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Post Traumatic Stress Disorder Treatment and Research: Moving Ahead Toward Recovery.

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APRIL 1, 2008

SERIAL No. 110-78

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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
JEFF MILLER, Florida, Ranking
HENRY E. BROWN, JR., South Carolina

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



April 1, 2008

Post Traumatic Stress Disorder Treatment and Research:  Moving Ahead Toward Recovery


Chairman Michael Michaud
    Prepared statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member, prepared statement of
Hon. Henry E. Brown, Jr.
Hon. John T. Salazar
    Prepared statement of Congressman Salazar
Hon. Phil Hare
Hon. Shelley Berkley


U.S. Department of Defense, Colonel Charles W. Hoge, M.D., USA, Director, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Department of the Army
    Prepared statement of Colonel Hoge
U.S. Department of Veterans Affairs, Ira Katz, M.D., Ph.D., Deputy Chief Patient Care Services Officer for Mental Health, Veterans Health Administration
    Prepared statement of Dr. Katz

American Occupational Therapy Association, Carolyn M. Baum, Ph.D., OTR/L, FAOTA, Immediate Past President, and Professor, Occupational Therapy and Neurology, Elias Michael Director of the Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO
    Prepared statement of Dr. Baum
Iraq and Afghanistan Veterans of America, Todd Bowers, Director of Government Affairs
    Prepared statement of Mr. Bowers
Matchar, David, M.D., Member, Committee on Treatment of Posttraumatic Stress Disorder, Board on Population Health and Public Health Practice, Institute of Medicine, The National Academies, and Director and Professor of Medicine, Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC
    Prepared statement of Dr. Matchar
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Chair, National PTSD and Substance Abuse Committee
    Prepared statement of Dr. Berger
Virtual Reality Medical Center, San Diego, CA, Mark D. Wiederhold, M.D., Ph.D., FACP, President
    Prepared statement of Dr. Wiederhold


American Legion, Joseph L. Wilson, Deputy Director, Veterans Affairs and Rehabilitation Commission, statement
Disabled American Veterans, Adrian M. Atizado, Assistant National Legislative Director, statement
Veterans of Foreign Wars of the United States, Christopher Needham, Senior Legislative Associate, National Legislative Service,


Tuesday, April 1, 2008
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 10:01 a.m., in Room 334, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding.

Present:  Representatives Michaud, Snyder, Hare, Doyle, Berkley, Salazar, Miller, and Brown of South Carolina.


Mr. MICHAUD.  I would like to call the hearing to order.  I would like to welcome everyone here to the Subcommittee on Health’s hearing.  We are here today to talk about post traumatic stress disorder (PTSD) treatment and research in the U.S. Department of Veterans Affairs (VA).

Post traumatic stress disorder is among the most common diagnoses made by the Veterans Health Administration (VHA).  Of the approximately 300,000 veterans from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) who have access to VA healthcare, nearly 20 percent, 60,000 veterans have received a preliminary diagnosis of PTSD.

The VA also continues to treat veterans from Vietnam and other conflicts who have PTSD.

With the release of the 2007 Institute of Medicine (IOM) report, we learned that we still have much work to do in our understanding of how to best treat PTSD.  I hope that my colleagues will continue to work with me in supporting VA’s PTSD research programs.

I look forward to hearing testimony today from several organizations that are working to provide comprehensive and cutting-edge treatment for PTSD.

The Subcommittee recognizes that this is an important issue and one that we will be working with for a long time to come.  We are committed to ensuring that all veterans receive the best possible treatment when they go to the VA. 

That is one of the reasons why we are having this hearing today.  We will have several more hearings dealing with PTSD because this is an important issue, an issue that there are still a lot of unanswered questions.  So I look forward to the testimony here today.

I would like to recognize Mr. Brown for any opening statement he might have.

[The statement of Chairman Michaud appears in the Appendix.]


Mr. BROWN OF SOUTH CAROLINA.  Thank you, Mr. Chairman, for holding this meeting today.  And this is a continuing of several meetings we have had dealing with this issue.  It is certainly an important problem, important issue that we need to face.  Thank you for your leadership on this.

Following every war in history, what we now call post traumatic stress disorder or PTSD has sadly affected the lives of many brave men and women who have worn the uniform.

This Committee, over the years, has held numerous hearings to bring to forefront the emotional toll the trauma of combat can lay on our veterans and the need for us as a Nation to effectively care for those who suffer with military-related PTSD and experience difficultly reintegrating into civilian life.

In response to the Congressional mandate, VA established a National Center for PTSD in 1989.  This center was created to advance the well-being of veterans through research, education and training, and the diagnosis and treatment of PTSD.

VA has since moved to expand its program and currently employs over 200 specialized PTSD programs in every healthcare network.  Available care includes omission behavior therapy, which has shown to be the most effective type of treatment for PTSD.

Many servicemembers who develop PTSD can recover with effective treatment.  Yet, PTSD is still the most common mental disorder affecting OIF and OEF veterans seeking VA healthcare.  About 20 percent of all separated OIF and OEF veterans who have sought VA healthcare received a PTSD diagnosis.

Even more alarming, a recent study conducted by VA shows that young servicemembers between the ages of 18 and 24 are at the highest risk of mental health problems and PTSD to be three times as likely as those over 40 to be diagnosed with PTSD and/or other mental health problems.  Clearly PTSD remains a very prominent injury that our veterans endure.  That is precisely why today's hearing is so critical. 

We must continue to focus on how best to strengthen research and rapidly disseminate effective clinical care in all settings so that we can finally understand this illness, break through it, and move forward with complete recovery, bringing relief to the many heroic veterans who still fight daily battles no less harrowing than the ones they fought in combat.

On that end, I want to thank our witnesses for being here today and to present their expert views on what may cause and, more importantly, preclude PTSD from emerging among our veterans.

Again, thank you and I yield back, Mr. Chairman.

Mr. MICHAUD.  Thank you very much, Mr. Brown.

Mr. Salazar, do you have an opening statement?


Mr. SALAZAR.  Thank you, Mr. Chairman.  First of all, let me thank you and Ranking Member Brown for having this important hearing.  I appreciate your dedication to our veterans and your hard work.

We are fortunate to have this opportunity today to discuss the impact of PTSD and what effect it is having on our returning troops, veterans and their families.  And I look forward to hearing the testimony of the experts that are joining us.

I want to thank you, Colonel, for your dedication to our servicemen and women and thank you for your service to our country.

I think an important part of our discussion today will be to hear about the research on PTSD cases regarding Vietnam, OEF and OIF soldiers.  I think it is important to look at them both individually and in comparison to one another.

I also look forward to hearing about the research that is done on exposure therapy.  Innovative and new treatments are essential to the health of our veterans and our current forces.

Our veterans deserve to know that once they leave the battlefield and return home that we have programs in place to take care of them.

Mr. Chairman, I want to thank you and the Members of this Subcommittee for being so dedicated and giving us the opportunity to discuss construction authorizations.

Thank you, Mr. Chairman, and I yield back.

[The statement of Congressman Salazar appears in the Appendix.]

Mr. MICHAUD.  Thank you.

Mr. Hare?


Mr. HARE.  Thank you, Mr. Chairman, and thank you very much for holding this hearing today.  And I thank the Ranking Member also for being here with us this morning.

Today is the third hearing that this Subcommittee has had examining mental health for our veterans.  And I find today's hearing on PTSD particularly poignant.  We can all agree that PTSD is the signature wound of the current conflict and that the need to provide treatment is key.

Unfortunately, we have over 22,000 brave men and women who will not have access to VA treatment because they were discharged from the military because of a so-called preexisting personality disorder, not PTSD, from their service.

The Secretary of Defense is today required to submit a report to the Armed Services Committee evaluating the efficiency and fairness of this practice.  And as we talk about the different treatment and research being done, I would ask that all the Members of this Subcommittee, all the people here today, all the panel Members keep those soldiers in mind who are fighting their battle against PTSD alone without access to the benefit of VA healthcare that they have earned.

I spoke to a young man named Louie in Chillicothe, Illinois, who had severe problems when he came back.  And he was asked and ordered, I should say, to have his reenlistment bonus with interest paid back.  This is a young man who gave everything he had to this Nation and is now, because of the conditions that he has, working two days a week at a Subway sandwich place because he cannot hold full-time employment.

We can do much better than that, Mr. Chairman, for our veterans.  We owe it to them.  And as I told Louie, I have asked him every month when he receives that bill to send it to my office and I will forward it with an appropriate response because Louie is not going to pay that bill.

He was screened four times prior to deployment and he does not have, I do not believe, personality disorder preexisting conditions.  It was a terrible way to treat somebody. 

And to think that there are an additional 22,000 people like Louie out there, I think, is a disgrace and something we have to address and fix.  And clearly this is something that I think we owe to the best and the brightest that we put in harm's way.

So I thank you, Mr. Chairman, for having this hearing today and look forward to listening to the panel and asking questions.  Thank you.

Mr. MICHAUD.  Thank you very much.

Mr. Miller?

Mr. MILLER.  Thank you, Mr. Chairman.  I understand that Mr. Brown was so kind as to already read my prepared statement and I will enter further the statement into the record.  Thank you.

[The statement of Congressman Miller appears in the Appendix.]

Mr. MICHAUD.  Thank you.

Ms. Berkley?


Ms. BERKLEY.  Thank you very much, Mr. Chairman, and welcome.  We are very appreciative that you are here for our third hearing on this particular issue.

Mr. Chairman, I want to thank you for holding this hearing on a very important issue that this Committee recognizes finally that it is important.  And I think that our Nation has truly ignored this issue for many, many years and for many, many wars.

There are 3,070 veterans enrolled in the VA's southern Nevada healthcare system with a diagnosis of PTSD.  As we know, nationally one in five veterans returning from Iraq and Afghanistan suffers from PTSD.  Twenty-three percent of members of the Armed Forces on active duty acknowledge significant problems with substance abuse.  

I do not think it is lost on anybody that our veterans need to receive the help that they need to deal with these issues.

A constituent of mine, and I have mentioned this before, but it bears mentioning again, Lance Corporal Justin Bailey returned from Iraq with PTSD.  He developed a substance abuse disorder.  His family, his loving parents insisted out of desperation that he check himself into a VA facility in west LA.  After being given five medications on a self-medication policy, he overdosed and died.  That is just horrific having survived his time in service to our country and then coming home and dying under the care of the VA.

I have introduced the "Mental Health Improvements Act," which aims to improve the treatment and services provided by the Department of Veterans Affairs for veterans with PTSD and substance abuse disorders.  In the interest of time, I will not read the different sections of this bill, but I would like to urge all of my colleagues on this Committee to co-sponsor the legislation.  It is imperative that we not only provide healthcare for our veterans, but mental healthcare as well.  I believe this bill and others that have been introduced will help in my opinion. 

I had dinner last night with an old friend of mine from northern Nevada who is a Vietnam vet.  I have known him since we were in high school in different parts of the State.  He talks to this day of having flashbacks and problems.  We know it exists. 

And I told him I thought that it should be mandatory when people leave the Armed Forces that they are interviewed and then followed up with periodically and make it mandatory that they do so.  He thought that would be a very good idea and would, in fact, prevent a lot of mental health issues that veterans in years gone by have suffered, but nobody recognized as PTSD.

And I thank you very much.

Mr. MICHAUD.  Thank you very much, Ms. Berkley.

Once again, Colonel, I would like to thank you for coming today.  On our first panel is Colonel Charles Hoge, who is the Director of the Division of Psychiatric and Neuroscience at Walter Reed Army Institute of Research.

We look forward to hearing your testimony and appreciate all the service that you have given this great Nation of ours.  And without further ado, you may begin, Colonel.


Colonel HOGE.  Thank you, Mr. Chairman, Ranking Member, Members of the Committee, thank you so much for the honor of being here.  I think this is my third testimony before this Committee.

And I was thinking about, you know, what is new since the last time that I testified and wanted to share a little bit about three different efforts that we have recently published just in the last six months that answer some fundamental questions about the importance of PTSD in our servicemembers coming home.

I am going to focus my comments on the wonderful work of my very dedicated team at Walter Reed Army Institute of Research, but I want to acknowledge up front and thank you and other members of Congress for the appropriation, fiscal year 2007 appropriation of $300 million for PTSD and TBI research which is now in the process of being distributed through grant mechanisms managed by Medical Research and Material Command at Fort Detrick to a variety of VA, civilian, and U.S. Department of Defense (DoD) researchers.

So I think that in the next few years, the hope is that we will see significant advancements in our understanding and ability to treat soldiers and veterans with PTSD.

The first thing I would like to mention is we have been doing some continuous assessments of the lessons learned from our post-deployment health assessment programs within the Army.  And the PDHA, the post-deployment health assessment, is completed when servicemembers initially return and then the post-deployment health reassessment (PDHRA) three to six months later.

And we have looked at now longitudinally at the relationship of answers that they gave on the first assessment with the answers they gave on the second assessment.  And I think that, you know, we have clearly confirmed the importance of that second assessment, particularly for our Reserve component servicemembers.

Twenty percent of our active component servicemembers were referred for mental health treatment or evaluation from the PDHA and PDHRA process and about 40 percent of our Reserve component members.  And that difference that develops between active component and Reserve, it is not apparent when they first return.  They look exactly the same.  But about six months later, you see this difference emerge and there is a variety of possible reasons for that.

The second thing I would like to comment on has to do with the multiple deployments and the dwell time.  We have just recently released our MHAT5 report, the Mental Health Advisory Team 5.  This is an unprecedented effort to survey and assess the well-being of troops while the war is going on.

We have done assessments every year in Iraq since the beginning of the war and two assessments in Afghanistan.  And the two things that we learned this year are that multiple deployments, that there is a direct relationship between the number of deployments and the psychological well-being of servicemembers. 

So those non-commissioned officers (NCOs) who are on their third deployment in Iraq, had a nearly 30 percent rate of significant combat stress or depression symptoms compared to about 20 percent of those NCOs on their second deployment to Iraq compared to 12 percent of those on their first deployment to Iraq.

So there is a clear linear relationship.  It is a little bit more difficult to show that relationship after they return from deployment because there is an attrition, there is an association of mental health problems with attrition from service.  And so the linear relationship between multiple deployments was very clearly evident in the MHAT5 data that we collected this past year.

The second thing we learned from the MHAT5 was that those soldiers serving in Afghanistan in brigade combat teams are experiencing rates of combat and mental health rates very comparable to those soldiers serving in brigade combat teams in Iraq.  So that is a fairly new development in the last year.

The third study that I would like to comment on briefly is the publication we just published January 31st  in the New England Journal of Medicine having to do with the relationship of mild traumatic brain injury (TBI) to PTSD.  And there has, I think, been a bit of confusion and I want to clarify terminology.  Mild traumatic brain injury is exactly the same thing as concussion. 

What is often reported in news media, for instance, is up to 20 percent of servicemembers coming back from Iraq have traumatic injury and often they show a seriously injured, seriously brain injured individual.  And it is often not made clear that the vast majority of those soldiers and servicemembers being labeled as having traumatic brain injury, in fact, have had concussions, what soldiers refer to as getting their bell rung or athletes refer to as getting their bell rung.

A concussion is an injury where there is a blow to the head or a jolt to the head that results in brief loss of consciousness or a brief alteration or change in consciousness.  There may be a memory gap that lasts for a few hours.

But there is expectation of full recovery after concussion and that is very different than moderate and severe traumatic brain injuries which almost always result in evacuation from theater and sometimes long-term care needed to rehabilitate servicemembers with moderate and severe TBI.

There has obviously been a lot of concern lately about mild traumatic brain injury and about potential long-term effects of mild traumatic brain injury possibly in association with blast exposures.  And some of the types of symptoms that servicemembers have coming back are things like headaches, irritability, concentration problems, memory problems.

And so our study looked to see what the relationship of those types of symptoms when servicemembers came home to having a concussion in theater.  And what we learned was that, it was a somewhat surprising finding to us, was that PTSD and depression was actually what we could attribute the symptoms to.  It is very difficult to attribute the symptoms in soldiers with concussions directly to the concussion.

What we found was that the vast majority of these physical health symptoms and post-concussive symptoms occurred in soldiers with PTSD and there was a very strong relationship between having a concussion in Iraq and developing PTSD.  Almost half of soldiers who had a concussion developed PTSD, met the criteria for PTSD when they came home.

What the implications are of this is, the unfortunate truth is that we really do not have a definitive diagnostic test that can tell us definitively who had a concussion or whether symptoms that soldiers are having in the post-deployment period are, in fact, due to that concussion.  And that makes it very difficult to do screening and know with accuracy what the cause of the symptoms are.

The major implication or finding is the soldiers coming back and getting post-deployment screening that there is a risk that they may get misdiagnosed as having brain injury when, in fact, the real problem is post traumatic stress or depression.

PTSD and depression, I think a lot of people do not realize are biological, physiological disorders that cause a variety of physical health symptoms and consequences.  And I think what is happening in Iraq is when a soldier suffers a concussion, that is a very life-threatening experience in that context of concussion on the battlefield, that very life-threatening traumatic experience then sets up the potential for PTSD and depression and then PTSD and depression can lead to the physical health consequences through a variety of mechanisms.

I guess I am a little bit over time, but I just wanted to mention that one of the issues with multiple deployments and the dwell time when soldiers come back, we have learned from the research that we have done that twelve months is not sufficient for soldiers to "reset" and be ready to go back for another deployment.  In fact, we see rates of PTSD rise as soldiers come home. 

And there is sort of a paradox.  We are asking soldiers to, when they come home, to reset and transition home and those very things that we label symptoms when they come home and can get them in trouble and can interfere with their functioning when they come home and their relationships when they come home, those symptoms of PTSD are, in fact, often necessary adaptive mechanisms that they need in combat, you know, the deprivation, the ability to the hyper-alert state that they have to maintain for long periods of time.

So we are asking a lot of our servicemembers when we ask them to transition and sort of turn on and turn off these skills and it is, I think, a little bit unrealistic and, in fact, our data have shown that rates of PTSD increase over the first year.  They do not decrease.  They do decrease for a certain percentage of individuals, but then there are other individuals who manifest the symptoms as the year goes on.

So I think that the key lessons that we have learned have to do with this relationship of PTSD and mild TBI and some things about multiple deployments and dwell time and some lessons learned from post-deployment health assessment.

Thank you very much for the opportunity to discuss this with you.

[The statement of Colonel Hoge appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Colonel, for your testimony this morning and your rundown of current DoD PTSD research programs.

Do you see any gaps in the current research programs and, if so, where are those gaps and what future research regarding PTSD does the Department of Defense have planned, if any?

Colonel HOGE.  Yes, sir.  I think the biggest gap in research has to do with clinical trials of the efficacy of psychotherapy and medication trials and understanding exactly what the elements of psychotherapy are that are effective and what works, what does not work, establishing group therapy practices that are effective.  We have not been able to show necessarily the effectiveness of group therapy the way we have for individual therapy.

So there is a lot of questions within the psychotherapy and medication treatment arena.  There are huge gaps in that area.  And I think that to some extent, the funding that has been allocated, you know, hopefully will fill some of those gaps, but I think the gaps remain.

Mr. MICHAUD.  What about the future research?  Does DoD have any future research planned on PTSD?

Colonel HOGE.  Within my own institute, I think one of the key studies that we are planning, we have done a lot of work with helping soldiers to transition through an educational program called Battle Mind.  And we show that to be moderately effective, particularly for those soldiers with the highest levels of combat experiences.

But, you know, it did not have the effectiveness that we would like to see.  And so we are working, my team is working on developing an advanced version of that that we hope to be able to test in a field trial in the coming time period.

I actually do not know to what extent how many clinical trials are going to be funded out of the appropriation, the fiscal year 2007 appropriation that is being managed by Medical Research and Materiel Command (MRMC), but I know there are clinical trials included in that as well.

Mr. MICHAUD.  Thank you. 

You had mentioned TBI screening sometimes being mislabeled.  Can you tell us some of the recommendations that your research group made to leaders of the Army in this regard.

Colonel HOGE.  There were three areas of recommendations that we made.  One pertained to modifications to our post-deployment screening to assure that all health problems are addressed and symptoms that are identified that need to be addressed, while at the same time minimizing the risks involved.  There are, I believe, enormous risks and mislabeling individuals as being brain injured.  And so we have provided some specific recommendations about how we might structure the post-deployment screening in a way to minimize those risks.

The second set of recommendations pertain to risk communication and/or education.  It is how we communicate about the disorder.  And I think even just the term mild traumatic brain injury, which is a synonym of concussion, for some reason, mild traumatic brain injury has sort of caught on as the term, you know, that is being most widely used.

I think that is unfortunate.  I think that soldiers and family members understand the word concussion much better and concussion is a lot less stigmatizing than the term brain injury.  So I have been advocating for communication strategies that promote the expectation of recovery and even to include just simply using the term concussion.

And so risk communication, the screening, and then I think the key focus of caring for soldiers with traumatic brain injury is getting the word out there.  The education strategy that is most important is that soldiers learn that they need to come in and get seen when they have a concussion on the battlefield and not blow it off as soldiers sometimes tend to do and athletes tend to do as well, you know, get them in, get them seen right there on the battlefield because that is really the time to be evaluated.  Once they come home, it becomes a lot murkier and difficult to sort out what the etiology of particular symptoms are.

Mr. MICHAUD.  Thank you.  I appreciate that. 

I have no problem with trying to call it what it is.  My only concern is if you look at, for instance, disability ratings, the VA tends to be higher than the Department of Defense because they look at the individual holistically. 

I just hope that changing the name does not necessarily prevent the Army from taking care of our men and women who served in uniform because that, I know, is a concern with a lot of veterans out there is trying to shift the burden back on to the veterans themselves versus taking care of it.  So I just hope the research that you are doing is not trying to not take care of our veterans. 

I think it is very important that we do take care of our veterans regardless of whether we call it a concussion or TBI and that is the bottom line for myself in that critical area. 

Colonel HOGE.  Absolutely, sir.  Agree completely.

Mr. MICHAUD.  Thank you.

Mr. Miller?

Mr. MILLER.  Thank you very much, Mr. Chairman, and I associate myself with many of the questions that you asked the witness because I think that we are all concerned and focusing from the same angle.

You mentioned $300 million that was appropriated in 2007.  I am interested in knowing a couple of things.  How are we doing with spending the money, can you elaborate a little bit on the programs?  This is a question that is loaded when I ask it, but was it enough and what else do we need to do?

Colonel HOGE.  Sir, I am not really the person in a position to comment on the expenditure of those funds because I run the research program at Walter Reed Army Institute of Research and I am not in charge of the program.  That is at a higher level.

So I will have to take that for the record, but that has certainly been information readily available.  And my understanding, you know, the processes have been put in place and the grants are now in the process of being awarded.  So I do not think there will be any issues with spending the full amount of that for the research.

[The following was subsequently received from DoD:]

Fiscal Year 2007 (FY07) Psychological Health and Traumatic Brain Injury Research Program Investment Strategy

The Department of Defense’s (DOD’s) investment strategy for the FY07 $150 million (M) post-traumatic stress disorder (PTSD) and $150M traumatic brain injury (TBI) appropriations included multiple highly competitive Intramural (DOD and Veterans Affairs [VA]) and Extramural award mechanisms.  Intramural funding mechanisms were dedicated to supporting only research aimed at accelerating ongoing PTSD- or TBI-oriented DOD and VA research projects or programs.  Intramural proposals were solicited under two PTSD- and two TBI-focused funding mechanisms, the Investigator-Initiated Research Award, which supports basic and clinically oriented research, and the Advanced Technology – Therapeutic Development Award, which supports demonstration studies of pharmaceuticals (drugs, biologics, and vaccines) and medical devices in preclinical systems and/or the testing of therapeutics and devices in clinical studies.  Approximately $35M each of the PTSD and TBI appropriations has been approved for funding ongoing DOD and VA research projects or programs.

The opportunities for funding research in PTSD and TBI through the Extramural award mechanisms were open to all investigators worldwide, including military, academic, pharmaceutical, biotechnology, and other industry partners.  The competition was open but rigorous, and the process ensured that the best and brightest are funded to provide solutions to the problems of those impacted by PTSD and TBI.  Applicants were encouraged to collaborate with military investigators to ensure that solutions will be military-relevant.  The Extramural award mechanisms solicited included the Investigator-Initiated Research Award and the Advanced Technology – Therapeutic Development Award, along with the Concept Award, which supports the exploration of a new idea or innovative concept that could give rise to a testable hypothesis; the New Investigator Award, which supports bringing new researchers into the fields of PTSD and TBI; the Multidisciplinary Research Consortium Award, which is intended to optimize research and accelerate solutions to major overarching problems in PTSD and TBI; and the PTSD/TBI Clinical Consortium Award, which combines the efforts of the Nation’s leading investigators to bring to market novel treatments or interventions that will ultimately decrease the impact of military-relevant PTSD and TBI within the DOD and the VA.  The Clinical Consortium is required to integrate with the DOD Psychological Health and Traumatic Brain Injury Center of Excellence (DCoE).  Further, outcomes from all Intramural and Extramural awards focused on treatment and interventions will be leveraged to support the DCoE’s efforts to expedite fielding of PTSD and TBI treatments and interventions.  

Congress mandated that the Program be administered according to the highly effective US Army Medical Research and Materiel Command two-tier review process, which includes both external scientific (peer) review, conducted by an external panel of expert scientists and programmatic review.  After scientific peer review has been completed for each proposal, a programmatic review is conducted by a Joint Program Integration Panel (JPIP), which consists of representatives from the Departments of Defense, Veterans Affairs, and Health and Human Services.  The members of the JPIP represent the major funding organizations for PTSD and TBI and as such are able to recommend funding research that is complementary to ongoing efforts.  Four rounds of peer and programmatic review have been completed, occurring between June 2007 and April 2008.  The final round of peer and programmatic review are slated for May and June 2008, respectively.

Mr. MILLER.  Do you think that the current timing of the post-deployment health re-assessment study, the six months, is the appropriate time frame within to do that study?

Colonel HOGE.  Yes.  Yes, sir.  Clearly when they first come home, when servicemembers first come home, the screening only identifies a small percentage of individuals who will then go on to develop problems.  So we need that second assessment. 

And there is about a two- to three-fold increase in rates of reporting mental health problems at that second assessment time point.  Three to six months seems to be about right.  We could go as early as two months or, you know, as late as six months, but somewhere in that range is certainly reasonable.

Mr. MILLER.  I think in the beginning of some of your testimony, you were talking about a twelve-month time frame, not having enough time to reset when they are redeployed.  I am wondering if six months is too soon or does there need to be, you know, a second risk assessment?

Colonel HOGE.  Some units are actually conducting the second assessment or conducting the second assessment three to six months and then they are doing it again shortly before redeployment to theater.  But I am not advocating that that be done, but I know that some units are in the process of—

Mr. MILLER.  Do we have any numbers that quantify that second risk assessment at all?  Is there a spike between the six and the ten months or—

Colonel HOGE.  Not really.  The six month and twelve month figures are very, very comparable to one another from the data that we have seen in a different context.  We have studied soldiers with surveys that use similar instruments on them at three, six, and twelve months and we found that six and twelve months are very similar in prevalence rates.

Mr. MILLER.  Thank you.  That is all, Mr. Chairman.

Mr. MICHAUD.  Thank you.

Mr. Hare?

Mr. HARE.  Thank you, Mr. Chairman.

Colonel, just a couple of questions here.  Do you believe that there is a stigma that surrounds PTSD and other mental health conditions that stops soldiers from actually seeking help?

Colonel HOGE.  Absolutely.  Our surveys have indicated that over half of soldiers who have significant mental health symptoms do not receive treatment.  They do not come in and get any help at all.  And we know that based on some of our survey data that concerns about perceptions within their unit, perceptions by their leaders, et cetera, are some of their concerns.

Now, we have been working ardently since the start of the war to destigmatize through education programs and the Battle Mind training, for instance, and other types of education programs.  And I think the word is getting out there.  We have a slight decrease in perceptions of stigma during this last visit to Iraq that my team took.  The perceptions of stigma seemed to improve slightly compared to previous years.

But we are not seeing, you know, huge changes in perceptions of stigma.  Small changes in perceptions of stigma from the work that we have been doing.

Mr. HARE.  It would seem to me one of the ways we could really handle this would be to—in my State of Illinois, I know particularly with the Guard, every returning person coming back is screened and, I would hope we could get to the point at some point where every person who serves is screened so that they do not have to say, I think there might be something wrong here or this may not manifest itself for some period of time.

The other part is, I have a Vet Center right by my district office and a lot of times, the family members will come over.  They will say we do not know what happened to him.  Why is he hitting the child or why are things going wrong.  And so it is that being able to not have to, cross the line and say, I think I have a problem here.

And I just would like to know from your perspective what happens to these people, who do not identify and you do not get the chance or people do not get a chance to help them? 

They are out there and, I am wondering, from your perspective, what happens without that treatment and, how long a person goes.  They need this treatment, as you said, while they are over there.  If they cannot get it, we try to get it for them when they are here.  What happens to these men and women?

Colonel HOGE.  There is universal screening, you know, in the PDHA and PDHRA.  So everyone does go through a systematic routine screening process.  But the screening processes themselves are somewhat inaccurate. 

In fact, one of the publications that we published in November when we looked at the relationship of referral or treatment for PTSD symptoms from the first screen when they initially come and the subsequent screen six months later, we found no direct relationship in improvement in symptoms, which was somewhat of a counterintuitive finding.  We were not expecting that.

And there a lot of potential reasons.  Part of that may have to do with the inaccuracy of the screening.  These are not a hundred percent, you know.  There is no way to a hundred percent identify individuals.  And we have a lot better screening, I can guarantee you, for PTSD than we have for mild TBI.  But that is kind of another topic.

So that is one inherent problem.  And then when we identify problems, it is still voluntary.  We cannot force a soldier to receive mental health treatment.  We can encourage them to.  We have a limited ability to get a soldier help if there is overt threats to self or others.  But aside from that, you know, it is a voluntary process.  We can encourage individuals to go in and get help and they can choose not to.  And that is an individual thing.

And then there is the stigma, which is not just in the military.  It is a stigma in society in general of receiving mental health treatment.  So there is stigma and there are barriers, depending on where a person lives, how close the clinic is, how accessible the doctor is. 

You know, in units, for instance, doctors rotate frequently and so sometimes there is a lack of stability.  You know, a person might develop a relationship with a physician and then three months later, the physician has been deployed.  And so that can affect the person's desire to continue with treatment. 

So there are a lot of factors and it is a tough question that you ask in terms of what is going to happen to these individuals because, you know, this is part of, you know, sort of what we have recognized since the beginning of the war.  There is going to be a significant psychological cost.

Mr. HARE.  Mr. Chairman, my time is up.

But, Colonel, first of all, thank you for your service to the country.  But, I was struck by the multiple deployments, the 30 percent, 20 percent, 12 percent, and, those figures.  I hope a lot more people are listening to those figures than the people sitting in this room. 

And also when you said the twelve months is just not enough for a person to be able to reset. We have been talking about getting people when they come back the opportunity to have some time to be able to, but then, some of these deployments and redeployments are happening so quickly that we are just asking—this is a recipe for disaster.

So I really appreciate your sharing those figures with us.  And, again, thank you very much.

And thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you very much, Mr. Hare.

Mr. Brown?

Mr. BROWN OF SOUTH CAROLINA.  Thank you, Colonel.  I appreciate your testimony and appreciate your service.

I noticed in your testimony that you alluded to the $300 million that is going to be, I guess, spread around between Department of Defense and the VA and also some private providers.

Could you share with me how that effort is actually taking place and if, in fact, the private sector is also contributing dollars to this effort?

Colonel HOGE.  Sir, I work at the Walter Reed Army Institute of Research and that program is managed by the command above me, the Medical Research and Materiel Command.  There is a very systematic process that involves putting out grant invitations to have grant proposals submitted and then those are all peer reviewed and there is a peer review process that establishes which ones get funded based on the science and also based on the needs of the military and the VA.

So there is a very systematic process in place to determine which proposals should get funded and which do not get funded and how the money is distributed.  And I will be happy to take the question for the record in terms of the details and specifics on how that is being done.

[The response was provided in the follow-up information provided by DoD, in response to Mr. Miller's earlier question.]

Mr. BROWN OF SOUTH CAROLINA.  Okay.  I would appreciate that, sir.  How about the National Institutes of Health (NIH)?  Are they contributing to this research too?

Colonel HOGE.  They have also had their own grant funding mechanisms, so they are also actively involved, participated in the planning, the meetings that were held to prioritize how the money should be allocated, and have also had the opportunity to apply for the funding in a collaborative manner with other investigators within DoD and VA.  So—

Mr. BROWN OF SOUTH CAROLINA.  And at the conclusion of this study, what do you hope to be able to accomplish?

Colonel HOGE.  The grants, again, this is a little bit outside my area because I am not responsible for this, but I know that the grant process spans the domain of basic science and applied research and clinical trials research.  My hope is that there will be sufficient lessons learned at sort of the upper end of that in terms of clinical trials and that is what I hope, you know, sort of would be my priority.  I think the biggest gap is in the area of clinical trials, new therapeutic modalities for the treatment of PTSD.

Mr. BROWN OF SOUTH CAROLINA.  I guess one of my greatest passions is the homeless veteran and how he sort of, you know, fell out of the system.  And I think most of those homeless veterans are suffering from some sort of mental disorder, PTSD or similar form. 

And I am hoping that we could find, at the end of the research, that we could find a way to diagnose those people that maybe have the problem or the potential of developing that problem later because by the time they come with the problem, they do not have the wherewithal to be able to find help. 

And so, I would hope as part of research that we would address, you know, the homelessness problem, we find ourselves with a lot of our veterans.

Colonel HOGE.  Yes, sir.

Mr. BROWN OF SOUTH CAROLINA.  Thank you, Mr. Chairman.  I yield back.

Mr. MICHAUD.  Thank you, Mr. Brown.  The homeless veterans' issue actually will be a full Committee hearing on April 9th on homeless veterans.

Ms. Berkley?

Ms. BERKLEY.  I will be very anxious to participate in that hearing as well, but let me remind my colleagues it takes a little bit of money to be able to care for these people.

Let me ask you a couple of questions, if I may.  Something that you said struck a cord with me when you said that there have been studies that demonstrate that if people are called back up to service before a year or even after a year, that it is just not enough time in between tours of duty. 

Did I hear you correctly?

Colonel HOGE.  Yeah.  Well, what we have found is that, yeah.  That is what I said.  What I said is that the twelve months is insufficient, appears to be insufficient based on the data that we have, ma'am.

Ms. BERKLEY.  Now, it is my understanding, and correct me if I am wrong, that our Armed Forces are so stretched right now that people are being called back to duty in a far shorter time than twelve months.  Twelve months is recommended.  But in many instances, they have a 90-day stay at home and they are back in the theater of war.

Is that your understanding as well?

Colonel HOGE.  I do not know actually, you know, how many units have rotated back before twelve months.  So I would have to find that out for you.

[The information from DoD follows:]

In general, the Army does not require Soldiers to violate individual dwell and has systems in place to honor the Soldiers' dwell time. Army policy is in place to honor dwell or adjust for the instances where Soldiers are at risk for violating dwell. There are instances where Soldiers may volunteer to break dwell and some instances where they may be required to break dwell due to their having a critical skill. HRC understands how this affects the Soldiers life and requires General Officer level approval any time this course of action is taken.

When assessing how many Soldiers have deployed prior to receiving their earned dwell we find that the cause is often more patriotic and selfless. As an example we had a unit this week that had greater than 100 personnel non-deployable due to their dwell time being too short. When queried by their leaders, forty of the Soldiers volunteered to break dwell. This demonstrates selflessness of our heroic Army.

Additionally, our dwell numbers have increased in some instances due to Soldiers voluntarily reenlisting specifically for a unit that is deploying. Once the Soldier arrives at their chosen unit they of course deploy with the same.

For example, in units that are deploying in the near future there are a total of 33,862 Soldiers. Of these Soldiers 33,246 (98.2 percent) have no dwell issues. Of the remaining 616 Soldiers, nearly half of them have volunteered to deploy short of their authorized dwell periods.

The system is not perfect and there are Soldiers, in the end, that are placed in situations where they must deploy repetitively and violate their dwell. It is up to the individual Commanders and Leaders to ensure that Soldiers are afforded their earned dwell time. Army Human Resources Command knows that this issue is important to the Soldier and has made strong efforts to prevent this sort of issue from occurring.

Ms. BERKLEY.  I would appreciate it because it is my understanding that it is a much shorter period of time in many instances.

And I am going to share with you another Nevada story.  A young man from Pahrump, Nevada, had done his tour of duty.  He was back home in Pahrump.  He had been raised by his grandmother, so he went back to his grandmother's home.  He was called back.  He did not want to go back.  He told his grandmother he would rather kill himself than go back. 

He was interviewed by a psychologist or a psychiatrist.  They said that he was depressed and gave him Prozac.  He was sent back.  He was on suicide watch and the day after he was taken off of suicide watch, he killed himself.

Now, it seems to me that we ought to be doing a better job of screening people and fully appreciating when they are not capable mentally of handling the strain of war.

Do you agree with that?

Colonel HOGE.  I agree completely in the sense that, you know, if we had the ability to accurately identify who will do well in combat and who will not—I mean, the fact of the matter is that—

Ms. BERKLEY.  Forgive me for interrupting.

Colonel HOGE.  Yes, ma'am.

Ms. BERKLEY.  But don't you think if the military put this young man on suicide watch that they had a pretty good inkling that he was not doing well mentally?

Colonel HOGE.  Yeah.  I cannot comment on the specifics of the case.  Presumably, you know, when they took him off suicide watch, you know, I am sure they, you know, had good reasons to do that, you know, based on what he told them. 

But unfortunately there are tragic situations that happen and, you know, there has been an increase of suicide rates in theater because everyone has access to firearms.  And so impulsivity that normally, you know, might not lead to suicide, in that circumstance where they have easy access to firearms can be a catastrophic event and a very unfortunate one.

Ms. BERKLEY.  Let me ask you another question on a different issue.  If you have a serviceman who gets a gunshot wound and he is bleeding profusely, do you have to ask his permission to treat him or do you just treat him?  And if we just treat him, why is it if somebody has a mental wound that we have to tread carefully? 

It would seem to me that somebody's mental problem is just as serious as somebody's physical wound and we ought not to have to get permission from that person in order to treat them.  Why is it that we make this distinction?

Colonel HOGE.  There are lots of answers to that and the first one that comes to mind is simply that the only way to get better is in part to have the desire to do so and to make that commitment.  And we cannot force people to get better with psychiatric problems.  The reason why therapy works is because of the alliance that we form between the doctor and the patient, between the counselor and the patient. 

Ms. BERKLEY.  Well, what if it was mandatory?  What if we determined that it was part of getting out of the service that you are interviewed by a mental health expert and then six months later and a year later and maybe five years later, but have it mandatory that they must, in fact, get this counseling, just to be able to keep track of the problems because I agree with you, unless you recognize you have a problem, it is very difficult to overcome it, but I surmise that a lot of these young men and women do not even recognize that they have the problem?

Colonel HOGE.  I agree with you, ma'am, that many of them do not recognize that they have a problem.  And sometimes when they do, they are not necessarily willing or interested in treatment.  There are options available to them to get treatment through other means. 

For instance, Military OneSource, which is a separate track that is not part of the medical system.  They can get care in the VA system or Vet Centers.  They can get help from chaplains.  There is a huge amount of counseling that is provided by chaplains.  And a lot of individuals actually do get better on their own, you know, with or without treatment. 

But I think that in terms of requiring mandatory counseling, I think that I could see it might seem valuable on the surface, but I think the second order of consequences, you know, would be enormous, draining much needed resources, which are already overstretched and overtaxed away from those who most need it would be one, for instance.

And also I just do not think that by and large if we force—we cannot.  We cannot ethically do that, force individuals to get better.  And they are not going to get better if we do.  They will find every way to rebel against that.

Ms. BERKLEY.  Okay.  Could I ask one more question?  Thank you.

There is something else.  I am getting a lot of calls from medical doctors in Las Vegas saying that the VA is not paying them on a timely manner, in a timely manner.  And they are becoming very reticent to renew their contracts with the VA, which could create a pretty big crisis in the VA health care system if the doctors that we are contracting with do not get paid.

I am wondering if you have heard anything from mental health experts, doctors, psychologists, psychiatrists.  I would assume that it is a challenge to find enough doctors, psychologists, psychiatrists that are trained to deal with mental health issues as it is and if we are not paying them in a timely manner, I would believe it would become even more challenging to get them to contract with the VA.

Are you hearing anything like that?

Colonel HOGE.  I cannot comment on the VA situation.  But within DoD, there was, as you know, I am sure, the Mental Health Task Force was a comprehensive self-assessment, very, you know, critical, you know, self-assessment by DoD to look exactly at that question of whether the resources were sufficient and available and accessible within particularly our remote operational, you know, locations, where the deployment platform locations, and it