    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

                             [H.A.S.C. No. 115-39]

                       POST-TRAUMATIC STRESS DISORDER AND

                        TRAUMATIC BRAIN INJURY--CLINICAL

                        AND RESEARCH PROGRAM ASSESSMENT

                                   __________

                                    HEARING

                                   BEFORE THE

                       SUBCOMMITTEE ON MILITARY PERSONNEL

                                     OF THE

                          COMMITTEE ON ARMED SERVICES

                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  HEARING HELD

                                 APRIL 27, 2017

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                       ______

                             U.S. GOVERNMENT PUBLISHING OFFICE

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                              Washington, DC 20402-0001

                       SUBCOMMITTEE ON MILITARY PERSONNEL

                        MIKE COFFMAN, Colorado, Chairman

    WALTER B. JONES, North Carolina      JACKIE SPEIER, California
    BRAD R. WENSTRUP, Ohio, Vice Chair   ROBERT A. BRADY, Pennsylvania
    STEVE RUSSELL, Oklahoma              NIKI TSONGAS, Massachusetts
    DON BACON, Nebraska                  RUBEN GALLEGO, Arizona
    MARTHA McSALLY, Arizona              CAROL SHEA-PORTER, New Hampshire
    RALPH LEE ABRAHAM, Louisiana         JACKY ROSEN, Nevada
    TRENT KELLY, Mississippi
                     Tom Hawley, Professional Staff Member
                    Craig Greene, Professional Staff Member
                             Danielle Steitz, Clerk

                                C O N T E N T S

                                  ----------
                                                                       Page

                  STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

    Coffman, Hon. Mike, a Representative from Colorado, Chairman,
      Subcommittee on Military Personnel.............................     1
    Speier, Hon. Jackie, a Representative from California, Ranking
      Member, Subcommittee on Military Personnel.....................     2

                                   WITNESSES

    Colston, CAPT Mike, M.D., USN, Director, Defense Centers of
      Excellence for Psychological Health and Traumatic Brain Injury,
      U.S. Department of Defense.....................................     3
    Ivany, LTC Christopher G., USA, Chief, Behavioral Health
      Division, HQDA, Office of the Surgeon General, United States
      Army...........................................................     6
    Johnson, CAPT Thomas M., M.D., USN, Site Director, Intrepid
      Spirit Concussion Recovery Center, Naval Hospital Camp Lejeune.     7
    Pflanz, Col Steven E., USAF, Deputy Director of Psychological
      Health, United States Air Force Medical Support Agency.........     4

                                    APPENDIX

    Prepared Statements:

        Coffman, Hon. Mike...........................................    27
        Colston, CAPT Mike...........................................    28
        Ivany, LTC Christopher G.....................................    49
        Johnson, CAPT Thomas M.......................................    56
        Pflanz, Col Steven E.........................................    40

    Documents Submitted for the Record:

        [There were no Documents submitted.]

    Witness Responses to Questions Asked During the Hearing:

        Ms. Speier...................................................    69

    Questions Submitted by Members Post Hearing:

        Mr. Coffman..................................................    73
        Mr. Knight...................................................    78
        Ms. Tsongas..................................................    76

    POST-TRAUMATIC STRESS DISORDER AND TRAUMATIC BRAIN INJURY--CLINICAL AND
                          RESEARCH PROGRAM ASSESSMENT

                                  ----------

                      House of Representatives,
                           Committee on Armed Services,
                            Subcommittee on Military Personnel,
                              Washington, DC, Thursday, April 27, 2017.
        The subcommittee met, pursuant to call, at 2:29 p.m., in
    room 2118, Rayburn House Office Building, Hon. Mike Coffman
    (chairman of the subcommittee) presiding.

     OPENING STATEMENT OF HON. MIKE COFFMAN, A REPRESENTATIVE FROM
         COLORADO, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

        Mr. Coffman. The hearing is now called to order.
        Good afternoon, and welcome.
        Today, the subcommittee will hear from the Department of
    Defense [DOD] and the military departments on their efforts to
    address the effects of post-traumatic stress disorder [PTSD]
    and traumatic brain injury [TBI] on our service members.
        For far too long, the real and proven effects of PTSD and
    TBI largely were ignored. Even worse, service members who
    demonstrated symptoms of PTSD were sometimes deemed weak or
    mentally unstable. Thankfully, we know better today and are
    taking aggressive steps to help those who have endured
    traumatic stress.
        As a nation, we have endured an extraordinarily long period
    of conflict with thousands of American troops deployed in
    harm's way. Some, as a result of their combat experiences,
    suffer from post-traumatic stress or TBI. But PTSD and TBI are
    not limited to combat injuries. PTSD can arise from any
    traumatic event, such as sexual assault. We expect the
    Department to treat all those suffering from PTSD and TBI
    equally, providing the best appropriate care for each.
        For more than a decade, Congress has provided funding and
    legislative direction for the Department's PTSD and TBI
    research and clinical approaches. In fact, relevant provisions
    of law are found in each of the last four NDAAs [National
    Defense Authorization Acts].
        Today, our intent is to review our progress and determine
    where we need to go from here. Our witnesses are experts in the
    fields of mental health, and I look forward to hearing their
    views of our clinical and research progress. If they have any
    suggestions for the subcommittee, I welcome them.
        Before I introduce the witnesses, I would like to turn to
    Ranking Member Speier for any opening comments she would like
    to make.
        [The prepared statement of Mr. Coffman can be found in the
    Appendix on page 27.]

        STATEMENT OF HON. JACKIE SPEIER, A REPRESENTATIVE FROM
     CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

        Ms. Speier. Thank you, Mr. Chairman. Let me join you in
    welcoming our witnesses here today.
        As post-traumatic stress disorder and traumatic brain
    injury began to emerge as prominent injuries from the conflict
    in Afghanistan and Iraq, and stories of service members facing
    difficulty in obtaining appropriate care became more frequent,
    Congress began to push the Department of Defense to be more and
    more proactive and increased resources for mental health
    prevention, treatment, and research.
        Since 2004, when Congress first directed the Secretary of
    Defense to conduct a study of the mental health services
    available to service members at the time, Congress has provided
    more than $1.5 billion in funding for PTSD- and TBI-related
    research. Of this, more than $800 million has gone to over 400
    research projects related to psychological health of service
    members, including PTSD, suicide prevention, military substance
    abuse, resilience, prevention of violence within the military,
    and family-related research.
        We need to better understand how that money has been used;
    what, if any, results have come from that research; where are
    there potential breakthroughs, and what areas may not be as
    productive; what gaps may exist that should be addressed; and
    how should we begin to prioritize the demands that continue to
    grow in this area.
        One area that I believe requires more focus is the
    relationship between TBI and the development of chronic
    traumatic encephalopathy, an issue that has been getting a lot
    of attention in particular because of professional football. I
    look forward to hearing how the Department is taking a
    leadership role in researching this connection.
        Just as important as research is the care and treatment of
    service members. We continually hear about access challenges
    and the lack of available care providers. A huge concern to me
    is the stigma that persists among service members that leads to
    them not seeking care in the first place.
        As we heard at the subcommittee hearing on review board
    agencies earlier this year, the stigma can lead not just to
    long-term mental and physical health problems but also
    employment or financial difficulties, as discharge status may
    not take into account a service member's PTSD or TBI history,
    even with liberal consideration guidance.
        I would like to learn more about what the services are
    doing to address these challenges, and I look forward to
    hearing your testimony today.
        Thank you, Mr. Chairman.
        Mr. Coffman. Thank you, Ms. Speier.
        I ask unanimous consent that non-subcommittee members be
    allowed to participate in today's hearing after all
    subcommittee members have had an opportunity to ask questions.
    Is there objection?
        Seeing none, without objection, non-subcommittee members
    will be recognized at the appropriate time for 5 minutes.
        We will give each witness the opportunity to present
    testimony, and each member will have an opportunity to question
    the witnesses for 5 minutes. We would also respectfully remind
    the witnesses to summarize, to the greatest extent possible,
    the high points of your written testimony in 5 minutes or less.
    Your written comments and statements will be made part of the
    hearing record.
        Let me welcome our panel. Our witnesses are mental health
    experts for the Department of Defense and the military services
    and are intimately involved in these issues across their
    respective organizations and the Department of Defense.
        They are: Captain Mike Colston, United States Navy,
    Director, Defense Centers of Excellence for Psychological
    Health and Traumatic Brain Injury; Colonel Steven Pflanz,
    United States Air Force, Deputy Director of Psychological
    Health, Office of the Air Force Surgeon General; Lieutenant
    Colonel Chris Ivany, United States Army, Chief, Behavioral
    Health Division, Office of the Army Surgeon General; Captain
    Thomas Johnson, United States Navy, Site Director, Intrepid
    Spirit Concussion Recovery Center, Camp Lejeune, North
    Carolina.
        With that, Captain Colston, you are recognized for 5
    minutes.

     STATEMENT OF CAPT MIKE COLSTON, M.D., USN, DIRECTOR, DEFENSE
     CENTERS OF EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND TRAUMATIC
                BRAIN INJURY, U.S. DEPARTMENT OF DEFENSE

        Captain Colston. Chairman Coffman, Ranking Member Speier,
    members of the subcommittee, thank you for your support of our
    Nation's service members, veterans, and their families.
        I am pleased to share DOD's efforts in research and program
    assessment for PTSD, TBI, and related conditions. Last year,
    about a quarter of service members were seen for PTSD, TBI, or
    a mental health condition. Allow me to describe our progress.
        First and foremost, we made PTSD and TBI leadership issues,
    with an emphasis on prevention. PTSD incidents decreased from
    17,000 to 14,000 from 2012 to 2015, and TBI incidents decreased
    from 31,000 to 23,000 over the period.
        With regard to mental health across the board, we expanded
    access to care by tripling our mental health infrastructure
    since 2001. A recent RAND study validated DOD's progress,
    finding that DOD outperforms civilian health systems in
    outpatient follow-up after psychiatric inpatient care for PTSD
    or depression.
        One of our largest tasks is better understanding why PTSD
    and TBI often present with depression, chronic pain, substance
    use disorders, and suicide risk. Longitudinal research efforts,
    such as the 15-year study on TBI, aid our understanding and
    provide a framework for creating effective rehabilitation and
    support programs.
        Advances from medical research accrue slowly in PTSD and
    TBI. On balance, it takes 15 years or more to take a medical
    discovery into clinical practice. Fortunately, with Congress'
    support, my office, the Defense Centers of Excellence for
    Psychological Health and TBI, has developed a knowledge
    translation process for use in DOD. This capacity gives us a
    pathway for advances in PTSD and TBI and comorbid conditions so
    that we can get them to clinics quickly and cost-effectively.
        I would like to touch upon program assessment. We have
    evaluated over 150 mental health, TBI, substance use, and
    suicide prevention programs over the last 5 fiscal years. This
    program evaluation has been invaluable. Publication of this 5-
    year study will be completed later this fiscal year and will
    help us progress on the vital work of ensuring our funding is
    tied to programs that work, such as the U.S. Army's embedded
    behavioral health program and its associated Behavioral Health
    Data Portal.
        I would like to briefly discuss the public health success
    in DOD that no doubt accrued from our increase in
    infrastructure, from which we might draw lessons for our Nation
    in addressing a disturbing national trend.
        In 2015, there were over 52,000 overdose deaths in America.
    Opiate overdose death rate went up to 10.4 per 100,000 in 2015.
    The DOD rate was 2.7 per 100,000, about one-fourth of that. How
    was this accomplished? In short, through leaders' focus on the
    wellbeing of service members and a focused, outcome-based
    effort on prevention--primary prevention, selected prevention,
    and indicated prevention--drug testing, provider training,
    pharmacy protections, and medication therapies.
        We hope to generalize some of the successes we have seen in
    PTSD and TBI incidents and opiate overdose deaths into other
    public health areas, such as suicide prevention and alcohol use
    disorders. With your continued support, I am confident that our
    research discoveries, clinical innovations, and relentless
    focus on readiness for PTSD and TBI will bear fruit in years
    ahead.
        I look forward to answering your questions.
        [The prepared statement of Captain Colston can be found in
    the Appendix on page 28.]
        Mr. Coffman. Colonel Pflanz, you are now recognized for 5
    minutes.

      STATEMENT OF COL STEVEN E. PFLANZ, USAF, DEPUTY DIRECTOR OF
     PSYCHOLOGICAL HEALTH, UNITED STATES AIR FORCE MEDICAL SUPPORT
                                 AGENCY

        Colonel Pflanz. Chairman Coffman, Ranking Member Speier,
    distinguished members of the committee, thank you for the
    opportunity to speak to you today about post-traumatic stress
    disorder and traumatic brain injury in the military and the
    ongoing leadership you have provided to the services regarding
    military mental health.
        The last decade has seen powerful advances in our
    understanding of evidence-based treatments for PTSD and TBI. I
    vividly recall standing outside the Air National Guard
    headquarters building in Cheyenne, Wyoming, on a crisp autumn
    evening in the fall of 2010. I had just completed my training
    in prolonged exposure therapy for PTSD. Thrilled with the
    excitement about the promise of this treatment, I literally
    said to myself in the parking lot, ``I feel like I have been
    given the cure to cancer.'' Growing up, there was no higher
    aspiration for medicine than that. That sentiment was not
    entirely hyperbole. Research has proven the tremendous efficacy
    of these therapies.
        Roughly 1 year later, in Afghanistan, I had the opportunity
    to serve combat warriors coming off the battlefields. There, I
    understood the importance of having real answers for difficult
    problems, of greeting elite professionals with elite care.
        I have repeated this story many times over the years
    because it is so important to have effective therapies to offer
    our patients, who have given so much in the service of our
    country.
        Today, all Air Force mental health providers routinely
    receive training in one or more of the several evidence-based
    therapies for PTSD, and all airmen can be confident that they
    will receive state-of-the-art treatment when they enter an Air
    Force mental health clinic.
        Fortunately, PTSD and TBI rates remain low amongst airmen.
    Even so, we are excited about the successful translation of
    research into clinical practice, including requiring evidence-
    based therapies for PTSD, event-driven protocols for
    recognizing TBI, and the use of progressive return to activity
    in the management of concussion.
        Integrating behavioral health care into primary care
    clinics, embedding mental health professionals into operational
    units within highly stressed career fields, and comprehensive
    screening for PTSD and TBI following deployments and throughout
    an airman's career are three additional developments that help
    us successfully identify and manage these conditions.
        On the horizon, the Invisible Wounds Clinic being
    established at Eglin Air Force Base in 2018 will be a powerful
    enhancement of our treatments for PTSD and TBI, both as a
    referral center and as a projection of treatment and expertise
    Air Force-wide.
        Likewise, research partners are helping us evaluate options
    to repackage the essential elements of evidence-based therapies
    for PTSD to fit existing delivery systems without losing
    efficacy. These emerging opportunities are every bit as
    exciting as the research already translated into practice.
        To be certain, there is much work still to be done. The Air
    Force partners with its fellow services and civilian academic
    institutions to constantly push the envelope of science so that
    our treatment techniques and systems delivery grow ever more
    efficacious.
        At the same time, we are studying our systems of care to
    close gaps in services. Currently, a multidisciplinary task
    force is identifying and resolving gaps in the continuum of
    care and the Integrated [Disability] Evaluation System for
    airmen suffering from invisible wounds, with work underway on
    27 specific solutions, ranging from education and training to
    culture and policy. These solutions will translate directly
    into improvements in services for these airmen.
        I wish to thank the committee for its interest in this
    topic and for your dedicated support of the men and women in
    the armed services. I am grateful for the opportunity to appear
    before you on this matter of importance.
        [The prepared statement of Colonel Pflanz can be found in
    the Appendix on page 40.]
        Mr. Coffman. Lieutenant Colonel Ivany, you are recognized
    for 5 minutes.

     STATEMENT OF LTC CHRISTOPHER G. IVANY, USA, CHIEF, BEHAVIORAL
     HEALTH DIVISION, HQDA, OFFICE OF THE SURGEON GENERAL, UNITED
                              STATES ARMY

        Colonel Ivany. Chairman Coffman, Ranking Member Speier, and
    distinguished members of the subcommittee, thank you for this
    opportunity to provide the Army perspective on providing
    behavioral health and traumatic brain injury care to our
    soldiers and their families.
        Health care is essential to readiness, which is the Army's
    number-one priority. I know of no area of health care that has
    faced as many challenges, made as many changes, and has
    achieved as many advancements as in Army behavioral health
    care.
        Over the course of my career, I have personally witnessed
    the impact of behavioral health support for soldiers in
    countless situations. From small outposts across Baghdad to
    clinics and hospitals across this country, Army physicians,
    psychologists, clinical social workers, nurses, and technicians
    have helped soldiers deal with the consequences of combat.
        Just as importantly, I have seen healthcare providers
    supporting the families of those that have volunteered to serve
    this country, as Army spouses and children also confront and
    overcome mental illness.
        The history of Army behavioral health care has included
    many challenges. Early in the wars in Iran and Afghanistan, the
    Army realized that the size and the organization of its
    behavioral health force was insufficient to meet the needs of
    our beneficiaries. In response, it greatly increased resources
    and expanded the number of clinical programs to serve this
    population.
        Senior Army medical leaders also made a pivotal decision to
    centralize the oversight and direction of all clinical programs
    and constructed a small team of professionals within the Office
    of the Surgeon General to do so. That team set out to analyze
    the effectiveness of all clinical programs, identify the best
    practices, and replicate them across the force.
        Out of this process came many programs, like embedded
    behavioral health, which has reduced many barriers to care for
    soldiers in combat units and improved access and readiness. The
    embedded model places professionals in small clinics in close
    proximity to where soldiers live and work. Today, over 450
    providers in 62 embedded behavioral health teams support every
    operational unit in the Army. Data has clearly shown that
    soldiers are receiving care earlier and needing less
    hospitalization to receive treatment.
        Other innovations were drawn from the civilian sector. For
    example, school behavioral health had shown clear promise in
    several school districts across the country. The Army embraced
    this approach and placed providers directly in schools on Army
    posts all over the world. Children in 60 schools on Army
    installations can now see a provider by simply walking down the
    hall from their classroom.
        In traumatic brain injury care, in partnership with the DOD
    and other services, the Army has implemented a clear set of
    clinical standards and delivers them in interdisciplinary
    clinics across the force. Clinicians have reduced unnecessary
    variance, a key step in improving quality of care.
    Simultaneously, the Army Medical Research and Materiel Command
    is advancing its state of the science through a gap-driven
    research portfolio.
        Finally, the Army recognized the need to accurately
    understand the true effect of each patient's treatment. It
    developed an automated process to measure from the patient's
    perspective how symptoms responded to the care. The Behavioral
    Health Data Portal is now in use in every Army behavioral
    health clinic and has been used over 2 million times. To my
    knowledge, it is the most widely used clinical outcome system
    for mental health care in the country. Soldiers with behavioral
    health conditions get better faster because of this technology.
        This transformation has been possible because the
    Department of Defense delivers the vast majority of the care
    for our soldiers with mental health conditions and a history of
    TBI. The civilian sector could not have adapted as rapidly or
    as completely to meet the challenges faced by soldiers and
    their families. As the Military Health System evolves to best
    care for its beneficiaries, it is vital that we continue to
    deliver the large majority of mental health care.
        While much has been done, many challenges still remain.
    Like the rest of the Nation, we continue to fight against
    stigma to seeking mental health care, we search for better ways
    to keep more soldiers engaged in care until they achieve a full
    clinical response, and we strive to find new technologies to
    assist our clinicians in delivering cutting-edge treatments.
        I am committed to ensuring we overcome these and other
    challenges to improve the health and readiness of the force. I
    look forward to working with Congress in this endeavor. I want
    to thank my partners in the DOD, my colleagues here on this
    panel, and you for your continued support.
        Thank you.
        [The prepared statement of Colonel Ivany can be found in
    the Appendix on page 49.]
        Mr. Coffman. And, Captain Johnson, you are now recognized
    for 5 minutes.

    STATEMENT OF CAPT THOMAS M. JOHNSON, M.D., USN, SITE DIRECTOR,
    INTREPID SPIRIT CONCUSSION RECOVERY CENTER, NAVAL HOSPITAL CAMP
                                LEJEUNE

        Captain Johnson. Chairman Coffman, Ranking Member Speier,
    distinguished members of the subcommittee, thank you for
    providing me with the opportunity to share my perspectives as
    the director of the Intrepid Spirit Concussion Recovery Clinic
    at Naval Hospital Camp Lejeune.
        Marine Corps Base Camp Lejeune and the surrounding area are
    home to approximately 50,000 warfighters and their families.
        Traumatic brain injury, or TBI, has been described as the
    signature injury of the wars of Afghanistan and Iraq.
    Approximately 80 percent of all TBIs are classified as mild.
    Individuals who have sustained a mild TBI may only experience
    subtle changes in mood, memory, sleep, and balance. They have
    no visible signs of their injury but are often struggling to
    function at work, at home, and in the community.
        I remember vividly when I met with a Marine sergeant and
    his wife in the clinic. I asked him about his medical issues.
    He told me that all he wanted me to do was fix his headaches so
    he could get back to his unit and deploy back to Iraq.
        I then asked his wife, ``What was bothering you?'' And
    there was this dramatic pause, and she burst into tears. And
    she told me that she felt that she hardly knew her husband
    since he had returned back from his last deployment, in which
    he had sustained a TBI. Tragically, the war does not end for
    those families when the service member comes home. It goes on
    and on every day, as they struggle heroically to overcome the
    trauma of war.
        The reality is that there is currently no diagnostic tool
    that is sensitive and specific for mild TBI. However, we have
    worked to overcome this by developing a holistic, integrated,
    interdisciplinary treatment model that employs a standard
    evaluation that includes physical, psychological, and spiritual
    dimensions. We then use this information to diagnose and treat
    each of our patients.
        We treat these service members like warrior athletes and
    employ both traditional therapies as well as complementary and
    integrative medicine to return them to the highest level of
    function possible after their injuries. We use a minimal amount
    of medication, almost no narcotics. And over 90 percent of them
    return to full duty upon completing our program.
        The great sacrifices made by warfighters and their families
    compel us to do everything in our power to support them on
    their road to recovery. Research in the prevention, diagnosis,
    and treatment of TBI is one way to fulfill this great
    obligation. The Military Health System, in partnership with
    civilian academic institutions, has a robust research portfolio
    to address gaps in knowledge and improve care for service
    members with TBI.
        For example, we have developed a progressive return-to-
    activity protocol that give providers guidelines on how to
    gradually increase activity in individuals in a way that
    maximizes recovery.
        We are committed to caring for people like the retired
    combat-decorated master chief petty officer who was a patient
    at Intrepid Spirit. He had been exposed to literally hundreds,
    if not thousands, of blasts during his career. After he
    retired, he noticed an insidious decline in his cognitive
    function, to the point where remembering where he was going
    when driving and then even driving itself became difficult for
    him. After an extensive workup in our clinic, it became
    apparent that he had a brain injury.
        To this point, the DOD has an ongoing longitudinal study on
    traumatic brain injury incurred by members of the Armed Forces
    in order to better understand what happens to individuals like
    the master chief so they get the treatment they need.
        Because Intrepid Spirit Camp Lejeune is located where the
    service members live and work, we are uniquely suited to
    support these important efforts. Every day, as we work with
    service members--sailors, marines, soldiers, airmen, and
    coastguardsmen--who have sustained a TBI, we are reminded of
    the urgency and importance of our mission.
        On behalf of the staff at Naval Hospital Camp Lejeune and
    service members like the Marine sergeant and the master chief
    that I mentioned earlier, we are grateful to the committee for
    your strong support. Navy Medicine is privileged to work hard
    at something that is so important and so rewarding.
        I look forward to your questions.
        [The prepared statement of Captain Johnson can be found in
    the Appendix on page 56.]
        Mr. Coffman. Thank you, Captain Johnson.
        Captain Colston, I think you had mentioned that, on TBI, on
    numbers, that I think that you dropped from 31,000 to 23,000.
    In what period of time was that? I am sorry.
        Captain Colston. Between 2012 to 2015.
        Mr. Coffman. Okay. And so I suspect that this was enhanced
    safety, because, I mean, TBI is produced by trauma. So how
    would you----
        Captain Colston. I think a couple things. I think the
    OPTEMPO [operational tempo] was pretty similar over those
    periods. So I know that there is a lot of leader intervention
    in regard to TBI and in regard to efforts that leaders make to
    tell people not to get TBIs--safety, other issues along those
    lines.
        As you know, sir, there are very few TBIs on the
    battlefield right now, something on the order of about 200.
    MVAs [motor vehicle accidents], sports accidents, and the like
    are where we are getting a lot of those, and prevention
    measures can be used in that regard.
        Mr. Coffman. Okay. Thank you.
        A question for all of you, each one of you individually. So
    I have a concern that a soldier, marine, airman, or sailor
    might be reluctant on Active Duty to go see a mental health
    professional or go see a neurologist about the consequences of
    a TBI for fear of what that may do to their career.
        I was a junior officer during peacetime, but I can remember
    deploying as a rifle platoon commander in the Marine Corps and
    then coming back. And if I look at the Marines, particularly
    during the height of Iraq and Afghanistan, that person in that
    same position that would have been in combat coming back and
    then, as a first lieutenant then, saying, ``Oh, I want to see a
    mental health professional because I am concerned about post-
    traumatic stress,'' and what the reaction for that command
    would have been; it wouldn't have been positive.
        And so I want you to--and I was aboard a ship not that long
    ago, an aircraft carrier in the Persian Gulf, and ran into the
    chaplain. And the chaplain was informing me, the ship's
    chaplain, that he would see a lot of the sailors that would
    prefer to see him versus see a mental health professional
    because there was no entry in their healthcare books, in the
    health record books.
        And so if each one of you can comment to me how significant
    this issue is today and what your branch of service is doing in
    response to it, to gain access for these military personnel.
        Captain Colston.
        Captain Colston. Yes, sir. Stigma is a huge issue. We
    suspect that perhaps even half of people who have a condition
    don't come see us because of stigma. Some of it has to do with
    security background questionnaires, and certainly we have
    worked over the last number of years to allay that concern in
    folks.
        One of the things that I remember from when I deployed as
    an Army psychiatrist was you have to work with the chaplains.
    In essence, there needs to be a close relationship in a
    deployed setting between mental health providers and chaplains.
        There is a presumption of nondisclosure in mental health. I
    would never, as a mental health provider, run to a commanding
    officer with things that don't have to do with the soldier's
    readiness. I have never shared personal details about patients,
    recognizing that I need to make it as easy as possible. It is
    also DOD policy that there is a presumption of nondisclosure,
    and that policy speaks directly to commanding officers.
        It is obviously a leadership issue, and it is one that we
    need to address closely. And, obviously, GAO has looked at it
    over a number of years.
        Mr. Coffman. Colonel Pflanz.
        Colonel Pflanz. Sir, I think all the services are moving to
    increasingly embed mental health resources closer to the
    soldiers, sailors, marines, and airmen. We are certainly doing
    that in the Air Force with our RPA [remotely piloted aircraft]
    community and our special operators, special tactics, and we
    are increasingly beginning to take that to maintainers on the
    units.
        You know, this proximity breeds familiarity, and with
    familiarity there is comfort. And as you get comfortable with
    individuals, you are willing to come and get care and get help.
    So the greater we bring care to them, the more likely it is we
    are going to break down those barriers and their reluctance to
    seek care.
        Mr. Coffman. Lieutenant Colonel Ivany.
        Colonel Ivany. Sir, I certainly agree with the previous two
    panelists here. This has been a key focus within the Army. I
    think we have made quite a bit of progress in this area.
        If you compare the number of mental health visits that were
    delivered in 2007 to all Army beneficiaries, it was about
    900,000 at that time. Last year, 2016, we delivered 2.1 million
    visits to Army beneficiaries, more than double the number of
    people and number of times that we have been able to see
    people.
        So I think our data shows that this issue is getting
    better. The core of our approach has been to move health care
    further forward to eliminate barriers to that care, and we have
    seen soldiers and their beneficiaries use it more frequently.
        Mr. Coffman. Captain Johnson.
        Captain Johnson. Sir, we have changed the way we do
    business to meet this need. Specifically, we have provided
    education to service members about the signs and symptoms of
    TBI and PTSD and, moreover, that it is a real, important issue.
    We have provided education to healthcare providers.
        We have also changed the way we do business in theater.
    Historically, if a service member had a problem, they may or
    may not go to medical. Now, it is an event-driven process. If
    you are in the proximity of a blast, you are to go to medical,
    regardless of your symptoms, and then the healthcare provider
    then can get history. They have more training to determine if
    you did indeed sustain a TBI or have PTSD or other medical
    issues.
        In addition, at Naval Hospital Camp Lejeune, through the
    Intrepid Spirit, because of our holistic, integrated,
    interdisciplinary approach with a standard evaluation,
    individualized treatment, most of the service members return to
    duty, so 90 percent or so. So their testimony when they tell
    other service members that they went to the Intrepid Spirit and
    that they had these symptoms and they got better is very, very
    powerful. And I think, ultimately, they are our greatest
    advocates that say that this is a real phenomena, it is
    treatable, and they should seek treatment.
        Mr. Coffman. Thank you, Captain Johnson.
        Ranking Member Speier.
        Ms. Speier. Thank you, Mr. Chairman.
        As I mentioned in my earlier comments, I am concerned about
    the relationship between TBI and CTE [chronic traumatic
    encephalopathy]. There was an international state-of-the-
    science meeting in 2015 that agreed to six recommendations, the
    first of which was the creation of a coordinated brain bank and
    tissue repository system.
        So, Captain Colston, has the DOD created or coordinated for
    such a repository? And, if so, how are service members informed
    about their opportunity to register and to donate?
        Captain Colston. Yes, ma'am. We called Dan Perl at USUHS
    [Uniformed Services University of the Health Sciences] a couple
    days ago about this matter. He is up to 51 brains in his brain
    tissue repository at USUHS. Up at VA [Veterans Affairs] Boston,
    there are 98 brains of veterans.
        So we have moved up from about a dozen to 51 at USUHS in a
    pretty short period, I think in about a year. The Center for
    Neuroregenerative Medicine [CNRM] is leading this process for
    DOD. And the Chronic Effects of Neurotrauma Consortium [CENC]
    is leading it for VA, Dave Cifu down at----
        Ms. Speier. So how are we informing veterans and/or those
    who are discharged from the military of the availability of
    this repository?
        Captain Colston. Right now, it is what you have on your
    driver's license. I know that efforts are afoot to approach
    that issue. Of course, what we need is brains and histories.
    And getting the word out is a big part of the effort at CNRM
    and CENC right now.
        Ms. Speier. It sounds like we could do a better job at that
    than we are.
        Captain Colston. I think the brains versus pathology
    progress, ma'am, is something that we need to work on. And
    certainly I could take that for the record.
        [The information referred to can be found in the Appendix
    on page 69.]
        Ms. Speier. All right.
        I have been working on this issue from a different
    perspective for close to a decade, and I have become aware of a
    professor and Nobel Prize winner at UC San Francisco, Stanley
    Prusiner, who was the first to identify the tau protein, which
    is related to mad cow disease and, as a result, also related to
    TBIs. And he sent me this letter, which I want to read parts of
    it and then get your comments.
        ``Seemingly mild TBIs can initiate progressive nervous
    system degeneration involving aggregation of the tau protein
    into tangles within the frontal lobes of the brain. As many as
    one in five soldiers deployed in Iraq and Afghanistan were
    within the distance of an IED [improvised explosive device]
    blast and suffered one or more mild concussive episodes. Drugs
    must be developed to treat such individuals.
        ``Combat-related TBIs exhibit disinhibited behaviors,
    including depression, insomnia, drug addiction, alcoholism, and
    suicide. These symptoms of central nervous system dysfunction
    are indistinguishable from those seen in CTE patients in whom
    modified tau proteins aggregate. Lowering the level of tau
    delays the onset of neurodegeneration.
        ``Large numbers of service members deployed in recent
    conflicts will develop CTE, which is one of the subset of
    conditions known broadly as post-traumatic stress disorder.
    Hence, the identification of such drugs is an urgent medical,
    societal, and national security issue. The development of such
    medicines and that the Congress continues to fund annual
    research and development in the Department of Defense budget to
    undertake this important work is key.''
        So I guess my question to each of you--and I have 1 minute
    and 15 seconds left--is: What are we doing in terms of seeking
    out medicines, and to what degree do you concur with Dr.
    Prusiner on his conclusions?
        Captain Colston. Ma'am, I was honored to meet Dr. Prusiner
    in the Assistant Secretary's office. Right now, he is working
    on a novel drug discovery compound, looking at about 20,000
    compounds that have to do with tau aggregation. As you know, he
    is an expert in mad cow disease. There is a question about
    protein scaffolding and the progress.
        The clinician in me says there probably is some nexus
    between TBI and CTE. But I also need to say, as a scientist,
    that that nexus is not fully established right now.
        Ms. Speier. And the idea that we need a drug in order to
    try and address this condition in our service members?
        Captain Colston. I think Dr. Prusiner's work is high-risk/
    high-reward. If, in fact, protein scaffolding is what causes
    CTE, I think his work will bear great fruit. As a Nobel
    laureate, those are the kind of people we want on high-risk/
    high-reward projects, and I think he is the perfect person for
    that job.
        Ms. Speier. Yes, Captain Johnson.
        Captain Johnson. At Camp Lejeune, we are making efforts to
    make service members more aware of the brain bank by having
    discussions with some of the medical leaders, both at MARSOC
    [Marine Corps Forces Special Operations Command] and in the
    MEF, the Marine Expeditionary Force, and the Special Operations
    Command.
        In addition, I personally am donating my brain to that
    brain bank. And, again, I think that is one way to get the
    message out, that I think it is so important that I want to
    participate in it.
        I also heard a story that I think merits discussion. There
    was a service member who donated his brain to the brain bank,
    and the family members said they felt that their son was still
    serving the country even after death by donating his brain to
    the brain repository.
        So we are doing everything we can, and we support it 100
    percent.
        Ms. Speier. Colonel Pflanz.
        Colonel Pflanz. The Air Force is very concerned about the
    impact of recurrent, chronic, or severe TBI on its airmen and
    other service men and women. I agree with Dr. Colston that, you
    know, the research on the link between blast injuries and
    chronic traumatic encephalopathy is unclear. And, more
    importantly, what do we do with it once we make that link?
        And so the Air Force and the other services are falling
    back clinically now on our DOD/VA clinical practice guidelines.
    Those are our bibles. You know, the latest literature, as it
    emerges, is incorporated into those clinical practice
    guidelines so that the physicians working in the trenches are
    using the best knowledge, best possible treatments.
        Ms. Speier. Lieutenant Colonel Ivany.
        Colonel Ivany. Ma'am, the Army recognized this as a key
    issue and is fully supportive of all research efforts in this
    area. And we feel, again, great motivation here. The Army is
    the lead service for the NCAA-DOD [National Collegiate Athletic
    Association-Department of Defense] Grand Alliance, which is a
    big part of the broader research assessment and following
    soldiers and athletes over time. And there are many other
    research efforts ongoing.
        We feel that it is very important to continue a broad
    research base in this area, because the clear connections from
    TBI to CTE are not yet fully established. And so we feel it is
    important to keep many research options on the table so that we
    have the best chance of developing care.
        Ms. Speier. Thank you. I yield back.
        Mr. Coffman. I recognize Mr. Bacon for 5 minutes, and then
    we will have to break or recess for three votes, and then we
    will return to finish the hearing.
        Mr. Bacon.
        Mr. Bacon. First of all, thank you for treating our service
    men and women and taking good care of them. I know, as someone
    who has commanded five times, the importance of what you are
    doing, because we have seen the impacts of when folks come back
    home.
        I would like to ask you briefly, do you feel like you have
    been adequately resourced and funded to treat PTS [post-
    traumatic stress] and TBI?
        We will start with Captain Colston.
        Captain Colston. Yes, sir. The Defense Centers of
    Excellence for Psychological Health and TBI has a $125 million
    annual budget. I feel that is more than sufficient to meet our
    need. And it has helped us to do really, I think, what we need
    to do, which is translate theory into practice.
        Mr. Bacon. Thank you. Our three service reps?
        Colonel Pflanz. Sir, I would agree that we are adequately
    resourced to address these issues. The services are leading the
    way in the adoption of evidence-based therapies for PTSD. The
    Air Force is at 80 percent using these in treatment of PTSD,
    whereas many of our civilian communities are somewhere between
    10 and 40 percent.
        And so certainly we are being resourced--the funding that
    is going to Fort Detrick and our military research is
    tremendous. That is helping us find the cutting-edge science to
    advance our treatments in the field.
        Mr. Bacon. Great to hear.
        Colonel Ivany. Sir, the Army does feel that we have good
    resourcing in this area. We feel that the major struggle is not
    in having enough resources but in finding qualified mental
    health professionals across the country to come work with the
    Army at many bases that are in places that are not necessarily
    highly desirable to live.
        So things in the area of a stable civilian hiring
    environment, lack of CRs [continuing resolutions] and hiring
    freezes and those types of things help very much with the Army
    to be able to use the resources that are provided to bring
    providers into the clinics to care for our soldiers.
        Mr. Bacon. Thank you. Captain Johnson.
        Captain Johnson. We would ask for you to continue with your
    leadership, your guidance, and your commitment to helping all
    of us take care of the service members and their family.
        Mr. Bacon. Thank you.
        Here is another question. I know earlier it was harder to
    find effects of PTS, and I think we are trying to be a lot more
    aggressive in finding it early. Do you have analysis that shows
    that we are seeing a lot more earlier reporting, earlier
    success at finding PTS when folks come back from deployment?
        I will just start off again with Captain Colston.
        Captain Colston. Well, sir, I think one of the first
    things, the way that we approach that problem is by screening.
    So we do do person-to-person mental health assessments within
    90 days of the deployment and then within 90 days after, 6
    months to a year and a half, and 1\1/2\ years to 2\1/2\ years
    after.
        We are studying it right now. For instance, we are studying
    from the standpoint of the disability evaluation system. We are
    studying it from the standpoint of the prevalence of the
    condition. But I don't have a final answer, because we really
    don't know what the final answer is.
        Mr. Bacon. Uh-huh.
        Colonel Pflanz. Sir, I don't know that we can say that we
    are doing a better job of identifying it earlier, but with our
    serial screening, we are certainly giving airmen, soldiers,
    sailors, marines an opportunity, multiple opportunities, to
    tell medical professionals that they are suffering from these
    symptoms.
        And if they are reluctant when they are first coming back
    from deployment because they are worried that perhaps they
    might be delayed, they have another opportunity 6 months later,
    and they have another opportunity----
        Mr. Bacon. Right.
        Colonel Pflanz. So this serial screening is so important in
    giving these airmen multiple opportunities, and that has to
    give us an advantage in treating these earlier.
        Mr. Bacon. Thank you.
        Colonel Ivany. Sir, within the Army, again, this has been a
    major area of focus, to try to identify these conditions as
    early as possible. Screening is key. And we feel like moving
    care forward has been another very important step. As I
    mentioned, we have seen many more soldiers, almost twice as
    many, twice as frequently on the outpatient side and have far
    fewer soldiers needing hospitalization for those same
    conditions.
        So, for us, that is an indication that we are getting to
    see soldiers earlier in the course of the illness, prior to
    major crisis events which lead to them going into the hospital
    and having very negative career events.
        Mr. Bacon. Thank you. Captain Johnson.
        Captain Johnson. I can just echo what my colleagues have
    said. There are more robust screening tools that are in use to
    identify service members who have TBI or PTSD earlier. The Navy
    has also moved forward by embedding mental health in more
    forward positions. So what that does is that increases access
    and decreases stigma.
        And, finally, in our clinic, because we use a holistic,
    interdisciplinary, integrated approach, frequently a service
    member may initially say they have TBI, but then, as you get
    more history, PTSD due to whatever causes will become more
    apparent.
        Mr. Bacon. Well, thank you very much. I yield back my 13
    seconds.
        Mr. Coffman. Thank you, Mr. Bacon. The hearing will resume
    following the vote series.
        [Recess.]
        Mr. Coffman. This hearing is now called back to order.
        I am still concerned about the issue of access to care and
    the stigma that might be--and I know you all have essentially
    said that access has dramatically increased, that the culture
    of the military has changed to where there is--you can't say no
    stigma, but you say--I mean, if someone is in a line position
    of leadership, particularly in a combat military occupational
    specialty, and they have got issues related to stress or TBI
    that they want to seek treatment on, you know, that is--that is
    a hard one.
        And let's go back to the culture. At least I am outdated
    here. But, you know--but I remember, say, back when I was a
    junior officer, I mean, in a rifle infantry company in the
    Marine Corps, where if I had an appointment of any kind, the
    company commander was made aware of that appointment where I
    was leaving the company to go do something on Mainside.
        So tell me about how that infantry rifle platoon commander
    who is expected to be--to act appropriately in a stressful
    environment, in a combat environment, leading marines in this
    particular instance, where that is not a stigma for that junior
    Marine officer to go to seek treatment. And it would be the
    same for a platoon commander of the United States Army infantry
    or anything in combat arms, in any--a pilot--a fighter pilot,
    or somebody involved in a stressful situation--in the United
    States Air Force or positions in the Navy. I mean, you know, if
    someone's a SEAL [Sea, Air, Land] team member or somebody, you
    know, in any kind of a combat role. I mean, what is their
    access to care, and is there a stigma associated to it? And do
    you have any ideas where legislatively we could look at
    changing the administrative process in terms of how somebody's
    healthcare record is kept and how somebody--I think you
    mentioned privacy issues.
        So let's go back now, starting with you Captain Colston,
    and talk about where we are today, access today. And what can
    we do to improve it if, in your estimation, there needs to be
    something to improve access to where someone doesn't feel that
    there is a stigma associated with receiving care?
        Captain Colston. Yes, sir. Well, first of all, I think you
    hit the nail on the head. Junior officers, and I remember my
    time as a junior officer, there wasn't any discussion of mental
    illness or suicide or anything along those lines. And also, the
    senior enlisted folks really do act as gatekeepers for health
    care. That has been one of the things that we have recognized
    over the years.
        So the first thing is policy. So we wrote a DOD policy
    6490.04 that says, it is DOD policy that mental health care is
    the same as a rash. Commanders need to make sure that folks
    view mental health care just like the sergeant coming up to you
    and say, hey, get that rash taken care of.
        Obviously, at the unit level we need to make sure that
    happens. And that is where I think the embedded providers come
    in, the OSCAR [Operational Stress Control and Readiness]
    providers in the Marine Corps, the embedded behavioral health
    providers in the Army, the psychologists on aircraft carriers.
    I think that is where the role is. I think it is really--I
    think with regard to policy, I think we are there.
        There has been talk of making all mental health care
    confidential. I don't know that that necessarily best balances
    the interests of what we need to do as a warfighting entity and
    meet the needs of our soldiers, sailors, airmen, and marines.
    But it is certainly something that we have explored and
    something that we have looked at in research.
        One of my predecessors, Chuck Engel, has the view that that
    is where we should go. I think when we have kind of been
    through the SF-86 Question 21 with other agencies, DNI
    [Director of National Intelligence], those folks, I think where
    we are going to end up is somewhere in the middle. And I don't
    know what that middle is.
        Mr. Coffman. In the civilian world, certainly in Colorado
    law, if a therapist has a patient who is a threat to his or
    herself or to someone else, then there is a reporting
    requirement for that.
        Captain Colston. Yes, sir. That is commonly known as the
    Tarasoff warning. I am required as a psychiatrist, whether I am
    in the military or in the civilian world, where I have also
    practiced, I am required to tell folks, tell authorities if
    someone is a harm to themselves or others.
        There has been some thought of saying, well, that is really
    where we should cut it off. I think when we look at it from the
    security standpoint, we need to be a little bit higher in DOD,
    though.
        Mr. Coffman. Okay. Colonel Pflanz.
        Colonel Pflanz. Sir, American culture is changing about
    mental health care. The military culture is certainly changing
    as well. The challenge we have is that perception is ninth-
    tenths of reality and what airmen, soldiers, sailors, marines
    believe is true mobilizes their behavior. What they see is, you
    know, the 1 airman in 10 that goes out with a medical
    evaluation board, and 9 out of 10 that come back, they saw me,
    they had satisfactory care, they don't raise their hand and
    say, you know, I had a great experience with mental health.
        So it is our messaging, it is our training, you know,
    continuing encouraging help-seeking behavior, educating airmen
    through suicide prevention training, resiliency training, other
    sorts of things that mental health care is a good thing. It
    doesn't have the negative outcomes, sometimes, but not usually,
    that they perceive it to have. And then embedding mental health
    closer and closer so that they are familiar with this, and the
    false notions that they have, they will start to learn are
    untrue. So again, changing perception is the most important
    thing. We are moving the dial, but we are not there yet.
        Mr. Coffman. Do you think confidentiality, though, should
    we enhance confidentiality requirements for the patient?
        Colonel Pflanz. What I found in 22 years working with my
    patients is that the confidential dial is titrated to the right
    level. Most of my patients that I interact with that I then
    speak to commanders, I am an advocate for that individual. They
    are appreciative of that communication. And for the 95 percent
    of patients that I never speak to their commander, they are
    appreciative of that as well.
        I think changing that will impair--if we make it more
    confidential, it will impair my opportunities to be that
    patient's advocate with a commander, to help that commander
    understand the mental illness, how it impacts the mission, and
    also help that commander understand that this airman with
    treatment is going to be a full-blown asset once we're done.
        Mr. Coffman. Under current regulations, do you have to
    receive permission from the patient, the airman being treated,
    to be able to discuss the issue with, say, that person's
    commanding officer?
        Colonel Pflanz. I do not need the airman's permission for
    things that impact duty performance, safety, mission safety,
    those sorts of things.
        Mr. Coffman. Lieutenant Colonel Ivany.
        Colonel Ivany. Yes, sir. I think the key here is two
    things. One is a trusting, working relationship between a small
    number of mental health providers and then line leaders. If
    line leaders trust and know and understand who it is they are
    going to talk to themselves or who it is they are sending their
    soldier to talk to, they are much more likely to use that care.
    If we just ask them to go up to the hospital to a nameless or
    faceless entity and clinic and just walk in and say I need
    help, that is a much, much harder sell than us saying, look,
    please come down to the clinic two blocks down from where you
    work to see Dr. Johnson who has seen all your soldiers and your
    unit for the past, you know, couple of years and worked with
    you on many different issues.
        So if you have a trusting working relationship, that
    changes the thought process, because that leader doesn't have
    to necessarily think differently about mental health care in
    general, they just have to think differently about at least one
    mental health provider that is there to help them and their
    unit. So I think that is one of the keys.
        The second is that while we want to make sure that we offer
    as much confidentiality as possible, we have to balance
    readiness. So when we identify a readiness impairing issue, it
    is in the best interest of the unit, of the leader, and
    ultimately the soldier themselves to make sure that is known to
    the appropriate people so that we can form a community to help
    that soldier to get better or to help them take the next steps
    in their life.
        Mr. Coffman. Captain Johnson.
        Captain Johnson. We have found that education of the
    service members, as well as healthcare providers, is one way to
    decrease stigma. In addition, when service members are referred
    to the Intrepid Spirit Concussion Recovery Clinic and when they
    recover and when they return to full duty, that is a testimony
    to the fact that TBI and PTSD are real issues and they are also
    treatable. And it encourages service members. It gives them
    hope to step forward, to seek treatment, and then return and
    get back into the fight.
        Mr. Coffman. Thank you very much.
        Ms. McSally, you are now recognized for 5 minutes.
        Ms. McSally. Thank you, Mr. Chairman. And thank you,
    gentlemen, for your service and your care for our troops.
        I am a big proponent of integrated medicine and--for myself
    and really from a public policy point of view. And alternative
    options are just sometimes challenging because they are not
    recognized often in the medical community. So can you speak a
    little bit more about--you know, I have talked to organizations
    that are involved with helping our troops, this is mostly with
    vets, hyperbaric oxygen therapy, or another organization our
    community is involved in, take and choose for PTSD on, you
    know, doing scuba-related underwater therapy, or service
    animals, other nontraditional things that there is, again,
    outside organizations that are already doing things like this.
    Sometimes it is tougher for a big bureaucracy to accept some of
    these alternative things that they say can't be proven.
        So just talk to me about some of the things that you might
    be working on or you think that may be useful. I have seen it
    in some of your testimony, Captain Johnson. Any other
    perspectives on these other treatments. Some of them, again,
    may be psychological, but also there is some physiological
    elements, I think, of a cortisol. And I am not a doctor, but
    other things related to the potential benefits for those that
    are suffering from PTSD and TBI.
        Captain Johnson. You have hit on a very important issue.
    Just to break down your question to the components, in regards
    to hyperbaric oxygen therapy, currently, the FDA [Food and Drug
    Administration] has I believe it is 13 approved indications for
    the use of hyperbaric oxygen therapy. The Navy and the DOD
    provides clinical care for these approved uses of hyperbaric
    oxygen therapy. So our use of hyperbaric oxygen therapy is in
    alignment with the FDA and the Undersea and Hyperbaric Medical
    Society. Having said that, there is always more to learn, and
    we certainly are open to discussion to explore research and
    other projects that involve hyperbaric oxygen that can help
    service members and their families.
        In regards to complementary and integrated medicine, we
    have found at Camp Lejeune that service members are very
    receptive to it. They are hesitant about taking a pill. We use
    a lot of acupuncture, yoga, various meditation techniques,
    Alpha stimulation, audio-visual entrainment, and various other
    tools. We have found that this results in a decreased need for
    medications, in particular, narcotics. It is a central part of
    our treatment plan.
        Ms. McSally. Are you bringing in experts from off base in
    order to partner with that or are you building expertise within
    the service?
        Captain Johnson. Both.
        Ms. McSally. Okay.
        Captain Johnson. For example, myself and one of my
    colleagues in the clinic has completed training in acupuncture.
    But we also have relationships through our NICoE [National
    Intrepid Center of Excellence] and Intrepid Spirit's network to
    discuss the latest and newest innovations in complementary and
    innovative medicine.
        Ms. McSally. Great. Thanks. Captain Colston, did you have
    something to add?
        Captain Colston. Yes, ma'am. We welcome complementary and
    alternative medicine in DOD. And, in fact, given the national
    opiate scourge, I think especially for pain disorders it is
    important to have yoga and acupuncture and mindfulness and
    other therapies available for patients. And I think--if I were
    to look at family practice docs across the board right now,
    lots of them are trained in battlefield acupuncture where we
    really are using it.
        Ms. McSally. Yeah. Is there also, as you are--maybe again
    this breaks up our thinking on some traditional mindsets,
    right, transitioning that to the VA, are you--I mean, are we
    seeing partnering with the VA to make sure, if you guys are all
    using this and it is working, as they are transitioning, they
    are not dealing with similar bureaucracy saying, sorry, that is
    not approved, we don't do that here? Anybody else want to jump
    in?
        Colonel Pflanz. I think that, you know, all the services
    are interested in the emerging research, and our partnership
    with the VA and our clinical practice guidelines is one of our
    great strengths. It makes us, despite our size, a very nimble
    organization as new research emerges. And almost all of our
    research projects are partnered with civilian institutions, so
    we have the best minds out there assisting us. And as this new
    research emerges, it is incorporated relatively quickly into
    our clinical practice guidelines. The one on PTSD is being
    updated as we speak, and that allows our practitioners in the
    field to have the cutting-edge tools to treat airmen, soldiers,
    sailors, marines in those clinics with the best possible
    science that has emerged.
        Ms. McSally. You have got to believe there is skepticism
    within the traditional medical community, right, on some of
    these things? I deal with it all the time. Right? So how are
    you overcoming that?
        Lieutenant Colonel Ivany, is that how you say it? Do you
    want to jump in?
        Colonel Ivany. Yes, ma'am. I think that the more that we
    put these alternative approaches out in clearly defined
    clinical practice guidelines, which is the clear state of the
    science that is a joint DOD/VA work, then more and more people
    out there in each individual clinic will see that this is
    clearly beneficial and this is not a competition. It is an
    augmentation to what they are doing to help their patients.
        Ms. McSally. Great. Thank you. I am over my time. I
    appreciate all of your work, gentlemen. Thank you. I yield
    back.
        Mr. Coffman. Thank you, Ms. McSally.
        Ranking Member Speier.
        Ms. Speier. Thank you. I just have a couple of quick
    questions.
        Lieutenant Colonel Ivany, you referenced in your statement
    that one of your biggest problems was hiring, that you have a
    15 percent turnover rate with your specialists who provide the
    services. And I can see for the service member having to
    redevelop a relationship with yet another behavioral specialist
    has got to be problematic. What can we do to fix that?
        Colonel Ivany. Ma'am, I think the biggest thing that we can
    do is to make sure that the healthcare providers who have
    options to work with us or work elsewhere have trust that there
    is a stable hiring environment within the U.S. Government and
    within the Army. So that--for instance, the recent hiring
    freeze, you know, as we identify and try to bring providers on,
    we had to have many of those providers wait. And they weren't
    able to come onboard to our clinics until we have worked
    through the steps to resolve the hiring freeze to get them
    through the gate.
        So they are hesitant to hear about sequestration. They hear
    about continuing resolutions, and it makes many hesitant. So I
    think that is the single most important thing at the national
    level that would help us at the clinical level.
        Ms. Speier. All right. Captain Johnson, you talked about
    some of those suffering from TBIs or PTSD self-medicating. I am
    presuming this is alcohol and drugs, unrelated to their
    condition. Is that right?
        Captain Johnson. That is correct.
        Ms. Speier. I have a lot of biotech in my district. And I
    was speaking to one of my CEOs just last night who said that
    they are close to finding a genetic marker for PTSD. Are you
    looking at that at all in the research that is being
    undertaken? And if not, why not?
        Captain Colston. Yes, ma'am. In fact, we have protocols
    underway right now to look at genetic loci for PTSD. I just say
    there are far more than one, and that is one of the things that
    we find across mental illness, across PTSD, depression, autism
    spectrum disorders. But we have funded research and we are
    looking at that closely.
        Ms. Speier. My colleague had to leave, but Congresswoman
    Shea-Porter is from New Hampshire where the opioid crisis has
    been particularly severe. And she got the impression from your
    testimony, and maybe it was you, Captain Colston, who talked
    about the success you are having. And she wants to know if
    there are certain procedures or policies or programs you have
    undertaken that has been particularly successful, could you
    share them with us? And if you could do that for the record,
    that would be helpful.
        Captain Colston. Yes, ma'am. Well, I would start with it is
    my opinion, but I think the fact that our death rate is 2.7 per
    100,000, and the national death rate is 10.4 for 100,000, for
    opiates, is obviously a significant difference between
    populations. Universally, we have random drug testing, which
    is, of course, not available to most people. You know, in
    regard to civil rights that you have when you are an Active
    Duty service member, there is a difference between being a
    civilian and in the military.
        I do think secondary prevention efforts are really where we
    have excelled with regard to pharmacy interventions, a
    prescription drug tracking system, various issues with regards
    to sole provider programs. And then goalkeepers, to be quite
    honest with you, ma'am.
        One of the things that I do as a psychiatrist, that I have
    a buprenorphine waiver. So I can give medication-assisted
    therapy for people who are addicted to opiates, give them a
    drug that they can't overdose on, give them a drug that they
    can't snort and, hence, die. I think that has been useful. And,
    of course, we have put naloxone into the hands of first
    responders. And in New England, New Hampshire, Vermont,
    Governor--I know the Governor in Vermont made the entire state
    of his governorship address one year on opiate overdose deaths.
        This is the single biggest public health crisis that we
    have faced. It is 55,000 overdose deaths a year. Car accidents,
    38,000; gun deaths, 36,000. AIDS was never this big. It is a
    huge issue. And frankly, it is a doctor-created problem and it
    is on us to fix it.
        Ms. Speier. Last question I have. To what extent are we now
    tracking those who have been diagnosed with TBI over the course
    of the rest of their lives to see what conditions they acquire
    that we would attribute to TBI?
        Captain Colston. So we have two studies underway. We have
    the 15-year longitudinal TBI study, which we are 7 years into.
    And I think that is going to talk an awful lot especially about
    how PTSD and TBI and suicidality and chronic pain and substance
    use all overlap. And we will learn a lot more about that. We
    also have an IMAP [Improved Understanding of Medical and
    Psychological Needs in Veterans and Service Members with TBI]
    study. In regard to the here and now, how do we look at--how do
    we look at TBI. Well, we have a very robust surveillance
    network with regard to TBI, and we look at scientifically
    something called incidence, which is new incidents and
    prevalence. In other words, how people are--if people aren't
    recovering from TBI.
        Most TBI is self limiting. Most mild TBI just gets better.
    It doesn't matter if you saw a doctor, it doesn't matter what
    you do. What we need to get on top of are the chronic cases,
    and we need to learn about those.
        Ms. Speier. So do you think the studies are going to
    provide you with that?
        Captain Colston. Yes, ma'am. I think longitudinal studies
    are really the way to go. The Framingham study, really, we
    learned a ton about coronary artery disease. I think the Army's
    STARRS [Study to Assess Risk and Resilience in Servicemembers]
    study in regard to suicide is going to yield great benefit. I
    think longitudinal studies like the Millennium Cohort Study,
    which in essence is a study that looks at what does military
    service do to you healthwise--I think they are all extremely
    important.
        Ms. Speier. Okay. Thank you. Thank you, Mr. Chairman.
        Mr. Coffman. Thank you, Ms. Speier.
        I wish to thank the witnesses for their testimony this
    afternoon. This has been very informative.
        There being no further businesses, the subcommittee stands
    adjourned.
        [Whereupon, at 4:12 p.m., the subcommittee was adjourned.]

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                                A P P E N D I X

                                 April 27, 2017

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                  PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                                 April 27, 2017

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    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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                  WITNESS RESPONSES TO QUESTIONS ASKED DURING

                                  THE HEARING

                                 April 27, 2017

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                  RESPONSE TO QUESTION SUBMITTED BY MS. SPEIER

        Captain Colston. The Department of Defense (DOD) is working to
    inform veterans and those discharged from the military of the brain
    tissue repository (BTR). Brain Injury Awareness month, supported by
    connected health efforts (e.g., internet, apps) and outreach events,
    advertises the crucial need for brain tissue donations to this
    repository. Service members can declare their desire to donate to a
    brain repository after death through a will or power of attorney. If no
    such documents exist, next-of-kin may also make a determination
    regarding donation. Donations will remain voluntary: ethical
    considerations forbid compelling the donation of brain tissue. DOD is
    also partnering with the Organ Procurement Organizations (OPOs) to
    establish a Memorandum of Understanding and Institutional Review Board
    approvals to obtain such specimens, since OPOs can reach out to
    individuals interested in brain donation. DOD plans similar outreach
    for the 15-year longitudinal study participants.   [See page 11.]

    ?

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                  QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                                 April 27, 2017

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

                       QUESTIONS SUBMITTED BY MR. COFFMAN

        Mr. Coffman. As we know, traumatic brain injury (TBI) is a
    significant health issue that affects service members and veterans
    during times of both peace and war. In addition, there is growing
    evidence that TBI is associated with a variety of short- and long-term
    adverse health outcomes that may include the acceleration of the onset
    of brain disorders that may result in dementia and other disorders that
    affect memory, movement and mood.
        Given this emerging link between mild, moderate and severe TBI and
    dementia, what initiatives are being undertaken by the Department and
    service surgeons general to advance research? How might the Department
    and services use public-private partnerships to advance their research,
    particularly as it relates to the link between TBI and dementia?
        Captain Colston. The Department of Defense (DOD) recognizes the
    importance of following Service members diagnosed with Traumatic Brain
    Injury (TBI) for an extended period in order to define risk factors
    associated with the delayed onset of dementia or chronic traumatic
    encephalopathy. DOD currently conducts and supports multiple clinical
    research studies to diagnose TBI earlier and to better understand the
    progression of TBI symptoms. The Department also collaborates with
    several private and academic groups. Of the many research initiatives
    supported or conducted by DOD, three are of note. The first is the
    congressionally-mandated 15-year longitudinal study exploring the
    natural history of TBI. The study intends to improve our understanding
    of TBI through neurobehavioral, neurocognitive, neuroimaging, blood
    specimen, sensory, and motor data from Service members and veterans
    injured since October 2001. It will document long-term outcomes and
    identify long-term, chronic effects of TBI. The second, one of several
    large-scale studies researching the relationship between TBI and
    neurodegenerative conditions, is the Chronic Effects of Neurotrauma
    Consortium, a DOD and VA collaboration exploring the long-term effects
    of mild TBI. The third, the DOD-sponsored National Collegiate Athletic
    Association Grand Challenge, targets collegiate athletes--including
    those at the military service academies--to ascertain the sequelae from
    concussion. DOD has played a key role in developing and supporting the
    Federal Interagency Traumatic Brain Injury Registry, which allows for
    data sharing across the entire TBI research community and for
    collaboration among research programs in the DOD, NIH, and academia.
    Additional DOD research includes efforts to better understand chronic
    traumatic encephalopathy (CTE). Two recent studies are noteworthy. One
    study examined postmortem brain specimens from eight military cases
    with chronic and acute blast exposure: this study found a distinct and
    previously undocumented pattern of brain scarring that could account
    for aspects of the behavioral symptoms of CTE. Beyond the results of
    these 8 brains, the repository includes approximately 80 samples and
    continues to accumulate more over time. The other study sought a
    premorbid test for CTE: this study, which used positron emission
    tomography (PET) scans, represents an important step toward identifying
    CTE in living Service members thought to be at risk.
        Mr. Coffman. The medical-scientific literature indicates there is a
    paucity of data for women affected by brain injuries particularly in
    the armed services. Although there are clear historical reasons,
    thinking into the future, how is DOD making an effort to accumulate
    more data on female service members as related to issues of brain
    injuries?
        Captain Colston. Given that sixteen percent of Service members are
    women, the Department of Defense (DOD) is working to accumulate more
    data on female Service members diagnosed with Traumatic Brain Injury
    (TBI). DOD has recently published on, and continues to investigate,
    gender differences in TBI. DOD is supporting several longitudinal
    studies designed to determine gender differences for the risk for TBI,
    differential clinical effects of TBI, intersex differences in symptom
    reporting, and differences in short- and long-term outcomes between
    sexes. Two of the largest studies are the congressionally-mandated 15-
    year longitudinal study and the Improve Understanding of Medical and
    Psychological Needs in Veterans and Service Members (IMAP) study. The
    15-year study explores the natural history of TBI. The IMAP study
    investigates health care, mental health care, and the rehabilitation
    needs of female Service members after they complete inpatient treatment
    in DOD, the Department of Veterans Affairs, or both. It focuses on the
    needs of concussed female Service members, as well as on the health and
    behavioral needs of disabled Service members' caregivers, who are
    primarily women. The DOD-sponsored National Collegiate Athletic
    Association Grand Challenge Partnership and the Concussion Assessment,
    Research and Education Consortium also address gender differences.
        Mr. Coffman. As we know, traumatic brain injury (TBI) is a
    significant health issue that affects service members and veterans
    during times of both peace and war. In addition, there is growing
    evidence that TBI is associated with a variety of short- and long-term
    adverse health outcomes that may include the acceleration of the onset
    of brain disorders that may result in dementia and other disorders that
    affect memory, movement and mood.
        Given this emerging link between mild, moderate and severe TBI and
    dementia, what initiatives are being undertaken by the Department and
    service surgeons general to advance research? How might the Department
    and services use public-private partnerships to advance their research,
    particularly as it relates to the link between TBI and dementia?
        Colonel Pflanz. The Department of Defense has multiple ongoing
    initiatives to advance research into our understanding of TBI.
    Specifically, the ongoing, congressionally mandated 15-year
    longitudinal study is intended to increase our understanding and
    awareness of both short and long-term outcomes of TBI. This would
    include cognitive and behavioral changes that would be expected to
    occur in TBI-related dementia or chronic traumatic encephalopathy
    (CTE). The Chronic Effects of Neurotrauma Consortium (CENC) is a
    public-private, multi-center collaborative effort between DOD, VA,
    civilian academic institutions, and private research entities. The CENC
    mission is to foster research to better understand the long-term
    neurodegenerative outcomes following TBI in Service members and to find
    effective treatments. In addition, CENC aims to find ways to identify
    the Service members most susceptible to these adverse long-term
    outcomes. The DOD has also partnered with the National Collegiate
    Athletic Association (NCAA) in sponsoring the NCAA-DOD Grand Alliance.
    This $30 million project is intended to research and prevent
    concussions by investigating sport-related mild TBI (mTBI). The United
    States Air Force Academy and the sister Service academies are all
    participating sites for this ongoing research. Finally, DOD has been
    involved in the development and support of the Federal Interagency
    Traumatic Brain Injury Registry (FITBIR). This system is intended to
    foster sharing of data amongst those performing TBI research, including
    entities within DOD, other governmental agencies such as NIH, and
    civilian research centers.
        Mr. Coffman. The medical-scientific literature indicates there is a
    paucity of data for women affected by brain injuries particularly in
    the armed services. Although there are clear historical reasons,
    thinking into the future, how is DOD making an effort to accumulate
    more data on female service members as related to issues of brain
    injuries?
        Colonel Pflanz. The ongoing, congressionally mandated 15-year
    longitudinal study of the natural history of TBI will allow meaningful
    comparisons between males and females exposed to TBI. In addition, the
    Improved Understanding of Medical and Psychological Needs in Veterans
    and Service members with Chronic TBI (IMAP Study) is another DOD and VA
    collaborative effort supported by the Services. Among other goals, this
    study is investigating the unique needs of female service members in
    terms of health care, mental health, and rehabilitation following TBI
    exposure.
        Mr. Coffman. As we know, traumatic brain injury (TBI) is a
    significant health issue that affects service members and veterans
    during times of both peace and war. In addition, there is growing
    evidence that TBI is associated with a variety of short- and long-term
    adverse health outcomes that may include the acceleration of the onset
    of brain disorders that may result in dementia and other disorders that
    affect memory, movement and mood.
        Given this emerging link between mild, moderate and severe TBI and
    dementia, what initiatives are being undertaken by the Department and
    service surgeons general to advance research? How might the Department
    and services use public-private partnerships to advance their research,
    particularly as it relates to the link between TBI and dementia?
        Colonel Ivany. As the scientific evidence emerges on potential
    associations between TBI and dementia or other disorders which may
    affect memory, movement and mood, the Department of Defense (DOD) and
    Surgeons General seek answers through a research portfolio cultivated
    to evaluate the spectrum of injuries. The DOD achieves this by grooming
    a research strategy including focal areas such as understanding the
    neuropathophysiology (brain damage at the cellular level) in living and
    deceased models, identifying assessment and diagnostic techniques that
    correlate with structural brain changes, developing treatments to slow
    or reverse the progression of disease, and monitoring the natural
    progression of TBI. Importantly, the DOD's current Combat Casualty
    Care-Neurotrauma Research Portfolio includes 104 open studies ($483M),
    effectively covering the spectrum of TBI by severity of injury (mild to
    severe), location in the injury/care continuum (point of injury,
    rehabilitation, or longitudinal study), and technology readiness level
    (time until it is a viable product). This DOD strategy, in combination
    with active program management, ensures a diversified, yet gap-driven,
    portfolio which is most likely to deliver solutions relevant to Service
    Members with TBI. Moreover, the DOD recognizes the importance of
    interdepartmental coordination and public-private partnerships in order
    to successfully advance understanding of TBI and the state of the
    science. One DOD supported effort looking at the natural progression of
    TBI is the Chronic Effects of Neurotrauma Consortium (CENC). The CENC
    is a joint DOD and Department of Veterans Affairs (VA) effort
    addressing the long-term consequences of mild TBI in Veteran, Active
    Duty, Reserve, and National Guard populations. It is part of a larger
    collaboration stemming from Executive Order 13625, which initiated the
    National Research Action Plan (NRAP) for Improving Access to Mental
    Health Services for Veterans, Service Members, and Families.
    Additionally, the DOD portfolio includes other longitudinal studies
    that seek unique but complimentary results in military relevant
    populations. The Department expects the CENC, National Collegiate
    Athletic Association (NCAA)-DOD Grand Alliance (Concussion Assessment,
    Research and Education Consortium), and the DOD/VA 15 year longitudinal
    study of TBI (including a neurological/neurobehavioral clinical data,
    blood specimens, and psychosocial impacts) collectively will inform the
    natural progression and long-term effects of TBI in sports, military,
    and civilian populations. For optimal outcomes from the research
    investments, the DOD supports public-private partnerships within the
    TBI portfolio. One example is the TBI Endpoints Development (TED)
    study, which in coordination with the National Institutes of Health
    (NIH), leverages datasets containing thousands of TBI subjects to
    harmonize and curate data into a large meta-dataset. The project seeks
    to validate this dataset and enter into FDA qualification processes to
    become acceptable ``standard measures'' for clinical trials. The DOD
    strategy also supports the NRAP requirement to place all federally
    funded study data into the Federal Interagency Traumatic Brain Injury
    Registry (FITBIR), a secure, centralized informatics system developed
    to accelerate analysis. As of 30 APR 2017, the FITBIR maintains data
    from 60 studies include over 1.5 million records from 42,500 subjects.
        Mr. Coffman. The medical-scientific literature indicates there is a
    paucity of data for women affected by brain injuries particularly in
    the armed services. Although there are clear historical reasons,
    thinking into the future, how is DOD making an effort to accumulate
    more data on female service members as related to issues of brain
    injuries?
        Colonel Ivany. The Army and Department of Defense (DOD) recognize
    there is a limited amount of scientific literature specific to female
    Service Members affected by brain injuries. Historically military-
    related mild TBI (mTBI) studies did not include high numbers of women
    because of the relatively low prevalence of the injury to women in
    combat. Recognizing the increasing role of women across the range of
    military operations, and increased exposure to combat situations, the
    DOD has made a concerted effort to evaluate potential gender
    differences in incidence, symptoms, and outcomes after Combat and Non-
    Combat-Related mTBI. The Congressionally mandated 15 year longitudinal
    study of TBI, required on Section 721 of the FY 2007 NDAA, is already
    producing results specific to gender difference which should help
    inform clinical practice and future study design. The NCAA-DOD Grand
    Alliance (Concussion Assessment, Research and Education (CARE)
    Consortium), as well as a parallel study of non-NCAA Service Academy
    Cadets, seek enrollment of all women at the Service Academies, and will
    surely add to the body of literature. However, other studies seeking
    enrollment of women have faced continued challenges due to a low
    prevalence. The DOD effort to mitigate that limitation is leveraging
    data to look at the gender differences in healthcare utilization, and
    provide insight into TBI-related comorbidities, long-term consequences,
    and health care costs specific to women. Additionally, the DOD funds a
    number of studies that have set out to examine how gender impacts TBI
    outcome in Service Members or Veterans.
        Mr. Coffman. As we know, traumatic brain injury (TBI) is a
    significant health issue that affects service members and veterans
    during times of both peace and war. In addition, there is growing
    evidence that TBI is associated with a variety of short- and long-term
    adverse health outcomes that may include the acceleration of the onset
    of brain disorders that may result in dementia and other disorders that
    affect memory, movement and mood.
        Given this emerging link between mild, moderate and severe TBI and
    dementia, what initiatives are being undertaken by the Department and
    service surgeons general to advance research? How might the Department
    and services use public-private partnerships to advance their research,
    particularly as it relates to the link between TBI and dementia?
        Captain Johnson. 1. The Intrepid Spirit Camp Lejeune, in
    partnership with Princeton University and Wayne State University are in
    the early phases of ``A Prospective Study of the Effects of Repetitive
    Low Level Blast Exposure (RLLBE) on Fitness for Duty in SOCOM
    Warriors.'' Follow on efforts include the development of validated
    baseline testing tailored for individual warfighters that can be
    repeated after subsequently sustaining a TBI. This baseline testing
    would be used to determine what effects the exposure had on their
    performance, how long their recovery was, and when they were fit enough
    to return to duty. Additionally, the development of individualized
    baseline testing will allow providers to detect subtle changes in
    cognitive function throughout their life. Partnering these types of
    tools with clinical history contributes exponentially to a longitudinal
    study on the long term effects of TBI. Due to the nature and frequency
    of exposures, the Special Operations community would serve as the
    initial community that this may prove best suited.
        2. The Surgeon General of the Navy has made partnerships one of his
    strategic priorities for Navy Medicine--Readiness, Health and
    Partnerships. As part of our initiative towards expanding and
    strengthening our partnerships to maximize readiness and health, we see
    significant potential for public-private partnerships as it relates to
    the advancement of research in TBI and dementia. In our pursuit to
    partner with academic, public, and private institutions, we are
    strategically assessing the landscape for future opportunities,
    removing barriers, and remaining vigilant that our partnerships are in
    alignment with our objectives. Intellectual sharing through
    partnerships can be a more cost effective and yet very impactful way to
    advance research.
        Mr. Coffman. The medical-scientific literature indicates there is a
    paucity of data for women affected by brain injuries particularly in
    the armed services. Although there are clear historical reasons,
    thinking into the future, how is DOD making an effort to accumulate
    more data on female service members as related to issues of brain
    injuries?
        Captain Johnson. It is my understanding that the Department of
    Defense is pursuing a number of longitudinal studies to gain a greater
    understanding of the risk profile, long-term effects, clinical
    differences, and outcomes for female service members impacted by TBI.
    Specifically, the Intrepid Spirit Camp Lejeune has presented at a
    national meeting on TBI in female service members. In addition, we are
    in the process of finalizing the publication of a retrospective study
    of approximately 300 service members, four of which are women, seen at
    Intrepid Spirit Camp Lejeune who had a reported history of TBI due to
    blast exposure. It is my observation that a shared data base between
    the Intrepid Spirit Center Camp Lejeune and other military treatment
    facilities would significantly increase the data collection on women
    impacted by brain injuries in the Armed Forces. For this reason, the
    Intrepid Spirit Camp Lejeune is establishing the final parameters under
    which a Memorandum of Understanding (MOU) could effectively operate a
    shared database with the National Intrepid Center of Excellence
    (NICoE).
                                     ______

                       QUESTIONS SUBMITTED BY MS. TSONGAS
        Ms. Tsongas. What are the current screening mechanisms that the
    services use to identify post-traumatic stress disorder (PTSD) for
    warfighters returning from deployment? What screening or monitoring
    measures are taken with service members who have suffered from PTSD
    before they are approved for a future deployment?
        Captain Colston. The Department of Defense (DOD) screens Service
    members for symptoms of Post-traumatic Stress Disorder (PTSD) at
    multiple points within the deployment life cycle, including annual,
    pre-deployment, and post-deployment health assessments. Service members
    deployed in connection with a contingency operation are assessed for
    PTSD and depression symptoms, suicide and violence risk, and substance
    use disorders using person-to-person interviews at four different
    periods before and after deployment. These interviews, conducted by
    trained health care providers, expand upon self-reported survey
    responses and include a review of health records. Service members are
    then referred for follow-up evaluation and treatment, as needed. In
    accordance with DOD policy, health care providers notify a Service
    member's Commander regarding concerns (e.g., risk of harm to self or
    others, mission impairment). Service members are not cleared for
    subsequent deployments unless they are free of deployment-limiting
    mental health conditions.
        Ms. Tsongas. How are the services screening for PTSD in service
    members as a result of non-combat deployment related causes--such as
    military sexual trauma that may not have been previously reported, for
    example? Specifically, please address how the FY15 NDAA requirement for
    annual mental health screening of service members has been implemented
    and what is covered in the screening.
        Captain Colston. The Department of Defense (DOD) leverages a
    Primary Care Medical Home model, using an evidence-based screening
    instrument, to screen Service members for Post-traumatic Stress
    Disorder (PTSD). The Post-Traumatic Stress Checklist screens for trauma
    at multiple points regardless of deployment status. Screening is
    conducted for all new patients, existing patients annually, and any
    patients for whom it is clinically necessary. Patients with PTSD who
    receive ongoing mental health treatment are screened periodically until
    the end of their treatment. During intake for all mental health
    appointments, in accordance with health care accreditation standards,
    providers ask Service members a number of questions related to whether
    they have experienced trauma. DOD complies with the National Defense
    Authorization Act for Fiscal Year 2015. As part of annual periodic
    health assessment, Service members receive annual mental health
    screening. This assessment includes the use of evidence-based screening
    instruments that produce a self-report of depression symptoms,
    posttraumatic stress, alcohol misuse, and overall functioning. The
    annual assessment includes a follow-up interview with a trained health
    care provider to further assess identified symptoms, review medical
    documentation, and provide referrals for applicable treatment and
    evaluation.
        Ms. Tsongas. What requirements exist for mental health screening as
    service members leave active duty to ensure that PTSD and other mental
    health issues are identified during service and there is a warm handoff
    to the VA?
        Captain Colston. During military separation, Service members must
    complete a separation health assessment that includes a review of
    medical history, medical concerns, and current health status. This
    assessment may be completed at a Department of Defense (DOD) or
    Department of Veterans Affairs (VA) facility--each entity shares
    results with the other. Service members currently receiving mental
    health care are automatically enrolled in the inTransition program
    during separation from the military. Service members can elect to opt
    out if they desire. The inTransition program supports a warm hand-off
    between the DOD and the VA for Service members who are in treatment for
    psychological health conditions by enhancing coordination between
    referring and gaining providers. Since the launch of the automatic
    enrollment requirement in April 2014, the inTransition program has
    completed 50,314 assessments in support of care transitions.
        Ms. Tsongas. We've heard in recent years of the development of new
    technologies that use physiological measurements to predict and help
    address the onset of PTSD episodes. What is the current research
    portfolio of technologies for the screening or monitoring of PTSD? Do
    the services see the measurement and use of physiological indicators as
    a way to provide even more comprehensive care to service members
    suffering from PTSD? What are the limitations in currently existing
    technologies?
        Captain Colston. Efforts to predict or treat Post-traumatic Stress
    Disorder (PTSD) using physiological measures are in incipient stages.
    Investigations regarding the possible utility and functionality of
    biosensors are underway. Biosensors have the potential to aid
    screening, monitoring, and treatment of many psychological health
    conditions. The Department of Defense (DOD) is currently studying
    biosensors that look and feel like Band-Aids, ``Fitbits,''
    ``Smartwatches,'' and other wearable technologies. These tools take
    physiological measurements and link to smartphones that collect data.
    While these innovative biosensors are not yet effective in clinical
    applications for PTSD treatment, they will likely be a part of PTSD
    management in the future. Studies continue to establish efficacy and
    then effectiveness in the field. Currently, DOD relies on evidence-
    based screening tools for the assessment and diagnosis of PTSD. For
    instance, the Post Traumatic Stress Checklist (PCL) is a series of
    questions that a patient answers and a provider scores. Providers
    integrate screening results with other clinical information to
    determine if patients meet criteria for PTSD. Since 2013, DOD has used
    a software platform and computer technology to create an electronic
    database, the Behavioral Health Data Portal, where patients' PCL
    responses are stored for providers to monitor. There are no predictive
    or diagnostic technologies beyond the research stage in DOD's current
    portfolio; several promising endeavors, however, are in progress. These
    include studies on Heart Rate Variability, attention bias biomarkers,
    brain imaging, and voice analysis. DOD is working to integrate
    technology into clinical care and apply technology to prevention
    efforts. Mobile applications for self-care tools that supplement
    treatment for Service members and veterans suffering from PTSD have
    been developed for use across the Services, DOD, and the Department of
    Veterans Affairs. Examples of these apps include PTSD Coach, PE Coach,
    and Dream EZ. Studies on the PTSD Coach indicated both high rates of
    perceived helpfulness and acceptability and also a reduction in some
    PTSD symptoms when combined with clinical treatment. While the
    measurement and use of physiological indicators (i.e., data that these
    apps help to collect) have not yet been incorporated into clinical
    care, substantial interest exists and research is underway to do so in
    the future. One challenge in developing technology to advance
    psychological health screening and treatment in DOD is privacy. Most
    applications use the internet to operate. It is difficult to interact
    digitally across the internet without attending to privacy issues.
    Additionally, technologies that support psychological health screening
    and treatment are new, so we are still learning how they can best aid
    Service members with PTSD. Finally, our understanding of the safety and
    effectiveness of the use of technology to support PTSD screening or
    treatment over time is limited. This is a challenge that merits further
    research.
                                     ______

                       QUESTIONS SUBMITTED BY MR. KNIGHT
        Mr. Knight. I am aware that Tinker Air Force base is currently
    conducting clinical trials on magnetic EEG/EKG-guided resonance
    therapy. Can you elaborate on the clinical trials and their results
    thus far? Are there any plans in the Department of Defense to expand
    these trials? Also, has Tinker AFB conducted clinical trials using
    repetitive transcranial magnetic stimulation (rTMS)?
        Colonel Pflanz. One study is underway on magnetic EEG/EKG-guided
    resonance therapy at Tinker AFB. The study is in its early stages,
    having completed the intervention with eight subjects so far; it is too
    early to draw any substantive conclusions. We are not aware of any
    plans for the Department of Defense to expand these trials. Tinker AFB
    has not conducted any clinical trials using repetitive transcranial
    magnetic stimulation (rTMS).

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