[Senate Hearing 111-837]
[From the U.S. Government Printing Office]
S. Hrg. 111-837
THE PROGRESS IN PREVENTING MILITARY SUICIDES AND CHALLENGES IN
DETECTION AND CARE OF THE INVISIBLE WOUNDS OF WAR
=======================================================================
HEARING
before the
COMMITTEE ON ARMED SERVICES
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
JUNE 22, 2010
__________
Printed for the use of the Committee on Armed Services
Available via the World Wide Web: http://www.fdsys.gov/
__________
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COMMITTEE ON ARMED SERVICES
CARL LEVIN, Michigan, Chairman
ROBERT C. BYRD, West Virginia JOHN McCAIN, Arizona
JOSEPH I. LIEBERMAN, Connecticut JAMES M. INHOFE, Oklahoma
JACK REED, Rhode Island JEFF SESSIONS, Alabama
DANIEL K. AKAKA, Hawaii SAXBY CHAMBLISS, Georgia
BILL NELSON, Florida LINDSEY GRAHAM, South Carolina
E. BENJAMIN NELSON, Nebraska JOHN THUNE, South Dakota
EVAN BAYH, Indiana ROGER F. WICKER, Mississippi
JIM WEBB, Virginia GEORGE S. LeMIEUX, Florida
CLAIRE McCASKILL, Missouri SCOTT P. BROWN, Massachusetts
MARK UDALL, Colorado RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina DAVID VITTER, Louisiana
MARK BEGICH, Alaska SUSAN M. COLLINS, Maine
ROLAND W. BURRIS, Illinois
JEFF BINGAMAN, New Mexico
EDWARD E. KAUFMAN, Delaware
Richard D. DeBobes, Staff Director
Joseph W. Bowab, Republican Staff Director
(ii)
C O N T E N T S
__________
CHRONOLOGICAL LIST OF WITNESSES
The Progress in Preventing Military Suicides and Challenges in
Detection and Care of the Invisible Wounds of War
june 22, 2010
Page
Chiarelli, GEN Peter W., USA, Vice Chief of Staff, U.S. Army..... 5
Greenert, ADM Jonathan W., USN, Vice Chief of Naval Operations,
U.S. Navy...................................................... 13
Amos, Gen. James F., USMC, Assistant Commandant, U.S. Marine
Corps.......................................................... 20
Chandler, Gen. Carrol H., USAF, Vice Chief of Staff, U.S. Air
Force.......................................................... 24
Jesse, Robert L., Acting Principal Deputy Under Secretary for
Health, Veterans Health Administration, Department of Veterans
Affairs........................................................ 29
(iii)
THE PROGRESS IN PREVENTING MILITARY SUICIDES AND CHALLENGES IN
DETECTION AND CARE OF THE INVISIBLE WOUNDS OF WAR
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TUESDAY, JUNE 22, 2010
U.S. Senate,
Committee on Armed Services,
Washington, DC.
The committee met, pursuant to notice, at 9:35 a.m. in room
SD-G50, Dirksen Senate Office Building, Senator Carl Levin
(chairman) presiding.
Committee members present: Senators Levin, Lieberman,
Akaka, Webb, McCaskill, Udall, Hagan, Begich, Burris, McCain,
Inhofe, Thune, and Collins.
Committee staff members present: Richard D. DeBobes, staff
director; and Leah C. Brewer, nominations and hearings clerk.
Majority staff members present: Gabriella Eisen, counsel;
Gerald J. Leeling, counsel; and Jason W. Maroney, counsel.
Minority staff members present: Michael V. Kostiw,
professional staff member; Diana G. Tabler, professional staff
member; and Richard F. Walsh, minority counsel.
Staff assistants present: Jennifer R. Knowles, Hannah I.
Lloyd, and Breon N. Wells.
Committee members' assistants present: James Tuite,
assistant to Senator Byrd; Nick Ikeda, assistant to Senator
Akaka; Greta Lundeberg, assistant to Senator Bill Nelson;
Gordon I. Peterson, assistant to Senator Webb; Tressa Guenov,
assistant to Senator McCaskill; Roger Pena, assistant to
Senator Hagan; Lindsay Kavanaugh, assistant to Senator Begich;
Amanda Fox, assistant to Senator Burris; Anthony J. Lazarski,
assistant to Senator Inhofe; T. Finch Fulton and Lenwood
Landrum, assistants to Senator Sessions; Richard Perry,
assistant to Senator Graham; and Ryan Kaldahl, assistant to
Senator Collins.
OPENING STATEMENT OF SENATOR CARL LEVIN, CHAIRMAN
Chairman Levin. Good morning, everybody.
The committee meets today to receive testimony on the
status of our efforts to prevent military suicides and the
challenges in detection, treatment, and management of the so-
called ``invisible wounds of war,'' which we consider to
include traumatic brain injury (TBI), and concussive events,
post-traumatic stress disorder (PTSD), and other combat-related
psychological health concerns.
A hearing on military suicides was requested by Senator
Inhofe several weeks ago, and we all appreciate that request.
Due to our committee markup schedule, we were unable to
schedule a hearing until this week. Originally, this hearing
was meant to focus on Service suicide prevention policies and
programs. But, given the recent disconcerting reports alleging
poor diagnosis and treatment of servicemembers suffering from
TBI and PTSD, I felt it important to broaden the scope of our
discussion today to include those topics as well, especially
given the fact that they can often occur concurrently, making
diagnosis of any or all of these illnesses difficult.
The increase in suicides by military personnel in the last
few years is alarming. In 2007, 115 Army soldiers committed
suicide. In 2008, the number increased to 140, and to 162 in
2009. Similarly, 33 marines committed suicide in 2007, 42 in
2008, and 52 in 2009. I understand there are a number of
additional cases where the Armed Forces medical examiner has
not yet concluded whether the deaths are by suicide so, the
2009 numbers will likely be even higher.
These increases indicate that, despite the Services'
efforts, there is still much work to be done. We must improve
our suicide prevention efforts to reverse the number of
servicemembers taking their own lives.
I am greatly concerned about the increasing number of
troops returning from combat with PTSD and TBIs, and the number
of those troops who may have experienced concussive injuries
that were never diagnosed.
Studies indicate that mild TBI, or concussion, is
associated with PTSD, depression, and anxiety. These
conditions, in turn, may contribute to the increase in the
number of suicides.
One key to suicide prevention is to make greater efforts to
end the stigma that too many perceive attaches when they
receive mental health care. Another key, of course, is the
proper and timely diagnosis and treatment of TBI and PTSD, and
increasing awareness of, and access to, mental healthcare
resources, as well as leadership support for those seeking such
care.
We hope to hear from our witnesses today the approach that
each Service and the Department of Veterans' Affairs (VA) is
taking to help detect, treat, and manage psychological health
problems, to include PTSD and TBI.
The numbers of suicides have increased in every Service,
but significantly more so in the Army and Marine Corps, the two
Services most heavily engaged in ground combat in Iraq and
Afghanistan. Congress has recognized the strain on these ground
forces, and has, over the past several years, authorized
significant increases in the Active Duty end strengths for the
Army and Marine Corps. It is our intent that these increases
will help to relieve the stress on those forces, but we also
have to make sure that we provide all the assistance that our
troops need to cope with the stress that they are experiencing.
The professionals tell us that common issues leading to
suicide include relationship problems, financial problems, and
legal problems, as well as mental health issues. I know that
each of the Services, as well as the VA, have programs to
address those as part of the suicide prevention efforts.
Undoubtedly, deployments and lack of dwell time have
contributed to these underlying problems that are linked with
suicides.
The Army is working with the National Institute of Mental
Health (NIMH) on a 5-year longitudinal study to help identify
and develop intervention and mitigation strategies to help
decrease the number of suicides in the Army. While this is an
important effort, we cannot wait for the full 5 years to occur
for these results. We must identify actions, and take them now,
to reduce suicides. General Chiarelli, we look forward to
hearing about interim findings from the study, and how the Army
might use those findings now to better target suicide
prevention efforts.
We must learn more about TBI and concussive events, and
their relationship to PTSD and suicide. Unfortunately, these
brain injuries remain relatively unknown territory in both the
military and civilian medical environments.
We look forward to learning more about the policies and
programs each Service has in place to handle incidences of TBI
and concussive events, both in theater and at home. We also
look forward to learning what policies, programs, and
initiatives each of the Services and the VA has implemented and
identified to ensure that our servicemembers, in both the
Active Duty and Reserve components, veterans, and their
families, receive all of the support that we can provide, and
that our All-Volunteer Force can continue to perform its
mission with the health and other services that they need and
deserve.
I'm pleased to welcome our witnesses. We have with us
General Peter Chiarelli, Vice Chief of Staff of the U.S. Army;
Admiral Jonathan Greenert, the Vice Chief of Naval Operations
of the U.S. Navy; General James Amos, Assistant Commandant of
the U.S. Marine Corps; General Carrol Chandler, Vice Chief of
Staff of the U.S. Air Force; and Dr. Robert Jesse, the Acting
Principal Deputy Under Secretary for Health for the Veterans
Health Administration of the VA.
General Amos, since Secretary Gates has just announced his
recommendation to the President to nominate you to be the next
Commandant of the Marine Corps, I know we all offer our
congratulations and great hopes for you in the future.
Senator McCain.
STATEMENT OF SENATOR JOHN McCAIN
Senator McCain. Thank you, Mr. Chairman.
Let me thank our witnesses for joining us today.
I'd like to also acknowledge Senator Inhofe, who initiated
a request in April for a full committee hearing on the tragic
and important issue of suicide in our military. Thank you for
your initiative, Senator Inhofe. I'm pleased that we are having
this hearing.
It's our privilege to serve the distinguished men and women
of our Armed Forces, who, even after more than 9 years of war,
love their country and risk everything to defend her. We have
greatest admiration and appreciation for them and for their
families, and we'll always honor their courage and sacrifice.
The burdens of our missions in Iraq and Afghanistan are
tremendous, and so are the consequences for those who serve.
Many of our servicemembers have answered their country's call,
with multiple deployments to combat and little time for rest
and recovery at home.
The enemy's signature weapon, the improvised explosive
device (IED), causes multiple injuries to parts of the body and
brain. As is the case with every war, many of the deepest
wounds are those that wrack the minds and souls of our citizen
soldiers, wounds that continue to plague them long after
they've returned home from the field of battle.
The Department of Defense (DOD) has documented nearly 2,000
suicides from 2001 to 2009. Today the Services report more than
140 during 2010.
Although the Air Force and Navy have previously experienced
rates of suicide higher than those reported today, rates for
the Army and Marine Corps are at historically high levels.
These are casualties that our Nation cannot accept and that our
armed services must work to prevent, both among troops who have
deployed and those who have not. We must erase cultural
barriers and attitudes from peers and leaders that may cause
soldiers who need care to turn away from it. We must conquer
any bureaucracy that stands in the way of compassionate care
for a man or woman who seeks it.
Since the attacks of September 11, we have devoted billions
of dollars to improving care for wounded and ill servicemembers
and their families provided not just by DOD and the Veterans
Administration alone, but by many agencies of government and
the private sector.
One important example is the National Suicide Prevention
Lifeline. Crisis counselors who respond to hundreds of calls
from current and former serving members of the military every
day. As a Nation, we can be proud of these efforts, but not yet
content with their results. Teaching our servicemembers and
their families to navigate complex pathways to care is
necessary, but leading them there is essential. As in all
military campaigns, the quality of leadership will determine
our success or failure.
Several of our witnesses report that military
servicemembers continue to distrust informing their chain of
command that they have a brain injury or that they're
experiencing stress or considering harm to themselves and
others, for fear of bringing a sense of shame to themselves and
their unit. This is unacceptable. There's no shame in admitting
that you are struggling with the hidden wounds of war, for
those wounds are every bit as real as those that are visible on
the surface.
The Services must increase focus on transforming the
culture of leadership, and must train more leaders to
understand that emotional and physical health are critical
factors in military readiness, and hold them accountable if
they fail.
Americans expect that high quality health and mental health
care, matched by compassionate involvement of military leaders,
can and will make a difference that is capable of saving lives
that would be lost to suicide. To meet this rightfully high
expectation, leaders at every level must exercise their sacred
obligation to take responsibility for their subordinates, know
about their lives and families, have conversations with them,
and listen to their concerns. These powerful human
interactions, which are the essential character of the core
military values of trust and cohesion, can save lives. Our
service men and women and their families deserve nothing less.
I thank you, and I look forward to hearing the testimony of
our witnesses.
Chairman Levin. Thank you very much, Senator McCain.
We'll start with General Chiarelli, and we'll just go right
down the table.
General Chiarelli.
STATEMENT OF GEN PETER W. CHIARELLI, USA, VICE CHIEF OF STAFF,
U.S. ARMY
General Chiarelli. Chairman Levin, Senator McCain,
distinguished members of the committee, I thank you for the
opportunity to appear before you today to provide a status of
the Army's ongoing efforts to reduce the number of suicides
across our force, and also detect and care for soldiers
suffering from PTSD, TBI, and other behavioral health issues.
I've submitted a statement for the record, and I look
forward to answering your questions at the conclusion of our
opening remarks.
As you are all aware, it remains a very busy time for our
Nation's military. We're in the ninth year of war being fought
in two separate theaters. The pace of operations is exceedingly
high, and will likely remain so for the foreseeable future.
I'm proud to report that the men and women serving in our
Army today are doing an absolutely outstanding job. They are
well trained, highly motivated, and deeply patriotic. Our
Nation has asked a great deal of them and of their families,
and they've exceeded expectations by a long shot.
However, the prolonged demand continues to put a
significant strain on our force. One of the symptoms of this,
albeit the most severe, is the historically high number of
suicides we've experienced in recent years. Fortunately, we've
seen a fairly significant reduction in suicides among Active
Duty soldiers this year, as compared to last year. However,
we've seen an unexpected increase in suicides among our
Reserve-component soldiers not on Active Duty, in particular,
the Army National Guard.
Needless to say, the loss of any soldier, Army civilian, or
family member to suicide is tragic and unacceptable. Each of
these suicides represents an individual and a family that has
suffered an irreparable loss. Over the past 12 months, we've
learned a great deal about suicides. For example, we now know
that soldiers with one or no deployments represent 79 percent
of all suicides. First-termers represent 60 percent of all
suicides.
I've worked closely with my colleagues from the Navy and
Air Force, and particularly with my good friend Jim Amos. Our
Army and Marine Corps ground forces share a similar mission,
and we're working together on many of the same issues.
You have my word that we will continue to work diligently
to learn even more, in an effort to further reduce suicides in
our force.
In the meantime, we've learned a tremendous amount about
the broader challenge of behavioral health issues affecting
many of our soldiers, Army civilians, and family members. After
8-plus years of war and multiple deployments, many are
suffering from depression, anxiety, TBI, and PTSD, often
referred to as the ``invisible wounds of war.'' These and other
highly complex injuries and conditions involving the brain pose
unique challenges, especially as compared to easily detectable
wounds, such as an amputation or a burn. In particular, the
comorbidity of symptoms can make diagnosis especially
difficult, in many cases, a fact not well understood or
appreciated by many.
The reality is, the study of the brain is an emerging
science, and there is still much to be learned. But, we're
making progress. Over the past 12 months, the Army's commitment
to health promotion, risk reduction, and suicide prevention has
changed Army policy, structure, and processes. We have
realigned garrison programs, increased care provider services,
refocused deployment and redeployment integration, and enhanced
treatment of PTSD and TBI, and promoted tele-behavioral
medicine.
Our success notwithstanding, we still have much more to do.
We face an Army-wide problem that can only solved by the
coordinated efforts of our commanders, leaders, soldiers,
program managers, and health providers.
This is a holistic problem, with holistic solutions, and
that is how we're approaching it. We remain focused on
investigating ways to promote resiliency, reduce stressors
caused by a variety of factors, improve leaders' and soldiers'
ability and willingness to identify when they or their buddies
need help, and be able and willing to take advantage of the
resources and support that are available to them.
I can assure the esteemed members of the committee there is
no greater priority for me and the other senior leaders of the
U.S. Army than the safety and well-being of our soldiers. The
men and women who wear the uniform of our Nation are the best
in the world. We owe them and their families a tremendous debt
of gratitude for their service and many sacrifices.
Mr. Chairman, Senator McCain, members of the committee, I
thank you for your continued and generous support and
demonstrated commitment to the outstanding men and women of the
U.S. Army and their families. I look forward to your questions.
[The prepared statement of General Chiarelli follows:]
Prepared Statement by GEN Peter W. Chiarelli, USA
Chairman Levin, Senator McCain, distinguished members of the Senate
Armed Services Committee; I thank you for the opportunity to appear
here today to provide a status on the U.S. Army's ongoing efforts to
reduce the number of suicides across our force; and, also detect and
care for soldiers suffering from post-traumatic stress, traumatic brain
injury and other behavioral health issues.
On behalf of our Secretary, the Honorable John McHugh and Chief of
Staff, General George Casey, I would like to take this opportunity to
thank you for your continued, strong support and demonstrated
commitment to our soldiers, Army civilians, and family members.
As you are well aware, it continues to be a very busy time for our
Nation's military. We are in the ninth year of war, being fought in two
separate theaters. The pace of operations is exceedingly high; and,
will likely remain so for the foreseeable future.
I will tell you, the men and women serving in the Army today are
doing an absolutely outstanding job on behalf of our Nation. They are
well-trained, highly-motivated, and deeply patriotic. Our Nation has
asked a lot of our soldiers and they have exceeded expectations by a
long shot.
However, the prolonged demand on them--and on their families--
continues to put a significant strain on our force. Many individuals
have deployed multiple times. They are tired. A significant number of
them suffer physical injuries, such as musculo-skeletal damage,
amputations, bullet or shrapnel wounds, or burns. Many more suffer from
behavioral health issues, such as depression, anxiety, traumatic brain
injury and post-traumatic stress--often referred to as the ``invisible
wounds of war.'' The Army is continuing to work very, very hard to
identify ways to address these behavioral health issues by alleviating
some of the stress on our force while also improving our ability to
detect, prevent, and treat these and other injuries.
Our overarching goals are to improve individuals' resiliency;
eliminate the longstanding, negative stigma associated with seeking and
receiving help; and, ensure soldiers, Army civilians, and family
members who may be struggling get the help that they need.
calendar year 2009 and calendar year 2010 army suicide reports
Suicides in the United States Army have been on the rise since
2004. In calendar year 2009, we had 162 active duty suicide deaths
(including activated members of the National Guard and U.S. Army
Reserves), with 244 across the total Army. During this same period, we
had 1,679 known attempted suicides.
However, so far this year, we've seen a fairly significant
reduction in suicides among active-duty soldiers. As of 10 June 2010,
there have been 62 suicides (includes 3 activated USAR soldiers and 3
activated ARNG soldiers); for the same time period last year there were
89.
Unfortunately, we have seen an increase in suicides among Reserve
component soldiers not on active duty [2010 total (as of 10 June)--53
(43 ARNG; 10 USAR); 2009 total--42 (same time period)].
The decrease in active duty suicides would seem to indicate the
refocused efforts by our Army are beginning to work. Conversely, the
increase in suicides among Reserve component soldiers not on active
duty may reflect the Army's more limited ability to influence these
soldiers once they return home.
We also track suicides among Department of the Army civilians [2010
total (as of 10 June) for DA civilians--13; 2009 total--21] and family
members [2010 total (as of 10 June) for family members--4; 2009 total--
11].
The loss of any soldier, Army civilian or family member to suicide
is tragic, incomprehensible, and unacceptable. Each of these suicides
represents an individual and a family that has suffered an irreparable
loss. Army leadership is working to better understand the causes of the
disturbing rise in soldier suicides and we've instituted prevention
measures that recognize everyone in the Army must be part of the
solution. You have my word that we will continue to work diligently to
further reduce suicides across our Force.
soldiers engaging in high-risk behavior
Equally alarming to the increase in Army suicides is the growing
population of soldiers engaging in high-risk behavior. Illicit drug
use, alcohol abuse, disciplinary infractions, misdemeanors and felony
crimes are all on the rise. There is a known spike in these behaviors
as soldiers return from deployments. A so-called ``star burst'' effect
has been recognized at about the 90 day mark, where an increase in
these and other high-risk behaviors has been noted. Meanwhile, there is
a clear link between suicides and these and other high-risk behaviors.
Of the 160 active duty suicide deaths in fiscal year 2009, 146 were
related to high-risk behavior (e.g., self-harm, illicit drug use, binge
drinking and criminal activity); including 74 drug overdoses. Data
collected since 2005 consistently show that approximately 33 percent of
suicides included either drug or alcohol use. In addition 32 percent
had some form of closed or pending misdemeanor or felony investigation.
prescription drug abuse
Meanwhile, recent estimates show that 14 percent--or approximately
106,000 soldiers--are prescribed some form of pain, depression or
anxiety medication. This ranges from Percocet for a simple tooth
extraction to powerful anti-psychotic medications prescribed to an
individual experiencing a true psychiatric crisis. The potential for
abuse (or misuse) is obvious. We are working with the legal and medical
communities to improve transfer of information between commanders,
medical professionals, and program and service providers, while
ensuring we protect the privacy rights of patients.
The office of the Army Surgeon General is also drafting a new
policy to provide guidance on the prevention and management of
polypharmacy with psychotropic medications and central nervous system
depressants. This new policy will assist in reducing adverse clinical
outcomes among patients receiving care in the military medical system.
This is one of the major risks associated with suicide:
polypharmacy, post-concussive syndrome and pain. I have mentioned the
first two; to address pain management, our medical department recently
led a task force consisting of subject matter experts from all Services
and Department of Veterans Affairs (VA). This task force has developed
a number of recommendations to improve pain management for our
patients; and, we are currently developing a campaign plan to address
this important issue. These efforts will improve care for all patients,
both in and out of uniform.
The Army is also continuing to conduct and evaluate programs for
substance abuse self-referral, pre-deployment and post-deployment
behavioral health screening, and the use of virtual communication
technology to provide more accessible behavioral health counseling.
The nationwide shortage of behavioral health care providers and
substance abuse counselors continues to present a significant
challenge. The Army is working hard to recruit more in order to meet
the increased need for these services across our Force.
For example, one hundred more Medical Corps officers were recruited
in fiscal year 2009 as compared to fiscal year 2007. One hundred and
twenty more civilian Behavioral Healthcare personnel were hired in
fiscal year 2008 compared to fiscal year 2007. Meanwhile, the Army has
increased funding for use of ``3R'' bonuses (recruiting, relocation and
retention) in order to hire more substance abuse and family advocacy
program counselors. The Army has also expanded its civilian force
structure to include supportive specialties such as Licensed
Professional Counselors, Licensed Marriage and Family Therapists
(LMFTs) and Military Family Life Counselors (MFLC).
army suicide prevention task force
After the all-time high of 20 suicides in a single month, January
2009, the Army mandated an unprecedented Army-wide stand-down followed
by a deliberate chain teaching program focused on suicide prevention.
The Secretary of the Army at that time the Honorable Pete Geren, and
Chief of Staff of the Army, General George Casey appointed me to lead
the effort to reduce the trend of suicides in the Army.
I ordered the immediate activation of the Army Suicide Prevention
Task Force (ASPTF)--a group of multi-disciplinary representatives from
across the Army staff--in March 2009 to dedicate focused energies and
resources to tackle all aspects of suicide.
Over the past year, the ASPTF examined the complexity of suicide,
taking into account national suicide trends, individual soldier risk
factors and the Army's institutional approach to suicide prevention.
The task force identified risk factors and indicators that help
potentially illuminate correlations to high-risk and suicidal behavior
in the Army. The task force continues to review over 70 existing Army-
wide programs, identifying those that work, while strengthening the
most effective programs and streamlining efforts where it makes sense.
The unique governance, policy, structure and process of the task
force, together with the Army Suicide Prevention Council (an interim
HQDA-level organization chartered under my authority and mandated to
expedite solutions from HQDA through appropriate commands) greatly
expedited implementation of many strategic changes over the past 12
months, including:
June 2009, reduced accessions waivers for adult felony
(major misconduct) convictions; and DAT (positive drug and
alcohol tests at MEPS); misconduct (misdemeanor/major
misconduct) for drug use; possession; or drug paraphernalia, to
include marijuana. This translated to nearly 4,300 fewer
applicants accepted into the Army as compared to 2008.
Revised legacy protocols for investigating and
reporting suicide.
Rewrote DA PAM 600-24, Health Promotion, Risk
Reduction, and Suicide Prevention (HP/RR/SP) for
synchronization of HP/RR/SP Program Portfolio. This policy
integrates HP/RR/SP programs and services at the installation
level.
vcsa suicide senior review group
In an effort to learn as much as possible from every suicide, in
March 2009 I also established the monthly VCSA Suicide Senior Review
Group (SRG). The SRG involves senior commanders from affected commands
across the Army. We meet in person or via video tele-conference and
review approximately 15 to 20 suicide cases each month. The cases are
discussed to glean lessons learned and identify trends and themes in an
effort to help prevent future suicides. The SRG is the most intense
2\1/2\ hours I spend each month.
Also, to aid in gaining as much information as possible from every
suicide, the task force developed a suicide event collection report,
comprised of data fields to be filled in by the Field Army. The report
provides me and Army leadership with instant, actionable information on
each individual Army suicide within approximately 72 hours of the
Criminal Investigation Command's initial response.
army campaign plan for hp/rr/sp report
The ASPTF is responsible for the development and publication of the
Army Campaign Plan for HP/RR/SP, a comprehensive plan outlining
unprecedented changes in Army doctrine, policy and resource allocation.
This holistic approach accounts for the many challenges our soldiers,
Army civilians, and families face. These challenges include, but are
not limited to: substance abuse; financial and relationship problems;
and, post-traumatic stress and traumatic brain injury.
The content of the Campaign Plan was informed and developed by
three concurrent efforts: (1) the collection of suicide data and
research; (2) the comprehensive review of existing policy, doctrine and
all known HP/RR/SP related documents from HQDA and across DOD; and (3)
the VCSA-led installation level assessment, which obtained input from
commanders, soldiers and family members and reviewed programs and
processes at the installation level.
I also chartered a multi-disciplinary team of experts led by a
General Officer that is writing a comprehensive report on the Army's
HP/RR/SP past and future efforts. The team is preparing to release its
full report as soon as it is completed and reviewed.
The report represents over a year's worth of work at the direction
of the Army's Senior Leadership to provide a ``directed telescope'' on
the alarming rate of suicides in the Army. The report is based on the
ASPTF's experience, ongoing research; and, presents new concepts and
modeling for HP/RR/SP governance, policy, structure, and process. It
represents the most comprehensive HQDA report of its kind, capturing
both the initial findings of the ASPTF and informing the future of
suicide prevention within the Army.
In an effort not to prematurely reveal out of context details on
findings, I will mention very few in this statement. Prior to the
formal roll-out, I and the Army's other senior leaders will come back
and brief the members and their staffs on the full contents of the
report.
Bottom line: this report indicates there is a confluence of
stressors that cause suicides, but no single panacea to prevent them.
As I have said many times over the past year, there is no one solution
to this problem.
Last year, shortly after Secretary Geren and General Casey
appointed me as lead of this ongoing effort, I visited six
installations with a team for the sole purpose of looking at suicide
prevention efforts in the Force. By the time we reached the third
installation, it was readily apparent to all of us that this challenge
was not limited specifically to suicides; but, to the overall health
and well-being of the Force after 8-plus years of war. In other words,
we quickly determined that suicide is merely a symptom--albeit the most
severe--of a much larger problem. The focus on suicide prevention was
too narrow and the aperture needed to widen to a more comprehensive
review of all soldier and family risk reduction and wellness programs.
That initial eye-opening experience led to the holistic approach we
have since adopted to achieve soldier wellness (promoting the physical,
mental and spiritual health of the force). We remain focused on
investigating ways to promote resiliency; reduce stressors caused by a
variety of factors; improve leaders' and soldiers' ability and
willingness to identify when they or their buddies need help; and be
able and willing to take advantage of the resources and support that
are available to them.
a team approach
As I emphasized previously, effectively addressing the challenge of
soldier suicides will require a team effort across all Army components,
jurisdictions, and commands, as well as continued cooperation with
partners outside of our organization, to include VA (has joined the
Army Suicide Prevention Council) and the National Institute of Mental
Health (NIMH).
In October 2008, the Army entered into a 5-year, $50 million joint
study with NIMH, the Army Study to Assess Risk and Resilience in
Servicemembers (Army STARRS). This study represents the largest DOD
longitudinal epidemiologic study of mental health, psychological
resilience, suicide risk, suicide-related behaviors, and suicide deaths
in the Army. The goal is to help identify those soldiers most at risk,
as well as develop intervention and mitigation strategies that will
help decrease the number of suicides across the Army.
This is the largest single study on the subject of suicide that
NIMH has ever undertaken. It includes soldiers from every component of
the force--Active Army, Army National Guard, and Army Reserve. The
study will follow willing soldiers as they enter the training base and
periodically thereafter for the next 5 years. The researchers will
conduct a variety of interviews, surveys, psychological evaluations,
etc.
Intermediate data and emerging results are reported quarterly to
inform the Army's ongoing intervention strategies. Initial findings
from preliminary analyses of suicide deaths include:
Suicide risk is highest for currently deployed
soldiers, next highest for previously deployed, and lowest (in
relative terms) for never-deployed soldiers;
Since 2004, suicide risk has been elevated among
soldiers with <1 year of service;
Most (about 53 percent) soldiers who die by suicide do
not have a record of an encounter with a behavioral health
diagnosis in the military healthcare system;
Mental disorders, particularly depression, anxiety,
and post-traumatic stress are among the most potent risk
factors for suicidal behavior; and
The average period between onset of PTS and an
individual seeking help is 12 years; during that period,
symptoms can manifest in a variety of ways, including spousal
abuse, anger management issues, divorce, drug/alcohol abuse,
loss of employment.
We are confident this study's findings will eventually lead to
predictive algorithms. Ultimately, we are trying to develop a
predictive model that accounts for the cumulative effect of transitions
of all types (accession, PCS, death of family member, TCS, retirement,
etc.) and stressors across a soldier's entire career. Ideally, this
would lead to tailored interventions based on known or predictive
levels of stress. The results will benefit the Army, the other military
Services, as well as the U.S. population overall, and may lead to more
effective interventions for both soldiers and civilians.
traumatic brain injury and post-traumatic stress
One of the challenges in preventing suicide is recognizing that an
individual--even someone as close as a family member or good friend--is
considering taking his or her own life and may need help. Too often
individuals will suffer in silence. They may be dealing with severe
depression or anxiety and choose to hide their concerns from family
members or friends.
Post-traumatic stress (PTS), traumatic brain injury (TBI), and
other behavioral health issues can present similar significant
challenges. I consider these ``invisible injuries'' to be among the
most common result of the ``signature weapon'' of this war: blast. In
fact, the majority (60 percent) of the soldiers enrolled in the Army's
Wounded Warrior program have PTS (43 percent) and/or TBI (17 percent)
as a primary service disqualifying injury of 30 percent or greater.
These injuries pose unique challenges, especially as compared to
easily-detectable wounds such as amputations and burns. PTS and TBI are
among the most difficult and debilitating in terms of accurate
diagnosis, treatment, and recovery. The study of the human brain is an
emerging science; and, there is still much to be learned about these
and other highly-complex injuries involving the brain. This pertains
not just within the military community, but throughout the entire
medical community as a whole, worldwide.
We are making progress, both in theater and at medical facilities
around the world. In a concerted effort to minimize the number and
severity of injuries, the Army implemented a new TBI management
strategy across the force aimed at prevention, early detection and
effective treatment of injuries. Additionally, the Army is instituting
a revised program of instruction for medics and other behavioral health
providers that includes training specific to TBI and PTS injuries.
We're also incorporating instruction on this important issue into
training programs at the National Training Center, Joint Readiness
Training Center and other locations.
The new TBI management strategy, ``Educate, Train, Treat, and
Track,'' is also being successfully implemented downrange. Deploying
soldiers receive training prior to their arrival in theater; in fact, I
personally have briefed several units. Last week, I briefed a deploying
Brigade Combat Team via VTC. This emphasizes to leaders and soldiers
just how serious I, and the Army's other senior leaders, are when it
comes to these very serious injuries.
The new TBI management strategy also includes strict ``event-
based'' protocols that govern exactly what leaders and soldiers must do
if involved in any type of concussive event. At a minimum, every
soldier must undergo a medical evaluation followed by a mandatory 24-
hour downtime period and a second exam before returning to duty. We
cannot permit the proud ``Warrior Spirit'' of our soldiers, which leads
many of them to ignore their concussions and remain in the fight, to
dominate the competing need to protect them against another injury
during the vulnerable period of healing.
Meanwhile, back at home, since 2002, the Department of Defense has
opened 52 TBI treatment centers across the country. These centers are
staffed with multidisciplinary teams of medical providers capable of
treating the full range of TBI, from mild to severe. The National
Intrepid Center of Excellence, dedicated to research and treatment of
military personnel and veterans suffering from TBI and other behavioral
health issues will open this summer. It is built on the Bethesda,
Maryland campus of what will become the new Walter Reed National
Military Medical Center, the DOD's largest and most advanced medical
complex, and across from the National Institute of Health--a key
partner in advancing the science and treatment of these injuries and
illnesses.
We are making progress, but it remains an incredibly challenging
endeavor. The reality is some of these neurological injuries or
conditions cannot be fully healed or repaired even with the most
advanced medical treatment available. Unlike an amputation, for
example, there is no standard procedure or prognosis for care for
moderate or severe TBI. This can understandably add to the frustration
felt by affected soldiers and family members.
In the past, individuals suffering from TBI, PTS, or what was
previously referred to as ``battle fatigue,'' were often told there was
nothing further that could be done for them. They were discharged from
the military and left to suffer in silence. This is absolutely
unacceptable. Next to the prosecution of current and future conflicts,
our highest priority remains caring for the brave men and women who
serve and sacrifice on behalf of our Nation.
In 2007, the Army established Warrior Transition Units (WTU) to
facilitate the treatment and rehabilitation of soldiers determined to
require complex medical care for 6 months or longer. Today, there are
29 WTUs and 9 community-based WTUs located around the world.
Approximately, 9,300 wounded or injured soldiers are receiving
treatment at these facilities. Teams comprised of nurse case managers,
health care providers, and cadre members assist them and their families
through the full recovery process. The feedback has consistently been
very positive. We are continually making improvements to the care and
services provided at these facilities based on lessons learned.
The Army activated the Warrior Transition Command to oversee the
WTUs and to guide the ongoing execution and development of the Warrior
Care and Transition Program. This included accomplishing a paradigm
shift from simply treating and discharging soldiers to a comprehensive
program that includes holistically preparing Veterans for a successful
and productive future in the Army or as a private citizen. The
overarching goal is to help soldiers and veterans to heal physically
and mentally while building bridges to positive opportunities that lie
ahead for them in the future.
I, and the Army's other senior leaders, are absolutely committed to
doing anything and everything possible to help these soldiers at all
stages of care, even after they leave military service.
changing the army culture
Today, there is a wide range of programs and services available to
soldiers, veterans, Army civilians and family members who need
assistance. However, individuals are frequently reluctant to seek help.
We must change the culture of our Army. In the past, there has been a
stigma associated with seeking help from any kind of mental health
professional. Soldiers avoided seeking this type of assistance for fear
that it might adversely affect their careers. However, that is not the
case; and, we are taking the necessary steps to change this
misperception across the Army.
web-based behavioral health care services
Today, soldiers and family members can access behavioral health
care services online through the TRICARE Assistance Program (TRIAP).
The program is open to:
Active duty servicemembers
Members eligible for the Transition Assistance
Management Program (TAMP) for 6 months after demobilization
Members enrolled in TRICARE Reserve Select, as well as
spouses and family members 18+ years
Soldiers and family members can access unlimited short-term,
problem-solving counseling 24/7 with a licensed counselor from home or
any location with a computer, Internet, required software download, and
webcam. If more specialized medical care is deemed necessary, an
immediate warm handoff can/will be made to a medical provider.
In conjunction with TRIAP, the Army is working to build a network
of locations and online providers for telemental health services, using
medically-supervised, secure audio-visual conferencing to link
beneficiaries with offsite providers. Once in place, this Network will
be able to provide the full-range of behavioral health care services,
including psychotherapy and medication management. Our long-term goal
is to create a network of counselors and certified mental health care
providers that encompasses the entire United States. Then, when a
Brigade redeploys, for example, a gymnasium full of stations/computers
could be put in place allowing every leader and soldier to participate
in a behavioral health evaluation online upon redeploying.
From 28 Oct 09 to 18 Nov 09, Tripler Army Medical Center (TAMC),
Schofield Barracks, HI, conducted a Behavioral Health (BH) virtual
pilot study with soldiers returning from combat duty to determine
clinical efficiency of BH screening, comparing face-to-face versus
webcam versus VTC. A total of 450 soldiers from 25th Infantry Division
were screened. The results were very positive. Young soldiers indicated
an overwhelming preference for online counseling versus face-to-face.
The pilot conducted at TAMC validated the use of virtual BH
counseling for our returning/redeploying soldiers. In March 2010, we
conducted a similar pilot for an entire returning Brigade Combat Team
(4-25 IBCT) at Fort Richardson, AK. Similar satisfaction and increased
BH referral rates were appreciated; and, we are now implementing this
virtual BH technology at other locations anticipating returning units.
These previous efforts will allow us to enhance collaboration with the
DVA and hopefully expand this capability in the future to include
TRICARE network BH providers.
behavioral health care
The good news is that soldiers are seeking behavioral health care
in record numbers with over 236,000 behavioral health contacts in
fiscal year 2009, indicating that our efforts to emphasize the
importance of behavioral health are working. In particular, recent
mental health assessments conducted in theater have shown a marked
increase in the percentage of soldiers willing to seek mental health
care without undue concern that it will be perceived as a sign of
weakness or negatively impact their careers. This is because soldiers
recognize the importance of individual help-seeking behavior and
commanders realize the importance of intervention.
That said, we recognize that we must do more. We must eliminate the
longstanding, negative stigma associated with seeking and receiving
help. There is absolutely no reason for an individual to suffer when
help is available simply because he or she is afraid of how others will
react.
closing
In my 38-year career in the Army, I have never dealt with a more
difficult or critical mission than the current charge to reduce the
number of soldier suicides and properly diagnose and treat individuals
suffering from TBI, PTS, and other behavioral health issues.
Over the past year, our commitment to health promotion, risk
reduction and suicide prevention has changed Army policy, structure and
processes. We have realigned garrison programs, increased care provider
services, refocused deployment and redeployment integration, enhanced
treatment of PTS and TBI, and promoted tele-behavioral medicine. Our
success notwithstanding, we still have much more to do. We face an
Army-wide problem that can only be solved by the coordinated efforts of
our commanders, leaders, program managers and service providers.
This is a holistic problem with holistic solutions, and that's how
we are going to continue to approach it with this campaign.
Again, I can assure the esteemed members of this committee that
there is no greater priority for me and the other senior leaders of the
U.S. Army than the safety and well-being of our soldiers. The men and
women who wear the uniform of our Nation are the best in the world, and
we owe them and their families a tremendous debt of gratitude for their
service and for their many sacrifices.
Chairman, members of the committee, I thank you again for your
continued and generous support of the outstanding men and women of the
U.S. Army and their families. I look forward to your questions.
Chairman Levin. Thank you very much, General.
Admiral Greenert.
STATEMENT OF ADM JONATHAN W. GREENERT, USN, VICE CHIEF OF NAVAL
OPERATIONS, U.S. NAVY
Admiral Greenert. Thank you, sir.
Chairman Levin, Senator McCain, and distinguished members
of this committee, thank you for the opportunity to testify
about the ongoing efforts to prevent suicides in our Navy and
to discuss what has been referred to as the ``invisible wounds
of war''--namely, PTSD and TBI.
Each suicide is a tragic loss that can destroy families,
devastate a community, and impact unit cohesiveness and morale.
While the contributing factors of suicide are unique to each
person, a common thread is a personal perceived inability to
cope with stress.
Our focus of effort is to better understand the stressors
that sailors and their families face, and equip them with
positive methods to cope with stress. We want to foster
resilience in our sailors and their families, increase unit-
and family-level vigilance, and encourage early intervention
and care.
Our acronym, or our brand, in this, is ACT, A-C-T--to
``Ask'' about a shipmate, to ``Care'' for the shipmate, and to
help that shipmate get ``Treatment.'' A first step in this is
awareness and training of the providers, the sailors, and the
families. To that end, in fiscal year 2010, training workshops
for leaders, for first responders, and for suicide prevention
coordinators, has been conducted at 20 locations in 5
countries, with 5 more being planned for the end of the fiscal
year.
A new training video, called ``Suicide Prevention: A
Message from Survivors,'' was distributed, just this April.
Interactive training programs, such as front-line supervisor
training and peer-to-peer training, have been distributed,
aimed at strengthening a culture of support. We have trained
about 120,000 people, so far, in operational stress control.
A key in all of this is taking control of stressors. Stress
is a fact of life. We want to reframe the issue, in terms of
operational stress control, a comprehensive approach to address
the psychological health of sailors and their families amidst a
period of high operational tempo, a dynamic work environment,
and increased deployments. It's a program designed to be
implemented by leadership at all levels, providing them with
practical decisionmaking tools for sailors, for leaders, and
for families to build resilience and improve their awareness of
stress response, and to take every action to mitigate the
effects of stress as part of a healthy lifestyle.
Our sailors deployed to Iraq and Afghanistan face a dynamic
environment with unique experiences and a preponderance of
events that could manifest PTSD. Accordingly, we are focused on
preventing PTSD, building resilience, and eliminating barriers
or stigma associated with the treatment after deployment.
Prevention efforts include incorporating operational stress
control continuum and stress first-aid principles for all our
sailors, from basic training to flag officer development, Web-
based information resources, and Navy career courses. Our
Project FOCUS (Families Overcoming Under Stress) is an example
of a selected intervention for families responding to the
challenges of deployment and related stresses. It has reaped
tangible results, and it is being instituted DOD-wide.
The combat and operational stress first-aid training is
designed to guide our sailors, our leaders, and caregivers to
provide support in a manner designed to overcome the stigma of
requesting help.
While there are several injury patterns in theater, an
important area for all of us remains TBI. The diagnosis and
treatment of TBI is a top priority. There is still much we do
not know about the injuries and their long-term impacts on the
lives of our servicemembers. But, through a collaborative
effort with other Services, Defense Centers of Excellence,
Defense and Veterans Brain Injury Centers, the VA, and
academia, we are committed to a full assessment of blast
injuries, immediate attention to injuries, and ensuring at
every sailor affected subsequently receives the best medical
treatment available.
Surveillance for injuries across the deployment continuum
is essential to the early identification of TBI. Predeployment
screening, which will establish a baseline, monitoring and
treating, in situ, sailors involved in a blast event, and
instituting tracking mechanisms for followup care are key
elements.
I want to thank you for your attention and commitment to
the critical issue of suicide prevention, and your interest in
the best possible care for the silent injuries of war: PTSD and
TBI. By teaching sailors to navigate stress, our Navy will make
our force more resilient. By assisting in treating those with
TBI and PTSD, we could eliminate a potential cause of
depression and suicidal behavior.
Our Navy is committed to a culture that fosters individual,
family, and command resilience and well-being. We honor the
sacrifice and the service of our members and their families,
and we will do everything possible to support our sailors so
that they recognize that their lives are truly valued and truly
worth living.
On behalf of the men and women of the U.S. Navy and their
families, thank you for your attention and commitment to these
issues. I look forward to your questions.
[The prepared statement of Admiral Greenert follows:]
Prepared Statement by ADM Jonathan W. Greenert, USN
Chairman Levin, Senator McCain, and distinguished members of this
committee, I would like to thank you for this opportunity to discuss
our efforts to prevent suicides and the treatment of traumatic brain
injury and post-traumatic stress.
Suicide loss destroys families, devastates communities, and
unravels the cohesive social fabric and morale inside our commands.
Navy has worked at multiple levels to understand and appreciate the
unique factors that contribute to each loss, and at the same time
recognize and foster the common factors of the organization and
environment that help keep people on a path to life.
what we know
In calendar year 2009, 46 Active Duty sailors and 6 Selected
Reserve sailors took their lives. This translates to an annual suicide
rate of 13.3 per 100,000. From January through May 2010, there have
been 13 suspected Active Duty suicides, compared to 20 through May in
2009; there are 3 suspected Selected Reserve suicides, compared to 2
through May in 2009.
Since 1993, Navy suicide rates per 100,000 have ranged from 17.3 in
1995, to 9.7 in 2005, with an average of 11.6.
Numbers and rates alone do not describe the entire situation nor
reveal all the lessons learned to save lives. Each suicide and each
suicide attempt is investigated. Further a DOD Suicide Event Report,
and other documents, provides the means to gather case data for
qualitative and quantitative analysis. Lessons learned are integrated
into the education and training continuum, communications plans and
policy changes. Demographic factors, such as age, time-in-service, pay
grade, and ethnic background have thus far revealed little regarding
suicide risk; Navy's demographic distribution of suicides largely
mirrors population demographics. Analyses conducted on deployment cycle
status, recent deployments, boots-on-ground deployment, and
``individual augmentee'' status are a relatively proportional to
suicides among sailors who had deployed (Center for Naval Analysis May
2010, CNO Executive Panel (CEP) 2010). A deployment experience may
influence the sequence of events to suicide in some individual cases.
But, as a whole, deployment history does not appear to affect suicide
risk.
Consistent with the last 10 years of analysis, sailors who commit
suicide tend to have multiple stressors (DONSIR Technical Report,
DODSER). Recent analysis suggests that as many as half of those who
committed suicide had transition-related factors, such as: change of
duty station, deployments, temporary duty or an upcoming separation
from active duty or retirement (CEP Study: 2010). Periods of duty
station transition introduce stress, may interrupt social support
systems, and could result in leadership and organizational systems
being less available to see some signs of change in a sailor.
Coincident with their decision to act, many sailors who commit suicide
had factors or were in situations that affected their judgment:
including alcohol, anger, high emotion, and/or sleep disruption. We are
working closely to analyze and understand how work load, operational
tempo and organizational (unit) factors may contribute to sleep deficit
and how sleep deficit may link to suicide.
The 2008 DOD Health Related Behaviors Survey reported that 5
percent of sailors surveyed had seriously considered suicide in the
past 12 months. Although that might be a generalization, using the
force level at that time (340,000), this translates to as many as
17,000 sailors contemplating suicide in a year. Since the long-term
annual average of sailors who have died of suicide is 40, it is clear
that the vast majority of sailors who consider suicide ultimately chose
a path to life. Factors such as resilience, leadership, peer
engagement, family bonds, support services, and a sense of purpose can
compel sailors to not choose suicide.
our approach
Potential solutions to suicide must enhance our ability, as a
community, to influence one to choose a path of life. That includes the
ability to recover from traumatic change or misfortune and regain
physical and emotional stamina. The center of gravity of our policy and
practice is the combination of resilience of sailors and their
families, the command's awareness and intervention. We consider it a
core responsibility to educate, build a resilient force, and provide an
environment in which sailors and families can thrive in the face of
dynamic and demanding operations. It is incumbent on every leader to
build trust and unit cohesion at the command level, and provide a clear
sense of mission and meaning to what our sailors do. Additionally,
leaders must identify and assist those faced with significant outside
stressors, to include relationships, financial and legal matters,
health and mental health issues, and depression. All of these are
similar to issues that affect suicide rates in the general U.S.
population.
what we've done
Navy's suicide prevention efforts focus on leadership, education,
and awareness. Prevention efforts in the past year have provided policy
guidance, training, tools, and communication to enable local command
suicide prevention programs, and strengthen a network of command
suicide prevention coordinators. Chief of Naval Operations instruction
(OPNAVINST) 1720.4A, published 4 August 2009, provides updated policy
for Navy suicide prevention programs centered on local command programs
supported by a designated suicide prevention coordinator, responsible
for support of training, intervention, reporting, and response. In
fiscal year 2010, training workshops for leaders, first responders, and
suicide prevention coordinators have been conducted at 20 locations in
5 countries, with 5 more planned by the end of the fiscal year. A new
training video, ``Suicide Prevention: A Message from Survivors'' was
distributed in April 2010. Interactive training options such as ``Front
Line Supervisor Training'' and ``Peer-to-Peer Training'' which include
skill-building exercises, based on scenarios and role play, have
further enhanced the command toolkit. Community-specific outreach
workshops and leadership briefs were provided, upon request, to
Reserve, Recruiter, and Supply Corps audiences.
Navy continues a robust communications plan about suicide
awareness, promoting the core message: ``Life Counts!'' A dedicated
website (www.suicide.navy.mil), poster series, brochures, videos,
leadership messages and newsletters communicate Navy's message on
suicide prevention. Expanded communications have included quarterly
update messages, public service announcements, and efforts to engage
sailors in creating innovative options such as our poster contest, in
which sailors designed the entries and chose the winner with online
voting. Providing families with information about risk factors, warning
signs, and support resources has also been a top priority since
families are the most likely the first to observe sailor distress.
Our program, ``Operational Stress Control (OSC)'', is an
increasingly integrated structure of promoting health, family
preparedness/resilience, and stress prevention. It is aimed at building
resilience and proactively addressing chronic problems before they
become acute. OSC \1\ addresses the psychological health needs of
sailors and their families; it is implemented by operational leadership
and supported by the naval medical community. OSC provides practical
decisionmaking tools for sailors, leaders, and families, developing
their abilities to identify stress responses and mitigate tension. By
addressing problems early, most individuals should be able to mitigate
the effects of personal turmoil and acquire the necessary help when
professional counseling or treatment warrants. The Stress Continuum \2\
is an evidence-informed model that highlights the shared responsibility
of sailors, families, leadership, and caregivers for maintaining
optimum psychological health. This model has been integrated into our
behavioral health communications to the Fleet. It includes suicide
awareness, substance abuse, navigating stress, and leader skills. This
past year has seen the introduction of a formal OSC curriculum for
sailors ``from boot camp through War College'', as well as for their
families. Within a few months, a 1-day, facilitated, skills-based
course will be available.
---------------------------------------------------------------------------
\1\ NAVADMIN 332/08 dated 21 November 08 established the Navy's
Operational Stress Control program.
\2\ The Navy and Marine Corps utilize the Stress Continuum Model.
Historically, Navy viewed those under stress as either fit or unfit
whereas now we understand four distinct stages of stress responses:
Ready (Green), Reacting (Yellow), Injured (Orange) or Ill (Red). This
model is used to recognize and intervene when early indicators of
stress reactions or injuries are present before an individual develops
a stress illness, such as PTSD or depression.
---------------------------------------------------------------------------
Recognition of stress related behavior must be followed by
effective action. We have developed a stress first-aid intervention to
recognize when a shipmate is in trouble, called Combat and Operational
Stress First Aid (COSFA). It is being taught to all sailors, to
intervene and engage that shipmate, and to connect that shipmate to the
next level of leader and caregiver support. The advantage of this
integrated approach is that we are training our sailors to look beyond
stereotypical warning signs, and to recognize changes in behavior and
initiate helpful actions to save lives, preclude further injury, and
promote personal growth.
The Chief of Naval Operations (CNO) directed the establishment of
the Navy Preparedness Alliance (NPA), represented by Chief of Navy
Personnel, Commander U.S.. Fleet Forces, Surgeon General, Commander
Navy Installations Command, and Chief of Navy Reserve, Chief of
Chaplains, and Master Chief Petty Office of the Navy to address a
continuum of care covering all aspects of individual medical, physical,
psychological, spiritual and family readiness across the Navy. The
``alliance'' has proven valuable in examining the tough readiness
issues that cross stakeholder boundaries and making informed decisions
on identified issues. For example, acting on the advice of the
``alliance,'' Navy placed a limitation on tour lengths for personnel
assigned to overseas detainee operations, based upon a review of the
results of the Behavioral Health Needs Assessment Survey (BHNAS) (a
battery of anonymous self-reports to evaluate psychological well-
being). The Chief of Naval Personnel chairs the NPA and routinely
reports its findings directly to the CNO. Navy's integrated approach
continues to rely on leadership monitoring a variety of indicators of
the ``tone of the force,'' including a comprehensive quarterly review
of personal and family readiness/preparedness metrics and trends,
various family readiness polls, and focus groups.
Support structures and intervention mechanisms initiated in the
last few years have become more integrated and effective. ``Navy Safe
Harbor'' \3\ continues its mission to provide nonmedical support for
all seriously wounded, ill, and injured sailors, and their families,
with Recovery Care Coordinators and Nonmedical Care Managers covering
17 locations. The Navy Reserve Psychological Health Outreach (RPHO)
Program, implemented in fiscal year 2008, provides two RPHO
Coordinators and three Outreach team members (all licensed clinical
social workers) to each Navy Reserve Region (five regions) for mental
health support. The RPHO teams engage in active outreach, clinical
assessment, referral to care, and follow-up services to ensure the
mental health and well-being of Reserve sailors and have been actively
involved in extending tracking and intervention for suicide related
behaviors in our Reserve community.
---------------------------------------------------------------------------
\3\ Safe Harbor is a Navy program, established in 2005, for the
non-medical care management of severely wounded, ill, or injured
sailors and their families. Safe Harbor sailors have had no suicides.
---------------------------------------------------------------------------
what is working
The 2009 Behavioral Health Quick Poll provided a baseline
assessment of our suicide prevention and OSC awareness and attitudes.
This annual poll will be repeated over the next few months to examine
changes over time. The 2009 poll indicated that 83 percent of sailors
polled reported receiving required annual training, and 86 percent of
sailors polled expressed confidence that they know what to do if
someone talks about suicide or shows warning signs. Over 84 percent of
enlisted sailors polled and 94 percent of officers polled believed an
at-risk sailor would get needed help. However, several perceived that
pursuing treatment would result in some negative impact to their
careers such as loss of security clearance, or that the individual
would be treated differently by their peers in the unit. These polls
have shaped our actions to foster new attitudes and habits, to
encourage early use of support resources and to provide viable paths to
unit reintegration and continued Navy service.
what we've learned
There is no conclusive evidence that suicide awareness efforts
alone reduce suicide rates. Evidence does support the effectiveness of
comprehensive approaches that include stress reduction, suicide
awareness, intervention skills, community building, leadership
engagement, and access to quality treatment. Communities engaged in
workshop training in 2008-2009 experienced relatively stable or
declining suicide numbers during this period. A rise in Navy's suicide
rate in 2009 was, in part, attributable to shore and training units
that were not systematically included in or utilizing comprehensive
training workshops, until 2010.
where we're going
Initiatives and areas of expanded focus for fiscal year 2011
include: providing one-day training workshops for Navy mental health
providers to improve skills in assessing and managing suicide risk;
articulation of policies and best-practices regarding communication
between commands and medical providers related to suicide assessments
and follow-up care; better communication processes for access to
support services for civilian personnel; continuing to implement OSC;
assessing tangible effectiveness of training efforts; expanding post-
intervention support for those affected by suicide loss; and
researching the means to measure organizational strain in terms of the
ratio of mission demands to end-strength resources, and how to reduce
or mitigate strain effects.
post-traumatic stress (pts)
What we know
Combat stress affects each sailor uniquely, falling along a
physical and emotional stress continuum ranging from stress reactions
to stress injuries and disorders, to include Acute Stress Disorder and
Post-Traumatic Stress Disorder. Early identification of symptoms
enables supervisors and unit leaders to aggressively intervene to
preclude stress reactions and injuries from becoming stress disorders.
Navy has channeled our psychological health-related efforts within the
domains of: reducing stigma through culture change, psychological
health promotion, surveillance, and clinical care.
What we've done
Culture Change:
Using a partnership of Navy line officers and clinicians/
caregivers, Department of the Navy embarked on developing a Maritime
Combat and Operational Stress Control doctrine that creates a new way
of thinking and talking about the effects of psychological demands on
our sailors, marines, and their families. This joint leader and
caregiver effort created the stress continuum model that provides a
color-coded paradigm for recognizing and communicating about stress
injury behaviors. This model has been integrated into our behavioral
health communications that include: suicide awareness, substance abuse,
stress management, and leader skills.
Psychological Health Promotion:
Psychological health promotion efforts are based on the Institutes
of Medicine three levels of prevention: universal, selected, and
indicated. Selected prevention efforts includes stress resilience
training in operational training, suicide and substance use awareness
training and leader after action reviews following critical events.
Project FOCUS (Families Over-Coming Under Stress) is an example of a
selected intervention for families responding to the challenges of
deployment. Indicated prevention efforts are those that provide
critical interventions for those who show stress injury behaviors. The
combat and operational stress first aid training is designed to guide
sailors, leaders, and caregivers to provide early non-stigmatizing
support.
Surveillance:
Navy medicine implemented an aggressive in-theater surveillance
program combining on-site mental health leadership consultation and
care through the Mobile Care Teams (MCT)--a small team of industrial/
organizational psychologists supported by a clinical mental health
provider. In conjunction with the consultation and care services, the
MCT executed the fourth installment of BHNAS. The BHNAS is the most
comprehensive in-theater mental health assessment conducted by the U.S.
Navy and provides data relative to critical mental health indices (PTS,
Depression, Anxiety, Morale, Suicide-Risk, and TBI) as well as
organizational variables (e.g., living conditions, leadership, unit
cohesion, family relationships). Data collection for BHNAS IV recently
concluded in Afghanistan and Kuwait and consisted of over 1,000 sailor
surveys. Analysis is ongoing.
Post-Deployment Health Assessments (PDHA) and Post-Deployment
Health Reassessments (PDHRA) are also utilized to assess the mental
health of our sailors. Current efforts are underway to expand the
Mental Health Assessment aspect of these tools to continue surveillance
for 2 years after redeployment.
Clinical Care: Beginning in 2007, Navy Medicine established
Deployment Health Centers (DHCs) as nonstigmatizing portals of care for
servicemembers staffed with primary care and psychological health
providers. We now have 17 DHCs operational. Our health care delivery
model supports early recognition and treatment of deployment-related
stress reactions and injuries within the primary care setting, enabling
early and effective interventions to reduce occurrence of post-
traumatic stress disorder and other mental health conditions.
Navy Medicine emphasizes the importance of evidence-based
treatments when caring for our wounded sailors and marines with post-
traumatic stress disorder. The Navy Center for Combat Operational
Stress Control (NCCOSC) has developed the Psychological Health Pathways
program and is currently pilot testing this program at Naval Medical
Center San Diego, Naval Hospital Camp Pendleton, and Naval Hospital
Twentynine Palms. The program is designed to track all patients
diagnosed with PTSD to ensure that clinical practice guidelines are
followed and evidence-based care is provided to each patient. It
involves aggressive mental health case management, standardized
measures, provider training and comprehensive data tracking.
What we've learned
Command and shipmate intervention can help prevent stress reactions
and injuries from developing into stress disorders such as post-
traumatic stress disorder, depression, and other mental health
conditions that could potentially lead to suicidal behavior. Navy's
broad array of prevention, early intervention, and treatment programs
serves to empower shipmates, supervisors, and leaders to identify
stress symptoms early in the reintegration process and get them the
level of support they need.
Where we're going
Navy is constantly assessing the effectiveness of current programs,
with a priority on increasing access to evidence-based programs with
proven outcomes. Research efforts are underway to build on the rapidly
growing body of knowledge regarding the innovative prevention and
treatment of stress disorders in military populations.
Navy Medicine is actively engaged in ongoing efforts with the
Department of Veterans Affairs (VA) and the other Services to implement
the Integrated Strategy for Mental Health. The goal of this effort is
to collaborate and coordinate across departments to develop a
population based continuum of care.
traumatic brain injury
What we know
While there are many significant injury patterns in theater, an
important focus area remains Traumatic Brain Injury (TBI). Blast is the
signature source of injury of Operation Enduring Freedom and Operation
Iraqi Freedom, and blast injury often causes TBI. Sailors are deployed
in support of operations in Iraq and Afghanistan and, accordingly,
treatment of TBI is a priority for Navy. The majority of TBI injuries
are categorized as mild--a concussion. There is much we do not know
about these injuries and their long-term impacts on the lives of our
service members.
What we've done
Education of sailors and medical personnel about the early
identification and treatment of TBI is critical to the successful
recovery. Navy medicine is addressing this issue by providing TBI
training to health care providers from multiple disciplines throughout
the fleet. This training is designed to educate personnel about TBI/
concussion, ensure all medical personnel are familiar with tools used
to assist in diagnosis of TBI, and to review guidelines for the
treatment of TBI.
Navy Medicine, in partnership with the Center for Deployment
Psychology at the Uniformed Services University, is providing hands-on
training on TBI/Concussion management and the Military Acute Concussion
Evaluation, an in-theater screening test for possible TBI. Initial
training has been provided to 688 medical officers, physician
assistants, and Hospital Corpsmen. Plans are underway to expand this
training.
Surveillance for injuries across the pre and post deployment
continuum is essential to early identification of TBI. Pre-deployment
screening with the Automated Neurological Assessment Metrics (ANAM)
establishes a baseline, and enables identification of individuals with
conditions that should preclude deployment. Navy has implemented ANAM
testing with targeted testing of the highest risk communities,
including: Navy Military Construction Battalions, Explosive Ordnance
Detachments, and Weapons Intelligence Units.
The Navy is standardizing a model for treatment of injured service
members with Traumatic Brain Injury/Concussion and will implement it
across the Navy Medicine enterprise. The multidisciplinary model will
be primary care based with active case management to ensure
coordination of care. Experts in treatment of TBI are available to all
individuals with TBI that need care beyond what can be provided in Navy
Primary Care.
We are employing a strategy that is both collaborative and
integrative by actively partnering with the other Services, Defense
Center of Excellence for Psychological Health and Traumatic Brain
Injury, Defense and Veterans Brain Injury Center (DVBIC), the VA, and
leading academic medical and research centers to make the best care
available to our wounded, ill and injured afflicted with TBI.
What we've learned
In order to detect TBI cases earlier, event-based reporting is
required to ensure that all at risk individuals receive proper
evaluation. Additionally, we have learned that there are other tools
available to help diagnose TBI that may be more effective than the
ANAM. Navy will continue to explore new ways to identify individuals
with TBI so that they can receive the care they need.
Where we are going
Navy Medicine is working with the Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury and the DVBIC, as well
as the other Services, to ensure we have a comprehensive TBI
surveillance program in place for the identification and early
management of TBI cases in theater. This process again emphasizes the
importance of collaboration between line and medical leaders. The new
in-theater TBI surveillance process will be based upon incident event
tracking and will require that leaders send all service members with
suspected concussions and those exposed within a set radius of an
explosive blast to medical for evaluation. This process will cast a
wider net to further ensure individuals with TBI are identified early.
Navy Medicine is also working to establish TBI Restoration Centers
in theater, where servicemembers can receive assessment and short-term
treatment from a team consisting of a psychologist, physical therapist,
occupational therapist, and a sports medicine trained family physician.
conclusion
On behalf of the men and women of the U.S. Navy, I thank you for
your attention and commitment to the critical issue of suicide
prevention and in your interest in the best possible care for the
silent injuries of war: PTS and TBI. By teaching sailors to navigate
stress, Navy will make our force more resilient. By assisting and
treating those with TBI and PTS, we could eliminate a potential cause
of depression and suicidal behavior. Navy is committed to a culture
that fosters individual, family, and command resilience and well-being.
We honor the service and sacrifice of our members and their families,
and we will do everything possible to support our sailors, so that they
recognize that their lives are truly valued and truly worth living.
Chairman Levin. Thank you so much, Admiral.
General Amos.
STATEMENT OF GEN. JAMES F. AMOS, USMC, ASSISTANT COMMANDANT,
U.S. MARINE CORPS
General Amos. Thank you, Chairman Levin and distinguished
members of the committee, for inviting me here today to discuss
the issues of suicide, TBI, and PTSD.
On behalf of the more than 240,000 Active and Reserve
marines and their families, I'd like to extend my appreciation
for the sustained support Congress has faithfully provided its
Marine Corps.
As we begin this hearing, I would like to highlight a few
points from my written statement:
You have rightfully focused on three of the most difficult
challenges facing the Marine Corps today. Let me assure you
that the leadership of the Marine Corps recognizes the
seriousness of the challenges we face with TBI, PTSD, and
suicide, and we are doing all that we can to prepare and to
protect our young men and women.
We have learned much in the last several years about the
effects of concussive events and combat stress on our marines
that we just simply did not know several years earlier in this
long war. With the knowledge we have gained, we have made
progress in training to develop resiliency in diagnosing and
treating TBI and PTS, and at educating our marines to prevent
suicides.
We also realize that we have much more to do. With the
benefit of research coordinated by organizations such as the
Defense Centers of Excellence for Psychological Health and TBI,
we will continue to improve our diagnostic tools and treatment
for these injuries.
The tragic loss of a single marine to suicide is deeply
felt by all of us who remain behind. We have experienced about
the same number or suicides this year as we had last year at
this same time. We recognize that our considerable efforts to
prevent suicides must continue if we are to turn the trend of
the last few years around.
We are building on the noncommissioned officer (NCO)
training program that we launched, late last year, to reach the
rest of our Marine Corps. We continue to examine each suicide
carefully and forensically, and disseminate the lessons learned
from that across all Marine Corps leadership.
I have personally been involved, along with General
Chiarelli, USA, in the development of theater guidelines for
the detection and treatment of mild TBI. The newly established
concussive protocol and regulations we have in place for
marines deployed in Afghanistan are squarely aimed at the
leaders and medical personnel, all in an attempt to further
care for our wounded marines and sailors. It will ensure that
those exposed to concussive events will be properly diagnosed
and receive immediate attention, and that this information will
have been properly recorded for future reference. The long-term
objective of this protocol is to reduce the chances that a
marine or sailor will suffer the effects of a blast injury at
some later date, perhaps even years later.
PTSD is a real injury that is often difficult to diagnose.
Many marines are reluctant to recognize the fact that they are
injured, and even more reluctant to come forward. Our efforts
to reduce this injury begin early on in our training regimen,
by training marines to be more resilient to the stresses of
combat. We have embedded mental health professionals in our
combat units to reduce the stigma and the barriers to seeking
help. We are exploring new ways to ensure that marines have
access to care, including the establishment of a new crisis
hotline aimed at marines, for marines and their families.
Partnering with the medical community, we are committed, as
a Corps, to making sure every marine struggling with stress
gets the support and, if needed, the treatment they need. While
there is no single answer that will solve the challenges of
rising suicides, TBI, and PTSD, we are committed to exploring
every potential solution and using every resource we have
available. We will not rest until we have turned this around.
Thank you again for your concern on these very important
issues. I thank each of you for your faithfulness to our Nation
and your confidence in the leadership and commitment of your
Marine Corps.
I request that my written testimony be accepted for the
record. I look forward to your questions.
[The prepared statement of General Amos follows:]
Prepared Statement by Gen. James F. Amos, USMC
Chairman Levin, Senator McCain, and distinguished members of the
committee; on behalf of your Marine Corps, I would like to thank you
for inviting me here today to discuss the issues of suicide, traumatic
brain injury (TBI), and post-traumatic stress (PTS). We are grateful
for your continued generous and faithful support and for your attention
to these critical issues.
suicide
With every suicide case there is a unique life to understand. As a
matter of practice, I am fully briefed on each and every suicide and
believe that suicide prevention is a leadership issue. We are certain
of this: there is no single answer that will prevent suicides, and
solutions must include initiatives that approach the problem from
multiple angles and from multiple disciplines.
Central to our efforts, we are educating all marines to be focused
on this fight. Whenever a Marine is in distress, whether due to a
relationship problem, mental illness, financial crisis or combat
experience, it is the responsibility of all marines to get that Marine
to help. We are working hard to eliminate the stigma that deters some
marines from seeking care.
Whether our total suicide numbers trend higher or lower, one
suicide is still one too many. The Commandant and I, along with other
Marine Corps leaders, remain actively engaged in this fight.
understanding the statistics
Between 2001 and 2007, the number of suicides in the Marine Corps
fluctuated between 23 and 34, but in the past 2\1/2\ years we have seen
a disturbing increase. From a recent low point of 25 suicides in 2006,
the number increased to 33 in 2007, 42 in 2008, and 52 in 2009. This
year, from January 1, 2010 through June 8, another 21 Marines have died
by suicide, which the exact same number of suicides that we had last
year through the 8th of June. Our suicide rate in 2009 was 24.0
suicides per 100,000 marines, which exceeded the national civilian rate
of 20.0 per 100,000 when adjusted to match the demographics of the
Marine Corps. Attempted suicides have also increased from 103 attempts
in 2007, to 146 in 2008, and to 164 in 2009. Through June 8 of this
year, 89 marines have attempted suicide. This is an increase from the
same time last year.
Marines who attempt suicide resemble our institutional
demographics: Caucasian male, 17-25 years old, and between the ranks of
Private and Sergeant (E1-E5). As with suicides, reported risk factors
and stressors for suicide attempts also center on mental health issues
and relationship problems.
Based on our ongoing assessment, we are also concerned that our
current surveillance and investigative procedures may be missing
qualitative data from the final 72 hours prior to a marine's death. As
a result, we are exploring a forensic psychological autopsy study to
more fully understand the detailed processes that lead to a marine
suicide, which we hope will further inform points at which intervention
may prevent another tragedy from occurring.
Additional analysis is being conducted to assess the impact that
operational deployments may have on suicide rates. To date, this data
suggests that while the continuing stress resulting from overall
operational tempo may be a factor in our increasing suicide rate, there
does not appear to be a difference in suicide risk resulting from
deployment history. Our analyses also suggest that there is no specific
time period post deployment that is associated with increased risk of
suicide for marines.
suicide reporting
We review and investigate all non-hostile casualty reports daily to
track both suicides and suicide attempts and we coordinate weekly with
the Armed Forces Institute of Pathology, who is the final arbiter on
the manner of death for the Marine Corps. When a suspected suicide or
attempt is reported, our Suicide Prevention Program Office makes
contact with the local command to verify the report and facilitate
their completion of the Department of Defense Suicide Event Report
(DODSER). This surveillance tool is standardized for use by all
Services. Along with the other Services, we initiated use of the DODSER
in January 2008 for suicides, and in December 2009, we began using it
for all suicide attempts. We believe that the standard operating
procedures put into place for reporting suicide attempts will
facilitate a richer dialogue between medical personnel and marine
leadership.
After each suicide, we do an extensive review of the factors
leading up to the suicide. We seek information from leaders, co-
workers, friends, and medical personnel. We do not require information
from family members so as not to burden the family at a time of such
tragic loss and grief, but include it when available in such a manner
that will not compound their loss.
In November 2009, I directed all Commanding Generals to personally
receive investigative information on all suicides under their command
and to report those deaths directly to me. Lessons learned identified
in these reviews are analyzed and selected for inclusion in a monthly
report that is sent to all Marine Corps General Officers, Senior
Executive Service civilians, and Sergeants Major across the Marine
Corps.
suicide prevention efforts
Training
We have learned that peer to peer leadership is essential and our
gradually increasing understanding of this problem over the last 5
years led directly to the creation of the Non-Commissioned Officer
(NCO) suicide prevention course, ``Never Leave a Marine Behind.'' The
course was developed with a targeted process approach to ensure it was
reality-based, relevant for and about NCO marines. Despite NCOs and the
marines they lead making up about 75 percent of the Marine Corps, that
group of Marines has accounted for up to 93 percent of marine suicides.
Since the implementation of the course, they now account for 81 percent
of marine suicides. We have directed the development of similarly
targeted courses for our youngest marines (private to lance corporal),
staff-NCOs and officers.
In addition to targeted training approaches, prevention is
incorporated into our formal education and training at all levels of
professional development and throughout a Marine's career; from recruit
training in boot camp and new officer training in The Basic School, to
the Sergeants Major Symposium and the Commanders Course for senior
leaders. Training is continuously evaluated and revised to reflect the
best practice as science knows it today. It is also taught using
warrior metaphors in the Marine Corps Martial Arts Program, in which
every Marine participates.
Partnerships
The complex nature of suicide requires an important balance between
immediate action and long-term thinking. We are fully engaged in
research efforts with both Federal and civilian partners to fill in the
gaps in our understanding and continue to guide our prevention efforts.
We continue to coordinate our suicide prevention efforts with other
experts from across the Federal Government, civilian organizations, and
with international military partners. Some specific examples include:
The Secretary of the Navy authorized $10 million to
fund the Marine Corps' participation in the Army's ground
breaking study with the National Institute for Mental Health
(NIMH) called the ``Study to Assess Risk and Resilience in
Servicemembers'' (STARRS). The Marine Corps and NIMH program
managers are currently developing the procedures that will
guide the study. The Army STARRS team is providing their full
and complete support as we join this unprecedented 5-year
longitudinal study on modifiable risk and protective factors
related to mental health, suicide and resilience. The study has
been specifically designed to return timely information to
Marine Corps leadership to inform our evolving prevention
strategies and is likely to inform our suicide prevention
program this year and for many years to come.
We actively participate as a member of the DOD Suicide
Prevention and Risk Reduction Committee (SPARRC), meeting
monthly with our DOD and Veterans Affairs (VA) partners to join
efforts in reducing suicides.
The Marine Corps also chairs the International
Association of Suicide Prevention Task Force on Defense and
Police Forces. This Task Force includes membership from 15
different countries working together to share best practices
and develop effective suicide prevention programs, building on
shared unique experiences in military culture that crosses
national boundaries.
traumatic brain injury and post-traumatic stress
Traumatic Brain Injury (TBI)
Naval medicine remains at the forefront of researching and
implementing pioneering techniques to treat TBI. The Marine Corps is an
active partner with the medical experts within and outside the
Department of Defense in continuing to advocate for innovative research
and best practice dissemination to improve the lives of our marines. We
are complying fully with the DOD directive for each deploying marine to
complete the Automated Neuropsychological Assessment Metrics test prior
to deployment. Along with the Vice Chief of the Army, I have personally
been involved in the development of theater guidelines for the
detection and treatment of TBI. These departmental level guidelines are
aimed at Leaders as well as medical personnel and will ensure that
marines who are exposed to potentially concussive events will have this
information recorded for future reference as well as removing the onus
from the individual to self identify to receive a medical evaluation.
We have put into effect this new protocol for concussive events
that will improve our ability to diagnose, track, and treat marines and
sailors who may suffer mild TBI. This protocol requires all personnel
in proximity to the blast event to be screened by medical personnel to
better identify those that might have suffered a concussion. Those that
show signs of a concussion are required to rest and are treated and
evaluated prior to being returned to duty. The protocol takes into
account the severity of the injury as well as whether this is the
marine's first concussive event or if he has been subject to previous
events. This new protocol will result in better diagnosis,
recordkeeping, and treatment of marines and sailors at the time of the
injury, which in turn will reduce the chances that the marine or sailor
will suffer effects of the injury at some later date.
Post-Traumatic Stress (PTS)
We are attentive to the mental health of our warriors and we are
dedicated to ensuring that all marines and family members who bear the
invisible wounds caused by stress receive the best help possible. We
developed the Combat Operational Stress Control (COSC) program to
prevent, identify, and holistically treat mental injuries caused by
combat or other operations. Again partnering with the medical community
we are committed as a Corps to making sure every marine struggling with
a stress issue gets the support and if needed, treatment, they need.
Resiliency Training
We have taken steps in our pre-deployment training to improve our
marines' resiliency and give them the tools to deal with the stresses
of combat. Realistic training prepares our deploying marines by
simulating as closely as possible the sights, sounds, smells, and
sensations of combat. Our Infantry Immersive Trainer at Camp Pendleton,
CA, is a state-of-the-art facility that seeks to give the experience of
combat to our marines in training. We are expanding this capability by
establishing other immersive trainers at locations such as Camp
Lejeune, NC.
Combat and Operational Stress Control Program
The COSC program is a program through which Marines and leaders are
trained to prevent, detect, and manage stress problems in marines as
early as possible. COSC provides leaders with the resources to
intervene and manage these stress problems in theater or at home.
Collaboration between warfighters in the Marine Expeditionary Forces,
Navy Medicine, and Navy Chaplains resulted in the Combat Stress
Continuum Model. This tool facilitates the identification of distress
in marines and offers a decision tree to guide leaders' responses.
To assist with prevention, rapid identification, and effective
treatment of combat operational stress, we have expanded our program of
embedding active duty Navy mental health professionals in operational
units--the Operational Stress Control and Readiness (OSCAR) Program--to
directly support all Active and Reserve ground combat elements in
theater. We are extending OSCAR capabilities down to all of our
infantry battalions and companies by providing additional training to
doctors and corpsmen, chaplains, and selected leaders within each unit
to make expertise more immediately available, and to decrease stigma
through building relationships.
conclusion
Suicides are a loss that we simply cannot accept. Leaders at all
levels are personally involved in efforts to address and prevent future
tragedies. Taking care of marines is fundamental to our ethos and
serves as the foundation of our resolve to do whatever it takes to help
those in need at every possible juncture whether it be suicide
prevention, documenting and tracking concussive events, and assisting
those with PTSD and combat operational stress. We are aggressively
acting to increase our prevention activities and follow-on care in
these areas. The further left of an incident is our best opportunity to
save lives by connecting Marines to needed help and mentorship.
Likewise, TBI and PTS are very real injuries that must be diagnosed,
recorded, and treated. We have taken concrete steps to do just that and
will continue our efforts to build resilience and reduce the stigma of
seeking help for these wounds. Thank you again for your concern on
these very important issues.
Chairman Levin. Thank you, General.
The testimony of all of our witnesses will be made part of
the record, and we thank you for that.
General Chandler.
STATEMENT OF GEN. CARROL H. CHANDLER, USAF, VICE CHIEF OF
STAFF, U.S. AIR FORCE
General Chandler. Thank you, Mr. Chairman, distinguished
members of the committee. Thank you for the opportunity to
address suicides in the Air Force, as well as the detection and
care of our airmen suffering from PTSD and TBI.
The Air Force is strongly committed to the physical,
emotional, and mental health of our airmen. We appreciate the
linkage between health of the force and mission readiness. The
number of airmen taking their own lives has been rising,
despite our commitment to prevention. Similarly, PTSD is an
area of increasing concern. Finally, our ability to detect and
treat TBI continues to be challenging.
The mental state of individuals contemplating suicide, and
the actual condition suffering PTSD and TBI, are similar, in
that they often do not manifest themselves in visible ways. The
Air Force suicide rate recently reached slightly more than 14
suicides per 100,000 total-force airmen. Nearly two-thirds were
not receiving assistance from mental health professional,
despite concerted effort to reverse a long-held bias against
seeking mental health assistance.
While no segment of the Air Force is immune to suicide,
there are known high-risk populations and known common risk
factors, like relationship problems, legal issues, financial
troubles, and the history of mental health diagnosis. The Air
Force recognizes suicide as a public health concern that
requires active and persistent involvement from commanders,
supervisors, and peers, often referred to as ``wingmen,'' at
all levels of the organization. Their increased involvement is
made easier and more effective through more available
professional counseling service and focused training. All part
of our improved resiliency program.
The Air Force initiated the Total Force Resiliency Program
in February of this year to holistically address the root
causes of suicide. The Air Force program reflects a broadbased
approach to supporting airmen and their families, recognizing
that physical, mental, and emotional health are critical to the
quality of life and readiness of the force.
Airmen Resiliency Programs and the Air Force Suicide
Prevention Program are complementary efforts that rely on
leadership and engagement, immediate family involvement, and
wingmen support are key components. In May, the Air Force Chief
of Staff directed a servicewide Wingman Day to reinforce the
significance and role of every airman as mutually-supportive
critical components in suicide prevention and resilience. There
is no substitute for airmen knowing their subordinates, and
their coworkers well enough to recognize changes in attitude,
behavior, and personality, and then intervening when something
is not right.
Part and parcel of these programs is an effort to expand
the availability of professional counseling. The Community
Action Information Board, which provides a forum for cross-
organizational review and resolution of individual, family,
installation, and community issues, is now chaired by me, the
Air Force Vice Chief of Staff, to provide adequate oversight,
in light of our increasing suicide rates. Also, professional
counseling is available, now more than ever, through primary
care clinics, the Airmen Family Readiness Centers, and through
DOD's Military OneSource Referrals for confidential no-cost
counseling. Complementing this increased capacity are training
programs to better prepare our individual airmen.
Resiliency training is delivered in a tiered fashion, based
on risk factors. Those most at risk receive the greatest and
most structured exposure to resiliency and suicide prevention
training, while basic education and training is made available
to low-risk audiences, via unit briefings, chaplain services,
financial classes, and computer-based training. Additionally,
the Air Force is identifying strategies to ensure all
accessions are exposed to Total Force Resilience and Suicide
Preventions Programs early on. Additionally, airmen will get
additional training and assistance as they deploy from combat.
A Deployment Transition Center, at Ramstein Airbase in
Germany, will open next month to provide 2 days of training to
assist in the transition from deployment to home station for
airmen regularly exposed to significant risks of combat-related
death, like convoy operators, explosive ordinance disposal
personnel, and security forces, and the Office of Special
Investigations. The goals of the Center include providing
reconstitution, wingman support, and fostering individual
resiliency skills for our most vulnerable airmen, those exposed
to traumatic situations, situations that may lead to PTSD or
TBI.
In 2003, more than 600 U.S. Air Force personnel were
diagnosed with PTSD. In 2008, that number increased to over
1,500, with over 78 percent of the diagnosis stemming from
deployment-related events.
Efforts to prevent, identify, and treat PTSD begin and end
at home, with screening and education, the use of forums, like
the Community Action Information Board, and the use of
traumatic stress response teams at each installation. All aim
to foster resiliency through focused education and
psychological first-aid.
While deployed, combat operational stress control teams
seek to prevent or minimize adverse effects of combat on our
airmen. Of note, even nondeployed airmen, like those piloting
remotely piloted aircraft and some of our intelligence
personnel, must be monitored for PTSD symptoms as well. They
too are actively engaged in combat operations.
Although, where it may not be possible to pinpoint the
instant PTSD is onset in an individual, this is rarely the case
with TBI. TBI is recognized in the Air Force as a physical
condition that can cause lifelong symptoms.
From 2001 to 2009, 1,008 airmen were diagnosed with TBI,
accounting for 4 percent of all DOD TBI cases. Baseline testing
of deployers and education of commanders and medical personnel
is increasing as we work to apply the best joint practices to
prevent, identify, and treat TBI. Our goal is simply to provide
the best possible treatment, minimize the impact on long-term
health, and maximize rehabilitation, recovery, and
reintegration.
In conclusion, airmen are our Air Force's greatest asset,
the key component of our ability to partner with the joint and
coalition team to win today's fight. There is a commonality
among suicide, PTSD, and TBI, beyond their obvious impact on
individuals and the mission. They all require heightened
awareness and understanding if we're to identify, prevent, and
treat them effectively.
Again, thank you for your continuing support for our
airmen, and thank you for the opportunity to discuss these
important issues today. I look forward to your questions.
[The prepared statement of General Chandler follows:]
Prepared Statement by Gen. Carrol H. Chandler, USAF
introduction
The Air Force is strongly committed to the physical, emotional, and
mental health of our airmen, and appreciates the linkage between health
of the force and mission readiness. The number of airmen taking their
own lives has been rising, despite our commitment to prevention.
Similarly, Post-Traumatic Stress Disorder (PTSD) is an area of
increasing concern. Finally, detection and treatment of Traumatic Brain
Injury continues to challenge us. All three are similar in that they
are difficult to detect, and may have significant impact on health and
mission readiness. We are taking action to reduce risk through measures
to prevent, identify, and treat each. Efforts to bolster every airman's
resilience must involve the entire chain of command, commanders,
supervisors, co-workers, base support agencies, and especially our Air
Force families throughout the Total Force.
suicide in the u.s. air force
In 2010, 45 airmen--27 Active Duty, 8 Guard, 3 Reserve, and 7
civilians--have taken their own lives, compared to 33 during the same
period last year. Currently, the Air Force suicide rate exceeds 14
suicides per 100,000 Total Force airmen. If these levels persist, the
Air Force suicide rate by year's end will be a significant deviation
from the 11.6 per 100,000 the Air Force averaged during the last 6
years.
Among our airmen who took their own lives, nearly two-thirds were
not receiving assistance from a mental health professional. Despite
concerted efforts to reverse a long-held bias against seeking mental
health assistance, many airmen continue to resist seeking help when
they most need it. Even among those who seek counseling, there is a
marked bias against involving their chain of command in their
treatment. Based on an anonymous review of more than 1,000 mental
health records in 2006, approximately 89 percent did not inform their
chain of command. Additionally, in the 2008 Health Related Behaviors
Survey 1 out of every 8 airmen responded that they believe that a
mental health appointment will ``definitely'' hurt their career.
While no segment of the Air Force is immune to suicide, there are
known high-risk populations. The most common risk factors associated
with Air Force suicides are relationship problems, legal issues,
financial troubles, and history of mental health diagnosis. The Air
Force seeks to identify these factors prior to enlistment and
throughout an airman's service. While not directly linked to
deployments or work-place stress, these factors can be exacerbated by
demanding military lifestyles. Notably, only approximately 20 percent
of Air Force suicide victims have deployment experience within the last
year. Over the past 2 years, the Air Force has had four suicides in the
U.S. Central Command area of responsibility--three in 2009 and one in
2010. In 2009, approximately 60 percent of all Air Force suicides were
committed by airmen in age groups 17-24 and 25-34, accounting for 29
percent and 31 percent of total Air Force suicides respectively. Thus
far in 2010, these age groups continue to be at the highest risk for
suicide, combining for more than 61 percent of Air Force suicides. The
security forces and intelligence career fields have the highest suicide
rates; both averaged approximately 24 per 100,000 during the last
several years. The Air Force recognizes suicide as a public health
concern that requires active and persistent involvement from
commanders, supervisors, and wingmen at all levels of the organization.
total force resiliency
In February of this year, the Air Force initiated Total Force
Resiliency to holistically address the root causes of suicide. Because
there is significant commonality between the Services, we have studied
the Army and Navy resiliency programs and shared best practices to
provide our airmen the skills they require to succeed during potential
physical and psychological challenges. The Air Force program reflects a
broad-based approach to supporting airmen and their families. It
recognizes that physical, mental, and emotional health are critical to
readiness and optimal performance, and is a comprehensive approach to
enhance well-being, not merely a safety net. Our resiliency program
focuses on the ability to withstand, recover and/or grow in the face of
stressors and changing demands. Airman resiliency and the Air Force
Suicide Prevention Program are complementary efforts. The key
components of our suicide prevention program are leadership engagement
and immediate family involvement. Both are helped by base support
activities which deliver relevant programs and services.
To emphasize the imperative of leader and peer participation, the
Chief of Staff directed a Service-wide ``Wingman Day.'' During the
month of May, every unit took time out to discuss suicide prevention,
Total Force Resiliency, and reinforce the significance and role of
every airman as supportive wingmen in prevention and resilience. This
effort generated positive momentum and challenged every member of the
Air Force to recognize his or her role in suicide prevention. There is
no substitute for airmen knowing their subordinates and coworkers well
enough to recognize changes in attitude, behavior, and personality--and
then intervening when something is not right.
availability of services
The Air Force Surgeon General, in collaboration with the Military
Health System Strategic Communication Group, is working to ensure
suicide prevention programs and messages receive sufficient breadth and
depth of exposure. At Headquarters Air Force, Major Commands, and base
level, the Community Action Information Board (CAIB) provides a forum
for cross-organizational review and resolution of individual, family,
installation, and community issues that impact the readiness of the
force and the quality of life for Air Force members and their families.
In a recent change, based on our concerns about the increased suicide
rate, the Air Force Vice Chief of Staff now chairs the HQ USAF CAIB.
In addition, the Air Force has significantly expanded counseling
services beyond those traditionally available through chaplains or the
mental health clinic. Mental health providers are now based in primary
care clinics across the Air Force. Airman and Family Readiness Centers
sponsor Military Family Life Counselors that offer counseling to
individuals or couples without generating documentation. Military
OneSource, a Department of Defense program that provides resources and
support to service members and their families, provides free access to
off-base counselors for as many as six sessions.
targeted training programs
Resiliency training is delivered based on a tiered model. The few
career fields with the highest risk factors, including those departing
or returning from deployments, receive the greatest and most structured
exposure to resiliency training and suicide prevention programs in the
Tier 1 category. Tier 1 training also ensures that members with acute
risk of suicide receive clinical care by mental health professionals.
Tier 2 training tailors and intensifies resiliency and suicide
prevention messages based on risk factors. Tier 3 training provides
basic education and training to the widest possible audience via unit
briefings, chaplain services, financial classes, and computer-based
training. Additionally, the Air Force is identifying strategies to
ensure all accessions, beginning with Basic Military Training at
Lackland AFB, TX, will incorporate resiliency training into their
curriculum to provide initial exposure. Shortly thereafter, this
training will be expanded to include commissioning programs and
technical training. In order to improve the effectiveness of healthcare
provider interventions, we are also focusing on advanced provider
training.
deployment transition center
A Deployment Transition Center (DTC) will begin initial operations
in July 2010 at Ramstein AB, Germany. This organization will provide 2
days of training to assist in the transition from deployment to home
station for airmen regularly exposed to significant risk of combat-
related death, and will be initially focused on convoy operators,
explosive ordinance disposal personnel, and security forces personnel,
although these services may be extended to other at-risk Air Force
members as the DTC matures. This overseas center will provide these
airmen centralized training and facilitate a graduated transition home
with positive family reintegration. The goals of the center include
providing reconstitution, utilizing the support of fellow airmen
returning from deployment, and fostering individual resiliency skills
and coping mechanisms. The center is part of the overarching resiliency
education and training program being developed with the goal of
supporting broader Air Force populations, not merely those airmen
considered most vulnerable due to high potential of exposure to
traumatic situations.
invisible wounds of war: post-traumatic stress disorder and traumatic
brain injury
In 2003, more than 600 USAF personnel were diagnosed with PTSD, and
in 2008, that number increased to over 1,500, with over 78 percent of
the diagnoses stemming from deployment related events. Over the same
period, there has been an increase in the number of medical visits for
PTSD, from more than 3,800 in 2003, to more than 14,300 in 2008. The
increase in medical care can be attributed not only to the increase in
PTSD cases, but also our increased awareness and treatment efforts. The
Air Force has taken numerous steps to address this threat to our
airmen, beyond the standup of the DTC already discussed.
Efforts to prevent, identify and treat PTSD begin at home, during
pre-deployment preparation. Prescreening and education at home bases
now enhance resilience through education on risk factors, symptom
recognition, benefits, and destigmatization of mental health care, and
promotion of the wingman culture. Also, the Integrated Delivery System
and the CAIB provide forums at each installation for cross-
organizational review and resolution of individual, family,
installation, and community issues associated with PTSD and other
issues that impact mission readiness. Additionally, mental health
providers are receiving training focused on prevention, identification,
and treatment of PTSD. Finally, Traumatic Stress Response teams at each
installation now foster resiliency through focused preparatory
education and psychological first-aid for those exposed to potentially
traumatic events.
Similarly, Combat Operational Stress Control teams seek to prevent
or minimize adverse effects of combat on our airmen in theater. In
addition to airmen deployed to the combat zone, nondeployed airmen,
like our remotely piloted aircraft crews and intelligence personnel,
must be monitored for post-traumatic stress symptoms--they too are
actively engaged in combat operations. Although challenges remain for
the Air Force to prevent, identify, and treat PTSD, we, along with our
joint partners, are actively engaged to improve our capability and
capacity institutionally, for what is often a very individualized need.
Recognizing PTSD is a challenge--as it often is for Traumatic Brain
Injury (TBI).
TBI is recognized in the Air Force as a physical condition that can
cause life-long symptoms. From 2001 to 2009, 1,008 airmen were
diagnosed with TBI, accounting for 4 percent of all Department of
Defense TBI cases reported. Effective early TBI detection is the
cornerstone of TBI care, and baseline Automated Neuropsychological
Assessment Metric is now collected on 56 percent of airmen deploying
into theater. Also, the Air Force will begin educating commanders and
medical personnel by the end of this calendar year, applying best joint
practices in prevention, identification, and treatment of TBI. Through
education that is focused on early detection and prevention, our goal
is to identify TBI cases and ensure our airmen receive the best
possible treatment, minimizing the impact on long-term health, and
maximizing rehabilitation, recovery, and reintegration.
conclusion
Airmen are our Air Force's greatest asset--the key component to our
ability to partner with the Joint and coalition team to win today's
fight. We ask for an extraordinary amount of selflessness and sacrifice
from them and their families. In return, our obligation is to assist
each of them according to their particular needs. There is commonality
among suicide, PTSD, and TBI beyond their obvious impact on individuals
and mission; they all require heightened awareness and understanding if
we are to prevent, identify, and treat them effectively. Also, although
it is possible to focus efforts on high-risk categories of people,
every individual remains vulnerable, valuable, and must be considered.
The needless loss of an airman and the resultant impact on their
families and the Air Force is not acceptable.
Chairman Levin. Thank you so much, General Chandler.
Dr. Jesse.
STATEMENT OF ROBERT L. JESSE, ACTING PRINCIPAL DEPUTY UNDER
SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION,
DEPARTMENT OF VETERANS AFFAIRS
Dr. Jesse. Good morning, Chairman Levin, Ranking Member
McCain, and members of the committee. Thank you for inviting me
here to discuss the VA efforts to respond to, treat, and
minimize the impacts of TBI, PTSD, and veteran suicide.
My written testimony provides greater detail about our
programs and about our cooperation with our partners at DOD and
the Services, but, in the few minutes I do have now, I'd like
to highlight a few key factors for the committee.
Before doing so, I would like to express our gratitude to
the committee for their insight into the importance of these
issues, and for their ongoing support of all of the initiatives
that are intended to mitigate this.
The VA has developed and implemented a range of innovative
programs to ensure that it provides world-class rehabilitation
care for veterans and servicemembers with TBI. We offer
services at 108 facilities across the country through an
integrated network that brings together some of the best minds
in medicine. We deliver comprehensive clinical rehabilitative
services through interdisciplinary teams of specialists, while
providing patient and family education and training,
psychosocial support, and advanced rehabilitation and
prosthetic technologies.
VA has placed nurse liaisons in military treatment
facilities to support coordinated care, patient transfers, and
shared patients. In terms of the population we treated between
March 2003 and March 2010, the VA has seen, at our state-of-
the-art Polytrauma Rehabilitation Centers, almost 1,800
patients, more than half of whom are Active Duty
servicemembers.
Second, the Federal Recovery Coordination Program is a
successful joint VA/DOD initiative that provides severely
injured veterans and servicemembers with access to the benefits
and care that they need to recover. Our 20 Federal Recovery
Coordinators work with military liaisons, member of the
Services' Wounded Warrior programs, Service Recovery Care
coordinators, TRICARE coordinators, and various VA staff
members, to bridge the transition from VA to DOD.
Each enrolled client has a specially tailored Federal
Individual Recovery Plan based on the goals and needs of the
veteran or servicemember, and based upon input from the client
and his or her family. This plan serves as the basis for
returning our wounded warriors to the highest level of
functionality independence they can achieve.
Third, VA has implemented a robust screening protocols for
PTSD, TBI, and suicidal tendencies. We screen every veteran
from Afghanistan and Iraq for brain injuries, and we screen
every veteran we see for PTSD, depression, and drinking
problems. If the PTSD or depression screen is positive, we
require an evaluation for suicidal tendencies. VA repeats the
screening at consistent intervals, since problems can arise at
any time. Any positive screen leads to further evaluation in
the primary care setting, followed by specialty care services
as needed.
The VA has established access standards for mental health
that require prompt contact of new patients, within 24 hours of
referral, by a clinician, to evaluate the urgency of the
veteran's needs. If the veteran has an urgent care need, we
require our staff to make appropriate arrangements, including
an immediate admission to one of our facilities. If the need is
not urgent, the patient must be seen for a full mental health
and diagnostic evaluation and development initiation of an
appropriate treatment plan within 14 days. Across the system,
the VA is meeting the standard over 95 percent of the time.
Finally, VA's suicide prevention efforts are having a
meaningful and positive impact on those veterans who come to us
for care. A suicide by a servicemember or veteran is a tragedy
for the individual, his or her friends and family, and to the
Nation.
We have initiated several programs to put VA in the
forefront of suicide prevention. Chief among these is
establishing a national suicide prevention hotline, placing
suicide prevention coordinators at VA Medical Centers,
significantly expanding mental health services, and integrating
primary and mental health care to alleviate the stigma of
seeking mental health assistance.
The return on investment for these efforts is significant.
Our suicide prevention hotline has saved the lives of more than
9,000 veterans and servicemembers since its inception. Other
data demonstrate that younger veterans who come to the VA for
healthcare services were 30 percent less likely to die from
suicide than those who don't come to us for care. More broadly,
the rate of suicide among veterans receiving healthcare from VA
has declined steadily since 2001. From a public health
perspective, this decline is significant, corresponding to
about 250 fewer lives lost as a result of suicide.
These are considerable accomplishments that both VA and
Congress can be proud of. But, it is imperative that we reach
more of our veterans and servicemembers, and deliver them the
care that they need.
In conclusion, VA and DOD maintain a longstanding
relationship that shares best practices, identifies joint
solutions, operates centers of excellence, and works to support
the brave men and women who wear the uniform.
Thank you again for the opportunity to discuss these
important issues with you today. I'm prepared to answer your
questions.
[The prepared statement of Dr. Jesse follows:]
Prepared Statement by Robert Jesse, M.D., Ph.D.
Good morning Chairman Levin, Ranking Member McCain, and members of
the committee. Thank you for inviting me here to discuss the Department
of Veterans Affairs (VA) efforts to respond to, treat, and minimize the
impacts of traumatic brain injury (TBI), post-traumatic stress disorder
(PTSD), and veteran suicide. My testimony will describe VA's programs
and initiatives in the areas of TBI and mental health, with a specific
emphasis on our suicide prevention programs, and highlight the close
cooperation VA maintains with the Department of Defense (DOD) and the
Services.
traumatic brain injury
Care, Management, and Transition of Veterans and Servicemembers
Polytrauma is a new word in the medical lexicon that was termed by
VA to describe the complex, multiple injuries to multiple body parts
and organs occurring as a result of blast-related injuries seen from
Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF).
Polytrauma is defined as two or more injuries to physical regions or
organ systems, one of which may be life threatening, resulting in
physical, cognitive, psychological, or psychosocial impairments and
functional disability. TBI frequently occurs in polytrauma in
combination with other disabling conditions such as amputation,
auditory and visual impairments, spinal cord injury (SCI), post-
traumatic stress disorder (PTSD), and other medical problems. Due to
the severity and complexity of their injuries, servicemembers and
veterans with polytrauma require an extraordinary level of coordination
and integration of clinical and other support services.
VA has developed and implemented numerous programs to ensure it
provides world-class rehabilitation services for veterans and active
duty servicemembers with TBI. VA has enhanced its integrated nationwide
Polytrauma/TBI System of Care. The VA Polytrauma/TBI System of Care
consists of four levels of facilities, including 4 Polytrauma
Rehabilitation Centers, 22 Polytrauma Network Sites, 82 Polytrauma
Support Clinic Teams, and 48 Polytrauma Points of Contact. The system
offers comprehensive clinical rehabilitative services including:
treatment by interdisciplinary teams of rehabilitation specialists;
specialty care management; patient and family education and training;
psychosocial support; and advanced rehabilitation and prosthetic
technologies. In 2005, VA expanded the scope of services at existing VA
TBI Centers, and accordingly renamed them Polytrauma/TBI Rehabilitation
Centers, to establish an integrated, tiered system of specialized,
interdisciplinary care for polytrauma injuries and TBI.
PRCs provide the most intensive specialized care and comprehensive
rehabilitation care for veterans and servicemembers with complex and
severe polytrauma. PRCs maintain a full staff of dedicated
rehabilitation professionals and consultants from other specialties to
support these patients. Each PRC is accredited by the Commission on
Accreditation of Rehabilitation Facilities, and each serves as a
resource to develop educational programs and best practice models for
other facilities across the system. The four regional centers are
located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA.
A fifth center is currently under construction in San Antonio, TX, and
is expected to open in 2011.
Since 2007, VA has placed Polytrauma Nurse Liaisons at Walter Reed
Army Medical Center and National Naval Medical Center (at Bethesda, MD)
to support coordination of care, patient transfers, and shared patients
between DOD and VA PRCs. Whenever an injured veteran or servicemember
requires specialized rehabilitative services and enters VA health care,
the Polytrauma Nurse Liaison maintains close communication with the
admissions nurse case manager at the VA PRC, providing current and
updated medical records. Before transfer, the Center's
interdisciplinary team meets with the DOD treatment team and family by
teleconference as another way to ensure a smooth transition.
va accomplishments
A total of 1,792 inpatients with severe injuries have been treated
at the Polytrauma Rehabilitation Centers from March 2003 through March
2010; 907 of these patients have been active duty servicemembers, of
which 754 were injured in OEF or OIF. VA continues following these
patients after their discharge from a VA PRC to assess their long-term
outcomes. Data available for 876 former PRC patients indicate:
781 (89 percent) are living in a private residence;
642 (73 percent) live alone or independently;
413 (47 percent) report they are retired due to age,
disability or other reasons;
206 (24 percent) are employed;
90 (10 percent) are in school part-time or full-time;
and
59 (7 percent) are looking for a job or performing
volunteer work.
Throughout the Polytrauma/TBI System of Care, we have established a
comprehensive process for coordinating support efforts and providing
information for each patient and family member. Specialized
rehabilitation initiatives at the PRCs include:
In 2007, VA developed and implemented Transitional
Rehabilitation Programs at each PRC. These 10-bed residential
units provide rehabilitation in a home-like environment to
facilitate community reintegration for veterans and their
families, focus on developing standardized program measures,
and investigate opportunities to collaborate with other
entities providing community-based reintegration services.
Through December 2009, 188 veterans and servicemembers have
participated in this program spending, on average, about 3
months in transitional rehabilitation. Almost 90 percent of
these individuals return to active duty, or transition to
independent living.
Beginning in 2007, VA implemented a specialized
Emerging Consciousness care path at the four PRCs to serve
those veterans with severe TBI who are slow to recover
consciousness. Patients with disorders of consciousness (e.g.,
comatose) require high complexity and intensity of medical
services and resources in order to improve their level of
responsiveness and decrease medical complications. To meet the
challenges of caring for these individuals, VA collaboratively
developed this care path with subject matter experts from
Defense and Veterans Brain Injury Center (DVBIC) and the
private sector. VA and DVBIC continue to collaborate on
research in this area, and incorporate improvements to the care
path in response to advances in science. From January 2007
through December 2009, 87 veterans and servicemembers have been
admitted in VA Emerging Consciousness care. Approximately 70
percent of these patients emerge to consciousness before
leaving inpatient rehabilitation.
In October 2008, all inpatients with TBI at VA PRCs
began receiving special ocular health and visual function
examinations based upon research conducted at our Palo Alto
PRC. To date, 840 inpatients have received these examinations.
In April 2009, VA began an advanced technology
initiative to establish assistive technology laboratories at
the four PRCs. These facilities will serve as a resource for VA
health care, and provide the most advanced technologies to
veterans and servicemembers with ongoing needs related to
cognitive impairment, sensory impairment, computer access,
communication deficits, wheeled mobility, self-care, and home
telehealth.
The PRCs have been renovated to optimize healing in an
environment respectful of military service. Military liaisons
located at the centers help to support active duty patients and
to coordinate interdepartmental issues for patients and their
families. Working with the Fisher House Foundation, we are also
able to provide housing and other logistical support for family
members staying with a veteran or servicemember during their
recovery at one of our facilities.
In fiscal year 2009, 22,324 unique outpatients had
83,794 total clinic visits across the Polytrauma Support Clinic
Team sites; an increase of over 30 percent from fiscal year
2008.
In addition to improvements in the Polytrauma/TBI System of Care,
VA developed and implemented the TBI Screening and Evaluation Program
for all OEF/OIF veterans who receive care within VA. From April 2007
through March 2010:
408,474 OEF/OIF veterans have been screened for
possible TBI;
56,161 who screened positive have been evaluated and
received follow-up care and services appropriate for their
diagnosis and their symptoms;
30,368 have been confirmed with a diagnosis of having
incurred a mild TBI;
Over 90 percent of all veterans who are screened are
determined not to have TBI, but all who screen positive and
complete a comprehensive evaluation are referred for
appropriate treatment.
VA continues to increase collaborations with private sector
facilities to successfully meet the individualized needs of veterans
and complement care in cases when VA cannot readily provide the needed
services, or cases where the required care is geographically
inaccessible. VA medical facilities have identified private sector
resources within their catchment area that have expertise in
neurobehavioral rehabilitation and recovery programs for TBI. In fiscal
year 2009, 3,708 enrolled veterans with TBI received inpatient and
outpatient hospital care and medical services from public and private
entities, with a total disbursement of over $21 million.
VA and DOD Cooperation on Outreach, Transition and Complementary Care
VA and DOD have shared a longstanding integrated collaboration in
the area of TBI through the DVBIC. Since 1992, DVBIC staff members have
been integrated with VA Lead TBI Centers (now Polytrauma Rehabilitation
Centers) to collect and coordinate surveillance of long-term treatment
outcomes for patients with TBI. Other significant initiatives that have
resulted from the ongoing collaboration between VA and DVBIC include:
developing collaborative clinical research protocols; developing and
implementing best clinical practices for TBI; developing materials for
families and caregivers of veterans with TBI; developing integrated
education and training curriculum on TBI, and joint training of VA and
DOD heath care providers; and coordinating the development of the best
strategies and policies regarding TBI for implementation by VA and DOD.
In addition to the longstanding affiliation with DVBIC, since 2007,
VA has collaborated with DOD to develop implementation plans for
Defense Centers of Excellence (DCoE) and the associated injury
registries, including Centers for Psychological Health and Traumatic
Brain Injury, Extremity Injuries and Amputation, Hearing Loss and
Auditory System Injuries, and Vision. VA has assigned personnel at the
Center for Psychological Health and TBI, and at the Vision Center. VA
continues to be involved in working groups with DOD representatives to
assist in developing concepts of operations and plans for the Hearing
Loss and Auditory System Injuries Center and the Center for Extremity
Injuries and Amputation.
VA, in collaboration with DVBIC, developed a uniform training
curriculum for family members in providing care and assistance to
servicemembers and veterans with TBI: ``Traumatic Brain Injury: A Guide
for Caregivers of Servicemembers and Veterans.'' In 2009, VA and DOD
collaboratively developed clinical practice guidelines for mild TBI and
deployed this to health care providers, as well as recommendations in
the areas of cognitive rehabilitation, drivers' training, and managing
the co-occurrence of TBI, PTSD, and pain.
In 2009, the VA-led collaboration with DOD and the National Center
for Health Statistics produced revisions to the International
Classification of Diseases, Clinical Modification (ICD-9-CM) diagnostic
codes for TBI, resulting in significant improvements in the
identification, classification, tracking, and reporting of TBI and its
associated symptoms.
The Federal Recovery Coordination Program
The Federal Recovery Coordination Program (FRCP) serves an
important function in ensuring that severely injured veterans and
servicemembers receive access to the benefits and care they need to
recover. Beginning in 2008, FRCP has helped coordinate and access
Federal, State, and local programs, benefits and services for severely
wounded, ill, and injured servicemembers, veterans, and their families
through recovery, rehabilitation, and reintegration into the community.
The program is a joint program of DOD and VA, with VA serving as the
administrative home.
The program has grown since enrolling the first client in February
2008. Not every individual referred to the program meets enrollment
criteria or needs the full services of FRCP. Some individuals are
enrolled for a period of time and then determine that they no longer
need the program's services. Currently, 538 clients are enrolled and
another 26 individuals are being evaluated for enrollment; 478 have
received assistance. Anyone can return for re-enrollment or additional
assistance if the problems are not resolved or if new problems develop.
Recovering servicemembers and veterans are referred to FRCP from a
variety of sources, including from the servicemember's command, members
of the interdisciplinary treatment team, case managers, families, or
clients already in the program, Veterans Service Organizations, and
other nongovernmental organizations. Generally, those individuals whose
recovery is likely to require a complex array of specialists, transfers
to multiple facilities, and long periods of rehabilitation are
referred.
FRCP outreach efforts include brochures, a presence on VA's OEF/OIF
Web site, participation and presentations at local, State, and national
events. Our toll-free number (1-877-732-4456), new in April 2009,
provides another avenue for referral or assistance. When a referral is
made, a Federal Recovery Coordinator (FRC) conducts an evaluation that
serves as the basis for problem identification and determination of the
appropriate level of service.
FRCs coordinate benefits and services for their clients through the
various transitions associated with recovery and return to civilian
life. FRCs work with military liaisons, members of the Services'
Wounded Warrior Programs, Service recovery care coordinators, TRICARE
beneficiary counseling and assistance coordinators, VA vocational and
rehabilitation counselors, military and VA facility case managers, VA
Liaisons, VA specialty care managers, Veterans Health Administration
(VHA) and Veterans Benefits Administration (VBA) OEF/OIF case managers,
VBA benefits counselors, and others.
Each enrolled client receives a Federal Individual Recovery Plan
(FIRP). The FIRP, based on the goals and needs of the servicemember or
veteran and upon input from their family or caregiver, is designed to
efficiently and effectively move clients through transitions by
identifying the appropriate services and benefits. The FRCs, with input
and assistance from interdisciplinary team members and case managers,
implement the FIRP by working with existing governmental and
nongovernmental personnel and resources.
FRCP staffing has grown to meet the program's needs. Eight FRCs
were initially hired in January 2008. We are adding 5 additional FRCs
to the 20 current positions in order to meet the growth and success of
the program. Most of these new hires will be placed at VA PRCs adding
additional support for severely wounded, ill, and injured
servicemembers and veterans. The table below shows the current
locations, as well as the locations for the new FRCs.
------------------------------------------------------------------------
Facility Name and Location Total FRCs
------------------------------------------------------------------------
Walter Reed Army Medical Center, DC........... 3
National Naval Medical Center, Bethesda, MD... 3
Brooke Army Medical Center, San Antonio TX.... 4
Naval Medical Center, San Diego, CA........... 3
Camp Pendleton, CA............................ 1
Eisenhower Army Medical Center, Augusta, GA... 2
James A. Haley VAMC, Tampa, FL................ 1
Providence VAMC, Providence, RI............... 1
Michael E DeBakey VAMC, Houston, TX........... 1
USSOCOM Care Coalition, Tampa, FL............. 1
Richmond VAMC Polytrauma, VA.................. 2 (new hire)
Palo Alto VAMC Polytrauma, CA................. 2 (new hire)
Navy Safe Harbor, DC.......................... 1 (new hire)
-------------------------
Total (FRC) FTE............................. 25
------------------------------------------------------------------------
Administrative staff includes an executive director, two deputies
(one for benefits and one for health), an executive assistant, an
administrative officer, and two staff assistants.
The FRCP is VA's lead for the National Resource Directory (NRD), an
online partnership of the U.S. Departments of Defense, Labor and
Veterans Affairs for wounded, ill, or injured servicemembers, veterans,
their families, caregivers, and supporting providers. The NRD is a
comprehensive online tool available worldwide with over 11,000 Federal,
State, and local resources organized into 9 easily searchable topic
areas including: benefits and compensation, families and caregivers,
employment, education and training, health care, housing,
transportation and travel, and homeless assistance. The NRD has an
average of 1,200 visitors a day where they access approximately 5,000
page views.
FRCP's success rests in its extraordinary and well-trained
problemsolving professional staff. We have learned a great deal over
the past 2 years and have been able to respond quickly to developing
needs or problems. We are looking forward to the results from a current
Government Accountability Office program evaluation and those from our
satisfaction survey. This input will guide the Program's future
development and adaptation.
mental health care and suicide prevention
VA has responded aggressively to address previously identified gaps
in mental health care by expanding our mental health budgets
significantly. In fiscal year 2010, VA's budget for mental health
services reached $4.8 billion, while the amount included in the
President's budget for fiscal year 2011 is $5.2 billion. Both of these
figures represent dramatic increases from the $2.0 billion obligated in
fiscal year 2001. VA also has increased the number of mental health
staff in its system by more than 6,000, since 2005 when VHA began
implementing its Mental Health Strategic Plan. During the past 3 years,
VA trained over 3,000 staff members to provide psychotherapies with the
strongest evidence for successful outcomes for PTSD, depression, and
other conditions. Furthermore, we require that all facilities make
these therapies available to any eligible veteran who may benefit. In
fiscal year 2010 and fiscal year 2011, we will continue to expand
inpatient, residential, and outpatient mental health programs and
continue our emphasis on integrating mental health services with
primary and specialty care. We thank Congress for its strong support
over the past several years, as without its help, none of this would be
possible.
VA is working closely with our colleagues at DOD to improve the
quality of care for veterans and servicemembers alike. Since October
2009, VA and DOD have held two major conferences related to the mental
health needs of veterans and servicemembers.
VA offers mental health services to veterans through medical
facilities and Community-Based Outpatient Clinics (CBOC), and in
addition, VA's Vet Centers offer another important component of mental
health care focused on readjustment counseling. Vet Centers embrace a
veteran-centric program model that goes beyond formal procedures in
making a personal and empathic connection that helps combat veterans
overcome stigma and other barriers to care. Approximately 80 percent of
all Vet Center staff members are veterans, and 60 percent are combat
veterans. In addition to 100 Operation Enduring Freedom and Operation
Iraqi Freedom (OEF/OIF) Veteran Outreach Specialists, more than one-
third of all staff now serving in Vet Centers are OEF/OIF veterans.
Early access to readjustment counseling in a safe and confidential
setting can help reduce the risk of suicide and promote recovery among
servicemembers returning from a combat theater. Through the end of
December 31, 2009, Vet Centers have made contact with 424,398 (39
percent) of all separated OEF/OIF veterans, and 317,309 were provided
outreach services, primarily at demobilization sites, while 107,089
received substantive readjustment counseling in a VA Vet Center.
VA has been making significant enhancements to its mental health
services since 2005, through the VA Comprehensive Mental Health
Strategic Plan and special purpose funds available through the Mental
Health Enhancement Initiative from fiscal year 2005 to fiscal year
2009. In 2007, VA approved the Handbook on Uniform Mental Health
Services in VA Medical Centers and Clinics to define what mental health
services should be available to all enrolled veterans who need them, no
matter where they receive care, and to sustain the enhancements made in
recent years.
VA's enhanced mental health activities include outreach to help
those in need to access services, a comprehensive program of treatment
and rehabilitation for those with mental health conditions, and
programs established specifically to care for those at high risk of
suicide. To reduce the stigma of seeking care and to improve access, VA
has integrated mental health into primary care settings to provide much
of the care that is needed for those with the most common mental health
conditions. In parallel with the implementation of these programs, VA
has been modifying its specialty mental health care services to
emphasize psychosocial as well as pharmacological treatments and to
focus on principles of rehabilitation and recovery. VA is ensuring that
treatment of mental health conditions includes attention to the
benefits as well as the risks of the full range of effective
interventions. Making these treatments available responds to the
principle that when there is evidence for the effectiveness of a number
of different treatment strategies, the choice of treatment should be
based on the veteran's values and preferences, as well as the clinical
judgment of the provider.
Screening, Treatment, and Access
Crucial to initiating such care, VA requires that all new patients
to primary care be screened for PTSD, depression, and problem drinking.
If the PTSD or depression screen is positive, an evaluation for
suicidality also is required. VA repeats this screening at consistent
intervals, since problems can arise at any time, not just on initial
access to VA care. Any positive screen leads to further evaluation in
the primary care setting, followed by initiation of mental health
services, if needed, in the primary care setting or through referral to
mental health specialty care.
For patients identified through these screens, or in any other way,
VA has established access standards that require prompt evaluation of
new patients (those who have not been seen in a mental health clinic in
the last 24 months) with mental health concerns. New patients are
contacted within 24 hours of the referral by a clinician competent to
evaluate the urgency of the veteran's mental health needs. If it is
determined that the veteran has an urgent care need, appropriate
arrangements (e.g., an immediate admission) are required. If the need
is not urgent, the patient must be seen for a full mental health
diagnostic evaluation and development and initiation of an appropriate
treatment plan within 14 days. Across the system, VA is meeting this
standard 95 percent of the time.
Screening usually occurs in the primary care setting where most
veterans initially seek care for mental health as well as physical
health problems. VA has expanded integrated mental health services in
primary care throughout the system. To ensure veterans are monitored
appropriately while they are receiving mental health services,
including treatment with psychotherapeutic medications, VA requires
that these integrated care programs include evidence-based care
management and co-located, collaborative care by a mental health
professional.
In addition, research has shown the value of having co-located,
collaborative mental health staff that can complement the medication-
focused care management programs with psychosocial interventions to
address depression and other mental health problems. The mental health
providers co-located in primary care also can engage with family
members when appropriate to listen to their concerns, ensure they
understand the care the veteran is receiving, and describe how they can
contribute to ongoing treatment for the veteran.
One important set of requirements in the handbook was to ensure
that evidence-based psychotherapies are available for veterans who
could benefit from them and that meaningful choices between effective
alternative treatments are available. VA implemented the broad use of
evidence-based psychotherapies in response to evidence that for many
patients, specific forms of psychotherapy are the most effective and
evidence-based of all treatments. Specifically, the Institute of
Medicine report on treatment for PTSD emphasized findings that
exposure-based psychotherapies, including Prolonged Exposure Therapy
and Cognitive Processing Therapy, were the best-established of all
treatments for PTSD. Other specific psychotherapies included in VA's
programs include Cognitive Behavioral Therapy and Acceptance and
Commitment Therapy for depression; Skills Training, Social Skills
Training for Veterans with serious mental illness, such as
schizophrenia; and Family Psycho-Education for schizophrenia. VA is
adding other treatments such as Problemsolving for Depression,
Cognitive Behavioral Therapy and Contingency Management for Substance
Use Disorder, and behavioral strategies for managing both pain and
insomnia.
For several years, VA has provided training to clinical mental
health staff to ensure that there are therapists in each facility able
to provide evidence-based psychotherapies for the treatment of
depression and PTSD as alternatives to pharmacological treatment or as
a course of combined treatment. More recently, VA has begun training
Vet Center mental health professionals in Cognitive Processing Therapy
(CPT). To date, 120 Vet Center staff members have participated in
training courses to develop full competency in this treatment approach.
Vet Center staff training will also be enhanced this year through
national training in May commemorating the Vet Center program's 30th
year in existence. VA is initiating a training academy for all Vet
Center team leaders.
VA has expanded care for veterans with Substance Use Disorders
(SUD), for example, greatly expanding Intensive Outpatient Centers for
Veterans with Substance Use Disorders. These Centers have the strongest
evidence base for effective treatment; they provide a team of mental
health professionals in a comprehensive program format that offers care
at least 3 days each week for at least 3 hours each day. In addition,
SUD care also has been integrated in PTSD Clinical Teams by including a
SUD provider to work with these Teams at each VA facility.
A central concept for all services is a recovery orientation. For
those with serious mental illness, the focus on recovery reflects major
scientific advances in treatment and rehabilitation. Although it is
still not possible to offer definitive cures for all patients with
serious mental illness, it is realistic to offer the expectation of
recovery. Veterans, often with their families, should collaborate with
their providers in planning treatments based on the goals that will
help the veteran live the kind of life he or she chooses, in spite of
any residual signs or symptoms of mental illness. To achieve this
vision, VA has hired a Local Psychosocial Recovery Coordinator at every
facility and has hired staff members to provide peer support, trained
clinicians in evidence-based strategies for treatment and
rehabilitation, enhanced the care in residential treatment settings,
developed Psychosocial Rehabilitation and Recovery Centers and
strengthened programs that involve families.
Suicide Prevention
Preventing suicides is a top priority for VA. A suicide by a
servicemember or veteran is a tragedy for the individual, his or her
friends and family, and the Nation. Data indicate that while civilian
suicide rates have remained fairly static over the past 30 years, there
has been a deeply concerning increase in the suicide rate among members
of the Armed Forces over the last 5 years. Eighteen deaths per day
among the veteran population are attributable to suicide. More than 60
percent of suicides among VA health care users are among patients with
a known mental health diagnosis. We have initiated several programs
that put VA in the forefront of suicide prevention for the Nation.
Chief among these are:
Establishment of a National Suicide Prevention
Hotline, including a major advertising campaign to provide this
phone number to all veterans and their families;
Placement of suicide prevention coordinators at all VA
medical centers;
Significant expansion of mental health services; and
Integration of primary care and mental health services
to help alleviate the stigma of seeking mental health
assistance.
In 2007, VA developed its signature program, the Suicide Prevention
Hotline (1-800-273-TALK (8255)), in partnership with the existing
Department of Health and Human Services Substance Abuse and Mental
Health Services Administration (SAMHSA) Suicide Prevention Hotline. At
the same time, VA provided specific funding and training for each
facility to have a designated Suicide Prevention Coordinator; it also
held the first Annual Suicide Awareness and Prevention Day. The same
year, VA initiated system-wide screening for suicide in primary care
patients, instituted training for Operation S.A.V.E. (which trains non-
clinicians to recognize the signs of suicidal thinking, to ask veterans
questions about suicidal thoughts, to validate the veteran's
experience, and to encourage the veteran to seek treatment), and
required Suicide Prevention Coordinators to begin tracking and
reporting suicidal behavior. In addition, VA added more suicide
prevention coordinators and suicide prevention case mangers in our
larger medical centers and community-based outpatient clinics, doubling
the number of dedicated suicide prevention staff in the field. By 2008,
VA had re-established a monitor for mental health follow-up after
patients were discharged from inpatient mental health units and held a
fourth regional conference on evidence-based interventions for suicide.
In 2009, VA launched the Veterans Chat Program to create an online
presence for the Suicide Prevention Hotline. Veterans Chat and the
Hotline are intended to reach out to all veterans, whether they are
enrolled in VA health care or not. VA also added a flag to patient
records to notify physicians of patients at risk for suicide. This
year, VA has already held a Suicide Prevention Coordinator conference
and co-hosted a conference with DOD to discuss ways VA and DOD can
reduce the prevalence of suicide among veterans and servicemembers.
VA has adopted a broad strategy to reduce the incidence of suicide
among veterans. This strategy is focused on providing ready access to
high quality mental health and other health care services to veterans
in need. This effort is complemented by helping individuals and
families engage in care and addressing suicide prevention in high risk
patients. VA cannot accomplish this mission alone; instead, it works in
close collaboration with other local and Federal partners and brings
together the diverse resources within VA, including individual
facilities, a Center of Excellence in Canandaigua, New York, a Mental
Illness Research and Education Clinical Center in Veterans Integrated
Service Network (VISN) 19, VA's Office of Research and Development, and
clinicians.
This evidence clearly demonstrates that once a person has
manifested suicidal behavior, he or she is more likely to try it again.
As a result, VA has adopted a comprehensive treatment approach for high
risk patients. This includes a flag in a patient's chart, necessary
modifications to the patient's treatment plan, involvement of family
and friends, close follow up for missed appointments, and a written
safety plan included in the veteran's medical record. This plan is
shared with the veteran and includes six steps: (1) a description of
warning signs; (2) an explanation of internal coping strategies; (3) a
list of social contacts who may distract the veteran from the crisis;
(4) a list of family members or friends; (5) a list of professionals
and agencies to contact for help; and (6) a plan for making the
physical environment safe for the veteran.
During 2009, the VA Call Center for the Suicide Prevention Hotline
(1-800-273-TALK) received approximately 10,000 calls per month,
approximately 20 percent of all calls to the National Suicide
Prevention Lifeline. Approximately a third of these calls are from non-
veterans. These calls led to 3,364 rescues of those determined to be at
imminent risk for suicide and 12,403 referrals to VA Suicide Prevention
Coordinators at local facilities. In 2009, the VA Call Center received
calls from 1,429 active duty servicemembers, a little more than 1
percent of all calls. To address the needs of the active duty
population, VA worked with SAMHSA to modify the introductory message
for Lifeline, developed memoranda of understanding with DOD, and
established processes for facilitating rescues, including
collaborations with the Armed Services in Iraq. Also during 2009, the
Hotline services were supplemented with Veterans Chat, which has been
receiving more than 20 contacts a day.
The online version of the Hotline, Veterans Chat, enables veterans,
family members, and friends to chat anonymously with a trained VA
counselor. If the counselor determines there is an emergent need, the
counselor can take immediate steps to transfer the visitor to the
Hotline, where further counseling and referral services can be provided
and crisis intervention steps can be taken. Since July 2009, when
Veterans Chat was established, VA has learned many valuable lessons.
First, it is clear that conversations are powerful and capable of
saving lives. As a result, opening more avenues for communications by
offering both an online and phone service is essential to further
success. Second, training and constant monitoring is very important,
and VA will continue pursuing both of these efforts aggressively.
The Lifeline and VA Call Center may be the most visible components
of VA's suicide prevention programs, but the Suicide Prevention
Coordinators are equally important. Both the VA Call Center and
providers at their own facilities notify the Suicide Prevention
Coordinators about veterans at risk for suicide. The Coordinators then
work to ensure the identified veterans receive appropriate care,
coordinate services designed specifically to respond to the needs of
veterans at high risk, provide education and training about suicide
prevention to staff at their facilities, and conduct outreach and
training in their communities. Other components of VA's programs
include a panel to coordinate messaging to the public, as well as two
Centers of Excellence charged with conducting research on suicide
prevention: one, in Canandaigua, focused on public health strategies,
and one in Denver, focused on clinical approaches. VA also has a Mental
Health Center of Excellence in Little Rock, AR, focused on health care
services and systems research.
Data also support the conclusion that high quality mental health
care can prevent suicide. The suicide rate for all veterans who used VA
health care declined significantly from fiscal year 2001 to fiscal year
2007. Fully understanding these data require some background on VA's
efforts to track suicide rates for veterans. First, it is important to
consider who accesses VA health care. For this, it is useful to refer
to findings on those veterans returning from Afghanistan and Iraq who
participated in the Post-Deployment Health Re-Assessment (PDHRA)
program administered by DOD. Between February 2008 and September 2009,
approximately 119,000 returning veterans completed PDHRA assessments
using the most recent version of DOD's form. Of the more than 101,000
who screened negative for PTSD, 43,681 came to VA for health care
services (43 percent). Among 17,853 who screened positive for PTSD,
12,674 came to VA for health care services (71 percent). These findings
demonstrate that veterans screening positive for PTSD were
substantially more likely to come to VA for care. Findings about
depression were similar. Both sets of findings support earlier evidence
that those veterans who come to VA are those who are more likely to
need care and to be at higher risk for suicide. The increased risk
factors for suicide among those who came to VA is often referred to as
a case mix difference.
Working with the Centers for Disease Control and Prevention's
National Violent Death Reporting System, VA recently calculated rates
of suicide for all veterans, including those using VA health care
services and those who do not. This analysis included data from 16
states for individuals aged 18-29, 30-64, and 65 and older for the
years 2005, 2006, and 2007 (during the period of VA's mental health
enhancement process). The year 2005 marked the beginning of
enhancement, while the year 2007 is the most recent one for which data
are available.
Suicide rates for veterans using VA health care services aged 30-
64, and those 65 and above were higher than rates for non-users, and
they remained higher from 2005 to 2007, probably a reflection of the
case mix discussed above. However, findings for those aged 18-29 were
quite different. In 2005, younger veterans who came to VA for health
care services were 16 percent more likely to die from suicide than
those who did not. However, by 2006, those younger veterans who came to
VA were 27 percent less likely to die from suicide, and by 2007, they
were 30 percent less likely. This difference appears to reflect a
benefit of VA's enhancement of its mental health programs, specifically
for those young veterans who are most likely to have returned from
deployment and to be new to the system.
Because the number of veterans from the 16 States in this group is
relatively low, the rates are, for statistical reasons, variable.
Nevertheless, they demonstrate important effects. In 2005, 2006, and
2007, respectively, those who came to VA were 56, 73, and 67 percent
less likely to die from suicide. Those who utilized VA services were,
to some extent, protected from suicide with an effect that appeared to
increase during the time of VA's mental health enhancements. More
broadly, the rate of suicide among veterans receiving health care from
VA has declined steadily since fiscal year 2001; specifically, the rate
declined more than 12 percent during this time. From a public health
perspective, the decline in rates is significant, corresponding to
about 250 fewer lives lost as a result of suicide.
conclusion
In conclusion, thank you again for the opportunity to speak about
VA's efforts to treat and reduce TBI, PTSD, and suicide among
servicemembers and veterans.
Chairman Levin. Thank you very much, Dr. Jesse.
Thanks to the VA also for the important work that they do
in this area, and the joint work that is being done between the
VA and DOD.
We are lucky that the chairman of the Senate Veterans'
Affairs Committee, Senator Akaka, is also on the Armed Services
Committee, which has allowed us to do a lot better with
coordination on these matters. It's a real break for us, and
more importantly, for our troops and our veterans, that Senator
Akaka is a member of this committee.
Let's try a 7-minute first round for questions.
General Chiarelli, let me start with you. A couple of weeks
ago, National Public Radio reported that the military is
failing to diagnose brain injuries in troops who served in Iraq
and Afghanistan, that the injuries were not documented on the
battlefield, and that soldiers with TBI don't always get the
best medical treatment. Interviews of soldiers at Fort Bliss
revealed that some soldiers with TBI, who were crying out for
help, still had to wait more than a month to see a neurologist.
Also, they reported that many military doctors have failed to
accurately diagnose TBI. Can you give us your response to those
reports?
General Chiarelli. Mr. Chairman, I provided a complete
response to National Public Radio in which I detailed my
problems with the report. I have three basic problems with the
report:
Number one, it criticized the leadership for not caring or
not doing anything about it. I think that's far from the truth.
I took great exception with the report stating that our
doctors don't seem to care, and are not properly diagnosing
these injuries, without explaining the real issue here. You
cannot isolate TBI without talking about PTSD.
As I mentioned in my opening statement, the comorbidity of
symptoms between these two make it very, very difficult for
doctors to make that diagnosis. Of my Army wounded warrior
population--the most severely wounded population I have, with a
single disqualifying injury of 30 percent or greater--60
percent have either TBI or PTSD--43 percent PTSD, 17 percent
TBI. I really believe that when you fail to talk about both
PTSD and TBI in this issue of comorbidity, you're doing a great
disservice, because, to state it flatly, our science on the
brain is just not as great as it is in other parts of our body.
Researchers are struggling today to find the linkages and to
learn everything they can about the brain, and because of this,
we're going to see some misdiagnosis.
I can tell you, of the folks that the National Public Radio
talked about, they had over 200 appointments apiece. There's no
doubt, you could go to any one of our posts and find soldiers
who are struggling because of our inability to nail down and to
diagnose exactly what treatment they need for these behavioral
health issues. But, I promise you, it is not for a lack of
trying or real care on the part of our doctors. Our leadership
is totally committed to working these issues.
Chairman Levin. In terms of the wait one of the soldiers
claimed it took a month or more to see a neurologist?
General Chiarelli. I will tell you that a neurologist is
not the answer, necessarily, to these soldiers' issues. I have
a total of 52 neurologists in the U.S. Army; 40 of them are
currently practicing. Forty, and that's when I include my child
neurologists. The team that will work with somebody on any
behavioral health issue is a team of a neurologist, possibly a
psychiatrist, nurse case manager, who will look at the entire
file or medical record of care given to that soldier, and work
to provide them the best that they can.
One of the problems we have here--I get this from talking
to doctors--is, the medications for PTSD and TBI are totally
different. So, if we misdiagnose, at the beginning, and provide
a diagnosis of PTSD, when in reality it's TBI, the medications
we're going to put that soldier on are going to be different
than what the real problem is, and may be different from
another behavioral health issue that that soldier may have,
because it's not all TBI and PSTD. There's anxiety issues,
depression issues, other issues that are the product of these
wars, that are causing us so much difficulty in this area.
I have 79 percent of the psychiatrists currently assigned
to the U.S. Army, based on my authorization prior to 2001. I
know that that authorization is lacking, but I only have 79
percent. It's not just an Army problem. This, I think you will
all agree, is a national problem, a shortage of behavioral
health specialists.
Chairman Levin. So, there are some areas of professional
need where we are short. Is this a matter of funding? Is this a
matter of finding people? Or, what is it?
General Chiarelli. No, I don't believe it's a matter of
funding at all. I think it's a matter of finding folks, getting
them to move to some of the places where the Army is stationed.
I think a psychiatrist might prefer to be in Nashville than in
Clarksville, TN. So, we have to rely on the TRICARE network,
many times, to provide some of the behavioral health
specialists that we need.
Chairman Levin. In terms of the delay issue, is the delay
the result of a lack of resources, in the cases that were
talked about on National Public Radio, or is that a matter of
the complexity which you just described?
General Chiarelli. I would argue it's the case of the
complexity, I really would. I'm not saying that, in every
instance, that we're getting soldiers in exactly when we want
them to be, but when soldiers are assigned to our Wounded
Warrior Transition Units (WTU), they have a primary care
manager, at the rate of 1 per 200, a primary care manager,
where you or I would have a primary care manager at a ratio of
1 to 1,200 to 1,500. They have a nurse case manager at a ratio
1 to 20, and they have a squad leader at a ratio to 1 to 10 or
less.
So, we've done everything we can to focus our resources,
our limited resources, in this area. But, I will tell you, we
are short behavioral health specialists.
Chairman Levin. But, again, that's not a funding issue?
General Chiarelli. It is not a funding issue.
Chairman Levin. All right.
Dr. Jesse, the VA, as you, I think, testified, screens all
of our Iraq and Afghan veterans who receive care from the VA
for TBI. Does that screening for TBI indicate that there is a
routine failure in the military to properly diagnose TBI before
you see that veteran, when they're still on Active Duty?
Dr. Jesse. No, sir. I don't think we can say that. The
problem with TBI is that there's no hard, fast diagnostic test.
There's not a lab test that you can send off and get a solid
answer back. The other one is that of temporal issues--often it
takes time for it to manifest some of the effects that show up.
So, I don't think that it's a failure, on DOD side, to find
these people. I think, it may just be the complexity of
disease, as you've heard, takes time to manifest in ways that
we can then identify it.
Chairman Levin. Thank you.
My time's up.
Senator Inhofe.
Senator Inhofe. Thank you, Mr. Chairman.
Chairman Levin. Again, thank you, Senator, for your
initiative in this area.
Senator Inhofe. Yes, sir.
Oddly enough, of all of the subcommittees of the Armed
Services Committee, the one I've never served on is Personnel.
I don't know a lot about these issues. But, when it was called
to my attention, the propensity of these suicides, and we
started looking into it, I made the request, Mr. Chairman--and,
also the request, which I think you may be doing in another
hearing, actually bringing in some of the medical experts and
soldiers, with their experiences.
General Chiarelli, I know that you have really made a study
of this thing. It was in your written testimony that on Active
Duty, you've actually had a reduction in suicides, but an
increase in the Reserve component. Is this correct?
General Chiarelli. That's correct, Senator.
Senator Inhofe. I can remember back during the 1990s, when
we were downsizing the military. Then, of course, when
September 11 happened, we have all these deployments--everybody
up on this side of the table hears from our people back home,
our Guard and Reserve, the OPTEMPO is just not livable. That
goes all the way across Services. I would think that, since you
made that statement, that perhaps the OPTEMPO might be some
leading cause of these, in that the OPTEMPO for the Reserve and
the Guard is much higher. Do you see that relationship?
General Chiarelli. I see that as one of the factors,
Senator. We've had a decrease of 15 Active component suicides
this year, compared to last year. When I talk Active, I'm
talking about the 547,400 we have in the Active component
force, plus about 200,000 that are mobilized at any one time
out of the Reserve and National Guard. It's about a 700,000-
person force.
Once a Reserve soldier is made an Active Duty soldier, he
is counted in my Active component numbers. We are down 15. We
are down two with our Reserve component soldiers not on Active
Duty. We are up 21 in our National Guard soldiers who are not
on Active Duty, and that concerns me greatly.
It's three things. I think its multiple deployments for
them. I don't think we're getting enough time with them at the
DEMOB station to give them the kind of behavioral health
checkouts that they need. Third, I think--Senator McCain said
it in his opening statement--this lack of human interaction, at
least with other soldiers, that they have when they leave the
Service within 5 to 7 days after a 12-month deployment, I
think, is a real issue here.
Senator Inhofe. OPTEMPO, that's what we're talking about.
There is an article--and perhaps you had implied that--on the
public radio thing, that that was not totally accurate. I agree
with you.
There's another article, from June 14, in USA Today. It was
pretty critical because it talked about the law that was passed
in 2008, and one of the main persons was this Representative
Bill Pascrell, of New Jersey--which said, there have to be both
``pre'' and ``post''--and apparently we're short on the
``post'' end of it. Can you elaborate on that a little bit?
General Chiarelli. Senator, we followed the law when it was
passed. The law stated that we were to use the Automated
Neuropsychological Assessment Metrics (ANAM) as a screening
tool in pre- and post-deployment. We still use the ANAM in
predeployment to get a baseline on cognitive skills of our
soldiers. But, what we found when we used the ANAM in post, was
that we were getting a number of false positives, a high number
of false positives, way too high. We were tying up our limited
behavioral health specialists in working their way through
these false positives from the ANAM.
Now, we still use the ANAM in post if a soldier
demonstrates any of the symptoms of TBI or any cognitive
issues. So, we are still using it. We're just not making it
mandatory for every soldier, so we don't take our short
behavioral health specialists and wade through a whole bunch of
false positives, which the test tended to produce.
We have other things that we're using. Virtual behavioral
health is something I'm very excited about, where we can give
every soldier a 30- to 40-minute triage session with a
behavioral health specialist, using the Internet putting
together a virtual net of providers who can take an entire
brigade and put everybody, from brigade commander to the
youngest private in that unit, through a 30- to 40-minute
screen. I mean, this is the kind of thing I would like to be
able to provide to Reserve component soldiers when they get
back, but I don't necessarily have the time necessary to do
that.
Senator Inhofe. I really appreciate the attention you've
given to this issue.
Do any of the rest of you want to comment on that, in terms
of how it relates to the provision that was passed in 2008 in
our authorization bill?
General Chandler. Senator, if I could, I would say that we
still use the ANAM, pre and post. We're fortunate, in a way,
based on the numbers that we're dealing with, that we can do
that, even with the false positives. Like the Army, we also
have other tools that we use. We had a fair amount of success
with a Post-Deployment Health Assessment, which takes place in
theater, face to face, or shortly after return. One of the
things that I think is very important is, 6 months later,
there's a post-deployment health reassessment. That assessment
has yielded 16 percent of those airmen that we're treating for
post-deployment stress syndrome. We think that 6-month follow
up is extremely important, as well.
Senator Inhofe. All right.
General Amos. Senator, we're in agreement with the Army and
the other Services here. We test, using the ANAM test, 100
percent of our marines, prior to deployment. We are not doing
that when they come back. It is used occasionally by our mental
health professionals, if they don't have anything better. But,
the issue of false positives, and the lack of reliability in
the ANAM on the post-TBI incident, especially when you come
home, leads our Navy doctors, our mental health professionals,
to seek other ways to take a look at our marines. We're doing
that.
Much like General Chandler talked about, we screen both 100
percent of the marines as they're coming out of theater, and
then, within 90 to 180 days later, we do it again. Just to give
you some numbers, for PTS, 15 percent of those that are
screened coming out theater answer some questions positively,
which would lead you to further screening. Of that further
screening, 7 percent see mental health professionals. Then, by
the time you dwindle this thing down, it's about 2 percent of
the marines actually need mental health care when they come
out.
Senator Inhofe. Right.
General Amos. So, it's just not that reliable on the back
side, sir.
Senator Inhofe. That's very helpful. I appreciate that.
My time has expired, but I wanted to ask you a question
that could be answered for the record, if that's all right, Mr.
Chairman.
Chairman Levin. Yes.
Senator Inhofe. A January 14 article said, ``When Soldiers
Deploy, Family Deploys.'' It's talking about tying in the
OPTEMPO with the families, with the deployments. The New
England Journal of Medicine did a study. I read this article
and then did a little bit more research on some of the findings
that they're having, in terms of the families--the wives, the
kids--and nothing was really said during the opening statements
about that.
So, I'd like to have the four of you address what we might
be doing, in terms of the wives, the children, that might be
having the same problem in the same ratio that the troops
themselves, or the Active and the Reserve components are
having.
Thank you, Mr. Chairman.
[The information referred to follows:]
General Chiarelli. The Army provides a wide array of services,
training and support to soldiers, wives, and families in the early
detection and treatment of psychological problems. The Comprehensive
Behavioral Health System of Care mitigates the effects that the stress
of deployment can have on the mental well-being Army families.
Inpatient and outpatient behavioral health care is available to family
members through medical treatment facilities at every Army installation
that hosts families. The Army leverages local healthcare providers in
the surrounding installation communities through the TRICARE network
system. TRICARE covers medically and psychologically necessary
behavioral health care services for family members to include
individual, family, and group therapies, collateral visits,
psychoanalysis, psychological testing, inpatient hospitalization,
partial hospitalization and residential treatment.
Other programs that provide training and behavioral health services
to Army families include Army Community Service; Battlemind; Child,
Adolescent and Family Behavioral Health; Family Assistance for
Maintaining Excellence; Military OneSource; Psychological Health in
Schools Programs; and the Warrior Resiliency Program. Through these
services and programs, family members receive help to deal with
depression, anxiety, behavioral health symptoms, and reintegration.
These services also provide crisis intervention, classroom
intervention, individual therapy, and resilience training.
Admiral Greenert. Operational Stress Control (OSC) is the Navy's
comprehensive prevention and awareness initiative to address the
psychological health needs of sailors and their families and reduce the
stigma associated with seeking assistance. The initiative is led by
operational leadership and supported by Navy Medicine. OSC provides
practical decisionmaking tools for sailors, leaders, and families to
identify stress responses and mitigate problematic tension. The Stress
Continuum is an evidence-informed model that highlights shared
responsibility by sailors, family members, and Navy leadership for
maintaining optimum psychological health. The model is used to
recognize and intervene early, when indicators of stress reactions or
injuries are present, before an individual develops a serious stress
illness, such as Post-Traumatic Stress Disorder or depression.
Working in collaboration with Navy Medicine, Fleet and Family
Support Programs (FFSP) have launched an OSC awareness effort focusing
on family members. OSC concepts are being incorporated into existing,
regularly scheduled family support services such as predeployment and
stress management workshops, Family Readiness Groups, Ombudsmen
training, transition assistance workshops, parenting classes, and
clinical counseling sessions, to familiarize family members with the
concepts and stress continuum language. This information provides
family members a framework from which they can identify behaviors/
symptoms early and speak to someone about obtaining help for
themselves, their children, or their military loved one.
Brief, solution-focused clinical counseling provided in Fleet and
Family Support Centers (FFSC) is another avenue where military and
family members can seek consultation and assistance from licensed
mental health professionals for commonly occurring situations and
adjustment issues before more significant problems develop that require
medical or psychiatric intervention. Placement of clinical counselors
for children in FFSCs and Behavioral Health Consultants in Child
Development Centers help identify and provide assistance to children
who are adversely impacted by their parent's deployment.
General Amos. The Marine Corps does not maintain surveillance of
the rates of mental illness among Marine dependents. There is no
evidence to indicate that rates of mental illness are higher among the
Marine dependent population than in a similar civilian population.
However, the leadership of the Marine Corps is acutely aware of the
stresses borne by Marine families as a result of deployments in support
of military operations overseas and is constantly making improvements
in the support provided to the physical and psychological health of
Marine families.
A full spectrum of mental health care is provided to Marine
dependents through TRICARE. Direct care, where available, is provided
by the Navy military treatment facilities which support the Marines.
Where care is not available through the direct care system, it is
provided through the TRICARE network.
Additional resources are available to support military dependents.
Marine Corps Community Services provides counseling and referral
services and conducts activities to facilitate return and reintegration
of families following deployment. Navy chaplains supporting Marine
Corps can provide spiritual counseling and informal referral to the
mental health care system. Military OneSource is available to provide
confidential life skills advice and up to six sessions with a mental
health counselor. The Exceptional Family Member Program provides a
spectrum of services and referral to Marine families with members who
have ongoing physical, psychological and emotional challenges.
Educational and Developmental Intervention Services are provided by
BUMED to children with physical or psychological needs related to their
education. Families Over-Coming Under Stress (FOCUS) is a very
successful program which provides developmentally appropriate
education, family-centered skill building and social support for
families of deployed servicemembers, particularly focused on children
with deployed, injured, or deceased parents.
General Chandler. The mental health of families is of significant
concern to the Air Force (AF) as family support is essential for
effective functioning of our servicemembers. The AF has had an increase
in utilization of mental health services over the past 5 years at
military treatment facilities and the TRICARE network. AF health care
records show that approximately 16,000 active duty family member
beneficiaries (approximately 3 percent of all beneficiaries) have a
primary diagnosis of some form of depression. This compares to an
estimated national prevalence of depression of approximately 10
percent.
AF Airman and Family Readiness Centers (A&FRC) champion the
resilience of AF families by offering proactive services and programs
to assist in identifying and resolving concerns brought about by
personal and familial stress. Those programs include support across the
entire cycle of deployment; contracted non-medical counseling by
licensed mental health professionals; emergency financial assistance
through the AF Aid Society; advocacy for military child education and
families with special needs; consultations on personal financial
readiness, spouse employment, relocation and transition assistance; and
information and referral to other appropriate agencies.
In addition to the services available through the A&FRC, more
formal mental health care is also available.
Mental health visits: Beneficiaries have access to mental health
treatment in both outpatient and inpatient settings. In the AF, due to
the primacy of the mission to active duty airmen, most care to family
members is arranged through the TRICARE network.
Behavioral Health in primary care: Studies show that half of all
medical visits for mental health concerns occur in primary care
clinics. Often this is enough, but over 60 percent of AF medical
treatment facilities have behavioral health providers embedded within
them. Seeing a mental health provider in primary care is a lower-stigma
alternative and typically involves a few visits for a focused
intervention. No separate mental health charting is necessary.
The TRICARE Assistance Program (TRIAP): TRIAP offers web-based
counseling for adult beneficiaries.
Chairman Levin. Thank you, Senator Inhofe.
Now, Senator Inhofe, made reference to a bill that has been
introduced by Congressman Bill Pascrell, who was the cofounder
and cochair of the Congressional Brain Injury Task Force. We
have received a statement from him, which we will make part of
the record.
[The information referred to follows:]
Prepared Statement by Congressman Bill Pascrell, Jr.
Mr. Chairman, in 2001, I cofounded the Congressional Brain Injury
Task Force with former Congressman Jim Greenwood of Pennsylvania. At
that time, there was little awareness and understanding of traumatic
brain injury and the issue was generally seen as problem in the
civilian realm. In contrast, today this issue has become most pressing
as roughly 1 of out 5 veterans of Operation Enduring Freedom and
Operation Iraqi Freedom are estimated to experience a possible
traumatic brain injury and as traumatic brain injury has been
recognized as the ``signature injury of the war.''
This month, the media extensively covered the military's failure to
identify, diagnose, record, and treat brain injuries. NPR and
ProPublica found that while millions of dollars have been pumped in the
system since 2007, there have been few results. Furthermore, USA Today
found that the Pentagon ``failed to comply with a congressional
directive to give all troops tests before and after'' combat.
To give some background, in 2007, through the fiscal year 2007
supplemental appropriations bill, Public Law 110-28, Congress gave the
Department of Defense $900 million to increase access, treatment, and
research for traumatic brain injury and post-traumatic stress disorder.
In 2008, my colleagues and I put in place protections for the troops in
the National Defense Authorization Act for Fiscal Year 2008, Public Law
110-181, requiring cognitive screenings of soldiers pre-deployment and
post-deployment. Two years later, the law has yet to be fulfilled as
less than 1 percent of approximately 560,000 members of the Armed
Forces have been given a post-deployment cognitive screening in order
to identify any possible brain injury.
We have let too many soldiers fall through the cracks and we cannot
continue to wait as our soldiers continue to come home from the
battlefield, without the proper diagnoses. The Department today uses
two different tests on soldiers pre-deployment and post-deployment.
These tests are not comparable and cannot detect changes to a soldier's
brain. To correct this, I included language in the 2011 Defense
Authorization bill, H.R. 5136, to require the same cognitive screening
tool be used pre-deployment and post-deployment to detect any cognitive
change in our soldiers and also to require the Department of Defense to
complete the studies necessary to find the best cognitive assessment
tools for our troops.
Over the last few years, Congress has continued to emphasize the
importance of this issue and has made funds available for the
identification and treatment of brain injuries in our soldiers. I am
disappointed that after so many Members of Congress weighed in on this
matter, that we must again push to have this problem addressed. I hope
that this hearing will help the Department to better understand our
goals and that they will be willing to demonstrate their desire to put
strong policies in place to identify, diagnose, record, and treat brain
injury for not only our troops who are currently still deployed, but
also for the soldiers that we have missed since the beginning of these
wars. I thank the Chairman for holding this hearing and look forward to
working with members as well as the Department of Defense to help our
soldiers in this area of need.
Chairman Levin. Senator Akaka.
Senator Akaka. Thank you very much, Mr. Chairman, for
scheduling this hearing on these vitally important topics.
I want to thank my brother and friend Senator Inhofe for
helping to bring this about.
I want to welcome our distinguished group of witnesses, and
thank each of you for your dedicated service to our country. I
also want to thank the men and women that you lead, and thank
them for their outstanding service.
Like you, the topics at hand today are ones that I care
deeply about. Continuing to work with you and my colleagues, we
can refine efforts to prevent military suicides and to look for
better ways to detect, treat, and care for those suffering from
invisible wounds of war.
General Chiarelli and General Amos, suicide prevention is
difficult and challenging. For all of you on our panel, this
has come about, of course, because of what we call ``combat
stress.'' As was mentioned, this includes PTSD, TBI, and
behavioral health issues that we are facing here.
As was previously stated, the Services have experienced a
rise in the number of suicides since the wars in Afghanistan
and Iraq started. There is a need to understand suicide, look
at the causes, and get a point where we can prevent it.
Generals Chiarelli and Amos, and also Dr. Jesse, how can
the DOD and VA better collaborate in the area of suicide
research and prevention? This has been mentioned, by General
Chiarelli, as a great need here. I'd like to have the three of
you give your perspectives on this.
General Chiarelli?
General Chiarelli. I will argue, the cooperation between
the VA and the Services, I believe, has never been better. I
think the disability evaluation system (DES) pilot that we're
running at different installations is proving to be a great
success for the U.S. Army. The wonderful thing about this is,
is that when a soldier goes through the DES, we ensure, that,
if they are leaving the Service, that they're in the VA system.
This is something that has never happened before, as far as I
know it. It is a wonderful benefit of this system, that when a
soldier makes the decision to leave the Service, he or she is
in that VA system. Before, we would, in fact, have soldiers
separate, and it would be their responsibility to work their
way through the process to get in to receive both their medical
benefits and other benefits through the VA system.
I think that you've hit upon a key piece here, and that is
stressors. But, it's not only combat stress, it's individual
soldier stress and family stress. When we look at those across
a continuum, what we're seeing in the Army, with the high
OPTEMPO that we're on today, that a soldier, in the first 6
years he or she spends in the U.S. Army, has the cumulative
stressors of an average American throughout their entire life.
That's when you combine high OPTEMPO, individual soldier
stressors, and family stressors.
This is an area we're looking at very, very hard. When you
realize that 79 percent of our suicides last year were
soldiers, 60 percent in their first term, 79 percent one
deployment or no deployments, I think, it points to doing
everything we possibly can to mitigate those stressors,
whenever possible, and as we're working so hard to do in the
Army, work to increase the resiliency of our soldiers,
particularly in their younger years.
Senator Akaka. Thank you.
General Amos?
General Amos. Senator, I'll be happy to talk about, not
only the relationship, but the handoff between the military
and, in my backyard, the Marine Corps and the Veterans
Administration. Like General Chiarelli, I have never seen it
better. The entire organization is well led, from the top down,
from VA. They are compassionate. They are passionate about the
care of our young men and women that enter their system. I've
never seen it better. I'm fortunate to get to travel around and
visit a lot of our VA hospitals and our wounded, and I come
away just completely wowed by what I see.
There is a systematic handoff. In the Marine Corps, this is
done through what we call our Recovery Care Coordinators. We
have them around the Nation, and they are not part of the
Federal Recovery, but they are linked to it--but, they are U.S.
marines whose job and life is to know everything they can about
the VA system. So, when a marine transitions--especially one of
our wounded marines--out heading into VA-land after a
disability board, and he's moving on to the next half of his
life, that Recovery Care Coordinator contacts a Federal
Recovery Care Coordinator, the District Injured Support Marine
we have out there, our network of Marine for Life, to put our
arms around this guy.
I've seen it firsthand, where the actual handoff for a
needy marine, in some cases 2 years after the initial injury--I
just saw this about last month, down in Corpus Christi, TX. A
young marine, TBI, 2 years ago, his life is unraveled right
now. Through the Federal Recovery Coordinator and the VA in San
Antonio, and our Care Coordinator, we were able to plug this
marine, get him back into a hospital right now for further
care.
So, I've never seen it better, Senator.
Senator Akaka. Yes.
Let me ask, Admiral Greenert, for your comments, as well as
General Chandler, after you.
Admiral Greenert. Thank you, Senator. I think General
Chiarelli and General Amos hit the nail on the head. The
cooperation is very good. In fact, we meet monthly with the
leadership of the VA and leadership of DOD to streamline the
DES.
I would say that what we are finding in our study of
suicides, the transitional period seems to be a spike in
stressors. This is an area we need to watch very closely, this
transition period, and be sure that our sailors have the social
support network that they've had as they've moved through their
career in the Navy, as long as it is. It's also a focus area,
to watch out for those stressors.
Thank you.
Senator Akaka. General Chandler?
General Chandler. Senator, we have approximately 700 airmen
in our Wounded Warrior Program. These are young men and women
whose lives have been changed forever, and that we are
dedicated to taking care of, from the time they've been wounded
until they no longer need our services in the Air Force, and we
make the transition to the Federal system, if, in fact, that's
required and we're not able to bring them back to the Air
Force.
We use much of the same system that General Amos described,
with Care Recovery Coordinators that allow us to do that around
the Nation, to service the young men and women that require
that kind of treatment and that kind of handling. We're very
comfortable with our relationship with the VA and the way
that's working.
Senator Akaka. I'm glad that we've been working on what we
call ``seamless transition.'' It appears that we are moving
along on that.
Dr. Jesse?
Dr. Jesse. Thank you, sir. So, as not to reiterate things
that have already been said, I'd just like to point out a
couple areas where this level of integration has really become
manifest. The first is in the post-deployment and health
reassessment exercises. The VA generally has a presence at
those exercises, not to administer the exams, but to be present
to make sure that those servicemembers are aware of all of
their benefits that the VA can provide. But, also, if there are
immediate health, and particularly mental health, issues that
arise, that they are there and can literally make an
appointment on the spot. They can get them enrolled in the VA,
make an appointment. If we need to take them into our care at
that point, we can do that, so that we participate in that.
The second is the polytrauma networks, which really are--
while the VA has four, and going on five now, Polytrauma
Centers of Care, are very tightly integrated into the Wounded
Warrior Programs at Walter Reed and Bethesda. In fact, I had
the real honor to accompany Deputy Secretary Gould and Dr.
Stanley on a tour of Walter Reed, and then come directly down
to Richmond and look at the seamless way that both patients and
their information move back and forth through those networks,
including the fact that there are VA representatives stationed
in the DOD facilities, and DOD clinicians in the VA Polytrauma
Centers, so that we ensure that any movement of patient is a
warm handoff and not just being sent to another place.
Finally, in the mental health area, I think there's just
been an extraordinary collaboration going on for some time now.
There was a joint conference, in the fall of 2009, that led to
an integrated VA/DOD strategic plan. The real goal was to make
sure that when, for instance there are evidence-based therapies
for treatment of PTSD, that the VA and the Services agree on
how we treat those patients so that as treatment begins in the
Services, and then transitions in the VA, we're not abruptly
stopping one form of therapy and entering into another. I think
this is a hugely important point of collaboration, that we've
gotten that far.
Senator Akaka. Thank you for your responses.
Thank you, Mr. Chairman.
Chairman Levin. Thank you, Senator Akaka.
The testimony of our witnesses, saying that the integration
of planning and diagnosis and treatment of our troops that are
veterans is going along at a good pace, is important news to
both of our committees. It's something we put a great focus on,
both Veterans Affairs and Armed Services. Our wounded warrior
legislation was aimed at accomplishing that. So, this is
important testimony, and good to hear.
Senator Collins.
Senator Collins. Thank you, Mr. Chairman.
General Chiarelli, I want to follow up on a question that
Senator Inhofe asked you.
Senator Inhofe, I want to thank you for suggesting this
hearing, as well as the chairman, for holding this important
hearing.
In the past year, I have met with a retired general in my
State, with returning members of the National Guard, and with a
whole variety of healthcare professionals, to discuss the
mental health needs of our troops and the troubling rise in
suicides. To a person, each of them has told me that it's
insufficient dwell time between deployments that they believe
is the biggest factor, that there's not sufficient recovery
time before deployments occur again. How important do you think
that factor is to the increase in problems with mental health
and the suicide rates?
General Chiarelli. I think, for the National Guard
soldiers, it may be higher than we're seeing with the Active
component soldiers. As I indicated, 79 percent of our suicides
last year were soldiers who had never deployed or only deployed
one time. So, that would argue that, in that group of 700,000,
there's a bit of resilience that grows with repeated
deployments. I'm just giving you the numbers we're seeing out
of NIMH, and as we start to pull the early results.
I really believe, though, the real issue here for our
National Guard soldiers is that, when they come back off of
multiple deployments, that second or third deployment, that we
have sufficient time at the DEMOB station to do the kind of
medical tests, such as a virtual behavioral health counseling
or other things, to ensure that, number one, we get a good read
on how they're doing; and, number two, that they fully
understand the medical benefits that they're going to have when
they return to their State.
One of the hardest things for any of us is that the
benefits for a National Guard soldier differ from State to
State. We've made great progress with TRICARE Reserve Plus. You
add that to the Transitional Assistance Management Program,
which gives you 6 months of care when you come back home. If we
can get the soldier to enroll in TRICARE Reserve Plus, we can
provide them continuous medical care to the next deployment. I
think this is critical.
I think we have to look at this population a little bit
differently, and, again, as Senator McCain said, I am able to
wrap leaders around returning Active component soldiers for the
entire time that they're back. We take a Reserve component
soldier today and, within 5 to 7 days, he's back in his
community, on his own.
Senator Collins. A related problem, at least in a rural
State like mine, is an absence of mental health professionals
in those rural communities. Even though the VA will provide the
assistance, or the National Guard will provide the assistance,
it's often many hours away. That's a problem that's in our
society as a whole, and you've mentioned the shortages that
you're facing, and that it's difficult to match the mental
health professionals where bases may be located. But, that's an
even worse problem when you're talking about National Guard
members or reservists who are going back to their home
communities, their regular jobs in small communities that may
not have any mental health professionals at all.
General Chiarelli. If I could just quickly comment.
Senator Collins. Yes.
General Chiarelli. We started a program, last August, which
gives counseling, 24-7, without a TRICARE referral, to anyone
who's authorized for TRICARE. It is done online. It falls short
of psychotherapy or prescription pain management, so we can't
do that online. But, where I really see us making up for this
shortage is to really explore what we can do with tele-
behavioral health.
Senator Collins. I agree.
General Chiarelli. Because this gets at the stigma issues,
it gets at the kind of shortages you're talking about in rural
areas, Senator. I really think that this is something that will
fix us now, rather than wait until we grow the necessary
providers that we need over time. I really think we should be
exploring this as hard as we possibly can.
Senator Collins. I completely agree. There's great
potential, particularly since so many of these young troops
have access to computers in their own homes, because the stigma
still is there. Despite all of our efforts, it's still there.
So, I'm delighted to hear you put an emphasis on that.
General Amos, even though we've given a lot of attention to
the Army's rising suicide problem, I was struck to see, in
2009, that the branch with the highest rate of suicides among
Active Duty personnel was actually the Marine Corps. The Army's
clearly done a great deal, is the Marine Corps matching that
effort, in stepping up your programs and trying to tailor them
to the culture of the marines?
General Amos. Senator, that's a great question. The short
answer is: absolutely, yes. We are joined at the hip with our
programs that we mutually share cross-boundary. We are aware of
all that each of the other Services do. We collaborate. We
share best practices. We steal good ideas from one another. So,
the answer is yes.
In 2009, we led the Department of the Defense in suicides,
percentage-wise. We had 52. That's double what we had in 2005,
when we had 25. So, you ask yourself, ``What is it that's
caused this?'' We don't have all the answers on this thing, and
you wouldn't expect me to, but you would expect me to be trying
to find out and do something about it.
Interestingly, the Marine Corps is the youngest Service,
age-wise, of all the other Services; for instance, 67 percent
of all of our 202,000 marines, between the ages of 17 and 25.
If you compare that to the other Services, we are woefully
more--when I say ``immature,'' I'm just talking about years--as
a whole-cloth force. So, that, in and of itself, causes some
issues. Our population, where our marines are killing
themselves, are between 17 and about 23/24; it's male; it's
about half married, half single; white. The deployment--for
instance, this year alone, we've had nine young marines take
their lives that had never seen their deployment. We have had
marines come right out of boot camp, and, after having spent 12
weeks in what is arguably a ``legendary boot camp,'' which
calls out an awful lot of folks who just can't handle the
stress, they kill themselves. They go home on leave, and every
now and then they'll take their life. They've never seen
deployment one, and they've just completed the most rigorous,
probably, physical and mental examination that they've ever had
in their life. So, what causes that?
We had a young lance corporal just check into his unit, who
were deployed in Afghanistan 2 weeks ago, his very first day,
he goes on duty, walks outside the perimeter, and shoots
himself. He did this--as you, kind of, do the forensics on this
thing--his girlfriend left him just before he left. He has
issues with his family at home, his mother and father, and so,
these are the kind of things that we're seeing.
So, what are we doing about it? First and foremost, in our
organization we're focusing on the leadership of the Marine
Corps. I know that sounds trite, but we're an organization
that's based on leadership, everything we do. So, we start with
the very top. The Commandant of the Marine Corps, the Sergeant
Major of the Marine Corps, are adamant about this, and it's
flowed all the way down through our senior leadership, that we
have to absolutely pay attention to this. This is not something
to be taken lightly, and it is an issue. So, that's the first
thing, the senior leaders' focus.
It took us about 6 months to develop--we pioneered it about
last July, a NCO suicide prevention half-day course. It's film,
it's in the vernacular of the NCOs, because looking at that
population of our young marines that are taking their lives,
it's that 17-to-22/23. That's where the NCOs--they own those
marines. They know them better than anybody. So, we focused
this effort on them. High reviews, just great reviews from the
NCOs. One-hundred percent of our NCOs have gone through this
thing, and they're taking that training down to the young
marines below them.
Interestingly, we've seen a drop in suicides this year,
even though right now we are on the same plateau as we were
last year. That's probably not very encouraging, but if you
consider this vector we've been on since 2005, which has been
very steeply vertical, the fact that we are even where we were
last year is an encouraging sign.
The further piece of news that's encouraging is, this NCO
course, it is too soon to tell, but last year, 92 percent of
our suicides were in this age group that I just described,
about 23 to 17, and a lot of them were NCOs. We've seen a drop
this year down to 84 percent, as of today. We've said, ``Okay.
Let's take a look at those real young marines, the privates
through lance corporals; let's take a look at the staff NCOs;
and let's take a look at our young officers, lieutenants to
captains, and let's build a very similar program.'' We're in
the throes of that right now. It should be published within the
next 2 to 3 months. We're going to do that whole thing for the
entire Marine Corps.
So, we think it's going to work. We think it has worked.
Too soon to tell. But, ma'am, we have increased our resiliency
training by--immersion training for our young marines, all that
predeployment stuff, trying to make our marines more resilient.
I have a list of things down here that I could go through.
But, I just want you to know this has our attention. This is
job one with the Marine Corps.
Senator Collins. Thank you.
Chairman Levin. Thank you, Senator Collins.
Senator Udall is next.
Senator Udall. Thank you, Mr. Chairman.
Good morning, to the panel.
General Chiarelli, I want to, in particular, note the
attention you've paid to these important issues. I had an
opportunity to travel with you to Fort Carson earlier this
year. I know you've immersed yourself in these difficult
discussions. I know we don't have all the answers yet, and
that's why we're holding the hearing, in part. I trust my
questions will be received in that spirit, as well.
I wasn't here earlier, during the questioning about the
ANAM test. I think you said that, while the Army uses it,
predeployment, for a baseline, you don't use it post-
deployment, not usually, because of the false positives that
often result, or result, to some extent of the time. Here's my
question. By definition, a baseline is supposed to give us
something to look back at, in the aftermath, a way to compare.
So, if we're not using, what is it, close to 600,000 pre-
deployment assessments to compare to the post-deployment
assessments, what are we doing with them? Why use ANAM at all
if it's not being used in that post-deployment situation?
General Chiarelli. Senator, I will tell you, we are using
the ANAM on post-deployment, but only if the soldier
demonstrates some kind of a symptom of having cognitive issues.
That may be cognitive issues that could be caused by TBI or
some other behavioral health issue.
So, the baseline is very, very important, because it gives
the doctor an additional tool that, when symptoms are
demonstrated, or in a post-deployment screening we have reason
to believe we should have that soldier go through the ANAM, we
go ahead and use it. What we're just not doing is doing a post-
deployment ANAM for every soldier irregardless--or regardless
of--my English teacher would have just been--thank you very
much.
Senator Udall. Mine too, General. [Laughter.]
General Chiarelli. Regardless of whether they show those
symptoms, because we were getting so many false positives. We
just don't have the behavioral health specialist folks, to work
through all those false positives and give the care we need to,
to the rest of those who need care.
Senator Udall. That's helpful, and we'll continue that
conversation. My next question will follow on that. I want to
talk about the post-deployment health assessment (PDHA). It's
supposed to catch things that weren't caught in theater, as I
understand it. A soon-to-be-published study has shown that the
standard screen on the PDHA fails to catch 40 percent of those
who sustained a TBI in theater. This comes from research at
Fort Carson, in my home State of Colorado.
I've been there, as I've mentioned, on a number of
occasions, to get briefings on how they're handling TBI
patients. I think they're doing it right. By using a more
thorough exam, with clinical interviews to augment the PDHA.
There's a concern, as I understand it, that individualized
approach would take too much time, and require scarce personnel
to administer, and that such an approach can't be replicated
across the force. But, I'm told that at Fort Carson it only
takes about 15 to 20 minutes of additional time to do this.
Could you speak to Fort Carson's approach and whether the
Army's looking at maybe applying this elsewhere?
General Chiarelli. I'll tell you, I disagree with Fort
Carson. I want them to institute the virtual behavioral health
screening, so that we can ensure that we get everyone. I don't
want to use any form. I don't want to use any series of
questions that automatically says that a soldier does not have
those issues. I think that what we really need to do is to get
to a standard that says we're going to give everyone a post-
deployment screen; follow that up, 90 days later and 180 days
later.
Here's my problem with the Fort Carson approach. The Fort
Carson approach focuses on soldiers with doctors that they have
assigned when they come back. They may get through a 15- to 20-
minute screening of a select population who's demonstrated,
based on a questionnaire, that they may have issues, they may
be medium to high risk. But, when you do that, you take away
the doctors that are providing care to those folks that we have
already found, because you're focusing on this group. That's
why this virtual network is so important, that you can do an
actual triage and get the number down to those that you can
treat with those people you have on base. I've had discussions
with Fort Carson about this.
I have to tell you, until I get doctors to use the virtual
method, many of them push back, and they push back because they
have never done this before. But what we're finding is that
those who go through it, the doctors--those doctors are the
biggest supporters of it, because we find that this generation,
in many times, opens up much greater using either Skype
technology or some kind of high-definition video teleconference
(VTC), even more so than sitting across a room, like you and I
are right here. They really feel they're able to get at some of
these issues and do a good evaluation.
Senator Udall. I respect the passion in your response.
Let's continue the conversation. Again, it points out General,
how involved you are, and how much you've paid attention to
details and soldiers.
Let me turn to another--perhaps a bit of a difficult
conversation that's tied to the National Public Radio story.
They report a term that's used by researchers, ``the miserable
minority,'' to refer to those who suffer from mild TBI, who
have long-term repercussions. It's true, from what I learned,
that most soldiers recover from mild TBI, but some who seem to
have symptoms persist for months or even years, and if you get
a repeat of a TBI incident, you can aggravate that mild TBI.
The National Public Radio story intercepted an email from
one of General Schoomaker's advisors, Dr. Hogue, who questioned
the importance of even identifying mild TBI accurately, asking,
quote, ``What's the harm in missing the diagnosis of mild
TBI?'' Can you help me understand whether finding ways to
diagnose and treat mild TBI is important to the Army?
General Chiarelli. It is extremely important to the Army.
Dr. Hogue represents a population of psychiatrists and
psychologists, quite frankly, you can find one who will support
just about any different way of attacking this. It is not this
well-developed science that we have in other areas, such as
heart surgery. I think the dialogue is good. I didn't
necessarily agree with Dr. Hogue when he wrote in the New
England Journal of Medicine. But, he did do a peer-reviewed
study where he talked about this.
I think the great disservice that National Public Radio did
to everyone was to try to isolate TBI from PTSD. That is just
not possible. As I indicated before, the comorbidity of these
two is what's giving us the difficulty today. I also think that
they did a disservice when they indicated that PTSD is a
psychological problem. It is not just a psychological problem.
It is a physical injury that occurs. If anything, I think could
be best described as a chemical injury, because that frontal
cortex doesn't turn on and stop the flow of those things that
keep a person at this altered state for 4 to 6 hours. So, I
think we have to look at these two together and realize the
real difficulty that doctors are having trying to separate and
understand the symptoms 100 percent in every single case.
Senator Udall. General, thanks. Let's continue this spirit
of discussion.
I want to thank all the members of the panel, as well, and
I thank you for your service.
Thank you.
Chairman Levin. Thank you, Senator Udall.
Senator McCaskill.
Senator McCaskill. Thank you, Mr. Chairman.
I thank all of you for being here.
There are basically three areas I'd like to try to cover,
quickly, that I think are important. An overarching concern is
that of confidentiality. So many of the issues surrounding
mental health, whether it is brought on by a brain injury or
whether it's brought on by substance abuse, alcohol abuse, or
prescription drug abuse, so much of the problem we have in the
military is the stigma associated with getting help,
particularly for Active military, Reserves, and National Guard.
I'm sure you all are aware of the pilot program that is
ongoing--I know General Chiarelli and I have talked about it--
for the confidentiality of alcohol and substance abuse
treatment at three different facilities, where these soldiers
are not being referred to their chain of command after they
have sought treatment.
General Chiarelli, could you address how that program is
going, and whether you think this pilot program shows real
potential for allowing folks to get help without the negative
impact to their careers that so many of them fear right now?
General Chiarelli. Tremendous potential. We've done it at
three installations. We started in Fort Carson in August 2009.
We're expanding it to two others. The only thing that's not--
and the secretary of the Army approved this, a month ago--the
only problem that we're having is trying to recruit the number
of drug and alcohol counselors that we need in order to ensure
that, when someone self-refers themselves for this problem,
that, in fact, they can be seen immediately and not be told,
``Well, come back 6 weeks from now and we'll take care of
you.'' But, we're seeing great results from the three
installations that we have started the pilot at.
Senator McCaskill. That leads to one of the other areas
that I wanted to cover today, and that is the availability of
counselors. In 2009 I was successful at getting a provision
that required the Institute of Medicine to assess whether
licensed mental health counselors should be allowed to practice
without supervision within the military for purposes of this
kind of counseling. That study was released in January, and
supported the conclusion that they should be able to practice
without that extra layer of supervisory personnel. I'm curious
now, with that, Do you see the ability for us to staff up at
more appropriate levels to get at this problem that we see, in
terms of availability of mental health professionals for our
men and women who need help?
General Chiarelli. Yes. This is a wonderful provision, and
we've come to about 92 percent of our pre-2001 authorization.
We've done an exhaustive study. Just as we reach, or are
getting close to reaching our goal, because of the increased
amount of drug and alcohol issues that we have in the Army--and
I'm not going to paper that over--we need about 225 more. So,
we have authorization to hire an additional 225, and this is
going to be a great help to us.
Senator McCaskill. I think it's so important that we look
at this as being just as important as so many of the other
tools we give to our fighting men and women. Our heroes need,
not just the protective armor of the battlefield, they need the
availability of help when they need it. I know that you've made
this a huge priority, I know all of you on this panel have.
I want to make sure that if there's anything that we can
do, as members of this committee, to continue to reinforce this
at the highest levels of leadership in our armed services, that
you let us know. The idea that we would stand between more help
for our men and women who are struggling, that we need to get
more people on board, is very frustrating. I want to make sure
that you know that there are many of us that want to go to
battle over this, if necessary.
That brings me to the final thing. Unfortunately, Missouri
has had one of the highest rates of suicide in our National
Guard. That is this notion of embedding, particularly for our
National Guard and our Reserves--embedding mental health
counselors within units. As you probably know, this has been
done in California, at a surprisingly low pricetag, because the
availability of the embed is for the weekends and for the 2-
week training, as opposed to 365 days, around the clock. That
help, during those weekends and during those weeks of training,
I think, it could be a huge assistance to our National Guard
members, and would want your reaction to that.
I know that we don't have a member of the Reserves on the
panel, or National Guard, but if----
General Chiarelli. No, I look for any way that I can get
behavioral health specialists down to National Guard units, and
I think embedding is an outstanding idea. I will work with the
surgeon generals but they have not brought that program to me.
We've been trying to expand at the telehealth capabilities to
our National Guard armories. But, I promise you, Senator, I'll
look into that and talk to the National Guard surgeon general
about just that.
Senator McCaskill. This is really important, because in
California, which has the largest Guard component in the
country, it has 40 different Guard units--the cost for 1 year
of mental health embeds was 820,000. That's a bargain,
particularly when we see this kind of increase.
We've lost five members of the National Guard in Missouri
already this year to suicide. That is something that is
unacceptable, and something we clearly--and I know the surgeon
general of the Missouri National Guard, General Danner, is very
concerned, and wants to move toward some kind of embed program.
I think the support of the people at this panel this morning
would be crucial for that to move forward. I think we could
also, obviously, do it for the Reserve units.
General Chiarelli. We need to look across the National
Guard, because as I indicated before, we've had an increase of
21 suicides across the National Guard, at the same time we're
down in all other categories. So, this really has my attention
and, I know, the attention of Ray Carpenter.
Senator McCaskill. Okay. I'll continue to follow up on
that.
Thank you, Mr. Chairman.
Chairman Levin. Thank you, Senator McCaskill.
Senator Begich.
Senator Begich. Thank you very much, Mr. Chairman.
I want to follow up, if I can, on just a few of the
comments and responses to some of the questions that were given
earlier.
First, General Chiarelli, I want to, one, thank you for the
work you're doing. You are definitely passionate about trying
to resolve this issue, or at least move forward in a positive
way, and I really appreciate that.
I appreciated your comments on telemedicine. I know, Dr.
Jesse, you've been subjected to my conversation before on this
issue, through the VA, for the Veterans Committee. I do believe
this is a huge opportunity that both the DOD and the VA can
really exploit in a positive way. With the new generation of
young people who--you think, 10 years back, where we were with
PDAs, telephones, cell phones, and computers, to where we are
today, is unbelievable. So, I'm curious, because I hear your
comment about some doctors push back on this new technology.
How are you getting them to see the value?
I say this in as polite way as I can. You're the military.
One thing I've learned about the military is, when you want to
do something, you just do it and get moving. I understand that
doctors have to grow into some of these things. But, time is of
the essence. What are you using to get these doctors to get on
step with telemedicine? Because that is the future, when it
comes to mental health services, especially in a State like
mine, where these folks come back from serving, and they're
sent back home, to a village--and I'll use the Guard as an
example--back to a village of 200 people. No medical services
that they can tap into, from a veteran's perspective. But, what
are you doing to get those doctors to get on step and get on
with the program, here?
General Chiarelli. We're doing exactly what you would
expect us to do now. We published an overall comprehensive
behavioral health plan. We're standardizing how we're going to
treat soldiers when they come back. Part of this time, I
believe we've seen a thousand flowers blooming, and I think
it's time----[Laughter.]
--to move away from that, ensuring that we look for
innovation and new kinds of treatments, but, at the same time,
we have standard program for returning soldiers, that not only
takes them from the day they return home, but at the 90-, 180-
daymark, when so many of us, I think, would agree, we start to
see many of these problems pop up.
Senator Begich. Right.
General Chiarelli. So, we're doing it exactly in the
military way that you allude to, Senator.
Senator Begich. Okay.
General Chiarelli. We're going to make sure that it's
standardized across our force.
Senator Begich. I think that's great.
Dr. Jesse, I know we've talked, but I'd love you to put on
here--I actually just saw some technology development, done by
an Alaska native corporation, on utilization of BlackBerrys,
PDAs, and others, on alcohol screening and alcohol abuse--kind
of, follow-up for those that decide to move forward. I saw that
technology, and it was impressive to me, because what it shows
is, it's reaching into how to get to these young men and women
in their world of technology, versus what we think is the right
way, bringing them into the office, sit them down. We're
touching them in a different way. So, that technology is very
unique, and I know the VA is starting to look at some of that.
Can you just put on the record a little bit of what you're
doing around electronic telemedicine?
Dr. Jesse. Sure. We have quite a long history in
telehealth, actually dating back even to the 1980s, with home
monitoring of pacemakers using TTM technology. We've invested
heavily in home telehealth by putting, if you will, ``boxes''
in patients' home. I think we have 43,000 of them deployed.
But, as you mention, the new technology is using smart phones,
where you don't even have to invest in something that ties
somebody to their home. Anybody who has a kid in their 20s now
knows you don't even bother to call them, you just text them.
Senator Begich. That's right.
Dr. Jesse. They don't answer their phone, but they'll text
you back.
Senator Begich. Right.
Dr. Jesse. Interestingly, as an example, you're all aware
of the VA's suicide hotline, which people can call in to, but,
about a year ago, they started a chat line for the younger
folks are much more used to chat lines on the Web than they are
to having phone conversations. That's been, I think, an
important emerging way to contact, for the younger people. So,
as we deploy that mental health technology, along with all of
other medical capabilities, using new technologies that the
people who need it understand and prefer to use, I think, is
going to be vital.
General Chiarelli. Could I mention one other thing?
Senator Begich. Please.
General Chiarelli. We just signed an MOU with the VA on
credentialing and privileging, which is a key and critical
piece, here. We can do that with the VA so their doctors can be
part of our virtual behavioral health----
Senator Begich. Excellent. Yes.
General Chiarelli. But, that is a real issue when you're
trying to provide the same kind of care across State lines, and
even within State lines. In the area of behavioral health, I
think we really need to look at some of those rules, and think
about, do they need to be the same for this branch of medicine
as they do, say, for a heart surgeon or someone else?
Senator Begich. You just got to my next question, so I'm
going to start with you and then come down the row here. I'll
leave my friend, Howie Chandler to last.
My next question is kind of the question that hasn't been
asked; I think Senator McCaskill started to get to it. What do
we need to do, here in Congress, to help make it easier for you
to deliver the services that you know, instinctively and as
well as data has shown you, to the young men and women? What
you just made a comment about, delivering these services over
State lines, or maybe you could elaborate. What are those one
or two things, each one of you, if you could just expand--
because part of what we should be doing here, honestly, is--
what do we need to do to support you? It's great to have a
hearing, but what's the next step?
General Chiarelli. I would mention credentialing and
privileging. Give you just a quick example. I can go ahead and
provide a TRICARE referral for a soldier at Fort Campbell,
Kentucky, to drive 100 miles to Nashville to see a
psychiatrist. I cannot hook him up over the Internet if he is
not at military installation, and privileged and credentialed
from that location. So, I can't hook into his office in
Nashville, yet I can put a soldier in a car and send him 100
miles to go see that doctor, as a TRICARE referral.
Senator Begich. Good example. My time is up, but if each
one of you can just give a quick one, and then I'll close out.
Thank you, Mr. Chairman.
Go ahead.
Admiral Greenert. Senator, for the Navy, if we could look
at the age of healthcare professional appointments and
mandatory retirements, there are a lot of people want to help,
out there, that may be over the age of 42. That, I think, if I
understand it right, is the limit for a lot of our healthcare
providers, particularly mental. That could be helpful.
Senator Begich. Very good.
General Amos. For the Marine Corps, your continued support
for our deployment cycles and in sustainment of our Marine
Corps while we are in between those deployment cycles, with
programs like the Yellow Ribbon Program, our Returning Warrior
Programs, those kinds of things that help our families--that is
a modest investment that has paid rich dividends. So, your
continued support on that would be great.
Senator Begich. General Chandler?
General Chandler. Senator, I would echo what my
counterparts have said, and also add to that, thanks for your
support for the bonuses and special pays. That has allowed us
to recruit, frankly, almost the numbers we need, in most areas.
We're suffering, as the Nation is, in a shortage of mental
health nurses. But, that's really the only shortage that's
dramatic at this point, and we appreciate your support for
that.
We've had some promising research at Lackland Air Force
Base, in San Antonio, with TBI and hyperbaric treatment. Any
support that we could receive in that area would also be very
helpful.
Thank you.
Senator Begich. Very good. Thank you very much.
Dr. Jesse, we've already had our conversation. I'll leave
that, if I can, because my time is expired. I'll be tapping
you, don't worry. [Laughter.]
Mr. Chairman.
Chairman Levin. Thank you, Senator Begich.
What kind of support do you need for that hyperbaric
treatment?
General Chandler. Sir, we're actually in our infancy, quite
honestly. If I can take that for the record and get back----
Chairman Levin. Is it a----
General Chandler.--in terms of costing.
But, as most things go, it becomes a personnel and dollar
issue. But, we've had some fairly promising results with
hyperbaric chamber treatment.
Chairman Levin. If you can just give us any example--and
this goes for all of you--where there is a funding shortfall on
the appropriations side, we would more than welcome it. We're
determined we're going to get you whatever funding you need to
address this issue.
[The information referred to follows:]
Congressional support for current Air Force (AF) hyperbaric oxygen
treatment (HBOT) for Traumatic Brain Injury (TBI) research is
sufficient and greatly appreciated. Department of Defense (DOD)
research on HBOT for TBI is in its infancy and is centered on chronic
mild and moderate TBI. It remains an unproven therapy and is not
accepted as a standard of care because only anecdotal case reports and
a small series of trial reports indicate some potential benefit for
TBI. Several prospective randomized clinical trials are underway within
DOD and civilian institutions to provide more conclusive evidence
regarding HBOT's use for TBI. Definitive phase 3 trials, which will
take 2-3 years and include randomized, multi-center (DOD facilities
only), double blind, definitive studies under the auspices of the Food
and Drug Administration with an investigational new drug registration,
are projected to start in fall 2010. If this research validates the
efficacy of HBOT for TBI, we will request additional congressional
support for the sustainment and possible expansion of hyperbaric
chambers and personnel in addition to presenting the evidence to the
Undersea and Hyperbaric Medical Society for consideration as an
accepted indication for use.
Chairman Levin. Senator Lieberman.
Senator Lieberman. Thanks, Mr. Chairman.
Thanks, to all of you. I apologize that I was drawn out to
another meeting in between.
I appreciate, very much, the work that all the Services are
doing on these problems, particularly, obviously, suicide
prevention programs. I know, for each of you, this is a deeply
personal issue, and I thank you for the time that you're
putting into it.
In my own work on this, I have become familiar with some
statistics that surprised me. I want to offer them, not to
diminish the problem that you and we are facing among
servicemembers, because every suicide is a tragedy, and we want
to prevent them all. But, what's interesting to me is that--and
obviously the most significant factor for all of us is the
extent to which the suicide rate among Active Duty U.S.
military personnel has increased, over the last decade, from
9.1 per 100,000 in 2001, to 15.6 per 100,000 in 2009. The
increase is in comparison to a rate among the civilian
population of 11.11 per 100,000 population. But, what's really
striking to me, and shows, really, a broader societal problem--
if you take out the young male population in the country--and
the military is still disproportionally composed of young
males, as compared to the overall population--the rate of
suicide among 18- to 24-year-old males is 17.8 percent.
This suggests a broader societal problem, which was a total
surprise to me as I went over the numbers. It doesn't diminish,
in any way, the importance of the efforts you are making, and
that we're trying to support you in making. But, what it says
is that rate of suicide among young males in military was
actually significantly lower than the general civilian
population. Certainly, a decade ago, now has come up, but still
is lower. Obviously, we'd like it to be zero.
But, I want to suggest, in these statements, no attempt to
minimize the problem, but to say that this cries out for some
larger societal response that deals with young males in our
society.
I don't know whether any of you want a chance to respond to
that.
General Chiarelli. If I could, real quick.
Senator Lieberman. Yes, General Chiarelli.
General Chiarelli. Sir, we've run across something that's
very, very interesting. As I indicated--I threw out some
numbers--but, when we look at the number of soldiers who are
first-termers----
Senator Lieberman. Right.
General Chiarelli.--who join the Army between the ages of
28 and 29, they account for three times their expected rate of
suicide. In other words, they're only 5 percent of the first-
term populations, but they account for 15 percent of the first-
term suicides, which would indicate that not only is it youth,
but it is also this combination of additional stressors.
Senator Lieberman. Interesting. Well, those are compelling
numbers.
Let me go on to another question. I apologize, I gather,
from staff, this hasn't been dealt with in depth, so I'll run
the risk of asking it again. This is the question of how the
Services diminish the understandable human fear, that anxiety
in a member of the Service, that going for help will be
detrimental to that serviceperson's career and advancement. I
know that the Air Force actually quantified that in their
study. But, my own sense, from conversations with members of
other Services, is that this is a pervasive problem. You all,
obviously, are deeply concerned about this and focused on how
to make it better. In some sense, my question is, how do you
transfer that concern down the chain of command so that
individual members of your Services feel that they can go for
help for a mental problem, just like you go for help if your
leg is bothering you?
General Chandler. Senator, I wouldn't minimize that problem
for the Air Force, quite frankly. I think it still exists, and
I think there is a stigma attached to that. I think the basic
answer to your question is, it becomes a leadership issue,
directly down to the senior NCOs and officers that look the
young men and women in the eye every day, that can recognize
whether or not they have an issue, and then act accordingly.
We have the same demographic issues that you described
earlier, in terms of young male airmen that are taking their
lives. We diverge a little bit from the other Services, in that
our biggest issue, in terms of suicide, are relationships;
about 70 percent of Air Force suicides involve relationship
issues of some kind.
Senator Lieberman. You mean within the military----
General Chandler. These are typically personal
relationships.
Senator Lieberman. Personal. Yes.
General Chandler. Second would be legal issues that a
member might have. Then, third, financial. Only 20 percent of
our suicide victims have been deployed in the last year. So, we
deviate, again, a little bit from the Army and the Marine
Corps, as we do that. But, if you look at the elements of the
Air Force where that occurs--those specific career fields--
those, in fact, are young male members, primarily in terms of
security forces, EOD--explosive ordinance disposal--and those
kinds of duties. But, at the same time, those career fields are
also under a fair amount of high OPTEMPO. Security forces are
at 1-to-1, in terms of dwell time.
So, I wouldn't minimize the way we get at this in the Air
Force, but we have moved our mental health care providers into
our primary care clinics, to try to keep people from having to
necessarily go someplace else, behind a curtain, to see a
mental health provider. Our airman family and readiness centers
also provide military health counselors, where you can actually
go get help with your family members or for yourself. Of
course, the Military OneSource provides, at no cost--I believe
the number is six visits that you can arrange for yourself to
do that. Again, all of these are confidential kinds of ways to
do this.
There are ways to get at it, including our Chaplain Corps,
which are all trained in suicide intervention, as well. We
approach this from a number of different directions. But, I
think the stigma issue is one that's going to be very, very
difficult to overcome.
Senator Lieberman. Thanks.
My time's up, but I wonder if any of the others of you want
to briefly comment on that. Essentially, what you're doing to
try to remove this----what General Chandler called--I think,
appropriately called, a stigma.
General Amos. Senator, you're absolutely right. I think
this is evolutionary. Just 5 years ago, we wouldn't have even
been talking about this in a battalion or a squadron or some
type of deployed unit. We would be sloughing this off. Now, my
sense in the Marine Corps is, we have the senior leadership of
the Marine Corps, both the enlisted and the officer side, that
are believers. They understand that this stigma is real and
that we have to set the conditions to get around it. I'm not
convinced that our middle-grade staff NCOs and our young
officers have the same sense of appreciation. I think it's
probably because they're younger, there's less----
Senator Lieberman. Right.
General Amos.--they've been exposed to it less. But, this
is a leadership issue that we're working on. To get around this
and to try to mitigate this, we've put mental health--we call
them OSCAR teams--we put them in the deploying battalions that
are forward-deployed. We have gone through--and that has mental
health providers, corpsmen; we brought our chaplains involved
in these things. Now we have embedded these units with every
single forward-deployed unit in Afghanistan right now. So,
we're trying to get away from that.
There's just a host of things we're trying to do to deviate
around this, or sneak around behind the backdoor of this stigma
thing--but, the last thing is, is that, on the suggestion of
our young marines, we are establishing, right now, with TRICARE
West, everything west of the Mississippi, a Marine Distress
Hotline. It's manned by marines, plugged into the TRICARE West
Region, 21,000 healthcare--mental health care providers. The
whole idea behind that, it's completely nonattribution. Family
members can use it 24 hours a day. You can call and say, ``I'm
having serious issues with PTSD,'' ``I'm having issues with
whatever.'' It's all anonymous.
Senator Lieberman. Right.
General Amos. So, we're working around it, Senator.
Senator Lieberman. Mr. Chairman, I know my time's up. I
leave it to you. I don't want to intrude on Senator Hagan's
time.
Chairman Levin. Admiral, that's fine. You can go ahead.
Admiral Greenert. Real quick, Senator, if I may. We have a,
kind of, statistically different situation. Our demographics
for those that committed suicide is sort of spread across the
age spectrum, and location and rating and seniority. The last
three suicides--we had a 40-year-old senior enlisted
individual, right before deployment; a 50-year-old captain
entering retirement; and an 18-year-old sailor, just out of
boot camp.
So, looking across that, our focus has been, no one's
immune to the stressors, and, if you can't deal with the
stressors, to a bad choice.
Senator Lieberman. Right.
Admiral Greenert. So, to us, as a leadership issue. We
focus on operational stress control and management. For those
that still have a stigma--and it does exist--we have what we
call Deployment Health Centers--there are 17 of them, they're
spread around where our fleet concentration area is--where
folks can go and see a clinician or a counselor, without the
stigma being attached. It's not attached to the hospital, it's
not attached to the fleet family support center; it's located
away, where our sailors feel more comfortable. We find that,
once they go there, then they'll see there's nothing wrong
seeking treatment, and they tend to migrate to the clinic.
Thank you.
Senator Lieberman. Good. Thank you.
Chairman Levin. Before I call on Senator Hagan, let me
mention this. I'm going to have to leave. There's a question,
that I'm going to ask you to answer for the record, about the
status of our Centers of Excellence for Traumatic Brain Injury.
[The information referred to follows:]
General Chiarelli, Admiral Greenert, General Amos, and General
Chandler, in the Wounded Warrior Act of 2008 (Public Law 110-417),
Congress mandated the establishment of Centers of Excellence to help
focus research projects, eliminate duplication of efforts, and to learn
and share best practices through collaboration with other Federal
agencies, academia, and the private sector. What is the current
relationship between each of the Services and the Centers of
Excellence?
General Chiarelli. The Suicide Prevention Program Managers from
each of the Services are represented in the Suicide Prevention and Risk
Reduction Committee (SPARRC), which is part of the Defense Centers of
Excellence (DCoE). To support Army family members, we promote and
utilize DCoE's resources, such as the DCoE Outreach Center, Real
Warriors Campaign, and Afterdeployment.org.
Admiral Greenert. Navy Medicine works collaboratively with the DCoE
for Psychological Health and Traumatic Brain Injury (TBI) and its
component centers: Defense and Veterans Brain Injury Center (DVBIC);
Center for the Study of Traumatic Stress (CSTS); Center for Deployment
Psychology (CDP); Deployment Health Clinical Center (DHCC); and the
National Center for Telehealth and Technology.
Navy Medicine also provides staff in support of the DCoE and is
working to ensure that professionals throughout Navy Medicine--
clinicians, researchers, educators and program managers--are working
with the DCoE to enhance research, education and outreach efforts.
Additionally, the Services support the other Centers of Excellence
by providing lead operational support as assigned by Assistant
Secretary of Defense for Health Affairs. Navy has the lead of the
Vision Center of Excellence which is focused on research and treatment
for improved vision care and restorative innovations for
servicemembers.
General Amos. The Marine Corps works collaboratively with the DCoE
for Psychological Health and TBI and its component centers: DVBIC;
CSTS; CDP; DHCC; and the National Center for Telehealth and Technology
(T2) on an ongoing basis. The interface for these interactions is
through various Headquarters level work centers, but principally Health
Services and Manpower and Reserve Affairs.
General Chandler. There is a Quad Services Meeting every week
between the DCoE, DVBIC, National Intrepid Center of Excellence, the
TRICARE Management Activity, and the four Services to discuss TBI
issues. This has been a great collaborative group.
Chairman Levin. If Senator Lieberman is not able to stay,
then I would ask Senator Hagan to adjourn the committee after
she is done.
Thank you.
Senator Hagan.
Senator Hagan. So, that means we might be here a while. No.
[Laughter.]
I think this is a very important hearing. I think anytime
we have one suicide, that's one too many, and certainly, the
numbers that we've been seeing are certainly unacceptable. So,
I really appreciate the time that the Services are putting into
helping address this issue.
General Chiarelli and General Amos, you have underscored
the importance of mental resiliency programs, proper and timely
diagnosis, transferring the culture of leadership with regards
to the invisible wounds, the strain of our forces, limited
dwell time; and personal problems, such as financial and
relationships, are certainly among the many challenges that we
have to overcome. However, we do have a responsibility to
effectively institute mental resiliency programs to prepare our
servicemembers for the combat stresses that they will
ultimately face. What are the Services doing to
institutionalize resiliency training at the predeployment and
the post-deployment stage?
General Chiarelli. Our program is comprehensive soldier
fitness. Senator, we've been working with the University of
Pennsylvania. We have trained over 1,200 master resilience
trainers, through a very intensive course. Our goal is to get
them down to every battalion in the U.S. Army. We are focusing
those trainers, right now, at the basic entry levels of our
soldiers, because we know we have to build their resiliency
early on in their career. It is absolutely critical.
In addition to that, we have the Global Assessment Tool
(GAT) that is a requirement for every soldier to fill out, to
understand where they stand when it comes to resiliency. We've
had, now, over 780,000 folks fill out the GAT. Plus, online
instruction, based on the results you get on the GAT, that is
available for a soldier to take, to work resiliency.
This is something that finally starts to get us to the
left, and not waiting until we see soldiers with problems, but
try to attack resiliency as far to the left as we possibly can.
Senator Hagan. Thank you.
General Amos.
General Amos. Senator, we, in the Marine Corps, believe
it's two-part. Resiliency is both physical and mental. The
beginning stages of a marines recruit training at Parris Island
or San Diego begins to build that physical strength. We
attribute a lot of our ability to be able to do the things the
Marine Corps does for this Nation as a result of its physical
strength training. So, it begins there.
Values-based training was instituted about a year ago in
the Marine Corp, at boot camp and at schools of infantry--at
North Carolina, at Camp Geiger, and out in San Diego, at Camp
Pendleton--which teaches some of these things, along with
suicide prevention, sexual assault prevention, those behavioral
health issues. So, that's where it begins.
When the marine enters his first unit and is preparing to
deploy, we believe the best thing we can do for them is to not
only get them physically fit, conditioning-wise, which we have
a combat fitness regimen we put them through, but the second
piece is what we call immersion training. In other words, we
want the marine to experience, back home, before he or she
leaves, most of what--the fear, the anxiety, the confusion, the
fog of war. We started on the west coast, we're now migrating
to Camp Lejeune, going out to Hawaii, and and we'll do the same
thing in Okinawa. But, an immersion trainer, inside a
building--it's a huge building--and we have transitioned from
an Iraqi village to an Afghan village. We have role players, we
have amputees in there, we have RPGs that fire, we have music,
well, we have everything in there. You couple that, and you
rerun the scenario over and over again, so the young marines
become accustomed to fear, and they become accustomed to the
uncertainty of warfare. You take that, you put them in an IED
lane that's as--2\1/2\ miles long, walking through villages,
IEDs are going off, RPGs, more role players. So, you get the
idea that our last attempt to build this resiliency is to
immerse them, as much as we can, and help them know that their
training is adequate and they will be okay.
We find that, if we do that, that when they are--when they
hit their first firefight, their chances of them surviving are
greatly enhanced. We believe, intuitively, that they'll
probably have less cases of PTS, down the road.
So, that's what we're doing to build that resiliency. We
follow along when they come home.
Senator Hagan. Thank you.
Admiral Greenert, you mentioned, in response to Senator
Begich's question, the last question that he asked, something
about the age of 42. I didn't quite get that. Could you
elaborate on that?
Admiral Greenert. Yes, ma'am. Healthcare providers who
desire to enter service, there's a maximum age of 42. That
allows them for a 20-year career, age-of-62 mandatory
retirement. That was the point. If we could raise that age--
because there are a lot of folks older than 42 that want to
help.
Senator Hagan. Okay. That's what I thought. Thank you.
Many of the burdens associated with the wars in Iraq and
Afghanistan have been shouldered by the Reserve and the
National Guard members. When these citizen soldiers redeploy,
they are almost immediately demobilized and returned to their
civilian lives. Unfortunately, for many, the lives and the jobs
that they left are not what they return to, which is compounded
by the isolation of not having a support structure that's
comparable to what is available to those on Active Duty.
One of the questions is, what efforts are being made to
ensure that our members of the Guard and Reserve have a soft
landing when they return home?
General Chandler. Senator, if I could?
Senator Hagan. Great.
General Chandler. I would tell you that, in your
reintegration and redeployment process, you need to go all the
way back to the beginning, obviously, before you start your
deployments, to make it successful. Our Guard and Reserve total
force, if you will, in the Air Force, and that includes Air
Force civilians, all have access to the same things that our
Active Duty people do, as well.
Your point is well taken, in terms of how we reintegrate
those people once they come home. I would tell you that the
Yellow Ribbon Reintegration Program, that's been a very good
part of our Guard and Reserve, has been very successful at, not
only preparing members and families for deployment, but caring
for families during deployment, and then giving us the
opportunity to reintegrate those Guard and Reserve members when
they return.
In my discussions with the commander of the Reserve and the
director of the Guard, they seemed to be very happy. We're
happy, at this point, with the results that we're getting.
We're getting the resources to do that, and for that, we
appreciate your support.
General Amos. Senator, for the Marine Corps, we will deploy
almost two types of--we don't have Guard, and two types of
Reserves. We'll deploy what we call a Selective Marine Corps
Reserve Unit, which is a whole-cloth unit, a squadron, a
battalion. It's some type of unit. They actually activate 4
months or so before they deploy. They go through the entire
training program, the resiliency training, the immersion, all
that stuff. When they come back, they do a unit reintegration.
They have access to the exact same capabilities and helps that
a regular unit does.
Where we struggle, and where we have been working hard the
last year and a half, are what we call ``individual augments.''
In other words, that's that young marine, out of the middle of
North Carolina or Oklahoma or someplace, that is pulled out of
what we call Individual Ready Reserve. He or she has
volunteered, perhaps, and come forward and said, ``I'll go to
Afghanistan. I'll join the staff of General McChrystal.'' That
individual then comes on Active Duty individually, doesn't have
access to all these great programs. We do our best, we have a
training program for them to get them set; but, when they come
home is where I worry the most about. That's where, just as
General Chandler talked about, the whole idea of the Returning
Warrior, or the Yellow Ribbon Program, has been such a huge
hit, because we reach out, harvest them in, and then plug them
into that program, along with their spouse, and it gets rave
reviews. So, that's how we are trying to accommodate those
onesy-twosies.
Senator Hagan. All right.
Thank you. My time is up.
Senator Lieberman.
Senator Lieberman [presiding]. Thank you.
I have no further questions. I thank all the witnesses for
what you're doing, and also for your responses to our
questions.
I know, from Chairman Levin and Senator McCain, for all of
us, this will be a continuing focus of concern for members of
the committee. We are so grateful to our military personnel.
They serve with such honor and capability and sacrifice. It's a
part of why, of all the great institutions in our country, I
think the military today remains one that still enjoys broad
public respect and trust. But, it takes its toll, that service
and sacrifice, and I think we're getting much more in touch
with the toll it takes on the minds and spirits of people who
serve. Therefore, we want to do everything we can to make sure
that we, one, prevent the most serious problems, such as
suicide; and, two, we treat problems much before we get to that
point.
So, I hope you will understand that you should feel free to
advocate to us what you think you need from Congress to fulfill
the goals that you have in this regard, which are the goals
that we have as well.
I thank you very much. The hearing is adjourned.
[Questions for the record with answers supplied follow:]
Questions Submitted by Senator Carl Levin
defense centers of excellence for traumatic brain injury and
psychological health
1. Senator Levin. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, in the Wounded Warrior Act of 2008 (Public
Law 110-417), Congress mandated the establishment of Centers of
Excellence to help focus research projects, eliminate duplication of
efforts, and to learn and share best practices through collaboration
with other Federal agencies, academia, and the private sector. What is
the current relationship between each of the Services and the Centers
of Excellence?
General Chiarelli. The Suicide Prevention Program Managers from
each of the Services are represented in the Suicide Prevention and Risk
Reduction Committee (SPARRC), which is part of the Defense Centers of
Excellence (DCoE). To support Army family members, we promote and
utilize DCoE's resources, such as the DCoE Outreach Center, Real
Warriors Campaign, and Afterdeployment.org.
Admiral Greenert. Navy Medicine works collaboratively with the DCoE
for Psychological Health and Traumatic Brain Injury (TBI) and its
component centers: Defense and Veterans Brain Injury Center (DVBIC);
Center for the Study of Traumatic Stress (CSTS); Center for Deployment
Psychology (CDP); Deployment Health Clinical Center (DHCC); and the
National Center for Telehealth and Technology.
Navy Medicine also provides staff in support of the DCoE and is
working to ensure that professionals throughout Navy Medicine--
clinicians, researchers, educators and program managers--are working
with the DCoE to enhance research, education and outreach efforts.
Additionally, the Services support the other Centers of Excellence
by providing lead operational support as assigned by Assistant
Secretary of Defense for Health Affairs. Navy has the lead of the
Vision Center of Excellence which is focused on research and treatment
for improved vision care and restorative innovations for
servicemembers.
General Amos. The Marine Corps works collaboratively with the DCoE
for Psychological Health and TBI and its component centers: DVBIC;
CSTS; CDP; DHCC; and the National Center for Telehealth and Technology
(T2) on an ongoing basis. The interface for these interactions is
through various Headquarters level work centers, but principally Health
Services and Manpower and Reserve Affairs.
General Chandler. There is a Quad Services Meeting every week
between the DCoE, DVBIC, National Intrepid Center of Excellence
(NICoE), the TRICARE Management Activity, and the four Services to
discuss TBI issues. This has been a great collaborative group.
2. Senator Levin. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, have you found the Centers of Excellence to
be a valuable resource for the military Services?
General Chiarelli. DCoE is a valuable resource for the Army,
particularly the Real Warriors Campaign, which promotes the processes
of building resilience, facilitating recovery and reintegration of
returning servicemembers and reducing stigma associated with seeking
help. As previously noted, due to the participation of all the
Services, the SPARRC facilitates sharing initiatives and best
practices.
Admiral Greenert. The Centers of Excellence have been a valuable
resource in a number of ways:
The DCoE has served a role in facilitating and
increasing collaboration among the Services. This is best
demonstrated through the development of the Department of
Defense (DOD)/Department of Veterans' Affairs (VA) Integrated
Mental Health Strategy and the Directive Type Memorandum (DTM)
developed by all of the Services to require event reporting and
tracking of individuals exposed to blast and, therefore, at
risk for TBI.
Education and Stigma Reduction as demonstrated by the
Real Warrior Campaign.
Since their establishment they have directed over $50
million in funding to further research on psychological health
and TBI.
General Amos. The Centers of Excellence have been valuable in a
number of ways:
1. The DCoE has served a role in facilitating collaboration among
the services. This is best demonstrated through the development of the
DOD/VA Integrated Mental Health Strategy and the DTM developed by all
of the Services to require event reporting and tracking of individuals
exposed to blast and therefore at risk for TBI.
2. Education and Stigma Reduction as demonstrated by the Real
Warrior Campaign and DCoE educational conferences and monthly webinars.
3. Coordination of Research, directing over $50 million in funding
to further research on psychological health and TBI.
General Chandler. The Quad Services Meeting every week between the
DCoE, DVBIC, NICoE, the TRICARE Management Agency and the four Services
is valuable for the discussion of TBI issues. This has been a great
collaborative group. Some initiatives from the group include:
1. Developed the DTM ``Policy Guidance for Management of
Concussion/Mild TBI in the Deployed Setting.''
2. Educated medical providers on mild to severe TBI (more than 800
DOD/VA clinicians attended the 2009 DVBIC 3rd Annual Military Training
Conference).
3. Conducted a media roundtable to increase awareness of DOD
initiatives during TBI awareness month in March 2010.
4. Developed education materials for servicemembers on TBI to
implement the DTM.
5. Developed a TBI pocket guide highlighting TBI clinical practice
guidelines.
6. Developed TBI Program Guidance for the Services to standardize
the treatment of our servicemembers across the DOD.
7. Identified Medical Treatment Facilities (MTFs) to participate
in the DOD Cognitive Rehabilitation Program.
3. Senator Levin. Dr. Jesse, the Centers of Excellence were
intended to be joint DOD-VA ventures. What role does the VA currently
play in the Centers of Excellence?
Dr. Jesse. Since 2007, VA has collaborated with DOD to establish
the DCoE and the associated injury registries, including the Centers
for Psychological Health and Traumatic Brain Injury (TBI), Extremity
Injuries and Amputation, Hearing Loss and Auditory Injuries, and
Vision. VA has assigned personnel to the Centers for Psychological
Health and TBI, including a deputy director for the Centers, and two
subject matter experts--one for TBI, and one for psychological health-
related disorders. VA has also assigned personnel at the Defense Vision
Center of Excellence, including: a deputy director, chief of staff, and
a vision rehabilitation specialist. VA is completing selections for
three additional staff positions (research optometrist, administrative
assistant, and a biostatistician) to be posted at the Vision Center of
Excellence.
VA continues to work with DOD representatives to finalize the
implementation plan to jointly establish the Center for Extremity
Injuries and Amputation. VA also continues to assist DOD
representatives with developing the concept of operation and
implementation plan for the Center for Hearing Loss and Auditory
Injuries. After the implementation plans for these two centers are
finalized by DOD and forwarded for review, VA will determine its level
of support for both of these centers.
______
Questions Submitted by Senator Jack Reed
later development of wounds
4. Senator Reed. General Chiarelli, Admiral Greenert, General Amos,
and General Chandler, acknowledging the imminent need to treat
invisible wounds today, we also have to prepare to care for the
conditions that may not manifest for 5, 10, or 15 years after a
deployment. How are the Services working to address the long-term
effects of invisible wounds on our Active Duty and Reserve component
servicemembers?
General Chiarelli. Timely detection and identification of a
soldier's behavioral health issues or TBI is the goal of the Army's
Comprehensive Behavioral Health System of Care. Long-term support of
our troops is a continuous process. Soldiers undergo screening for
behavioral health issues as they enter the Army, during periodic health
assessments (PHAs) mandated for soldiers throughout their military
service, and upon discharge from the Service. During pre-deployment
readiness processing, soldiers undergo extensive screening for medical
and behavioral health issues, including family problems, in order to
document baseline soldier well-being, and to detect/treat conditions
that may interfere with meaningful military service. Upon redeployment,
soldiers are promptly screened in Post-Deployment Health Assessment
(PDHA) for Post-Traumatic Stress, major depression, and TBI, as well as
for concerns about family issues and drug and alcohol abuse. Soldiers
who screen positive undergo further clinical assessment as needed, and
are provided definitive treatment as clinically indicated.
All medical encounters and care are recorded in the soldier's
electronic health record. This information is available to healthcare
providers throughout the Military Health System. It is also available
to providers in the VA health system through the Bidirectional Health
Information Exchange (BHIE). The BHIE allows providers at DOD Military
Treatment Facilities and VA health facilities to view clinical data
when a shared patient presents for care. The capture of a soldier's
health information electronically and the ability to share a soldier's
health information with the VA ensures continuity of care even if the
soldier presents for behavioral health care in future years in either
the Military Health System or the VA.
Admiral Greenert. Tracking sailors with increased risk for the
invisible wounds of this conflict will help us to follow them into the
future to learn about the long term effects and to offer treatment as
new discoveries occur. This tracking currently is accomplished in a
number of ways:
The Combat Trauma Registry, located at the Naval
Health Research Center, tracks all combat injuries which allows
for inquiries into injury patterns and casualty management that
are helpful in guiding prevention and treatment efforts both
now and in the future.
Additionally, the new requirement, established by the
Directives Type Memorandum, for tracking individuals exposed to
blast, regardless of symptoms, will allow for enhanced follow
up care and evaluation.
The Centers of Excellence are also developing
registries that will track individuals with various conditions
specific to their mission. As an example, the Vision Center of
Excellence, led by Navy, is developing a registry that will
allow all individuals with eye injuries to be tracked and
followed.
Research also continues help to redefine how we care for wounded
warriors today and in the future. Navy Medicine is coordinating with
organizations such as the DVBIC, the NICoE, and the Center for
Neuroregenerative Medicine at the Uniformed Services University of the
Health Sciences to complete and publish clinical research about the
clinical outcomes of individuals diagnosed with TBI as a result of
combat. We hope these efforts allow us to be better able to detect the
long-term effects of concussions/mild TBI resulting from combat
deployment or blast exposure.
General Amos. Tracking patients with increased risk for the
invisible wounds will help us to follow them into the future to learn
about the long term effects and to offer treatment as new discoveries
occur. This tracking currently is accomplished in a number of ways:
1. The Combat Trauma Registry, located at the Naval Health
Research Center, allows for tracking of all combat injuries which
allows for inquiries into injury patterns and casualty management that
is helpful in guiding prevention and treatment efforts both now and in
the future.
2. Additionally, The new requirement for tracking individuals
exposed to blast, regardless of symptoms will allow for enhanced follow
up care and evaluation.
3. The Centers of Excellence are developing registries that will
track individuals with various conditions specific to their mission.
Research will also help to define how we care for wounded warriors
in the future. Navy Medicine is coordinating with organizations such as
the DVBIC, the NICoE, and the Center for Neuroregenerative Medicine at
the Uniformed Services University of the Health Services to complete
and publish clinical research regarding the clinical outcomes of
individuals diagnosed with TBI from combat. In this manner we hope to
be better able to detect the long-term cognitive sequelae of
concussions/mTBI resulting from combat deployment or blast exposure.
General Chandler. While airmen are offered pre- and post-deployment
education that encourages them to get help for problems early,
surveillance for mild TBI or post-traumatic symptoms is primarily
through periodic mandatory assessments.
Airmen undergo a PDHA upon return from deployment, which is a face-
to-face assessment that asks specifically about symptoms related to
Post-Traumatic Stress Disorder (PTSD) and TBI. Positive responses are
assessed and treatment is offered. Later, between 90 to 180 days post-
deployment, the airman completes a Post-Deployment Health Reassessment
(PDHRA) questionnaire, again screening for PTSD and TBI symptoms in
addition to other physical/psychological symptoms. If airmen respond
positively to critical items, they are contacted by a provider and an
appointment is arranged for further assessment. In addition to the
PDHRA, members undergo an annual PHA that assesses physical and
psychological symptoms. The airman sees their Primary Care Manager
(PCM) for further evaluation if they report symptoms related to TBI/
PTSD. In the event that there are still undisclosed symptoms at the end
of an airman's career, these can be identified during the separation
physical examination occurring upon discharge from the Air Force.
timing of treatment received
5. Senator Reed. General Chiarelli, Admiral Greenert, General Amos,
and General Chandler, how long, on average, does it take for a
servicemember to begin receiving mental health treatment once a need is
identified?
General Chiarelli. A soldier may begin receiving mental health
treatment at the time the need is identified if the medical situation
dictates. The Army is committed to meeting the mental health needs of
our soldiers by providing quality care, at the appropriate level, and
in a timely manner. Timely treatment is of particular importance since
mental health diagnoses are treatable, and treatment delay has been
shown to be an important factor associated with response to functional
outcomes. The Army offers an extensive array of mental health referral
and program options that promote early detection and treatment.
Admiral Greenert. In-theater services are typically provided by
embedded medical and mental health providers. This allows for immediate
evaluation, treatment and medical evacuation for emergent conditions is
available as required.
In response to the recommendations by the DOD Mental Health Task
Force, the Assistant Secretary of Defense for Health Affairs (9 Oct 07)
issued a memorandum making the initial, non-urgent/emergent mental
health assessments be booked similar to routine primary care
appointments for which the TRICARE access standard is 7 days. Since 15
Jan 08, Navy Medicine military treatment facilities have been directed
to operate under this new access standard. Data, provided via the
TRICARE Operations Center (Health Affairs/TRICARE Management Activity),
allows Navy Medicine to monitor our ability to meet this standard.
Current data indicates that across Navy Medicine: (1) acute mental
health care appointments occur within the 24-hour standard 89 percent
of the time; and (2) routine mental health appointments occur within
the 7-day standard 85 percent of the time.
General Amos. In-theater services are typically provided by
embedded medical and mental health providers. This allows for immediate
evaluation, treatment and emergent medical evacuation available as
required.
In response to the recommendations of the DOD Mental Health Task
Force, ASD (HA) (9 Oct 07) issued a memorandum requiring initial, non-
urgent/emergent MH assessments be booked similar to routine primary
care appointments for which the TRICARE access standard is 7 days.
The Marine Corps works closely with Navy Medicine on issues
concerning in-garrison medical care. As of 15 Jan 08, Navy Medicine
MTFs have been directed to operate under this new access standard.
Data, provided via the TRICARE Operations Center (Health Affairs/
TRICARE Management Activity), has been available since September 2009
allowing Navy Medicine to monitor the percentage of time the mental
health access to care standards are being met. Current data indicates
that across Navy Medicine: (1) acute mental health care appointments
occur within the 24-hour standard 89 percent of the time; and (2)
routine mental health appointments occur within the 7 day standard 85
percent of the time.
General Chandler. Mental health issues identified by servicemembers
as emergent or urgent in nature are addressed on an immediate or same
day walk-in basis with access to care in the military treatment
facilities or through civilian network partnerships. Routine or non-
urgent mental health concerns identified by servicemembers are
addressed by referral to either behavioral health optimization program
mental health providers embedded in primary care or by referral to
mental health providers in specialty mental health clinics. Over 76
percent of beneficiaries seeking mental health treatment for routine,
non-urgent concerns are seen in the military treatment facilities
within the routine access to care standard of 7 days of identifying
their need. An additional small percentage of servicemembers that
identify a mental health concern either decline the option for mental
health services or decline offered evaluation within the access to care
timeframe, opting for a later appointment at their discretion.
Additionally, many servicemembers are opting to utilize the available
mental health resources offered through TRICARE and Military OneSource
to address stress and other psychological health concerns.
guard and reserve
6. Senator Reed. General Chiarelli, Admiral Greenert, General Amos,
and General Chandler, in what ways do you coordinate with your Reserve
component counterparts to ensure that our guardsmen and reservists are
receiving the mental health treatment they may need following their
demobilization?
General Chiarelli. The Army is implementing improvements in letting
demobilizing guardsmen and reservists know what services are available
and how they can receive them before they leave the mobilization
platform. These services include use of the Department of Veterans
Affairs (VA) medical system, TRICARE resources and the Yellow Ribbon
Reintegration Program (YRRP).
The Army coordinates healthcare delivery for Reserve component
soldiers coming off active duty with the VA. The VA routinely provides
direct care for Reserve and other remote or geographically dispersed
soldiers. An Army and VA partnership embeds VA Liaison Case Managers in
14 prioritized Army MTFs under an initiative called VA Liaison and Care
Management Program, which ensures soldiers receive seamless continuity
of care as they migrate from active duty to veteran status in the VA
Healthcare System.
TRICARE also has programs that assist Guard and Reserve soldiers
and families. A National Guard or Reserve member separating from a
period of active duty that was more than 30 consecutive days in support
of a contingency operation is eligible for Transitional Assistance
Management Program (TAMP). The TAMP provides 180 days of transitional
health care benefits to help certain uniformed services members and
their families transition to civilian life.
Additionally, Guard and Reserve members who are experiencing common
psychological health concerns like combat stress and family separation
may use a new initiative called TRICARE Assistance Program (TRIAP),
which provides video chat and instant messaging to give quick and easy
access to counseling services. This program is also available to
spouses, and other family members 18 years or older.
Further post-demobilization support is provided through the The
YRRP. The YRRP provides deployment support, reintegration programs,
services and training for National Guard and Reserve members throughout
all phases of deployment to include demobilization. It provides
soldiers with transition information on available resources and
connects them with providers who can assist in overcoming the
challenges of reintegration.
Admiral Greenert. Commander, Navy Reserve Forces Command has
assumed responsibility for overseeing implementation of the PDHRA
program for the Navy Reserve. With strong leadership support they are
actively engaged in program execution and because of this increased
focus, Servicemember compliance rates have improved.
Providing mental health support to Reserve sailors is an integral
component of Navy mental health care. To meet this need, the Navy
implemented the Navy Reserve Psychological Health Outreach (NRPHO)
program in fiscal year 2008. The NRPHO program has a team of 25 social
workers who provide initial mental health clinical assessment of
Reserve component servicemembers and provide appropriate health care
referral if needed. They are also making visits to two to three Navy
Operational Support Centers (NOSC) per month in each of the five Navy
Reserve Regions where they provide psychological health education
including the Operational Stress Control (OSC) Awareness brief to NOSC
staff and Reserve unit members.
As June 2010, the NRPHO Teams have clinically assessed and referred
almost 2400 reservists to appropriate sources of mental health care;
have made outreach calls to an additional 1860 reservists; and have
made 281 visits to the NOSCs, providing the OSC Awareness brief to over
29,400 RC members and NOSC staff. In addition, Navy Medicine has hired
a full-time Director of Psychological Health (DPH) for Navy Reserve to
oversee and expand Reserve Navy Reserve psychological health programs.
General Amos. A primary tool to discover unmet needs of Reserve
marines, like all marines who deploy, is the PDHRA instrument.
reservists should be completing these surveys post-deployment just like
their active duty counterparts. reservists have access to TRICARE
health care benefits for 180 days following their separation from
Active Duty.
While I defer to my military medicine colleagues on the actual
delivery of care, our Wounded Warrior Regiment (WWR) and battalions
stay connected to marines in need of services even after they leave
active duty. I believe that our Wounded Warrior construct is a superb
model and we will continue to leverage its successes moving forward.
General Chandler. In-theater services are typically provided by
embedded medical and mental health providers. This allows for immediate
evaluation, treatment and medical evacuation for emergent conditions is
available as required.
In response to the recommendations by the DOD Mental Health Task
Force, the Assistant Secretary of Defense for Health Affairs (9 Oct 07)
issued a memorandum making the initial, non-urgent/emergent mental
health assessments be booked similar to routine primary care
appointments for which the TRICARE access standard is 7 days. Since 15
Jan 08, Navy Medicine military treatment facilities have been directed
to operate under this new access standard. Data, provided via the
TRICARE Operations Center (Health Affairs/TRICARE Management Activity),
allows Navy Medicine to monitor our ability to meet this standard.
Current data indicates that across Navy Medicine: (1) acute mental
health care appointments occur within the 24-hour standard 89 percent
of the time; and (2) routine mental health appointments occur within
the seven day standard 85 percent of the time.
______
Questions Submitted by Senator E. Benjamin Nelson
centers of excellence's suicide prevention and risk reduction committee
annual report
7. Senator Ben Nelson. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, a vital and significant component of our
force is the operational Reserve. Last year, as Chairman of the
Personnel Subcommittee of the Senate Armed Services Committee, I held a
hearing on DOD suicide prevention programs and raised a concern that
Services were not collecting information on Guard and Reserve members
who commit suicide, while not on active status. Statistics show that
servicemembers are more likely to commit suicide while not deployed,
when they are removed from their support structure. I expressed that
concern to Secretary Gates, and following 7 months of engagement with
the Department, DOD established a policy to begin reporting suicides of
Guard and Reserves in civilian status. The policy letter went into
effect October 22, 2009, and was a critical step in understanding how
the whole-of-Reserve Forces are being affected by suicides. If we don't
collect data on our Reserve and Guard forces, we have no ability to
know whether we are providing appropriate support and programs for our
Guard and Reserve Forces. Those statistics were to be reported in the
DCoE's SPARRC Calendar Year 2009 Annual Report--has this report been
completed?
General Chiarelli. The Army Suicide Prevention Task Force (ASPTF)
provides the Armed Forces Medical Examiner (AFME) with quarterly
suicide statistics for Active Duty, Reserve component on active duty,
and Reserve component not on active duty. AFME provides this data to
DCoE, which then provides service-wide statistics that are shared among
DOD officials. DCoE prepared the 2009 DODSER annual report, which
included data on active duty suicides, including Guard and Reserve
soldiers in an active-duty status. The report has been completed and is
with the Office of the Assistant Secretary of Defense for Health
Affairs for review/approval. A release date has not been established at
this time.
Admiral Greenert. Navy provided Selected Reserve (SELRES) sailor
suicide information to the DOD SPARRC Calendar Year 2009 Annual Report
which has not yet been published. Navy began collecting DOD Suicide
Event Reports (DODSERs) for suspected suicides and suicide attempts of
SELRES sailors beginning in April 2009 to better understand the factors
affecting this population and identify needs and prevention
opportunities. Suicide numbers based on death certificates for SELRES
sailors were available before that date. In 2008, there were nine
suicides of Navy SELRES personnel not on drill or duty status at the
time of death; there were six in 2009; and, there have been four to
date in 2010.
General Amos. The DOD Task Force on the Prevention of Suicide by
Members of the Armed Forces has completed its study, with delivery of
the report to the Secretary of Defense (SecDef) expected in early
August. The Marine Corps is in full compliance with the Reserve
tracking policy. We collect data using the DODSER on all Select Marine
Corps Reserve members and report those numbers throughout the Marine
Corps leadership in an attempt to identify lessons learned. We also
submit the numbers quarterly to DOD leadership in accord with policy,
through the DCoE on Psychological Health and TBI, SPARRC.
General Chandler. The 2009 DOD SPARRC 2009 annual report is
currently being reviewed within the Defense Center of Excellence prior
to release to Congress. The Air Force is very concerned with suicides
throughout our total force. The Air Force has collected and monitored
Guard and Reserve suicide events that occur while not on active status
and reporting this to the SPARRC since 2009. The suicide prevention
program manager has provided Air Force senior leaders weekly reports on
total force suicides since December of 2009.
8. Senator Ben Nelson. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, two reporting periods have passed since the
Under Secretary for Personnel and Readiness established this new
reporting requirement. I would like to know how the numbers compare for
that population and what we are doing to understand and assess the new
information. Can anyone speak to this change in reporting and what we
are finding?
General Chiarelli. For calendar year 2010, suicides for the Reserve
component not on Active Duty year-to-date exceeds last year's number
for the same timeframe. The ARNG suicide cases also exceed the number
of suicides for the same timeframe last year; USAR suicide cases are
the same as this timeframe last year.
A Senior Review Group (SRG) briefing is conducted on a monthly
basis by the Vice Chief of Staff of the Army (VCSA). A designated
general officer from each reporting unit/command briefs the VCSA on
circumstances related to the specific suicide cases that are presented.
The ultimate goal of the SRG briefing is to develop solutions that the
Army can implement to prevent or mitigate future suicides. These
solutions are captured through lessons learned and themes and trends,
which are then published for distribution to Army senior leaders.
Admiral Greenert. Navy provided SELRES suicide information to the
DOD SPARRC Calendar Year 2009 Annual Report, which has not yet been
published. The Navy began collecting DODSERs for suspected suicides and
suicide attempts of Selective Reserve sailors beginning in April 2009
to better understand the factors affecting this population and identify
needs and prevention opportunities. Suicide numbers based on death
certificates for SELRES sailors were available before that date. In
2008, there were nine suicides of Navy Selective Reserve personnel not
on drill or duty status at the time of death; there were six in 2009;
and, there have been four to date in 2010.
Population denominators for Selective Reserve not on active duty
have not been standardized for exact rate calculation and rates tend to
have considerable variance with relatively small numerator numbers;
but, approximate suicide rates for Navy SELRES are very comparable to
the active component suicide rate.
The Navy Reserve Psychological Health Outreach (NRPHO) Program has
made significant strides in extending the suicide prevention training,
surveillance, outreach, and follow-up provided to our Reserve
population and, based on success of the approach, has served as the
model that the U.S. Marine Corps is now implementing.
General Amos. Suicides and attempts while a reservist is on active
duty are captured within the Marine Corps Total Force System and
reported in our annual active duty statistics. We also track inactive
Select Marine Corps Reserve suicides and attempts, and report those
numbers separately. We have not found any risk factors or
characteristics unique to inactive reservists in our data, but continue
to analyze for any actionable information to prevent suicides and get
help to all marines.
Suicide data for Active Duty reservist and Inactive Select Marine
Corps reservists:
Active Duty Reservists
------------------------------------------------------------------------
Year Suicides Attempts
------------------------------------------------------------------------
2005........................................ 3
2006........................................ 0
2007........................................ 0
2008........................................ 2
2009........................................ 1 4
2010 (through 19 July)...................... 0 3
------------------------------------------------------------------------
USMC began tracking in 2009.
Calendar Year 2009 data through 19 July, for comparison, were
zero suicides and four attempts.
Inactive Select Marine Corps Reservists
------------------------------------------------------------------------
Year Suicides Attempts
------------------------------------------------------------------------
2009........................................ 12
2010 (through 19 July)...................... 4 0
------------------------------------------------------------------------
USMC began tracking in 2009.
Inactive SMCR Suicide Reporting required effective 1 January
2009.
Calendar Year 2009 data through 19 July, for comparison, were
five suicides and four attempts.
General Chandler. The Air Force Guard and Reserve have established
processes to identify suicides by not-in-status members and the Air
Force is tracking this data as part of our Total Force Suicide
Prevention efforts. These numbers are reported weekly to Air Force
senior leaders. The smaller populations of these groups result in
greater year-to-year variability in their overall rates. Over the past
several years, the rates of suicide in the Air Force Guard and Reserve
have been comparable to that of our active duty servicemembers.
2007
AD: 34 suicides (10.3 per 100,000)
ANG: 17 suicides (16.9 per 100,000); 15 not-in-status/2 AGR
AFR: 10 suicides (14.1 per 100,000) 9 not-in-status, 1 active
2008
AD: 40 suicides (12.1 per 100,000)
ANG: 9 suicides (8.4 per 100,000); 7 not-in-status/2 AGR
AFR: 5 suicides (7.4 per 100,000); 4 not-in-status, 1 active
2009
AD: 41 suicides (12.4 per 100,000)
ANG: 15 suicides (13.9 per 100,000); 13 not-in-status/2 AGR
AFR: 8 suicides (11.8 per 100,000); 5 not-in-status, 3 active
On average, the age of both Air Force Guard and Reserve suicides is
higher than the average age of active duty suicides, and this
demographic difference is consistent with the higher average age of Air
Force Reserve component personnel compared with active duty personnel.
We continue to analyze the data developed by these efforts to better
focus our suicide prevention efforts.
9. Senator Ben Nelson. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, I am interested in how the Guard and
Reserve population is being supported and if the report has highlighted
any challenges or concerns that the Reserve components face. How are
our prevention programs working for them and what else must be done?
General Chiarelli. The Army National Guard and the Army Reserve
have implemented the Army's Campaign Plan for Health Promotion, Risk
Reduction and Suicide Prevention. This multi-level, holistic approach
takes into account the many challenges our Army National Guard and Army
Reserve soldiers, Department of the Army civilians and family members
are confronted with. The Centers of Excellence's SPARRC Annual Report
further highlighted the issues faced by this same population. These
concerns include substance abuse; financial and relationship problems;
post-traumatic stress and TBI. The Army National Guard and Army Reserve
have revised their internal policies, programs and support in order to
leverage enhanced health promotion and suicide prevention support for
soldiers, civilians, and family members who are located far away from
our installations and garrisons. Despite significant efforts to address
these challenges in the last year, it is too early to tell whether they
will have the desired outcome in reducing the rate of suicide across
the Force. The Army National Guard and the Army Reserve prevention
program efforts are constant, evolving efforts to provide our Army
family with the resources they need. Challenges remain with access to
medical and behavioral health services for non-active duty soldiers who
do not qualify for VA benefits, along with the lack of case managers to
support medical issues within the same community.
Admiral Greenert. The Navy Reserve has been completely integrated
in Navy Suicide Prevention activities. The Chief of Navy Reserve
attends weekly updates provided to the Chief of Naval Operations on
suicide trends and prevention activities. Reserve commands have suicide
prevention coordinators, leaders participate in program informational
briefings, and Reserve component sailors receive the same spectrum of
training in OSC and suicide prevention as their Active component
counterparts. Additionally, the Navy Reserve PHOP conducts
consultations, referrals, and support and follow-up for commands,
sailors, and family members.
General Amos. The Calendar Year 2009 DCoE on Psychological Health
and TBI report has not been released. All Marine Corps suicide
prevention policies apply equally to our Active and Reserve marines. In
addition to our regular suicide prevention initiatives, the Marine
Corps has a number of programs designated specifically to meet the
needs of our Reserve marines. One such program is the PHOP. There are
30 Marine Corps Reserve Psychological Health Outreach staff members
available to assist all returning units. We have also called upon the
Military Family Life Consultants (MFLCs), a program sponsored by the
DOD, that is available to support returning units, whenever need is
identified by the command. In addition, the Marine Corps Mobilization
Command has a Family Readiness Team that helps track those in the
Inactive Ready Reserve (IRR) in need of support. There are several
initiatives already underway within Navy Medicine to provide support to
the IRRs to include family readiness days.
Further, we support many reservists and Veterans through our WWR
with liaison officers at the VA polytrauma centers and headquarters.
The WWR's Call Center regularly coordinates with the VA by referring
Veteran wounded, ill, and injured marines to appropriate VA divisions
for assistance. The WWR participates in the VA's Return Integration
Location process whereby demobilizing reservists at various post-
deployment reassessment sites receive information on VA entitlements.
To support remote and isolated reservists, the WWR has District Injured
Support Cells (DISCs), who are geographically dispersed mobilized
marine reservists who conduct face-to-face visits and telephonic
outreach to Reserve and veteran marines and families located throughout
the country. The WWR's DISCs and the marines from the Reserve Training
Centers have immediate access to the WWR's Medical Cell and Clinical
Services Staff for psychological health and TBI issues.
General Chandler. The data suggests the Air Force suicide
prevention program results in the Guard and Reserve are roughly
comparable to those in the Active-Duty Force. Data on suicides by
Reserve and Guard members not in active status is drawn from local
medical examiner determinations and may not be as consistent as death
determinations made by the Armed Forces Medical Examiner for our active
duty personnel. It is more challenging to collect accurate data on all
Guard and Reserve members as much of their medical care is provided in
the civilian system. There is also less visibility regarding the
details of day-to-day activities and potential risk factors or
stressors leading up to suicide events for these personnel.
Air Reserve Component (ARC) members participated in the recent Air
Force Chief of Staff directed Wingman Day stand-down and have the same
suicide prevention training requirements as active duty members.
Current and future efforts are focused on clear communication and
coordination between active duty component personnel and their ARC
counterparts throughout the entire process from working on projects,
initiatives and working groups, through the final coordination process.
department of defense oversight of services
10. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, what is DOD doing to understand
what programs related to suicide the Services are undertaking and what
works?
General Chiarelli. The DOD Task Force, formed in August 2009, was
directed to address trends and causal factors, methods to update
prevention and education programs, suicide assessment by occupation,
suicide incident investigations, and protective measures for
confidential information derived from investigations for all the
Services. Their findings are due to be released in the third quarter,
calendar year 2010.
In addition, DOD contracted with RAND Corporation to evaluate
suicide prevention efforts within DOD. The report assessed programs
within each of the Services to identify strengths and weaknesses in our
suicide prevention efforts. The information collected will be used to
improve development of future suicide prevention programs.
Admiral Greenert. Navy supports the efforts of the Defense Center
of Excellence, the DOD SPARRC, and the DOD Task Force on Prevention of
Suicide by Members of the Armed Forces in understanding Navy's suicide
prevention initiatives and assessing effectiveness.
Navy efforts to assess effectiveness of programs have included an
annual Behavioral Health Quick Poll (to assess perceived stress,
attitudes, and suicide prevention knowledge and confidence) and an
upcoming study, in conjunction with the Uniformed Services University
of the Health Sciences (USUHS), on the effectiveness of the latest
suicide prevention training. Navy OSC includes assessment and analysis
as a centerpiece of the program. OSC has used various polls and
questionnaires, focus groups, and studies to establish baseline
measures of stress, knowledge, and the use of stress navigation
strategies. This feedback helps to develop and assess leadership tools,
communication efforts, and program goals, and is integral to continual
process and program improvement.
General Amos. The Marine Corps shares all of our programs, both
implemented and under development, with our sister Services and DOD
through our active membership in the SPARRC, chaired by DCoE on
Psychological Health and TBI, in the Office of the Assistant Secretary
of Defense (Health Affairs). However, the Marine Corps has contracted
with both the Uniformed Services University of the Health Sciences and
the American Association of Suicidology to ensure best practices are
applied and that our efforts are studied for effectiveness.
General Chandler. DOD has established the SPARRC, which provides
oversight of the annual DOD suicide prevention conference. This
conference provides a forum for sharing of best practices across the
Services, the Department of Veteran Affairs and civilian agencies. The
SPARRC has been instrumental in establishing consistent data collection
processes across the Services, as well as standardizing the reporting
of suicides. The SPARCC meets on a monthly basis to facilitate
communication across DOD agencies and the Services regarding efforts
underway in suicide prevention programs. The DOD recently took part in
a Congressional Task Force on Suicide Prevention. This task force will
provide a comprehensive review of suicide prevention efforts in DOD.
The Air Force suicide prevention program and the SPARRC stand ready to
respond to findings and recommendations from this task force.
11. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, is DOD overseeing a best practices
model, taking into account the differences of the Services and
incorporating those things and treatments that could work Service-wide?
General Chiarelli. Through the Services' collaborative efforts, the
SPARRC evaluates policy and best practices among the Services in order
to provide input to DCoE for policy/procedural changes at the DOD
level. Specifically, the DCoE, with input from the Services through the
SPARRC, is working on formalizing these changes through a new DOD
Instruction.
Admiral Greenert. Navy supports the efforts of the Defense Center
of Excellence, the DOD SPARRC, and the DOD Task Force on Prevention of
Suicide by Members of the Armed Forces to understand Navy's suicide
prevention initiatives and best practices. The annual DOD/VA Suicide
Prevention Conference is a forum that brings together researchers,
treatment providers, and policy makers for understanding and sharing of
the latest information as applied to various populations and
circumstances.
General Amos. The Marine Corps shares all of our resources, plans
and findings with our sister Services through the SPARRC, chaired by
DCoE on Psychological Health and TBI, in the Office of the Assistant
Secretary of Defense (Health Affairs). We regularly compare our
initiatives to the best practices registry sponsored by the Department
of Health and Human Services through the federally funded Suicide
Prevention Resource Center.
General Chandler. DOD is overseeing the collection of best practice
models through the DCoE. The DOD has established the SPARRC, which
provides a forum for sharing of practices across the Services. The
SPARRC has been instrumental in establishing consistent data collection
processes across the Services through use of the DODSER, as well as
standardizing the reporting of suicides across the Services, which
allows a better comparison of suicide rates across DOD. The SPAARC
provides oversight of the annual DOD suicide prevention conference.
This conference provides a forum for sharing of best practices across
the Services, the Department of Veteran Affairs and civilian agencies.
12. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, if we are not doing this, how can
we do this and who should oversee the overall mental health and
wellness of our armed services?
General Chiarelli. We are doing this through the efforts of the
SPARRC.
Admiral Greenert. Responsibility for administering chapter 55
(Medical and Dental Care) of title 10, U.S.C., is vested in the
Secretary of Defense. The purpose of the chapter is to create and
maintain high morale in the uniformed services by providing an improved
and uniform program of medical and dental care for members and certain
former members of those services, and for their dependents.
Navy Medicine is an active participant in the VA and DOD Integrated
Mental Health Strategy which aims to improve access, quality,
effectiveness, and efficiency of mental health services for all active
duty and Reserve sailors and their families.
Navy Medicine works collaboratively with the DCoE for Psychological
Health and TBI and its component centers: DVBIC; CSTS; CDP; DHCC; and
the National Center for Telehealth and Technology.
General Amos. The Marine Corps is responsible for the overall
mental health and wellness of your marines and it is a responsibility
that is our foremost priority. Along with our partners in Navy Medicine
and Chaplaincy, we strive to improve our understanding of mental health
and wellness, stressors, barriers to care, and breaking stigma.
General Chandler. The Assistant Secretary of Defense (Health
Affairs) (ASD(HA)) has oversight of health and wellness of our armed
services as administrator of the Military Health System. While each
Service's surgeon general tailors the delivery of care to the specific
mission under the direction of the respective service chief, there is
also extensive coordination both between the VA and the Services and
between each of the Services. This coordination and integration has
been on a course of steady improvement over the last 15 years.
Assistant Secretary of Defense (Health Affairs)
Since 1994, the ASD(HA) has been the principal advisor to the
Secretary of Defense on DOD health policies, programs and activities
and is responsible for a number of the organizations that directly
affect the health care of servicemembers and their dependents including
the TRICARE Management Activity.
The DOD/VA Joint Executive Council
The DOD/VA Joint Executive Council (JEC) was established in 2003 to
oversee and guide the joint health and benefits activities of the
Departments. The JEC links three supporting councils: the Health
Executive Council (HEC); the Benefits Executive Council (BEC); and the
Interagency Program Office (IPO). Under this structure, the DOD and VA
work closely with one another across departmental lines to improve
access, quality and efficiency.
The Wounded, Ill, and Injured Senior Oversight Committee
In May 2007, the Wounded, Ill, and Injured Senior Oversight
Committee (SOC) was created by VA and DOD, and co-chaired by their
Deputy Secretaries. The SOC was established as a means to bring high-
level Department attention to addressing the recommendations and issues
associated with the care and services for returning servicemembers.
yellow ribbon reintegration program
13. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, the goal of the YRRP is to prepare
members of the National Guard and Reserves and their families for
mobilization, sustain their families during mobilization, and
reintegrate the servicemembers with their families, employers, and
communities after deployment. How is the YRRP working for your Service?
General Chiarelli. The YRRP works extremely well for the Army
National Guard. Through May 2009, the National Guard had conducted 619
events involving 47,182 servicemembers and 58,350 family members.
Attendees were provided information on available services to help
prepare soldiers and their family members for mobilization, sustain
families during mobilization and reintegrate soldiers with their
families after mobilization. The YRRP is a proactive outreach to
servicemembers, families, and employers throughout deployment cycle.
Admiral Greenert. The Navy Reserve provides three specific
activities that have been designated as YRRP events: Pre-Deployment
Family Readiness Conferences (PDFRCs), the Returning Warrior Workshop
(RWW), and the PDHRA.
PDFRCs are conducted every 12 to 18 months at 128 NOSCs across the
country and are the Navy Reserve's largest pre-deployment event.
Designed to build resilience, the PDFRC provides education, resources,
and the opportunity for sailors and families to resolve a broad
spectrum of issues prior to the rigors of a deployment and the
challenges of family separation.
The RWW is a reintegration program sailors and their guests
normally attend between 30 and 60 days following demobilization. This
2-day weekend retreat provides a safe, relaxed atmosphere to help
sailors and families with post-deployment reintegration. In 2009, more
than 1,800 servicemembers and 1,400 family members attended one of 27
RWWs held in every region of the country. In 2010, 13 workshops were
attended by 832 servicemembers and 699 family members with an
additional 38 workshops scheduled through July 2012.
The PDHRA is the 90-day YRRP event and occurs between 90 and 180
days after demobilization. The Navy Reserve has sustained a 98 percent
rate for PDHRA compliance. Sailors complete the PDHRA online and a
qualified health care provider follows up with each sailor by phone.
Further follow-up in person is conducted if and when warranted. The
PDHRA process is also used to provide information about VA health
benefits, Military OneSource, etc.
Since program inception, the response from our Navy reservists and
their families has been overwhelmingly positive in regards to all three
aspects of the Yellow Ribbon Program. It has proven to be a Navy force
multiplier and a vital part of preparedness, sustainment and
reintegration.
General Amos. The YRRP is working well for Marine Forces Reserve,
our mobilizing units, small detachments, and individual augmentee
servicemembers and their families. We are aggressively implementing the
YRRP program to ensure servicemembers and their families are properly
informed of and have access to myriad programs, resources, and services
to minimize stress before, during, and after deployments. The Office of
the Secretary of Defense is engaging on our behalf on logistical
challenges, such as a proposed change to the Joint Federal Travel
Regulations to permit non-dependent family members--or any designated
representative chosen by the servicemember--funded travel and per diem
to YRRP events. Language to address this issue is also included in the
proposed National Defense Authorization Act (NDAA) for Fiscal Year
2011.
General Chandler. The YRRP for members and families has proven to
be highly successful for the Air Force Reserves and Air National Guard.
Deployment support and reintegration programs are provided in all
phases of deployment, including, but not limited to, pre-deployment,
deployment, demobilization, and post-deployment and reconstitution
phases. Reconstitution activities are held at approximately 30, 60, and
90-day intervals following deployment or demobilization. These
activities focus on reconnecting servicemembers and their families with
providers to ensure they understand their benefits and entitlements as
well as the resources available to help overcome the challenges of
reintegration. Best practices from the most successful programs are
collected and shared. Positive survey input from servicemembers and
families have validated this program.
14. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, is the YRRP available to all
members of your component when they deploy?
General Chiarelli. Yes, the YRRP is made available to all members
of the Army National Guard when they deploy. Additionally, the National
Guard makes every attempt to ensure that all Service branches within
our States, Territories and the District are included, whenever
possible, in our YRRP process throughout all phases of the deployment
cycle.
Admiral Greenert. Although YRRP legislation addresses only the
Reserve components, similar programs are available to all members of
the Navy. Predeployment assistance is provided to Active component
sailors through their local commands, and PDFRC are available to all
reservists and their family members. RWWs are available to all
redeploying Navy sailors, Active and Reserve component, and their
families.
General Amos. The YRRP is available to all members of the Marine
Corps Reserve component.
General Chandler. Yes, the YRRP is made available to all members of
the Army and Air National Guard when they deploy. Additionally, the
National Guard makes every attempt to ensure that all Service branches
within our States, territories, and the district are included, whenever
possible, in our YRRP process throughout all phases of the deployment
cycle.
15. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, could the YRRP be modified to help
further extend support services to members and families to help address
suicide prevention?
General Chiarelli. Section 595 of NDAA for Fiscal Year 2010 has
already expanded the YRRP to include a more enhanced suicide
prevention, community healing and response training provision. In
complying with this expansion, the National Guard ensures that suicide
prevention, education and training are provided throughout all phases
of deployment. However, the National Guard is moving towards placing
this critical area within our Behavioral Health programs and has
already started a Warrior Care Initiative that encompasses programs
like Buddy-to-Buddy, Flash Forward, and Peer-to-Peer.
Admiral Greenert. Suicide prevention education is provided annually
to all Navy reservists as part of the Navy's Total Force policy and
program.
The RWW provides the ideal opportunity to reinforce this important
issue with redeploying sailors and their families. Considered a YRRP
event, sailors and their guests normally attend a workshop between 30
and 60 days following demobilization. Mental health screening and
suicide prevention education are provided as part of the workshop.
In addition Navy Medicine has funded the Navy Reserve PHOP (further
discussed in the answer to question 18), which also provides outreach
and education services to reservists and their family members to help
address suicide prevention in addition to other stressors.
General Amos. The NDAA for Fiscal Year 2010 directed DOD to develop
suicide prevention awareness and training in the Reserve community. As
such, the Marine Corps is an active member of the Yellow Ribbon Suicide
Prevention Working Group. Training includes describing the warning
signs for suicide teaching effective strategies for prevention and
intervention; examining the influence of military culture on risk and
protective factors for suicide; and engaging in interactive case
scenarios and role plays to practice effective intervention and
strategies. Additionally, the program provides the families and
communities of National Guard and Reserve members with training that
promotes individual and community healing in response to a suicide. We
are happy with the YRRP authorities that exist today. As we fine-tune
our efforts and gather data and lessons learned, we can recommend
changes or extension of the YRRP program Office of the Secretary of
Defense, Office of Reintegration Programs.
General Chandler. Section 595 of the 2010 NDAA has already expanded
the YRRP legislation to include a more enhanced suicide prevention and
community healing and response training provision. In complying with
this expansion, the National Guard (NG) ensures that suicide prevention
education and training are provided throughout all the phases of
deployment. However, the NG is moving towards placing this critical
area within our Behavioral Health programs and has begun a Warrior Care
Initiative that encompasses programs like Buddy-to-Buddy, Flash
Forward, and Peer-to-Peer, all of which embrace more of the Behavioral
Health aspect of suicide prevention.
16. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, have you found that the YRRP varies
significantly among States?
General Chiarelli. The YRRP implementation requirements are
standardized throughout the States. However, while we provide policy
and guidance on what needs to be accomplished/presented during an event
or activity throughout the deployment cycle, we do not tell our States,
Territories, or the District how this information should be presented.
For example, if you attend a National Guard YRRP post deployment event,
Veterans Administration, Employer Support of the Guard and Reserve, and
financial briefs will be presented, but how they are being presented is
entirely up to the State.
Admiral Greenert. YRRP events have been standardized throughout all
Navy regions. In particular, the Navy has developed policy and
execution guidance governing its three Yellow Ribbon events: PDFRCs,
the RWW, and the PDHRA. Every effort is made to ensure the agenda,
content, and messages delivered via PDFRCs and RWWs are consistent in
every Navy region. The Bureau of Medicine and Surgery has developed
standard procedures for conducting the PDHRA nationwide.
General Amos. No. The Marine Forces Reserve executes the program
consistently throughout the Nation.
General Chandler. The YRRP implementation requirements within the
National Guard (NG) are standardized throughout our States. However,
while we provide policy and guidance on what needs to be accomplished/
presented during an event or activity throughout the deployment cycle,
the States/territories and district determine how the information is
presented. For example, if you attend a NG YRRP post-deployment event,
you will receive information on VA, Employee Support to Guard and
Reserves (ESGR), and a financial brief, but the presentations may vary
based on need.
17. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, is there an effort to standardize
the approach to provide guidance of what works to Guard and Reserve
units across the country?
General Chiarelli. Yes, and it's going very well. The Army Reserve
shares after-action reports and best practices with the DOD's Center
for Excellence. In evaluating the YRRP, the Army Reserve is working to
provide sequential, progressive, and interactive approaches for all
topics, to include suicide prevention. Pre-deployment suicide
prevention training focuses on coping with the difficulties of extended
separation and deployment. It then shifts to ensuring that family
members get connected and remain connected with their unit's rear
detachment and family programs staff during the soldier's deployment.
The initial post-deployment focus is on reuniting, reconnecting, and
reintegrating the soldier with their family members. Finally, the Army
Reserve attends to each soldier's physical, behavioral, and mental
health concerns through the PDHRA and other discussions approximately
90 days following the soldier's release from active duty.
Every 2 weeks the Army Reserve uses feedback to provide informal
guidance to the field through teleconferences for all Yellow Ribbon
points of contact in the Regional Support Commands and Operational and
Functional Commands. Each quarter, the program managers provide
informational meetings and workshops where issues are discussed and
disseminated to all for incorporation into local/regional events. The
Army Reserve is projected to publish new guidance for program
implementation at the start of fiscal year 2011 based on the first 2
years of feedback from commanders, Yellow Ribbon points of contact, and
event participants.
For the National Guard, there is policy and implementation guidance
published on what topics and issues that should be covered during a
particular YRRP event. Additionally, in coordination with the Army and
Air Guard, we are also developing a ``Best Practices Toolkit,'' which
will be available on our Joint Services Support website that all of our
State event coordinators, as well as the other Reserve components, can
access. As we continue to work with our Services within our States, the
toolkit will be updated to ensure that the guidance being provided is
relevant and up to date.
Admiral Greenert. Following each Yellow Ribbon event, the
responsible command, either a regional Reserve Component Command or
NOSC, provides a detailed after-action report to Commander Navy Reserve
Forces Command (CNRFC) to document attendance, money spent, and
identify lessons learned, best practices, and potential improvements.
CNRFC then evaluates this after-action report and forwards it to the
Office of the Secretary of Defense for Reserve Affairs' Yellow Ribbon
office. The most significant lessons learned, best practices, and
program modifications and improvements are provided to the NOSCs so
they can be shared with Reserve unit leaders and sailors, induce
greater participation in Yellow Ribbon events, and convince sailors of
the enduring value of these programs. In addition, the Yellow Ribbon
Center for Excellence has established an online tool to capture best
practices, termed ``Golden Nuggets,'' for Yellow Ribbon events.
General Amos. Promising practices identified in Marine Forces
Reserve are shared with the Office of the Secretary of Defense (OSD)
Office of Reintegration Programs to be offered to all Services for
their edification. All of the Service Program Managers converse with
the OSD Office and each other at least monthly to share challenges and
solutions. In addition, regional and State partnerships between Service
representatives ensure solutions to common challenges are shared and
benefit all.
General Chandler. The Air Force Reserve YRRP is not managed by
State, but rather by Air Force Reserve Command, which extends to all
Air Force Reserve units. When planning a joint event (between Air Force
components or between Services) a standardized agenda is used which
includes presentations from the VA and TRICARE. The Office of the
Secretary of Defense YRRP Working Group is developing a standardized
curriculum for all YRRP events. The National Guard (NG) has made an
effort to standardize the guidance for the program. The NG's Policy and
Implementation Guidance provides guidance on topics and issues that
should be presented/covered during a particular YRRP event.
Additionally, in coordination with the Army and Air Guard, we are
developing a ``Best Practices Toolkit'' that will be available on our
Joint Services support website and is available to all State YRRP event
coordinators and Reserve components. This information will be updated
periodically to ensure the guidance is accurate and relevant.
18. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, Guard and Reserve members who do
not live in close proximity to a military installation, or who live in
very remote locations, can experience their own set of issues when it
comes to access to health care and family support programs that may be
needed following a deployment. Are there any specific programs,
including Yellow Ribbon, in place in each of the Services to address
the unique needs of Guard and Reserve members and their families, to
ensure that there are no gaps in access to help and support for the
Guard and Reserve when it comes to suicide prevention?
General Chiarelli. In addition to the Yellow Ribbon program, which
provides support both before and after a soldier deploys, many States
and Territories have developed local programs to promote soldier health
in the National Guard, such as Michigan's Buddy-to-Buddy peer program,
California's embedded psychologist program, and Kansas' resiliency
program. The Army National Guard's resilience, risk reduction, and
suicide prevention efforts would be greatly improved with additional
funding to sustain Army Family Covenant type services, provide
behavioral health/emergent care/substance abuse treatment for soldiers
and families regardless of status, and additional behavioral health
providers for clinical and administrative case management.
Admiral Greenert. The Navy Reserve has been completely integrated
in Navy Suicide Prevention policy, programs, and activities. The Chief
of Navy Reserve attends weekly updates provided to the Chief of Naval
Operations on suicide trends and activities. Reserve commands have
suicide prevention coordinators, leaders participate in program
informational briefings, and sailors receive the same spectrum of
training in OSC and suicide prevention as their active duty
counterparts.
While lack of day to day observation and contact can be a challenge
to supporting SELRES between monthly drill periods, the Navy PHOP has
provided a very helpful resource in extending the reach for
consultation and referral, support, and follow-up for commands,
sailors, and family members in the area of psychological health. As of
30 June, the PHOP teams had reached out to more than 1,860 Navy Reserve
members, clinically assessed and referred 2,376 reservists to
appropriate sources of mental health care, and conducted 281 visits to
NOSCs nationwide, providing the OSC awareness and suicide prevention
briefs to 29,400 SELRES and full-time support staff.
The Navy began collecting DODSERs for suspected suicides and
suicide attempts of SELRES sailors beginning in April 2009 to better
understand the factors affecting this population and identify needs and
prevention opportunities.
General Amos. As an active member of the Yellow Ribbon Suicide
Prevention Working Group, the Marine Corps is working with its sister
Services to identify and remove gaps which may limit access to help and
support for its Reserve component. The Marine Corps Reserves' efforts
mirror those of the total force and include noncommissioned officer
peer-to-peer training along with annual suicide prevention training. We
are expanding efforts to reach family members as key partners in the
effort to prevent suicides. In addition to our regular suicide
prevention initiatives, the Marine Corps has a number of programs
designated specifically to meet the needs of our Reserve marines. One
such program is the PHOP. There are 30 Marine Corps Reserve
Psychological Health Outreach staff members available to assist all
returning units. We have also called upon the MFLCs, a program
sponsored by DOD, that is available to support returning units whenever
need is identified by the command. In addition, the Marine Corps
Mobilization Command has a Family Readiness Team that helps track those
in the IRR in need of support, and Navy Medicine has several
initiatives underway to provide support to the IRRs to include family
readiness days.
General Chandler. For the Air Force Reserves (AFR), the Office of
the Secretary of Defense recently authorized one adult MFLC, one child
and youth MFLC and one Military OneSource coordinator to work at
Headquarters, Air Force Reserve Command (AFRC). Some of their roles and
responsibilities will be to coordinate with State-level Joint Family
Assistance Program offices and assist in ensuring reservists and their
families are aware of benefits to which they are entitled. AFR and Air
National Guard (ANG) airmen and Family Readiness offices assist
commanders and first sergeants with their responsibility of contacting
families of deployed personnel to keep them abreast of their benefits
and direct them to support services such as Military OneSource, which
has been a tremendous asset for geographically dispersed families. When
it comes to suicide prevention, the YRRP provides needed resources and
support by means of a Chaplain presence and State Directors of
Psychological Health at Yellow Ribbon events. We work with the
servicemembers and their families, as well as commanders that may need
guidance. We also realize that monitoring and providing support doesn't
end after completed Yellow Ribbon events. We must train and educate the
servicemember, families, and commanders and units on suicide
prevention.
19. Senator Ben Nelson. General Chiarelli, Admiral Greenert,
General Amos, and General Chandler, how are these programs reviewed and
managed to ensure that Reserve and Guard soldiers in Nebraska have the
same benefits and support as those in other States?
General Chiarelli. The Yellow Ribbon program is a standardized and
funded program and each State individually requests the funding it
needs to meet its annual requirements. The ARNG has developed a
synchronization matrix to set overall standards while providing States
the flexibility to meet their Yellow Ribbon goals.
Admiral Greenert. DOD has an instruction which establishes a core
curriculum for the Services' YRRP events.
Additionally, YRRP events have been standardized throughout the
Navy Reserve. In particular, the Navy has developed policy and
execution guidance governing its three Yellow Ribbon events: PDFRC, the
RWW, and the PDHRA. Every effort is made to ensure the agenda, content,
and messages delivered via PDFRCs and RWWs are consistent in every Navy
region. The Bureau of Medicine and Surgery has developed standard
procedures for conducting the PDHRA nationwide.
General Amos. There is one Reserve company based in Nebraska.
Marine Forces Reserve executes the YRRP consistently across the country
regardless of where they reside. Each battalion and squadron-level unit
and above has a full-time, nondeploying Family Readiness Officer (FRO),
whose responsibility it is to educate that unit's marines and family
members on methods and resources to employ for attaining and
maintaining a continual state of readiness for any exigency of the
military lifestyle, including mobilization and deployment. FROs
encourage socialization of the unit families through hosting of
periodic family day and recreational events. They also schedule
educational sessions to support the resiliency needs of families
associated with welcome aboard; indoctrination into the Marine
Corps lifestyle; pre-, during, and post-deployments; and life skills
that cover a broad array of support to build knowledge, skills, and
critical identification abilities in the areas of combat and
operational stress, suicides, casualty assistance, elder care, and
deployment impacts on children.
General Chandler. The Air Force Reserve YRRP is not managed by
State but rather by Air Force Reserve Command (AFRC), which extends to
all Air Force Reserve (AFR) units. As such, all AFR members receive the
same benefits and support regardless of the State in which they reside.
For the Air National Guard (ANG), the guidance set by the Office of the
Secretary of Defense (OSD) as well as the policy memorandum (dated 20
July 2009) signed by General McKinley, Chief, National Guard Bureau
(NGB), gives specific instruction as to what topics should be covered
during each phase of the YRRP. In addition, the NGB Joint Staff Yellow
Ribbon Office and the ANG Yellow Ribbon program managers work
collaboratively to collect best practices, attend events and review
policy and guidance to ensure each member eligible for the YRRP
receives the necessary resources and information. Each State may
orchestrate the events differently, but standards and guidelines are
set by OSD as well as the Chief of the National Guard Bureau.
______
Questions Submitted by Senator Jim Webb
prescription drugs
20. Senator Webb. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, in response to a question for the record
for the military departments' surgeons general following a March 10,
2010, Personnel Subcommittee hearing on the military health system, DOD
responded that the Services do not have the capability to track
prescription medication use in theater, and that ``the Military Health
System Pharmacy Data Transaction Service (PDTS) has no visibility of
pharmacy data for prescriptions dispensed in forward operating areas.''
It is my understanding that the PDTS serves to track the administration
of medications to enhance patient safety and avoid medication
contradictions. However, in-theater doctors and medics are not linked
to the PDTS; therefore, not only are prescriptions themselves not being
tracked, but doctors and medics in-theater are required to treat
patients without complete medical case histories. What policies and
processes are the military departments instituting to ensure proper
data collection and record keeping for the prescription of psychotropic
and other drugs administered to forward-deployed servicemembers?
General Chiarelli. Providers document theater-generated outpatient
prescriptions in the Armed Forces Health Longitudinal Technology
Application-Theater (AHLTA-T). This is the deployed version of the
Military Health System's electronic medical record. Currently U.S. Army
Medical Command (MEDCOM) is working with U.S. Central Command (CENTCOM)
to develop a policy to ensure theater systems training requires
entering all medications within the Medications Orders menu in AHLTA-T.
This will improve standardization of documentation and ease in
reviewing medications by the deployed provider. All prescriptions
appear in the consolidated medications list within the Theater Medical
Data Store (TMDS), which will comply with the current policy of
electronic health record reach back capability via AHLTA-Warrior and
TMDS.
Additionally, MEDCOM is developing training for providers on their
responsibility to advise Commanders, as appropriate, about medications
prescribed to a soldier if the medication affects mission readiness or
fitness for duty.
Admiral Greenert. It is not a completely accurate assumption that
the Services do not have the capability to track prescription
medication use in theater. Theater generated prescriptions are
documented and viewable through TMDS and this information can be
accessed by garrison providers via a web interface. Deployed health
care providers have full reach back capability to the servicemember's
garrison prescription history via TMDS, Armed Forces Health
Longitudinal Technology Application (AHLTA)-Warrior, or by Enterprise
Remote Access (ERA) web based AHLTA virtualized access.
PDTS is a pharmacy claims service used to prevent drug-drug
interactions, duplications, fraud, and assist with billing in the
military MTF, retail pharmacy and mail order points of service and
while the data forms a fairly solid picture of outpatient pharmacy use
in DOD in the 3 points of service, it is not designed to answer
questions about medications being prescribed in theater.
PDTS is currently not available in a deployed setting, however
there are two electronic health records in theater: AHLTA-T (theater)
(outpatient) and TC2 (inpatient). Each is a stand-alone system with the
information entered into it uploaded to TMDS. This can be accessed via
the web by other locations although internet connectivity in theater is
a limiting factor. TMDS is currently the most comprehensive and best
organized application to view theater health history (individual
patient issues). TMDS is also available via AHLTA.
TMDS is not ideal for viewing medication history and does not
perform drug checks against the greater enterprise. Drug interactions
can also be checked utilizing Lexi-Comp medication resource electronic
clinical reference that is available through the Navy Medicine Online
telelibrary and downloadable.
The ASD/HA memo Policy on Worldwide Use of Theater Medical
Information Program-Joint 03 November 2008, signed by Assistant
Secretary of Defense for Health Affairs addressed the collection and
storage of theater health related data on servicemembers. Navy Medicine
is in compliance with this memorandum, with all outpatient care in
theater being documented in AHLTA-T and inpatient care documented in
TC2. Both systems feed data into TMDS. The provider notes are also
visible to any provider anywhere in the world via TMDS or viewable as
previous encounters in AHLTA.
General Amos. PDTS is a pharmacy claims service used to prevent
drug-drug interactions, duplications, fraud, and assist with billing in
the military MTF, retail pharmacy and mail order points of service. The
system was not designed for individual patient medication management
and is a poor tool to accomplish this task. PDTS is useful in providing
data to answer population based inquiries.
While leaders in Washington, DC may not have direct view of
theater-generated prescriptions, patient encounters are documented and
viewable through TMDS and this information can be accessed by garrison
providers via a web interface to TMDS. Deployed health care providers
have full reach back capability to SM's garrison prescription history
via TMDS, AHLTA-Warrior, or by Enterprise Remote Access (ERA) web based
AHLTA virtualized access.
The ASD/HA memo Policy on Worldwide Use of Theater Medical
Information Program-Joint 03 November 2008, signed by Assistant
Secretary of Defense for Health Affairs, S. Ward Casscells, M.D.,
addresses the collection and storage of theater health related data on
SMs.
General Chandler. There are two electronic health records in
theater: Armed Forces Health Longitudinal Technology Application-
Tactical (AHLTA-T) for out-patient and emergency room records and
Theater Medical Information Program Composite Health Care System Cache
(TC2) for in-patient records. Each is a stand-alone system with the
capability to upload information to the TMDS. This can be accessed via
the internet; however, connectivity is often a limiting factor.
Medication data is not transferred from AHLTA-T to PDTS, so reports
cannot be run to evaluate medication usage. In the near term, DOD is
testing the ability to run ad hoc reports through TMDS and is
considering options for passing medication data from TMDS to PDTS for
use in running reports. To address this in the long-term, TRICARE
Management Activity's Defense Health Information Management System
(DHIMS) personnel are working to identify data requirements for PDTS to
be able to fully interface with theater systems (TMDS, AHLTA-T, and
TC2). This information could be used for clinical decision support
(e.g., screening for drug-drug interactions) and for analysis and
reporting purposes. Requirements are being built into the next PDTS
contract to transfer theater data to PDTS; however, the estimated
completion date is unknown.
21. Senator Webb. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, when will comprehensive data be available
from the Services for prescription drug use for the Active-Duty, Guard,
and Reserve components?
General Chiarelli. Providers can view all medications prescribed to
deployed soldiers.
Providers document and view all medications prescribed in garrison
through the Armed Forces Health Longitudinal Technology Application
(AHLTA), the Military Health System's electronic medical record. The
system includes both inpatient and outpatient prescribed medications.
This provides ready visibility of these medications without requiring
additional information systems. Deployed healthcare providers have full
reach back capability to a soldier's garrison prescription history via
AHLTA-Warrior, a web-based AHLTA view only interface, or by Enterprise
Remote Access, a web-based AHLTA virtualized access.
Providers document theater-generated outpatient prescriptions in
AHLTA-Theater. These prescriptions are then viewable through the TMDS,
which is the data repository and a web-based program to access theater-
generated electronic medical records. Garrison providers can access
Theater outpatient information via a web interface to TMDS and via
AHLTA. The Assistant Secretary of Defense (Health Affairs)/DHIMS is
currently working to simplify the process of reviewing all prescribed
medications within AHLTA with an implementation timeline of
approximately September 2010.
Admiral Greenert. CENTCOM submitted a requirement requesting a new
capability to: track patients deployed in theater who are being
prescribed medications that by themselves may require follow-up; track
patients who are being prescribed medications in theater that may
disqualify them from being in a deployed status; and identification of
patients who may be going to multiple providers and/or clinics in the
pursuit of multiple prescriptions for drugs that are prone to patient
abuse. This capability is targeted for release, by the Office of
Assistant Secretary of Defense for Health Affairs, in late September or
early October 2010. DOD is testing the ability to run adhoc reports for
medication data through TMDS.
Also, the TRICARE Management Activity has developed requirements
that would allow PDTS to receive medication information from in
theater. This information could be used as clinical decision support
(screening for drug-drug interactions) and reporting purposes. The
Office of Assistant Secretary of Defense for Health Affairs anticipates
that software development work should begin in early fiscal year 2011.
General Amos. CENTCOM submitted a requirement requesting a new
capability to: track patients deployed in theater who are being
prescribed medications that by themselves may require follow-up; track
patients who are being prescribed medications in theater that may
disqualify them from being in a deployed status; and identification of
patients who may be going to multiple providers and/or clinics in the
pursuit of multiple prescriptions for drugs that are prone to patient
abuse. This capability is targeted for release in late September or
early October 2010.
DOD is testing the ability to run ADHOC reports for medication data
through TMDS. DHIMS is working to improve the reporting capabilities.
TRICARE Management Activity has developed requirements that would
allow PDTS to receive medications from theater systems. This
information could be used as clinical decision support (screening for
drug-drug interactions) and reporting purposes. It is anticipated work
should begin in early fiscal year 2011.
General Chandler. DHIMS personnel are currently working to identify
data requirements for the PDTS to be able to fully interface with
theater systems. These theater systems include the TMDS, Armed Forces
Health Longitudinal Technology Application-Theater (AHLTA-T) and
Theater Medical Information Program Composite Health Care System Cache
(TC2). The estimated completion date of this interface is unknown.
22. Senator Webb. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, what is being done to review the policies
governing the prescription of psychotropic medications in general,
including their prescription in combination with other drugs
(polypharmacy)?
General Chiarelli. In June 2009, Office of the Surgeon General/U.S.
Army MEDCOM issued guidance to providers caring for patients who
receive treatment with multiple medications. This policy was revised in
September 2009, and is currently being updated further to fully address
the problem of polypharmacy among soldiers receiving treatment,
especially when psychotropic agents or central nervous system
depressants are involved. The purpose of this policy is to provide
guidance on the prevention and management of polypharmacy with
psychotropic medications and central nervous system depressants to
reduce adverse events and optimize clinical outcomes among soldiers
receiving care in the military medical system. This policy mandates
that care providers carefully monitor soldiers with complex or multiple
medical and/or behavioral health problems to reduce the risk of serious
drug interactions and polypharmacy. Providers will review the
medication profile at each visit, assess for ongoing clinical
indications for medication treatment, screen for the potential side
effects, including the effects of drug-drug interactions, and refer to
a clinical pharmacist for further review and reconciliation if the
number and nature of the patient's medications triggers a pharmacy
referral.
Risk has been greatly reduced for Warrior Transition Unit (WTU)
soldiers, who are at the highest risk among our troops, by implementing
intensive monitoring by primary care physicians in close collaboration
with pharmacists assigned to the WTUs. Consequently, soldiers'
medications are reviewed within 24 hours of arrival in the WTU,
reviewed thereafter at least weekly, and more often if changes in
dosage or medication are made in the course of treatment. High risk
soldiers are assigned to only one health care provider to access
controlled medications that may put them at greater risk. Soldiers who
have demonstrated difficulties in complying with treatment on opioid
analgesics and other controlled medications are enrolled in the Sole
Provider Program for more intense monitoring and control.
Admiral Greenert. Medication reconciliation, a National Patient
Safety Goal of the Joint Commission accreditation agency, is a complete
review of all patient medications and any potential interactions with
other drugs. Today, medication reconciliation is performed by the
medical provider at each patient encounter, both in and out of theater.
The WTU Pharmacy Prescription Medication Analysis and Reporting
Tool is a DOD-consolidated medication screening tool containing
medication from all points of service (MTF, retail and mail order).
This tool also provides reports on four targeted categories (sedative
hypnotics, narcotics, antidepressants, and antipsychotics) and can be
used to identify at-risk patients prior to deployment.
Current pre-deployment screening procedures address all medication
usage including psychotropics as documented on the NAVMED 1300/4, which
was revised April 2010.
General Amos. While I defer to the military medicine professionals
regarding appropriate management of all medical conditions, the Marine
Corps adheres to all current directives regarding medications usage and
deployment. Specifically, the Marine Corps is well aware of and
adherent to the guidance contained in the CENTCOM ``Individual
Protection and Individual/Unit Deployment Policy'' Mod 10 released 05
March 2010 and DOD DTM dated November 7, 2006 ``Policy Guidance for
Deployment-Limiting Psychiatric Conditions and Medications.''
General Chandler. Several processes, programs, and directives are
in place at Air Force MTFs to closely monitor and manage medication
therapy, including the prescribing of psychotropics and the monitoring
of polypharmacy:
Medication Reconciliation
This is a National Patient Safety Goal of the Joint Commission on
Accreditation of Healthcare Organizations. The objective is for
providers to review and evaluate all medications with each patient at
each encounter. The patient leaves each encounter with a list of
current medications from all providers, all pharmacies and any over the
counter medications or vitamins.
Composite Health Care System (CHCS) Profile Review
All prescriptions filled through CHCS are screened for drug
interactions, overlaps, duplications, and early fills. Prescriptions
filled at network pharmacies are also screened through the Prescription
Data Transaction Service. When potential problems are identified (e.g.,
duplications/overlaps, drug-drug interactions, etc.), pharmacy
personnel follow-up with the patient and, when appropriate, with the
patient's provider.
Prescription Restriction Program
This is a program available through the Pharmacy Operations Center
that can be used to limit patients to one pharmacy and one provider. It
is usually used for controlled substances, but can also be used as a
patient safety tool to prevent patients from receiving prescriptions
from multiple providers or pharmacies for the same or similar
medications.
Pre-Deployment Screening
Pre-deployment screening addresses all medications including
psychotropics. It is directed in Air Force Instruction (AFI) 48-120 (in
coordination), which will implement DOD Directive (DODD) 6490.02E,
Comprehensive Health Surveillance; DOD Instruction (DODI) 6490.03,
Deployment Health, Joint Chiefs of Staff (JCS) Memorandum, 2 Nov 07,
Procedures for Deployment Health Surveillance; and, Headquarters United
States Air Force (HQ USAF)/Assistant Vice Chief of Staff (CVA)
Memorandum, 23 Feb 06, PDHRA. The AFI provides guidance for all Air
Force and Air Reserve component (ARC) installations in meeting the
requirements of the deployment health and medical surveillance program.
When published, it will supersede Air Force Surgeon General's
Memorandum, dated 22 May 03, ``Medical Procedures for Deployment Health
Surveillance.'' Additionally, a tool available to assist in the pre-
deployment screening process is the Prescription Medication Analysis
and Reporting Tool (P-MART), which is a consolidated medication
screening tool that displays medications from all points of service
(MTF, retail, and mail order). This tool provides reports on four
targeted categories (sedative hypnotics, narcotics, antidepressants,
and anti-psychotics), and can identify at-risk patients.
______
Question Submitted by Senator Mark Udall
npr and propublica investigation interview
23. Senator Udall. General Chiarelli, you mentioned in your
testimony that you provided to National Public Radio a complete
response to its recent report on brain injuries in the Army, in which
you detailed your problems with the report. Would you please provide me
your complete response for the record?
General Chiarelli. A copy of my letter to NPR is attached.
[GRAPHIC(S)] [NOT AVAILABLE IN TIFF FORMAT]
______
Questions Submitted by Senator Roland W. Burris
families of servicemembers
24. Senator Burris. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, as you know, war wounds and mental trauma
do not only affect the injured veteran, dealing with these conditions
is also very hard on the family members. Are there any statistics
available about the incidence of suicide and depression of the families
of servicemembers?
General Chiarelli. The ASPTF has tracked family member suicides
since calendar year 2009. Army Criminal Investigation Division (CID)
investigates the death of all Army family members that occur on post.
When the death of a family member occurs off-post, CID coordinates with
the local law enforcement agency on the investigation. If the death
appears to be the result of a suicide, CID notifies the ASPTF liaison
officer. ASPTF does not track the incidence of depression in family
members. However, this data may be obtained from medical channels if
the family member was seen at one of the Army's medical facilities, or
a TRICARE provider. Tracking Reserve component (not on Active Duty)
family member suicides has proven to be problematic.
Admiral Greenert. It is difficult to accurately quantify because
dependents often access mental health services outside of the Military
Health System. Additionally, psychiatric disorders are diagnosed by a
cluster of symptoms rather than the presence of measurable physical
findings. This leads to a disparity in the reported incidence rates and
other epidemiologic statistics for the majority of psychiatric
disorders calling into question their reliability.
We are however, able to infer a change in the psychological health
status of our servicemembers' family members by their utilization of
mental health services. For example, between 2007 and 2009 there was an
increase of more than 14 percent in the number of family members under
the age of 18 who received mental health treatment; 95 percent of this
increase was in the diagnoses of conduct, adjustment and anxiety
disorders as well as developmental disorders from increased learning
problems in school. This supports the fact that children, when
stressed, typically become anxious or act out their stress through
behavioral problems rather than complain of sadness or depression. From
these findings we can conclude that family members are also having
difficulties with managing the impact of the war on the family unit of
our veterans' and servicemembers.
Programs are in place to support the family; assist in building on
the baseline resilience that family members bring with them; and treat
mental health conditions once they are identified.
General Amos. The Marine Corps tracks family member suicides that
are reported through the personnel casualty reporting system. Over the
last 5 years, there have been 0 to 2 Marine dependent suicides per
year. We do not have detailed information on these deaths as they have
occurred in the civilian area of responsibility with minimal military
opportunity to investigate. This is below the National civilian suicide
rate. the Marine Corps do not track statistics on the incidence of
depression in families of servicemembers.
General Chandler. The mental health of families is of significant
concern to the Air Force as family support is essential for effective
functioning of our servicemembers. Air Force health care records show
that approximately 16,000 active duty family member beneficiaries
(approximately 3 percent of all beneficiaries) have a primary diagnosis
of some type of depression. This compares to estimated national
prevalence of depression of approximately 10 percent. The Air Force has
had an increase in utilization of mental health services over the past
5 years both at military treatment facilities and through the TRICARE
network.
There is currently no requirement for local authorities to report
family members' cause of death to the Air Force. The Air Force suicide
prevention program is working with Air Force Manpower and Personnel to
develop a process for collecting this data and tracking Air Force
family member suicides by obtaining data on Servicemembers Group Life
Insurance claims. We will share this process with our Sister Services
to ensure future tracking of this important issue across DOD.
25. Senator Burris. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, what types of mental health services are
available to family members and caregivers?
General Chiarelli. Inpatient and outpatient behavioral health care
is available to family members through MTFs at every Army installation
hosting families. The Army additionally leverages local healthcare
providers in the surrounding installation communities through the
TRICARE Network system. TRICARE covers medically and psychologically
necessary behavioral health care services for family members to include
individual, family, and group therapies, collateral visits,
psychoanalysis, psychological testing, inpatient hospitalization,
partial hospitalization and residential treatment.
There are also numerous programs that provide training and
assistance for families experiencing stressors related to military
service and deployments. These programs include an extensive array of
behavioral health services that address symptoms of depression,
anxiety, and other psychological health issues, and specifically
provide training to assist families with identification of symptoms
that may indicate depression, anxiety and other psychological health
issues. These support programs for soldiers and their families include
the following:
Army Community Service. Army Community Service
programs offer real-world solutions to problems commonly
encountered by soldiers and their families. The program equips
people with the skills and education that they need to face the
challenges of military life today and tomorrow.
Battlemind. Numerous Battlemind products have been
developed and implemented to train soldiers and families to
cope with the rigors of deployment and redeployment. These
training products are designed to enhance the recovery and
resiliency of soldiers before, during, and after deployment.
Battlemind resources include training programs and videos
focusing on post-deployment recovery, marital relationships,
and supporting children from pre-school to teen.
Child and Adolescent Center of Excellence. This COE
works to characterize the effects of belonging to a military
family; focuses on the impact of being a child with a parent
who deploys, is wounded or killed in action; follows them over
time; focuses on interventions, programs, and policies to
assist families in relation to these unique stressors; and
provides targeted healthcare solutions, support products, and
services to military dependent children and adolescents and
exports them DOD-wide.
Family Assistance for Maintaining Excellence. Formerly
known as Families Adapting to Military Experience, Family
Assistance for Maintaining Excellence provides standardized,
evidence-based behavioral health assessments; services include
education, prevention, screening, and/or treatment for Spouses.
Military OneSource. A free 24-hour, 7-days-a-week
information center and website where soldiers can seek
assistance. Counseling is provided by phone or in person by
Masters-level consultants on issues such as family support,
emotional stress, debt management, and legal concerns at no
cost to the soldier or family member for up to twelve sessions.
Psychological Health School Programs. A preventive
approach intended to strengthen individual servicemembers,
their families, their units, and communities, enhancing their
ability to cope with stress. Resilience promotion involves a
continuum of care from non-clinical to clinical settings.
Warrior Resiliency Program. Focuses on the prevention
and treatment of combat and deployment stressors impacting on
warriors and their families. This is a preventive approach
intended to strengthen individual soldiers, their families,
their units, and communities, enhancing their ability to cope
with stress. Resilience promotion involves a continuum of care
from non-clinical to clinical settings.
Caregivers who are not eligible beneficiaries can receive education
counseling, research and referrals through Military OneSource
(www.MilitaryOneSource.com) when the mental health concern is related
to or on behalf of a servicemember. For mental health issues unrelated
to the servicemember, Military OneSource will work with the non-
dependent or parent to refer them to the appropriate behavioral health
resource in the community. While there are no costs associated with
using Military OneSource, the non-dependent is responsible for any
resource other than the assistance provided by Military OneSource.
Admiral Greenert.
For Families--
Project FOCUS (Families Over-Coming Under Stress) addresses
difficulties that children and families face during the challenges of
multiple deployments and parental operational stress. FOCUS works in
coordination with Navy's Fleet and Family Support Centers as well as
the Marine Corps Community Service's programs to provide a thorough
continuum of care to servicemembers and their families.
Navy Fleet and Family Support Centers (FFSCs) offer a wide-range of
services to families to include pre- and post-deployment programs,
including counseling services. They have incorporated the OSC concepts
into their programs as appropriate.
Medical Care for Dependents--
Eligible beneficiaries can access a wide range of mental health
services in the Military Health Service. TRICARE covers medically and
psychologically necessary behavioral health care services including
outpatient psychotherapy, psychological testing and medication
management; acute inpatient psychiatric care, psychiatric partial
hospitalization program, residential treatment center care (limited to
beneficiaries under age 21), and substance use disorder services. The
web-based TRIAP provides online access (chat, web-based video) to
counseling for short-term, non-clinical issues. The Telemental Health
Program is available at participating TRICARE facilities where
beneficiaries can use secure audio-visual conferencing to connect with
offsite TRICARE network providers for clinical counseling.
Respite care services are available to injured servicemembers and
are provided by a home health agency authorized by TRICARE and approved
by the servicemember's case manager. Respite care provides rest and
change for the primary caregiver who has been caring for the patient at
home and assisting with activities of daily living.
For Caregivers--
The Caregiver Occupational Stress Control (COSC) Project provides
training and materials to educate caregivers on compassion fatigue and
secondary trauma. COSC enhances the resilience of caregivers to the
psychological demands of exposure to trauma, wear and tear, loss, and
inner conflict associated with providing care.
General Amos.
For Families--
Project FOCUS (Families Over-Coming Under Stress) addresses
difficulties that children and families face during the challenges of
multiple deployments and parental operational stress. FOCUS works in
coordination with Navy's Fleet and Family Support Centers as well as
the Marine Corps Community Service's programs to provide a thorough
continuum of care to servicemembers and their families.
Marine Corps Community Services (MCCS) offer a wide-range of
services to families to include pre- and post-deployment programs. They
have incorporated the OSC concepts into their programs as appropriate.
For Caregivers--
The COSC project provides training and materials to educate
caregivers on compassion fatigue and secondary trauma. Caregiver OSC
enhances the resilience of caregivers to the psychological demands of
exposure to trauma, wear and tear, loss, and inner conflict associated
with the therapeutic use of self.
Respite care services are available to injured servicemembers and
are provided by a Home Health Agency authorized by TRICARE and approved
by the servicemember's case manager. Respite care provides rest and
change for the primary caregiver who has been caring for the patient at
home and assisting with activities of daily living.
Medical Care for Dependents--
Eligible beneficiaries can access a wide range of mental health
services in the Military Health Service. TRICARE covers medically and
psychologically necessary behavioral health care services including
outpatient psychotherapy, psychological testing and medication
management; acute inpatient psychiatric care, psychiatric partial
hospitalization program, residential treatment center care (limited to
beneficiaries under age 21), and substance use disorder services.
The web-based TRIAP provides online access to counseling for short-
term, non-medical issues.
The Telemental Health Program is available at participating TRICARE
facilities where beneficiaries can use secure audio-visual conferencing
to connect with offsite TRICARE network providers.
General Chandler. There is a comprehensive spectrum of mental
health care and support available to family members and beneficiaries
who may also be care-givers of the wounded, ill, and injured.
The following types of treatments are available to family members:
Formal mental health visits:
In the Air Force, due to the primacy of the mission to active duty
airmen, most care to family members is arranged through the TRICARE
network.
Behavioral Health in primary care:
Studies show half of all medical visits for mental health concerns
occur in primary care clinics. More than 60 percent of Air Force MTFs
have behavioral health providers embedded within them. Seeing a mental
health provider in primary care is a lower-stigma alternative and
typically involves a few visits for a focused intervention.
The TRICARE Assistance Program:
TRIAP offers web-based counseling for adult beneficiaries.
Nonmedical counseling
Military OneSource offers nonmedical counseling with licensed
providers for family members and is easily accessed through a toll-free
telephone number by self-referral. MFLCs and licensed mental health
providers offer confidential support to military members and family
members through base Airman and Family Readiness Centers.
Support and referral
Recovery Care Coordinators (RCCs) and Family Liaison Officers
working with wounded, ill, and injured airmen also help support family
members and caretakers and refer them to any needed services.
Additionally, our chaplains are active in supporting family members and
caretakers and are trained in suicide prevention strategies.
In summary, there is a broad spectrum of mental health services
available to beneficiaries who need mental health services.
26. Senator Burris. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, is it only military dependents that qualify
for these services, or are there resources available to affected non-
dependents such as parents?
General Chiarelli. Army Behavioral Health services are not
available to non-dependents such as parents. However, parents and non-
dependents are eligible to receive education counseling, research and
referrals through Military OneSource (www.MilitaryOneSource.com) when
the mental health concern is related to or on behalf of a
servicemember.
For mental health issues unrelated to the servicemember, Military
OneSource will work with the non-dependent or parent to refer them to
the appropriate behavioral health resource in the civilian sector.
While there are no costs associated with using Military OneSource, the
non-dependent is responsible for any resource other than the assistance
provided by Military OneSource.
Admiral Greenert. Section 1672 of the NDAA for Fiscal Year 2008
authorizes a family member who is not otherwise eligible for medical
care at a Military Treatment Facility (MTF), and who is caring for a
member of the Armed Forces recovering from serious injuries or
illnesses, to receive medical care at the MTF on a space-available and
reimbursable basis. Such care includes available mental health services
in the MTF. Earlier this year, the Deputy Secretary of Defense signed
out a memorandum on April 1, 2010 expanding eligibility of care to non-
family members.
Additional help is available to primary caregivers of homebound
injured active duty servicemembers. Respite care services are available
to the family members of injured servicemembers and are provided by a
home health agency authorized by TRICARE and approved by the
servicemember's case manager. Respite care provides rest and change for
the primary caregiver who has been caring for the patient at home and
assisting with activities of daily living.
General Amos. Section 1672 of the NDAA for Fiscal Year 2008
authorizes a family member who is not otherwise eligible for medical
care at a Military Treatment Facility (MTF), and who is caring for a
member of the Armed Forces recovering from serious injuries or
illnesses, to receive medical care at a MTF on a space-available and
reimbursable basis. Such care includes available mental health services
in the MTF. Deputy Secretary of Defense Memorandum of April 1, 2010
expanded eligibility for this care to non-family members.
Additional help is available to primary caregivers of homebound
injured active duty servicemembers. Respite care services are available
to injured servicemembers and are provided by a Home Health Agency
authorized by TRICARE and approved by the servicemember's case manager.
Respite care provides rest and change for the primary caregiver who has
been caring for the patient at home and assisting with activities of
daily living.
General Chandler. Current policy does not provide these services to
non-dependents such as parents unless they are designated as the
caregiver by the servicemember. Caregivers must be certified by medical
personnel prior to designation. Those designated as caregivers are
authorized inpatient and outpatient care at a military treatment
facility on a space-available basis.
differences in services' statistics
27. Senator Burris. General Chiarelli and General Amos, all of the
Services have seen an increase in their suicide rates. However, the
Army and Marine Corps have seen a much higher rate of suicides than the
Navy and the Air Force. For example, in 2008, the Army and Marine Corps
had suicide rates of 18.5 and 19.5 per 100,000 servicemembers,
respectively. However, the Navy and the Air Force had rates of 11.6 and
12.1 per 100,000 servicemembers, respectively. Why do you believe
suicide rates in the Army and Marine Corps are so much higher?
General Chiarelli. The U.S. Army Public Health Command (Prov)
technical paper dated 29 April 2010, based on an overall assessment
over the study period from 2003-2009, indicates that the primary high
risk population for suicide among Army soldiers is young males with a
behavioral health (BH) condition, which is consistent with data on
civilian risk factors. Other than having a BH diagnosis, other factors,
such as participation on first deployment, levels of combat exposure,
and personal and work-related stressors likely contribute to suicide
risk. On the latter, they did indicate ``further analysis is required
to understand their relative impact and to prioritize areas for
prevention and intervention.''
According to the Army suicide reports used for the VCSA's Senior
Review Group meetings, the leading factor associated with a completed
suicide event involves a relationship problem (55.8 percent of 520
cases), with military/work stress being the second leading factor (49.6
percent of the 520 cases). In most cases, there are multiple
contributing factors.
General Amos. The Marine Corps consists of an overwhelmingly young,
male and mostly single population whose life-skills and resilience are
still developing. Impulsivity is known to play a role in suicide-
related behavior and we believe that our young marines are at increased
risk. In addition, we believe that high sustained operational tempo is
a stressor that may be experienced uniquely in the different Services.
28. Senator Burris. Admiral Greenert and General Chandler, do you
believe there are any components of your suicide prevention programs
that can account for your lower numbers?
Admiral Greenert. We believe that a sustained, multi-faceted
strategy that includes introducing and sustaining OSC training
throughout the career continuum, local level leadership engagement,
education, and outreach has reduced variability in Navy suicide rates
over the years. We are committed to a systematic approach with
continuous process improvement. We are glad to see lower numbers but
hesitate to draw premature conclusions, and recognize the need to
maintain vigilance regardless of the direction of the numbers.
General Chandler. Given the different missions and cultures of the
Services, it is difficult to directly compare suicide prevention
efforts between the Services. The Air Force is concerned with the
health and resilience of all servicemembers and extends great effort to
reduce the risk of loss of a single servicemember to the tragedy of
suicide. The Air Force Suicide Prevention Program is founded upon 11
enduring elements as a community-based prevention program. The first,
and key, element to this program is senior leader involvement.
Messaging from senior leadership regarding the importance of seeking
help when needed has been a critical factor in the success of the Air
Force Suicide Prevention Program. The Air Force Suicide Prevention
Program is also based on a strong research foundation. The prevention
program is engaged in a number of studies with researchers at the USUHS
to examine case data on past suicides, including data collected through
our Suicide Event Surveillance System, and the DODSER and Personal
Health Assessment data, to look for factors that may allow us to better
identify those at risk for suicide. Recent efforts in this area have
allowed us to identify career fields that appear to be at greater risk
for suicide, allowing leadership to target additional prevention
efforts at these groups.
The Air Force is also collecting data on new recruits entering the
Air Force regarding past behavioral history. This data collection
appears to show promise in allowing us to identify, from a recruit's
earliest days in the Air Force, those airmen who may be at higher risk
for a variety of problems. The Air Force is now exploring ways to reach
out to these airmen to improve their ability to cope with the rigors of
military life and improve resiliency.
warrior transition units
29. Senator Burris. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, numerous Warrior Transition Units (WTU)
have been established to assist wounded servicemembers in their
recovery. What types of programs are in place in the WTUs to assist
servicemembers who are struggling with TBI and PTSD?
General Chiarelli. Soldiers in WTUs are assigned to a healthcare
team that includes a PCM, a case manager, and a social worker. This
team conducts extensive screening for TBI and PTSD during their initial
and ongoing visits with the soldier. If a soldier screens positive for
either TBI or PTSD, the team has access to referral resources within
the Military Health System and in the civilian community. The DCoE for
Psychological Health and TBI provide resources to healthcare
professionals through their outreach center and through monthly video
conferences.
There are a number of resources available to soldiers and families.
U.S. Army MEDCOM has developed a number of TBI clinics and specialty
programs located at Military Treatment Facilities at installations
throughout the United States and Europe. The VA and DOD have
collaborated on and published a TBI clinical practice guideline fact
sheet. Similarly, soldiers diagnosed with PTSD have access to
Behavioral Health specialists who are experts in the treatment of PTSD.
The DOD DHCC, a component of the DCoE for Psychological Health and TBI,
offers a specialized care program for patients experiencing PTSD.
Soldiers and family members also have access to Behavior Health
Specialists through Military OneSource.
Admiral Greenert. Safe Harbor is the Navy's Wounded Warrior Program
for non-medical care management of recovering servicemembers. Safe
Harbor does not operate WTUs. The Navy's model for warrior care is to
transition sailors enrolled in the program close to their original
homeport or command or wherever they can receive top quality medical
care and be close to their support network of family members and
Shipmates. While the Army and Marine Corps wounded warrior population
tends to be younger, unwed and living in a barracks environment prior
to injury, Navy has an older population. The average Navy wounded
warrior is 34 years of age, married and no longer a barracks resident.
These factors make the Navy model of not garrisoning wounded, ill, and
injured a good choice for our sailors and coastguardsmen and optimize
the success of their recovery, rehabilitation and reintegration
activities.
Safe Harbor works closely with Navy Medicine and other agencies/
organizations both in the government and private sectors to ensure that
sailors and coastguardsmen who are struggling with TBI and post-
traumatic stress receive the care and assistance necessary to meet all
their needs and those of their families. All Navy Wounded Warriors have
access to TBI and PTSD care offered within DOD and VA Health Systems,
including the Navy's Comprehensive Combat and Complex Casualty Care
(C5) at Naval Medical Center San Diego, the NICoE and the DVA
Polytrauma Centers. Examples of other programs that Safe Harbor assists
in facilitating access to include DOD Computer/Electronic
Accommodations Program, the Bob Woodruff Foundation initiatives, Navy
Marine Corp Relief Society Visiting Nurse, and many more.
General Amos. In its non-medical care capacity, the Marine Corps'
WWR has different programs in place to assist our marines and their
families struggling with TBI and PTSD. Licensed clinical consultants,
who are located at the WWR's headquarters in Quantico, VA, and its
battalions at Camp Lejeune, NC, and Camp Pendleton, CA, provide
resources and coordinate referrals to military, VA and community
treatment facilities. The WWR's TBI program coordinator screens marines
with blast exposures for entry into Hyperbaric Oxygen Treatment (HBOT)
research studies. RCCs assist Active Duty and Reserve marines with TBI
and PTSD through coordination of a marine's non-medical and medical
care providers and the completion of a comprehensive transition plan
(CTP) that helps marines define their personal goals for recovery,
rehabilitation and reintegration. The WWR's Warrior Athletic
Rehabilitation Program and its involvement in DOD's Warrior Games give
marines an outlet to overcome TBI and PTSD through physical activity
and competition. The Families OverComing Under Stress Program is a
resiliency program designed to assist and promote strong Marine Corps
families so they are better equipped to contend with the stressors
associated with military life and injuries such as TBI and PTSD.
General Chandler. While the Air Force does not operate WTUs, we
provide close support to our wounded, ill, and injured airmen through
our medical staffs and the Air Force Warrior and Survivor Care program.
Our RCC provide close personalized support to our airmen, monitor those
with signs of post-traumatic stress and make referrals to the
appropriate medical specialist. The team approach of clinical case
manager, RCC, and the unit command works in concert to identify and
treat airmen with PTSD or TBI. Additionally, our Air Force Wounded
Warrior Program provides long-term outreach support and referral to
medical specialists as needed. Since we have experienced excellent
success with our RCC program, we are expanding that program this year
by adding 14 additional RCCs throughout the country. Our goal is to
provide improved coverage, especially for Reserve component units in an
effort to ensure we are supporting all of our wounded, ill, and injured
airmen.
The Air Force works in conjunction with the DCoE for Psychological
Health and TBI in development of protocols, education and training,
prevention, patient, family and community outreach. The DVBIC is the
DOD point of evaluation, treatment and clinical research on TBI. It
provides treatment and follow-up TBI care to active duty
servicemembers, veterans and their family members.
Air Force mental health providers deliver evidence-based treatments
for PTSD, including prolonged exposure therapy and cognitive processing
therapy. In addition, eight Air Force sites conduct virtual reality
treatment for PTSD patients. The Air Force operates a TBI clinic at
Elmendorf Air Force Base (AFB).
Through joint collaboration with the Centers for Deployment
Psychology (CDP) at the USUHS, psychology and social work residents
attend a two week training that focuses on identification and treatment
of TBI and PTSD. In addition, CDP also offers training on evidence-
based treatments for PTSD to Air Force providers. DVBIC offers similar
education on TBI which Air Force providers have attended.
30. Senator Burris. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, by the very nature of the population in the
WTUs, is it reasonable to conclude that there is a higher instance of
substance abuse in these units?
General Chiarelli. While it certainly is true that soldiers in WTUs
represent a concentration of those with behavioral health issues such
as depression and PTSD, as well as TBIs, it is not accurate to
characterize these conditions, in and of themselves as predisposing
these soldiers to greater risk of substance abuse behavior than other
soldiers. There is no data to suggest soldiers in a WTU have a higher
incidence of substance abuse or are at a higher risk than the general
Army population. Substance abuse is as much a social phenomenon as it
is related to behavioral issues. This is why the Army has made such a
considerable investment in cultivating resilient soldiers and families
so that they adopt alternative means for coping and dealing with
anxiety and stress and maintain healthy lifestyles. Any soldier in a
WTU who exhibits substance abuse problems is immediately referred to
the Army Substance Abuse Program. For those warriors in transition who
are determined to be at risk, the PCM will enter that soldier into the
Sole Provider Program. This program limits access to prescriptions,
requires weekly medication reconciliation by the WTU pharmacist and
close monitoring by the PCM of all prescribed medication.
Admiral Greenert. Navy's equivalent of the WTU is Safe Harbor,
which has not noted any major substance abuse problems. While the other
Services' average wounded warrior population is 19-20 years old, unwed
and live in a barracks environment, Navy has an older population. The
average Navy wounded warrior is 34 years of age. Sixty-one percent of
the Safe Harbor population is married. Navy transitions sailors in this
program close to their homeport or command, whichever is more
convenient for the servicemember. Both of these factors, older average
age and environmental stability, may tend to reduce substance abuse.
General Amos. By virtue of their wounds, illnesses or injuries and
subsequent treatment, our Wounded Warriors are an at-risk population
for substance abuse. Wounded, ill or injured servicemembers utilize
prescribed pain medications at a higher rate than the general military
population because of their medical conditions. We are aware that
servicemembers, in particular, with PTSD may use alcohol as a way to
try to relieve PTSD symptoms. With this heightened awareness, our
wounded warrior battalion staff screens new admissions, reconciles
their medication use, and refers marines in need to appropriate
treatment programs. The WWR also supports alternatives to pain
medication such as acupuncture, yoga, electrical stimulation and
biofeedback to decrease the need for traditional pain medications.
General Chandler. The Air Force does not have WTUs. Based upon
information from PDHAs and PDHRAs, there is no current evidence of a
significant trend in substance abuse issues for deploying personnel in
the Air Force.
psychotherapeutic drugs
31. Senator Burris. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, in light of recent concerns that some
psychotherapeutic drugs could actually increase the risk of suicide,
what controls are in place to ensure that patients taking multiple
drugs are receiving proper clinical review?
General Chiarelli. The increasing rate of soldier suicide in the
past 5 years has received the proactive attention of senior Army
leadership and has led to an unprecedented effort to comprehensively
address all known domains of risk reduction, to include recent policies
directing more in-depth oversight of medication prescribing. The intent
is to minimize iatrogenic risks e.g., overdosing on respiratory drive
depressants such as narcotics, particularly in combination with alcohol
and/or other central nervous system depressants, etc.
In June 2009 the Office of the Surgeon General/U.S. Army MEDCOM
issued guidance to providers caring for patients who receive treatment
with multiple medications. This policy was revised in September 2009,
and is currently being updated further to fully address the concerns of
polypharmacy among soldiers receiving treatment, especially when
psychotropic agents or central nervous system depressants are involved.
The purpose of this policy is to provide guidance on the prevention and
management of polypharmacy with psychotropic medications and central
nervous system depressants to reduce adverse events and optimize
clinical outcomes among soldiers. This policy mandates that care
providers carefully monitor soldiers with complex or multiple medical
and/or behavioral health problems to reduce the risk of serious drug
interactions and polypharmacy. Providers will review the medication
profile at each visit, assess for ongoing clinical indications for
medication treatment, screen for the potential side effects, including
the effects of drug-drug interactions, and refer to a clinical
pharmacist for further review and reconciliation if the number and
nature of the patient's medications triggers a pharmacy referral.
Risk has been greatly reduced for WTU soldiers, who are at the
highest risk among our troops, by implementing intensive monitoring by
primary care physicians in close collaboration with pharmacists
assigned to the WTUs. Consequently, soldiers' medications are reviewed
within 24 hours of arrival in the WTU, reviewed thereafter at least
weekly, and more often if changes in dosage or medication are made in
the course of treatment. High risk soldiers are assigned to only one
health care provider to access controlled medications that may put them
at greater risk. Soldiers who have demonstrated difficulties in
complying with treatment on opioid analgesics and other controlled
medications are enrolled in the Sole Provider Program for more intense
monitoring and control.
Admiral Greenert. National Patient Safety Goals of the Joint
Commission of Hospital Accreditation regarding medication requires
medication reconciliation at each patient encounter which includes a
full review of all medications a patient is currently taking. The
review is performed not only by the provider, but also the pharmacist
dispensing the medication.
The local Military Treatment Facility (MTF) Pharmacy and
Therapeutics Committees also review all adverse drug reactions and
report those of significance to the FDA via a MEDWATCH form. The FDA
also requires a Risk Evaluation and Mitigation Strategy (REMS) on
certain drugs (many psychotropics and opiates are included) to ensure
the benefits outweigh the risks. As part of the REM a Medication Guide
is required to be dispensed to the patient to help avoid serious
adverse events and warn the patient of any risks.
Additionally, Case Management works closely with the behavioral
health providers to ensure that members receive the correct medications
and understand the instructions for use. Case managers perform
medication review/reconciliation in AHLTA (electronic records system)
and provide education and drug interaction information for those
patients taking multiple drugs.
General Amos. While I defer to the military medicine professionals
regarding appropriate management of all medical conditions, the Marine
Corps is committed to engaged leadership. We are attentive to the
mental health of our warriors and we are dedicated to ensuring that all
marines and family members who bear the invisible wounds caused by
stress receive the best help possible. We developed the Combat
Operational Stress Control (COSC) program to prevent, identify, and
holistically treat mental injuries caused by combat or other
operations.
General Chandler. Proper clinical review is assured through
education, policy, and process.
It is correct that psychotropic medications such as antidepressants
and anticonvulsants may cause a small increase in suicidal risk in
patients. Air Force providers have received education on this risk from
multiple sources including professional organizations, their medical
treatment center leadership, pharmaceutical companies, and the DOD
Patient Safety Center.
AF MTF pharmacy and therapeutics committees review medication
safety information and medication alerts from agencies such as the Food
and Drug Administration (FDA) and educate providers at professional
staff meetings on new safety information on medications.
By Air Force Surgeon General policy, the Chief of the Medical Staff
at each MTF is charged with assuring the proper education of providers
on medications and their effect on suitability for continued service
and deployment. Deploying airmen are required to demonstrate more than
90 consecutive days of stability on psychotherapeutic medications
before deployment. In the case of suicidal risk, airmen at higher risk
are tracked weekly by the mental health clinic, which communicates with
the command and the patient's primary care physician.
Overuse of pain medications can pose a larger risk. In January 2009
the Surgeon General instructed ongoing review of patients with chronic
pain by MTFs via pharmacy and therapeutics committees, a staff
communication log or multidisciplinary review forum. These venues help
assure that individuals at risk for overuse of opiate medications are
prevented from engaging in dangerous use of the medication.
Finally, pharmacy staff are trained to check for therapeutic
duplications, drug-drug interactions, and that the patient is taking
medications as prescribed (e.g., not receiving early prescription
refills).
In summary, adverse effects from medication or misuse of
medications do occur, but through education, policy and procedure, the
Air Force works to minimize these risks.
prevention programs
32. Senator Burris. General Chiarelli, Admiral Greenert, General
Amos, General Chandler, and Dr. Jesse, DOD and VA, as well as each of
the individual Services, have numerous programs and initiatives in
place to put emphasis on suicide prevention. However, as the statistics
show, the success of these programs is questionable. Are there any
independent oversight entities at DOD and VA to monitor these programs?
General Chiarelli. At this time there are no independent oversight
entities within DOD to monitor the programs and initiatives in place.
However, the SPARRC meets regularly to share and discuss the numerous
programs and initiatives in place across DOD. In addition, the SPARRC
has representation from the VA to ensure interagency collaboration on
suicide prevention efforts.
The congressionally mandated DOD Suicide Prevention Task Force has
spent the past year conducting a comprehensive analysis of the numerous
programs and initiatives currently being used within DOD. Their
findings will highlight areas of strength and identify areas for
improvement for DOD's suicide prevention programs.
Admiral Greenert. The DCoE for Psychological Health and TBI chairs
the SPARRC, which was formed to establish standard definitions,
standardize reporting requirements, track suicide rates, collaborate
with other experts in the field, and advise and coordinate future DOD
prevention initiatives. The DCOE and the SPARRC consult numerous
entities, such as the RAND Corporation, for program evaluation and
feedback.
Members of the SPARRC include non-service entities such as VA,
Substance Abuse and Mental Health Association, the USUHS, and
recognized civil sector experts.
The Annual DOD/VA Suicide Prevention Conference is a collaborative
body for sharing best practices.
The Joint Commission provides oversight to MTFs.
Navy efforts to assess effectiveness of programs have included an
upcoming study, in conjunction with USUHS, on the effectiveness of the
latest suicide prevention training.
General Amos. I defer to DOD and VA.
General Chandler. The DOD SPARRC serves as an important forum for
sharing Service initiatives and has established standardized data
collection and reporting processes. This data standardization is
essential for evaluating the ultimate effectiveness of Service suicide
prevention programs. The forum for sharing initiatives allows the
Services to benchmark the practices reviewed at the SPARRC. The SPARRC
also leads the annual DOD/VA Suicide Prevention Conference, which
provides a review of military and civilian programs from around the
country. The Surgeons General and Assistant Secretary of Defense for
Health Affairs monitor and discuss suicide prevention efforts through
the Senior Military Medicine Advisory Council. There is also strategic
planning for provision of mental health services, including suicide
prevention, between the DOD and VA under the DOD/VA Senior Oversight
Council. Within the Air Force, suicide prevention data is monitored
weekly by the Chief of Staff. Additionally, the Air Force had its
suicide prevention program evaluated by outside experts and the Air
Force Suicide Prevention Program has been identified as a best practice
on the U.S. Department of Health and Human Services Substance Abuse and
Mental Health Services Administration list of evidence-based programs
for the prevention of suicide.
Dr. Jesse. Oversight of VA's Suicide Prevention Program is managed
by internal administrative structures as well as the VA Suicide
Prevention Steering Committee, a group composed of members representing
various and relevant VA groups. The member list follows:
Ira Katz, MD, PhD, Senior Consultant for Mental Health
Program Analysis, Co-Chair
Kerry Knox, PhD, Director, Center of Excellence at
Canandaigua, Co-Chair
Robert Bossarte, PhD, Acting Chief, Epidemiology and Health
Services Research, Center of Excellence
Charles Clancy, MSW, Chief, Social Work Service, Louisville
VAMC
Susan G. Cooley, PhD, Chief, Geriatric Research and
Evaluation, Chief, Dementia Initiatives, Office of Geriatrics
and Extended Care
Charles Flora, Associate Director, Readjustment Counseling
Services (RCS)
Theresa Gleason, PhD, Program Specialist, Office of Research
and Development, VACO
Kim Hamlett-Berry, PhD, Director, Office of Public Health
Policy and Prevention, VACO
Terri Huh, PhD, Associate Director for Education and
Evaluation, VA Palo Alto GRECC
Mark Ilgen, PhD, VA Serious Mental Illness Treatment Research
and Evaluation Center (SMITREC)
Bradley Karlin, PhD, Director, Psychotherapy Programs, Office
of Mental Health Services, VACO
Janet Kemp, PhD, Mental Health Program Director, Suicide
Prevention and Chief Education, Training and Dissemination,
VISN 2 Center of Excellence
Laurent Lehman, MD, Coordinator, Mental Health Disaster
Response, VACO
Peter Mills, PhD, Director, Field Office, VA National Center
for Patient Safety, White River Junction VAMC
Edward Post, MD, PhD, VA Health Service Research and
Development (HSR&D), SMITREC
Todd Semla, MS, PharmD, Pharmacist Specialist, Hines VAMC
Suzanne Thorne-Odem, RN, MS, Mental Health Clinical Nurse
Advisor, Office of Nursing Services
Gary Tyndall, MD, Emergency Department Medical Director,
Syracuse VAMC
Marcia Valenstein, MD, VA HSR&D, SMITREC
Antonette Zeiss, PhD, Acting Deputy Chief, Mental Health
Services, VACO
VA is beginning to see some level of success since the inception of
our comprehensive suicide prevention programs. Although the trends are
promising, it is still too early to determine if they are sustainable.
There has been a decrease in suicide rates among Veterans who receive
care in the VA from 2001 through 2007 (the last year for which national
data are available). We will continue to monitor these rates. In
addition, there are numerous anecdotal stories and documented
information concerning callers to the Hotline and referrals to the
Suicide Prevention Coordinators that indicate that the numbers would be
much higher without these programs. We will continue to implement new
programs as the evidence builds for specific interventions and
strategies, but in the meantime we will maintain the programs we have
in place with continued emphasis on the identification of those
Veterans at risk in order to provide enhanced levels of care.
traumatic brain injury treatments
33. Senator Burris. General Chiarelli, Admiral Greenert, General
Amos, General Chandler, and Dr. Jesse, a recent study at Louisiana
State University's School of Medicine used hyperbaric oxygen therapy on
blast-injured veterans to repair brain injuries. The results were
rather impressive, with treated veterans showing a 15-point IQ
increase, a 40 percent reduction in post-concussion syndrome symptoms,
a 30 percent reduction in post-TBI symptoms, and a 51 percent reduction
in concussive depression. Is this a treatment option that is currently
being examined by DOD or by VA?
General Chiarelli. Yes, in the next few weeks the U.S. Army Medical
Research and Materiel Command and the DCoE for Psychological Health and
TBI will be initiating a pilot study of hyperbaric oxygen for traumatic
brain injured patients. We are aware that the Navy and Air Force are
also conducting or participating in research involving oxygen
therapies. The results of all of these DOD trials will solidify the
pivotal, larger, multicenter clinical trial scheduled to begin early
2011.
We believe the military studies by design will further answer
definitive questions where other studies anecdotally report results
without adequate controls to distinguish real treatment safety and
effectiveness from other confounding factors such as the placebo
effect, the Hawthorne effect and the practice effect from repeated
testing. The Louisiana work mentioned above are initial results from a
pilot study that has not been published in the peer-reviewed medical
literature at this time, so details of this study are limited and the
strength of inferences about the effect of hyperbaric treatment are
limited because this study lacked a non-hyperbaric oxygen control
group.
Admiral Greenert. Navy Medicine is committed to providing all
available therapies to servicemembers and their families as soon as
there is sufficient evidence to ensure safety and efficacy of the
therapy. DOD has three placebo-controlled clinical trials planned or in
progress on the use of hyperbaric oxygen. Two of these are feasibility
studies which will provide information on appropriate selection of
hyperbaric oxygen doses and pressures as well as efficacy of procedures
utilized in providing exposure to affected individuals. One of these is
a large prospective, efficacy study to assess the effects of hyperbaric
oxygen therapy on the symptoms of mild and moderate TBI. One of the
feasibility studies is expected to have data available in early 2011
and the other in late 2011. The large efficacy study will have data
available in 2014. Navy Medicine is funding travel for active duty
servicemembers to participate in these studies and, in partnership with
the VA, is the lead for one feasibility study.
The study which is referred to in this question does not appear to
have been published in a peer-reviewed journal; the results, however,
are encouraging and it is hoped the DOD trials will provide
confirmation as to efficacy and safety, as this would allow our wounded
servicemembers and their physicians to have another therapeutic option
available.
General Amos. DOD has three placebo-controlled clinical trials
planned or in progress. Marines who desire to participate in these
studies, after appropriate informed consent, will have leadership
support in doing so. In fact, in one study currently underway 90
percent of the subjects are marines or former marines.
General Chandler. Congressional support for current Air Force HBOT
for TBI research is sufficient and greatly appreciated. DOD research on
HBOT for TBI is in its infancy and is centered on chronic mild and
moderate TBI. It remains an unproven therapy and is not accepted as a
standard of care because only anecdotal case reports and a small series
of trial reports indicate some potential benefit for TBI. Several
prospective randomized clinical trials are underway within DOD and
civilian institutions to provide more conclusive evidence regarding
HBOT's use for TBI. Definitive phase 3 trials, which will take 2-3
years and include randomized, multi-center (DOD facilities only),
double blind, definitive studies under the auspices of the FDA with an
investigational new drug registration, are projected to start in the
fall of 2010. If this research validates the efficacy of HBOT for TBI,
we will request additional congressional support for the sustainment
and possible expansion of hyperbaric chambers and personnel in addition
to presenting the evidence to the Undersea and Hyperbaric Medical
Society for consideration as an accepted indication for use.
Dr. Jesse. Yes. DOD and VA are actively collaborating on the
development and implementation of a portfolio of research projects
focused on understanding the benefits of hyperbaric oxygen therapy
(HBOT) on the efficacy and utilization of HBOT for treating mild
traumatic brain injury (TBI) and post-concussive symptoms. This
collaboration has three pilot trials and one large definitive trial. A
joint VA, DOD, and academic task force recommended the research
designs, implementation and outcome measures for all of the trials.
A VA clinical researcher is participating in the clinical trial
that has begun recruiting subjects at Quantico Marine Base, and VA
neuropsychologists are coordinating the data collection and analysis of
the definitive trial. The full definitive trial in Salt Lake City, UT,
is projected to begin in late 2010.
While HBOT demonstrates effectiveness in treating certain
disorders, there are presently only clinical reports but no
demonstrated double-blinded, controlled, scientific evidence that
supports using HBOT to treat mild TBI. Presently, neither the Food and
Drug Administration (FDA) nor the Undersea and Hyperbaric Medical
Society--the medical specialty society and authority that provides
guidance to Centers for Medicare and Medicaid Services (CMS) for use of
HBOT--recognize use of HBOT as a primary or adjunctive therapy for TBI.
______
Questions Submitted by Senator James M. Inhofe
npr and propublica investigation interview
34. Senator Inhofe. General Chiarelli, please provide your
interview responses to the NPR and ProPublica for the record.
General Chiarelli. A copy of my letter to NPR is attached. There
are no other recorded responses. David Zwerdling of NPR spent 6 hours
with me at Fort Carson, CO, touring the WTU, but there was no formal
recorded interview.
[GRAPHIC(S)] [NOT AVAILABLE IN TIFF FORMAT]
health and quality of the force
35. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, the strength of our military is in its
people--our service men and women, their families, and our civilians
who support them. We know the deployments over the past decade have
astronomically increased the strain and stress on the force, presenting
specific indicators such as an increase in suicide rates, divorces,
substance abuse, and in some instances, murders and other serious
criminal activity. This committee is aware of shortfalls in the manning
of our medical units in certain medical specialty areas such as mental
health care specialists and providers. What is being done to get after
the mental health care provider issue?
General Chiarelli. Since 2007, the Army has added 1,265 civilian,
military and contract behavioral health (BH) providers to help meet the
needs of a stressed and growing force. This represents a 69 percent
increase in BH assets. The Army currently has approximately 89 percent
of its current BH provider requirements. The Army Medical Department
continuously monitors the need for BH providers based on the reliant
population's ongoing and changing demand. While access to BH care
providers is critical, it is just one aspect of the holistic approach
the Army is implementing to address the mental fitness and resilience
of our soldiers.
Behavioral Health (BH) hiring difficulties are not due to lack of
funding. Hiring difficulties continue to stem from the National
shortage of qualified providers, the need for these providers in remote
locations, and compensation limitations inherent to government
employment. The Army is using numerous mechanisms to recruit and retain
both civilian and military providers including bonuses, scholarships,
and an expansion in training programs. The U.S. Army MEDCOM has
increased funding for scholarships and bonuses to support expansion of
our provider inventory.
The Army expanded the use of the Active Duty Health Professions
Loan Repayment Program and offers a $20,000 accessions bonus for
Medical and Dental Corps Health Professions Scholarship Program (HPSP)
applicants. MEDCOM increased the number of HPSP allocations dedicated
to Clinical Psychology and significantly increased the annual number of
graduate students admitted to its Clinical Psychology Internship
Program. Prior to 2004 the Army historically trained 12 interns per
year and has progressively increased that number, admitting 33 interns
in 2009. In addition, the Army is attempting to hire or contract an
additional 146 psychologists.
MEDCOM provided centrally funded reimbursement of recruiting,
relocation, and retention bonuses for civilian BH providers to enhance
recruitment of potential candidates and retention of staff. The Army
used a one-time Critical Skills Retention Bonus (CSRB) for social
workers and BH nurses and the Army Medicine CSRB for clinical
psychologists. The Army also implemented an officer accessions pilot
program that allows older healthcare providers to enter the Army, serve
2 years, and return to their communities.
In partnership with Fayetteville State University, MEDCOM developed
a Masters of Social Work program which graduated 19 in the first class
in 2009. The program has a current capacity of 30 candidates.
Admiral Greenert. The current Navy mental health workforce
(including uniformed, government service and contract personnel) are
trained to address combat, operational, developmental, and occupational
mental health needs and meet the access to care standard for an initial
assessment.
Navy Medicine is expanding its medical end-strength that is organic
to the Marine Corps, including mental health providers. Further, Navy
has met the fiscal year 2010 NDAA Section 714 requirement to grow
mental health by 25 percent, which has been programmed to begin in
fiscal year 2011. This would be additive to the figures identified
below. The resulting increase in our beneficiary mission is currently
planned and funded to be handled through direct and private sector
care.
Despite outstanding efforts to aggressively recruit and retain
qualified medical personnel, manning remains below authorized levels.
As of June 2010 uniformed Mental Health manning percent (Inventory/
Billets) is as follows:
Psychiatry - 83 percent (93/112)
Clinical Psychology - 81 percent (105/127)
Social Work - 69 percent (24/35)
Mental Health Nurse Practitioners - 60 percent (12/20)
Navy Recruiting Command is addressing these shortages through
aggressive recruiting/accession programs. Incentives are a key
component of recruiting. fiscal year 2010 incentives include:
Psychiatrists - eligible for critical wartime
specialty bonus of $272,000
Clinical Psychologists - eligible for $37,000 (with 3
year contract) or $60,000 (with 4 year contract)
Social Workers - eligible for $18,750 (with 3 yr
contract) or $30,000 (with 4 year contract)
Mental Health Nurse Practitioners - All nurses are
eligible for the standard bonus of $20,000 (with 3 year
contract) or $30,000 (with 4 year contract).
General Amos. First off, the billets within the Marine Corps for
psychological health care providers are a priority fill for Navy
Medicine. To date, all of these billets have been successfully filled.
I defer to Navy Medicine to answer their manning issues for the medical
enterprise in its entirety.
General Chandler. The Air Force continues to face challenges to
recruit and retain fully qualified mental health specialists as we
compete with the private sector and other Federal agencies where
multiple deployments are not an issue. There are significant pay
disparities, increasing sign-on bonuses, annual compensation packages,
and retirement packages offering similar benefits as the military.
To address these issues, the Air Force has an aggressive three-
pronged approach to enhance recruitment and retention of mental health
care providers.
The first is to offer educational scholarships and ``grow our own''
specialists over time. This includes training through the Uniformed
Services University of the Health Sciences and through civilian or
military-sponsored psychiatry and psychology residency and subspecialty
programs. We have also optimized our enlisted commissioning programs,
such as the Nurse Enlisted Commissioning Program as a pipeline into the
mental health specialties of mental health nurse and psychiatric nurse
practitioner. Additionally, the Air Force gains new health
professionals through other training venues, such as the Airman
Education Commissioning Program, Reserve Officer Training Corps, and
United States Air Force Academy. The Nurse Transition Program is a
robust recruiting tool that also feeds the mental health nurse
pipeline. It provides an incentive for new nursing graduates to
consider Air Force nursing as a career option upon graduation. Other
educational opportunities include aggressive use of subspecialty
training and post-baccalaureate-awarding degree programs for our Nurse
Corps officers to go into specialties such as the mental health field.
Our optimization project partners mental health specialties with
Veteran Affairs hospitals and other non-Federal facilities. ``Growing
our own'' encompasses accessing new recruits, developing their skills
and specialties, and maintaining and expanding on those capabilities
for use in both state-of-the-art medical centers and to the deployed
and austere environments of wartime and humanitarian missions.
The second is enhanced recruiting and retention of mental health
professionals is through direct compensation with associated service
obligations to encourage mental health specialists to a make the Air
Force their career. The Air Force has funded accession and multiyear
bonuses, and incentive pay to recruit and retain selected fully
qualified mental health specialists. These have a positive effect on
recruiting and retention. Each bonus has caps and the larger bonuses
have multiyear contractual requirements. Although it does not reach
parity, the contractual incentive packages help offset some of the pay
disparities between the military and private sector compensation
packages. The ability to recruit and retain fully qualified specialists
without bonuses is extremely limited.
Lastly, our members grapple with decisions to remain in the service
and we understand the family is greatly involved in this decision.
Quality of life issues concerning the availability of schools,
frequency of moves and deployments, and general base services are at
the forefront of any discussion. We have addressed many of these issues
both for the new member and the 20-plus year veteran. For those mental
health specialties with increasing wartime deployments, we are able to
spread the deployment load more evenly among our bases and members. By
keeping our deployments at 6 months in duration, we can maintain
predictability, stabilize our force and retain more of our skilled
assets. The Family Health Initiative with embedded Behavioral Health is
a medical model that better leverages our personnel. We are partnering
to build force sustainment models and being more proactive in managing
the numbers of professionals in each mental health specialty.
While recruiting and retention of the mental health professions
remains a challenge, we remain committed to exercise all available
authorities in concert with the other Services and under Health Affairs
to obtain the best value in mental health care for our Nation's
military and their family members through enhanced recruiting and
retention efforts maximizing the tools provided for education,
compensation, and quality of life efforts for our mental health
professionals.
pre- and post-deployment cognitive assessments
36. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, the NDAA for Fiscal Year 2008 (Public Law
110-181) required capability to conduct both pre- and post-deployment
cognitive assessments of the same type for a comprehensive, comparable
process. Recent reports by the Army Surgeon General state that data
from an in-theater study of cognitive assessment technology selected by
DOD for pre- and post-deployment assessment was no better than a
``coin-toss''. However, a recent study of more than 10,000 pre- and
post-deployment assessments collected at Fort Campbell, KY, indicates
that cognitive assessment accurately reported cognitive change
associated with TBI and even differentiated levels of cognitive change
associated with mild TBI incidents. Why are cognitive assessments good
enough for the pre-deployment assessments but not for the post-
deployment assessments?
General Chiarelli. The intent of Army medicine is to use the best
available evidence-based tools to identify, evaluate, and treat our
soldiers. The Automated Neuropsychological Assessment Metrics (ANAM) is
administered prior to deployment in order to obtain a baseline of
cognitive functioning. This is necessary because there is a wide range
of individual differences in cognitive function. The ANAM baseline can
be compared to post-injury assessments and help guide decisions about
further assessments and intervention. Follow-up cognitive assessment is
conducted if a soldier experiences any event that results in potential
decreased cognitive functioning. The results of the ANAM test may help
healthcare staff compare a soldier's speed and accuracy of attention,
memory, and thinking ability before and after an injury.
Screening for mild TBI, also known as concussion, is intended to
capture those soldiers who may have sustained a TBI while deployed and
perhaps have symptoms that require further assessment and treatment.
Positive screens are not diagnostic of TBI but do trigger a clinician
interview for further evaluation. Screening for TBI now takes place
proximate to the time of the injury event, similar to how medical
clearance is required after aviation incidents. The Army implemented
the ``Educate, Train, Treat, and Track'' mTBI/concussive injury
management strategy in late 2009. This management strategy was
reinforced by DTM 09-033 dated 21 June 2010, titled ``Policy Guidance
for Management of Concussion/Mild Traumatic Brain Injury in the
Deployed Setting''. This DTM directs that that any soldier who sustains
a direct blow to the head, or is dismounted within 50 meters of a
blast, or is in a building or vehicle damaged by a blast/accident must
undergo a medical evaluation. This early identification of concussion
and immediate intervention with 24 hours rest and medical clearance
prior to return to duty should go a long way to improve the health of
our soldiers.
Since May 2008 all soldiers returning from deployment answer a
series of questions on the PDHA that report exposure to injury event,
presence of subsequent loss of consciousness or alterations in
consciousness, presence of symptoms at time of injury, and presence of
current symptoms. The third post-deployment screen occurs during the
PDHRA conducted 90-180 days after return from deployment. These tools
reveal whether an event occurred and whether any symptoms have
resulted. Detailed cognitive assessments, which the ANAM is a
component, can then be performed as part of a larger medical workup as
necessary.
Admiral Greenert. The NDAA for Fiscal Year 2008 required pre-
deployment testing but did not specify that post-deployment testing be
done with the same instrument as for pre-deployment testing. The
Automated Neurocognitive Assessment Metrics (ANAM) assesses only
cognition, but in the pre-deployment window serves adequately to
establish a baseline for comparison later on if an individual is
exposed to blast or suffers a concussion. It sets a baseline, but does
not serve as a screening test.
The goal of the post-deployment screening is to identify all
servicemembers who may be having persistent symptoms from a concussion/
TBI and thus need further evaluation. This is accomplished through the
PDHA and PDHRA. The most common clinical symptom following concussion
is headache. Concussion can produce a variety of symptoms (with or
without cognitive dysfunction) such as headache, dizziness, insomnia,
irritability, mood and anxiety disturbances, in addition to isolated
cognitive disturbances. Navy Medicine is focused on evaluating and
treating all aspects of post-concussion symptoms.
Navy Medicine providers using their clinical judgment, request
detailed neurocognitive testing in the post-deployment period as
warranted. Neurocognitive assessments are focused exclusively on
assessing cognition and the ANAM measures only select areas of global
cognition. Comprehensive neuropsychological testing is indicated when
servicemembers are being seen for comprehensive evaluation. The recent
Ft. Campbell study uses ANAM for pre- and post-deployment screening and
reports (although not yet in a peer-reviewed journal) significant
improvement in minimizing false-positive test results. However, this
study did not examine the false-negative rate (where servicemember is
re-assured that testing is normal yet has cognitive impairment); this
is a significant omission and would have implications on the utility of
ANAM for routine post-deployment testing.
General Amos. The recent Fort Campbell study uses ANAM for pre- and
post-deployment screening and reports (although not yet in a peer-
reviewed journal) significant improvement in minimizing false-positive
test results. However, this study did not examine the false-negative
rate (where servicemember is re-assured that testing is normal yet has
cognitive impairment); this is a significant omission and would have
implications on the utility of ANAM for routine post-deployment
testing.
The NDAA required pre-deployment testing but did not specify that
post-deployment testing be done with the same instrument as for pre-
deployment testing.
The Automated Neurocognitive Assessment Metrics (ANAM) serves
adequately to establish a baseline for comparison later on if an
individual is exposed to blast or suffers a concussion. It sets a
baseline, but does not function well as a population screening test.
DOD is actively researching a variety of cognitive assessments that
will efficiently and accurately sort out servicemembers who have or at
high risk for persistent TBI signs or symptoms from those who do not.
The recent publication of the DTM 09-033 that mandates tracking of
servicemembers exposed to potentially concussive events will
significantly improve defining the highest risk marines that require
close follow up.
General Chandler. The Air Force agrees with the Army Surgeon
General that the Automated Neuropsychological Assessment Metric (ANAM)
is poor at detecting TBI. The broad scientific consensus is that ANAM
is not a useful tool for pre- and post-deployment assessment of
cognitive impairment due to lack of specificity about impaired scores
on testing. Neurocognitive assessments are very sensitive to external
factors such as sleep disturbances (which are common in post-deployment
servicemembers due to extended travel and time zone changes), as well
as testing environments (rooms filled with multiple people taking tests
simultaneously). Also, since cognitive performance patterns for
uninjured post-deployed servicemembers are not known; the clinical
utility of these test results from all post-deploying servicemembers
would be minimal. Given high false positive rates, retesting everyone
on redeployment would result in a prohibitive number of unnecessary
referrals. Currently, using ANAM only when clinically indicated (after
concussive event) together with neurocognitive assessments, is useful
to assist in clarifying the extent of cognitive impairments in those
who may subjectively complain of cognitive symptoms.
37. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, why aren't post-deployment assessments
being conducted by the Services?
General Chiarelli. Post-deployment assessments are currently
underway by all Services. The PDHA and the PDHRA solicits any history
of TBI and any symptoms resulting from TBI. Based on a review of all
PDHA responses from 2004 as reported in the Journal of the American
Medical Association in 2006, the PDHA detects a 19.1 percent positive
screening rate. These symptom questionnaires are a proven reliable and
valid method of determining if servicemembers require or desire further
evaluation/treatment. Both the PDHA and PDHRA are constantly being
improved, and are now entering their third generation of development.
In addition, the Army is fielding an Automated Behavioral Health system
to enhance screening for PTSD and other behavioral health problems.
Admiral Greenert. Post-deployment assessments are being conducted
by the Navy and include screening for TBI. Post-deployment assessment
of individuals follows Institute of Medicine recommendations to
evaluate the spectrum of concussion symptoms (cognitive, behavioral,
and physical) and then to complete neurocognitive testing on
individuals who have a positive TBI screen when the clinical assessment
requires it. The current method to complete this TBI screen is through
the PDHA and PDHRA, which all returning deployers are required to
complete. Navy reports overall Navy PDHRA compliance at 90 percent (87
percent Active component and 96 percent Reserve component).
General Amos. Post-deployment assessments are being conducted.
Post-deployment Assessment of individuals follows Institute of Medicine
recommendations to evaluate the spectrum of concussion symptoms
(Cognitive, Behavioral, and Physical) and then to complete
neurocognitive testing on individuals who have a positive TBI screen
when the clinical assessment requires it. The current method to
complete this TBI screen is through the PDHA and PDHRA, which all
returning deployers are required to complete.
General Chandler. The Services are conducting post-deployment
assessment by asking about concussive events during deployment and TBI
symptoms the patient is experiencing. If the patient reports a
concussive event or cognitive symptoms they are referred to a provider
for assessment. The broad scientific consensus is that the ANAM is not
a useful tool for post-deployment assessment of cognitive impairment
due to lack of specificity about impaired scores on testing. In
addition, given a high false positive rate, retesting everyone on
redeployment would result in a prohibitive number of unnecessary
referrals. Current retest using ANAM only when clinically indicated
(after concussive event) is preferred. In addition, patients with
continued cognitive complaints are referred to a neuropsychologist for
a series of cognitive tests able to diagnose the specific problems
better than the ANAM. The Air Force is conducting post-deployment
assessments via the PDHA and Post-Deployment Health Risk Assessment
(PHDRA) and TBI questions were added to the PDHRA Questionnaire in Jan
2008.
38. Senator Inhofe. General Chiarelli, is there an official version
of the in-theater study by the Army available? If so, can we be
provided with the details of the study to include the study design, the
data, and the study summary?
General Chiarelli. Yes, the National Academy of Neuropsychology has
the in-theater results available at: http://www.nanonline.org/NAN/
Conference/Handouts.aspx under Course 51, Russell et al.
39. Senator Inhofe. General Chiarelli, the ANAM pre-deployment/
post-deployment study at Fort Campbell showed the following results
regarding false positives:
- 2 percent when a post-deployment assessment was compared with
a baseline pre-deployment assessment
- 20 percent when a post-deployment assessment was not compared
with a baseline pre-deployment assessment
Are you aware of the study at Fort Campbell and can you provide
comment to the results, to include clarification on false positives?
General Chiarelli. The official results of the Fort Campbell study,
conducted by researchers from the Walter Reed Army Institute for
Research, have not been completed nor published. I will provide you
with a copy of the results when they are published.
traumatic brain injury
40. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, General Chandler, and Dr. Jesse, I am glad that both General
Chiarelli and Dr. Jesse made mention of the VA led collaboration with
DOD and National Center for Health Statistics regarding the effort to
revise methods for identifying, classifying, tracking, and reporting of
TBI, PTSD, depression, substance abuse, and other combat related
injuries. However, reporting from multiple open sources have stated
that DOD does not have full accountability of how many servicemembers
have TBI and that even with millions of dollars spent on programs since
2005, positive results have been marginal. Additional reporting
indicates that the information share between DOD (all Services, Active,
Guard, and Reserve components) and the VA has not improved accordingly
and that there is still a backlog of cases in the medical board process
and that information transference remains a significant issue. A major
concern is that a disconnect exists between DOD and the VA for the
transference of servicemember data. In some instances, new veterans
have to start over, due to the loss of their medical information. Is
this a valid assessment and, if so, what needs to be done to correct
this?
General Chiarelli. Information sharing between DOD and VA has
improved significantly since the 2004 implementation of the DHIMS BHIE.
This system permits providers at DOD Military Treatment Facilities and
VA health facilities to view, in real time, electronic clinical data
from each other's systems when a shared patient presents for care. BHIE
currently covers clinical data between DOD and VA on over 3.66 million
correlated patients.
Currently, there is not a disconnect between the Army and VA in the
transfer of medical records for servicemembers participating in the
Disability Evaluation System (DES) pilot. On average medical record
transfer in the DES Pilot occurs within 7 calendar days, exceeding the
standard of 10 calendar days and allowing servicemembers an opportunity
to start the claim development phase. The DES Pilot sites meet current
DOD standard of 290 days total processing time, from initiation to
transition and receipt of VA benefits. For sites not participating in
the DES Pilot, transfer of medical records is not as rapid, but
continuous efforts are underway to migrate all Army sites to the DES
pilot process.
Admiral Greenert. There is a strong connection between DOD and the
VA for the transference of servicemembers' health information. The
Federal Health Information Exchange is a DOD/VA Information Technology
health care initiative by which DOD health information on separated
servicemembers is electronically transferred to a secure joint
repository accessible by VA. This bi-directional information exchange
was established in 2002, and provides Electronic Health Record data to
VA clinicians who are able to view all clinically pertinent, historical
health information. There are issues pertaining to controlling access
to health information and is related to safeguarding the privacy of the
information, not the data sharing capability.
General Amos. I defer to DOD and VA.
General Chandler. The Air Force recognizes the importance of
closing perceived gaps in medical care provided to patients with TBI.
The Air Force concurs with DOD and VA diagnostic criteria for mild,
moderate, severe and penetrating TBI as defined by the DVBIC. DOD has
identified, classified, and compiled the number of servicemembers
diagnosed with TBI and determined the severity of the injury using
electronic medical records data on an annual basis dating back to 2000.
We remain committed to providing the most accurate and available
medical information to the (VA) for all of our airmen transitioning
from the Military Health System to the VA or private-sector based
health care.
Achieving a seamless, bi-directional healthcare information
exchange (BHIE) process between the DOD and VA electronic health record
systems remains an important Information Management/Information
Technology (IM/IT) goal. Although limited BHIE is currently available,
existing capabilities do not offer the ability for providers to review
comprehensive medical information at either the DOD or VA user
interface points. DOD and VA IM/IT officials continue to improve
existing mechanisms and develop and evaluate potential automated
solutions to achieve a more robust BHIE process.
Over the last 18 months, the Air Force has implemented a new
process that more efficiently transfers the Service Treatment Record
(the paper medical and dental records) for each retiring or separating
airman from his or her active duty military treatment facility (MTF) or
Reserve component medical unit to the VA. This new process requires all
entries from the DOD electronic health record be printed and added to
the paper record(s) before the records are transferred to one central
Air Force health records disposition center located at Randolph AFB,
TX. The central records disposition center verifies all required
medical and dental records (if available) have been obtained,
documented as received, and mailed to either the VA regional office
processing the airman's VA disability claim or to the VA's Records
Management Center in St Louis, MO. VA records managers now only have to
interact with one central Air Force medical records center instead of
almost 130 Air Force active duty MTFs and Reserve component medical
units. Performance metrics indicate the new process is working.
Through the DOD-VA DES Pilot program, servicemembers receive a
single disability exam from the VA and a single VA disability rating.
The VA disability exam takes place prior to the beginning of a Medical
Evaluation Board (MEB). Before the VA exam, the participating military
treatment facility (MTF) is required to provide the VA with a copy of
the member's complete health record. This new program offers a unique
opportunity for the VA to medically evaluate members and determine
their disability ratings. If the servicemember is determined to not
meet retentions standards by the Informal Physical Evaluation Board (I-
PEB), the VA exam results are rated by the VA Disability Rating Office.
In this way, the Board's findings and the VA ratings can be provided to
the servicemember at the same time.
Dr. Jesse. VA, in collaboration with DOD, continues to strive to
improve communication and coordination across Departments in our
Service to injured veterans and servicemembers. Since 2005, VA has
supported over 2,200 Post-Deployment Health Reassessment (PDHRA) events
for Reserve and National Guard units.
VA and DOD currently share considerable health information through
the Bi-Directional Health Information Exchange (BHIE) framework. In
addition, there are specific data exchange capabilities between major
DOD centers and the VA Polytrauma Centers to facilitate the exchange of
information including scanned documents. VA and DOD are working
together to expand the types of data exchanged to include additional
reports from procedures and items such as Audiology Reports and Neuro-
Cognitive Assessments. This is the list of data types that can be
shared from the most recent BHIE Fact Sheet:
BHIE data includes:
Clinical theater data
Drug and food allergy data
Inpatient discharge summaries from DOD's major
military treatment facilities
Laboratory orders
Laboratory results
Outpatient pharmacy data
Pre- and Post-Deployment Health Assessments and Post-
Deployment Health Reassessments
Ambulatory clinical encounter notes
Radiology text reports
Vital sign data
Response to Comment: BHIE is fully deployed across the VA
enterprise so that clinicians at every VA Medical Center and clinic
have access to DOD data shared through BHIE. At VA facilities,
clinicians view BHIE data by using Remote Data Views within the VistA
Computerized Patient Record System (CPRS); VA clinicians may also
choose to view BHIE data through Vista Web. Both applications are
implemented at every VA facility. To the extent that some hospital
staff believe they cannot view BHIE data, VA is working to improve
clinician awareness as well as clinician training on how to use the
system. VA has identified some of the factors that contribute to
clinician confusion about the availability of DOD data. For example,
the term ``BHIE'' refers to the technical framework that supports data
sharing; however, the names of the VA applications used to access DOD
data that are known to VA clinicians are ``Remote Data Views'' or
``Vista Web.'' When clinicians are asked about BHIE, they may not be
familiar with the term although they do have the tools that are used to
view DOD data. Additionally, at times, technical issues within the BHIE
framework may prevent the viewing of specific types of data, such as
DOD clinical progress notes; however, this does not preclude access to
all other DOD health data shared over the framework. There are ongoing
efforts to resolve all technical issues with BHIE. These efforts are
closely managed by both VA and DOD leadership and involve the
development of software and hardware enhancements that are being
jointly implemented and tested by VA and DOD.
In 2009, VA launched a VA-wide BHIE awareness initiative. The
purpose was to improve clinician awareness of the availability of DOD
data. As part of this effort, VA sent awareness materials, such as
brochures, videos, and pamphlets, to every VA Medical Center through
the facility Chiefs of Staff and Public Affairs Officers. Additional
ongoing efforts include briefings and participation at National
Veterans Health Administration face-to face and phone conferences
attended by VA clinicians, including clinical leadership from each
facility. At some of these conferences, such as the recent Veterans e-
Health University (VeHU) held in August 2010, a number of classroom
``how to access DOD information'' seminars were provided to VA clinical
staff. Finally, to ensure that the clinicians treating our most
severely wounded patients are trained on the availability of DOD data,
VA technical and implementation staff make routine site visits to our
four level one polytrauma rehabilitation centers to conduct clinician
training and provide onsite support.
41. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, General Chandler, and Dr. Jesse, what does the screening portion
of this joint venture consist of?
General Chiarelli. Screening for mild Traumatic Brian Injury (TBI),
also known as concussion, is intended to capture those servicemembers
who may have sustained a TBI while deployed and perhaps have symptoms
that require further assessment and treatment. Positive screens are not
diagnostic of TBI but do trigger a clinician interview for further
evaluation. Screening for TBI now takes place proximate to the time of
the injury event, similar to how medical clearance is required after
aviation incidents. The Army implemented the ``Educate, Train, Treat,
and Track'' mTBI/concussive injury management strategy in late 2009.
This management strategy was reinforced by DTM 09-033 dated 21 June
2010, titled: ``Policy Guidance for Management of Concussion/Mild
Traumatic Brain Injury in the Deployed Setting''. This DTM directs that
that any servicemember who sustains a direct blow to the head, or is
dismounted within 50 meters of a blast, or is in a building or vehicle
damaged by a blast/accident must undergo a medical evaluation. This
early identification of concussion and immediate intervention with 24
hours rest and medical clearance prior to return to duty should go a
long way to improve the health of our soldiers. Additionally, TBI
screening occurs at several intervals and locations once a soldier
leaves theater. Soldiers aeroevacuated from theater will receive their
first screen when they arrive at Landstuhl Regional Medical Center
(LRMC) in Germany. Since May 2006, all servicemembers evacuated from
theater for battle or non-battle injuries and illnesses are screened
for TBI upon arrival to LRMC. The main purpose of this screen is to
identify co-morbid TBI in the context of polytrauma and to ensure
proper evacuation to an appropriate facility in the Continental United
States. Second, since May 2008 all servicemembers returning from
deployment answer a series of questions on the PDHA that report
exposure to injury event, presence of subsequent loss of consciousness
or alterations in consciousness, presence of symptoms at time of
injury, and presence of current symptoms. The third post-deployment
screen occurs during the PDHRA conducted 90-180 days after return from
deployment. Finally, since April 2007 any servicemember entering the VA
medical facility for any clinical care undergoes TBI screening
identical to that of the PDHA with an instrument called the ``TBI
Clinical Reminder''.
The questions used in the PDHA, PDHRA, and VA's TBI Clinical
Reminder are an adaptation of an instrument called the ``Brief TBI
Screen (BTBIS)''. This instrument has had preliminary validation
published in peer-reviewed medical literature. These reviews were
utilized by the White-House-appointed TBI External Advisory Committee
to the Defense Health Board and the Institute of Medicine. These panels
both recommended the use of the BTBIS. In December 2008, the Defense
Health Board recommended continued use with minor modifications.
Admiral Greenert. TBI is screened for by questions in the PDHA and
PDHRA. If a servicemember has clinical symptoms, the unit's medical
personnel evaluate and then refer for specialty care as needed.
Servicemembers with clinical symptoms are also encouraged to seek
medical care independent of post-deployment screenings.
General Amos. I defer to DOD and VA.
General Chandler. Screening for mild Traumatic Brian Injury (TBI)
is intended to ensure those servicemembers who may have sustained a TBI
while deployed and have symptoms receive further assessment and
treatment. Positive screens are not diagnostic of TBI but do trigger a
clinician interview for further evaluation. TBI screening occurs at
several time points and locations once an airman leaves theater. For
airmen air evacuated from theater the first screen occurs when they
arrive at LRMC in Germany. Since May 2006, all servicemembers evacuated
from theater for battle or non-battle injuries and illnesses are
screened for TBI upon arrival to LRMC. The main purpose of this screen
is to identify co-morbid TBI in the context of polytrauma and to ensure
proper evacuation to an appropriate facility in the Continental United
States. Second, since May 2008 all servicemembers returning from
deployment answer a series of questions on the PDHA that reports
exposure to injury event, presence of subsequent loss of consciousness
or alterations in consciousness, presence of symptoms at time of
injury, and presence of current symptoms. The third post-deployment
screen occurs during the PDHRA conducted 90-180 days after return from
deployment. Finally, since April 2007 any servicemember entering the VA
medical facility for any clinical care undergoes TBI screening
identical to that of the PDHA with an instrument called the ``TBI
Clinical Reminder.''
The questions used in the PDHA, PDHRA, and VA's TBI Clinical
Reminder are an adaptation of an instrument called the BTBIS. This
instrument has had preliminary validation published in peer-reviewed
medical literature. These reviews were utilized by the White House-
appointed TBI External Advisory Committee to the Defense Health Board
and the Institute of Medicine. These panels both recommended the use of
the BTBIS. In December 2008, the Defense Health Board recommended
continued use with minor modifications.
In addition to TBI screening, the VA and DOD have expanded the bi-
directional healthcare information exchange capability to make the
following information viewable by the VA from the PHA: patient answered
questions for general health, tobacco use, alcohol use, injury
prevention, chronic diseases or conditions, dental health, reproductive
health issues and mental health concerns.
Dr. Jesse. VA requires that all new patients presenting to VA for
the first time be screened for the presence of PTSD, depression, and
alcohol misuse. If the Veteran screens positive for any of these
problems, they are further evaluated by a primary care provider or by
referral to a mental health clinic for confirmation of the diagnosis.
This may be followed by initiation of mental health services, if
needed, in the primary care setting or through referral to mental
health specialty care. Veterans who screen positive for PTSD or
depression are also assessed for suicide risk. Veterans who screen
positive for alcohol misuse are provided with alcohol counseling, as
well. Veterans are screened for PTSD every year for the first 5 years
the Veteran is in VA care and every 5 years thereafter, unless there is
a clinical need to screen earlier. Veterans are screened for depression
and alcohol misuse annually.
New patients with mental health concerns (those who have not been
seen in a mental health clinic in the last 24 months) or have a
positive screening for PTSD, depression or alcohol misuse, are
contacted within 24 hours of the referral by a clinician competent to
evaluate the urgency of the Veteran's mental health needs. If it is
determined that the Veteran has an urgent care need, appropriate
arrangements (e.g., an immediate admission) are required. If the need
is not urgent, the patient must be seen for a full mental health
diagnostic evaluation and development and initiation of an appropriate
treatment plan within 14 days.
VA also developed and implemented the TBI Screening and Evaluation
Program for all Veterans who have served in Iraq or Afghanistan, upon
their initial entry into VA for health care. Veterans who screen
positively for possible mild TBI are referred for a comprehensive
evaluation by an interdisciplinary rehabilitation team, and receive
follow-up care and services appropriate for their diagnosis and their
symptoms.
For patients identified through these screens, VA has established
access standards that require prompt evaluation of new patients. For
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans
who have a positive TBI Screening, the VA standard is that: (1) timely
contact is made to schedule an appointment for comprehensive evaluation
(contact within 5 days of a positive screening); and (2) that a
comprehensive evaluation is completed in a timely manner (within 30
days of having a positive screening).
42. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, General Chandler, and Dr. Jesse, is data available to healthcare
providers in the VA, TRICARE, and private practice for those providing
care for members of all components of the armed services?
General Chiarelli. Yes. The results of the TBI screening performed
at LRMC and in the Veteran's Affairs health facilities using the VA's
TBI Clinical Reminder are part of the soldier/veteran's medical record
and is available to VA, TRICARE, and private practice healthcare
providers. The PDHA and PDHRA for soldiers of all components can be
accessed either in the paper medical record or in AHLTA if scanned or
soldiers can print out copies of their completed Deployment Health
Assessments via AKO and release this information to their providers.
More importantly, servicemembers of all components who screen positive
on the PDHA and PDHRA are sent for a clinical confirmation evaluation
and that care is documented as part of their medical record.
Admiral Greenert. Yes. There are a number of instances in which
medical information is provided to the VA by the Services. Specifically
regarding TBI patients undergoing care through the VA, the following
directly applies:
``VA and DOD Memorandum of Agreement (MOA) Regarding Referral of
Active Duty Military Personnel Who Sustain Spinal Cord Injury, TBI, or
Blindness to Veterans Affairs Medical Facilities for Health Care and
Rehabilitation Services''
This MOA was effective 1 Jan 2007. It specifies that ``The
referring MTF will provide a copy of all pertinent patient medical
record documentation requested by the VA health care facility needed to
make a medical decision.'' Therefore, if a patient is transferred to
the VA for treatment, their medical information should be provided to
facilitate their care and reduce duplication of effort and delays in
care.
In addition to providing medical records, the care teams ensure
that the servicemembers have a smooth transition of care in a number of
other ways including:
Navy Military Treatment Facilities and VA Poly Trauma
Facilities hold multidisciplinary clinical case management
video teleconferences to discuss patient transition and care
needs and to provide follow up information on previously
transferred patients.
Transition support within the Navy consists of medical
care case managers and non-medical care managers working
collaboratively and with RCCs and VA Federal Recovery
Coordinators and Case Managers. This close cooperation ensures
a smooth and seamless handoff of each patient's recovery needs
as a member transitions between DOD care locations, or from DOD
to the VA and/or into the civilian sector.
Navy Medicine and Safe Harbor are involved in a DOD-VA
Information Sharing Initiative that is linked to a larger
effort called Virtual Lifetime Electronic Record. This effort
shares medical and non-medical (benefits, service records, pay,
etc.) data in electronic means, allowing for ``one-stop
shopping'' of information on an individual.
General Amos. Yes. There are a number of instances in which medical
information is provided to the VA by the Services. Specifically
regarding TBI patients undergoing care through the VA, the following
directly applies:
``VA and DOD Memorandum of Agreement (MOA) Regarding Referral of
Active Duty Military Personnel Who Sustain Spinal Cord Injury, TBI, or
Blindness to Veterans Affairs Medical Facilities for Health Care and
Rehabilitation Services''
This MOA was effective 1 Jan 2007. It specifies that ``The
referring MTF will provide a copy of all pertinent patient medical
record documentation requested by the VA health care facility needed to
make a medical decision.'' Therefore, if a patient is transferred to
the VA for treatment, their medical information should be provided to
facilitate their care and reduce duplication of effort and delays in
care.
In addition to providing medical records, the care teams ensure
that the servicemembers have a smooth transition of care in a number of
other ways including:
1. Navy Military Treatment Facilities and VA Poly Trauma
Facilities hold multidisciplinary clinical case video teleconferences
to discuss patient transition and care needs and to provide follow up
information on previously transferred patients.
2. Transition support within the Navy consists of medical care
case managers and non-medical care managers working collaboratively and
with RCC and VA Federal Recovery Coordinators and Case Managers. This
close cooperation ensures a smooth and seamless handoff of each
patient's recovery needs as a member transitions between DOD care
locations, or from DOD to the VA and/or into the civilian sector.
General Chandler. For patients being treated by both DOD and VA,
the Departments continue to maintain the jointly developed Bi-
directional Health Information Exchange (BHIE) system. Using BHIE, DOD
and VA clinicians are able to access each other's health data in real-
time, including the following types of information: allergy, outpatient
pharmacy, inpatient and outpatient laboratory and radiology reports,
demographic data, diagnoses, vital signs, problem lists, family
history, social history, other history, questionnaires, and theater
clinical data, including inpatient notes, outpatient encounters, and
ancillary clinical data, such as pharmacy data, allergies, laboratory
results, and radiology reports. To increase the availability of
clinical information on a shared patient population, VA and DOD
collaborated to further leverage BHIE functionality to allow bi-
directional access to inpatient discharge summaries from DOD's
inpatient documentation system. Access to DOD discharge summaries is
operational at some of DOD's largest inpatient facilities representing
approximately 71 percent of total DOD inpatient beds. In addition to
sharing viewable text data, VA and DOD have expanded the BHIE
capability to make the following information viewable by the VA from
the PHA: patient answered questions for general health, tobacco use,
alcohol use, injury prevention, chronic diseases or conditions, dental
health, reproductive health issues and mental health concerns.
The Federal Health Information Exchange provides the VA with a one-
way transfer of medical data from the DOD on servicemembers who have
separated the military. Information supplied to the VA includes:
outpatient pharmacy data, lab and radiology results, inpatient
laboratory and radiology results, allergy data, consult reports,
admission, disposition and transfer data, standard ambulatory data
record elements including diagnosis and treating physician, pre/post-
deployment health assessments (PPDHA), and PDHRA. As of June 2010, over
2.8 million PPDHA and PDHRA forms on more than 1.2 million individuals
have been sent from DOD to VA.
Data exchange between the DOD and non-VA providers is limited to
transferring copies of paper records to the civilian provider. The
National Health Information Network (NHIN) is in its infancy and at
present is being developed and tested via pilot programs. As the NHIN
is built out, it will allow information to be exchanged between private
practices, the VA and the DOD using standards-based data elements. The
information that can be exchanged at this stage is very limited and
available in only a few geographical locations.
Dr. Jesse. VA data sharing with private practices or health care
systems is still in a very early stage with active National Health
Information Network Pilots in place in San Diego, CA, and Hampton
Roads, VA.
43. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, General Chandler, and Dr. Jesse, are all personnel who are
diagnosed with TBI having that information entered into their medical
records or only those who have received Purple Hearts?
General Chiarelli. All personnel diagnosed with TBI have their
medical care documented in the medical record.
Admiral Greenert. Any servicemember undergoing care for any type of
medical condition should have their information entered into the
medical record. Their receipt of a medal has no impact on the medical
care provided, nor the requirement to properly document care in the
medical record.
General Amos. Any servicemember undergoing care of any type should
have their information entered into the medical record. Their receipt
of a medal has no impact on the medical care provided or the
requirement to properly document care in the medical record.
General Chandler. Yes, all airmen with a diagnosis related to TBI
have those diagnoses entered in their medical charts. This is done at
the time of diagnosis and is part of the process of the medical
appointment. It occurs regardless of whether the airman receives a
Purple Heart.
Dr. Jesse. All Veterans who are diagnosed with TBI have information
entered into their medical record regarding their evaluation,
diagnosis, and treatment. In addition, VA developed and implemented a
national template to ensure that it provides every Veteran receiving
inpatient or outpatient treatment for TBI, who requires ongoing
rehabilitation care, an individualized rehabilitation and community
reintegration plan. VA integrates this national template into the
electronic medical record, and includes results of the comprehensive
assessment, measureable goals, and recommendations for specific
rehabilitative treatments.
alternative treatments for traumatic brain injuries
44. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, General Chandler, and Dr. Jesse, alternative treatments for TBI
have been a significant focus of many members in Congress, specifically
the use of HBOT. In conjunction with oxygen carrier drugs, such as
Oxycyte, the positive impacts of the HBOT treatment may be magnified.
In the fiscal year 2011 markup, the House passed language that will
continue support for HBOT research and development. What are your
thoughts on alternative treatments for TBI and specifically HBOT, and
the associated TBI drugs and what needs to be done to expedite the
research and development process?
General Chiarelli. It is very important that we evaluate safety and
effectiveness of all therapeutic and alternative medicine options
through controlled trials for TBI prevention, treatment, and
rehabilitation. Currently DOD is examining hyperbaric oxygen for those
with persistent brain-related sequelae. The U.S. Army Medical Research
and Materiel Command and the DCoE for Psychological Health and TBI and
will be initiating a pilot study of hyperbaric oxygen for traumatic
brain injured patients in the next few weeks with a goal completion by
December. We are aware that the Navy and Air Force are also conducting
or participating in research involving oxygen therapies.
The results of all of these DOD trials will solidify the pivotal,
larger, multicenter clinical trial scheduled to begin early 2011.
The military has funded Oxygen Biotherapeutics research using the
fiscal year 2007 PH/TBI war supplemental funding to conduct clinical
trials using Oxycyte with the ultimate goal of improving brain oxygen
delivery, and patient outcome, after severe TBI. After seeing good
results in nine patients, the FDA put the Phase II trial on clinical
hold because of transient platelet suppression, which did not have any
documented clinical adverse effect, until the mechanism of that
transient suppression is determined. The U.S. Army Medical Research and
Materiel Command has just funded a number of projects that are designed
to answer that mechanism question with the intent to restart the
clinical trial in the near future.
To expedite the research and development process it is necessary to
conduct programs, not projects. It is most efficient to develop a
programmatic approach rather than conduct a multitude of disconnected
studies. A programmatic approach will utilize goals, milestones,
timelines and future funding projected over several years to maximize
the potential of selecting and advancing products or new technologies
through FDA approval into the hands of health care providers. To
minimize the loss of data, research time and risk to the human research
subjects, it is imperative that studies be conducted as well controlled
clinical trials. Data repositories and data sharing allow a far greater
number of researchers to analyze existing pieces of information
therefore increasing the size of the research base. It is also very
important to engage the FDA in clinical trials research early and often
to focus the research efforts on questions and issues that will need to
be addressed for FDA review and approval.
Admiral Greenert. Navy Medicine continually seeks to identify and
implement the best methods to evaluate and treat servicemembers who
sustain a TBI. Prior to implementing therapies for our servicemembers
Navy Medicine, in adhering to nationally and internationally recognized
standards of good clinical practice, require that any treatment
provided to our servicemembers has demonstrated safety and
effectiveness. In those cases where the treatment fulfills these
critical criteria, Navy Medicine will expedite use. Conversely, if a
treatment does not have scientific merit or is found to be more
detrimental than beneficial, Navy Medicine will not make it available
until further research demonstrates a benefit.
DOD has three placebo-controlled clinical trials planned or in
progress on the use of hyperbaric oxygen. Two of these are feasibility
studies which will provide information on appropriate selection of
hyperbaric oxygen doses and pressures as well as efficacy of procedures
utilized in providing exposure to affected individuals. One of these is
a large prospective, efficacy study to assess the effects of hyperbaric
oxygen therapy on the symptoms of mild and moderate TBI. One of the
feasibility studies is expected to have data available in early 2011
and the other in late 2011. The large efficacy study will have data
available in 2014. Navy Medicine is funding travel for active duty
servicemembers to participate in these studies and, in partnership with
the VA, is the lead for one feasibility study.
The drug, Oxycyte, is currently undergoing evaluation in a clinical
trial to treat severe TBI. The initial results are promising but this
larger study will allow us to better gauge its efficacy and
appropriateness for our population. Of note, examining the categories
of Navy TBI numbers from 2000-2009 (provided by the Defense Veteran and
Brain Injury Center), an estimated 76 percent are mild, 20 percent are
moderate, 2 percent are penetrating, and only 1 percent are severe.
Navy Medicine actively supports and engages in clinical investigation
to determine better methods of detecting and treating TBI.
General Amos. DOD has three placebo-controlled clinical trials
planned or in progress. Marines who desire to participate in these
studies, after appropriate informed consent, will have leadership
support in doing so. In fact, in one study currently underway 90
percent of the subjects are marines or former marines.
Moving forward I expect to continue to collaborate with and
challenge the medical community for ever better tools for the diagnosis
and treatment of all the wounds of war, both visible and invisible.
General Chandler. I do not believe there are any current studies
looking at the use of oxygen carrier drugs.
There are ongoing studies to validate the efficacy of HBOT in TBI
patients and we are eagerly awaiting the results. The use of associated
TBI drugs will be undertaken as further information about them evolves.
The continued support from Congress for research and development is
appreciated.
Dr. Jesse. DOD and VA are actively investigating the efficacy and
utilization of hyperbaric oxygen therapy (HBOT) for treating mild
traumatic brain injury (TBI) and post-concussive symptoms. While HBOT
demonstrates effectiveness in treating certain disorders, there are
presently only clinical reports but no demonstrated double-blinded,
controlled, scientific evidence that supports using HBOT to treat mild
TBI. Presently, neither the Food and Drug Administration nor the
Undersea and Hyperbaric Medical Society--the medical specialty society
and authority that provides guidance to Centers for Medicare and
Medicaid Services (CMS) for use of HBOT--recognize use of HBOT as a
primary or adjunctive therapy for TBI.
There is presently no rigorous research evidence to support usage
of alternative therapies on a clinical level for TBI of any severity;
e.g., HBOT, vibratory treatments, acupuncture, herbals and supplements,
yoga and other movement therapy, music therapy, oxygen carrying drugs,
or any experimental drugs. VA stringently supports the need for
additional research to design and execute randomized controlled trials
of all of these agents to better understand their potential for TBI
care. Currently, the potential risks of all these treatments must be
considered higher than their potential for benefit and therefore they
should not be recommended.
In order to expedite research and development related to TBI, VA
strongly advocates collaborative research and joint research
initiatives across all federal agencies. VA is currently engaged in
collaborative TBI-related research efforts with DOD, academia, the
National Center for Disability and Rehabilitation Research, and other
agencies.
medications
45. Senator Inhofe. General Chiarelli, the Army is the only Service
I have heard directly address the topic of prevention and management of
polypharmacy with psychotropic medications and central nervous system
depressants. This could have a significant impact on our suicide
numbers and the extended suffering by our servicemembers. Can you
elaborate on your statement of how this new policy will assist in
reducing adverse clinical outcomes?
General Chiarelli. The ASPTF has identified polypharmacy as one of
the risk factors involved in some suicides and accidental fatalities
among soldiers in treatment. To address these concerns, the U.S. Army
MEDCOM and the Office of the Surgeon General has published policies for
the WTUs in particular and for the Army Medical System in general to
reduce the risks of polypharmacy.
In April 2009 the MEDCOM published a policy for the Warriors in
Transition High Risk Medication Review and Sole Provider Program. This
program is in part a medication reconciliation program for our Wounded
Warriors assigned to the WTUs. Components of this program include the
assignment of clinical pharmacists to the WTUs to monitor and support
safe and effective medication of soldiers in treatment; they review
medication profiles of their cases at least weekly. The Primary Care
providers in the WTUs perform medication reconciliation for each
soldier in treatment within 24 hours of arrival at the WTU and each
time the soldier's medication regimen is changed to identify and
prevent potential adverse medication interactions, side effects, or
potentially lethal medication combinations. Additionally, case managers
in the WTUs perform clinical risk assessments on each soldier assigned
to the unit to identify soldiers who may be at risk of intentionally or
accidentally harming themselves. Soldiers at risk are closely monitored
as well as immediately referred to the appropriate behavioral health
resources. Soldiers identified to be at risk of abusing their
medications are closely monitored and dispensed small amounts of
medication (1-week supply) with frequent clinical visits, and can be
restricted to one prescriber and one pharmacy for their medications.
Soldiers identified to be at risk of abusing drugs or alcohol while on
their medications are educated regarding the risks and referred to the
Army Substance Abuse Program, and routinely undergo screening with
random urine drug testing.
In September 2009 the MEDCOM published Guidance for Enhancing Risk
Reduction and Patient Safety via Appropriate Behavioral Health Referral
and the Conservative Use of Central Nervous System Depressants. This
policy guides the conservative use of medications to reduce the
occurrence of harmful polypharmacy for our troops in general.
Healthcare providers are strongly encouraged to refer soldiers to
specialty care (e.g. behavioral health resources) for non-medication
therapies to augment medication therapy and obtain the best clinical
outcomes. Additionally, medication reconciliation is a requirement of
the joint commission to reduce the risks of polypharmacy. Medication
profiles are reviewed and reconciled upon initial contact and
periodically thereafter by each prescribing healthcare provider,
especially as they transition from one care setting to another
(admission or discharge from hospital). Finally, the MEDCOM has
deployed electronic measures system-wide that automatically screen
medications each time healthcare providers order them for our soldiers.
This screen identifies and flags duplicate orders for the same
medication, duplicate orders for the same class of medication, and
potential interactions among medications prescribed to the soldier that
may put them at risk.
total force health care and transition to veteran care
46. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, how are each of the Services dealing with
Reserve components--providing care once they are off Active Duty,
following up on mental health care, and ensuring their families are
cared for?
General Chiarelli. The Army routinely coordinates healthcare
delivery for Reserve component soldiers coming off active duty with the
VA. At the local installations, VA representatives attend many PDHRA
sessions and provide follow-up appointments as necessary within their
system. The VA provides direct care for Reserve component and other
remote/geographically dispersed soldiers. Soldiers, both Active and
Reserve component, have routinely utilized VA PTSD treatment programs,
such as the one at the Palo Alto VA Medical Center. Additionally, the
Army utilizes VA liaisons to coordinate healthcare. Through the Army
and VA partnership, VA Liaison Case Managers are embedded in 14
prioritized Army MTFs under an initiative called VA Liaison and Care
Management Program. This ensures soldiers receive seamless continuity
of care as they migrate from active duty to veteran status in the VA
Healthcare System.
TRICARE also has programs that assist Guard and Reserve soldiers
and families. A National Guard or Reserve member separating from a
period of active duty that was more than 30 consecutive days in support
of a contingency operation is eligible for TAMP. The TAMP provides 180
days of transitional health care benefits to help certain uniformed
services members and their families transition to civilian life.
TRICARE Reserve Select is a premium-based health plan that qualified
National Guard and Reserve members may purchase to receive care in
their local area. TRICARE Reserve Select requires a monthly premium and
offers coverage similar to TRICARE Extra and Standard.
Additionally, Guard and Reserve members who are experiencing common
psychological health concerns like combat stress and family separation,
may use a new initiative called TRIAP which provides video chat and
instant messaging to give quick and easy access to counseling services.
This program is also available to all spouses and other family members
that are 18 years or older.
Admiral Greenert. reservists and their families have access to
TRICARE health care benefits for 180 days following their separation
from Active Duty.
Commander, Navy Reserve Forces Command has assumed responsibility
for overseeing implementation of the PDHRA program for the Navy
Reserve. With strong leadership support they are actively engaged in
program execution and because of this increased focus, servicemember
compliance rates have improved. Providing mental health support to
Reserve sailors is an integral component of Navy mental health care. To
meet this need, the Navy implemented the NRPHO program in fiscal year
2008. The NRPHO program has a team of 25 Social Workers who provide
initial mental health clinical assessment of Reserve component
servicemembers and provide appropriate health care referral if needed.
They are also making visits to two to three NOSCs per month in each of
the five Navy Reserve Regions where they provide psychological health
education including the OSC awareness brief to NOSC staff and Reserve
unit members.
As of June 2010, the NRPHO Teams have clinically assessed and
referred almost 2,400 reservists to appropriate sources of mental
health care; have made outreach calls to an additional 1,860
reservists; and have made 281 visits to the NOSCs, providing the OSC
awareness brief to over 29,400 RC members and NOSC staff. In addition,
Navy Medicine has hired a full-time DPH for Navy Reserve to oversee and
expand Reserve Navy Reserve psychological health programs.
The RWW has become the keynote Reintegration event, as this program
has become available to RC and AC sailors, marines, and their spouses
throughout the country. The Navy Reserve has led the way in crafting a
standardized RWW that represents the ideals of DOD's YRRP, serving the
RC and AC, and fulfilling the full spirit and intent of the Total Force
initiatives. In 2009, more than 1,800 servicemembers and 1,400 family
members attended one of 27 RWWs throughout the country. An additional
13 have been held in 2010, attended by 832 servicemembers and 699
family members and 2 more are scheduled through the end of the current
contract (30 July 2010). 38 more RWWs are planned for the next contract
through July 2012.
General Amos. Reservists and their families have access to TRICARE
health care benefits for 180 days following their separation from
Active Duty.
While I defer to my military medicine colleagues on the actual
delivery of care, our WWR and battalions stay connected to marines in
need of services even after they leave active duty. I believe that our
Wounded Warrior construct is a superb model and we will continue to
leverage its successes moving forward.
General Chandler. The Air Force, regardless of component, regularly
screens servicemembers for psychological conditions using the PHA,
PDHA, and PDHRA. These tools ask questions to help screen for mental
health conditions related to deployment. The Air National Guard (ANG)
tracks combat injuries to include mental health conditions through the
daily casualty reports. ANG members with mental health conditions are
tracked through the ANG Medical Group (MDG) in coordination with the
ANG DPH and the servicemember's home State/territory for follow-up
care. The DPH is available to ANG members and families throughout their
care and the remainder of their service.
ANG members may retain health benefits following deployment for
deployment related conditions to include mental health. The Air Force
offers Deployment Transition Centers (DTC) for airmen (including Guard
and Reserve components) returning from combat theaters. The 2-day DTC
readjustment agenda assists airmen with their return and provides
mental health resource information. The ANG offers the federally-
mandated YRRP to provide psychosocial and mental health education and
referral resources for Guard members throughout the deployment cycle.
47. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, do all the Services follow the same process
for transitioning your servicemembers from DOD control to VA control as
part of the medical board process?
General Chiarelli. Yes, the transition process is the DES consists
of a MEB phase and a PEB phase. In the traditional or Legacy system
there were minor differences in how MEB and PEB cases were processed.
In the DOD/VA DES pilot process the phases are similar across all
Services.
Admiral Greenert. Yes, the transition process is the DES and it
consists of a MEB phase and a PEB phase. In the traditional or Legacy
DES system there were minor differences in how MEBs and PEBs were
processed. In the DOD/VA DES pilot the phases are similar across all
Services.
General Amos. Yes, the transition process is the DES and it
consists of a MEB phase and a PEB phase. In the traditional or legacy
DES there were minor differences in how MEBs and PEBs were processed.
In the DOD/VA DES pilot process the phases are similar across all
Services.
General Chandler. An Air Force member who separates or retires,
regardless of whether it is through the DES or not, is provided
counseling on VA benefits and application procedures as part of
transition assistance counseling. In a medical board process, the
Integrated DES Program (formerly referred to as the DES Pilot) being
implemented across DOD prescribes that servicemembers are evaluated for
VA disability rating as part of their DES evaluation, saving
servicemembers time in applying for VA benefits upon separation or
retirement. The process includes a single physical examination
conducted by the VA in the MED phase. The VA then provides a draft
rating decision for all conditions claimed by the servicemember. The
Service conducts a PEB to determine which medical conditions, if any,
make the servicemember unfit for continued military service. The
Service PEB uses the VA-determined disability ratings for fitting
conditions to determine the servicemember's disposition (medical
separation or retirement). This process is prescribed by DOD.
48. Senator Inhofe. General Chiarelli, Admiral Greenert, General
Amos, and General Chandler, what are your observations on the process
by which servicemembers are assessed, diagnosed, treated, and
transitioned either back to Active Duty or onward to the VA?
General Chiarelli. When a soldier is assigned to a WTU, he or she
develops a CTP in consultation with his or her family, unit leaders,
and health professionals. The CTP is designed to be a roadmap for
recovery and transition, with personal and professional milestones,
such as passing a physical fitness test, taking college courses, or
participating in internships and job training. The goal is to keep each
soldier goal-oriented and constantly striving to recover. This helps
focus his or her attention and energies on healing and the future,
which produces a positive mental outlook.
The Warrior Care and Transition Plan includes developing a
comprehensive and responsive network of available facilities to treat
Warriors in Transition that include military treatment facilities, VA
facilities, civilian facilities, and the TRICARE network of providers.
The Triad of Care (Squad Leader, Nurse Case Manager, and PCM) manages
each soldier's progress closely and coordinates care through this
network of resources to ensure comprehensive coverage of care and
support requirements.
In WTUs, pharmacists and medical providers collaborate to ensure
appropriate medication use for each Warrior in Transition. Members of
the health care team are trained to first consider utilizing treatment
methodologies other than medicating soldiers as the best approach to
ensuring appropriate care and treatment.
VBA counselors work on-site with Warriors in Transition to ensure
coordination of all necessary services prior to a soldier leaving the
Army. The Army established liaison teams at VA polytrauma centers to
ensure appropriate care and support when soldiers enter VA health care
programs. The Army and the VHA continually develop ways to ensure that
the CTP follows each soldier into VA care and that the soldier's
continuity of care is ongoing and consistent.
Admiral Greenert. Challenges remain with stigma and other barriers
to care, such as the desire of a sailor to not go to medical after an
exposure to a blast because they are motivated to ``stay in the
fight.'' We must continue to work to reduce or eliminate these
barriers. We need to encourage leaders to get their people to the
medical experts who can assist them in getting the care they need.
Once our sailors get into the medical system they receive expert
medical care throughout the continuum of care from assessment and
diagnosis to recovery and return to duty or reintegration.
Case managers work with the care team to ensure that our wounded
warriors receive the care they need and transition between DOD, VA, and
civilian facilities smoothly. The DES Pilot, that is now being expanded
across DOD, has been beneficial in ensuring that those members who must
transition out of the military do so with their Military and VA
benefits established prior to discharge. The medical care, coordination
of care, and transition assistance, has improved and continues to
improve to meet the needs of our wounded warriors.
To assist seriously wounded, ill, and injured sailors,
coastguardsmen, and their families in their transition and
reintegration back into their communities, Safe Harbor provides support
through its Anchor Program. The Safe Harbor Anchor Program partners
with 128 NOSCs across the country as well as Navy Retired Activities
Offices, American Legion, Navy League, Fleet Reserve Association, and
other community-based organizations to provide mentor volunteers to
assist recovering servicemembers (RSM) and their families reintegrate
back into the community. The mentors, whether a near-peer Navy
reservists or a senior mentor from our partner organizations provide
local professional, social and spiritual assistance to RSMs and their
families solidifying the ``lifetime of support'' provided by Safe
Harbor.
General Amos. While I am not a medical expert, I believe there is
more to be done to meet the needs of all Wounded Warriors. However, my
lack of satisfaction with the status quo should not be construed to
mean that I feel that the Marine Corps has failed to make significant
strides in this area.
As a Marine leader, I believe the centerpiece of any successful
Marine Corps effort in this arena, and especially in the areas of TBI
and PTSD, is Engaged Leadership. No individual is better positioned to
notice a change in a marine's behavior or apparent well-being than
another marine.
Building on this understanding, we have already developed training
and awareness programs for leaders at all levels of the Corps on these
subjects with the goal of intervening at the earliest possible
opportunity before a small problem balloons into an overwhelming
problem.
After successful treatment of their condition, successful re-
integration of a marine into the business of being a marine is critical
for our force and for the individual. I am committed to seeing all of
our leaders embrace this re-integration process. For those marines with
medical conditions that prevent them from continuing on active duty,
the process of transitioning to the VA must be as seamless as possible.
For over 200 years we have prided ourselves on the fact that
marines take care of marines. I am committed to seeing that tradition
hold true far into the future.
General Chandler. The Air Force DES evaluates all cases where a
member is found to have a duty limiting condition that is disqualifying
for worldwide duty in accordance with Air Force Instruction (AFI) 48-
123, Medical Examinations and Standards, and completes a fitness for
duty determination. The complexity of the system depends greatly on the
participant and the medical conditions they have. The goal in all cases
is to complete a thorough medical evaluation and provide an appropriate
disposition.
The simplest cases are processed through the Assignment Limitation
Code Fast Track Program (ALC Fast Track). Such cases are Air Force
members who present with conditions which, while limiting for worldwide
duty, are stable, have a low risk of sudden incapacitation and
minimally impact the ability to perform primary military duties.
Approximately 60 percent of all cases fit these criteria. In these
cases, the PCM reviews the condition, conducts the appropriate
evaluations and, where appropriate, begins treatment. She/he then
initiates a MEB which is referred to the profile officer for review. If
the diagnosis is felt to be suitable for ALC Fast Track, the PCM is
notified and completes a robust medical note outlining all current
information regarding the condition, the severity and the associated
sequellae. This is forwarded to Air Force Personnel Center (AFPC)
medical standards branch where disposition is made. They may return the
member to full duty, provide an assignment limitation code, or
determine that the case is not compatible with the ALC Fast Track
limitations and refer it for full MEB/PEB processing. These
determinations can be completed usually within 7 days and greatly
expedites the process.
Cases referred for full MEB/PEB processing are those which do not
meet the criteria for inclusion in the ALC Fast Track Program. These
cases undergo full MEB/PEB processing, and go through a similar
evaluation by the PCM to determine the exact diagnosis, potential
treatment and impact on the ability to perform future military duties.
These cases are sent to the AFPC medical standards branch and go
through the steps of the MEB, the I-PEB and the formal PEB as required.
Similar to the ALC-Fast Track, the disposition may be return to duty,
provision of an assignment limitation code, or recommendation for
medical discharge.
In cases where a medical discharge is recommended (or down the road
for individuals who are retained but later separate or retire), the
disability rating is provided by the VA. The new DES-Pilot system (also
being referred to as the Integrated DES) allows veterans to undergo a
single rating physical exam and receive one disability rating.
______
Question Submitted by Senator Susan Collins
information sharing
49. Senator Collins. Dr. Jesse, I have been contacted by officials
from the Maine Office of Substance Abuse regarding their concern that
the VA is preventing VA hospitals, such as Togus Medical Center, from
participating in the State's Prescription Monitoring Program. The
Prescription Monitoring Program shares prescription drug information
among physicians to prevent drug abuse by ensuring that doctors know
what prescriptions have already been provided to a patient. Without
access to the prescription drug data from VA medical centers,
physicians in Maine are concerned that they may inadvertently provide
duplicative prescriptions to veterans, including prescriptions for
particularly strong drugs, such as narcotics. Understanding that there
are privacy consideration, is the VA committed to working with each
State to ensure that necessary medical information is shared, while
protecting the privacy rights of patients?
Dr. Jesse. Patient safety is always a major concern within VA.
Within our internal national system we have mechanisms to monitor and
evaluate prescription drug use. Currently, there are statutory barriers
that prevent VA's participation with the States. VA is, however,
evaluating possible remedies that may allow participation in these
programs.
[Whereupon, at 11:40 a.m., the committee adjourned.]
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