<DOC>
[109th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:22708.wais]
The Department of Defense (DoD) and Department of Veterans Affairs (VA): The
Continuum of Care for Post Traumatic Stress isorder (PTSD)
Wednesday, July 27, 2005
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, D.C.
The Committee met, pursuant to notice, at 10:27 a.m., in Room 334, Cannon
House Office Building, Hon. Steve Buyer [Chairman of the Committee] presiding.
Present: Representatives Buyer, Burton, Miller of Florida, Boozman,
Evans, Filner, Michaud, Herseth, Strickland, Hooley, Berkley, and Udall.
Also Present: Hon. Ted Poe of Texas, Hon. Grace Napolitano of California,
and Committee Counsel Linda Bennett.
The Chairman. The full Committee hearing on the House Veterans' Affairs
Committee July 27th, 2005 will come to order.
Today the Committee is meeting to examine efforts of the Departments of
Defense and Veterans' Affairs to identify recent combat service members at
risk for post-traumatic stress disorder, referred to as PTSD, including
Reserve and National Guard members, and to assess their capabilities to meet
an increase in demand for PTSD-related services from Operations Enduring
Freedom and Iraqi Freedom.
The wounds of wartime service are not always as visible as those caused
by a bullet or shrapnel. Wounds to the mind and spirit, however, are just as
serious and demand every bit as much care and attention.
We have, since the days when it was called "shell shock," learned much
about PTSD. Yet we have much more to learn so that we can accurately diagnose
and effectively treat it. Perhaps there are ways that we can prepare our
young warriors before they deploy so that they will be less vulnerable to the
trauma.
These are things we must learn about so that we can take appropriate
action.
Recently, the VA Inspector General report indicated that waiting times for
health care appointments have been underreported, and we owe our veterans
better, regardless of the burdens of their service that they bear.
So I want to bring this up. I also will note, I read your statements last
night, and I'm hopeful that the witnesses today will address this in your
testimony. This recent IG report that was examining the state variances in VA
disability compensation payments noted some really significant numbers. And
that is rather alarming, and I welcome the comments from the experts here
today.
During fiscal years 1999 to 2004, the number and percentage of PTSD cases
increased significantly. Now this is from the IG report dated May 19th, 2005.
While the total number of all veterans receiving disability compensation grew
by only 12.2 percent, the number of PTSD cases grew by 79.5 percent, from
120,265 cases in Fiscal Year 1999 to 215,871 cases in Fiscal Year 2004.
During the same period, PTSD benefit payments increased 1248 percent from $1.7
billion to $4.3 billion.
Compensation for all other disability categories only increased by 41
percent. While veterans being compensated for PTSD represented 8.7 percent of
all compensation recipients, they're receiving 20.5 percent of all
compensation payments. That's a "wow." It's a distortion also in the
compensation system. I don't understand the reasons for what's happening out
there, and I welcome the input from the experts on this today. And we may
even have to do follow-up with regard to this.
I now yield to my Ranking Member, Mr. Evans, for his opening remarks.
Mr. Evans. Thank you, Mr. Chairman, for holding this hearing. It's really
important to hear from these witnesses today. I hope we can move forward
quickly on legislation to ensure that the VA and DOD are taking steps to
address mental health care needs for returning servicemen and women.
I also want to thank Mrs. Stefanie Pelkey for her service to our country
in the Army Reserve and for her husband Michael's honorable service. We owe
so much to you that we can never repay for what you have suffered, what you
have lost.
She told her husband's story in her written statement, and it indicated to
me the truth of the perception among veterans that the war's outcome doesn't
end when they come home. Their service to this country demands that they get
the health care they need, the compensation, pension programs and educational
benefits and the GI Bill benefits they need.
So, thank you, Mr. Chairman. I appreciate your yielding and your time.
[The statement of Hon. Lane Evans appears on p. 69]
The Chairman. Thank you. Our colleague from Texas, Judge Ted Poe, wanted
to be here to introduce his constituent who will testify next, and if you
would indulge me, rather than take his statement and submit it, if I my read
the introduction of his constituent, our first witness. This is the statement
on behalf of our colleague, Ted Poe, of Houston, Texas. Quote: "I want to
thank Chairman Buyer and Ranking Member Lane Evans for holding this important
hearing on a problem that impacts all of our communities. Stefanie Pelkey is
a constituent of mine from Spring, Texas. She was a captain in the Army where
she served with her husband, Captain Michael John Pelkey. Today, Stefanie
Pelkey will tell you the story of her husband, a man whom she loved who and
loved his country and how he was a changed man when he came back from Iraq.
She will talk about their experience as they tried to deal with her husband's
emotional turmoil, and she will talk about how post traumatic stress disorder
hurt both the patient and everyone within their circle of friends and
families. Her story is an important story as it serves to underline an
important and growing problem as more and more of our armed forces members
return from combat with injuries, not all of which are physical, and turn to
the VA and DOD for assistance." Ms. Pelkey, you are recognized and may take
as much time as you like.
STATEMENT OF STEFANIE PELKEY, SPRING, TEXAS; AC-
COMPANIED BY MS. SHERRY FORBISH
STATEMENT OF STEFANIE PELKEY
Ms. Pelkey. Mr. Chairman, Ranking Member Evans, and other members of the
Committee, my name is Stefanie Pelkey and I am a former captain in the U.S.
Army. This testimony is on behalf of my husband, CPT Michael Jon Pelkey, who
died on November 5th, 2004. Although he was a brave veteran of Operation
Iraqi Freedom, he did not die in battle, at least not in Iraq. He died in a
battle of his heart and mind. He passed away in our home at Fort Sill,
Oklahoma from a gunshot wound to the chest. My Michael was diagnosed with
post traumatic stress disorder, PTSD, only one week before his death, by a
licensed therapist authorized by TRICARE.
The official ruling by the Department of Defense is suicide. However,
many people, including myself, believe it may have been a horrible accident.
We also believe that he would not have been sleeping with a loaded weapon if
it weren't for PTSD.
When I met my husband, he was responsible and hardworking. He loved life,
traveling and having fun. He hailed from Wolcott, Connecticut and was one of
six siblings. He received his commission from the University of Connecticut.
Being a soldier was a childhood dream for him.
We were married in November 2001, and our journey as a military family
began. Michael deployed for Iraq with the 1st Armored Division in late March
of 2003, three weeks after our son Benjamin was born. He left a happy and
proud father. He returned in late July 2003. It seemed upon his return that
our family was complete and that we had made it through our first real world
deployment. He seemed so happy to be home.
A few days after returning to Germany, he reported to his primary care
physician on July 28, 2003, as part of a post-deployment health assessment.
He expressed concerns to his primary care physician that he was worried about
having serious conflicts with loved ones. The physician referred him to see a
counselor. However, the mental health staff on our post was severely
understaffed with only one or two psychiatrists. Michael was unable to get an
appointment before we moved from our post in Germany to Fort Sill, Oklahoma.
He noted several concerns on his DD Form 2796, post-deployment health
assessment. However, the most worrisome notation from this form was the
admission of feeling down, depressed and sometimes hopeless. He also noted
that he was constantly on guard and easily startled after returning from his
deployment.
When we got to Fort Sill, we both settled into our assignments.
Everything seemed normal for a while. Six months later, the symptoms of PTSD
started to surface, only we did not know enough about PTSD to connect the
dots.
When my husband returned from Iraq, there were no debriefings for family
members, service members, or forced evaluations from Army Mental Health in
Germany. As a soldier and wife, I never received any preparation on what to
expect upon my husband's return. I believe that it is crucial that spouses be
informed about the symptoms of PTSD. Spouses are sometimes the only ones who
will encourage a soldier to seek help. Most soldiers I know will not
willingly seek help at any military mental facility, for fear of repercussions
or even jibes from fellow soldiers.
After months arriving in Oklahoma, there were several instances in which I
would find a fully loaded 9mm pistol under Michael's pillow or under his side
of the bed. I could not seem to get through to him that having this weapon
was not necessary and it posed a danger to our family. Michael finally agreed
to put his pistols away. I thought the situation was resolved. As a soldier
myself, I could understand that having a weapon after being in war might
somewhat be habitual for him.
Little by little, other symptoms started to arrive, including
forgetfulness, chest pains, high blood pressure and trouble sleeping.
Remembering to mail bills and recalling simple things became a great problem
for him. One of the greatest tests PTSD posed to our marriage was that
Michael began to suffer from erectile dysfunction, which would cause him to
break into tears. He did not understand what was happening. I did not know
what was happening to my husband.
On other occasions, he would overreact to simple things. One night we
heard something in the garage. It was still light outside. Michael proceeded
to run outside with a fully loaded weapon and almost fired at a neighbor's
cat. These overreactions occurred on several occasions.
These symptoms would come and go to a point that they didn't seem like a
problem at the time. There were times that everything seemed just right in
our home, and he seemed capable enough. He was succeeding in his career as
the only captain in a research and development unit at Fort Sill. It was a
job in which he was entrusted with researching and contributing to the Army's
latest in targeting developments.
We soon bought a new house, and he was so proud of it. We were finally
getting settled. Finally, the nightmares began. this would be the last
symptom of PTSD to arise, and it was the one symptom that I feel ultimately
contributed to my husband's death. These nightmares were so disturbing that
Michael would sometimes kick me in his sleep or wake up running to turn on the
lights. He would wake up covered in sweat, and I would hold him until he went
back to sleep. He was almost child-like in these moments. In the morning, he
would joke around, and, sadly, we both laughed it off.
However, at this time I do want to point out that Michael was seeking help
for all of these symptoms I have discussed. He was put on high blood pressure
medication. He also complained of chest pains and was seen on three occasions
in the month preceding his death. He even sought a prescription for Viagra to
ease marital tensions. However, no military physician who ever saw Michael
could give him any answers. No doctor ever asked him about depression or
linked his symptoms to the war.
Michael tried to seek help from the Fort Sill mental health facility but
was discouraged that the appointments he was given were sometimes a month
away. So he called TRICARE and was told that he could receive outside therapy
if it was family therapy, so we took it. Family therapy, marital counseling,
or whatever they wanted to call it, we were desperate to save our marriage.
After all, the symptoms of PTSD were causing most of our heartache.
In the two weeks prior to his death, we saw a therapist as a couple and
individually. This therapist told Michael that he had PTSD and that she would
recommend to his primary care provider that he be put on medication. He was
so excited and expressed to me that he could see a light at the end of the
tunnel. He finally had an answer to all of his problems and some of our
marital troubles. It was an exciting day for us, not to mention two weeks
before his death, he interviewed for a position in which he would be running
the staff of a general officer. He was beaming with pride.
He met with the therapist on a Monday. Tuesday we celebrated our third
wedding anniversary. It was a happy time. I felt hope and relief with the
recent positive events. Michael must have felt something else. Friday my
parents were visiting. I was at a church function, and my father returned from
playing golf to find Michael. He looked as if he were sleeping peacefully,
except for the wet spot on his chest. His pain was finally over and his battle
with PTSD was won. No, he wasn't in Iraq, but in his mind, he was there day in
and day out. Although Michael would never discuss the details of his
experiences in Iraq, I know he saw casualties, children suffering, dead
civilians and soldiers perish. For my soft-hearted Michael, this was enough.
Every man's heart is different. For my Michael, it may not have taken much, but
it changed his heart and his mind forever.
My husband served the Army and his country with honor. He was a hard
worker, a wonderful husband and father. He leaves behind a 28-month-old son,
Benjamin. One day I would like to tell my son what a hero his father was. He
went to war and came back with an illness.
Although PTSD is evident in his medical records and in my experiences with
Michael, the Army has chosen to rule Michael's death a suicide without
documenting this serious illness. I have been told by the investigator that
PTSD diagnoses must be documented by Army mental health psychiatrists to be
considered valid. At the time Michael sought help, he knew it was an urgent
matter and was not willing to wait a month or even a few days. We accepted
the help TRICARE offered us, and now Michael is not going to get the credit
that he deserves. Why pay outside mental health providers to care for our
soldiers if their diagnoses are not considered valid? He is a casualty of
war. I have heard this spoken from the mouths of two generals. He came home
with an injured mind. And to let him become just a suicide is an injustice to
someone who served their country so bravely. He loved being a soldier and he
put his heart into it.
I will be submitting petitions to have PTSD officially documented and to
have my husband put on the official Operation Iraqi Freedom Casualty of War
list. There are so many soldiers who have committed suicide due to PTSD in
Iraq and received full honors and benefits without an official PTSD diagnosis.
Michael deserves the same honor.
If only the military community at that time had reached out to family
members in some manner to prepare them for and make them aware of the symptoms
of PTSD, my family's tragedy could have been averted.
So many soldiers are suffering from this disorder, and so many families
are suffering from the aftermath of this war. I don't want my Michael to have
died in vain. He had a purpose in this life, and that was to watch over his
soldiers. I intend to keep helping him do so by spreading our story. He
suffered greatly from the classic symptoms of PTSD. It is plain to see in
retrospect. His weapon became a great source of comfort for him. He endured
sleepless nights due to nightmares and images of suffering that only Michael
knew.
My husband died of wounds sustained in battle. That is the bottom line.
And the war does not end when they come home.
Thank you.
[The statement of Stefanie E. Pelkey appears on p. 76]
The Chairman. Mrs. Pelkey, thank you for sharing your story. It takes
courage for you to sit there and share publicly, but I know you do that on
behalf of your husband. Actually you're telling his story, and I think it's
extremely important.
Sitting to your left is your congressman, Congressman Ted Poe. And he was
with the President, but I'm glad he's now arrived. I want you to know,
Congressman Poe, I read your introduction of your constituent into the record,
but I'll yield to you for any comments that you may have.
Mr. Poe. Thank you, Mr. Chairman, and thanks for having this hearing.
Besides the fact that Mrs. Pelkey is a constituent of mine, a little more
background about her.
She graduated with an Associate degree from the New Mexico Military
Institute in Roswell, New Mexico back in 1996 and went on to graduate and
receive her commission as a second lieutenant from the New Mexico State
University in Las Cruces, New Mexico. And then graduating officer's basic
course, Mrs. Pelkey received her first assignment as the battalion chemical
officer for the 1st 94th Field Artillery Battalion in Germany. It is important
to note that she was the first woman to serve in this field artillery
battalion and one of the first three women in Germany to ever be placed in an
all-male combat arms unit.
After she met her husband, they were married on November they were married
on November 2, 2001, and their son Benjamin was born on March 15, 2003 in
Germany. Her second assignment was as the brigade chemical officer for the
75th Field Artillery Brigade at Fort Sill, Oklahoma.
She left the Army and ended her time in service in September of 2004. And
her husband Michael died on November the 5th, 2004.
And I want to thank you, Mr. Chairman, for having this hearing, and I also
want to thank Mrs. Pelkey for her moving testimony.
I yield back. Thank you.
The Chairman. Thank you very much. Mrs. Pelkey, your pain will last for
some time, and I think as those of us here listening to your story, we seek to
empathize and sympathize with your position. I could not help reflect upon my
best friend, who was 16, and took his own life with a pistol. His baseball
cap sits behind my desk so I can look at it every day. And a lot of people
walk into my office and they think probably it's my baseball cap, but it's my
best friend's. And, you know, I have for the last 27 years, when I think of
him, thought of why, and what could I have done to prevent it. And it's going
to happen to you, you're going to ask in your mind, "Did I do all that I
should have done?" Now when you do that, what is important for us, though, is
for you not to place that burden so much upon yourself. You're going to. I
do, and will continue to ask, "What could I have done?"
But let me shift it. You touched on the fact that your husband sought
treatment, but there was an access problem. Can you develop that a little
more for us to understand? Because here, for those of us who have oversight
over the VA, the reason we've asked the military to come here is that these
soldiers transition, as you know, from the military to veteran status. The VA
also cares for some of the active duty in our system and then they transition
back and VA gets reimbursed for that care.
For this transition, we are trying to make sure that that health care is
seamless, so that help is available when you find yourself in a position that
is very challenging. Help us understand when you play this back in your mind,
where did the system break down, and where should the help have been?
Ms. Pelkey. I want to point out that at this time that my husband was
redeployed back to Germany was in the very early stages of them even bringing
people back from Iraq. I think they were more, or the Army was more on a
level of preparing for units to come back at that time and not individual
soldiers.
They did have the post-deployment health assessment in place, and the
doctors did refer him to see mental health. But I think the breakdown in the
system overall for my husband was the lack of staff at the mental health
facility in Germany at that time. And I know there have been improvements
since.
But also, when he was seen at Fort Sill, there was no system in place for
when these symptoms arise for the primary care providers, the nurses, the
doctors, to recognize these symptoms. They should be able to trigger some
kind of post traumatic stress disorder diagnosis, you know, or referral when
they see some of these symptoms, and that's just not in place, to my
knowledge. And I think that's where my husband really, really lost out was
that they just didn't recognize the physical symptoms.
The Chairman. So when the doctors were treating the physical symptoms,
they were being very narrow rather than taking it to a PTSD level?
Ms. Pelkey. Right.
The Chairman. How many doctors did he see, do you recall? How many
different medical doctors at Fort Sill?
Ms. Pelkey. He saw his primary care provider, who consulted with the same
physician each time. And I can tell you there were about seven or eight
different visits for chest pains, high blood pressure, erectile dysfunction
and even noted depression.
The Chairman. At any time did you think of or suspect PTSD?
Ms. Pelkey. No, I did not suspect PTSD. I didn't really know anything
about it at that point. I think that my husband and I thought that we were
just going through marital problems.
The Chairman. So when was the first time you heard about PTSD?
Ms. Pelkey. I heard of PTSD shortly before my husband died, when he was
diagnosed, by his outside provider.
The Chairman. And who was the outside provider?
Ms. Pelkey. She was a therapist. Her name was Joanie Sailor, and she was
an off-post provider that generally TRICARE sends the soldiers to for
treatment.
The Chairman. So she's a civilian therapist. Is she a doctor?
Ms. Pelkey. She's a civilian therapist. She's an MA. She's a licensed
therapist.
The Chairman. So at Fort Sill -- well, maybe this is a question for others
-- do you know how many referrals there were -- were there others that you
knew who were being referred to TRICARE?
Ms. Pelkey. I know that, I mean, from general knowledge, that the Army as
a whole is having problems with marriage in general, divorce rates and
everything. So I can imagine that there are plenty of people that are being
seen --
The Chairman. That's right. You got there through family therapy as the
access, because you weren't getting that access from the military?
Ms. Pelkey. Yes sir. We had the opportunity to, but like I said, my
husband was not willing to wait. I think at that point he knew that we needed
to do something immediately, and he was not willing to wait the amount of time
which was given to him, which was a month.
The Chairman. You know, in the military we talk about the Army family,
right, the Army of One. And somewhere in there was a breakdown in the family to
help take care of our own. I mean, that's my sense by your story here. And
that's very bothersome to me.
Let me yield at this time to Mr. Filner for any questions he may have.
You're now recognized for five minutes.
Mr. Filner. Thank you, Mr. Chairman. And thank you for having this hearing,
and thank you for scheduling Mrs. Pelkey here with us. I know we were all
affected, Mrs. Pelkey. I appreciate your courage and your willingness to
testify in public. It's very important. I'm glad there are people from the DOD
and VA here to hear it. I don't know if you've tried to talk to them, go up
that chain of command, but I'm glad they heard it.
We talk a lot, we argue about numbers here. Is a billion dollars enough,
two billion? But it gets down to whether we have the services for people like
you and your husband, and we simply don't. It comes down to being able to get
the needed help; appointments not being available, and veterans having to
wait. It's not just statistics, it's human beings, and you've pointed that
out.
First of all, you made a very powerful statement about families being
educated. I mean, that's rather an obvious and fairly simple thing in
essence, if the Army, and other defense agencies recognized it.
We've seen it with our atomic veterans, our Agent Orange from Vietnam,
PTSD. At first, nobody wanted to recognize the truth. They said it's only
just, as the Chairman said, shell shock or it's in your head. And it looks to
me, there's an institutional dynamic to deny illnesses, maybe because it's
going to cost money, or they don't want to admit mental problems on behalf of
our brave young men and women.
But the outreach to families, the outreach to soldiers coming back has to
be incredibly expanded. I think you would agree with me that if you had known
this from the beginning, you could have pressed for the proper attention. And
even if you press for that, by the way, I can tell you there's not enough
resources now. And for some reason, the VA is still messing around with a
mathematical model to tell us how many people are going to have mental health
problems.
It just doesn't seem to me they're recognizing it still. You have an
important role to play. I hope we can work with you to do that.
Even with your knowledge now of PTSD, if your husband was not diagnosed as
PTSD service-connected, there's no provision for services, is there? If
something happened, let's say two years, more than two years down the line, if
these symptoms became graver then, he would have had the same problems. Is
that your sense of it?
Ms. Pelkey. He would have had the same problems, but I do want to make
very clear that I have seen with my own eyes that, after my husband's death,
that the Army became very proactive on the Fort Sill community. They started
a program there that has just grown, and they're not waiting around for any
models to come out. They're trying to see what works for the soldiers. And
they have some very low budget programs that are working wonderfully for the
soldiers.
There are group therapies. There are things out there that are working
that don't cost a whole lot of money. And they're working. Soldiers don't
want to see PowerPoint presentations. They don't want to see videos. They
want to be in a safe environment.
They want to talk with one another, just as I know in my experience
talking to Vietnam veterans and other war veterans, that they feel safe
amongst themselves talking about it, and this is what they've done at Fort
Sill.
They've modeled the program to integrate the soldiers wherever they're
comfortable. They go into motor pools wherever they have to, and they're
talking to the soldiers, and then the soldiers that have apparent problems are
put into group sessions and they talk, they joke around, and then they really
get down to the problems that they have. And this is what's working, from what
I've seen.
So there are things out there that are being done.
Mr. Filner. I think we know how to deal with it if we put the resources in.
Do you think the families, whether it's the spouses or the children are getting
-- while the service member is deployed, that's when some education should be
done. Is that being done also at Fort Sill?
Ms. Pelkey. They are -- they have a very strong pre- and post-deployment
there now. I mean, yeah, it did take a loss or maybe even, you know, a couple
of losses. But the command has been very proactive there. They now brief
spouses, and they're starting a program for children where they even sit the
children down and tell them, you know, these are the things that scare mommy
or daddy. These are the things, slamming doors and -- they try to educate the
children and they're trying their hardest, but it's crucial I think to educate
the spouses, because spouses, whether they're male or female, are ultimately
the ones that are going to push their spouse to go and get help, whether it's
because of marital tension or, you know, just they're the ones. They're the
ones that are going to urge the soldier to go.
Mr. Filner. Yes. I've sat in some of the PTSD discussions. They're very
powerful. I just hope what you're describing at Fort Sill keeps going even
after a change of command. Sometimes these things are personally driven as
opposed to institutionally driven. And what you've taken as your job and
which we want to support is to get all this institutionalized, provide
whatever money is needed. We've seen what happens in Vietnam if you don't
treat the mental state. You know, half of the people on the streets today are
Vietnam vets, and that's partially because we didn't take it very seriously.
The Chairman. Thank you.
Mr. Filner. And we see it happening again, and I appreciate your efforts.
The Chairman. Thank you, Mr. Filner, for your contribution. I now
recognize Mr. Michaud. Ma'am, he's the Ranking Member on our Health
Subcommittee. He's from the State of Maine.
Mr. Michaud. Thank you very much, Mr. Chairman. I'd ask unanimous consent
for my full opening statement to be submitted for the record.
The Chairman. Hearing no objection, so ordered.
[The statement of Hon. Michael Michaud appears on p. 74]
Mr. Michaud. Also, Mr. Chairman, I'd ask that testimony from the National
Mental Health Association be entered into the record.
The Chairman. We have an entire list when I get to the end that will be
submitted. They are on the list.
Mr. Michaud. Okay. Great. Thank you, Mr. Chairman. Mrs. Pelkey, first
of all, I want to thank you for your courage and your willingness to come
before this Committee and share your experience. It is tragic what happened
to your husband, but your willingness to speak out will help many other
families who will face the challenges of caring for family members with PTSD.
Many American military families are in your debt for your testimony here
today, and for that, I want to thank you for that testimony because,
unfortunate that it happened, but I think hopefully we'll learn from it and be
able to help others.
I just have one question. In your testimony, you indicated that you would
like your husband to be recognized as a casualty of combat. Has the Army
explained to you the process by which you can petition to have your husband
acknowledged as a casualty of war?
Ms. Pelkey. The fact that it's not being recognized in his file, in his
case file, is one reason that the subject has never come up between myself or
a casualty officer. So it hasn't been discussed yet. It's something I would
like to do, because I believe that it will open the door to this being
recognized as a wound of war and for them to be recognized as casualties.
And they've already done so in recognizing one soldier that I know of.
His name is Master Sergeant Koontz from Katy, Texas. His family submitted a
petition to have him recognized as a casualty of war. He committed suicide at
Walter Reed in their outpatient -- I don't believe it was a care facility. It
was like a motel room, outpatient living quarters. And they successfully had
him put on the Casualty of War list.
They have opened the door for this to be recognized, and I would like to
have my husband also on the Casualty of War list because I truly with all my
heart believe that I have the medical evidence and just my own experiences
that he suffered from this disorder. And it will open the door further for
other soldiers to be recognized and for the illness to be taken seriously.
Mr. Michaud. Okay. But as of yet, you have not asked and they have not
offered that process to you as of yet?
Ms. Pelkey. No one has offered to explain the process. But I also have
not inquired about the process.
Mr. Michaud. Okay. Thank you.
Mr. Filner. Mr. Michaud, would you yield for a minute?
Mr. Michaud. Yes.
Mr. Filner. I do have some legislation aimed at Vietnam, that I think
could be expanded here. If you are a casualty but not from the battle itself
in Vietnam, your name can't be on the wall at the Vietnam War Memorial. And
this seems to be the same problem.
In other words, we do not recognize the heroism because of some
bureaucratic sense that, you didn't die in battle. We need to work together
to make that happen both for previous wars and for this.
Mr. Michaud. Thank you, Mr. Filner. At this time I'd yield back my time.
The Chairman. I'll be more than generous to give you time which Mr. Filner
had taken from you. All right. Ms. Herseth.
Ms. Herseth. Thank you, Mr. Chairman, and I apologize for arriving late to
hear your testimony, but I've had a chance to review your written statement
for the record, and I'd like to echo the thoughts of my colleagues here today.
The Chairman. You know what, Ms. Herseth? I apologize. You need to stand
down.
Ms. Herseth. We should defer to other of my colleagues who have been here
a while.
The Chairman. We would request that you would defer to your --
Ms. Herseth. That's what I will do. Thank you.
The Chairman. Thank you. Ms. Hooley I think is next.
Ms. Hooley. Thank you, Mr. Chair. First of all, Mrs. Pelkey, thank you so
much for taking your time to be here. Your story reminds all of us that we
need to have a comprehensive approach to addressing the mental health needs of
our men and women of the armed services.
With soldiers returning from Iraq and Afghanistan, it places a greater
burden and demand on our VA hospitals. And I know that it is incredibly
important that we have the means necessary to treat our soldiers that are
returning.
I'm from Oregon, and from our VA hospital, we have had, because of budget
freezes, we've had to reduce the number of therapists. For example, we're
about 25 percent short of needed therapists in the Portland VA hospital.
They've been asked to cut their sessions down from 50 minutes to 30 minutes.
They've been asked to have a greater length of time between sessions. It used
to be well, can you deal with this in ten sessions? Well, we all know when
you have mental health problems, some of those sessions, I mean, sometimes you
can deal with it fine, sometimes it's going to take 35 or 50, whatever it
takes is what we need to be doing.
One of the things -- because in Oregon we don't have a base, we have a lot
of soldiers returning from the military, but a lot of them are Guard and
Reserve. So one of the things we did because we knew this was going to be a
problem, and we brought everyone involved in the military together with
employers.
We brought our mental health workers together and said we need to do more
than just a debriefing when the soldiers return. We need to make sure their
families are included, and that we do this not just the first time when they
return, but we do it three months, six months, because a lot of these problems
don't come up until much later. I mean, sometimes it happens six months
later, sometimes it happens a year later.
My question is, what kind -- I mean, you talked a little bit about what
resources were available and if you wanted to get in sooner than a month, he
had to go off base. But is there now any place for a spouse to go or a soldier
that's returning to just say, hey, something's wrong here? I don't know what
it is, but something's wrong. Is there someplace you can go now?
Ms. Pelkey. Yes. And I apologize for only being able to use Fort Sill as
a resource, but --
Ms. Hooley. Right. That's what you know.
Ms. Pelkey. -- that's near and dear to my heart and they have done an
excellent job in trying to reform their program, and they have also really
started to focus on the spouses there.
I know that just recently, a group of drill sergeants that returned from
Iraq were counseled, and out of about 50 drill sergeants, 12 of those needed
referrals, as well as they had a session with just the wives of the drill
sergeants, and it was just kind of a closed, informal discussion. And that's
the way they're approaching it at Fort Sill is a comfortable setting. These
spouses all had a chance to say, you know, I feel the same way. I feel like
my husband is not here anymore, or he's disconnected. He doesn't love me. I
don't feel pretty any more. I don't feel wanted by my husband. And they
realized, hey, this is not just some kind of divorce phenomenon, it's for a
reason.
And that's the approach they're taking there. Another point I wanted to
make is that the consistency with the care providers, whether they be primary
care providers, physicians, or mental health physicians, the soldiers have
even said, I see a different person every time. I'd like to see the same
person for at least six months, for at least a year, the same person who will
be able to recall some of the things that I've spoke about, some of the
things, the deep personal things that I've shared with them.
And the armed services, they're having a problem keeping these contracted
people to stay there for that length of time. And they need to support, they
need the money to keep that consistency, to keep those providers there for up
to a year to follow up with these soldiers. And they do need a system of
checks and balances.
And there are also hotlines that have been set up where even some soldiers
can talk directly 24 hours a day to the on call mental health physician there.
And they have actually intervened 20 suicide attempts.
Ms. Hooley. That's really good news The thing that bothered me most is
that if you have to see a different person every time, it seems to me you're
telling your story over and over and over again and not making forward
progress.
Did your husband when he came back, or did you -- did they talk about
what signs to look for, for PTSD?
Ms. Pelkey. They did not talk to me as a spouse about it.
Ms. Hooley. Did they talk to him about what you need to look for? Do you
know if that happened?
Ms. Pelkey. The only counseling my husband got when he came home was like
I said, in the post-deployment health assessment, but they mostly talked about
backaches, knee pains. She made a referral to see a mental health physician,
but like I said, in Germany at that time, there was only one or two
psychiatrists for the whole community.
Ms. Hooley. How long did it take before you or your husband recognized
that this was a serious problem after he came back? Was it a week, a day, two
months?
Ms. Pelkey. Well, initially, he showed signs of anxiety, appetite loss,
but these all subsided within weeks. When we got back to the United States, it
seemed like they were almost all gone and everything was back to normal. And
six months later, everything started to surface in small increments.
The pistol, him sleeping with the pistol or carrying a loaded pistol
around lasted for, you know, one to two months until I finally thought it was
resolved. He put it in a high place in his closet. And I thought, okay,
well, that's done. Then, you know, a couple of months later, he started having
problems with his blood pressure, chest pains, erectile dysfunction, and --
thoughts. Okay, well, he has a problem with blood pressure. He got it
physically treated with blood pressure medication. The erectile dysfunction
caused marital problems.
Ms. Hooley. Right.
Ms. Pelkey. But they are also noted physical symptoms of post traumatic
stress disorder. And I truly believe with all my heart that that was the root
of our marital troubles, family problems. And as a spouse, if I had been
informed about these things and I had talked to other women or just a
counselor about these things, I think that not only would I have understood
what was going on, I would have urged my husband to get help more quickly, and
I would not have had the reactions that I did to my husband's problems.
When he would forget things, I would yell at him. I would say how can you
forget to mail a bill? You're a captain in the Army. I just don't
understand. You are not -- this is not the same person that left. But if I
thought something else was wrong with him, I would have never labeled it or
known that it was post traumatic stress disorder. And with the intimacy
issues, it's very personal, but it needs to be said. A lot of the soldiers
are suffering from intimacy issues with their wives, and I believe it's
directly related to the high divorce rate. Because that is one of the
symptoms, and it does cause problems when you are so consumed with what you
saw over there that you can't function with your wife and with your family.
Some of the soldiers have even noted that they come home and they send their
children to their rooms. They don't want to interact with their families.
The Chairman. Thank you, Ms. Hooley.
Ms. Hooley. Thank you so much for taking your time and your testimony.
The Chairman. Thank you. I now recognize Ms. Berkeley. Ma'am, she's our
Ranking Member on Disability Assistance and Memorial Affairs from the State of
Nevada.
Ms. Berkley. Thank you, Mr. Chairman. Mrs. Pelkey, I want to thank you
very much for coming here and sharing what is a very intimate tragedy with all
of us and with our country. People need to hear these things. While you were
speaking and when I read your testimony last night, I was trying to put myself
in not only your husband's place but in your place. You never know how you're
going to react to something unless you're actually thrust into the situation.
I grew up during the Vietnam War. I was in high school and college. And
so many of the kids that I went to school with that went to Vietnam came back
dramatically changed, and it seems like those that were the most quiet and the
most sensitive were the ones that were most dramatically affected by what they
saw and experienced over there, and I suspect it's very similar in Iraq right
now.
What astounds me now as a member of Congress is that knowing what
transpired in Vietnam with our veterans that returned and knowing the mental
problems that they experienced, and knowing that so many of our homeless in
this country are veterans of the Vietnam War, and I meet with my homeless
veterans quite often in Las Vegas. They're my contemporaries. And, you know,
you think if not for the grace of God. They went to war as kids, 19, 20, 21
years old, and they came back changed forever.
I would have hoped by now that we would not put such a stigma on mental
illness as to pretend it doesn't exist or to avert our eyes or don't put the
necessary resources in so that we can truly holistically treat these men and
women that are coming back and help to educate the families that are here so
they could recognize the symptoms and get help.
So it seems to me from what you were saying and from what I feel is that
we need a multi-pronged approach to this, but we need to provide resources so
we can counsel the families before their loved ones return so you know what to
expect, and then put the necessary resources in so we can hire the right
amount of professional people that deal with mental illness.
Because you are quite right. Taking care -- providing medication for
high blood pressure or providing Viagra for erectile dysfunction is just
superficially treating symptoms that aren't really going to get to the core of
the problem.
So I again want to thank you for being here and for all of your sacrifice
on behalf of this country. And let's make sure that your husband's death is
not in vain and that we help hundreds of thousands of other Americans that are
coming home and are suffering needlessly. And if there's any way that we can
help and support them, we should be in this with both feet.
So thank you very much. And perhaps if I can suggest it, I'm sure your
member of Congress already has this in the back of his mind, perhaps you can
work with him and make sure that your husband is recognized appropriately. I
think we would all be very happy when that happens for you.
Thank you very much for being here.
Ms. Pelkey. Thank you.
The Chairman. Thank you, Ms. Berkley. Congresswoman Grace Napolitano, please
come on up here and you may sit on the other side of Ms. Berkley. That's where
Mr. Udall sits. You may join us here on the dias.
She is Co-Chair of the Mental Health Caucus, and we welcome you to the
Committee. With no objection, we're pleased for you to join us.
Okay. Ms. Herseth, we've been waiting for this.
[Laughter.]
Ms. Herseth. Well, I appreciate that, Mr. Chairman. And in deferring to
my colleagues who have certainly shared with our witness today our concern,
our empathy for the situation that you face and our appreciation for your
courage and your willingness to share your experiences and how that guides
this Committee and other members of Congress.
Congresswoman Napolitano and the hard work that she's doing with many of
our colleagues with the Mental Health Caucus to eradicate the stigma that Ms.
Berkley indicated is a shame still exists. And in your written statement, you
had indicated that you sensed particularly perhaps in the military environment
on the base how that may or may not be exacerbated when one returns and what
that means for one's career and the fears that perhaps your husband had in
that regard.
So I appreciate you being here and working with us to address this issue
as a matter of sufficient resources, but also how we go about allocating
various resources in ways that are not only going to get at the heart of the
problem but help us to identify what symptoms are becoming manifest sooner so
that we can seek treatment that is going to be unique and particular to each
individual based on what he or she may be suffering.
Just a couple of questions. The first is, some military treatment
facilities are using nurses to help manage patients' care. Do you believe
that a person whose job it is to look at the whole picture of the patient's
care may have helped your primary care doctor to connect the dots of your
husband's symptoms and led to an earlier and better treatment of the PTSD
from which he suffered?
Ms. Pelkey. Yes I do. And I believe that it is of tremendous importance
for not only -- I know we've been talking about educating the families and the
spouses and the children, but something has to be done also for the medical
profession to also help them because they're overwhelmed. It's not -- it's a
lack of education too there and a lack of time and a lack of funding there
also.
They do the same thing with pregnant women on most military posts. I know
when I was in Landstuhl, Germany, I saw a different provider every time, a
different health care provider every time I was given a screening for my
pregnancy. And it's the same thing that's going on with these soldiers.
They're seeing some one different every time. They need to see one person
that's in charge of everything and that's keyed onto these physical symptoms
also.
Ms. Herseth. So your sense is that if we're addressing the issue of
turnover and the need for the continuity of care, but at the same time looking
at individuals that are providing health care to our veterans, perhaps nurses,
where we may or may not have as much turnover based on which facility the
soldier may be getting treatment, that if we at least in the short term while
we address these issues going forward more effectively that there needs to be
one person that you get to see on a more ongoing basis rather than, as you
just described, someone different each time you come in, each week, each
month, each three months, however frequently one is going to seek the care?
Ms. Pelkey. Yes. Consistency is --
Ms. Herseth. And then the last question is, when you completed your
service, were you briefed on your VA benefits and resources for your family?
Were you aware that the vet centers offer bereavement counseling, and has the
vet center in your area been of help to you and your family during your time
of grief following your loss?
Ms. Pelkey. When I exited the service of course my husband was not
deceased, but I was given a very intense briefing on my benefits. And I also
had help with my disability, with my application for disability. And, yes, I
have used the grieving services with the VA.
Ms. Herseth. I'm pleased to hear that. And, Mrs. Pelkey, thank you very
much for being here today. I yield back, Mr. Chairman.
The Chairman. Thank you very much. And I yield to Mr. Udall.
Mr. Udall. Mr. Chairman, thank you very much, and I appreciate very much
the Committee focusing on this very important issue.
Mrs. Pelkey, thank you for your testimony. Clearly, it's very difficult,
as all of us can see, for you to tell your husband's story here today. But
rest assured, I think with your courage and the courage of others and all of
you stepping forward and talking about this, I think it really makes a
difference in terms of moving the cause forward, and not only do we hear it,
but I think the word spreads to many, many others.
I was struck by what you talked about in terms of the contrast between the
military and TRICARE. And I think what I heard is that it was in TRICARE
where this was discovered and was starting to be dealt with.
And that tells me a couple of things. One is that the military were not
focusing enough, although there's very hopeful things you've talked about in
terms of Fort Sill and the involvement that's going on there. But tell me a
little bit about the TRICARE situation and what enabled them to discover what
was going on? And did you feel that they were on the right path at the time?
Ms. Pelkey. I believe the reason that my husband and I had to seek help
from TRICARE is that the military, and especially the medical facilities, are
not receiving the funding and the help that they need to make these diagnoses,
have the consistency that I've been talking about.
TRICARE offered marriage or family counseling for my husband and I. And
like I said in my testimony, we took it, because we felt at that point that
our marriage was falling apart, and we wanted to save it. And whatever you
want to call it, TRICARE sent us to an off care provider for quote/unquote
"family therapy." That's what it was coded as.
And I think that's where the problem is, is that a lot of these soldiers
are having family problems and family issues connected to post traumatic
stress disorder which you can directly link to the divorce rates and the
suicides.
But TRICARE does have off post providers, and she did immediately
recognize the symptoms of post traumatic stress disorder. I have a letter
that she's written. And I just really feel that the military medical
community is overwhelmed with not only post traumatic stress disorder, but
with everything that goes along with that; the families, the stress in the
families. I mean, so many things.
I know as a soldier myself, I could get a same-day appointment to see a
military medical doctor. But the problem is, is that with post traumatic
stress disorder, they just need some help with connecting the dots there,
some kind of system of checks and balances.
Mr. Udall. What was the time period from when he finished his service in
Iraq until the actual family therapy and you started discovering what the
problem was?
Ms. Pelkey. Well, the symptoms started arising about six months after he
came back from Iraq, and the family therapy started only one week before his
death. So it was a little over a year.
Mr. Udall. And one of the things that I think you said that was striking
about what they're doing at Fort Sill now involving group therapy and having
the soldiers talk with each other. And then the essence of that is really
them not feeling that they're alone in these kinds of mental health issues
that are coming up.
Do you think that knowing what they're doing now and kind of seeing what
is happening there at Fort Sill as a result of what they saw happen with your
husband, that if he'd had that kind of support, that might have been a much
different situation for him? That if they had spotted it early and given him
the opportunity to visit with other soldiers and have a chance to share the
things that he was feeling inside, do you think there would have been a
different outcome?
Ms. Pelkey. I feel like there would have been a different outcome, because
like I said, I think the soldiers that have served in Iraq in Operation
Enduring Freedom, they have a comfort level amongst each other that is unlike
being in front of a counselor, or unlike discussing it with your spouse who
has no connection. I mean, even though I was an Army captain myself, I hadn't
been to Iraq. So the comfort level still wasn't there between my husband and
I.
And what they've done at Fort Sill is provide a comfortable environment.
I don't even know if this matters, but they've provided, you know, comfortable
furniture, just kind of like a living room environment for these soldiers to
sit down and share their thoughts on it. And there's a moderator for this in
which afterwards the soldiers, after they feel comfortable, can come up to
that provider and ask for a referral, and that's how they're identifying most
of the patients there is in these group therapy sessions that are being
moderated. And then afterwards, they all stand in line and, you know, take a
questionnaire.
But I do feel like this can be brought on on a bigger scale. I mean, a
facility to deal with post traumatic stress disorder in the same kind of
comfortable environment. I can see it on a bigger scale.
Mr. Udall. Mrs. Pelkey, thank you very much for your testimony, and we
really appreciate you stepping forward on behalf of all veterans that are in a
similar situation. Thank you.
Ms. Pelkey. Thank you.
The Chairman. I thank the gentleman for his contribution. I ask unanimous
consent from the members that Grace Napolitano of California, not a member of
the Committee, would be recognized at end of all members of the Committee
having asked questions, and if she would like to ask any questions, she would
be recognized at this moment.
Mrs. Napolitano. Thank you, Mr. Chair, and yes, I would.
The Chairman. Hearing no objection, so ordered. You are now recognized.
Mrs. Napolitano. Thank you, Mr. Chair, and thank you to the members. I'm
very interested in the issue of PTSD for a number of reasons.
It has been something that has been a long-standing issue with city
members of councils throughout the United States, simply because a lot of our
soldiers from previous wars have not been able to deal with the issue of PTSD
and end up being homeless, and therefore being found under freeway overpasses
and in many areas of, especially cities like Los Angeles, where everybody
thinks they're just crazy, and there's no way that anybody has been able to
address the problem, wrap their arms around it, and be able to really identify
what has happened to the individuals who have had a long-standing, 20, 30
years of dealing with mental health issues.
That said, I have been to both Bethesda and Walter Reed and have visited
with some of soldiers that have returned with disabilities and asked the
surgeons in charge whether or not they provide mental health services to the
people they're treating. The answer is yes, very, very good services. They
also have on the third floor the ability to have drop-in, day care, if you
will, or big clinics rather.
My concern has been that only those that are identified or self-identified
get help. Others go home thinking they can deal with it, that it is something
that they can withstand, and eventually it begins to rear its ugly head. Just
recently I was traveling to Washington, sitting in an airport next to an
individual who wore a pin that I recognized, and we got into a conversation.
And he indicated to me, because he asked me what Committees I sat on and
what I was doing in Washington, and I indicated I was co-chair of the Mental
Health Caucus, and he told me a story that kind of set me back, and that was
that he was a Vietnam veteran and had 17 jobs in 20 years. Something is
wrong, that we are not helping our soldiers be able to cope with it.
And, besides that, the most important thing, if a soldier is going home
to a family, how is that family going to learn how to identify? You're a
captain. You were able to understand because at least you've served with part
of it, or you've been exposed to it. What about the families that have not?
Those that take irrational behavior as something they can no longer tolerate.
And so then that individual either gets thrown out, or the family moves away,
and they are left to their own devices.
I have had individual VFW groups approach me that now they're seeing
soldiers returning, needing help and asking them for help at the VFW and
American Legion posts.
We are not dealing with it. And my concern has been that we need to not
only deal with the actual service to the service individual, but also their
family so that they can have a strong support system that can recognize and be
able to refer them to adequate assistance, whether through the VA or a local,
like a TRICARE, especially if the wife has additional insurance.
Notwithstanding the fact that our medical institutions do not train doctors to
recognize depression and areas that need to be recognized at any level,
whether it's a soldier or an individual who has suffered trauma, which also is
classified as PTSD.
So I'm thankful that you're here, and I'm sorry -- thank you, Mr. Chair.
It's of grave importance to all of us. And I think that we need to stress the
need to expand beyond that scope of service that we are now rendering our
servicepeople. And I thank you so very much for being here and for being so
open about your testimony.
Thank you, Mr. Chair.
The Chairman. I thank the gentlewoman for her contribution. I'd like to
thank you for coming. And before you leave, would you please introduce the
lady who is accompanying you to your right?
Ms. Pelkey. This is my dear friend, Sherry Forbish, who is actually the
moderator of my grief group through my church in my home town, and she's been
a tremendous support to me as well as my Christian church community. And
she's a wonderful friend.
The Chairman. At any time did you ever turn to the chaplaincy corps of the
Army?
Ms. Pelkey. Yes. We did receive or go for marriage counseling twice to a
chaplain. However, I do want to say that he was a family friend. So some of
the things we were sharing with him were, you know, on a very personal level
and just more personal than we would have been with just a counselor I think.
The Chairman. People know their boundaries, right?
Ms. Pelkey. Yes.
The Chairman. Whether it's the chaplaincy, whether it's therapists,
whether it's psychiatry, whether it's an MD or internal medicine, everybody
knows their boundaries, but they also then do referrals, right? When they
know it presses the bounds, then they do that referral. But did referrals
occur here from the chaplaincy?
Ms. Pelkey. No. We again saw him for two sessions, and there of course
were other things discussed.
The Chairman. Right.
Ms. Pelkey. And I think it's a good point too that the chaplains need to be
educated on this, because a lot of soldiers do feel very comfortable with
turning to the chaplains. But you also have to remember that chaplains are few
and far between, and they're very short-handed on chaplains also.
The Chairman. The point is, there are many different entries.
Ms. Pelkey. Yes.
The Chairman. Let me conclude with this, ma'am. You have within your rights
to make an appeal through the Surgeon General of the Army with regard to your
husband's case, and you have a very able and compassionate Member of Congress
there to your left who can also be of assistance to you in that appellate right.
And I would encourage you to do that.
Mr. Filner. Mr. Chairman?
The Chairman. Mr. Filner.
Mr. Filner. I just want to follow up on that if I may.
The Chairman. Sure.
Mr. Filner. Have you met with the Secretary of VA or Secretary of Defense,
or have you requested that?
Ms. Pelkey. No sir, I haven't.
Mr. Filner. Mr. Chairman, I think this Committee should work with Mrs.
Pelkey to try to get those appointments. I think it would be very helpful. As
you saw, she's an incredible source of knowledge and compassion. And I would
hope that we could help her get those appointments.
I thank you for yielding.
The Chairman. If I may finish, ma'am, I would encourage you to work with
your congressman, who understands this process. You are here as a witness of
this Committee. We will work with him. You do not need an appointment with
the Secretary of Defense or with the Secretary of the Army. There are
processes for this to occur, and we will work with you to do that.
I think what would be helpful here also is if I invite you to stay,
because we have two more panels that are going to testify, and we're going to
hear from the Army. We're going to also hear from experts. And I'd like for
you to listen to what they have to say, and then I'd like to come back and
speak with you afterwards about your thoughts on what you hear. Will you be
helpful to us in that fashion?
Ms. Pelkey. Yes. I would be proud to.
The Chairman. All right. Thank you very much. We appreciate your
testimony.
Ms. Pelkey. Thank you.
The Chairman. Thank you. You are now excused.
The second panel would please come forward. And when they step up from
their seats, ma'am, you can occupy one of theirs. First is Colonel Charles W.
Hoge, M.D., who currently directs collaborative research programs to enhance
resiliency and reduce the impact of mental disorders among soldiers and their
family members. He directs the WRAIR Land Combat Study designed to assess the
mental health impact of Operation Iraqi Freedom (OIF) and Operation Enduring
Freedom (OEF), and identify new prevention and intervention strategies.
Next we will hear from Colonel Charles C. Engel, Jr., M.D., MPH. He is
the Assistant Chair of the Department of Psychiatry at the Uniformed Services
University and the Director of the Department of Defense Deployment Health
Clinical Center at Walter Reed in Washington, D.C. He was the 1st Cav
Division Psychiatrist during the 1991 Gulf War and since then has served as a
DOD medical adviser on post-war physical and mental health, particularly as
it relates to post-war idiopathic physical symptoms, physical health concerns,
and the improvement of post-deployment clinical services.
We'll then hear from Matthew J. Friedman, M.D., Ph.D. He is the Executive
Director of the U.S. Department of Veterans' Affairs National Center for Post-
Traumatic Stress Disorder, and Professor of Psychiatry and Pharmacology at
Dartmouth Medical School. He has worked with PTSD patients as a clinician and
researcher for 30 years, and has published extensively on stress and PTSD,
biological psychiatry, psychopharmacology, and clinical outcome studies on
depression, anxiety, schizophrenia, and chemical dependency.
We'll then hear from Alfonso R. Batres, a Ph.D. MSSW. He is the Chief
Officer of the Department of Veterans' Affairs Readjustment Counseling
Service. He has direct oversight of the 206 Vet Centers providing
readjustment counseling service to war zone veterans nationally. He is
recognized as a national and international leader in pioneering the
development and provision of services for veterans with combat-related trauma.
Dr. Batres serves on the VA's National Leadership board and is currently
extensively working in the VA's response to the needs of returning combat
veterans of Iraq, Afghanistan and the Global War on Terrorism.
We'll then hear from Terence M. Keane, Ph.D. Dr. Keane is a Professor and
Vice Chairman of Research and Psychiatry at Boston University of Medicine. He
is also the Chief of Psychology and Director of the National Center for PTSD
at the VA Boston Healthcare System. The past President of the International
Society for Traumatic Stress Studies, Dr. Keane has published three books and
over 140 articles on the assessment and treatment of PTSD. His contributions
to the field have been recognized by many honors, and we appreciate you being
here today.
At this point, I will now yield to Dr. Hoge. You are recognized.
STATEMENTS OF COLONEL CHARLES W. HOGE, M.D., CHIEF
OF PSYCHIATRY AND BEHAVIOR SCIENCES, DIVISION
OF NEUROSCIENCES, WALTER REED ARMY INSTITUTE
RESEARCH, UNITED STATES ARMY; ACCOMPANIED BY
LTC CHARLES C. ENGEL, JR., M.D., MPH, CHIEF, DOD
DEPLOYMENT HEALTH CLINICAL CENTER, WALTER REED
ARMY MEDICAL CENTER, UNITED STATES ARMY;
MATTHEW J. FRIEDMAN, M.D., PH.D., EXECUTIVE
DIRECTOR, NATIONAL CENTER FOR POST-TRAUMATIC
STRESS DISORDER, DEPARTMENT OF VETERANS' AF-
FAIRS; ALFONSO R. BATES, PH.D., MSSW, CHIEF, OFFICE
OF READJUSTMENT COUNSELING, DEPARTMENT OF VET-
ERANS' AFFAIRS; AND TERENCE M. KEANE, PH.D., PRESI-
DENT, ASSOCIATION OF VA PSYCHOLOGIST LEADERS, VA
BOSTON HEALTH CARE SYSTEM
STATEMENT OF DR. CHARLES W. HOGE
Dr. Hoge. Thank you, Mr. Chairman, and members of the Committee. It's a
great honor --
The Chairman. If you could pull the mic closer to you and turn it on.
Thank you.
Dr. Hoge. It's a great honor to be here and I thank you for the
opportunity to discuss the Army's research on PTSD and other mental health
issues associated with deployments to Iraq and Afghanistan.
I'm also grateful for the opportunity that I had to be here for the moving
testimony of Mrs. Pelkey and the subsequent questions from the Committee.
I'm Colonel Hoge. I'm Chief of Psychiatry and Neurosciences at Walter
Reed Army Institute of Research. The Army and Department of Defense have
taken a proactive approach to understanding and mitigating the mental health
concerns associated with deployments to Iraq and Afghanistan. We've made it a
priority to learn as much as possible and adjust programs as the war is
ongoing to meet the needs of our service members and their family members.
And your interest in this matter along with previous support from Congress has
greatly enhanced the body of scientific knowledge.
Mental health symptoms are common and expected reactions to combat, an the
research following other military conflicts has demonstrated that combat
exposure confers considerable risk of mental health problems, to include PTSD,
major depression, substance abuse and social, family, and occupational
problems, as we've heard previously.
However, virtually all studies that have assessed the mental health
effects of prior combat in prior wars, including the first Gulf War, we
conducted years after soldiers returned from the combat zone. To address
these concerns, a team of Walter Reed Army Institute of Research, which I'm
privileged to lead, initiated a large study in January 2003 with support from
senior Army medical and line leaders and Marine line leaders as well, to
assess the impact of current military operations on the health and well being
of soldiers and their family members.
This study is ongoing, and we have collected over 20,000 surveys to date
from soldiers from multiple brigade combat teams deploying to Iraq and
Afghanistan, both active component and National Guard, as well as personnel
from Marine Expeditionary Forces.
We have conducted assessments now out to 12 months after returning from
deployment. We've published results of our initial findings from three months
post-deployment in July of 2004. We have also conducted similar assessments
in theater as part of the mental health advisory team efforts.
Our studies confirm the importance of PTSD and other mental health
concerns associated particularly with deployments to Iraq. Overall, based on
our latest findings, 15 to 17 percent of service members surveyed three to
twelve months post-deployment met the screening criteria for post traumatic
stress disorder, and 19 to 21 percent met criteria for depression, PTSD and
anxiety. In parallel with our survey-based data, there has also been a
substantial increase in military health care utilization and use of military
heath services in military treatment facilities among our OIF veterans.
Alcohol misuse, which is strongly associated with PTSD, also has increased
post-deployment. Other outcomes that we're looking at include aggression in
family functioning, and preliminary data indicates that there are likely
deployment-related effects in these areas similar to what previous studies
have shown. The strain of repeated deployments on soldier and family well
being is evident in some units anecdotally.
One of the most important findings of our research is what we've learned
about barriers to care in the military, particularly stigma. Our studies
showed that soldier and marines are not very likely to seek professional help
if they have a mental health problem, and they are concerned that they may be
somehow treated differently if they do. Our data has helped us to focus on
approaches to facilitate access to care.
We're conducting a number of ongoing research projects to improve
identification and intervention, reduce stigma and barriers, and our primary
focus really is on improving access to care. And we're also attempting to
evaluate programs that are being implemented, such as the Department of
Defense post-deployment health assessments.
Our research has shown that soldiers are much more likely to report their
mental health problems three to four months or subsequently after coming home
than immediately on their return. And as a result, DOD has expanded the post-
deployment health assessment program to include a survey now at three to six
months post-deployment. We are also evaluating interventions such as
psychological group debriefings, and we're developing standardized training
modules for soldiers, leaders, and health care providers.
Considerations for improving assess to care include co-locating mental
health services in primary care clinics. And we heard this morning discussion
about the fact that soldiers, virtually all soldiers access primary care, and
this is obviously one portal for soldiers to get help.
We want to improve awareness among primary care professionals of
depression, PTSD evaluation and treatment, and it's important to ensure that
there's adequate resources to support continued services in the operational
setting in Iraq and Afghanistan as well as to ensure that service members who
are identified through our screening programs or who refer themselves receive
timely evaluation and treatment.
One of the most important aspects of our work is to provider the best
interventions within the medical model of care while conveying the message to
our service members that many of the reactions that they experience after
combat are common and expected. Helping to normalize these reactions is a
key to stigma reduction and early intervention.
Thank you very much.
[The statement of Dr. Charles W. Hoge appears on p. 84]
The Chairman. Thank you very much for your testimony. Colonel Engel, you
are now recognized.
STATEMENT OF DR. CHARLES C. ENGEL
Dr. Engel. Mr. Chairman, members of the Committee, I appreciate the
opportunity to appear before you today and discuss the ways that the
Departments of Defense and Army are working proactively to identify and help
military personnel with mental illness after service in Iraq and Afghanistan.
We appreciate Congress's interest in this topic and this Committee's
consistent support of DOD and VA mental health.
I have three main points. First is the need to bring safe, accessible and
confidential care to service members rather than waiting for them to seek
care. Second, primary care affords an excellent opportunity for early
recognition and care. And third, many DOD efforts are currently underway to
reach out to providers, service members, families, the severely ill and
wounded.
I am privileged to direct a unique DOD center of health care excellence
called the Deployment Health Clinical Center. We began caring for Gulf War
veterans in 1994 at Walter Reed. In 1999, we were designated the Deployment
Health Clinical Center, and our mission expanded to include provision and
improvement of tri-service post-deployment medical care.
We have provided care for over 15,000 service members with health concerns
following service in various deployments, including Iraq and Afghanistan. We
have helped those with both physical and mental wounds. Colonel Hoge tells us
mental illness occurs to one in four of those returning from Iraq, with rates
rising.
A study of injured soldiers evacuated through Walter Reed led by CPT Tom
Grieger, Colonel Steve Cozza, shows that about half of those with initial PTSD
and depression quickly improve, but overall, rates rise two- or three-fold in
the next few months.
What should we do abut this? First, we must provide, safe, confidential
and continuous care. We cannot diagnose mental illness simply by looking,
and there are no laboratory tests. We must build trust so service members
offer frank accounts of their mental state and we can do accurate screening
and provide proper care. Without protection from adverse career actions,
mental illness is driven underground. Soldiers keep problems private until
they balloon out of control, and we miss opportunities to prevent tragedies
and threats to mission success.
Second, Colonel Hoge's data reinforced civilian findings that most people
with trauma-related mental illness don't receive care. Misconception, stigma
and local barriers to care are prevalent. These data compel is to bring
services to soldiers rather than waiting for them to seek it.
Third, mental illness occurs on a spectrum of severity, and we must
provide care to the whole spectrum. A mild definition of PTSD yields rates of
pre-war PTSD of nearly 25 percent, and post-war rates over 50 percent. This
tells us that many are distressed after war, and most distressed is not
severe. Only 5 to 10 percent of military personnel seek specialty mental
health care every year, but over 90 percent use primary care. The impact
will be great if we improve the mental health of those getting primary care.
Deployment Health Clinical Center has partnered with the MacArthur
Foundation, Dartmouth, Durham VA, and Indiana University in a Fort Bragg
Primary Care Improvement Initiative. The goal is successful implementation of
VA-DOD mental health guidelines. The program is called "RESPeCT-MIL" and
builds on a scientifically tested approach for depression developed by Allen
Dietrich at Dartmouth. Use of RESPeCT-MIL improves continuity, maximizes
existing primary care resources, and frees mental health providers to practice
specialty care. We look for broader implementation and evaluation in the
future.
Many with PTSD may benefit from psychosocial approaches offered in primary
care. Our investigators have collaborated with Brett Litz of the Boston VA
and the National Center for Post Traumatic Stress Disorder, Richard Bryant in
Australia to develop an NIH-funded computer-assisted therapy tool called
DESTRESS. DESTRESS offers anonymity and a scientifically valid approach that
primary care doctors can prescribe to patients in need. Many will obtain
relief, and for others, DESTRESS may reduce stigma.
We are also pushing information to clinicians through the Deployment
Health Clinical Centers pdhealth.mil website and Uniformed Services
University's Courage to Care program. pdhealth.mil gets over 700,000 hits a
month. Thirteen hundred providers receive our daily science and news e-mail
digest, and we have distributed 10,000 deployment health tool boxes to primary
care providers across the services. We also run toll free telephone and
e-mail help line for providers, service members and families.
Providing care for the severely wounded and ill is a fulfillment of a
scared trust, the promise every combat medic makes to assist injured comrades.
Walter Reed's Psychiatry Consultation Service led by Hal Wain follows ever
wounded soldier. Deployment Health Clinical Center serves as a worldwide
referral center for severe post-deployment illness. We have run nearly 120
cycles of two different specialized care programs, one for unexplained illness
and another for PTSD.
We published the unexplained illness approach in JAMA, the Journal of the
American Medical Association, after a 20-site VA cooperative studies program
study.
Mr. Chairman and members of the Committee, I hope I have communicated my
three main points. First, we must bring safe and confidential mental health
care to service members rather than waiting for them to seek it. Second,
primary care is an excellent opportunity for doing just that. And third, many
DOD efforts are underway to reach providers, service members, families, the
severely ill and the wounded.
The Deployment Health Clinical Center and its devoted staff are privileged
to assist the inspiring men and women who serve our nation. We owe our
success to an unwavering support from Congress, DOD, Uniformed Services
University and the Army Medical Department. Thank you for allowing me to
appear before you today. I would be pleased to respond to any questions from
members of the Committee.
[The statement of Dr. Charles Engel appears on p. 91]
The Chairman. Thank you very much for your testimony. I now recognize Dr.
Friedman.
STATEMENT OF DR. MATTHEW J. FRIEDMAN
Dr. Friedman. Mr. Chairman, distinguished members of the Committee, I am
Matthew Friedman. I am the Executive Director of VA's National Center for
PTSD, Professor of Psychiatry, Pharmacology and Toxicology at Dartmouth
Medical School.
I've been a VA psychiatrist for over 30 years and spent much of that time
treating men and women who have developed PTSD and other problems as a result
of their service in combat areas.
I've been asked to comment on the PTSD syndrome itself, and I've submitted
extensive information about that in my written testimony which I will not
cover in my oral comments.
I would like to emphasize, however, as have the previous speakers, that
most people who return from a combat zone do not have psychiatric or
psychological problems. A large number of them who do, have transient
problems, adjustment disorders, from which they recover quite quickly. But
there is a significant minority, an important minority, who will develop
recurring and sometimes totally incapacitating psychiatric problems, of which
PTSD is the most symptomatic.
I've been asked to comment about the comparisons between the current
situation and the post-Vietnam era in which I cut my teeth as a clinician.
And I think the news is good. I want to emphasize two points in particular.
First of all, when our men and women returned from Vietnam, they returned to
a hostile public, a public that did not reward or recognize their courage.
That's not the case today, and I think it's very important. We know that
social support is a key factor in whether or not people are going to
readjust successfully after their combat experiences. Hopefully it is a
very good sign that we're having these hearings today which may help our
returnees from the OIF and OEF deployments.
The second news is also good, and that is that there has been a great deal
of scientific progress in the past 30 years. When we were first faced with
the Vietnam veterans, we didn't have any evidence-based treatments. We didn't
really know what to do for them. It was really a bootstrap,
seat-of-your-pants type of an operation. Now we have medications that work,
two of which have FDA approval. We have psychosocial treatments that are
very, very effective.
Last year there was a joint VA-DOD practice guideline process to develop
state-of-the-art, evidenced-based treatments for PTSD. And now the VA has
made an institutional commitment to support that effort through a best
practices project through which PTSD will be the pilot project to disseminate
this information so all VA clinicians can provide the best care for people
who come into our offices.
The problem is, will they come? Will the stigma that Dr. Hoge's research
has indicated keep them away? Will they know, as Mrs. Pelkey did not know,
what's available, what the signs of PTSD are, what kinds of services are
available should they recognize a treatable problem among a loved one or
within themselves? I think that the challenge of dissemination of
information to families and to servicemen and to veterans is a great one and
a very, very important one.
Unlike our DOD colleagues, we VA clinicians do not have a mandate to
provide direct services to families. I think that's a disadvantage, with the
glaring exception -- or the wonderful exception of the Vet Centers that Dr.
Batres will comment on, we clinicians can only see families as adjunctive to
treatment of our veterans. I think that were our mandate changed and there
were appropriate resources to serve that mandate, we could do a much better
job and perhaps prevent some of the problems that might otherwise develop.
In addition to my concern about stigma, I'm worried about the Guard and
reserves. And I've commented on that in two "New England Journal of Medicine"
editorials. They really fall into the cracks. Will they recognize what's
available in the VA hospitals? Will they know about their eligibility? I
don't know. I think we need to make every effort to inform them. To get the
word out.
Other concerns are military sexual trauma, which is even more toxic than
combat trauma, in terms of producing PTSD. I'm concerned about the men and
women returning from these deployments, who will have severe medical problems.
A loss of limbs, loss of eyesight. Other kinds of persistent problems.
They're a very high risk for PTSD, and we need to be able to monitor and
provide the best treatment that we can.
We need to recognize that we have a new, young cohort of people seeking
our treatment, with fresh trauma problems, and we need to be able to provide
the best services. In short, the VA has the best expertise, the most
sophisticated clinicians, the best spectrum of treatment in the world. We
need to make sure, and cherish what has been accomplished, and have our
services available, so that we can help those who seek our help.
My final comments, which I'll run through quickly, concern collaborations
between the National Center and the DOD. You've heard about three of them.
We've been working with Colonel Hoge, in terms of the de-briefing study which
was done in Kosovo and which will be repeated with OIF/OEF troops. We're
working with Dr. Engel on the Web-based treatment at Walter Reed, as well as
the pilot project at Fort Bragg, integrating primary care and mental health
care, which, I think, had it been accomplished, might have helped Mrs. Pelkey
and her husband.
We're looking at doing brain imaging, with troops from Fort Drum, as well
as drug studies. We're doing a major post-deployment study of 17,000 troops.
And so, I would like to close by just thanking the Committee for its attention
and concern, and thanking all the support that we've received from VA and DOD.
Thank you.
[The statement of Matthew J. Friedman appears on p. 103]
The Chairman. I thank the gentleman for his testimony. And could we pause
to ask Colonel Hoge, Colonel Engel, Dr. Friedman, Dr. Batres, Dr. Keane -- do
each of you have written testimony? And would each of the witnesses like that
to be submitted for the record? All witnesses have answered in the
affirmative.
Hearing no objection, it will be so ordered.
We'll now recognize Dr. Batres.
STATEMENT OF DR. ALFONSO R. BATRES
Dr. Batres. Thank you, Mr. Chairman and Committee members, for the
opportunity to present on services provided by the program that I am
privileged to head, to returning veterans from Operation Enduring and Iraqi
Freedom.
I just wanted to add a few brief points to the comments I submitted to the
Committee with my written testimony. The VA program that I represent, was
initiated by Congress 25 years ago, to address readjustment challenges in
Vietnam combat veterans. Matt Friedman, to my right, was one of the field
docs who actually was instrumental in putting up one of very first Vet
Centers, at that time.
The Vet Center is the first of its kind, and represents the foundation
from which VA became the world leader in providing these services to war
veterans. The Congress subsequently extended these services to all our combat
veterans and their families. Therefore, any veteran who served in a combat
zone, is eligible. Not unusual to find a World War II veteran alongside with
a Korean War veteran, and now, an Iraqi Freedom veteran, at our Vet Centers.
The heart of our program is veterans and their families. The 207 Vet
Centers dispersed nation-wide are staffed, primarily, by veterans, many of
whom have served in a combat zone, and who understand the culture of the
military, and the sacrifices that service members make to this country.
On a personal note, I want to put into the record that my dad was a World
War II veteran, as well as his five brothers. They all served in World War
II. I am a Vietnam combat veteran, and I have a son who served in the Persian
Gulf, with the 82nd Airborne. I am typical of the employees in the Vet Center
program.
The Vet Center program is a VA gold standard in veteran and family
satisfaction. 99 percent of our clients and families not only rate us highly,
but they would recommend us to other veterans. We are also the gold standard
in VA, for employee satisfaction. We are located in easy-to-access locations
within their community, and we have minimal bureaucratic barriers to accessing
care.
A veteran will be seen when they walk in -- we have no waiting list --
along with their families. The program laid the foundation for outreach
services to combat veterans in our great country, characterized by a focus on
providing a safe, confidential environment, where veterans who have been
traumatized, or have gone through experiences, can come in, and receive timely
and friendly services.
In Fiscal Year 2003, with a few months of war under our belts, we saw
about 1,900 OEF/OIF veterans. In Fiscal Year 2004, we saw over 9,600. And
for this year, we're projecting over 14,000 new OEF/OIF veterans walking
through our Vet Centers. They currently represent about 10 percent of our
client workload.
We do not include in this count, the growing number of veterans and their
families, to whom we provide education, de-briefing, and outreach services to
beam-up sites, and National Guard and Reserve locations all over this country.
In order to get a better handle on that, we just did a survey for the month of
June in this Fiscal Year, in which we documented 5,000 servicemen and women in
that particular month, who received services in that category.
Included in that are family members of National Guard and Reserve folks,
who have deployed, but are currently not eligible for VA services, because
their family member is an active military member. We are reaching a fair
amount of these veterans, but I have to honestly say that we have a lot of
work to do, in making sure that we are providing comprehensiveness to all
these veterans.
The Secretary of VA, and my bosses, Dr. Kussman and Dr. Pearlin,
authorized the hiring of 50 veterans from Operation Enduring Freedom and Iraqi
Freedom, to become outreach workers for my program, approximately a year ago.
Again, these are recently-returned combat veterans, many of them disabled, who
have recently returned from their tours in Iraq and Afghanistan.
The initial 50 program proved so successful, that the underSecretary has
authorized an addition 50 FTEE positions for this year. These veteran
employees continue the program emphasis -- our program emphasis on hiring
veterans into the VA.
As you have read in my written testimony, we have initiated a bereavement
program for family members of those who died while on active duty. In
coordination and referral from DOD casualty assistance officers, we have
provided services to well over 400 families in the last year and a half. The
majority -- over 300 of them -- coming from KIAs in Iraq.
Our standard is to offer services directly to the family, within two days
of the notification, in the community in which they reside. We will be
conducting an analysis of our year-and-a-half worth of work with DOD, to see
if we can improve on our services, and get feedback from our consumers, about
how we can move to improve these types of services.
We are very cost effective in that. As a rough benchmark, the VA reported
OEF/OIF veterans who have been seen for comparable mental health services
within the VA. Our numbers are about 50 percent of those that have been seen.
It's not including in the ones we provide outreach services to.
The Vet Centers continue to provide a unique service, that is integrated
with traditional mental health services, and adds value to serving veterans
and their families. I don't want to confuse what we do, with what the VA
medical centers do. We only provide one component of the services, primarily
focused on outreach, assessment, and treatment of veterans who are closer to
home, and may not require the extensive services that VA offers.
The DOD concepts of having mental health services available to soldiers
while in the combat area, represent a major investment in dealing with the
social and psychological psycholi of combat service. The study by Colonel
Hoge, and the work done by Dr. Engel -- Colonel Engel -- are really
instrumental in providing a continuum of care for the soldiers.
The soldiers are going to face a transition, where when you blink, you go
from a very supportive community environment, back into civilian life. And I
think they need all the assistance that we can provide to them, to make that
step into civilian life. And to keep them healthy, and connected. And quite
frankly, to provide a varied assortment of service, to include employment
issues. Benefit kinds of things, that is critical, not only to the soldier,
but to their family, in an integrated fashion.
Yesterday, I heard a presentation by the surgeon general of the Navy, I
believe VADM Arnold, who described their Marine Corps OSCAR teams, and how
they operate. Along with the Army combat stress teams, I think the Marine
Corps has done an exceptional job -- both of them have -- in developing these
types of interventions within the combat zone.
The OSCAR teams are embedded in their unit, and are not a separate
component, or a medical unit, therefore, promoting an integration into the
Marine Corps unit, for functioning. This is an exact model of how Vet Centers
operate. We are embedded in your local communities, and geographically
located outside of VA medical centers.
This goes a long way to avoid the stigma of accessing care, and promotes
the normalization of issues that will arise in most of our veterans, that
being the recognition that serving in a combat zone presents challenges to any
soldier. And that the integration of these types of services, as has been
indicated before, is really critical. Thank you.
[The statement of Alfonso Batres appears on p. 111]
The Chairman. Dr. Batres, on behalf of this Committee, let me extend an
appreciation to your family, for their service to their country, not only
including your uncles and your father, but yourself and your son.
Mr. Batres. Thank you, sir.
The Chairman. Dr. Keane, you're now recognized.
STATEMENT OF TERENCE M. KEANE
Dr. Keane. Thank you, Mr. Chairman. And thank you, too, members of the
Committee, for permitting me to testify here today, with my distinguished
colleagues. Today, I am representing the Association of VA Psychologist
Leaders. And while I've spent some 28 years in the Department of Veterans'
Affairs, in three different VA medical centers, as chief of psychology, my
comments today represent that group of VA psychology leaders.
The VA represents the best in mental health systems in the world. This
has been touted in both the "New England Journal of Medicine," as well as in
the "Lancet" in the past two years. With expertise in post-traumatic stress
disorder, schizophrenia, the neuro sciences, geropsychiatry, and substance
abuse, we address the full range and spectrum of combat-related psychological
problems.
With reference to today's hearings, I do want to say that as a professor
and faculty member at Boston University, one of the largest health care
systems in the City of Boston, there is not a single expert in the area of
post traumatic stress disorder on faculty. Not one. It would seem hard for
me to fathom how private-sector resources could be marshalled to provide the
kinds of care that's provided by VA, in the Vet Center program, and in the
many different installations across the country.
I do want to comment, for a moment, about the VA's leadership role in the
President's New Freedom Commission. The VA has established an outstanding
action agenda. And with the current administration, there is tremendous
support for moving forward, and implementing many of the ideas represented,
and creatively developed, by the VA mental health care employees.
There are many examples of VA's tremendous support for the returning OEF
and OIF veterans. But there are also some important issues for us to discuss
here today. Our group -- and that is the AVAPL VA psychologist leaders --
fully supports the notion of a fully-resourced President's New Freedom
Commission agenda. These resources should be implemented. They should be
evaluated, they should be monitored.
And the question that remains for us, is how will these resources, and a
system that is strained for resources -- how will these resources be
protected, to ensure that they deliver the kind of care that is intended?
With the growing numbers of mental health needs, we also, in VA, need to
employ the most contemporary, the most creative methods of delivery of
services.
This will require that our aging workforce be re-tooled, and re-trained,
with a major educational initiative. And what direction should this take?
This should be training in the use of tele-health, already one of Dr.
Pearlin's major initiatives. This should be directed in the area of mental
health, so that services can be provided. As well, Web-based interventions
should be prioritized, so that patients can get needed education, and needed
support, when and where they need it.
We have information that the availability of Internet is quite strong,
among younger generations, and we should make use of this resource for the
delivery of whatever services are viable in that modality. As well, continued
collaborations with the Department of Defense, in integrating care and
conducting research on these newest veterans, needs to continue to be the
highest priority.
Our organization also supports, as many of my colleagues have already
stated, the changes in eligibility that have already been made, and would like
to see increased eligibility, again, for families, for spouses, for partners,
affected by activation, deployment, injury, of death. As well, we support the
completion of the National Vietnam Veterans' Longitudinal Study.
We support the completion of this study, not only for what it will tell us
about Vietnam veterans, the largest cohort of veterans that exists in VA
today, but as well, what it will tell us about the current group of the newest
veterans. Our group also supports an increase in the research budget that's
allocated to study mental health and behavioral health problems.
It is, indeed, the case, that the behavioral science, the mental health
research workforce, is graying in VA. There needs to be a concerted effort to
support junior people, to study the problems associated with military service,
and combat trauma. But as well, and perhaps, most importantly, from my
perspective, behavioral health services, psychiatric and psychological, need
to be paired with physical rehabilitation, in order to maximize and optimize
the outcome.
VA is one of the world's leaders in the area of physical rehabilitation.
We suggest that combining mental health services, at significant levels, with
the outstanding physical rehabilitation, will yield the best possible outcomes
for the people who are so injured. There are many other recommendations
reflected in my written report. I'd be happy to answer any questions, and
thank you all for the opportunity to speak with you here today.
[The statement of Terence Keane appears on p. 118]
The Chairman. Thank you very much for your testimony. I would like to
exercise a cautionary counsel to my colleagues, with regard to Mrs. Pelkey's
testimony from the first panel. Only she has the right to privacy, and if she
waived the right to privacy, with regard to her comments regarding her
husband's case, we now know that she has an interest in filing an appeal with
the surgeon general of the Army.
So, I would exercise caution, and I think it would be inappropriate to ask
any of the experts on this panel or the next panel to comment directly upon
her husband's case. But obviously, process and procedures are open. And that
would be my counsel to my colleagues.
Where do new doctors turn in the private sector, and in military settings,
to gain awareness and then develop an expertise with regard to how to deal
with PTSD? Because it's not just those who serve in the military. You're also
dealing with police officers, after gun battles. You're dealing with
firefighters. You know, the first responders in our society.
We also have teams that will arrive upon the scenes of tornadoes,
hurricanes, and traumatic events. So, how are we doing as a country, and where
is this really being generated? I'll just open it up. Anybody that would
like to comment.
Dr. Keane. I'll begin. I'm sure there'll be others who will speak. It is
a major initiative of ours at the National Center for PTSD, to try to
influence the education and training programs, in both psychiatry residency
training programs, as well as in psychology. Clinical psychology training
programs.
We have engaged in this initiative for the full 16 years, that we've been
involved in this work. We've been supported by the National Institute of
Mental Health, in providing education and training, at the most advanced
levels, for some 12 years, now. And it's through these mechanisms, that we
have actually conducted, I think, significant education and training, both in
our own institutions, but as well, in a variety of different places across the
country.
It is solving a problem -- given that PTSD's really only widely recognized
since 1980, it's been solving a problem for this country, that has taken some
of our time. How do you create and generate a whole cadre -- a whole cohort
of people, who can take care of people who have been sexually assaulted? Or
the other kinds of events that you've mentioned?
It has not been easy to do this. There are not experts at every medical
school in the country. There are not experts at every clinical psychology
training program in the country, in these areas. Yet, it's actually a vastly-
improved situation today, than it was when I entered the field 28 years ago.
The Chairman. Dr. Friedman?
Dr. Friedman. I appreciate your question, Mr. Chairman. I think that
you're right on target, that although PTSD treatment and research began in VA,
I think that we have really been a major force in influencing the civilian
sector in many, many different ways.
In addition to our -- our graduates, and people who've benefitted from our
programs, and people who come into VA, and gone on to influence the training
programs in psychiatry, psychology, social work, and nursing throughout the
United States, and certainly in the developed nations, as well, there has been
recognition that sexual trauma, that disaster trauma, the recent tsunami, to
be one of many examples, call for the kind of expertise that was first
developed for treating veterans with PTSD.
One of the things that the National Center, and the field in general, has
done, has moved from the VA, as the spawning ground, and taken the same
technologies, the same conceptual tools, the same clinical tools, and used
them with women who've been sexually traumatized, with disaster victims. The
National Center has had a five-year collaboration with SAMHSA, with the
emergency disaster branch of SAMHSA. And we were major players in the
post-9/11 recovery.
In terms of what's happened institutionally, within the field in general
-- there have been independent efforts, with a lot of overlap and
collaboration with VA practitioners, to develop evidence-based practice
guidelines from other organizations. The International Society for Traumatic
Stress Studies, of which Dr. Keane and I are both past presidents, actually
developed the first practice guideline for PTSD, which was published in 2000.
Since then, there have been two other practice guidelines. One was the
American Psychiatric Association's practice guideline, which came out last
year. And the joint VA/DOD practice guideline, which I mentioned in my
testimony. So, perhaps that's responsive to your question.
The Chairman. With regard to the seamless transition, medical records.
DOD to VA, VA back to DOD. Are these occurring electronically, or is this
paper? What's happening, out there, right now? Does anybody know?
Dr. Keane. Most of the -- most of the -- the hand-offs are by paper, and
by phone. And it actually, at least, by my report, in my experience, it's
actually working very well, in many, many, many instances. So, we're very
pleased about how this integration has occurred. I think you were asking --
The Chairman. What about the post-deployment health surveys? Do you get
those? Is the VA getting those?
Dr. Keane. No.
The Chairman. Great. You know, we put a lot of effort into this. I wrote
the law for a reason. For you to do these as pre-deployments, and post-
deployments, and then, to make sure they get to the VA. So, if DOD doesn't
care about them getting to the VA, are they getting there? Let me turn to DOD.
Tell me what's happening.
Dr. Engel. If I may. There are a number of challenges in the data sharing
area, not the least of which is -- are the HIPPA laws.
The Chairman. No, no, no. You can't pull HIPPA on me. Uh-uh.
Dr. Engel. Sir --
The Chairman. No, you can't pull HIPPA, no, no, no, no. You can't do
that. We, Congress, say you can move that data. So, go to the next comment.
You can't pull HIPPA on us.
Dr. Engel. Well, sir, I'm really not trying to pull --
The Chairman. Right. Well, I'm just saying, --
Dr. Engel. I --
The Chairman. Just erase HIPPA.
Dr. Engel. I --
The Chairman. Now, go to the next --
Dr. Engel. -- the level at which I operate, these are challenges that we
-- that we are -- that we --
The Chairman. HIPPA's a challenge, but it's not a challenge with regard to
the sharing of information, and how we get it from DOD to VA. That's the only
point I want to make.
Dr. Engel. Yes, sir. I mean, I think we've made enormous strides in
taking the post-deployment health assessment data. It's all in a data
repository, where it can be analyzed in near-real time. And I think that we,
as an organization, would welcome the opportunity to share that data with the
VA, and do so rapidly.
The Chairman. All right. Mr. Filner.
Mr. Filner. Thank you, Mr. Chairman. Just for the record, I wish you were
not so defensive about anything that comes from this side of the aisle. But
if I were you, I would walk Mrs. Pelkey over to the Secretary of Defense, and
the Secretary of Veterans Affairs, and have her talk to them. Maybe we can
help her do that.
What amazes me, gentlemen, when I hear people from various bureaucracies
talking, doing their studies, and working hard -- it's almost as if you're
working in a vacuum, outside the real world. You all have just heard an
incredibly emotional and moving testimony by Mrs. Pelkey. I didn't hear one
statement reacting to that. I didn't hear any passion about "oh, we're going
to correct that, and here's what we need."
You read your statements, that you wrote earlier. You make incredible
claims, like Colonel Hoge said we have a distinctly pro-active approach.
That's demonstrably false, at least in terms of the vast majority of our
soldiers. We don't have a pro-active approach, and I don't know how you can
say that. Everybody there is Pollyanna. You haven't made one suggestion for
change!
I thought we would hear from you after listening to the testimony, "what
do we have to do, and how much money do we need to do it?" It seems to me,
that that's what you ought to be reacting to, on a human scale, and not on
your bureaucratic studies. I have a Ph.D. I understand research. But Colonel
Hoge, you told us nothing meaningful.
Mrs. Pelkey could have told you all that, just by sitting down with the
interviewer and telling her experiences. And a lot of spouses could have done
the same thing. I hope you're going more than a year out, but that's all you
talked about. And we know these symptoms occur later on.
And even within the context of your own testimony, which was so
Pollyannish, I don't understand how you can not sit there and be angry about
what we are doing as a nation to meet these needs. I think Colonel Hoge, or
as Colonel Engel said, your center had seen 1,500 post-Iraq servicemen.
1,500, out of the tens of thousands? You said in your own testimony, there's
700,000 hits a month on your Web site. And that means -- that's an incredible
number of people interested in what we are doing. And we're meeting only a
few.
Your one-in-four statement, after 12 months, I don't understand why you
would stick to that, when we know these things first, come up after 12 months.
And second, how difficult it is for people to admit this kind of situation, or
to even get data on it, as we have heard so movingly in the testimony. CPT
Pelkey wouldn't have been in one of your statistics, and yet, there he was,
very sick. Very ill.
I appreciate Dr. Friedman saying, the only suggestion I really heard from
you, is that you don't have a mandate in the VA to deal with families, as
opposed to the individual veterans. That's an important statement, and we
ought to remedy that. And I appreciate you saying that. But we could have
heard 25 things, probably, from you all who are experts, to tell us what we
had to do. And I didn't -- all I hear is, we're doing everything right.
The statement that the Vet Center had gone up from a few thousand to
14,000 in last year, that shows what you're trying to do, and the need. I
don't think there's been a great increase in the number of staff there, to
serve this incredible increase. You need to say, we went from 3,000 to
14,000, and our staff had too few people to deal with that.
That's what we have to know. What do we have to do, to meet the needs?
And all I hear is that everything is fine. Everything is not fine. We have
suicides, we have divorces, we have domestic violence, we have crime, we have
homelessness. Let's get passionate about these problems.
The fact that a veteran is not being helped, and commits suicide, or is on
the street, should get everybody angry, as an American citizen, about this
issue. We know how to treat these illnesses. We know how to do it. We've
advanced that far. And yet, we're not getting the services that veterans
need.
So, I'm very disappointed by all your testimony. You are locked in these
studies, and your journals. Go out and talk to veterans and their families,
and you'll get all the information you need. I just want to know, how much
money does it cost to do the kind of work that Mrs. Pelkey laid out? We know
we have to deal with the families. We know we have to spread the information
to all the service providers. We know we have to have peer discussions.
Just tell me how much that's going to cost, and let's do it. Thank you,
Mr. Chairman.
Dr. Hoge. Sir, if I may --
Mr. Burton. [Presiding] Go ahead. Respond.
Dr. Hoge. -- respond to that. I think that the - the critical -- if I
understand your question, sir, the critical element is, given the research,
which shows that there is a significant risk of mental health problems,
particularly PTSD, are the resources sufficient to take care of our
servicemembers coming back, and --
Mr. Filner. That was a great translation of my emotion, into bureaucratic
language. I don't know why you have to talk that way. Talk as a human being,
and not, you know, "the study based on," and "we have to get the resources
conditioned on" -- I mean, come on. These are people who are suffering. I
want to know how much money do we need, to make sure they stop suffering?
That's all you have to do.
Mr. Burton. Okay. I think he understands this. Let him respond.
Dr. Keane. I would just like to add, if I can, that there are
approximately 10 very specific recommendations in my written testimony, that,
I think, warrant consideration by the group. And I'd be happy to elaborate on
them, if given the opportunity.
Mr. Burton. Since I'm sitting in for the Chairman, and he's not yet
returned -- I'm interested in some of the comments from my colleague. In the
last couple of years, there've been, as the chief of staff was just pointing
out here, that there have been about 100 people added to take care of the
need. Is that sufficient in the Vet Centers.
Mr. Batres. We just got an additional 50. The original 50 --
Mr. Burton. Yes, I understand that. He just told me that, too. But if
what my colleague has said is correct, there was 15,000 last year? Is that
what you said? 14,000? Are 100 new people in the last couple of years
sufficient to deal with that problem? And I'd also like for you to elaborate
a little bit more on what he was asking about the families. Is there a
mechanism for these families, to get the kind of assistance that they need as
well?
You know, I know some people that were in Vietnam. And when they came
back, there was a great deal of stress upon them, but also on their families,
because the adjustment to these people was really substantial. You know when
they have a loved one that goes, that's a pretty warm, fuzzy guy, and when he
comes back, he's a hardened veteran, who's seen some of the worst atrocities,
and tragedies that you can imagine. And the family has to adjust. Is there
any provision, as well, for the family members? And if not, should there be?
Mr. Batres. A point of clarification. And I don't think you were here
when it was said. My program --
Mr. Burton. Well, I apologize for that. Go ahead.
Mr. Batres. -- does have eligibility for family members. So, we see
family members. We see these significant others, and the children. In our
bereavement program, the whole aim is to treat the whole family, because DOD
only treats one individual. Usually, the significant other. We've expanded
our services to the entire family of operation. And we've been doing that for
awhile.
The other thing is that you're exactly right. We became very pro-active,
early on, to get those 50 FTEE authorized, so we can begin to do the outreach
mechanisms. Before this operation, we had no experience with the number of
National Guard and Reserve folks that are being activated, and some of them
doing their second and third tours, right now.
So, in anticipation for that, we designated those folks, and we hired from
within, the returning soldiers, to do the outreach. And to provide access to
care for the VA. And they're bringing in a significant number. I suspect
that the next 50 will also be equally as effective, in doing that. I think we
need to assess, and see if 100 is enough. And if it's not, I think we should
get more, or I would certainly advocate for more resources, through my
particular avenue.
I do want to dispel the perception that we're not passionate. I'm a
disabled Vietnam combat veteran, and I take my job seriously, as I think most
VA folks do. And we are working very pro-actively, to do what we can for our
fellow veterans, and I think that I would extend that to a good number of our
folks in our program.
The problem is, from my perspective, that, you know, figuring out what
would be appropriate for the increasing numbers, when you don't know what
they're going to be initially. And then, as you go along, developing those,
and then, quickly staff them. I am -- I feel very fortunate to have the
additional 100 FTEE, and I'll guarantee you, they're being put to very good
use.
Dr. Friedman. I'd like to comment, also, in response to some of the
earlier statements. It's a new ballgame. I think that looking, and trying to
project resources based on traditional accounts of people that come through
the turnstiles, to VA clinics, or Vet Center clinics, is only a piece of it.
As Mrs. Pelkey indicated, and as some of us indicated in our testimony,
there are new initiative. New kinds of things that we really are just
beginning to get our heads around. The collaboration between the VA and the
DOD is unprecedented, in my experience. It's very, very welcome. The fact
that I'm doing a number of projects with these two gentlemen, as well as many
other people in uniform, is something that hasn't happened until very, very
recently.
Much of the effort, I think, has to be about prevention, about education.
As Dr. Keane said, using Web-based technologies. We've developed -- and I
gave four CD-ROM copies to the Committee -- in conjunction with Walter Reed
Army Medical Center, the Iraq War clinician guide, which is a state-of-the art
manual on how to treat these people. It's available on the Web, it's
available by CD-ROM. Prevention. Outreach to families.
Costing that out, I think, is something that we're really unfamiliar with.
Mr. Burton. Well --
Dr. Friedman. And I think we need to do it, because it's a major part of
what has to be done.
Mr. Burton. Well, we have a Vietnam veteran sitting there, next to you.
And with the experience in Vietnam and Korea, and the other conflicts with
which we've been involved, it strikes me as unusual that you're saying you
don't have the experience to deal with some of these problems. I mean, we've
had war after war after war in our history. And each one of those wars gave
information to the various agencies on how to deal with these stressful
problems that are created.
And I mean, you know, they had horrible things in World War I and II,
trench warfare, and Korea and Vietnam. And from what I'm gathering from you
folks is that you're experiencing something new, because maybe the National
Guard's involved. They're still military personnel who are involved in
combat. It seems to me that the statistical data that you've had from
previous conflicts could be a real benefit.
I just don't understand why you seem, I don't know, somewhat bewildered,
because this is something new. I don't think it is anything new, is it?
Dr. Friedman. May I clarify?
Mr. Burton. Sure. I'd like to know.
Dr. Friedman. I thought I covered some --
Mr. Burton. You'd better turn your mike on.
Dr. Friedman. I thought I covered some of that in my testimony.
Mr. Burton. Well, I apologize. I wasn't here.
Dr. Friedman. What's certainly new, are evidence-based treatments. And as
I said, we didn't have the kind of treatments 30 years ago for the Vietnam
vets, that we have now. And we're learned a great deal from Vietnam.
What is new, is the immediacy and the collaboration with the DOD. It was
10, 15, 20 years after people returned from Vietnam, before VA had the
capacity and offered the eligibility so that Vietnam veterans could come to
VA. What's new, now, is the fact that there are families out there, with
returnees who've just come in a day or two ago. That's new.
It's new for VA, and it's an important opportunity. It's an opportunity
that we welcome, so it's not about being bewildered. It's about recognizing
the problem, identifying it, and trying to be as pro-active as possible.
Mr. Burton. Well, how long will it take before you know how many
additional personnel you're going to need to deal with this large number of
people who need attention and care? I mean, I think you said 14,000? Is
that correct? 14,000?
Dr. Friedman. I think it's very hard to make projections. I'll defer to
Dr. Hoge. I mean, it's very early in the game. The data we have on Vietnam
veterans, we obtained in the mid-1980s.
Mr. Burton. Okay, based upon the data you had back then, how long would it
take to take care of 14,000 people and give them the attention they need? And
how much would you need additional personnel for that?
Dr. Hoge. Sir, I think there's ample data available for us to project
service utilization needs, and resource needs. And I would like to take the
question for the record, and get back to you on specifics of exactly what
resources we would like to request, to best serve our service members.
Mr. Burton. So, what you're saying is, from the experience you've had in
the past, Colonel, that you could project the need fairly accurately.
Dr. Hoge. Yes, sir. I --
Mr. Burton. Why hasn't that been done before now? I'm just curious.
Dr. Hoge. Well, I think that the combined data of what we --
Mr. Burton. I mean, the war's been going on, there, for over two years.
Dr. Hoge. Yeah.
Mr. Burton. And we also had Desert Storm before that. Why hasn't there
been some statistical data, showing what the need would be before now?
Dr. Hoge. Virtually every study that was conducted in prior wars, sir,
were done literally years, sometimes decades after servicemembers came home.
This is the first war where we're actually collecting data in real time, and
calculating rates. But we now have two years' worth of data. And I think
that's sufficient to make reasonable -- you know, maybe not the most accurate,
but I think reasonable projections --
Mr. Burton. How long would it take for us to get that here on the
Committee? I know the Chairman and others would like to have that.
Dr. Hoge. Well, I'm a researcher, and I -- and I will do the -- my very
best, to go to my leadership, and get that answer for you, as quickly as
possible, sir.
Mr. Burton. You can't give us any timeframe? A month? Two months? Two
weeks?
Dr. Hoge. I don't see any reason why it can't be done in the next month,
or so. I mean, I'm -- I can't speak for my leadership, but it's -- it's
something which we have been wrestling with. What are the resource needs, for
instance, with the upcoming post-deployment reassessment, that's going to be
done at three to six months?
Mr. Burton. Uh-huh.
Dr. Hoge. That reassessment is going to generate a large number of
soldiers coming in for care. And there's a lot of serious questions being
asked about what are the resources that are necessary to provide the services
for those servicemembers that identified. And my --
Mr. Burton. Well, let me just say, because I know the Chairman's going to
be back here in a minute, I would personally, as a member of the Committee and
one who's been on and off this Committee for about 20 some years, like to have
not only the statistical data on how many people you would need to take care
of those who are coming back, but also, if you could project out how many
people you would need, based upon past experience, to deal with some of the
family members that are suffering from the results of the stress caused by the
conflict on these soldiers.
So, you don't have to be precise. I don't think anybody expects you to be
precise. But we'd like to know what the need is. Congress can't authorize or
appropriate the resources necessary to take care of a problem, unless we've
got some pretty good data.
Dr. Hoge. Yeah.
Mr. Burton. And if people are vague about that, you know, we go to the
authorizing Committee, and they say, well, how much do you need, and why? And
if nobody has an answer, then they can't authorize. And the appropriators are
very difficult to deal with, if you can't give them some pretty clear-cut
information. So, if you could get that for us, you said you think maybe
within a month, you could get it, that would be great.
Dr. Hoge. I'll work with the leadership at the surgeon general's office,
and DOD, to try to get those -- those more specific estimates of resource
needs, to the Committee.
Mr. Burton. So, for the record, do you think you can get that within a
month, maybe?
Dr. Hoge. I -- I shouldn't promise that --
Mr. Burton. Will you try to get it within --
Dr. Hoge. I will -- I will do the best I can, to nudge the system along,
to -- do that. Yes.
Mr. Burton. Okay. Thank you, Colonel, very much. I see the Chairman's
back. I'll turn the chair back over to him.
The Chairman. [Presiding] Mr. Udall.
Mr. Udall. Thank you, Mr. Chairman. Thank you all, for your testimony
here, today. Many of the veterans that return, come from rural areas. And I
don't -- at least, from my own experience, in my Congressional district, in my
state, it seems like they're disproportionately from rural areas.
And I was wondering, the -- in terms of the services that each of you have
talked about, and what's being provided now, do we have the capability to deal
with veterans that are two, and three, and four hundred miles from the large
hospitals -- are rural veterans treated differently, because they live so far
from those facilities? I mean, what is being done to deal with that kind of
situation?
And any of the members of the panel that can speak to that.
Dr. Engel. Sir, if I may. I would like to say that CPT Pelkey's terrible
story is, for me, a sober reminder of the overwhelming charge that we have, to
care for our own. At the Deployment Health Clinical Center, what we are doing
with Respect Mil study, and as Dr. Friedman mentioned, we're collaborating
with the National Center on this, and exploring ways to go broader, within
DOD.
This is a potential -- has the potential to maximize services for people
who are in outlying places. People who are otherwise, maybe falling through
the cracks. So, I think that again, the -- the opportunity to afford good
mental health care, through primary care, is a way of reaching out to rural
communities. And if we can bolster continuity in primary care, people will
not fall through the cracks, and we won't experience the sorts of terrible
tragedies that we've heard about today.
Mr. Udall. And do you think they're getting the training they need, out in
these primary care facilities, to recognize PTSD, and --
Dr. Engel. Sir, one of the -- in the Respect Mil effort, we have developed
a primary care education module, for primary care docs, that speak to them at
their level of understanding of post-traumatic stress disorder, and facilitate
care, and improve the structure of primary care, by allowing them to use good
screening tools, and tools that measure the severity of patients' illness.
It's not just a knowledge issue. There are also important structural
changes that have to take place in the clinic, so that patients who struggle
with these sorts of challenges, get the intensive time and attention that they
need.
I would also add too, that Uniformed Services University's department of
psychiatry and its Center for the Study of Traumatic Stress is a leader in
creating educational materials through its Courage to Care program for
communities that are dealing with disaster or terrorism, and our PD.mil
website has extensive information about the clinical practice guidelines for
post-traumatic stress disorder, for depression and other mental health
conditions. We make specific efforts to design that site so that primary care
clinicians can access them quickly.
As a mental health practitioner who has worked in a rural area all of his
professional life, I thank you for your question. I think that the challenges
of any health delivery, especially mental health delivery in rural areas are
very unique and very important.
I think that within VA there are a number of options. Certainly the vet
center program is one of them and Dr. Batres can describe that. There are
also community-based outreach clinics or outpatient clinics where VA
practitioner and VA clinics are set up in places at a distance from the
flagship hospital, so the transportation and road condition programs that
often are barriers to access in rural areas can be overcome.
There are also partnership with community mental health centers that have
been done in certain areas.
In addition -- this is kind of traditional stuff, but I think that given
the information age, the internet, the tele-health capability, this is really
-- and this is one of the things I have been wanting to address in some of my
answers or my initial comments is this is a very good way to reach rural
practitioners.
The national center's website, which is getting 65,000 unique users a
month, is one way that people can access the latest on treatments and
download it no matter where they are. We have even been able to do this
with people providing help in the tsunami-stricken areas.
We are working on a state-of-the-art curriculum. We call it PTSD 101,
which will be a web-based production.
In partnership with the Uniformed Services University health sciences, we
have proposed a very, very ambitious and extensive educational initiative,
which will be using tele-health and web-based technologies as well as
face-to-face to upgrade the skills of DOD and VA practitioners, so I think
that there are many, many options that we have available, and we need to make
good use of them.
Mr. Udall. Any other comments from the panel?
Dr. Batres. I just wanted to briefly say a few things.
One of the ways we extend our services is our contract for a fees program
within the Vet Center program where we contract with private providers in
rural areas. Although limited, we have found that that particular program is
very effective if we can find the providers with the skills and the training
to provide the services.
We have also established outreach centers that are what we call "
outstations."
For example, we have five vet centers on Native American land. These are
very rural areas, places like Hopi and Navajo and other reservations we have
gone out and established an outstation in the particular reservation to
provide services closer to their communities.
For example, if you were a Hopi or Navajo, as you well know, you have to
drive a long way to get to Phoenix or to Albuquerque. So we promote services
and are local and attempt to do that.
The other thing that we are doing, especially with the National Guard and
Reserve, is working very closely with General Blum and the National Guard
registry as well as the reservists. We are establishing, and I think the
National Guard will be rolling out a plan that is state-based where we are
creating coalitions of all community resources and coordinating the services,
and I think that will help to improve our services to rural areas, but I want
to also say what Matt said, and that is that is a challenge, when veterans are
dispersed all over a great geographical area and getting the appropriate
services to them.
Those are some of the things that we have enacted.
Mr. Burton. [Presiding] Mrs. Napolitano --
Mr. Udall. Thank you.
Mrs. Napolitano. Has he finished?
Mr. Burton. Are you finished? Do you have a follow-up question?
Mr. Udall. No, I didn't have a follow-up. My time was out, but I noticed
Dr. Keane wanted --
Mr. Burton. Oh, sure. Proceed. Sure, that's fine. Thank you.
Dr. Keane. I just want to concur that these are complicated matters when
you have a centralized system, but the CBOCs, the community-based outpatient
clinics, is one important answer, as are the many programs that Dr. Batres has
put into place.
The issue with CBOCs, however, is the extent to which there is specialized
care, and among the concerns that many of us have is that primary care doctors
are already extraordinarily busy and very hard-working, and to take on the
burden of both diagnosing and treating combat related problems becomes a
burden that may just be too much for them to bear.
The question of course is at what point can we have and how can we have
mental health services in these clinics, and this is being actively debated
and discussed and in many places implemented, but I think we could likely do
more there.
Mr. Udall. Thank you very much.
Mr. Burton. If I might follow up before we yield to Mrs. Napolitano, could
not be included in the information that I requested earlier some kind of
analysis on how much revenue would have to be requested from the government to
take care of the need for these people in the rural areas who need psychiatric
help. If you could give us that. As I said before, I think one of the
problems with this Committee and every Committee in Congress -- I was
Chairman of the Government Reform Committee for six years -- is that we don't
get enough information from the various bureaucracies to be able to ascertain
how much money we need to spend and how many people are going to be needed to
do the job, so if you could try to get that along with Colonel Hoge?
Dr. Hoge. Yes, sir.
Mr. Burton. We would really appreciate it. I mean he has already said he
could get all this done in about two weeks -- or did you say four weeks?
[Laughter.]
Dr. Hoge. Sir, I said I would go to my leadership and pass on your request
for --
Mr. Burton. Well, we'll call your leadership and tell them you made a hard
commitment for a week, how's that? As quickly as you can get it done. I'm
sorry. Does that answer your question?
Mrs. Napolitano.
Mrs. Napolitano. Thank you, Mr. Chair, and I have listened with great
interest because PTSD has been something that I have been very interested in,
very involved in since my days in state assembly in California.
Some of the questions -- one of the answers that Dr. Batres gave in regard
to the treatment, I believe you said it was bereavement only. What happens
with treatment to the families or assistance to the families and those that
have not lost a member? Because that is important. It isn't just those that
have lost a loved one, but it is a family whose member has gone through these
atrocities, who has been injured -- not necessarily dead -- and cannot deal
with because they don't know how.
So does that include also services to the families?
Dr. Batres. We would cover that. Any problem that is related to their
military service we would cover, so it is not limited to just bereavement.
Mrs. Napolitano. So the resources needs would be for the service
individual and the family?
Dr. Batres. Correct.
Mrs. Napolitano. Is the family aware of the services? Is it something
that is given to them, talked about, sent to/mailed to them, emailed? How do
you get that information to them?
Dr. Batres. We get the information out through the typical formats. It is
on our website. We inform folks. We do our debriefings at the demob sites
and wherever we interact with the military we pass out that information to
them, that they are eligible.
And they have been eligible for 25 years. It's not a new eligibility. We
have always included the families as part of our treatment.
Mrs. Napolitano. Okay, but that still does not -- many families don't
have access to computers so they can't access the website. Is it possible
then that you might include in writing when the VA sends information to a
veteran to remind them that these services are available, that their families
might seek help in instances where there is an issue of PTSD that may not
recognize it's PTSD.
I am trying to figure out a way to be able to get information to the
family itself as to how they can help it. They may not recognize it. They may
not know what PTSD is.
Also you indicated that you have a website. Can you share the website so
members of Congress -- I'd love to have on my website the ability to link some
of my veterans' organizations and say "Go" because I am being asked now what
do we send these -- you know, we are starting to get these youngsters coming
in, asking for help at the local VFW and American Legion.
How do we tell them here is a place for you to go or refer them to? I'm
sure somebody at the VFW has an access to a computer, but assistance to them
at that level, because you can't do it all, but how do we know what you are
doing and how we can lend a hand in that?
Dr. Friedman. Our web address is in my testimony. The National Center has
sent its annual report to this Committee every year. We have a section
devoted to the web, with the web address, telling you all the bells and
whistles and stuff. If you would like more information, I would be delighted
to tell you about our website.
Mrs. Napolitano. I'm sorry. I don't have your testimony. Maybe I missed
it, because I am not a member of the Committee. I did happen to pick up stuff
from outside, but I will look for it.
Any other website that you gentlemen might have?
Dr. Engel. If I may, our website is pdhealth.mil -- m-i-l -- and the other
comment I would make, ma'am, is that if you have a constituent friend or
otherwise that needs assistance I would be glad to bring the full resources of
my center to assist. We are taking care of patients directly at my center.
Certainly the numbers that we take care of are nowhere near the total number
of people who are injured, but we come face to face with these folks every day
and we are trying to develop innovative programs, and I assure you if you
refer anyone to me and my center, we will take good care of them.
Mrs. Napolitano. Thank you for the offer. I will take you up on it if I
need and my staff needs it. But Mr. Chair, may I ask that you include in your
request for information from Colonel Hoge how best to get information out to
families on PTSD. That might take some doing, whether it is advertisement --
we have done it for the recruitment of personnel for the armed forces. Why
cannot we start making some kind of inroads in indicating that there is help
for those individuals who may be -- and their families for that matter -- who
may need help, services that you can provide.
Again, this will take money and this is something that maybe this
Committee might be interested in working with you.
Going to primary care, primary care is TRICARE, I am assuming?
Dr. Engel. Ma'am, primary care is a treatment setting before specialty
care. There is primary care within TRICARE. There is primary care within the
VA and there is primary care within the Department of Defense.
Mrs. Napolitano. My concern has been because in my area I had one clinic
for my veterans, and I have a high percentage of veterans in my area, they
were going to close it down. This was about six years ago. We have had a new
clinic open, but it is outsourced. I am being told by the physicians that
they cannot give certain services because they are not reimbursed for them.
That creates a problem for me, because if veterans are going in,
indicating that they have PTSD and they are required to -- how would I say --
prove that it happened during a wartime, whether it was Vietnam, whether it
was a prior war, and these individuals are having problems. I am just telling
you what problems I face in my area, so I am concerned about how can we get
veterans who might not be identified as possible PTSD, that they can then go
to an individual, whether it is a private servicer or VA, and say to them we
need some mental health services.
I'm sorry, but this macho thing prevents a lot of my veterans from
admitting that they do have a problem. Unfortunately, we just need to be able
to de-stigmatize so that it is something that they know they can be treated
for and get help for. Question?
Dr. Friedman. The primary care initiative is really an important one from
a number of perspectives. I think that in the case of Mrs. Pelkey's husband,
where he did see a primary care practitioner, that was a missed opportunity.
I think that just to take that particular example, not knowing any of the
other details, one of the goals -- and Dr. Engel has been in front on that --
Dr. Gerald Cross, head of VA's primary care has been very, very supportive in
this regard -- is to acknowledge that because of stigma, other issues, and
associated medical problems, veterans or Guardsmen, et cetera, with PTSD
aren't recognized by primary care practitioners. This, unfortunately, is
often the case. This needs to change since the first clinical port of call
will often be the primary care clinic.
That is the reason why we are so committed to trying to develop integrated
primary behavioral health models of care which have been shown to be
successful with depression.
A project that we are doing in collaboration with Dr. Engel at Fort Bragg
is testing this model. Dr. Cross has been very enthusiastic in supportive
about this. Indeed, every veteran who comes to a primary care clinic will
receive a PTSD screen annually so that --
Mrs. Napolitano. Sir, I'm sorry, but what if they don't go to the primary
care on PTSD? What if they just go for an issue? Can that primary care
provider be able to identify that there is an issue with mental health?
Dr. Friedman. That is the point of the screening. That is exactly the
point of the screening.
Mrs. Napolitano. But are they trained? That's my point. Are they given
that?
Dr. Friedman. That is an initiative that is underway.
Mrs. Napolitano. That is why we are asking for the funding to be able to
additional trained personnel so that we can then say we have enough people to
address what we perceive is a growing issue.
Dr. Engel. Ma'am, as part of this program that Dr. Friedman is speaking to
that we are piloting at Fort Bragg, there is an education package for the
primary care doctor, and there is a sort of clinic design that is put in
place. It is called the prepared practice for recognizing people. The
dissemination of that is something that we look forward to the opportunity to
do.
Mrs. Napolitano. So it's still in progress. One more follow-up, just very
quickly --
The Chairman. [Presiding] I have been very patient.
Mrs. Napolitano. Thank you so much. Very quickly -- go ahead, never mind.
Just go on.
The Chairman. Go ahead. Make it quick.
Mrs. Napolitano. It's gone -- went in one ear and out the other.
The Chairman. Thank you. We have votes coming up and we have another
panel. That was the only reason, ma'am, that --
Mrs. Napolitano. Thank you.
The Chairman. The last thing, Dr. Hoge, we really haven't talked about
your study, and you put a lot of time into this. Mr. Burton asked a question
about data and getting that information to the Committee. In order for that
to ever occur, how predictive are the results of your study?
Dr. Hoge. I think the results of our study are predictive, and we have
additional analysis that we have conducted, such as looking at how many
servicemembers who have come back from OIF have accessed services, what
percent have seen mental health, what are the reasons that they have accessed
services. So we know, I think we can predict with some degree of accuracy
what percentage of our servicemembers are in need of services, mental health
services, and then obviously the second question to that is are the resources
adequate.
That is something I just can't comment directly on in my position --
The Chairman. Is the data being shared with the VA?
Dr. Hoge. Excuse me?
The Chairman. Is it being shared with the VA?
Dr. Hoge. Yes, sir. Yes, sir. All of our data, and that is one of our
primary missions is to get the information out in a timely manner so that it
can influence policy directly.
The Chairman. Well, we recognize that the President in his budget
increased $100 million in the VA for mental health.
Dr. Friedman, I want to thank you for the team you sent to Newark city
immediately after September 11th on behalf of the country. Your response to
that and help is noted.
I would like to thank this panel. You have invested a great deal of your
life into these studies and being able to help our soldiers and the families.
We know we have got them in the military but we don't pause and say why?
You know, we train them to kill and break things, when you think about it, and
there are some mental consequences from warriors doing such things, and we
train them to be rough and tough, but they are also someone's cuddly son,
right? Cuddly spouse? And they do have a warm, compassionate side to that
warrior spirit, and when that veil gets pierced there are real consequences,
and that is where you as professionals step in.
At some point in time though, through PTSD and a diagnosis, through
treatment, they can get better, can they not?
Dr. Hoge. Yes, sir.
The Chairman. It is a curious matter with regard to the escalation of 100
percent PTSD disabilities and how people get worse, and all of a sudden when
they get a 100 percent disability rating, then they get better. So I think
what we are going to have to do is when we come back we may have to do a
secondary hearing with regard to the IG report, because it is pretty alarming
with what is happening out there. We want to make sure that the precious
resources we have, that the care and attention go to individuals that need it
and not to individuals who are perhaps using some form of excuse for bad
behavior.
It is a delicate matter and a delicate issue but it's one we have to
confront, and I know that you were able to sit here and listen to the
testimony from the first panel witness and I am glad you were here and could
hear that.
There are reasons we call certain circumstances a tragedy, and we label
them a tragedy because when you go back and you do an analysis of it, there
are failures all around. This member of the army family didn't get the
support that he needed, and every port of entry for access or referral wasn't
there. I mean that is why we call it a tragedy, and so I imagine that perhaps
there are some other cases out there, but I appreciate your leading forward,
and this panel is now excused.
The third panel will please come forward.
Michael E. Kilpatrick, M.D., is deputy director of the Deployment Health
Support, office of the Deputy Assistant Secretary of Defense (Force Health
Protection and Readiness). Dr. Kilpatrick is responsible for providing
assistance to Gulf War veterans and facilitating the operational support for
Force Health Protection initiatives and the coordination of health-related
deployment issues between the Office of Assistant Secretary of Defense for
Health Affairs and the military departments.
We will also hear from Brigadier General Michael J. Kussman, M.D., MACP,
who is U.S. Army, Retired. He was appointed Deputy Under Secretary for Health
for the Veterans Health Administration, of the Department of Veterans Affairs
on May 29, 2005, and in this capacity he leads the clinical policy and
programs for the nation's largest integrated health system.
If both of you would introduce who you have accompanying you, and then I
would then yield to Dr. Kilpatrick.
Dr. Kilpatrick. Mr. Chairman, I have Dr. Jack Smith with me. He is head
of the Clinical and Program Policy in Health Affairs for DOD.
The Chairman. Very good. Thank you. You are now recognized. If you have
a written statement, both of you gentlemen? You do?
I ask unanimous consent that it be submitted for the record. Hearing no
objection, it shall be entered. Dr. Kilpatrick, you are now recognized.
STATEMENTS OF DR. MICHAEL E. KILPATRICK, DEPUTY DI-
RECTOR, DEPLOYMENT HEALTH SUPPORT DIRECTORATE,
OFFICE OF THE DEPUTY ASSISTANT Secretary OF DE-
FENSE, Department of Defense; ACCOMPANIED BY
DR. JACK W. SMITH, DIRECTOR OF CLINICAL AND PRO-
GRAM POLICY INTEGRATION, OFFICE OF THE ASSISTANT
Secretary OF DEFENSE FOR HEALTH AFFAIRS, Depart-
ment of Defense; DR. MICHAEL J. KUSSMAN, DEPUTY
UNDER Secretary FOR HEALTH, VETERANS' HEALTH
ADMINISTRATION, DEPARTMENT OF VETERANS' AFFAIRS;
JOHN E. BARILICH, OPERATIONS OFFICER FOR VISN 110,
DEPARTMENT OF VETERANS' AFFAIRS; AND DR. MARK
SHELHORSE, DEPUTY CHIEF PATIENT CARE SERVICES
OFFICER FOR MENTAL HEALTH AND CHIEF MEDICAL
OFFICER FOR VISN 6, DEPARTMENT OF VETERANS'
AFFAIRS
STATEMENT OF DR. MICHAEL E. KILPATRICK
Dr. Kilpatrick. Mr. Chairman, distinguished members of the Committee,
thank you for the opportunity to appear before you today and discuss the
Department of Defense's efforts to prevent, identify and treat post-traumatic
stress disorder.
I would like to provide some brief opening comments.
I would first like to start by thanking Ms. Pelkey for her courageous
testimony today. I would like to also express my sincere condolences to her
for her loss.
I am going to be talking about policies and health in the Department of
Defense and then the ultimate evaluation policies that must be evaluated and
how well they serve and support our men and women in uniform who serve. When
that doesn't happen, then we need to take a look at is there an issue with the
policy, is there an issue with the implementation, and I think that those are
areas where we must continue to learn as an organization and as a society.
The Department of Defense is firmly committed to safeguarding the health
and fitness of our active and reserve component servicemembers both before,
during and after deployments, and this includes emotional health.
The department's ongoing education programs for military health providers
focus on prevention programs and early intervention for behavior and health
issues. You have heard about those education programs. They're still early.
We need to have similar education programs for our military leadership, the
operational leadership, so that they can support their soldiers, sailors,
airmen, Marines getting help early when they need it.
We need to make sure that that education program reaches out to touch the
families so they are part of this issue on bringing to bear early intervention
and then finally our servicemembers must understand that they have a safe
haven to come to seek that health care.
I believe we have made great progress in the areas of prevention,
identification and care for stress-related health risks such as anxiety,
depression, and acute stress reaction and we are really focusing now on post-
traumatic stress disorder. These conditions are part of a continuum of mental
health issues that are caused by operational stressors and combat trauma.
The Department of Defense is making a sincere effort to screen our people
for mental health problems annually as part of their preventive health
assessment. Servicemembers attend briefings about the psychological
challenges of deployment during pre and post deployment processing, often
with family members. They learn what to expect on homecoming and how to
reduce anxiety and family tensions. They also learn to recognize when and
how to seek professional help.
From the beginning of the current Operation Iraqi Freedom deployment we
employed medical and environmental surveillance to monitor possible health
risks. We deployed combat stress teams to provide education and address
specific member concerns. At the request of the OIF leadership, the Army
sent a 12p-person mental health advisory team to Iraq and Kuwait. This was
the first time we have ever assessed behavioral health care in the field.
Based on the advisory team's recommendations we deployed additional combat
stress teams for the OIF deployed force. In additional to the medical
support, members of the chaplaincy provide counseling before departure, in
the theater, and after troops return.
Upon their return, servicemembers receive a post-deployment health
assessment, with a face to face discussion with the primary care health
provider. The assessment includes specific questions about behavioral health
issues associated with deployments. If the individual's responses indicate a
risk of behavioral health issues, he or she is referred for medical
consultation if PTSD or other behavioral health issues can be identified.
Of the 138,000 troops who returned in calendar year 2004 and received a
post-deployment health assessment, 16 percent were subsequently seen by mental
health providers for evaluation.
We are now implementing the new post-deployment health reassessment
program to identify and recommend treatment for deployment-related health
concerns that may arise three to six months after deployment. We are reaching
out to veterans three to six months after they have returned to provide a
proactive wellness check to see how they are doing, especially those
servicemembers transitioning from active duty to inactive or civilian status.
The reassessment begins with a questionnaire that includes questions
designed to highlight possible stress-related issues. Importantly, the
questionnaire is followed by a one on one consultation with a primary health
provider. Again the professional administering the reassessment will refer
individuals to follow up evaluation when it is indicated.
This program certainly requires that education of the primary health care
providers so they understand the program, making sure leadership understands
this.
Dr. Winkenwerder yesterday testified that the Department of Defense has
committed $100 million to do this program this year and next fiscal year for
the servicemembers who will be in that three to six month window. After
servicemembers return from deployments, military and VA providers provide a
jointly-developed post-traumatic stress clinical practice guideline and a
post-deployment health clinical practice guideline to provide focused health
care on post-deployment health problems and concerns. There are really
algorithms for the care providers to follow to make sure that those issues are
appropriately addressed.
Military members and their families can also proactively seek health care
through Military OneSource, a 24-hour, seven-day a week toll-free family
support service accessible by telephone, internet and email. Military
OneSource offers information and educational services, referrals and face to
face counseling for individuals and families. This confidential service is
especially helpful for those who are not sure if their symptoms merit medical
attention. Their going to Military OneSource does not get reported to the
military leadership. If needed, counselors can refer the individuals for
suitable care.
OneSource is provided in addition to local installation family support
services. The National Guard Bureau has recently signed a memorandum of
understanding with the Department of Veterans' Affairs to promote a seamless
transition from DOD to VA. The DOD provides timely data regarding a
demobilization of National Guard troops so the VA can provide those
individuals with information regarding available care and support. This
includes the use of Vet Centers which provide professional readjustment
counseling and are a link between the veteran and the VA.
The department recognizes that stress-related health risks are ongoing
threats to our servicemembers and that we must continue to improve our efforts
to safeguard their emotional and behavioral health. Our education programs
for military and family members and leaders and health care providers have
been well received. Our early intervention programs, combat stress teams and
health assessments have proven to be effective. All of this has been done in
partnership with the VA, bringing us closer to our ultimate goal of a seamless
transition from DOD to VA care.
Mr. Chairman, I thank you again for inviting me here today. I am pleased
to answer your questions.
[The statement of Dr. Kilpatrick appears on p. 124]
The Chairman. Dr. Kussman.
STATEMENT OF DR. MICHAEL J. KUSSMAN
Dr. Kussman. Thank you, Mr. Chairman. Let me introduce, on my immediate
left is Mr. Barilich and then Dr. Shelhorse to his left. Both of these
gentlemen have been critically important to us and have been heroes in
developing our mental health strategic plan and the implementation of our
mental health processes, and I am very proud to have them with me today.
Before I get to my remarks, I'll make a few comments. I also had the
opportunity to stop and talk to Mrs. Pelkey, and obviously told her how much I
appreciated her courage and dedication and conviction and told her how sorry I
was for her loss. I mean clearly it is a case where, as you articulated, that
we should learn from, both DOD and the VA.
Sir, just one other thing. I have been in this position since 29 May but
as you know I was acting in this position for over a year, so I would like to
say I am no longer acting but I am still pretending.
[Laughter.]
Dr. Kussman. Mr. Chairman and members of the subCommittee, I appreciate
the opportunity to be here today. Nearly every servicemember who actively
participates in combat comes away with some degree of emotional distress.
Some have short-term reactions but thankfully the majority do not suffer
long-term consequences from that experience and we have heard that from the
previous panel.
Current efforts at early identification of emotional stress by DOD and VA
clinicians increases the possibility of lowering the incidence of long-term
mental health problems through a concerted effort at early detection and care.
With DOD's help, the VA regularly compiles a roster of servicemembers who have
separated after active duty in the Iraq and Afghanistan theaters.
VA medical centers have treated over 100,000 of the close to 400,000
OIF/OEF veterans who have separated from active service. Two of the most
common diagnoses of health problems that have been cited so far are
musculoskeletal ailments and dental problems. However, as was mentioned, we
have a drop-down menu, so that when the person comes for whatever the issue
is, a menu drops down and stimulates the primary care provider to do a mental
health assessment to include PTSD.
So of the people we have seen, the over 100,000, 24,000 have been
diagnosed with potential mental health disorders including adjustment
reaction, substance abuse, psychoses, as well as PTSD.
Over 14,000 of this group, OEF/OIF veterans, have sought VA care at both
Vet Centers and VA medical centers for issues associated to their adjustment
reactions, such as PTSD.
VA's approach to treating these servicemen and women is guided by an
emphasis on the principles of health promotion and preventive care and is
compliance with the President's New Freedom Commission on Mental Health. We
focus on providing the patient and the patient's family education about good
health practices and behaviors. We believe that education and
destigmatization will go a long way in helping people get care and benefit
from that.
VA is engaged in a number of activities to inform veterans and their
families of the benefits and services available to them. In collaboration
with DOD we have emphasis on outreach to returning members of the Reserve and
National Guard, and this is of special concern to us, and has expanded
significantly.
In Fiscal Year 2003, VA briefings reached nearly 47,000 Reserve and Guard
members. So far this year, we have briefed more than 68,000 Reserve and Guard
members. In addition, both departments have developed a brochure together,
which is entitled, "A Summary of VA Benefits for National Guard and Reserve
Personnel." The VA has distributed over a million copies of this brochure.
In the interests of time, I was going to comment on the Vet Centers and
the Global War on Terrorism counselors that we have hired, and there were 50
for the first year. We have increased now to hire another 50, and Dr. Batres
commented on that, so I won't reiterate his comments.
OIF/OEF returning servicemembers seek out and enter the VA care from a
variety of sources, including referral from military treatment facilities,
Transition Assistant Program briefings, Vet Centers, and home town community
service providers. When OEF/OIF veterans present to VA clinicians with
mental, emotional, or behavioral complaints, they are assessed both for the
symptoms, functional problems and total clinical needs. Treatment plans may
include referral to mental health and Vet Centers for specific treatment of
mental health issues.
So, as was discussed by the previous panel, there is a tiered approach
that people can get to us through our 157 facilities, our 206 Vet Centers, as
well as our 850 CVOCs that are distributed all around the country.
The goal of the VA's public health approach is to decrease the incidence
of serious mental disorders. There is evidence from VA's initial activities
in the field that these approaches are accepted both by clinicians and the
veterans they serve. They may well decrease the incidence of chronic mental
disorder for veterans. For those who do develop mental disorders, decreasing
the stigma or receiving care by teaching the public about the effect and
efficacy of evidence-based treatment can increase the beneficial use of these
services whose goal is the restoration and preservation of optimal social and
occupational functioning.
In conclusion, the VA will continue to monitor and address the mental
health needs of OIF/OEF servicemembers. We are prepared to provide
state-of-the-art evidence-based care to all those who come to see us.
Now Mr. Chairman, that concludes my statement and I would be happy to
answer any questions you have
[The statement of Dr. Kussman appears on p. 131]
The Chairman. I would like for you to explain a little bit more about this
24,000 of 100,000. You've got to break that number down. That is like saying
one in four. Something just doesn't fit right, feel right. Come on. We have
all worn the uniform here. We know what it is like to go over there. We know
what it is like to come home. We know what the mental adjustments are.
It is hard for me to look at my soldiers and say one in four have what?
Dr. Kussman. Oh -- let me try to answer a little more thoroughly than I
did. As I hope I was getting across, and the message that we are all saying,
is that almost everybody who serves has some kind of readjustment or
reintegration problem. Most of the time it's not illness. It is normal
reactions to abnormal conditions, and to label this as "mental illness" would
be inappropriate --
The Chairman. Thank you.
Dr. Kussman. -- clinically and would be inappropriate for the
servicemembers and their family. It's just not a true statement. But of that
100,000 who came, 24,000 had a diagnosis that would be consistent with
adjustment reaction beyond what I just described to you.
The Chairman. Take the next step. Of the 24,000, then what happens?
Dr. Kussman. Of those 24,000 there's 14,000 of them that have actually
got a diagnosis of a mental health thing and there's a gamut of that
diagnosis. Some are adjustment reactions, of which PTSD is one of the
adjustment reactions. There can be substance abuse, pure psychoses, acute
stress reactions, and they fall into that 14,000 who actually do get a
diagnosis under the ICD code.
The Chairman. You have to break this down a lot farther for me. I don't
want there to be any confusion.
Of that 14,000 then, however you're coding that, break them out into all
the categories, because if you are including alcoholism, drug abuse,
narcolepsy, sleep disorders -- just go down the list. What are we talking
about?
Dr. Kussman. Sir, Dr. Shelhorse will get that list. It's by percentage.
I believe that -- and he will get that out of the lists for you. Just a
second.
Sir, what I have is the actual, most updated, and the number is 15,000
versus 14,000. I wasn't trying to be disingenuous. What I put into the
statement came before the latest number.
Of the numbers of patients who have -- and you can have more than one --
and it is entitled, "The Frequency of Possible Mental Disorders among Iraqi
and Afghanistan Veterans," adjustment reactions, which is ICD code 309. I
would be happy to give this to you for the record.
There were 15,000 of them, who had a potential adjustment reaction, of
which -- and this is administrative data, as you know, sir, and so you would
have to go back and look at the charts to determine whether they really end
up having PTSD or not, or what kind of adjustment reaction because you could
put down as a primary care internist, if somebody came to me and I was
evaluating for whatever their physical thing was as well as their full
evaluation, I might put down "Rule out PTSD" or "Rule out adjustment reaction"
and that gets coded and gets picked up on these numbers.
But then you would have to go back and look at the chart and see whether
"rule out" actually turned out to have PTSD, as may have referred them to a
mental health provider to actually make that diagnosis.
But in the administrative data, about 15,000 people have the adjustment
reaction, but under the 24,000 -- the total people who have come that might
have mental illness -- under that are nondependent drug abuse -- there's
10,000 people who could have had an adjustment reaction and drug abuse.
Depressive disorders are 8,000. Affective disorders, 7,000. Affective
Psychoses, 4,000. Alcohol dependency syndrome, 1,000. Sexual deviation
disorder -- sounds awful -- 1,200. Special symptoms that are classified --
I'll leave it to Dr. Shelhorse to describe that -- about1,100. Acute reaction
to stress, 945. And drug dependency, 740.
The Chairman. Thank you for the breakout. Ma'am?
Mrs. Napolitano. Thank you, Mr. Chair. Quickly, what was the 100,000
basis? Is that actually identified? Out of how many?
Dr. Kussman. We categorize people who come that were OIF/OEF veterans.
There were 100,000 people who have come to us so far that had served in the
two theaters.
Mrs. Napolitano. Self referred?
Dr. Kussman. Well, there is a mix of those. Some of them are transfers of
care that are, as you may or may not know -- the Chairman knows this very well
-- that we have a lot of seriously injured people that are case managed with
the DOD, particularly at Bethesda Walter Reed, Brook, Eisenhower, and we have
also branched out into Fort Hood and Fort Carson and some Navy basis, Marines
as well, where we case manage those cases, so they are in that 100,000 as
well.
Most of them -- that is a relatively small number -- most of them have
come to us for whatever they want, because they are veterans and they have a
DD-214.
Mrs. Napolitano. But have you done any outreach to those veterans from the
Afghanistan war?
Dr. Kussman. Oh, yes, ma'am. The outreach is a very critical thing for
us, both in mental health and whatever the disease may be, because, as we have
heard from the previous panel, you can have all the infrastructure you want,
but if people don't avail themselves of it or know it's there, it is not very
productive, and this is particularly challenging in mental health issues
because of society's stigma, and we are not immune to that and people are
reluctant to go.
What we have tried to do is be sure through briefings, the BDD process,
the TAP, and all these different things, be sure that the separating
individual, whether they go back to being a Reserve or a National Guard
person, or they just get out of the active duty and no longer serve, have as
much information as possible, understand what the websites are, the 800
numbers.
As we all know, people remember and keep track of a very small percentage
of what you tell them in briefings, especially when you have come back from a
place like Iraq and Afghanistan, and they want to get home. Indeed, as we
have learned, it is not required for the National Guard or Reserve to actually
go through the process, so a lot of them actually leave their demobilization
site, whatever, without ever getting the thing. So what we have tried to do
is be sure that we have videotapes.
We have partnered with the National Guard and Reserve, the states, to go
their sites, where they get back together, to have our VBA and VHA counselors
go under our seamless transition office chaired by Colonel (Retired) John
Brown and Major General (Retired) Matthewson-Chapman who work for him. She has
been a leader and a point person on the National Guard and Reserve.
But one of the things that we have done is these pocket cards. You know,
people lose everything that we give them, but we are hoping that -- people
don't usually lose their wallets, so we could give them a pocket card that
they could stick in. If it is six months later or a year later, when they are
having problems or their spouse is having problems, somebody might remember.
Do you remember that pocket care we gave you?
Mrs. Napolitano. I don't want to stop you --
Dr. Kussman. I'm sorry?
Mrs. Napolitano. -- but at my age I am losing it before I can get to the
next question, which has to do with exactly what you are talking about.
In regard to the National Guard, because they are National Guard, and just
recently I think we were considering a measure whereby they would only be
given three months of TRICARE services. If they are not identified at the
time they are mustered out or had not sought help for mental health treatment,
does that preclude them from getting treatment at a VA hospital or any other
institution that will help them? There's no record of it.
Dr. Kussman. Let me say that we are potentially mixing two things. I mean
they get their TRICARE benefit as having served on active duty, and the
Department of Defense has extended that to be sure there was more time for
them and their families to get care, but there is a two year window after you
leave, if you have served in combat, to come to the VA for anything that came
up during that period of time when you served, and with no co-pays.
You are categorized as a Category 6 person, so it doesn't make any
difference what your income is or anything like that, and you have that two
year window.
After that they have a DD-214, and they are veterans, so they can come to
us any time that they have for whatever they may need.
Mrs. Napolitano. But it wasn't identified prior to their being released
and being mustered out of service or they'd been still eligible, and I am
thinking of one veteran who didn't recognize he was suffering from PTSD until
20 years later, until he had a group, a mentoring group of other veterans, who
were rendezvousing, had been going through the same feelings and he was not
alone, and then he sought help. But what happens to that veteran?
Dr. Kussman. Well, we don't just -- I mean with the enrollment management
change that took place in the 1990s, 1996 I believe, we changed it to you
don't have to have a service-connected illness to come to the VA. Now having
said that, there is one priority that we have, the decision was made if you
are a Priority 8, and that is developed on an economic basis, but short of
that you don't have to prove connection to be seen.
What you might have to prove is connection to get comp and pen, but we
still would take care of the person.
Mrs. Napolitano. Thank you, Mr. Chairman.
The Chairman. Thank you. Dr. Kussman, what DOD data would be most helpful
to the VA as you attempt to assess future mental health workload? What would
be helpful to you?
Dr. Kussman. Well, as I mentioned in my testimony, we are working very
closely with DOD to get as much information as we can as early as we can, and
the comment was made about the post-deployment screen, and I would leave that
to Dr. Kilpatrick, but I believe that they are scanning those and trying to
make them electronic and then forwarding them to us, and there has been a
great deal of progress on that. It's not perfect.
Other piece of information that we would like to have, whether it is
mental health or anything else, is that we have learned clearly with our
outreach at Walter Reed and Bethesda with the individuals that have what we
describe as polytrauma, that if we are going to be effective in our ability to
make this as seamless as possible, and god knows we still have a way to go,
but I believe in my heart that we are much better than we were two years ago
in what we are doing.
We would like to know who entered the disability process and when they
entered it so we could then determine if they choose to use the VA -- and as
you know, sir, if the individual gets medically separated or discharged,
particularly medically discharged, they have different options. They can
continue to use the military system. They can use TRICARE or they could come
to the VA But if they do want to come to the V.A, the sooner we can find out
that information, get their comp and pen exam done, and get them appointments
at the VA so when they leave they don't fall through the cracks and have to
tumble along themselves.
And as you know, sir, the V.B.A. has been reasonably good in the past
about trying to make sure that at TAP and BDD there was education on
non-health care benefits. The VA in the past has not been as aggressive as
we would like to be, and the servicemember had to show up and knock on the
door.
But we have changed that and we are actually partnering and being sure
that not only do they get their comp and pen evaluation but, if appropriate,
they get the appropriate appointments and get enrolled in the VA long before
they actually get their DD-214.
As you know also, we can't provide them anything or give comp and pen to
anybody until they are a veteran. They have got to get that DD-214, but the
thrust is that everything is in place when they actually get the DD-214 and
there isn't a long gap.
The Chairman. Well, I accept your testimony about progress. I remember
Dr. Winkenwerder being over here two years ago talking about this, so please
convey this to Dr. Winkenwerder. He was invited to come here. He came to the
Armed Services Committee, and chose not to come here. He sent you instead and
I still haven't seen the progress, so you can tell him that for me, okay?
Dr. Kussman. Yes, sir.
The Chairman. I yield to counsel for the limited purpose of three
questions.
Ms. Bennett. Thank you, Chairman. I am looking at VA's own data, in which
they look at evaluation of programs. I believe that is your NEPEC Center, the
Northeast Evaluation Program Center, that looks at the mental health service
projections.
They show that from the first half of '03, fiscal year '03 to now the
first half of fiscal year '05 that the VA's seen at least a 10 percent
increase in the number of veterans for just the very limited area of
outpatient by the special PTSD clinical teams.
Those veterans then have generated a 21 percent increase in the number of
visits.
VA has been working on a mental health model to do projections for
capacity, to identify gaps in services.
Did your model accurately project in just even that narrow area a 10
percent increase?
Dr. Shelhorse. PTSD symptoms, PTSD diagnoses are actually wrapped into a
group within the model and they are combined with compensated work therapy and
some other specialized programs. In hindsight, it would have been
advantageous for us to separate PTSD out as a separate entity from that group
so we could begin to make the accurate comparisons that you are mentioning,
and that will indeed be something we do in a future iteration.
So as it stands right now, I cannot tell you that the model predicted "x"
percentage of PTSD diagnoses versus what we actually experienced because it's
actually blended with these other diagnostic entities within the group and in
the model.
Ms. Bennett. In VA's model that you created basically to identify these
gaps, that model does have implications for VA's budget.
The first iteration of the model identified deficiencies in mental health
service capacity that would require roughly at least $1.6 billion to address
the chasm between the demand and the capacity for mental health services,
including substance abuse, PTSD, depression, and a range of mental health care
issues.
The model was then revised and re-projected. There was a significant drop
in the gaps that were identified.
In the revision of the model, it was estimated that roughly $700 million,
or less than half of the original projection, would be needed to close the
gaps by fiscal year 2007.
Did the model include projections for OIF and OEF veterans that are
coming, and does it -- are you now revising it to take into account Colonel
Hoge's research and the outcoming research of increasing need for mental
health services from returning soldiers?
Dr. Kussman. Let me take a stab at the first part of your question.
Yes, it's true that the original assessment was in the numbers that you
have described. However, when we looked at it critically and reviewed it --
and by the way, this wasn't done in a vacuum, it was done with our subject
matter experts including people who work in the NEPC and our seriously mental
ill and all the other groups found that there were serious flaws in the design
to look at that that didn't take into account reliance, age cohorts, and
things like that, because clearly mental health resources potentially we have
seen from historically the Vietnam veteran needs more than the World War Two
veteran, so that got revised on the $700 million.
It was agreed upon and appreciated by all the people inclined, and as you
know, our mental health providers and advocates are not shy and they certainly
would have held us to a much level if they didn't agree with that number that
was projected.
I'll ask Mark about the second part of the question.
Dr. Shelhorse. The model is essentially run off of data that is three
years old, so '05 would be run off '02 actuals; '06 would be run off '03
actuals, so by '02 and '03 we would have seen very little of the influx of
patients that we might be seeing at present from OIF, OEF. The next year's
run will take into account '04 data, and so it probably will be a better
approximation of the information that you are asking for about what the impact
of OIF and OEF will be.
Mr. Barilich. And if I could also add, in addition each year the model is
revised and refined. Speaking with Barbara Manning this morning, who is one
of the people who works on this, these type of things come up and need to be
projected into the future obviously that weren't known at the time of the
baseline year.
Also along with that, I think it is important to note, too, that one of
the other things that is included in that model is what is referred to as "vet
pop" and what that is is the list of discharges from service of our potential
veteran population, so that information is also blended into these models.
Ms. Bennett. Just to follow up, have you yet revised your '07 projections,
because that was a $700 million number that did not take into account OEF,
OIF, or the intensity of their usage of mental health services from VA
Are you revising it for your '07 budget?
Dr. Kussman. Let me try to answer that by saying that we believe that that
$700 million was an iterative thing over the course of our efforts to -- of
the strategic plan, and as you know, the underSecretary to kick-start that put
$100 million toward that goal in '05 and it will be continued in '06. We are
developing the '07 budget right now.
The Chairman. There was a DOD collaborative effort to provide clinical
practice guidelines to be useful tools. Are they being utilized?
Dr. Kilpatrick. On the DOD side, the use is not what we would like to see.
What we are seeing at this point is about one to three percent of people
coming back coming in to primary care on answering, "Yes. I am here today
with a concern that may be related to a deployment."
With the numbers of folks coming back, I would expect that that ought to
be a lot higher and so we are taking a look at, with the services drilling
down, to say how is this being used?
Some places you swipe your ID card and you have to electronically answer,
"Have you returned from a deployment? Is this a deployment related issue?"
That data is very robust. In some areas people are actually not asked
that, so the policies there, the implementation, is not as robust as we would
like. But currently we are seeing about three percent of people coming in to
primary care are indicating this is for a deployment-related issue.
The Chairman. Dr. Kussman?
Dr. Kussman. Sir, as I mentioned to you, when anybody comes to us and
comes to enroll and needs an appointment, part of the protocol is to ask, "Are
you OIF?" "Oh, yes." Because we were giving and are giving them top priority
to get in for access to whatever, to be sure that they get in within 30 days,
obviously faster if it is urgent or emergent.
Also I mentioned that in our electronic health record, if you come, even
if you come for your back pain or headache or arm pain, the primary care
provider who sees you, a drop down menu automatically forces the individual
practitioner to ask questions related to potential deployment.
We also have a very robust employee education system, as you know, that is
geared toward educating not only patients and we also have a very robust
employee education system, as you know, that is geared toward educating not
only patients but our staff, both doctors, nurses, nurse clinicians, PAs on
the best approaches to PTSD and mental health in general, because, quite
frankly, nationally there aren't enough mental health providers to provide
the full need that the country needs, and so you couldn't rely on the number
of psychiatrists and psychologists in the job. You have to rely on your
primary care people to provide appropriate level of mental health care as part
of their full service care to their patients.
When I was a practicing internist, that was part of my job, to evaluate my
patient for mental health, and if I didn't think or by the guidelines I was
using if that was inappropriate for me to do it, they needed more advanced,
then I would refer them on, but you can't treat the full patient without
assessing the mental health as well, but again it is hard to get people to
admit that they have got problems and we go back to the stigma. The
particular issue with mental health is that if the individual doesn't
recognize that they have a problem, it's particularly challenging to treat
them because if they keep denying the problem it is hard to force people to
get help.
The Chairman. Dr. Kussman, I think we are going to have to come back and
maybe do it for another day, and that is I want you to, I am going to ask of
you to become intimate with the IG report, because trying to separate out of
all of this -- as soldiers and as we are matriculated into a system, a value
system, an ethos -- we don't understand how some would then try to seek to use
the system and do fraudulent claims and we don't like to talk about that.
It's sort of like the big elephant in the room that everyone wants to
ignore that there would actually be someone who would deface that value and
then try to file fraudulent claims, and the IG has identified a practice going
on out there and websites, and here is how you file your claims and if you
get denied in this particular region, then start forum shopping.
And we have this huge mushroom, an explosion now, of claimants, and what
we want to do is make sure that we take care of people who particularly need
it, right? There is a challenge that we are confronting here, are we not?
Dr. Kussman. If I could comment --
The Chairman. Yes.
Dr. Kussman. -- because you asked for that in your opening remarks.
Obviously, as you quoted, it is a delicate issue and we are truly sensitive
and aware of that problem. It is a combined VA/VBA/VHA issue of benefits as
well as making the diagnosis.
As you know, the Secretary is acutely aware of this, but we are not
unique, by the way, in our interaction with our fellow countries that
practice medicine and provide benefits like we do. The Brits, the Canadians,
the Aussies and the New Zealanders are actually seeing the same type of
problem exploding with a lot of benefits, particularly mental health benefits,
and they are struggling the same way that we are.
The Secretary has charged us to look at that critically and make some
recommendations to him and that is what we are starting to do, sir.
The Chairman. When someone receives a 100 percent disability rating for
PTSD, can't they continue to receive treatment and get better, so the
disability rating could actually go down?
Dr. Kussman. Yes, sir.
The Chairman. The system doesn't prevent --
Dr. Kussman. Oh, no, sir, it doesn't prevent them from doing it. We
encourage them. I mean obviously if somebody has a 100 percent disability for
any kind of mental health thing, we would presume that ongoing therapy would
be a good thing and that they drop out of service. Obviously we can't admit
-- I mean impact on the course of their events.
The Chairman. Once they get their check, and they get their 100 percent
disability rating, and now they drop out of treatment, they have achieved a
particular goal.
Dr. Kussman. You could, sir, suggest that there are perverse incentives
here.
The Chairman. Well, that is what the IG report is indicating with this
explosion. It is something we need to look at.
Dr. Kussman. Yes, sir, we are.
The Chairman. Let me ask this one to professionals, and I'm sure that is
the other panel.
Is there a reluctance among the practice of psychiatry to really give that
second opinion about someone else's diagnosis or not? Is it pretty free-
flowing?
Dr. Kussman. I don't think so, but I will turn to my psychiatrist here.
The Chairman. I am just curious.
Dr. Shelhorse. Not to my knowledge. I, in fact, did these exams for many,
many years and we had many remands where we had second opinions or even third
opinions. A panel would be required. They were quite common. No reluctance,
no hesitation to give a second opinion even if it was a different opinion than
the original examiner.
The Chairman. Okay. Well, that's good.
Well, please convey my earlier remarks to Dr. Winkenwerder. I mean the
reason I came up with pre- and post- deployments was from the lessons learned
coming out of the Gulf War and the synergies of my service on the Armed
Services Committee and here, and so we put a lot of people through these, and
then if that data is not being referred on to the VA, then we've got problems,
so I just want you to know that it is very bothersome to me that this is
continuing to occur.
I want to thank you for your work that you are doing out there and
continue to remain vigilant. And this hearing is now concluded. Thank you.
[Whereupon, at 1:57 p.m., the Committee adjourned.]