Colonel Charles W. Hoge, M.D., USA
Mr. Chairman and Members of the Committee, thank you for this opportunity to discuss the Army’s research on Post-Traumatic Stress Disorder (PTSD) at Walter Reed Army Institute of Research (WRAIR). I will focus on research initiatives at WRAIR but want to first acknowledge and thank Congress for the tremendous increase in funding for PTSD and Traumatic Brain Injury (TBI) research. The $300 million dollars allocated to PTSD and TBI research in the FY07 appropriation is in the process of being awarded to numerous Department of Defense (DoD), Department of Veterans Affairs (VA), and civilian research organizations under the management of the US Army Medical Research and Materiel Command’s Office of Congressionally Directed Medical Research Programs (CDMRP).
I would like to briefly discuss the findings of three studies published since my last testimony to this committee in September 2006, which highlight both the successes and challenges in addressing the mental health needs of our service members.
The first is a study reported this past November in the Journal of the American Medical Association (JAMA) involving nearly 90,000 Soldiers who completed both the post-deployment health assessment (PDHA) and the post-deployment health reassessment (PDHRA) after return from deployment to Iraq. Soldiers completed the PDHA immediately upon their return and they completed the PDHRA six months later. The study confirmed that many mental health concerns do not emerge until several months after return from deployment, highlighting the importance of the timing of the PDHRA, particularly for Reserve Component Soldiers. 20% of Active Component and 42% of Reserve Component Soldiers were identified as needing mental health referral or treatment, most often for PTSD symptoms, depression, or interpersonal conflict. About half of Soldiers with PTSD symptoms identified on the PDHA showed improvement by the time of the PDHRA, often without treatment. However, more than twice as many Soldiers who did not have PTSD symptoms initially became symptomatic during this same period. One counterintuitive finding was that we could not demonstrate any direct relationship between referral or treatment for PTSD as identified on the PDHA and symptom improvement six months later on the PDHRA. The difficulty in demonstrating the effectiveness of the PDHA assessment may reflect, in part, the inherent limitations in screening or the fact that mental health services remain overburdened with the current operational tempo, despite the extensive efforts to bolster services and training. An encouraging finding was that many Soldiers sought care within 30 days of the PDHA and PDHRA even if they were not referred, which suggests these assessments may be encouraging individuals to seek help on their own following discussion of mental health issues with a health professional or participation in concurrent Battlemind education.
The second study I’ll discuss is the recently released Mental Health Advisory Team 5 (MHAT-V) report. We have conducted MHAT evaluations every year in Iraq since the start of the war, and twice in Afghanistan. The MHATs have shown that longer deployments, multiple deployments, greater time away from base camps, and combat intensity all contribute to higher rates of PTSD, depression, and marital problems. The MHAT-V included for the first time a sizable number of Soldiers on their 3rd rotation to Iraq. The study showed that with each deployment there is an increased risk; 27% of Soldiers on their third deployment reported serious combat stress or depression symptoms, compared with 19% on their second, and 12% on their first deployment. The MHAT-V also showed that Soldiers in brigade combat teams deployed to Afghanistan are now experiencing levels of combat exposure and mental health rates equivalent to those experienced by Soldiers deployed to Iraq.
Soldiers encounter a variety of traumatic experiences and stresses as part of their professional duties. The majority cope extraordinarily well and transition home successfully. However, surveys in the post-deployment period have shown that rates of mental health problems, particularly PTSD, remain elevated and even increase during the first 12 months after return home, indicating that 12 months is insufficient time to reset the mental health of Soldiers after a year-plus combat tour. Many of the reactions that we label as “symptoms” of PTSD when Soldiers come home are, in fact, adaptive skills necessary in combat that Soldiers must turn on again when they return for their next deployment.
The 3rd study I’ll discuss is one that we just published in the New England Journal of Medicine pertaining to the relationship of PTSD to mild traumatic brain injury (or “mild TBI”). It is important to clarify terminology. Reports have indicated that as many as 20% of troops returning from Iraq and Afghanistan have had traumatic brain injuries, but what is not always made explicit is that the vast majority of these are concussions. “Mild TBI” means exactly the same thing as “concussion,” which athletes or Soldiers also refer to as getting their “bell rung” or being “knocked out.” I advocate using the term “concussion” because it is less stigmatizing than the term “brain injury,” is better understood by Soldiers and Families, and is less likely to be confused with moderate or severe TBI. A concussion is a blow or jolt to the head that causes a brief loss of consciousness or change in consciousness, such as disorientation or confusion. Full recovery is expected, usually within a few hours or days. This is very different from moderate or severe TBI, where there is an obvious injury to the brain that almost always requires evacuation from theater. Although most Soldiers are able to go back to duty quickly after concussions, there has been concern that concussions in combat, particularly from blasts, may have lasting effects that are not immediately visible. Some Soldiers report persistent symptoms (termed “post-concussive symptoms”), such as headaches, irritability, fatigue, dizziness, problems concentrating, sleep disturbance, balance problems, and cognitive or memory difficulties. Our study involving 2,500 infantry Soldiers was one of the first to look at the relationship between concussions Soldiers sustained while deployed to Iraq and these types of physical and mental health outcomes three months after their return.
There were three key conclusions from this study:
First, the study highlighted a problem that we face with not having an accurate diagnostic tool in the post-deployment period. We are not aware of any questionnaire or test that can accurately tell us who had a concussion while deployed, or which symptoms were caused by a concussion that occurred months earlier, as we are attempting to do with post-deployment screening. In our study sample, 15% of Soldiers reported a concussion while deployed based on the questions currently being used on the post-deployment assessment forms. However, only one-third of these, or 5% of the Soldiers, reported an injury in which they were knocked unconscious, usually for just a few seconds or minutes. The rest had injuries that only involved being briefly “dazed or confused” without loss of consciousness, and it was not clear how many of these were true concussions. We found that this type of injury did not confer much excess risk of adverse health effects after redeployment.
The second important finding was that having a concussion was strongly associated with PTSD. 44% of Soldiers who lost consciousness met the criteria for PTSD, compared with 16% of those who had other types of injuries and 9% who had no injury.
Third, and the most important finding, was that the symptoms that we thought were due to the concussions were actually attributed to PTSD or depression. If a concussion was the cause of the post-concussive symptoms we should have been able to confirm an association of these symptoms with a concussion, both in those Soldiers who had PTSD and in the larger group of Soldiers who did not. We did not see this in either group. Instead, all the physical health outcomes and symptoms were associated with PTSD or depression. Both PTSD and depression are biological disorders that are associated with a host of chemical changes in the body’s hormonal system, immune system, and autonomic nervous system. Many studies have shown that PTSD and depression are linked to physical health symptoms, including all of the symptoms in the “post-concussion” category, to include cognitive and memory problems.
This study allowed us to refine our knowledge about what distinguishes concussions in combat from concussions in other settings. Concussions on the football field, for example, are not known to be associated with PTSD. It is possible that there is an additive effect in the brain when a Soldier who is already seriously stressed in combat sustains a blow to the head, or there may be something unique about blast exposure, as many people are speculating. However, a hypothesis that is better supported by our data as well as other medical literature is the life threatening context in which the concussion occurs. Being knocked unconscious from a blast during combat is about as close a call as one can get to losing one’s life. There are frequently other traumatic events that occur at the same time, such as a team member being seriously injured or killed, all of which can precipitate PTSD or depression.
The most important implication of this study is that current post-deployment TBI screening efforts may lead to a large number of service members being mislabeled as “brain injured” when there are other reasons for their symptoms that require different treatment. The optimal time to evaluate and treat concussion is at the time of injury, and it is my opinion that post-deployment screening efforts months after injury may actually lead to unintended harmful effects. As a result, my research group has provided recommendations to medical leaders at Army and DoD to refine the post-deployment screening efforts to assure that all health concerns are addressed in a way that minimizes potential risks. These recommendations are now under consideration. In addition to screening and treatment, our study has important implications for educating Soldiers and Families about mild TBI (i.e. concussion).
Thank you so much for your attention and I look forward to your questions.