[House Hearing, 111 Congress]
[From the U.S. Government Printing Office]
[H.A.S.C. No. 111-155]
IMPLEMENTATION OF THE REQUIREMENT TO PROVIDE A MEDICAL EXAMINATION
BEFORE SEPARATING MEMBERS DIAGNOSED WITH POST-TRAUMATIC STRESS DISORDER
(PTSD) OR TRAUMATIC BRAIN INJURY (TBI) AND THE CAPACITY OF THE
DEPARTMENT OF DEFENSE TO PROVIDE CARE TO PTSD CASES
__________
HEARING
BEFORE THE
MILITARY PERSONNEL SUBCOMMITTEE
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
APRIL 20, 2010
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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58-290 WASHINGTON : 2010
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MILITARY PERSONNEL SUBCOMMITTEE
SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas JOE WILSON, South Carolina
LORETTA SANCHEZ, California WALTER B. JONES, North Carolina
MADELEINE Z. BORDALLO, Guam JOHN KLINE, Minnesota
PATRICK J. MURPHY, Pennsylvania THOMAS J. ROONEY, Florida
HANK JOHNSON, Georgia MARY FALLIN, Oklahoma
CAROL SHEA-PORTER, New Hampshire JOHN C. FLEMING, Louisiana
DAVID LOEBSACK, Iowa
NIKI TSONGAS, Massachusetts
Michael Higgins, Professional Staff Member
Jeanette James, Professional Staff Member
James Weiss, Staff Assistant
C O N T E N T S
----------
CHRONOLOGICAL LIST OF HEARINGS
2010
Page
Hearing:
Tuesday, April 20, 2010, Implementation of the Requirement To
Provide a Medical Examination before Separating Members
Diagnosed with Post-Traumatic Stress Disorder (PTSD) or
Traumatic Brain Injury (TBI) and the Capacity of the Department
of Defense To Provide Care to PTSD Cases....................... 1
Appendix:
Tuesday, April 20, 2010.......................................... 21
----------
TUESDAY, APRIL 20, 2010
IMPLEMENTATION OF THE REQUIREMENT TO PROVIDE A MEDICAL EXAMINATION
BEFORE SEPARATING MEMBERS DIAGNOSED WITH POST-TRAUMATIC STRESS DISORDER
(PTSD) OR TRAUMATIC BRAIN INJURY (TBI) AND THE CAPACITY OF THE
DEPARTMENT OF DEFENSE TO PROVIDE CARE TO PTSD CASES
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California,
Chairwoman, Military Personnel Subcommittee.................... 1
Wilson, Hon. Joe, a Representative from South Carolina, Ranking
Member, Military Personnel Subcommittee........................ 2
WITNESSES
Carr, William J., Deputy Under Secretary of Defense for Military
Personnel Policy, Office of the Under Secretary of Defense for
Personnel and Readiness........................................ 5
Rice, Dr. Charles L., President, Uniformed Services University of
the Health Sciences, Performing the Duties of the Assistant
Secretary of Defense for Health Affairs, U.S. Department of
Defense........................................................ 3
APPENDIX
Prepared Statements:
Carr, William J., joint with Dr. Charles L. Rice............. 29
Davis, Hon. Susan A.......................................... 25
Wilson, Hon. Joe............................................. 27
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
Mrs. Davis................................................... 47
Mr. Pascrell................................................. 49
Dr. Snyder................................................... 48
Questions Submitted by Members Post Hearing:
Ms. Fallin................................................... 53
IMPLEMENTATION OF THE REQUIREMENT TO PROVIDE A MEDICAL EXAMINATION
BEFORE SEPARATING MEMBERS DIAGNOSED WITH POST-TRAUMATIC STRESS DISORDER
(PTSD) OR TRAUMATIC BRAIN INJURY (TBI) AND THE CAPACITY OF THE
DEPARTMENT OF DEFENSE TO PROVIDE CARE TO PTSD CASES
----------
House of Representatives,
Committee on Armed Services,
Military Personnel Subcommittee,
Washington, DC, Tuesday, April 20, 2010.
The subcommittee met, pursuant to call, at 5:35 p.m., in
room B-318, Cannon House Office Building, Hon. Susan A. Davis
(chairwoman of the subcommittee) presiding.
OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE
Mrs. Davis. The hearing will come to order.
Today the subcommittee will hear testimony about the
efforts of the Department of Defense (DOD) to implement Section
512 of the National Defense Authorization Act, Fiscal Year
2010.
The section requires the Secretaries of the military
departments in certain cases to conduct a medical examination
before administratively separating a member under less than
honorable conditions if the member has been deployed overseas
in support of a contingency operation.
The purpose of the examination is to evaluate a medical
diagnosis or assertion by the member that Post-Traumatic Stress
Disorder, PTSD, or traumatic brain injury, TBI, might have
caused the behavior that resulted in the commander's decision
to pursue separation. The subcommittee considered this
legislation at the request of the gentleman from North
Carolina, Mr. Jones, who, unfortunately, is not able to be
here, and I want to commend Mr. Jones for bringing this issue
before the attention of the subcommittee.
I agree with the gentleman that it is unacceptable that the
military departments were separating service members because of
misconduct that was caused by a PTSD or TBI injury that
occurred during his or her combat tour. Now that we know so
much more about the extent of those injuries in the force, we
owe every returning service member the assurance that we will
not punish them for an injury that resulted from combat
service.
The unfortunate truth is that we have very likely already
separated a number of service members where the commanders did
not consider that the member was experiencing the consequences
of PTSD or TBI. That is why the provision we adopted last year
also requires the Discharge Review Boards in the military
departments to provide expedited review of cases that involve a
diagnosis or assertion of the influence of PTSD or TBI.
We intend to learn about the status of DOD efforts to
implement this law and improve the general access to mental
health care. As always, if the Congress needs to do more, we
would like to know what further action is needed.
I want to welcome our witnesses here today. We are very
pleased that you are here joining us. Mr. Bill Carr, Deputy
Under Secretary of Defense, Military Personnel Policy Officer
of the Under Secretary of Defense for Personnel and Readiness;
and Dr. Charles Rice, MD, Dr. Rice is performing the duties of
the Assistant Secretary of Defense for Health Affairs and is
president of the Uniformed Services University (USU) of Health
Sciences.
Again, we are pleased that you are here and look forward to
your discussion.
Mr. Wilson, do you have any comments you would like to
make?
[The prepared statement of Mrs. Davis can be found in the
Appendix on page 25.]
STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH
CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE
Mr. Wilson. Thank you, Chairwoman Davis, for holding this
hearing.
I believe Congress and this nation has no greater
responsibility than to provide the care and support needed by
members of our armed forces, who endure the horrors of war to
protect our freedom.
I am aware of the challenges the Department of Defense and
the Department of Veterans Affairs (VA) have in providing
mental health care to the growing numbers of combat veterans
returning with Post-Traumatic Stress Disorder and traumatic
brain injury. I am also aware that the legislation Congress
passed last year requiring medical examinations prior to
administratively separating service members who may be
experiencing Post-Traumatic Stress Disorder or traumatic brain
injury may increase the burden on the two departments. But that
does not mean we should allow one combat veteran to slip
through the cracks and be discharged from the service without
the proper recognition of and medical benefits for the mental
health issues they may be facing.
As a former president of Mid-Carolina Mental Health
Association, I especially appreciate mental health care.
Thankfully, the mental health profession now understands that
Post-Traumatic Stress Disorder and traumatic brain injury may
cause behaviors that previously would only be considered
reasons to administratively discharge service members.
Identifying the underlying mental health issues and brain
injuries is often further compounded by a service member's
reluctance to seek help. Too often they are self-medicating,
which leads to behavior problems. Simply discharging these
troops without the possibility of necessary medical care is not
the answer. We owe it to our combat veterans and their families
to proper diagnose combat-related mental health and brain
injury issues and to provide the care, regardless of cost, to
facilitate their recovery.
I am interested in hearing from our witnesses today how the
Department of Defense is providing the required medical exams
before separating a service member. I am particularly
interested in how you are accomplishing this, given the
recognized shortage of mental health providers. I would also
like to know how many previously discharged service members
have been screened by the Discharge Review Board and how many
have been identified with Post-Traumatic Stress Disorder or
traumatic brain injury. Finally, I would like to know how we
can help.
With that, I welcome our witnesses and thank them for
participating in the hearing today. I look forward to your
testimony.
[The prepared statement of Mr. Wilson can be found in the
Appendix on page 27.]
Mrs. Davis. Thank you, Mr. Wilson.
I want to ask unanimous consent that Congressman Bill
Pascrell be allowed to participate in the hearing.
Without objection, so ordered.
I know that you have a plan to present short opening
statements, and without objection, your full statements will be
entered into the record.
Mrs. Davis. Do I understand, Mr. Carr, you are going to
start?
Oh, Dr. Rice. Okay, please proceed.
STATEMENT OF CHARLES L. RICE, M.D., PRESIDENT, UNIFORMED
SERVICES UNIVERSITY OF THE HEALTH SCIENCES, PERFORMING THE
DUTIES OF THE ASSISTANT SECRETARY OF DEFENSE FOR HEALTH
AFFAIRS, U.S. DEPARTMENT OF DEFENSE
Dr. Rice. Thank you, Madam Chair and distinguished members
of the committee, it is a pleasure to join my colleague, Mr.
Carr, the Deputy Under Secretary For Military Personnel Policy,
and thank you for the opportunity to discuss with you today our
efforts to both implement the requirements for pre-separation
medical examinations for service members diagnosed with Post-
Traumatic Stress Disorder or traumatic brain injury, and to
ensure that we have the resources to meet the demand for
behavioral health services.
DOD continues to apply the necessary resources to develop
and improve policies and programs that address all behavioral
health issues for our service members. Our clinical programs
provide a continuum of care, whether through prevention,
treatment, rehabilitation, reintegration, or transition.
DOD screens all service members returning from the
operational theater for potential traumatic brain injury.
Although positive screens are not necessarily diagnostic of
traumatic brain injury, they do trigger the requirement for
further evaluation by a clinician. TBI screening of service
members can occur at several time points and locations. Our
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
patients who are medically evacuated from the combat theaters
are screened at Landstuhl Medical Center in Germany. In
addition, all service members will be screened after any
deployment and upon admission to a VA health care facility.
All service members identified as having sustained a
traumatic brain injury, whether from deployed or non-deployed
locations, are provided care following evidence-based clinical
care guidelines to ensure maximum treatment benefits for any
level of severity of their traumatic brain injury.
Similar guidelines also exist for Post-Traumatic Stress
Disorder. DOD providers not only have very detailed treatment
guidelines but receive ongoing training and education on the
screening, diagnoses, common symptoms, and recognized
treatments for TBI and PTSD.
Regarding DOD's policy on separation examinations, service
members scheduled for separation from active duty must have had
a physical examination within 12 months prior to separation and
a termination evaluation for any occupational exposure in which
they are enrolled. Waivers to this policy are granted only when
both the service member consents and the unit commander
concurs. Service members with work limitations related to TBI
or PTSD must be referred for a medical board to determine
fitness for retention and may receive a disability evaluation
and separated appropriately.
The Joint Executive Council has recently directed
establishment of a DOD VA work group to reexamine and make
recommendations concerning our separation examination policies.
Regarding our ability to meet the demand for behavioral
health services, we are addressing access issues with every
tool available. Our active duty mental health professionals are
largely focused on serving those in uniform. We have placed an
unprecedented number of these professionals into the combat
theaters. We have also increased our capacity to leverage a
combination of contracted professionals in our medical
facilities and on our managed care support contractor networks
in the civilian community to serve the needs of our families.
Our VA partners are part of the network, and within the
medical treatment facilities (MTFs), the services have
contracted for additional mental health specialists to augment
existing staff, adding almost 2,000 additional mental health
providers to our direct care system.
We have entered into a collaborative relationship with the
United States Public Health Service (PHS) that has resulted in
over 130 PHS officers either assigned or in the process of
being assigned into DOD positions, and we are making
significant progress in bringing those resources on board.
TRICARE management activity monitors the adequacy of the
TRICARE civilian network, and we work with our TRICARE
contractors to find remedies for service areas that are not
meeting our standards for access. In 2009, we established a new
program within TRICARE in which telephone mental health
services may be offered to beneficiaries, providing the
opportunity to address medically underserved populations by
using resources that are available in other communities.
We have also established the TRICARE Assistance Program,
called TRIAP, which permits beneficiaries to contact a
counselor for assessment and advice via the Internet. And
finally, our managed care support contractors offer a health
care finder capability for TRICARE prime beneficiaries to
assist service members and their families in locating mental
health providers who accept TRICARE.
VA medical facilities also provide services for post-
traumatic stress and other mental health problems to our
beneficiaries through both local and national resource sharing
agreements. While we offer patients choice in facilities, they
can use these facilities and resources when they are proximate
and they can provide timely access to care.
Madam Chair and distinguished members of the committee,
thank you again for inviting us here today. The Department is
working constantly to improve and to monitor the content and
performance of these examinations. We look forward to actively
participating in the Joint Executive Committee Working Group
focused on this important issue. We hope to gain valuable
insight that will enhance the evidence-based guidelines we use
in the process. We are intently focused on ensuring available
behavioral health services to those we serve, to include when
they are ready to separate and require examination.
We are both pleased to answer to any questions you have and
to participate in a continuing dialogue to better serve our
current and former service members.
[The joint prepared statement of Dr. Rice and Mr. Carr can
be found in the Appendix on page 29.]
Mrs. Davis. Thank you very much, Dr. Rice.
And that would be your statement as well, Mr. Carr.
STATEMENT OF WILLIAM J. CARR, DEPUTY UNDER SECRETARY OF DEFENSE
FOR MILITARY PERSONNEL POLICY, OFFICE OF THE UNDER SECRETARY OF
DEFENSE FOR PERSONNEL AND READINESS
Mr. Carr. It would be. I would just add one thing to put in
historical context. The committee's actions on 512 were timely,
and they are producing results.
To put it in historical context, if we went back to the
time when I was a company commander in the 1970s, you had a
different type of soldier than you would have today, and you
could have a motivational problem, or you could have a
distressed psychological condition. And so you would, perhaps,
refer the soldier to a psychiatrist, and a diagnosis, if it
came back a personality disorder, then the separation would be
immediate. And, therefore, it was often used.
As we ran into 2008, the question arose, has that become a
practice where we would look toward a personality disorder,
which is an expedient separation of a problem, when it was
masking, just as the committee did in 512, when it was masking
PTSD? And we decided it could. And so the rule we established
was that in the event that you ever separated someone who had
been deployed in the past 24 months, then you had to rule out
PTSD. And if you didn't want to do that, then you could have an
exception but the exception had to be sent to the surgeon
general of the service, so it was clearly administratively
something a commander would never do because it was simply too
much.
That had the same impulse that 512 did, and that was to
guard against PTSD and the possibility that we could do harm
administratively to someone who was doing the best they could
and suffered and was separated for some reason other than their
disability. So those actions have taken place, and we applaud
512 to this day.
[The joint prepared statement of Mr. Carr and Dr. Rice can
be found in the Appendix on page 29.]
Mrs. Davis. Thank you. I appreciate your sharing that with
us because we know this is a somewhat different time.
We are going to want to talk about the needs, the
capacities, certainly, of the mental health community within
the services and the general population as well, and being able
to meet these requirements as well as having the numbers really
to review a number of these cases.
But I wanted to focus initially on the commanders in the
field and talk about how we are educating them and the role
that you think they are actually playing in trying to assess
the severity or the possibility that someone could be suffering
with PTSD or TBI. One of the things we know is how difficult it
is to diagnose and certainly in a subjective fashion to be able
to get that information, but yet the commander plays a pretty
significant role. What are we doing, and what is the status of
that? How do you think we are doing in trying to move that area
forward?
Mr. Carr. The first is for the commanders. We use the term
PTSD, but what does it mean? How do you spot it? What does it
mean in concrete terms? If you can express it in a way that
they comprehend, then the likelihood of their uniting that
circumstance with medical help is that much greater. The Army
and the Marine Corps have active programs and training where
they instruct the field in the terms.
For example, for PTSD, my point before this was that
commanders have guides that allow them to take a situation that
presents and make some more rational and informed judgment as
to whether or not the symptoms they are seeing represent PTSD.
And for example, some of the instruction presents to them that
if the person reports disturbing memories and disturbing
dreams, reliving and so forth, those are things we would all
say, yes, I recognize that now as PTSD.
But unless we actively say it to the chain of command, then
they will hear it, and they won't understand the medical
significance of what they have just heard. So the education and
training programs of the Army and the Marine Corps and making
sure commanders know that.
Mrs. Davis. Can you be more specific in helping us
understand? I think in the testimony there was some notion of
how much time is spent, but what does that look like in terms
of that training?
Mr. Carr. It would take the form of about one hour
training, and I am going to have to, I am sorry, I will have to
confirm back to you exactly how it would play out for a unit at
let's say Fort Bragg, what specifically do they experience? I
would be glad to provide that back. There are a number of
references on the Web that are available to those who go look
for them, and they are easily found. But I think the question
from the Chair is, what do we present so it is deliberately
placed before the chain of command so that these terms are
described? And I am sorry, I can't define that now, but I will
provide that.
[The information referred to can be found in the Appendix
on page 47.]
Mrs. Davis. Dr. Rice.
Dr. Rice. Yes, ma'am.
Madam Chair, I think it is important to emphasize that the
emphasis on this comes from the very top. General Chiarelli,
the Vice Chief of Staff of the Army; General Amos, the
Assistant Commandant of the Marine Corps, have talked about
this over and over and over again with their commanders. Once a
month, for example, General Chiarelli has a video
teleconference with all of his commanders where a suicide has
occurred, and the general officer at that particular post or
station is there to report on what were the specific
circumstances that led up to the suicide.
Obviously, we don't want to be tumbling to this problem
after a suicide has been completed, but I think it does bring
to bear the fact that the emphasis from the Vice Chair, Vice
Chief and from the Assistant Commandant is continuous; it is
important, and they are very emphatic about making sure that it
gets disseminated down the chain of command.
I think the other, in addition to the point that Mr. Carr
made, the other place that it is really important is at the
senior noncommissioned officer level, because those are the
people who are really in day-to-day contact with the troops.
Education in this area has been incorporated into the sergeant
major course, for example. All of the senior noncommissioned
officer (NCO) leaders are taught about how to recognize various
aspects, and the details and content of those courses are
something, like Mr. Carr, I would have to get back to you on.
[The information referred to can be found in the Appendix
on page 47.]
Mrs. Davis. Thank you very much, because I think we all
know how long it takes the medical professional to be able to
describe and understand, and I think there is a great deal for
our commanders to be doing, and certainly the officers. And it
is difficult to even find some of the time for that. But I
think that, while we had a great deal of emphasis early in the
last few years and had to focus a great deal on suicide in the
units, I think that we want to be sure that we are spending
enough time doing that, because in many ways, they really are
the critical factor in this.
Dr. Rice. Yes, ma'am, I think that is exactly right. I
think the most important thing that the commander or the senior
NCO does is to convey to a member of his unit it is okay to go
ask for help. It takes a strong person to do that.
Mrs. Davis. Mr. Wilson.
Mr. Wilson. Thank you, again, for both of you being here.
Mr. Carr, how has DOD reached out to former military
members who are administratively discharged, separated, to
inform them of the opportunity to request a review of their
separation through the Discharge Review Board (DRB)? And to
date, how many individuals have requested such a review?
Mr. Carr. The outreach was through media principally to
ensure that it reached cities and towns. And to date, the
number is relatively low, 129 Army have applied to the
Discharge Review Board. So it was a media effort.
Mr. Wilson. A media effort. And also, I am sure for persons
discharged, you all send--I have seen them--periodic
newsletters to the discharged personnel, and it would have been
in that publication, too, wouldn't it?
Mr. Carr. I am almost sure it was in those publications as
well.
Mr. Wilson. Inadvertently, one of my sons who served a year
in Iraq, I kept getting his mail, and it was really very
enlightening and very encouraging to me how helpful the
information that was provided, and of course, I would get it to
him right away. And then they got his correct address.
What is your plan for providing additional mental health
assets required for the pre-separation exams and the Discharge
Review Boards, how many additional personnel do you anticipate
needing? Additionally, I am very grateful, I work with a
volunteer organization called Hidden Wounds of Columbia, South
Carolina, which is serving as a back-up for discharged
personnel. They are actively promoting mental health
assistance, and so it is DOD, VA, and then volunteer
organizations, but how many more personnel do we need?
Mr. Carr. For the Discharge Review Board function, as long
as the criteria are kept broad, for example, we don't stipulate
a grade and whether active or reserve and are not overly
restrictive in the academic disciplines, my understanding is
that the manning requirements will be met for the DRBs, that
that wouldn't impose the restraint on the flow of applications.
Mr. Wilson. And it is encouraging to me, I went to a
pancake breakfast to raise money for Hidden Wounds, and the VA
had a table set up there with personnel from the VA hospital. I
could see it was a really positive interaction between
volunteer organizations and DOD and personnel and VA personnel.
Mr. Carr. Yes, sir.
Mr. Wilson. It is my understanding the same neuro-cognitive
assessment test used for pre-deployment assessment is not
authorized for post-deployment assessment of our returning
soldiers in the Army. Do you feel this is a violation of the
law in the fiscal year 2008 National Defense Authorization Act
aimed to create a comprehensive approach to address the mental
health of our soldiers? If not, why not?
Dr. Rice. I think our understanding of what an appropriate
instrument is for a pre-deployment screening for psychological
condition and for post-deployment is evolving. And so the Army,
I know, has been reevaluating the use of an instrument called
the automated neurological assessment metric (ANAM) at the
point of pre-deployment. There has been some professional
disagreement within the community about whether or not the ANAM
is an appropriate post-deployment instrument.
I think this is all evolving. I think the important point
to make is that there is screening going on. Exactly how we are
going to ultimately get to a point where we are satisfied that
we have a comparable instrument that was used before deployment
and post-deployment, I don't think we are quite there yet, but
certainly, we are working hard at it.
Mr. Wilson. Well, again, I appreciate your working with our
troops. As a parent of two sons who have served in Iraq and
another in Egypt and another one who may be on the way as an
engineer, I appreciate, on behalf of my constituents and my
family, what you are doing. Thank you.
Dr. Rice. I can't help but point out that one of your sons
is a USU graduate.
Mr. Wilson. We have a USU graduate in the family, so Dr.
Rice has been very helpful. I am very proud of his Navy
service. But I see Army people in the back, and I want to
verify that the other three are Army National Guard.
Mrs. Davis. Thank you.
Mr. Pascrell.
Mr. Loebsack, I am sorry, I was thinking of our joint----
Mr. Loebsack. Actually, I wouldn't mind, as long as I can
have my five minutes, I wouldn't mind letting my colleague, Mr.
Pascrell, go before me if that works for the committee.
Mrs. Davis. I would need to let Dr. Snyder go first, and
then, since Mr. Pascrell is not on the committee, the rules say
he would have to go last.
Mr. Loebsack. Thank you, Madam Chair.
I do want to thank both witnesses for being here today, and
also thank the chairwoman and the ranking member for holding
this hearing. This subcommittee has looked into some really
critical issues this year, and I appreciate your leadership,
Madam Chair and Ranking Member, in taking a critical look at
some of the really tough issues facing our services, the troops
and their families.
Mental health care of our armed forces is an issue that I
know we all take extraordinarily seriously, and I have a
personal interest in this as well. I have had a number of
family members affected by mental illness, so this is kind of a
personal concern of mine, I have to admit.
And given the shortage of civilian mental health
professionals in the country, I think the challenges facing the
Department in recruiting these specialists is understandably
difficult, and that is mentioned in your testimony as well.
But I have an ongoing concern about access to mental health
services for members of the reserve components, not unlike Mr.
Wilson, and their families, those components and their
families, especially those living in rural areas. I am from
Iowa, and there are a number of us, obviously, in this Congress
who represent rural areas.
In your testimony, on page 40, you mention a telehealth
initiative that the Department has undertaken. Can you go into
the status of that program, how you are making service members
and their families aware of it, and how service members who are
determined and need in-person care through a telehealth session
are in fact receiving that treatment?
Dr. Rice. Yes, sir. Thank you.
The telehealth program was developed specifically to
address those in more remote areas, especially among the guard
and reserve, who frequently had difficulty accessing qualified
behavioral health specialists. Through a variety of media on
post and in camps and stations, we make the web site known.
People can access this over the Internet and communicate
directly. There are educational materials provided on the web
site, and there is the ability for someone to self-refer if
they require further evaluation, or screening, or consultation.
The ability for someone, particularly in a rural area, to
seek consultation with a qualified behavioral health provider
who understands the context of the experience that that guard
or reserve member has been through has been a challenge.
Mr. Young, several years ago, in collaboration with the
American Psychological Association, asked us to develop a
program, the Center for Deployment Psychology. This is based at
the Uniformed Services University. This program offers a one-
and two-week training course for civilian psychologists,
usually not near a military base, but who are likely to see
guardsmen or reservists returning from deployment, and educates
them about the kinds of experiences these guardsmen and
reservists have been through during their deployment.
So far, I think we have offered, and I forget the exact
numbers, but approximately 50 courses of the two-week type and
a similar number of the one-week type and have reached several
hundred, if not a thousand, civilian practitioners.
Mr. Loebsack. I will keep following up with you folks on
that particular issue as we move forward and as a member of
this committee and someone who does represent, as I said, rural
America in many ways, so I really appreciate that. I think this
is going to be a huge issue, there is no doubt about it,
especially as more and more of these folks--and in Iowa, I am
talking about the guard in particular--as they continue to
deploy and do multiple deployments and all of the problems that
get presented. I will continue to follow up on that.
I do have one other question. Can you walk me through the
steps that are taken if a member of the reserve components is
determined to be suffering from PTSD or TBI due to a combat
deployment after they have already been taken off title 10
active duty? What sort of treatment do they get? Who provides
the treatment? And while undergoing treatment, are they put
back on title 10?
Dr. Rice. Medical treatment for someone who is already
separated, they would likely be referred to the VA. And they
are, of course, eligible for care at the VA for anything, for
any combat-related problem.
Mr. Carr. For the reservist, let's say national guard, I
have been on active duty, I have been on deployment, I am now
back in Iowa, and I have been there for eight months. And I
believe I have PTSD. I am going to probably proceed with my
physician on my own medical program to discuss it.
Or I could, as Dr. Rice said, take it up with the VA on the
expectation that in short order, when I address this with the
VA, they will administratively determine it to be a consequence
of combat, therefore combat-related, therefore something that
must be addressed by the VA.
So that is the exchange with the VA, where you have a
logical talk about, I believe I have this, and if I do, it
could, I believe, only have come from there; the potential is
so high that I will be rated by the VA, that I would like to
pursue this conversation with you because I don't have health
insurance. Then it would be the VA.
Mr. Loebsack. Sometimes those ratings are problematic, and
that is why I raise the issue.
Thank you so much for your time.
Mrs. Davis. Thank you.
Dr. Snyder.
Dr. Snyder. Thank you, Madam Chair.
Last week, Mrs. Davis held a hearing on the Centers of
Excellence, which I thought was a good discussion of what has
been described and was described by our witnesses last week as
the signature issue of these wars, which is the blast injury.
And this discussion today is a continuation of that discussion
in many ways.
I have been having some discussion with our colleague Dr.
Tim Murphy, a Ph.D. psychologist from Pennsylvania, about this
issue of traumatic brain injury. The question I want to ask is
this: We are aware that the unfortunate circumstance of war is
every injury you can imagine has occurred in war or will occur.
Some are minor, and some are absolutely devastating and lead to
death. And then we have all the spectrum in between.
So when we think about traumatic brain injury, and that is
what I want to ask about, TBI, pretty much isolated from the
psychological aspects of it, so we are familiar with the
devastating injuries in which our brave men and women end up as
a total care individual. And then we have been talking a lot
today about people who may have mild TBI, may have PTSD, but
they are at home. They need some mental health counseling, but
they are working and performing at home.
What I want to ask you about is the folks that have
recovered from their wounds, I think this falls under, Dr.
Rice, in your statement about the separation policy. You talk
about the people that you conclude, the military concludes, are
not fully capable of performing their tasks, so they are going
to be released from the military. The segment of the population
I want to ask about are those who, if you saw them walking down
the street, you would not even notice anything different about
them. But if you were a family member or their caretaker, you
would realize in their own way this person is also going to
need some kind of 24-hour care. Perhaps they can walk into
town. Perhaps they can be dropped off in town. But they are
going to need, in the olden days we called it a domiciliary, or
some kind of a residential care facility. Tell me where that
fits into the discussions you are having.
Clearly, this is probably going to be a veterans' health
care part of things, but your separation policy, people need to
get separated, not just released, but they need to end up
immediately on the right perch. Would you discuss that segment
of the population, and do you have any idea of what the numbers
might be for the person I am describing?
Dr. Rice. No, sir, I don't have a sense of the numbers off
the top of my head. We will certainly take it for the record.
[The information referred to can be found in the Appendix
on page 48.]
Dr. Snyder. Do you share my concern about those types of
injuries?
Dr. Rice. Yes, sir, I do. And as you know very well, there
is no gold standard diagnostic study for traumatic brain
injury. We are working very hard on a program in collaboration
with the National Institutes of Health to pursue that, to see
whether there are either biomarkers or there are sophisticated
neuro-imaging techniques that may shed some light on both a
sensitive and a specific diagnostic test for traumatic brain
injury.
With respect to the question of people who are not
functional any more or are having challenges in functioning, if
they are still on active duty, they would undoubtedly be
referred to a Medical Evaluation Board to determine whether or
not they are fit for duty. If they are found not fit for duty,
they would go through the Disability Evaluation System.
Dr. Snyder. And I assume that that process would occur at
the point the medical team determined this person has probably
recovered as much as they are going to recover?
Mr. Carr. If they have the potential of being unfit, and if
that is the case, then it will go to the Medical Review Board
to decide if we have that condition before us, or is this
something easily remediable? But if it is long term and likely
to be chronic unfit, then it would be evaluated for disability
evaluation and either severance or retirement.
Dr. Snyder. The people I am talking about would clearly fit
into that category. But I am concerned about what happens to
them afterwards. So, at the time of separation, how do we make
sure they have the continuity of care so that they end up in
the right place and not be lost, to their detriment, for maybe
a matter of hours, days or weeks?
Dr. Rice. That is a discussion that we are having on a
regular basis with the Department of Veterans Affairs to make
sure that if somebody is medically retired with a disability
rating of greater than 30 percent, they are medically retired
from the armed services and are eligible for care, either in
the military system or in the VA, if they are separated with
less than that, then they are eligible for care in the VA.
The VA rating system is different. That is a whole other
discussion. But they are eligible for care in the VA, and the
VA is very sophisticated in providing that kind of continuing
and long-term care for people with those injuries.
Mr. Carr. Another way we can go at this is just to follow
on through that I was on active duty. I spotted this person in
Roanoke, and they don't seem to be able to care for themselves.
So, first, how did they get there? Were they recognized and
disability processed?
However it works, if that which is the physical problem
resulted from military service, then either the military,
because we catch it while they are on active duty and we see
these things and we classify them and we rate them as a
disability; or we don't spot it, no one takes note of it,
somehow it escaped undetected, and then it emerges later. In
that latter case, they were not separated for medical
disability, and in that instance, the most likely course of
action is they would come in contact with some veterans group
and probably be advised to go to the board. There are various
ways.
The likely way, go to the Board For the Correction of
Military Records and assert that I separated. I felt these
things, but I never expressed them. I ended up in Roanoke, and
I am even more confused, and these are the events which have
progressed. I assert, therefore, that I had this condition
while in the military, and my record should be reflected to
show my current diagnosis, which by my symptoms is 50 percent
disability.
Then, at that point, that adjustment would be made. If it
were made and it were accepted, you would be a medically
retired member of the military. Or it could be caught in a
different way later, and you would be entirely managed by the
VA.
But it would come down to, what is it that is your
impairment? How would that rate as a disability? And when the
rating is high, who is responsible? Somebody is, assuming it
was led to their military service. Was it the military that was
responsible for solving that and missed it? Even in good faith,
it was never mentioned. Or was it instead something that was
dormant and manifest years later and reasonably was not at the
fault, if you will, of the military, in which case I would take
that up with the VA?
So I trust that that person is going to come in touch with
social network, and that social network is probably going to
guide them to a veterans' support and that will lead them on
the path. That is the scenario I would sort of see for the case
we described to make it right under either of the two systems,
as if it had been caught if it should have been caught.
Mrs. Davis. Mr. Pascrell.
Mr. Pascrell. Thank you, Madam Chair and Ranking Member
Wilson, for allowing me to sit on the committee today. I
appreciate that.
As the co-chair of the Brain Injury Task Force in the
Congress, I have been committed to bringing awareness of the
prevalence of TBI since 2001. As everyone here knows, and I
want to thank Dr. Rice and Mr. Carr for their service to our
country, I take this very seriously. And I know you do, too.
This has been dubbed the major injury of the wars in Iraq
and Afghanistan. It is estimated that 360,000 Iraq and
Afghanistan veterans, or nearly 20 percent of those deployed,
may have suffered brain injury. We are talking about over
70,000 of our bravest. The best way to determine the health of
returning service members, because that is what this hearing is
about, is to provide for a baseline neurological test.
And finally, in the fiscal year 2008 National Defense
Authorization Act, and I want to refer to the exact words of
the act: Public Law 110-181, the National Defense Authorization
Act, Fiscal Year 2008, Title 16, Section 1618, the two
sections, 6 and 9, one is assessment and one is managing and
monitoring. The words are very clear. I won't read the whole
thing. I won't suffer you through that. But it says, including
a system of pre-deployment and post-deployment screenings of
cognitive ability in members for the detection of cognitive
impairment. It also says that at the end of the section on
management, on managing and monitoring, including the
monitoring and assessment of treatment and outcomes.
Why have a baseline if you are not going to follow it up
with a comparative test in separating yourself from the
service? You need a consistent test. You need a consistent
metric. And, therefore, what we are using is absolutely
inadequate.
I read through this several times. It didn't just happen
the other day. This is not the baseline. It has nothing to do
with the baseline, and no comparison can be made. No comparison
can be made in terms of what tests are given to that brave
soldier when he goes or she goes before the front line, before
they go to the front line. So we are not doing
neuropsychological testing afterwards, which is what the
language says we must do.
I wrote a letter, on April 19, which several my colleagues
have signed onto to Mr. Gates, the Secretary of Defense, and
John McHugh, Secretary of the Army. And I said in the letter,
in the second paragraph, We were reassured that the Department
of Defense had implemented pre-deployment neurocognitive
assessments across all services. Unfortunately, we recently
learned that the use of the same neurocognitive assessment
instrument is specifically not authorized for post-deployment
assessment of our returning soldiers. Not only is this approach
ineffective at identifying brain injuries, we believe that it
violates the intent, if not the letter of the law certainly,
and I believe it is the intent of the law, the spirit of that
law.
One of these provisions here was the language that
required--and the language is specific about this--that the
Department of Defense provide pre- and post-deployment. And as
I said, you cannot do this unless you have established a
baseline and then follow it up with something where you can
make a specific comparison. The only effective way to identify
traumatic brain injury is to use the same neuropsychological
testing, both pre- and post-incident, in order to produce a
consistent metric.
In late March 2010, we learned that the Army has been using
an automated neuropsychologic metric--I just raised it to you,
I just showed you--for pre-deployment assessment. The U.S. Army
Medical Command had also issued a memo stating that ANAM was
specifically not authorized for post-deployment assessment for
our service members. Instead, only concussion-related questions
have been added to the post-deployment questionnaire. Read pre-
deployment, you will see that questionnaire, but they also are
giving the baseline test. Service members fill this out
themselves. This post-deployment health assessment is filled
out by the soldier himself or herself, and yet we are making
the comparison to a test that is given, a baseline test, which
is given. It does not make scientific sense.
So I don't believe that the DOD is conducting
neurocognitive assessments in a uniform manner, and our troops
are suffering because of that. Common sense would suggest that
the same neurocognitive assessment tool should be used
throughout the term of service to properly identify and manage
long-term changes in cognitive ability. The DOD has failed, and
I have worked closely with the DOD. I have worked closely with
General Sutton and I have worked closely with Colonel Jaffee
and I have worked closely with my brother who is no longer with
us, Congressman Murtha. We worked in the past four or five
years; we have accomplished, all of us together, quite a bit.
Why has the Department of Defense selected two incompatible
neurocognitive assessments for pre-deployment and post-
deployment, specifically using a automated baseline
neurocognitive assessment for pre-deployment and symptom survey
for post deployment? Are you just trying to follow the letter
of the law while ignoring the actual intent of it? Either one
of you.
Dr. Rice. I think that, certainly, you are absolutely right
that you cannot compare two different instruments before and
after and expect to get consistent results.
I think the challenge has been validating the instrument to
be used to make sure that it is both sensitive and specific for
what we are trying to detect. And as I understand it--I am a
trauma surgeon, not a neurologist or a psychiatrist--but as I
understand it, there has been disagreement among the experts in
the field about the extent to which the ANAM is an accurate
representation of cognitive ability.
It is my understanding that that was the motivation behind
looking for a test that was perceived to be more accurate, more
sensitive and more specific. I would be happy to look further
into that issue and get back to you.
[The information referred to can be found in the Appendix
on page 49.]
Mr. Pascrell. So you believe the instrument in the pretest
is valid?
Dr. Rice. I am not certain. And again, this is not my area
of expertise, but I am not certain that there is general
agreement among the experts in the field that the ANAM is a
valid test.
Mr. Pascrell. So you don't--you can't state for the record
that the baseline neurocognitive assessment is valid?
Dr. Rice. I believe there is disagreement among experts in
the field about its validity.
Mr. Pascrell. So are you telling us today that the test we
are using before someone goes on the battlefield may not be
valid; is that what you are saying?
Dr. Rice. I am not sure that it is. That is right.
Mr. Pascrell. Well, that says something, doesn't it?
Mr. Carr, what would you say to that? What is your
response?
Mr. Carr. I think this is more a matter of judgment on the
medical validity, the scientific validity of this baseline
against that later measurement, and that is, unfortunately, not
my policy province or my area of expertise.
Mr. Pascrell. Madam Chair, if I may, in conclusion, the
law, the words right in front of me are very, very specific. I
would contend that they are not being followed, that we are
breaking the law, and we are not doing service to our bravest.
I don't think the gentlemen on that side of the table want
that, and certainly I know the people on the panel who are
sensitive to this issue don't want that. I would suspect that
there needs to be a sense of urgency on this issue, otherwise
we are not doing justice, and we are just doing empty words.
And we have had enough of that.
Thank you, Madam Chair.
Mrs. Davis. Thank you for joining us today and raising
that. I know it was raised earlier.
And I think, Dr. Rice, if I am not mistaken, you basically
said that they were working on it, in terms of a post-
deployment assessment and an instrument that is working. But I
think we have had some other concerns that there is no way to
align that if in fact the earlier instrument is not giving us
the kind of information that is really important to be able to
do that.
What do you think the next step should be? We are in a
quandary, then, in terms of how we really can represent to
anyone who is in a situation of having been--this hearing, of
course, is about separation and the appeals and how we move
forward, but clearly that is something that we need to do.
Where do you think we should be?
Dr. Rice. Well, I think, I believe I am correct in saying
this, that the Army, that all three of the services, actually,
have engaged their experts in a very intense discussion of what
the right psychometric evaluation should be and what the best
available tools to deploy are, remembering that we are
administering this to a very large number of people and
therefore to make sure that we capture, in the most effective
and efficient----
Mrs. Davis. What I am trying to determine is, are the tools
out there to do that? Is it that we still have research to do
to determine that? I know that a lot of money, even through the
Centers of Excellence, have been focusing on some of these
issues. Is there a problem just administratively to get this
together and to focus appropriately?
Dr. Rice. No ma'am, I don't think it is an administrative
problem, I think it is a conceptual problem of, what do we
measure? If we take a screening test, what do we measure it
against that we accept as a yardstick that is valid? I think
that is where the disagreement among the experts has been.
Mrs. Davis. How do we move that forward then?
Dr. Rice. We are pushing on that very hard. There is a keen
sense that, as Mr. Pascrell indicated, that this is an
important need. We are concerned about people who have
repetitive exposure to mild blast injuries, and we are not sure
what the cumulative effect of that repeated exposure is. So
determining what somebody's baseline cognitive functioning is
so we can compare it to what we assess after such an exposure
is very important.
Mrs. Davis. It seems, though, that there are a lot of
reasons to have good instruments, and the one that we are
focusing on today, it seems somewhat simple, in terms of being
able to determine the extent to which someone's behavior, that
the contributions to that have been as a result of a blast
injury in some way and that that would be demonstrated. It
seems to me there is some clarity there. There may not be for
some other purposes, but there may be some clarity there. Am I
missing something in terms of how we, the whole appeal process?
Mr. Carr. It gets linkage to the appeal process.
Mrs. Davis. Sure, whether of not--the purpose that we are
looking at right now is the appeal process and the extent to
which a person has been rightly or wrongly separated and that
they can continue with either their military career or at least
have the honor of being separated----
Mr. Carr. I would say, no, and the reason I would say it is
because comparing the condition that presents against something
independent of this at the moment, the standard we would look
at for any bodily function is, what represents a disability in
my elbow or in my PTSD? I compare the condition to that. For
example, usually PTSD is, I can't do my occupation. And
depending on how severely I can't do my occupation, the
percentage of disability would rise. So that judgment is made
in contrast to me against doing my work quite independent of
this.
So, no, it wouldn't affect the capacity to correctly and
properly dispose of the disability, to rate it, and to pay it.
I think, instead, it was a matter of classifying the change,
but that change, even if it were classified, hadn't made its
way into the disability rating system. So that, this is--it is
important for all of the reasons the congressman pointed out.
But as far as a direct deleterious effect on an incapacitated
soldier, that judgment is made against the circumstances that
present, against the description of, in this case, being able
to do my occupation.
Mrs. Davis. I know Mr. Wilson earlier asked a question
about the number of individuals and the appeals, and I think
you said 128. Is that correct?
Mr. Carr. 129, yes, ma'am, in the Discharge Review Board.
But I would like to distinguish, the Discharge Review Board is,
I got a discharge that was not an honorable; I would like
another look. That has been for decades.
The more recent items have been the Physical Disability
Review Board established by the Defense Authorization in 2008,
on which the committee played a key part. And that board said
if you went out for less than 30 percent, because 30 percent is
military retirement, it is valuable to the member, as opposed
to 20 or 10 percent, if you went out for less than 30 percent
and you think you were wronged, you may apply to the Physical
Disability Review Board. It started in 2008, and it really got
moving, its first full year was 2009, and 690 applications came
in. Most, about 58 percent, were Army, and about 61 percent of
them were upheld. By that I mean, I now have an assertion from
Bill Carr that you got it wrong. I am comparing the evidence
that existed on me at the time of my separation, not new stuff,
against the standard in making a determination. And in 61
percent of the cases, it is being adjusted upward for those 690
that are through so far. There are more to come, to be sure.
I also should mention that, of those that come in, it is
not PTSD or TBI or what we might have suspected going in. It is
80 percent orthopedic, so it is arthritis and joints and back;
and 22 percent is PTSD. So there certainly are some where we
missed, according to the Board's recent conclusions, its newest
conclusions, it looked at this, and it said that there was more
than half in error. But the vast majority had to do with
orthopedic as opposed to PTSD, and that is a little understood
fact.
Mrs. Davis. Thank you.
My conclusion from this is some folks may say, in some
ways, it is a premature hearing to try to get at these issues
because there are some things that I understand are definitely
in progress. On the other hand, I think, it may be too late.
So what I would like to do is to have some time and to come
back in a few months and really take a look at this again,
because it may be that we may want to strengthen some language
in the authorization bill. We want to take a look at where we
were. And whether we can put additional urgency on this I am
not certain with the language, but it is clear that we have a
problem, and we need to be addressing it. I know there is a lot
of seriousness about it, but we need to put some real focus and
try to understand better where we are. So if we can do that in
a few months, that would be very helpful. Do you think that
there is--what would be your timeline? What would you suggest
that would be a good time to come back and really be sure that
we are moving ahead with the instruments that are needed to
align them properly?
Dr. Rice. A couple of things occur to me. Obviously, as
someone here who is not an expert in the cognitive evaluation
of large numbers of people, either before or after deployment,
so it is entirely possible that there is a great deal more
sophistication that could be brought to bear immediately on
that to better answer your question.
Absent that, however, I would think that an opportunity for
us to see what the current state of thinking among our experts
is about the various tools that are available to assess
cognitive ability is something that we could do within a
relatively short period of time and be able to get back to you
within six weeks, six to eight weeks.
Mrs. Davis. Okay.
Mr. Carr, did you have anything to add.
Mr. Carr. Only that as we--section 512, which was an
important section that we are implementing, the committee
directed, the Congress directed that 240 days afterwards there
be a report, and that will be the 25th of June. And our report
will lay out how it is we are going to do that which 512
directs, which essentially means publishing a policy that
integrates health, disability, and Board For Correction of
Records all in one. Much of it is already completed in draft.
But what we will deliver to the committee at the deadline is
the report. In other words, at that point, the system will
exist. People will not have been through it. A couple of months
later, as people go through it, call that implementation, then
we will provide another update to the committee.
So June 25, we will meet, and that is, how are we going to
do that which was directed by 512 exactly? Are there any
shortages? What are the qualifications of the people, the
physicians that will be involved, and the earlier question?
Provide that report on June 25, and then implement shortly
thereafter and update the committee on how the numbers are
working. Are there any bottlenecks, and are the skill sets
proper and so forth?
Mrs. Davis. So you are saying that the committee would have
that report by the 25th?
Mr. Carr. Yes, the 25th of June.
Mrs. Davis. Okay.
Again, you have seen some of that report. Do you think it
answers the kinds of questions that we are after?
Mr. Carr. I think it does. It addresses the concern, which
was, be certain that we haven't disadvantaged someone who can't
take care of themselves by misclassifying or rushing to
judgment that which could be a subtle injury or disease. In
that case, yes, we will have reported how exactly it is that we
will allow for success against that standard, exactly what the
protocol, the procedure, and the flow will be, and what the
manning of it will be to make for a successful implementation.
Mrs. Davis. Wouldn't that be dependent on having
instruments that can properly make those assessments?
Mr. Carr. No. Because, for now, we are operating on whether
or not there is a disabling condition quite apart from--so
there is a standard that says if you can't perform your
occupation and so forth. Now quite apart from that, for these
signature diseases, can science tell us in more cogent terms an
expression that is better than he can't do his occupation? For
example, if it can show a shift of a certain quantity, and that
is a cogent correlation to not being able to do my occupation,
that makes it more empirically reliable.
But the fact that you don't have that empirically reliable
document at the moment doesn't stop you from doing what we have
done for decades, and that is to take the standard as it is
written and apply it fairly to the patient and reach a
determination as to what the disability percent should be.
Mr. Pascrell. Madam Chair?
Mrs. Davis. Yes, Mr. Pascrell.
Mr. Pascrell. I think that is preposterous, and I will tell
you why.
To a layman, and I am a layman, how can you prescribe care
unless you have something to go on? We have taken the protocol
and moved it into the area of sports, and I don't want to
compare sports to what these brave men and women have endured
on the battlefield, but we are now using protocol to protect
our children in middle school, high school, and college, in
terms of prevention, in terms of what happens when there is a
concussion on the field in gals basketball or guys football; it
doesn't matter. In fact, there is more injury in women's sports
than male sports. How do you prevent this from happening? And
then, if there is a concussion, what do you do? So now they are
testing them before they go on the field, aren't they, Mr.
Carr?
Mr. Carr. They are.
Mr. Pascrell. In order to do that and the reason why they
do that is to have a baseline. And then they are testing them
after they get a concussion in order to make the comparison.
Mr. Carr. Yes, sir.
Mr. Pascrell. You are not going to be able to prescribe
care unless there is a comparative baseline, unless you use the
same kind of test, whatever those tests are.
Mr. Carr. You are right.
Madam Chair's question was, are we blocked from proceeding
with the business of handling a disability absent that? And the
answer is, no, we are not. We will continue to dispose of cases
with the tools at hand.
The congressman is entirely correct, that our empirical
base, so that we can reach--so that we can quickly and
decisively and accurately and cogently know that this shift has
occurred.
Mrs. Davis. Mr. Carr, I am afraid we are going to have to
stop. But I can assure you that we will continue to discuss
these issues and perhaps bring in additional individuals who
will be helpful in the discussion. I think it is a very
important one, as you know and appreciate, and Dr. Rice, I know
as well, to our troops and to their families and to their
futures. And so we will want to continue to try and understand
it better.
I appreciate my colleague being here and Mr. Wilson, and we
will continue. Thank you very much.
[Whereupon, at 6:44 p.m., the subcommittee was adjourned.]
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A P P E N D I X
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?
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WITNESS RESPONSES TO QUESTIONS ASKED DURING
THE HEARING
April 20, 2010
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RESPONSES TO QUESTIONS SUBMITTED BY MRS. DAVIS
Dr. Rice. The Army implemented Mild TBI (mTBI) Chain Teaching in
the Fall of 2007, for all Soldiers in the Active and Reserve
Components, to address symptoms of mTBI, Soldier and leader actions,
and resources for assistance. The chain teaching, with video
illustrations, is taught by a facilitator and takes about 30 minutes.
Newly assigned Soldiers receive this training within 30 days of
assignment. In fall 2009, an ``Educate, Train, Treat & Track'' campaign
plan was implemented to facilitate line and clinical collaboration for
acute concussion identification and management in conjunction with the
new mTBI/concussive injury management strategy. This protocol directs
that any Soldier who sustains a direct blow to the head or witnessed
loss of consciousness; is within 50 meters of a blast (inside or
outside); is in a vehicle damaged by a blast event, collision or
rollover; or is command directed, must undergo a medical evaluation.
Appropriate treatment includes assessment, a mandatory 24-hour
downtime, followed by medical clearance before returning to duty.
Comprehensive medical evaluations are mandatory for anyone sustaining
three concussions within 12 months. The Vice Chief of Staff of the Army
(VCSA) has addressed deploying units at Ft Campbell, JRTC, NTC, and Ft
Stewart about the TBI protocol ``Educate, Train, Treat & Track'' via
VTC since Dec 2009. The VCSA spent up to 90 minutes at each session.
These training sessions are on-going.
The Marine Corps provides training on Operational Stress Control to
leaders and Marines at all levels. This training focuses on developing
the observational skills to detect when a Marine is ``not acting quite
right.'' The Marine leader's responsibility is to notice a change and
engage appropriate help and resources. The curriculum includes six
hours of training for approx 50 Marines per battalion or equivalent
command.
All Air Force Airmen receive basic instruction on Traumatic Brain
Injury (TBI), Post Traumatic Stress Disorder (PTSD), and suicide
awareness. Commanders and Supervisors are provided approximately 60
minutes of additional training on recognition and mitigation of these
problems in their subordinates. Instruction is a combination of
didactic lectures, on-line instruction, publications, and interactive
classes. It is incorporated into pre-deployment training for all
deployers, including commanders and Senior Non Commissioned Officers.
The Navy is planning a programmed release of the formal Operational
Stress Control (OSC) curriculum in all accession and leadership
schools--recruit training and ``A'' school, petty officer and chief
petty officer indoctrination and officer candidate school, to name a
few--in the very near future. In addition, specific pre- and post-
deployment OSC training is being delivered at all Navy Mobilization
Processing sites and Returning Warrior Weekends. The extensive OSC
training continuum, while not specific to PTSD, provides training to
commanders and the chain-of-command, along with Sailors and families,
to help them recognize and address the symptoms of many different
stress reactions and injuries. [See page 7.]
Mr. Carr. The Army implemented Mild TBI (mTBI) Chain Teaching in
the Fall of 2007, for all Soldiers in the Active and Reserve
Components, to address symptoms of mTBI, Soldier and leader actions,
and resources for assistance. In fall 2009, an ``Educate, Train, Treat
& Track'' campaign plan was implemented to facilitate line and clinical
collaboration for acute concussion identification and management in
conjunction with the new mTBI/concussive injury management strategy.
The Army's Proponency Office for Rehabilitation & Reintegration (PR&R)
developed the following courses, which are being uploaded to Military
Health System (MHS) Learn for training for health care providers. The
TBI 101 module will also be available on Army Knowledge Online (AKO)
for viewing by all Soldiers.
(1) TBI 101: TBI Foundation: (All Audiences) This course describes
TBI in non-clinical terms: core TBI message of early detection and
recognition of symptoms; correlation between sports concussion and
(mTBI); the magnitude of how TBI affects the military; and discusses
the military's plan to address TBI from in-theater to home.
(2) TBI 201: TBI Overview for Healthcare Personnel (All healthcare
personnel (Stateside and Deployed)) This course addresses TBI
definition and discussion on levels of severity; mechanisms of Injury/
Pathophysiology, and identification, assessment, and management of
common symptoms.
(3) TBI 301: First Responder Training: Battlefield Management for
mTBI (Deployed Healthcare Personnel) This course addresses Field
management guidelines; MACE: Military Acute Concussion Evaluation
tool--test administration process; emergency care techniques; pre-
hospital treatment; triage and transport; and documentation and coding.
(4) TBI 401: mTBI Symptom Management Guideline. This course
addresses Primary Care Providers and TBI healthcare team (Non-deployed)
Section 1: Assessment techniques, clinical algorithms, medication
awareness, duty restrictions, and DOD/VA Clinical Practice Guidelines;
Section 2: Clinical interviewing, evaluation techniques with patient
and Families, TBI management including profile writing, and
documentation and coding; Section 3: Principles of TBI identification,
TBI screening process, resources, and tools for diagnosis.
The Marine Corps provides training on Operational Stress Control to
leaders and Marines at all levels. The Marine leader's responsibility
is to notice a change and engage appropriate help and resources. The
curriculum includes six hours of training for approximately 50 Marines
per battalion or equivalent command. Trains XOs, senior enlisted,
junior leaders, medical and religious ministry personnel to provide,
prevent and manage many stress problems tools, strategies, and
resources (Causes of Stress Continuum [COSC], Five Core Leader
Functions, COSC Decision Flowchart, listening skills and referrals) for
preventing and managing stress problems. Senior Marines discuss
advanced COSC issues and tools, COSC risk management, training for
resiliency, stress mitigation strategies, psychological fitness to
deploy, health assessments & confidentiality. Junior Marines role play
scenarios to apply new skills and tools.
All Air Force Airmen receive basic instruction on Traumatic Brain
Injury (TBI), Post Traumatic Stress Disorder (PTSD), and suicide
awareness. Commanders and supervisors are provided approximately 60
minutes of additional training on recognition and mitigation of these
problems in their subordinates. It is incorporated into pre-deployment
training for all deployers, including commanders and Senior Non
Commissioned Officers. All Airmen now receive TBI and Post Traumatic
Stress (PTS) computer based training (CBT), which takes about 30
minutes to complete, when they complete the Self Aid and Buddy Care
(SABC) CBT housed on the Advanced Distributed Learning System. A
Leaders Guide to Managing Personnel in Distress is published guidance
on how to handle PTSD and other ``distress'' conditions. Frontline
Supervisor Training, Assisting Airmen in Distress, is targeted at
lower-level supervisors who work side-by-side with their Airmen. This
in-depth training course enhances supervisors' abilities to recognize
and effectively intervene with personnel suffering from emotional
distress due to a variety of life problems, build on skills first
learned during annual suicide prevention training and various
professional military education (PME) activities.
The Navy is planning a programmed release of the formal Operational
Stress Control (OSC) curriculum in all accession and leadership
schools--recruit training and ``A'' school, petty officer and chief
petty officer indoctrination and officer candidate school, to name a
few--in the very near future. In addition, specific pre- and post-
deployment OSC training is being delivered at all Navy Mobilization
Processing sites and Returning Warrior Weekends. The extensive OSC
training continuum, while not specific to PTSD, provides training to
commanders and the chain-of-command, along with Sailors and families,
to help them recognize and address the symptoms of many different
stress reactions and injuries. [See page 7.]
______
RESPONSE TO QUESTION SUBMITTED BY DR. SNYDER
Dr. Rice. There is a continuum of TBI severity ranging from mild
TBI (otherwise known as concussion) to severe and penetrating. For mild
TBI, assisting living programs are rarely required. Most concussed
patients do not require a caregiver nor are they unable to take care of
themselves from a supervision and assistance standpoint. These
individuals can usually be managed with outpatient care and services.
For more severe TBI patients, the assisted living pilot program is
available for Service members who are unable to function independently
without supervision or assistance. The numbers of patients who require
these services appear to be low at this time.
Currently, there are seven Service members enrolled in the Veterans
Health Administration (VHA) assisted living pilot program with two more
anticipated by July 1, 2010. The VHA anticipates that by the end of
Fiscal Year 2010, there will be 12-15 patients enrolled. Should more
information be needed, the Department of Veterans Affairs could provide
more details. [See page 11.]
______
RESPONSE TO QUESTION SUBMITTED BY MR. PASCRELL
Dr. Rice. For clarity, there are three programs, each with
different intent and purpose. These include the
1) Pre-Deployment Health Assessment Program, 2) Neuro-Cognitive
Assessment Tool, and 3) Post-Deployment Health Assessment Program.
The Pre-Deployment Health Assessment Program serves to identify
conditions that may impair performance during an upcoming deployment
and to get a Service member to care if these conditions warrant. In
addition to the Pre-Deployment Health Assessment, the Department
implemented a Pre-Deployment Neurocognitive Assessment tool, using the
Automated Neuropsychological Assessment Metrics (ANAM), to serve as a
baseline for comparison if a Service member is injured while deployed.
In this case, retaking the ANAM test will help inform a return-to-duty
determination in theater following concussion. It also is used for
post-deployment concussion management to help further elucidate
cognitive symptoms and complaints. The third program, the Post-
Deployment Health Assessment, enables health care providers to identify
and refer for treatment those Service members who have physical or
mental symptoms from their deployments due to a variety of conditions,
one of which may be concussion.
The Department has based its neurocognitive testing programs on
injury platforms, that is, the primary purpose of pre deployment
neurocognitive baselining is to better inform a return to duty
determination. We understand Congress wants the Department to base the
neurocognitive programs on evaluating cognitive function before a
Service member goes into war and when they come out of war to see if
there are any differences. If there are differences, then
theoretically, the clinical teams can evaluate these Service members
and treat them, thus not allowing any Service member to ``fall through
the cracks.''
While the Department understands the Congressional intent, the
inherent problem with this wider based platform (all Service member
vice injured Service member) is that the evidence does not support this
concept for two reasons: 1) we have completed two studies with military
populations, one at Ft Bragg and one at Ft Campbell that both showed
that population based cognitive testing was not effective for screening
or diagnosing concussion and 2) we do not know what ``new cognitive
normal'' is after a theater experience. We have no normative data that
would suggest what retesting these cognitive domains should look like
after war. Therefore, any difference between pre-deployment and post
deployment assessment cannot be attributed to any specific factors.
[See page 15.]
?
=======================================================================
QUESTIONS SUBMITTED BY MEMBERS POST HEARING
April 20, 2010
=======================================================================
QUESTIONS SUBMITTED BY MS. FALLIN
Ms. Fallin. The FY2008 NDAA included language mandating pre- and
post-deployment neurocognitive assessments. The idea behind this being
that a pre-deployment assessment would provide a baseline, to which a
post-deployment assessment could be compared to. This was well
understood by OSD Health Affairs at the time. Recent copies of orders
that I've received from Army Medical Command have prohibited post-
deployment neurocognitive assessments. Additionally, it's been brought
to my attention that DOD considers itself to be complying with the law
if paper and pencil evaluation is administered overseas before
deployment back to the home station. Is it true that pre- and post-
deployment neurocognitive assessments are not administered using the
same test? What is the purpose of a pre-deployment baseline, if
different methods of testing are used post-deployment? It is my
understanding that DOD maintains a database of all data regarding pre-
deployment assessments. Is this database accessible by the VA? Are the
results in this database linked to each soldier, sailor, airman's
health care file? May an individual serviceman or woman access the
information related to their pre-deployment assessment? Finally, how
does what DOD considers to be the post deployment assessment permit
``differential diagnosis of traumatic brain injury in members returning
from deployment in a combat zone''?
Dr. Rice and Mr. Carr. 1 & 2) No, DOD currently uses the same pre-
deployment cognitive assessment tool (Automated Neuropsychological
Assessment Metrics (ANAM)) to perform post-deployment cognitive
assessments for returning Service members who have sustained a
concussion. The Department does maintain a database of pre-deployment
assessments as part of the Pre-Deployment Neurocognitive Program to
serve as a baseline for comparison if a Service member is injured while
deployed and to help better inform an injured Service member's return-
to-duty determinations.
3) DOD maintains a database with pre deployment neurocognitive
baselines of deploying Service members. These baselines will be
available to the VA by December 2010. Milestone 4.2.A.3 in the VA/DOD
Joint Executive Committee (JEC) Strategic Plan for FY 2010-2012 states
``VA will begin implementing technical solution to enable VA providers
to view DOD neuropsychological assessment data by June 30, 2011.''
4) The results from the pre deployment neurocognitive baseline
tests are not currently linked to a Service member's electronic health
record.
5) The results are housed in a centralized repository so they may
be retrieved if necessary post injury for comparison. Service members
may access these results, when requested.
6) The population-based Traumatic Brain Injury assessment (versus
cognitive screen) that occurs is the Post-Deployment Health Assessment
(PDHA), is done by a health care provider. This assessment evaluates
the entire spectrum of symptoms that may be associated with concussion.
These include physical symptoms, i.e. headache; behavioral symptoms,
i.e. irritability and cognitive symptoms, i.e. memory problems.
Multiple diagnoses may result from these symptoms, to include but not
limited to, posttraumatic stress disorder, high blood pressure,
obstructive sleep apnea, or toxic chemical exposure. Thus, the presence
of these symptoms does not diagnose a concussion or any other disorder,
but they indicate the need for further clinical evaluation by a trained
provider.
The TBI screening questions that have been on the Post-deployment
Health Assessment form (DD 2796) since January 2008, are survey-type
questions that ask about an injury event, alteration in consciousness
while sustaining that injury event, symptoms reported immediately after
the injury event, as well as current symptoms experienced. These
questions have been endorsed by the Institute of Medicine and have gone
through validation studies as the questions to ask to ascertain whether
a Service member may have sustained a concussion. However, diagnosis is
not made until a clinician evaluates and examines the Service member to
determine whether a concussion has occurred. The assessment process is
the first tier approach to cast a wide net for those who possibly have
sustained a concussion. It is not expected to be a process that has
high specificity but rather high sensitivity.
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