[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]





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                   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

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                                                                   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

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                   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).

                                  [all]