything from AHLTA is rendered as 
a single, well organized, easily searchable portable digital format 
(pdf) file. All of these files are stored in HAIMS and automatically 
copied from HAIMS to the VBA's system as soon as a claim is filed, 
completely eliminating the need to mail STR requests and printed copies 
of records between Departments.
    A July 2014, DOD Office of Inspector General report covered the 
period 6 months before and after the DOD HAIMS capability was put in 
place. The report compared the previous time preparing to mail a record 
with the current time to compile it into HAIMS, and did not highlight 
the time saved within the VA. Subsequent to this report, DOD and VA 
have significantly refined and improved on execution. The number of VA 
late pending STR requests, which was over 6,000 in August 2014, has 
been consistently less than 1,000 since May 2015, and most STRs for new 
VA requests are now provided within one day of the date requested. The 
Services track late STRs by name until the request is closed out with 
the VA. DOD has imposed aggressive targets upon the Services, and they 
report compliance weekly.
    The complimentary means of sharing the STR is through the 
electronic health information exchange that the Departments have been 
working on for a decade. Since December of 2013, everything from AHLTA 
has been accessible through the Joint Legacy Viewer (JLV), and 
constraints on system capacity were eliminated by the summer of 2015. 
JLV displays complete notes from AHLTA just as they appear when 
printed, a significant improvement over previous VA viewers. The viewer 
gives providers an integrated, chronological view of medical 
information familiar to clinicians of both Departments. It provides 
real-time electronic health record information from all DOD and VA 
facilities, as well as information received from a growing number of 
DOD and VA commercial health care partners. Today more than 70,000 VA 
clinicians have access to this system, a number that increased more 
than 60-fold in the past 15 months.
    All of these improvements in health information access apply 
equally to Reserve Component Service members, and the archival process 
for them includes collecting and scanning any documentation held at the 
unit level.
    Regarding pharmaceutical prescriptions, a just-released GAO audit, 
``Actions Needed to Help Ensure Appropriate Medication Continuation and 
Prescribing Practices,'' found no evidence to dispute a rigorous 2015 
Veterans Health Administration study showing that 97 percent of 
transitioning Service members maintained clinically appropriate 
medication treatment through their transition from DOD to VA health 
care.
    Beginning on June 1, in accordance with the National Defense 
Authorization Act for fiscal year 2016, section 715, ``Joint Uniform 
Formulary for Transition Care,'' both the DOD and VA will be mandated 
to stock the same medications to treat pain, sleep, and psychiatric 
disorders, and any other conditions determined appropriate by the DOD 
and VA Secretaries. This synchronization will further ensure that 
patients leaving Active Duty have continuity of medication treatment 
during this transition.
    Finally, DOD has worked closely with VA and HHS, and the Executive 
Office of the President, including the President's Office of National 
Drug Control Policy, to ensure that the President's mandates, vis-`-vis 
the potential for medication misuse, in Executive Order 13625 and 
subsequent 2014 Executive Actions are carried out. DOD is a national 
partner in the important effort to stem the scourge of prescription 
opiate abuse and overdose deaths. Integrated and extensive prescription 
drug monitoring programs, an extensive research portfolio coordinated 
between agencies, and execution of recent mandates in state and federal 
law will help turn the tide on this urgent public health problem.
    Veterans Health Administration Response. The Department of Veterans 
Affairs (VA) has taken a number of actions in collaboration with the 
Department of Defense (DOD) to identify and track Servicemembers who 
are transitioning to civilian life and to ensure that those in need of 
care do not fall through the cracks. Enhanced health care information 
sharing has been accomplished through the DOD-VA Joint Legacy Viewer 
(JLV). JLV represents groundbreaking agency-to-agency interoperability. 
JLV combines and shares data and gives both VHA clinicians and Veterans 
Benefits Administration rating specialists a composite view of 
Veterans' treatment history.
    VA's ``Pilot Evaluation of Medication Continuation for Veterans 
Transitioning from the Department of Defense Health Care System to the 
Department of Veterans Affairs Health Care System'' validated VA's 
long-standing practice of continuing medications for transitioning 
Servicemembers. This long-standing practice was institutionalized by VA 
with respect to mental health medications with the policy directive 
entitled, ``Continuation of Mental Health Medications Initiated by 
Department of Defense Authorized Providers.''
    The link to the pilot evaluation is available at: http://
www.pbm.va.gov/PBM/vacenterformedicationsafety/othervasafetyprojects/
DOD--VA--Medication--Continuation--Report.pdf
    The link to the VA Directive is available at: http://www.va.gov/
vhapublications/ViewPublication.asp?pub--ID=3075

    2. Senator Blumenthal. Captain Greenhalgh, and Captain Colston: How 
do you plan to address the remaining shortfalls in the system?
    Captain Greenhalgh and Captain Colston. Aside from issues regarding 
electronic health records and prescription drugs--including opiate 
overdose deaths nationwide, another concern that Department of Defense 
(DOD) and the Department of Veterans Affairs (VA) face is suicide 
deaths in recently discharged Service members.
    The DOD's National Telehealth and Technology Center, a component of 
its Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury (DCoE), expertly manages the DOD Suicide Event 
Report (DODSER), the most comprehensive database regarding death by 
suicide. Leaders at DCoE, in collaboration with VA researchers recently 
published a seminal article in the Journal of the American Medical 
Association regarding the relation of suicide risk to deployment and 
separation status. While deployment was not associated with the rate of 
suicide, separation from military service had a robust effect. The 
effect was pronounced in persons who separated with less than 4 years 
of military service or who did not separate with an honorable 
discharge.
    In an effort to mitigate suicide risks by translating research 
findings into practice, then-Assistant Secretary of Defense for 
Readiness and Force Management promulgated the DCoE researchers' 
article to each of the Service's Assistant Secretaries for Manpower and 
Reserve Affairs (M&RA), with guidance to commanders to ensure a warm 
handoff to the Department of Labor for Service members who receive a 
less than honorable discharge. This handoff includes employment 
services and integration into social service systems, as appropriate, 
in the local community. The handoff is executed by name to ensure 
continuity between the commander, or his designee, and a Department of 
Labor representative at a specific American Job Center in the 
community. Additionally, inTransition is a free voluntary program to 
provide behavioral health care support to Service members and Veterans 
as they move between health care systems or providers. Personal 
coaches, along with resources and tools, assist participants during the 
transition period and empower them to make healthy life choices.
    Recognizing risks associated with early separation while balancing 
readiness imperatives, the DOD has endeavored to drastically reduce 
separations of first-term Service members under the rubric of 
personality disorder, which does not carry the benefit of medical 
retirement. After policy was implemented in 2007, personality disorder 
separations were reduced from over 4,000 per year to 300 per year in 5 
years. Each of the Service's Assistant Secretary for M&RA creates an 
annual report auditing the separation process for personality disorder; 
and the DOD has endeavored to listen to stakeholder's concerns about 
this matter over the past decade, including Veterans Service 
Organizations and representatives from the Yale Law Clinic. The change 
in policy carries a requirement to treat in place more Service members 
who are less able to weather the routine vicissitudes of military life. 
As such, the effort requires ongoing leadership and judgment from 
commanders, as the cohort of retained Service members presents risks 
for poor outcomes, including suicide. System-wide changes, such as the 
creation of service lines for mental health care and use of a 
behavioral health data portal, are designed to emphasize outcomes in 
the identification and management of those receiving mental health 
care.
    It is important to note that a growing body of research suggests 
that mental health issues, such as depression or personality disorder, 
are only one part of a complex interplay of risk factors related to 
suicide. Suicide is a culmination of complex interactions between 
biological, social, economic, cultural and psychological factors 
operating at individual, community, and societal levels. Risk and 
protective factors span across the fields of medicine, epidemiology, 
sociology, psychology, criminology, education, and economics. Research 
also shows that many Service members and Veterans who are at risk for 
suicide will not seek help from mental health providers. Therefore, 
despite the efforts to improve access to clinical approaches, a suicide 
prevention response exclusively based on a mental health approach will 
not address suicide prevention efforts relevant to most of the at-risk 
population. A holistic, community approach that relies on a variety of 
interventions is more likely to increase effectiveness of suicide 
prevention efforts.
    Defining suicide risk, and adequate treatment strategies, is an 
imperative in the DOD. Today, a $160 million military and operational 
medicine health research portfolio focuses on suicide. DOD integrates 
its suicide research efforts with other government agencies, especially 
VA and the Department of Health and Human Services (HHS), through the 
National Institute of Mental Health. A collaborative effort to improve 
understanding of suicide, along with Traumatic Brain Injury (TBI) and 
Posttraumatic Stress Disorder (PTSD), is focused in a National Research 
Action Plan (NRAP). The NRAP, mandated by an Executive Order in August 
2012, created a roadmap to better coordinate and partition research 
portfolios to match agency expertise.
    Comorbidity in military populations is becoming better understood, 
and research shows that TBI, PTSD, depression, substance use disorders, 
and chronic pain, are risk factors for suicide. The public health 
approach acknowledges the role of these various factors in suicide, but 
recognizes that these diagnoses can often be a result of other factors; 
for instance, pain and hopelessness that arise from other variables, 
such as relationship, financial, and legal problems; difficult 
transitions; and feelings of isolation. Therefore, addressing suicide 
with both clinical and non-clinical approaches provides the necessary 
multi-prong approach to address the various interconnected causal 
factors. Longitudinal research efforts like the Millennium Cohort 
Study, the largest study ever created to ascertain the health effects 
of military service, are slowly aiding scientific understanding to this 
issue.
    There continues to be a comprehensive coverage of research 
portfolios across the DOD, VA, and HHS. Along with the epidemiological 
effort to collate and analyze annual suicide data in the annual DODSER, 
progress continues throughout the research continuum. While suicide 
prevention has been keenly focused upon by military leaders for many 
years, challenges still exist. One challenge is a low base rate for 
suicide, even in high risk groups making it difficult to target 
assistance to those who need it. Under the medical approach, the Army 
Study to Assess Risk and Resilience in Soldiers (Army STARRS) and its 
follow-on STARRS Longitudinal Study (efforts with projected outlays 
near $100 million), are attempting to enable clinicians to separate 
patients into risk cohorts, so interventions can be tailored according 
to risk. Additionally, randomized clinical trials under the auspices of 
a Military Suicide Research Consortium are evaluating cognitive-
behavioral suicide interventions in high risk groups, such as 
hospitalized patients. Another challenge is translating a vast body of 
research, containing a wealth of information about suicide prevention 
practices that have been tested and validated in different populations 
to the military. Using the public health approach, these practices are 
being reviewed, and some are piloted for implementation among Service 
members and Veterans. As an example, ``Window to Hope'' is an 
Australian program to reduce hopelessness that can lead to suicide 
after sustaining a traumatic brain injury. This program was recently 
adapted and evaluated for feasibility for U.S. military Veterans. Other 
studies have looked at components of post-traumatic stress disorder as 
a risk factor for suicide, finding that feelings of guilt and shame 
were underlying mechanisms of suicidal thoughts. Clinical trials now 
are underway to target these specific feelings.
    The urgency of the suicide problem, with some military rates 
exceeding age-adjusted civilian rates for the first time in recent 
years, continues to push the DOD and VA's joint effort to develop 
effective prevention, intervention, and postvention strategies for 
suicide. It is necessary to maintain strong partnerships and 
collaborations during this process and ensure adequate communication. 
It is also crucial to use a public health approach in addition to 
addressing clinical factors related to suicide. The transition from 
active service is challenging and it is important to continue to forge 
the way in performing research, maintaining data, translating research 
findings into actionable outcomes and efforts, and measuring progress 
to address this vulnerable population and prevent suicides.
    Veterans Health Administration Response. VA has multiple programs 
in place to facilitate transition from DOD and is continuously working 
to ensure that we monitor and respond to potential shortfalls in order 
to best meet the needs of our Veterans. For example, VA and DOD 
transition assets and capabilities supporting continuity between the 
health systems include liaison and care coordination staff to 
facilitate a seamless transition process, as well as numerous 
interagency initiatives that support shared standards of care and 
interoperable processes for care delivery that facilitate transition 
between the systems. For example, VA has 43 Liaisons for Healthcare 
stationed at 21 Military Treatment Facilities (MTF).
    VA Liaisons for Healthcare, either licensed social workers or 
registered nurses, are strategically placed in MTFs with concentrations 
of recovering Servicemembers returning from Iraq and Afghanistan. VA 
Liaisons for Healthcare coordinate health care as Servicemembers 
transition from the MTF to a VA health care facility closest to their 
homes or the most appropriate location for the specialized services 
their medical condition requires. VA Liaisons are co-located with DOD 
case managers and provide onsite consultation and collaboration 
regarding VA resources and treatment options. VA Liaisons for 
Healthcare meet with Servicemembers directly to provide education about 
the VA system of care, the eligibility process, health care benefits, 
and services. They also assist in the understanding of the individual's 
health care needs in order to coordinate initial health care. VA 
Liaisons for Healthcare connect with Transition and Care Management 
Program Managers to coordinate this initial care and to have a VA case 
manager assigned.
    VA Liaisons for Healthcare facilitate the connection between the 
DOD and VA case managers and treatment teams, ensuring that current 
health care needs are communicated. The expectation with each referral 
is that the Servicemember will leave the MTF registered for VA health 
care with a scheduled VA appointment. Since this connection has been 
made prior to leaving the MTF, the Servicemember is already engaged 
with Transition and Care Management Program Managers upon arrival home. 
This early connection with Servicemembers and their families/caregivers 
starts the process of building a positive relationship with VA and 
ensures early coordination of health care with VA.
    VA has also coordinated with DOD's inTransition program to receive 
Servicemembers separating from the service who have been seen by a 
mental health provider while on Active Duty or who self-refer to the 
inTransition program. This DOD program provides coaching to assist 
Servicemembers who are transitioning between health care systems, 
status, or locations. inTransition's mission is to support continuity 
of care for the Servicemember during transition. A transition coach 
provides support and guidance on psychological health concerns, 
resources, and healthy living, while motivating and assisting the 
Servicemember to connect with a treatment provider post-transition. In 
the second quarter of fiscal year 2016, inTransition opened 1,900 new 
coaching cases. From February 2010 to March 2016, the cumulative number 
of coaching cases opened by the inTransition program was 16,509. Survey 
respondents expressed high levels of satisfaction with inTransition, 
with 89 percent indicating the assistance received from the program 
increased their likelihood of continuing treatment at the new location 
and 90 percent indicating that inTransition products and services met 
their needs.
    The link to the inTransition program is available at: http://
intransition.dcoe.mil/.
  
  
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