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[H.A.S.C. No. 109–64]








JULY 26, 2005

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JOHN M. MCHUGH, New York, Chairman
JO ANN DAVIS, Virginia
JOHN KLINE, Minnesota
JIM SAXTON, New Jersey
WALTER B. JONES, North Carolina
JIM RYUN, Kansas
ROBIN HAYES, North Carolina

VIC SNYDER, Arkansas
MARTY MEEHAN, Massachusetts
SUSAN A. DAVIS, California
MARK UDALL, Colorado

JEANETTE JAMES, Professional Staff Member
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DEBRA WADA, Professional Staff Member
JENNIFER GUY, Staff Assistant




    Tuesday, July 26, 2005, Mental Health


    Tuesday, July 26, 2005

TUESDAY, JULY 26, 2005



    McHugh, Hon. John M., a Representative from New York, Chairman, Military Personnel Subcommittee

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    Snyder, Hon. Vic, a Representative from Arkansas, Ranking Member, Military Personnel Subcommittee


    Arthur, Vice Adm. Donald C., Medical Corps, Surgeon General, U.S. Navy

    Hughes, Capt. Kristiaan C., C Company, First Battalion, 46th Infantry, Fort Knox, KY, U.S. Army

    Hughes, Samantha, Military Spouse

    Kiley, Lt. Gen. Kevin C., M.D., the Surgeon General, U.S. Army

    Kussman, Hon. Michael J., M.D., Deputy Under Secretary for Health, Department of Veterans Affairs

    Patterson, Col. Virgil J., Social Work Consultant to the Surgeon General, U.S. Army

    Stretch, Stephanie R., Specialist E–4, 233rd Military Police Co., Illinois Army National Guard

    Taylor, Lt. Gen. George P., Jr., Surgeon General, Department of the Air Force, U.S. Air Force
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    Winkenwerder, Hon. William, Jr., M.D., Assistant Secretary of Defense for Health Affairs


Arthur, Vice Adm. Donald C.

Hughes, Capt. Kristiaan C.

Hughes, Samantha

Kiley, Lt. Gen. Kevin C.

Kussman, Hon. Michael J.

McHugh, Hon. John M.

Patterson, Col. Virgil J.

Snyder, Hon. Vic

Stretch, Stephanie R.

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Taylor, Lt. Gen. George P., Jr.

Winkenwerder, Hon. William, Jr.

[There were no Documents submitted.]

[There were no Questions submitted.]


House of Representatives,
Committee on Armed Services,
Military Personnel Subcommittee,
Washington, DC, Tuesday, July 26, 2005.

    The subcommittee met, pursuant to call, at 11 a.m., in room 2118, Rayburn House Office Building, Hon. John McHugh (chairman of the subcommittee) presiding.


    Mr. MCHUGH. The subcommittee will come to order.
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    Today, the subcommittee will hear testimony regarding the mental health services that are available for our military personnel and their families. We are particularly interested in the mental health programs and policies that support our troops and their families before, during and after deployment in both Iraq and Afghanistan.

    Among our witnesses today are two soldiers who have served with distinction in Iraq and continue to serve today in both the active Army and the Army National Guard. These incredible soldiers answered the call to battle and have witnessed the horrors of combat as they carried out America's commitment to freedom for the Iraqi people. Both have also fought another battle dealing with the emotional trauma of combat. Their perspectives on that battle will be especially instructive.

    We will also hear from another witness who serves our nation with distinction, a military spouse. Military spouses must have the same commitment that these brave soldiers have displayed. As we will learn today, spouses share and must deal with many of the same stresses as the soldiers to whom they are married. The courage of these individuals inspires us all. We owe them a debt of gratitude and I surely want to thank them both for their service and for their willingness to come before us today and to tell their stories.

    Another reason for this hearing was highlighted last year when The New England Journal of Medicine reported the results of a study conducted by Colonel Charles Hoge and his colleagues. That study found that 16 percent of our troops returning from Iraq and Afghanistan are experiencing mental health problems, including post-traumatic stress disorder (PTSD), major depression and anxiety.
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    The study also included the disturbing revelation that most of the troops who reported having mental health problems also indicated that they did not seek or did not receive care for those problems. There were a variety of reasons cited for this, but the most common was the perception of being stigmatized for admitting to needing help and not having it available when they did need it the most.

    This subcommittee will be very interested to hear from our medical leadership what actions have been taken to not only prevent the mental health problems our troops are experiencing, but, equally important, to remove the barriers to care wherever or whatever they may be.

    Last weekend, we published the results of the second mental health assessment team, MHAT–II, during Operation Iraqi Freedom (OIF). I would first like to commend the Army and Lieutenant General Kiley for sending this team to Iraq two years in a row to look at the mental health system in-theater and ensure that it is meeting the needs of our troops. The report clearly shows that there is an overall improvement in the mental health care system in-theater, but there is more work that needs to be done.

    I understand that the MHAT–II was also in Afghanistan. The subcommittee is anxious to see the results from this assessment and I trust the Army will be releasing the results of that report soon. I want to encourage the other services and the department to conduct similar assessments of the mental health care provided to their troops in-theater as well.

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    With regard to the availability of mental health services here in the United States, we want to make sure that the Department of Defense (DOD) and the Department of Veterans Affairs have the types and number of programs needed by our servicemembers and veterans and that they are easily accessible. I understand that the two departments are working in partnership to provide these services and to make the transition from one to the other in a seamless way for our troops. We are not there yet. We wish to hear from the leadership how this work is progressing.

    The subcommittee is particularly concerned about the availability of mental health care for returning reserve component personnel and their families. These incredibly dedicated and brave citizen soldiers go back to their hometowns, to their jobs and to their families, and we understand they often have difficulty in adjusting to being home. They must rely on TRICARE and the VA for their mental health care. We expect to hear about TRICARE and how the Veterans Administration is providing the services and eliminating any barriers to our reservists and their families receiving care.

    I hope our witnesses will address these issues as directly as possible in their oral statements in response to the subcommittee member questions.

    With that, before proceeding to the introduction of our first panel of two, I would be pleased and honored to yield to the distinguished ranking member, the gentleman from Arkansas, Dr. Vic Snyder.

    [The prepared statement of Mr. McHugh can be found in the Appendix on page 59.]
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    Dr. SNYDER. Thank you, Mr. Chairman.

    I have a written statement. I think in the interest of time, Mr. Chairman, I will just submit it for the record.

    Mr. MCHUGH. Without objection, so ordered.

    Dr. SNYDER. I concur in everything you said. We appreciate everyone being here today on these panels. It is a topic that is of great interest to the Congress and the American people. I know it is to you also. I will reserve my comments for the question period.

    Thank you.

    [The prepared statement of Dr. Snyder can be found in the Appendix on page 67.]

    Mr. MCHUGH. I thank the gentleman, and always thank him for his participation and leadership in these kinds of important issues.

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    With that, let me introduce the first panel: the Honorable William Winkenwerder, Jr., assistant secretary of defense for health affairs.

    Mr. Secretary, good to see you again.

    The Honorable Michael Kussman, deputy undersecretary for health, Department of Veterans Affairs.

    It is so good of you to be with us here today, sir.

    Lieutenant General Kevin Kiley, surgeon general, Department of the Army.

    Nice to see you, sir.

    Vice Admiral Donald C. Arthur, surgeon general, Department of the Navy.

    Admiral, a pleasure.

    And Lieutenant General George P. Taylor, Jr., surgeon general, Department of the Air Force.

    Thank you so much for being here as well, General.

    I would say that we have all of your written testimony and we will, without objection, enter it all in its entirety into the record. Without objection, so ordered.
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    With that, we would go to the witnesses in the order in which I have introduced them. We would appreciate hearing all of the salient points that you wish to make, but to the extent you can compress and abbreviate those, it would be greatly appreciated.

    Secretary Winkenwerder, our attention is yours, sir.


    Dr. WINKENWERDER. Mr. Chairman, thank you, and thank you for your comments and for your concern for our men and women and for their mental health.

    Thank you for the opportunity to discuss mental health care in the military health system. With your approval, I will summarize my remarks and submit my full statement for the record.

    Deployments in the support of the war on terrorism place unique types of stresses on servicemembers and their families. For that reason, we operate a system of support for mental health that includes pre-deployment screening, theater-based services, follow-up, post-deployment outreach, command-level leadership, and then clinical care. This support system assists servicemembers and their families with any mental health issues that they may experience, but more importantly it reaches out to prevent the harmful effects of stress and war.

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    Specifically for servicemembers, we have a series of periodic screenings and assessments that are designed to identify mental health problems early so that they can be addressed. These screenings occur throughout a servicemember's career or their whole time in the military. Importantly, while in combat, each unit has a mental health team that provides proactive treatment for acute stress disorders related to combat experiences. As an integral part of the unit, this team provides the command and its leadership with an assessment of the overall mental health of the unit.

    Let me say emphatically that these professionals are doing an exceptional job of caring for our troops' mental health. Indeed, the Army's most recent mental health assessment study, which General Kiley will speak about a bit later, found reduced rates of mental health problems and improved morale among our deployed forces. We were, to say the least, very encouraged by these results. Although there is, as you well point out, always room to improve and that will be our target, we were nonetheless gratified that we are on a positive trend.

    A new screening program, the post-deployment health reassessment, which will occur three to six months after a servicemember returns home from a deployment, is a new program that we are implementing. Combat-related illnesses may not emerge immediately. It may take several weeks or months for them to appear. This reassessment program will afford us the opportunity to reach out to our servicemembers at the three to six month time after they come back home to see if the transition to home is going well, or if there is some assistance that we can provide. We literally want to reach out and say, ''How are you doing? How are things going? How are things at home? Is there anything that we can do to help you?'' We are doing this in a systematic, very scientifically valid way.

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    A number of other services exist to help our military members and their families adjust to redeployment. One in particular is Military OneSource, which is a 24-hour-a-day, 7-days-a-week confidential toll-free support service that can offer mental health information, referrals and counseling. I think this is particularly important for those who may be worried about the stigma of seeking support in a visible way right there on base.

    Our soldiers, Marines, airmen and sailors, veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom, deserve our highest attention. A minority do develop severe chronic mental health problems. With the Department of Veterans Affairs, we are working diligently to ensure a seamless and excellent set of services and transition for these men and women. There has been a tremendous amount of work that has taken place just in the past year. I know that Dr. Kussman will be glad to describe that.

    Mr. Chairman and committee members, we take very seriously our duty to serve the men and women who protect this great country. We strive to protect their health, and when needed to provide them with the best health care possible. We proudly accept this challenge. I look forward to working closely with you further to implement the military health system's mental health programs and policies.

    With that, let me just say thank you again, and at the right time I will be glad to respond to all your questions. Thank you.

    [The prepared statement of Dr. Winkenwerder can be found in the Appendix on page 71.]

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    Mr. MCHUGH. Thank you very much, Mr. Secretary. As I said, we appreciate your being here today and the efforts that you put forward on a regular basis on behalf of our men and women in uniform.

    Next, we are pleased to recognize the Honorable Michael Kussman, deputy undersecretary for health at the Department of Veterans Affairs.

    Mr. Secretary, thank you, sir, for being here. We are anxious to hear your comments.


    Dr. KUSSMAN. Thank you, Mr. Chairman. Mr. Chairman and Members of the subcommittee, I appreciate the opportunity to appear before you 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. Current efforts at early identification of emotional distress and stress by DOD and VA clinicians increases the possibility of lowering the incidence of long-term mental health problems through a concentrated effort at early detection and care.

    With DOD's help, VA regularly compiles a roster of servicemembers who have separated from active duty in the Iraq and Afghanistan theaters. VA medical centers have treated over 100,000 of the 393,000 to 400,000 OIF/OEF veterans separated from active service. Two of the most common health care problems that have been cited are musculo-skeletal elements and dental problems.
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    However, no matter what the person comes for, our electronic health record has a drop-down menu that requires all physicians and providers to screen the person for mental health issues. As a result, nearly 24,000 patients have been diagnosed with potential mental health disorders, including a wide gamut of things such as adjustment reactions like PTSD, drug and alcohol problems, psychosis and other mental health issues.

    Over 14,000 OIF/OEF veterans have sought VA care at both our rehabilitation counseling centers known as Vet Centers and VA medical centers for issues associated with adjustment disorders, of which PTSD is one of these types of adjustment disorders. VA's approach to treating these service men and women is guided by an emphasis on the principles of health promotion and preventive care, and is in 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 to avoid.

    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, emphasis is on outreach to returning members of the reserve and national guard, which is a special concern, 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 new brochure together entitled, ''A Summary of VA Benefits for National Guard and Reserve Personnel''. The VA has distributed over one million copies of this brochure.

    The Vet center program's capacity to provide outreach to veterans returning from combat operations in OEF and OIF was augmented by the Veterans Health Administration's undersecretary of health in February 2004. Targeted Vet centers hired and trained a cadre of approximately 50 new outreach workers from the ranks of recently separated Global War on Terrorism veterans. These positions are located in or near active military out-processing stations, as well as national guard and reserve facilities. Based on the success of the initial Global War on Terrorism veterans outreach program, the undersecretary of health authorized the further hiring of 50 more Global War on Terrorism veterans outreach workers.
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    OIF/OEF returning servicemembers seek out and enter VA care from a variety of sources, including referral from medical treatment facilities, transition assistance programs, briefings, Vet centers, and hometown community service providers. When OEF/OIF veterans present to VA clinicians with mental, emotional or behavioral complaints, they are assessed both for symptoms, functional problems and clinical needs. Treatment plans may include referral to a mental health clinic or a rehabilitation counseling center.

    The goal of VA's public health approach is to decrease the incidence of serious mental disorders. There is evidence from the 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 disorders for veterans. For those who do develop mental health disorders, decreasing the stigma of receiving care by teaching the public about the 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 populations. We are prepared to provide state-of-the-art evidence-based care to all who come to us for care.

    Mr. Chairman, this concludes my statement. Thank you.

    [The prepared statement of Dr. Kussman can be found in the Appendix on page 79.]

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    Mr. MCHUGH. Thank you, Mr. Secretary. As I said, we appreciate your testimony and your being with us here today.

    Our next presenter is Lieutenant General Kevin Kiley, surgeon general, Department of the Army.

    General, thank you for being with us.


    General KILEY. Thank you, Mr. Chairman.

    Mr. Chairman and distinguished Members of the committee, thank you for the opportunity to discuss the Army's mental health services for deployed soldiers, their families and our veterans of the Global War on Terrorism. The mental and physical health of the Army is a critical component of readiness. Your concern for the emotional well being of soldiers and families is greatly appreciated. I also would like to take a moment to thank you and the Congress for your continued support of the Army and for Army medicine.

    Approximately 5 percent of all deployed soldiers who complete a post-deployment health assessment immediately following a redeployment have reported PTSD-type symptoms and are likely to meet the criteria for PTSD diagnosis. In an anonymous survey administered 3 months post-deployment, up to 17 percent of soldiers met screening criteria for depression, anxiety or PTSD. This number increased to 19 percent at 6 months post-deployment.
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    There are three main reasons for the increase in reporting over time. First, soldiers who return home from Iraq and Afghanistan may not recognize the symptoms of PTSD or the deployment-related stress immediately upon redeployment. Second, our continued outreach and research of the issue may increase reporting over time. Finally, time, education and outreach mitigate some of the negative stigma attached to seeking mental health care in our society and profession of arms.

    However, a majority of soldiers experiencing post-deployment stress symptoms do not require acute medical intervention. Most require reassurance that their reaction is normal given their combat experiences. They need to understand what triggers their symptoms and they need to know how to seek help when needed. Additionally, the largest proportion of returning soldiers with post-war mental illness have relatively mild manifestations and may benefit from lower intensity psycho-social interventions offered within primary care, rather than a more intimidating specialty mental health clinic setting.

    The Army has implemented a series of aggressive improvements in our mental health delivery system to address research findings like these that I have just mentioned. Let me take a few minutes to highlight some of these. Last week, as you noted, we released our second mental health advisory team assessment of mental health support to forces in Kuwait and Iraq.

    The study conducted between November 2004 and March 2005 assessed the need for mental health care by U.S. forces in Iraq and Kuwait and the health care system in place to deliver mental health care, the mental health training requirements of deployed forces, and the effectiveness and adequacy of measures put in place after the first MHAT assessment conducted in 2003.
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    Additionally, the team looked closely at the theater commander's suicide prevention program. You will hear later today from Colonel Pat Patterson, my social work consultant, and the leader of both MHAT teams. I do believe our attempts to improve mental health services in-theater are a success and will have a long-term impact on the prevalence and acuity of mental health illness among OIF veterans.

    Today, more than 200 Army psychiatrists, psychologists and social workers and behavioral health technicians are deployed to Southwest Asia in support of Operation Iraqi Freedom and Operation Enduring Freedom. They work closely with unit commanders and chaplains to help soldiers cope with both the stresses of combat and the challenges of being away from families for long periods of time.

    Their role is to provide education, preventive services and treatment services. Typical educational activities include combat and operational stress control and suicide prevention classes, and preparation for reunion with their families. Clinical work includes individual and group evaluation and treatment.

    Principles of combat stress control have been developed over the past century and have been codified in the principles of PIES, proximity, immediacy, expectancy and simplicity. Combat stress control focuses on education and treatment as close to the frontlines or to the soldiers' units as much as possible. Evacuations from the theater are avoided if at all possible because we have learned from experience that few patients who are evacuated return to duty. However, if a patient is persistently dangerous to themselves or others, they may need to be evacuated to Landstuhl Regional Medical Center or the United States for further treatment.
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    Soldiers evacuated from Iraq and Afghanistan for mental health or other injuries or illness receive tremendous support from the mental health professionals and chaplains at our hospitals and medical centers. Particularly noteworthy is the work of Colonel Steve Cozza at Walter Reed and Navy Captain Tom Greiger at the Uniformed Services University of Health Sciences. Their research suggests that rates of PTSD among battle casualties are lower than would be expected by other studies of returning veterans in civilian populations exposed to traumatic injury.

    The approach to identifying and treating patients and the proactive efforts to identify and respond to potential mental health problems early on may have played a role in the low initial rates of PTSD. Also, the caring attitude of all health care providers and the esprit de corps among injured soldiers at the medical center may have also helped these soldiers cope with their experiences.

    Based on research conducted at the Walter Reed Institute of Research and the Army's European Regional Medical Command with the First Infantry Division, Dr. Winkenwerder has directed the service to implement a post-deployment health reassessment within 90 to 180 days after redeployment. Never before has the department attempted a longitudinal follow-up of health status after redeployment.

    The Office of the Assistant Secretary of the Army for Manpower and Reserve Affairs has taken the lead in implementing this program across the Army. The support of Mr. Denning has been essential to ensuring we have a comprehensive strategy that coordinates the efforts and resources of Army medicine and chaplains in the active and reserve components to screen, evaluate and treat soldiers for post-traumatic stress disorder. We intend to implement our reassessments beginning September 1 of this year.
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    I am committed to working with the Army, DOD leaders and the Members of Congress to ensure we have adequate services available to meet the mental health care needs of our OIF and OEF veterans. But I want to caution everyone that one size does not fit all in terms of solutions to prevent or resolve PTSD among redeploying soldiers.

    PTSD manifests itself in a wide variety of symptoms and severity. Our programs to identify and treat those suffering from PTSD must be flexible and scaled appropriately to ensure we provide appropriate care at the appropriate time in the appropriate setting.

    Thank you again, Mr. Chairman, for inviting us to speak today with you. I will be happy to take the committee's questions when ready.

    [The prepared statement of General Kiley can be found in the Appendix on page 89.]

    Mr. MCHUGH. Thank you very much, General Kiley.

    Next, Vice Admiral Donald Arthur, surgeon general, Department of the Navy.

    Admiral, thank you, sir, for being here.


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    Admiral ARTHUR. Good morning, Mr. Chairman, Dr. Snyder and distinguished members of the panel. Thank you very much again for allowing us to come and testify in front of you.

    General Kiley just well elucidated all of the programs that we have. We join him in those programs. Since he did such a good job, I will not repeat a lot of what he said, but I would like to give you a different take on the mental health aspects of this conflict.

    About a year ago, the Chief of Naval Operations (CNO), Vern Clark, asked me if our casualties could be treated in civilian hospitals like the Mayo Clinic and Johns Hopkins. Great institutions. I said, they sure can. We can treat illnesses and injuries just as well at Mayo Clinic or Johns Hopkins or any of the other fine hospitals around the country, but they will not understand two things. They will not understand, first, that the injuries and illnesses are not just to the servicemembers. They are to the servicemember and his or her entire family; that injuries and illnesses belong to the family and families must be involved in their treatment.

    I said the second thing that they will not understand is these Marines, these sailors, soldiers, airmen, Marines, and Coast Guardsmen are still in combat, even though they are lying between nice clean sheets at Bethesda, Walter Reed or other of our great facilities here in the Continental United States (CONUS). They are still experiencing the effects of combat.

    Shortly after I took this job, someone gave me a presentation on combat stress. They said that 15 percent of people who enter combat are significantly affected by the experience. I challenged that person because I think it is more like 100 percent of people who experience combat are in some way affected. We must pay attention to these effects, not only in the member, but in the family and the job environment. I think that is why we pay so much attention to it.
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    We have had a lot of success in the post-deployment health assessment, pre- and post-deployment. We are 98 percent for sailors and over 90 percent for Marines. But one of the nicest programs that we have established is called the OSCAR, the Operational Stress Control and Readiness Program, which the Marines have. They have embedded a psychiatrist, two psychologists, a psych technician and a chaplain with the Marines. They work side-by-side with them every day and they become part of the Marine unit.

    As part of the Marine unit, they develop a rapport with the Marines that allows the Marines to come and talk with them where they would not necessarily talk with someone if they had to go up to the hospital and make an appointment. So we embed our psychological and social workers in the Marine environment.

    They also train the Marines and they train them to accept stress as part of the job and to express that stress. We try to have the most senior Marines express stress so that the junior Marines will feel more comfortable. That is, a senior Marine getting up in front of a group of his junior Marines and saying, you know, that was a very difficult deployment that we just had, and I felt stressed, and it is okay. We want to prevent stress disorders, not do treatment. That is why that program is embedded. We also have psychologists in other areas of Navy deployment such as aircraft carriers.

    The post-deployment health reassessment survey has already started in the Marine Corps. We started that in July with these bubble sheets at Camp Pendleton, where we have our Marines who are returning fill out these forms which have been validated for their sensitivity for mental health stresses.
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    In summary, it is not about post-traumatic stress disorder. It is about a normal adjustment to very abnormal stresses. I think that we are making great strides, much more than in any other conflict because we are paying attention to it. Although the New England Journal article stressed that you have I think it was a 14 percent rate of combat stress returning, we are experiencing much less than that because we are paying attention to it.

    Thank you very much.

    [The prepared statement of Admiral Arthur can be found in the Appendix on page 98.]

    Mr. MCHUGH. Thank you very much, Admiral. We appreciate your being here as well.

    Next, Lieutenant General George P. Taylor, Jr., surgeon general, Department of the Air Force.

    General, we look forward to your comments.


    General TAYLOR. Thank you.
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    Mr. Chairman, Representative Snyder and Members of the committee, thank you for this opportunity to discuss how the Air Force meets the needs of our deployed airmen. The psychological well being of our airmen directly affects our ability to carry out operations and we greatly appreciate your interest and support in these vital issues.

    The Air Force assesses the mental health of our personnel repeatedly throughout their careers. They are screened upon accession and yearly through preventive health assessments. They are screened again through the pre-deployment health processes prior to each deployment.

    To take care of our deployed airmen, we deploy two types of mental health teams with them: a rapid response team and an augmentation team. These teams use combat stress control principles to provide consultation to leaders, as well as the prevention and intervention to deployed airmen. I was involved in the medical combat service support lay-down for Operations Enduring Freedom and Iraqi Freedom. One of my highest priorities was to ensure the Air Force fielded mental health professionals early and as far forward as possible, not only to treat combat casualties, but to put in place strong prevention and outreach programs.

    Mr. MCHUGH. Excuse me, General. I apologize, but some of my colleagues, including me, are having a little bit of trouble hearing you. Can you pull that microphone a little closer? Is it on?

    General TAYLOR. Even better.

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    Mr. MCHUGH. Thank you.

    General TAYLOR. Yes, sir.

    I was involved in the mental health combat service support lay-down for Operations Enduring Freedom and Iraqi Freedom. One of my highest priorities was to ensure the Air Force fielded mental health professionals early and as far forward as possible, not only to treat combat casualties, but to put in place strong prevention and outreach programs.

    Today, the Air Force has 44 mental health personnel deployed for current operations, 32 of whom are supporting ground component requirements. Following a deployment, all airmen complete a post-deployment health assessment and a visit with a health care provider for medical screenings. Referrals to mental health providers occur when psychological symptoms warrant further evaluation and possible treatment.

    Efforts are now underway, as described, to reassess the mental health status of all airmen 90 to 180 days after deployment. We are in the process of hiring 35 mental health professionals to better execute the requirements of this post-deployment health reassessment.

    The Air Force is also standardizing existing redeployment and reintegration programs and offers the excellent tools and programs to help airmen and their families adjust following deployments. We have implemented Air Force OneSource, which provides personal consultation via the World Wide Web, telephone or in-person contacts. It is available 24 hours a day and can be accessed from any location. Post-deployment psychological care is primarily delivered through our Life Skills support centers, where more than 1,200 professionals deliver care for alcohol and family violence issues, as well as general mental health concerns.
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    Active duty personnel receive care through their medical treatment facilities and TRICARE, to include veterans' facilities in the TRICARE network. Air Reserve component personnel receive care through a combination of active duty military treatment facilities, TRICARE, VA facilities and contractors.

    We are encouraged by the data collected from our post-deployment health assessments. Between January 1, 2003 and June 30, 2005, more than 99,000 active duty and 34,000 guard and reserve airmen had completed the post-deployment health assessment. Mental health data for active and reserve components are virtually identical. Few responders, about one percent, expressed interest in receiving help for a stress-related problem. The vast majority, or 96 percent of redeployers, reported none of the four possible post-traumatic stress disorders. These results are consistent with the limited exposure to traumatic stress reported by our airmen when deployed.

    Data on medical evacuations and medical holds also indicate the Air Force has had relatively light exposure to combat stress. We have medically evacuated 155 airmen for psychological diagnoses since October 10, 2001, which represents only 8 percent of all military medical evacuations for such diagnoses. Currently, 3 active duty airmen and 42 Air Reserve component airmen are in medical hold status for psychological disorders.

    These results were further supported when we looked at other behavioral indicators from fiscal year 2000 to the present. Child abuse rates remained virtually unchanged throughout the Air Force and spouse abuse rates and alcohol-related incident rates have actually declined somewhat. To date, there have been no Air Force suicides in Iraq or Afghanistan during OEF and OIF, and only three suicides involved personnel who committed suicide within 12 months of returning from these theaters.
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    In summary, our reviews indicate airmen experience shorter deployments and have faced less exposure to traumatic stress than their Army and Marine counterparts, and therefore have experienced less adverse psychological impact during recent operations. Should this scenario change, we remain prepared to help them every step of the way, caring for both mind and body.

    Thank you.

    [The prepared statement of General Taylor can be found in the Appendix on page 110.]

    Mr. MCHUGH. Thank you very much, General.

    Again, thank you all.

    Let me stipulate having, as I know all my colleagues have, reviewed the data, the material and the reports, the efforts. Clearly, the department, the VA and various services care deeply about this issue. I think many of us are under the impression that somehow this is a new challenge. It is not so much the challenge that is new, but rather the terminology.

    We have gone through a litany over the time of military engagement of what we called this challenge. In World War I, we called it shell-shock and war neuroses, to World War II where it was generally considered combat exhaustion, the post-Vietnam syndrome, to today it is post-traumatic stress disorder. Whatever you call it, it remains a very, very critical part of the experience of being in combat, and a critical responsibility, it seems to me, of the services to try to respond to it and provide adequate care.
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    One of the things as I looked over the various reports and such, that I think raises some questions that I would like to hear some of you, in fact all of you, respond to, is that of data collection. Let me begin with Dr. Kussman from the VA.

    There was a Government Accounting Office (GAO) report in 2004 that I assume you are familiar with that stated that the VA does not really have a count on the total number of veterans that are receiving PTSD services at VA facilities and Vet centers. The result of that, of course, is that it is somewhat difficult to determine the total number of providers and total number of health care professionals that are needed.

    I am just curious, since that 2000 report has the VA attempted to respond to that? Have you tried to get a better read on that? If not, why not? If so, maybe just briefly what you have done to get a better handle on the scope of the challenge.

    Dr. KUSSMAN. Yes, sir. Thank you for the question.

    I am well aware of that study. As you know, there was some controversy about the full GAO report with that. The administration went back with some questions about the findings of the report.

    Having said that, we are putting a great deal of emphasis getting the proper data collected. As I mentioned to you, I think we have a pretty good handle on the new veterans that are coming in who have it. We are using leveraging of our electronic health record and are putting that into and expanding it into the rehabilitation counseling centers. So I think that we have a much better handle than we did when GAO first came, to look at the total number of people who have the ICD codes and other DRGs that are related to mental health.
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    I think an evidence of that is, as I mentioned in my statement, that we have a pretty good handle on the new OIF/OEF people that have a potential diagnosis of PTSD as part of the spectrum of adjustment reactions. So we are following that very closely.

    Mr. MCHUGH. I do appreciate that. I thought it was important for you to have the opportunity to get that on the record.

    If you have the opportunity either today or in reviewing the testimony of the second panel, I suspect you are going to hear some concerns about the access, the availability problem with VA. It is one thing to know what the scope of the challenge is. It is another to make sure that those who need it have the available access, which of course in turn rolls back to the issue of making sure you have adequate providers.

    How does the VA assess the accessibility issue right now? Do you see this as a particular challenge? Do you feel you are ahead of that data that you feel you have a good handle on for OIF/OEF, et cetera?

    Dr. KUSSMAN. Yes, sir. As I said, we are monitoring that very carefully because we realize this is one of our core issues. The VA has been a leader on particularly PTSD as far as making the diagnosis, treatment and research. We have 206 rehabilitation counseling centers around the country, 157 facilities, and over 850 community-based outpatient clinics. Obviously, we cannot be everywhere, but we believe with that distribution of resources, a large number of veterans have relatively easy access to the system.

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    We realize how challenging it is with mental illness in general, as was already commented on. You, sir, commented on the Hoge study and the stigma and the challenge that people want to come. We are trying to be sure that one of our major emphasis is education, to be sure that people know what services are available to them if they choose to use us and need us.

    We are getting these lists from DOD. The secretary sends out a letter to all the discharged veterans whether they came from active duty or the national guard and reserve, explaining all the issues and all the services that are available. There is robust counseling information available through the transition system.

    We realize that in this conflict as compared to many others, there are obviously a large number of national guard and reserve that have not been traditionally part of the combat deployments. It has been a long time since that has happened. We have put a lot of emphasis on working with the national guard and reserve to ensure that there are follow-up briefings at the sites of the national guard and reserve. We are working with the states and their centers that have veterans and the people working with them. It is part of a major portion of our seamless transition, so we are working hard.

    When people need to come to us, obviously we are not perfect. We accept responsibility. When we know that people have had problems, we will rise to the occasion and try to fix it. But we believe that there is a great deal of emphasis being put on this. We spend a lot of money on mental health services, between $2.5 billion and $3 billion a year. We have identified a lot of money for PTSD and combat-related stress. So we acknowledge the problem and we are working very hard to remedy it.

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    Mr. MCHUGH. Thank you very much.

    You raise an important question. You can construct the best program in the world, whether it is mental health services or something else, and make sure all the providers are there. I am not suggesting you do not have challenges in both those areas here, but if folks do not know about it, I am not sure it does any good.

    I want to ask the Army in a second about their results showing that 40 percent of the troops surveyed said they had adequate training. That is up from 29 percent. It is also leaving 60 percent unaware. But before I get to that, because I thought the MHAT, and I mentioned this in my opening comments, I thought the MHAT was a great idea.

    Can the other services tell me, are they contemplating an MHAT approach? If not, why not? And why haven't they done one? They do not feel there is an efficacy there. I am just curious. It seems to me to be such a useful tool that it would be helpful if all the services did it, yet to my knowledge the Army is the only one that has.

    If I have to pick, in the order in which they spoke, I guess I would go to General Kiley first. But you guys did one, so forgive me. Admiral Arthur, you unfortunately from my perspective are next on the list.

    Admiral ARTHUR. Thank you very much.

    I think the Army's MHAT experience is very, very valuable. I think we would like to pattern some of that experience. We do collect data. We were the first to get the post-deployment health reassessment survey on the ground. I think we are finding that to be an efficacious vehicle through these bubble sheets that I showed you. So I think we all have a standardized means of doing the mental health reassessment.
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    Mr. MCHUGH. But everybody is doing the post-deployment, and I think that is wonderful. That is step removed from MHAT. You are not contemplating one of those, I am assuming?

    Admiral ARTHUR. We already have our OSCAR teams that are in-country collecting some of the same data. We just have not reported it in the same fashion, but the OSCAR teams are fully-embedded with the Marine Corps units.

    Mr. MCHUGH. General Taylor.

    General TAYLOR. In my testimony and written statement, we told you the low prevalence of reported issues in the field. Certainly, you have asked a good question. I think we will take it back and think about whether it is worth that kind of study. Obviously, the Army has much larger exposure to combat stress than we do, and the lessons they learned are easily important. So we will go back and look.

    Mr. MCHUGH. I appreciate that.

    Mr. Secretary, why doesn't the department take an overview? Why doesn't the department say to all the services, this is a valuable and necessary exercise; why don't we just all do it?

    Dr. WINKENWERDER. We are doing that. We just had a discussion this very week on this issue. On the positive side, I want to commend the Army because the thrust for doing this work came from the Army's line leadership, which I thought was just great because that told me they were, like me, concerned about these issues and really wanted to understand them.
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    I think you have raised a great question. I think that we have Marines fighting and living and working alongside of Army soldiers. I would agree with General Taylor, the Air Force, though you do have people on the ground, are far fewer in number. But I think you make a good case and we will take it back and look at it.

    I think we need follow-up. These two studies have been very helpful. It would be good to know how we are doing a year from now. I am a big believer in measuring. It is one thing to say we are doing a good job, trust us, but I like to see the data. The Army's data has been very helpful.

    Mr. MCHUGH. I agree. It is like the old adage, a little knowledge is a dangerous thing. It makes me a very dangerous man in this area. I would concede that in a heartbeat. It just seems to me intuitively that if I were in the service and I were to hear more, rather than less, about this challenge from my superior officers; if I were told by the command and asked, are you experiencing this, that demystifies it and it takes away the stigma that is a major barrier. We all know this. It is a major barrier against those who need help, seeking it out. So I think the more you can do to analyze it, as a secondary benefit you also help to take away that stigma and to demystify it.

    That having been said, and I do commend the Army, and I purposely attempted to do that in my opening comments. But having studied it, we do see that 40 percent have received training, in their estimation up to 29 percent. What are we doing to get it to the other 60 percent, because I think that also is part of that component of demystification and removing the stigma of the need for mental health care.
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    General KILEY. Yes, Mr. Chairman, thanks.

    A couple of broader statements first before I address that, just to say that our sense has been that this has been a very complex process, requiring a lot of synchronization between resources both during the mobilization process and during the deployment, which is what prompted the first MHAT, the analysis of which led to some changes which then sent the second MHAT in to see how was it going. As you have already pointed out, most all of the comparisons significantly improved in terms of the metrics of performance.

    I will take the question about the 40 percent and re-check that. My impression was that there had been some training in as many as 70 percent of the soldiers, but that only 40 percent felt the training was effective and sufficient, which is really what you are getting it, which is the issue of are we properly preparing our soldiers for the stress of combat.

    One of our take-aways, which really I think the other services can certainly work with, is that proper aggressive leadership, realistic and tough training prior to deployment, in an environment that is reflective of what the soldiers, Marines, sailors and airmen will see in-theater, is going to be the biggest success metric for us.

    We have seen that soldiers who are well led and well motivated are not surprised by their environment, and do much, much better than those who have a mission change, for example, who are trained in one operational stance and then, for example, convoy operations in-theater have changed remarkably. We are doing convoy training now in our basic training that teaches soldiers how to react corporately under convoy operations.
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    All of these changes create stressors, and so even in the face of training soldiers, preparing them, counseling them, putting them in groups prior to mobilization or prior to deployment and talking about this, is not ever as effective as being in-theater, experiencing it, and then having the mental health assets, doctors, psychologists and social workers with them there to tell them that they are doing okay and that they will continue to be healthy and mental.

    So I think we have a lot more to do. I think we have learned more from the MHAT. I think the steps we have taken between MHAT–I and MHAT–II have shown us that we are making inroads. We still have some work to do.

    Mr. MCHUGH. I thank you for that and for taking the question. We do need to follow that up.

    I have not seen the 70 percent figure. I may have left out the word ''adequate'' when I said ''trained.'' If I did, I apologize.

    General KILEY. But that is the key point.

    Mr. MCHUGH. But it is still 40 percent to 41 percent adequately trained, which means that even the 41 percent are in question, and leaving us 60 percent to 59 percent who are not. That is a challenge and you know that.

    General KILEY. Yes, sir.

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    Mr. MCHUGH. So let's see what your follow-up data provides. I appreciate that.

    With that, I will be happy to yield to the distinguished ranking member, Dr. Snyder.

    Dr. SNYDER. Thank you, Mr. Chairman.

    Thank you all for the work that you all do.

    General Kiley, what do you say today to men and women in the service and their family members that may be having difficulties related to their service and what they saw and did, but have apprehensions that if they step forward that there is going to be a problem in their military career? What are your words of wisdom and reassurance to that?

    General KILEY. Sir, I think that is an excellent question and strikes to the heart of a lot of what we have seen in the studies by Dr. Hoge and also the MHAT, is this global concern that somehow soldiers and their families are either inadequate or weak. I strongly disagree with that. I do not think anyone in the health environment agrees with that.

    I think frankly in my 30-year career in the military, I have seen a sea-change in terms of senior leadership of the Army who now agree that mental health services and seeking mental health services when you feel you need them is as important, frankly, as anything else we do in training, maintaining, curing and leading soldiers, going to the dental chair, being it physical exams, or being it a sick child that you bring to the emergency room.
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    I do think that there are impediments to that. Some of them consist in the optempo and the training tempo and the deployment tempo. Some of it has to do with the dislocation of families from military communities that project our forces around the world. Some of it has to do with local shortages of behavioral health specialists, working inside of our direct health care systems, and sometimes it is in the local communities. Nationwide, my sense is there is increasing demand for behavioral health counseling and support. The military in that respect is no different.

    I think as each generation of leaders grows in our Army, there is less and less of an old-school thought that if we just train you hard enough and tough enough that you will not have these mental health issues. I do not believe, in fact I know that we have senior leaders who have been briefed on these issues and are extremely receptive to them. The challenge is translating that down to the younger, newer leaders. Their day-to-day lives in leading soldiers is so busy that even carving out time for things like sick call or frankly for routine wellness health care can sometimes be a challenge.

    So what I would say to those individuals is they have several different options. We have a military OneSource with counseling types of issues, marital issues, that they can access counseling capabilities without anyone ever knowing. We have interested and committed behavioral health specialists who understand the concern about perceived stigma associated with seeking counseling for mental health. We have the chaplains who are fully engaged as another alternative. We have TRICARE providers in the network that are also providing a service.

    My end-game in this issue, though, what I hope to achieve is a new mindset in our military starting with the Army, which I am terming a mental health re-set, which simply says that when we bring Bradleys and when we bring Strykers and when we bring Apaches back from combat operations, we set them. We send them all to depot and strip them down. We check ever component and piece and make sure they are working okay. You don't get a bye on that. You get somebody that says, oh, that looks okay; let's just pass it on.
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    We are not doing that yet, but I want to attempt to achieve that same sense of mental heath re-set with our forces very, very similar, frankly, to the requirement for every soldier to sit in a dental chair after they deploy to have a dental check, to make sure that they are still dental category-one ready to deploy.

    What I would like to see us do is to direct every soldier, regardless of whether they think they need counseling or not, to have an opportunity to sit down with a counselor, not just a family practice, nurse practitioner screener, but a counselor for a short visit that says, these are the normal things that happen to well-trained, well-disciplined effective soldiers in combat operations; here is what happens to their families.

    So what we do not have is an issue at a demobilization site or an installation receiving soldiers that have returned where those soldiers that answer ''yes'' because they are either so severely stressed or they do not have a concern about any issues about the stigma of seeking mental help, or both, they will answer yes and they will get right into referral, or they will answer a series of questions that clearly indicates they need to seek counseling. But the rest either deny it or do not want to see anyone and go on their way, and if we follow those soldiers we start to see rising numbers of soldiers with concerns.

    We want to preempt that whole thing. Instead of waiting for somebody to have a significant dental problem, we get them in the dental chair and we check them out. It is our intent, at least it is my intent to start a pilot next month to do that exact same thing, and ask all soldiers to go through it. And I think as we work our way through it, as we put the large number of mental health providers in-theater, over 200 that are there, in response to the MHAT–I, commanders see the benefits of getting soldiers a couple of minutes of counseling and how they continue to be combat-effective because of that.
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    And that when they return, not only to our installations and begin the retraining process, but if they return home as reserve and national guard soldiers, they reenter their communities healthier and better. I think we will continue to get support at the highest levels of the military, both in uniform, and I know the secretary feels the same way, that we are going to have a healthier, more effective fighting force.

    So I am very encouraged. I think we still have more work to do. I think we are being very aggressive. Dr. Winkenwerder's post-reassessment will help us get an even better assessment of the total numbers. But I would say to a young soldier and a family that if they have concerns about that, that there are multiple avenues. They can see a primary care manager, and we would like to see our primary care physicians more engaged, and we intend to do that. They can seek chaplains.

    And only if they present with a series of signs and symptoms that early indicates that they are going to be at risk for themselves or for their loved ones in terms of their mental health would we get more directed and insist on them seeking more sophisticated psychologists or psychiatric help. But I do not think we are going to turn a light switch and just make this happen all of a sudden. It is going to have to take a corporate effort to do that.

    Dr. SNYDER. Thank you.

    Dr. Winkenwerder, Dr. Schwarz, he and I had a letter published in an AMA newsletter a month or so ago that called attention to the fact that a majority of American physicians have not signed up or participate in the TRICARE program.
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    How do you track where we are at with regard to availability of mental health professionals for those people who use the private health care providers as their TRICARE providers? I am not getting information where I can actually get some kind of assessment on how we are doing with regard to the availability of mental health professionals from our TRICARE folks.

    Dr. WINKENWERDER. That is a good question. Let me try to separate it into two parts.

    First, of course, is when people come back during that initial period of redeployment and they are directly our responsibility at the base or at the unit, to go through the post-deployment process.

    Let me also say that with the new program that is being put into place, that is the check on every single returning, redeploying servicemember at the three- to six-month interval, that will include all guard and reserve, every single person we intend to touch and to reach out to.

    We are hoping through that process to learn more about if there are any problems for that person in terms of access to mental health services in your community. So that will be one way, one window to learn the answer to that question, because once the servicemembers, guard and reserve, are separated, unless he or she opts to continue in TRICARE for six months or to sign up for the new benefit, TRICARE Reserve Select, which we would encourage people to do if they do not have health coverage or if they think this is a better deal for them, then they will be part of our network, and we have pretty good metrics, a pretty good way of understanding the access to and availability of psychiatrists, psychologists, mental health social workers, mental health providers.
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    But when they move into the private community-based health care system, we do not have availability. What we would know is what anyone else would know about the availability of mental health care in that particular community. So it is an important question and it needs further evaluation. Through this three- to six-month check, that is one avenue where we are hoping to find out more about if there are problems. I do not have any indicators at this point, even anecdotes that tell me that there is a problem, but that does not necessarily mean that there aren't.

    Dr. SNYDER. We have not had our annual TRICARE health care holiday marathon session that Mr. McHugh, our chairman, likes to do once a year. We have had some scheduling issues. I hope that we will do that.

    One of the issues, I think we are back to having, maybe we never got away from it, but I think we are having problems again with TRICARE providers being available, even ones that may have their name on a list, they may be not taking new patients, so they may have great restriction on the number they see.

    Anyway, I think that is something we need to pursue. I do not see any numbers before me to tell me how well we are doing. Like, if a community has 10 psychiatrists and three Master of Social Work (MSWs) that are TRICARE providers, and we look, and I would think you could come back and say, well, we only have two of those signed up, that that would be an indication that we may have some potential problems. There is certainly a narrowing of the selection. I think that kind of information would be helpful.

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    Mr. Chairman, I think my time is up. I have some other questions. Maybe we can go around again. I don't think I will keep asking questions.

    Thank you.

    Mr. MCHUGH. I appreciate the gentleman's courtesy.

    With that, I would be happy to yield to the gentleman from Minnesota, Mr. Kline.

    Mr. KLINE. Thank you, Mr. Chairman.

    Thank you, gentlemen, for being here.

    Secretary Winkenwerder, in your testimony you say that military members and their families may also use Military OneSource, a 24-hours, 7-day-a-week toll-free family support service which is accessed by telephone, Internet and e-mail. And then as part of that service, apparently, counselors can refer members or family members to suitable mental health are. Is that right?

    Dr. WINKENWERDER. That is correct.

    Mr. KLINE. It sounds like a great idea. Let me just see if I can take my time here to gain a little bit more detail on the program. How do military members and their families know about Military OneSource? Is there an advertising campaign?
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    Dr. WINKENWERDER. It is extensively advertised, and there are lots of efforts. I do not know if any of the surgeons would care to comment on that, but there really is an outreach Web-printed materials, all kinds of things at bases to let people know that this is a new service that is available to them. As I understand it, there has been, I do not have any at-hand statistics for you, but my understanding is that it has been quite heavily used. It has been significantly used.

    Mr. KLINE. It looks like the table that I think the committee staff prepared here, it looks like something by the end of May there were already 80,000 or 90,000 calls, and then many more Internet or online accesses.


    Mr. KLINE. So apparently it is being advertised somewhere. I just wonder if there was a real promotional campaign where you actually had printed materials?

    Dr. WINKENWERDER. We do.

    Mr. KLINE. Okay. Then that leads to the question, one of the most frustrating things I think for all of us anytime we call a 24-hour, 7-day-a-week toll-free number is, does somebody answer the phone before you do need mental health, and slam the phone down.

    How many people are there answering the phones? Is this 50, 100, 1,000? What is the size of the operation?
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    Dr. WINKENWERDER. I do not have those figures for you. We can get them.

    I am not aware of any problems with people being able to reach a person on the other end of the phone. If you do have anecdotes or reports of that, we sure would want to know about them so that we can go back to the contractor that operates the program and make sure that that is not the case.

    Mr. KLINE. I do not have any such feedback. I was sort of wanting to know if you in any of the services or you had had such feedback and in general what the feedback is. Obviously, it is being used with 80,000 or 90,000 phone calls already and many more Internet contacts. What is the feedback you are getting and do you have a mechanism for getting feedback?

    Dr. WINKENWERDER. Those are good questions. Remember, it is a confidential line, so I think by definition people are not inclined to say that they called and used this. So you raise an important point in terms of our getting a better understanding of that question.

    General Kiley, do you have any thoughts on that?

    General KILEY. Yes, sir. This program started out as an Army OneSource program under the G–1 of the Army through Community and Family Support Center (CFSC) and not through the Army Medical Department or the surgeon general's office. I think that was intentional, getting back to Dr. Snyder's question about stigma and those kinds of things.
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    Our data would say it has had 54,000 calls and 78,000 online inquiries, with almost 13,000 cases resulting in some kind of counseling referral; 500-plus cases have actually met a threshold for duty to warn, so that individuals calls and said, I am really concerned about this or that, and it has risen to the level where the counselors at the other end of the phone or during counseling, and I have no more details than that, have responded and said, we need to get you into a behavioral health clinic or some capabilities either on-post or off-post.

    But it is a program run by the Community and Family Support Center, versus the Army Medical Department. And it is for those kinds of services that do not rise to the level of what we might call a diagnosis, like PTSD or depression, anxiety attacks. It is more for counseling, marriage counseling, financial counseling, acute counseling for stress concerning family issues.

    Mr. KLINE. I have another meeting to go to. Plus, I want to be observant of my time limits here. If you could just get for me, I would take the question for the record, if you will, the size of the operation, how many counselors, how many people are answering the phone, what is the delay in getting through. Somebody must be tracking those metrics. It seems like a great idea.

    Dr. WINKENWERDER. We would be glad to do that for you.

    Mr. KLINE. Thank you very much.

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    Mr. Chairman, I yield back.

    Mr. MCHUGH. I thank the gentleman.

    Next is the distinguished vice chairman of the committee, the gentlelady from Virginia, Ms. Drake.

    Mrs. DRAKE. Thank you, Mr. Chairman.

    I also have several questions, and I am very grateful to have you all here today.

    My first one deals with prescription medications that you would use for our military members and our reservists. Are you able to use the entire range or are you limited by cost, so the range is smaller of what is available?

    Dr. WINKENWERDER. Maybe I will take that one. Our pharmacy formulary here in the United States is very broad. It covers all classes of pharmaceuticals, and typically every drug within that class. Now, we have begun to implement a new pharmacy benefit that still maintains availability of every drug within the class, but with a somewhat different copayment; $22 versus $9.

    We just made an announcement recently to apply that to the erectile dysfunction drugs. As I recall, Levitra is the drug that we are covering at the lower rate, and the others, Viagra and Cialis people will have to pay more for it. We did the same thing with Nexium, putting it into the higher co-pay category, but they are still always available.
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    In-theater, the mental health providers and the physicians have a wide availability of pharmaceuticals. There are very good logistics and inventory system that can make just about anything available that is needed for care.

    Mrs. DRAKE. Thank you.

    I was also concerned about, especially with reservists, when reservists go over and come back, and this does not show until maybe they are separate or not active duty anymore. Do we have the right facilities to be able to make sure they are cared for? Because they are going to be in a VA hospital and I think every one of us as Members of Congress have had people call our offices and say they have been told they do not qualify or we are not going to see you, and we have had to refer people and have our staff work on those issues.

    So I am concerned about, are they covered, to make sure they are covered if they are currently separated, since you have already identified this does not show right away, and to make sure that we have the facilities and that they know those facilities are there for them.

    Dr. WINKENWERDER. Yes. Great question.

    Let me describe for you what the coverage is for people after deployment. They are eligible for up to six months of continued TRICARE coverage for themselves and their families. That is, for all guard and reserve, so there is a full six months of TRICARE coverage.

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    Then with the new TRICARE Reserve Select program, which the Congress passed last year and we very much supported that, and thought that was a good move in the right direction for those who have served, they can sign up for continued coverage. For each 90 days of service, they are eligible for one year of coverage at a very favorable premium. It is a very, very competitive, very favorable premium. So if they serve for up to two years, they could have eight years of continued health care coverage for themselves or their family.

    They are also eligible to go to any VA, as I understand it, clinic or hospital for two years if they have served.

    Mrs. DRAKE. I think that is what we want to make sure of, that we have the capability to treat them in these VA hospitals and they are not being turned away, or unnecessarily long waiting periods.

    Dr. KUSSMAN. Yes, ma'am. Obviously, they are veterans and they have a DD–214 and they are eligible to come to the VA. There is a special program for combat-related servicemembers that are eligible for two years of care for anything that was related to their experience over there, and they are enrolled as a priority six, so there is no economic issue one way or the other.

    If for instance something happened after those two years, clearly they are still a veteran and they can enroll with the VA for whatever services that they need, but would have to then deal with the enrollment issues that we have.

    Mrs. DRAKE. Is the Military OneSource available for reservists after they come back, or is that just on active duty?
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    Dr. WINKENWERDER. My understanding is that is an active duty program, but if they have continued TRICARE coverage, again it would be available to them for up to six months.

    Mrs. DRAKE. Just one last question, too, because I know one of the big factors in the civilian world is that people will not seek care. In the military, I think it would be even harder because of being concerned about impacts on your career or your buddies thinking you are not as tough as they are. So if someone, if you identify they need care, and they will not agree to it, do you have a way to see they get that care? As you know, in the civilian world, you cannot give people care who do not want it. So do you have a way to deal with that or are your hands tied?

    Dr. WINKENWERDER. Maybe I will turn to one of the surgeons for that.

    General TAYLOR. I guess I will take a short shot at it.

    I am a flight surgeon by training. Don and I are both flight surgeons by training. It is hard to drag pilots into a flight surgeon's office to get seen. It is the same way with folks who have mental health problems. Therefore, it takes a community effort to let them know what the resources are. Mental health folks do not do real well if they sit behind the glass wall in the office.

    So all of us have outreach programs where our mental health professionals get out among the community. There is an integrated delivery system that we put together that includes chaplains, family support centers, the medics, the security folks, the commanders and the senior NCOs to try and make sure there are multiple avenues, as General Kiley stated, into a system for people who have problems, whether they are mental health problems or sexual harassment or sexual abuse problems, or family abuse issues. We have multiple entry points into a system that is completely integrated.
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    So our hope is that people understand how to use a variety of sources. The people who work in the family support center are well aware of the mental health capabilities, as the chaplains are, and we can build a system that outreaches to those people who have issues getting in. It is critically important, as General Kiley stated and as Dr. Winkenwerder stated, that our senior NCOs and our commanders understand the assets that are available to them. We spend an extraordinary amount of time training the folks to understand what those assets are.

    Admiral ARTHUR. Also, the embedding of people in the units helps with that rapport. It is very easy to talk to a corpsman or a medic who is with you in combat, and I think the corpsman or medic gets to know the Marines and soldiers. They can tell when they are having problems, when they have family difficulties, and difficulties in re-acculturating after coming back. I think it is much easier when you have the folks right there side by side, and that is what we have done.

    Mrs. DRAKE. Thank you.

    Thank you, Mr. Chairman.

    Dr. WINKENWERDER. Let me, if I might, just make one other comment along those lines. That is that really our whole effort, and this is relatively new in the last three to four years, certainly with the institution of the pre- and post-deployment health assessment, that we are not waiting for people to surface with problems. Before they deploy, they are asked questions that relate to their mental health.

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    While they are in-theater, they have the OSCAR teams and the combat stress control. When they come back at the point of redeployment they are asked again with a more extensive question, and now we are adding on another required program at three to six months. So it is really all along those points.

    I would emphasize these are not optional. Everyone goes through this. So someone can sort of hold it all in and say I am fine, but I would say that with the systems that we have put into place, it is very difficult for people to do that, for someone not to know that they have a problem.

    Mrs. DRAKE. Thank you.

    Thank you, Mr. Chairman.

    Mr. MCHUGH. I thank the gentlelady.

    Next, the gentleman from Texas, Mr. Conaway.

    Mr. CONAWAY. Thank you, Mr. Chairman.

    I thank the panel for being here today. I appreciate that.

    In terms of the VA, I know there is a separate oversight committee that grills you guys extensively, but do you have waiting lists? How do you assess what the backlog is of folks seeking mental health treatments in your system, waiting lists or time for service or time between service, that kind of data?
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    Dr. KUSSMAN. Yes, sir. We track our waiting lists. I do not think it is divided by symptom or diagnosis, but we clearly have a priority for OIF/OEF patients. When we know them, they go to the top of the list and we meet our access standards of within 30 days getting a new appointment and 30 days for a subspecialty appointment. So there are waiting lists, like there is in any delivery system. It is not perfect. Everybody can't be seen instantaneously, but we have culled out and given special priority for the veterans coming back from OIF/OEF.

    Mr. CONAWAY. In the services, do you have waiting lists? Do you have the right capacity to deal? If you do not have waiting lists, then obviously you do not have to say anything, but if you do have capacity issues, then we ought to know about it.

    General KILEY. Sir, I mentioned it a little bit earlier, our hospital commanders monitor backlogs, waiting lists and availability for all kinds of appointments, to include behavioral health. In those areas where we have an installation, and frankly most of our Army installations to one extent or another have been involved either in deploying soldiers or in mobilizing and demobilizing.

    Those commanders have had the authority and the resources to bring on board mental health assets they need to handle the demand as it is incurred, either through the pre- and post-deployment screening, the mobilization and demobilization process, or just through family support, because we consider taking care of families as important as anything for readiness.

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    Part of the challenge, of course, is that depending on the community, the local community may not have all the mental health assets that the community or the Army would like to tap into if we need to. We have had opportunities, at least occasionally, to contract for health care providers, psychologists, even psychiatrists. So as it stands now in support of the Global War on Terrorism, we have been resourced.

    Are there areas that are very, very busy? Yes, sir, there are. On any given day, do we have a behavioral health clinic, a psychologist, a psychiatrist that does not have appointments available? I would never say no, but we are very sensitive to this issue. The commanders work this routinely. They know that they have the support from the secretary and from the department as they identify their needs. We do have standards of access in general through TRICARE and we are working pretty aggressively to make sure we meet those.

    Mr. CONAWAY. Okay. Mr. Kussman, does the VA have the same kind of regional look? You are talking about individual commanders on the various posts. Does the VA have the same opportunity for assessing across a variety, geographically looking at the issue and making sure that you are not inordinately short in some areas of the country versus others?

    Dr. KUSSMAN. Yes, sir. They are done by facility and region, what we call our veterans integrated service networks, the VISNs. So we track that very closely. If we cannot meet the standard, then we have the ability to fee-base, or get services in the community. We have initiated a lot of programs to put more robust mental health in our community-based outpatient clinics to meet performance standards as well.

    There are some challenges geographically. Sometimes we are in a place where no matter how much money you throw at it, it is hard to get the people. They are just not available in the civilian community to hire, but we are working very hard at that and we are well aware of our needs.
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    Mr. CONAWAY. One quick one. There is going to be subsequent testimony to the fact that there was like three months between appointments for mental health visits with a professional. Is that the normal standard of care? Is three months between visits normal?

    Dr. KUSSMAN. No, sir, of course not. It would be driven by the clinical necessity, if somebody had to be seen weekly or whatever. So I can't say that it would be any regular thing. If it was the judgment of the provider that the person can go 90 days for the next appointment, then it would be that way.

    Mr. CONAWAY. So that would be driven by the needs of the person, not the needs of the system?

    Dr. KUSSMAN. Yes, sir. It would be driven by the clinical needs of the patient.

    Mr. CONAWAY. Okay. Thank you, Mr. Chairman. I yield back.

    Mr. MCHUGH. I thank the gentleman.

    Next, the gentlelady from California, Ms. Davis.

    Mrs. DAVIS OF CALIFORNIA. Thank you, Mr. Chairman, for holding this important hearing, and to all of you for being here.
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    I want to follow up for a second on the training and the training of the commanders in the field, and what we are doing to really help them. You have mentioned several things, that we have certainly some individuals, mental health care providers that are embedded, and also trying to find those resources when they need them.

    But how many hours, what are we doing to really help the commanders in the field to be able to identify these issues and problems?

    Dr. WINKENWERDER. Let me just make a general comment, then maybe I will turn to General Kiley on some of the more specifics.

    I think it is an awareness that has grown that this is important. It is part of taking care of soldiers or Marines or sailors or airmen. In my experience as a civilian leader in the department, when I go to visit I see that with my own eyes with the commanders, the things they talk about, the way they are engaged in specific concerns for their soldiers or Marines. It is impressive.

    I was just six weeks ago in Iraq, about six months ago in Afghanistan. I can just tell you, I met with leaders and they talk about these things. I talk about health issues, so I come to meet with them about health issues. I ask them, how is it going, do you have needs, do you have the resources? It is always a very positive conversation. That is one indicator I have.

    And around the Pentagon, we bring up these issues with the leaders. I do not get people looking down at the floor or looking away. They care about this. So as to the specifics, maybe what we are specifically doing, maybe that would be a good thing to add on.
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    Mrs. DAVIS OF CALIFORNIA. I was going to ask, just the specifics. Do we feel that at least we need to point to a certain few hours of training specifically for identification?

    And then I wanted to follow up, also quickly, with how are we training the mental health providers, whether or not there are certain schools that are doing a better job in doing that, because certainly up until a few years ago, PTSD was not a major part of the curriculum.

    Where are we finding those mental health providers? How much training specifically are they getting? Those who are embedded with the military, obviously they are going to have a different sensitivity, and I think that is very important, but they need to be prepared for that, too. I am just wondering, where are they getting that training from?

    Dr. WINKENWERDER. Let me ask General Kiley and Admiral Arthur to talk about that.

    General KILEY. That is a very good question. I would like to take your question about the specific hours for the record and we will come back and give you a specific answer.

    But the broader issue, as Dr. Winkenwerder has addressed, and if I could for just a second. There are several different definitions for ''training,'' at least in my comments this morning. Soldiers that do rigorous vigorous training with good leaders is one of the tools that we think makes a difference in terms of the mental health and the esprit and morale of soldiers.
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    Inside the training curriculum, the block of construction as it relates to suicide prevention, suicide recognition, anxiety, depression, PTSD-type symptoms and the recognition of that, if you look at the two groups that need training, you have really identified both of them.

    One is our combat service and combat service support units. Clearly, during mobilization processes and during the SRP, as we call it at our camps, posts and stations, soldiers clearly get some instruction and discussion leaders get that. Whether that is one hour or three or four hours, sitting here I can't tell you, but we will take that for the record.

    There is also on our installations the FRGs, the family support groups, the discussions about how families are going to react to deployment; the issues about separation. The chaplaincy is clearly engaged in that same arena, some of the broadcasting of the issues about Army OneSource.

    Additionally, our medical personnel get training, the 91-whiskeys get a little bit of training during their train-up to become EMT-certified technicians with some mental health. We certainly have a whole host of what we call 91-xrays, which are our mental health technicians themselves. Psychologists and psychiatrists obviously have the training. Over the last few years with the publications of issues about PTSD and combat stress, they are for the most part very well versed, to include in particular our reserve and national guard personnel that fall in on those combat stress control teams.

    When I was in Afghanistan, I had an opportunity to meet a couple of psychologists, and psychologists that were reservists that were falling in. One had just arrived and the other was getting ready to leave. They were very well versed on the issues about the stress of combat, deployment, separation, the uncertainty in length of deployment, the uncertainty of walking down the streets of Baghdad and getting blown up.
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    The last piece of this puzzle that is probably not as robust as I would like it to be, but one of the things we are taking on is the issue of the broader education for our physicians, our nurse practitioners, and other health care providers, both in and out of the combat zone, as it relates to recognizing the signs and symptoms of stress, depression and PTSD. In general in training in obstetrics and gynecology or family practice, recognizing depression and handling it or properly referring it has been pretty mainline for a while now, but the PTSD piece of that is relatively new.

    Again, I will take for the record your question about exactly how much training physicians and nurse practitioners in training get for that, but it is clearly part of this matrix to answer the problem.

    Mr. MCHUGH. The gentlelady's time has expired.

    Mrs. DAVIS OF CALIFORNIA. Thank you, Mr. Chairman.

    Mr. MCHUGH. Thank you.

    Mr. Hayes, the gentleman from North Carolina?

    Mr. HAYES. Thank you, Mr. Chairman.

    Gentlemen, thank you for being here. This is a vital issue and we appreciate certainly your attention to it.
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    It has come to our attention that under TRICARE, the military health care system does not allow service men and women access to licensed professional counselors without physician referral and supervision. Typically, private insurance plans do allow this.

    We have H.R. 1358 in the defense bill to address that issue. Under the present system, there are numerous hoops that folks have to jump through in order to access care, so we certainly want to do everything we can to help you all provide the care for the folks. I would appreciate your comments on that, if appropriate.

    And then my other question would be, there always seems to be a stigma with service folks coming to professionals for mental health. Is there anything in your experience that we can do from your side or our side of the table that would make that stigma at least partially go away and help both families and service men and women get the help that would be appropriate for them?

    Dr. WINKENWERDER. Thank you, Congressman. Let me answer your first question first and then the second.

    With respect to the proposed legislation on the mental health counselors, I appreciate your interest in the issue and the concept of trying to extend or improve access to mental health counselors and support personnel.

    However, I do want to note for the record here today that we asked the RAND Institute to perform a study on this issue to compare with two populations what effect that would have, without requiring a referral and without using the normal subsets, the current subsets of personnel that we use to provide those services. That study did produce some findings that were of concern for me with respect to the quality of care.
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    What they found was that there were differences between these two populations, the ones that continue to use the system as we have it organized and the one that had direct access to these personnel. They found that the use of psychiatric medication was lower and the rate of hospitalization was higher in the group that was directly accessing the mental health counselors, and the use of psychologists and psychiatrists was also lower.

    So that concerned me, as I looked at and thought about the quality of impact. Typically, we want to make sure that people are getting psychotropic medication if they need it. We know also that that keeps people out of hospitals.

    So for those reasons, we are not supporting, I am not supporting, the department is not supporting that legislation. So I think it is something that we need to continue to look at, and we would we glad to work with you on it, but that honestly is our assessment at this time.

    Mr. HAYES. If I can interrupt you for just a minute to make sure we are on the same page.

    Dr. WINKENWERDER. Yes, sir.

    Mr. HAYES. Here is the destination, here is the serviceman or woman, and here is the in-between physician referral, which certainly medically has some very positive points. What I want to make sure is that in order to avoid the stigma and other things, when appropriate be able to access the same person that they would access through the referral physician, but without the other issues there. So we would appreciate the opportunity to work with you and make sure we get that one right.
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    Dr. WINKENWERDER. Thank you.

    With respect to your second question about stigma and what can be done, I think just one thing, with all of us talking about it wherever we go and reinforcing the message, and leadership taking on the issue is important.

    With respect to specific recommendations, I do not know if there are any studies or anything further we could do or should do that would better elucidate the problem of stigma or how to confront it. In my judgment, the best way to confront it is by leaders standing up and talking the talk. That is, if you go get support and help, it is not going to affect your career. I think that is the thing that people worry about the most.

    I would invite Admiral Arthur or General Kiley to comment on that.

    Admiral ARTHUR. I think that is exactly right. It is the line leadership that has to set the standards and set the stage and set the example.

    One of the compelling truths of this is we value mental toughness. That is what we go into combat with as tough a soldier or Marine mentally and physically as we can. That is what causes them to survive. And then to admit to a mental weakness is a very difficult and challenging dichotomy in thinking. So I think it is up to the leadership to say, I have been affected; it is okay; I have gone to counseling. Or to in some other way set the example that it really is okay.

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    Mr. HAYES. Thank you, gentlemen.

    Thank you, Mr. Chairman.

    Mr. MCHUGH. I thank the gentleman very much.

    The gentleman from Colorado, Mr. Udall?

    Mr. UDALL. Thank you, Mr. Chairman. I want to again thank you for calling this hearing. I think this is a very, very important topic.

    I think you put your finger on it when you talked about demystifying or destigmatizing mental illness, not only in the military, but across our society. I think once again the military has an opportunity which it has taken on so many occasions to help lead society in this regard, so there is a form of collateral benefit to the work that you are doing.

    I am eager to hear from the next panel, so I was inclined to pass, but I want to take advantage of what you all have to say. I did want to thank the next panel, because I am going to have to leave, for taking the time to share their perspective with us, those individuals.

    But I wanted to just follow up on Ms. Davis's line of questioning. She was talking about the servicemembers themselves.

    Secretary Winkenwerder, how about the families that access the eight visits that can be undertaken without referral? Do we have some numbers on the family members, number one? And then number two, what happens if those eight visits are utilized and there is a need for additional treatment and counseling?
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    Dr. WINKENWERDER. Let me make sure I understand your question. Your question was about do we have numbers about the families utilizing the visits and how many have?

    Mr. UDALL. Yes, the servicemembers and the families are of course very important, and spouses who are seeking treatment are in some ways in the same potential dilemma. Will this affect my husband's or my wife's career? Does this stigmatize me in my community somehow because we are not perceived to be tough enough?

    Dr. WINKENWERDER. I do not have those numbers for you right here, but I am sure that we can obtain them. We do track by visit-type what people are in for in terms of their medical care. Of course, we would know as well as we know the individual as to whether it was a family member of servicemember. So we will seek to obtain that data. You raise an interesting question, is there any change in the trend, and have we seen an increase or decrease or is it about the same.

    Typically, we do these types of efforts to plan for how many types of personnel we need to offer a certain kind of service. I can say that there has been a lot of planning in the last couple of years, particularly thinking about mental health and do we need more people. There has been some more hiring of people where we thought we would see more visits. Frankly, I think we probably have, but I need to get you the precise numbers and we will do that.

    Mr. UDALL. I think part of the argument I hear you all making on the panel is it is better, if you will, to employ a pound of prevention, wherever that point on the spectrum is reached, when trying to rebuild lives that are shattered or badly damaged.
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    We have asked you quite a bit about what you are doing. I want to give the secretaries, and then in turn if there is time, the general officers a chance to find out what the Congress could do to be more helpful. You have my permission, if you will, to talk about money if that is a part of the calculation.

    Secretary Kussman mentioned $2.5 billion to $3 billion a year. I think that is still a roughly small percentage of VA's budget, but I would welcome your comments about what the Congress can do.

    Dr. WINKENWERDER. We will take that for the record.

    I will say on the specific question of do we have the money we need, do we have the resources, my answer is yes. We have looked at the cost or what we think the costs will be for this new additional program which will require some resources. We think the number is under $100 million to pick up and take care of and see all of those who have redeployed since I think it was March of 2004, going back a full year. At some point we hope to touch everybody who has deployed who has not separated from the service.

    That is well within our reach. Fortunately in terms of our budget this year and last year, we have been able to manage effectively and actually return a few tens of millions of dollars back to our comptroller, so we are trying to anticipate our budget needs. So far, let's keep our fingers crossed, but we are doing just fine on that.

    Mr. UDALL. Secretary Kussman, do you have any comment?
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    Dr. KUSSMAN. Yes, sir. Thank you for the question.

    Obviously, we continue to monitor our needs. As you know, there was a lot of interest in the VA budget. We are very appreciative of the support of Congress and the administration to give us the resources that we need. We are continuing to look at mental health.

    We believe that we have a very robust mental health strategic plan. We believe we are kind of unique in that regard, in that it has over 200 initiatives in that. It is monitored by our own mental health people who look at potential gaps in our care. We then look at that and see how we can resource it appropriately. So we are very appreciative of the support that you all have given us.

    Mr. UDALL. Again, Mr. Chairman, let me just thank the panel.

    General Kiley, I thought you put it perfectly when you talked about the mental health re-set, and we can all help you spread that word.

    Mr. MCHUGH. I thank the gentleman.

    The gentlelady from Virginia, Ms. Davis?

    Mrs. DAVIS OF VIRGINIA. Thank you, Mr. Chairman.

    Thank you, gentlemen, for being here to testify on an issue that I know is probably one of the growing problems, not one that we want to be a problem, but nonetheless I think it is there.
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    Many of my questions have already been answered and asked. I think I heard Lieutenant General Kiley state you were hiring I think it was 40-plus more folks, if I heard correctly. And Lieutenant General Taylor said 30-some. So I would take it from that that we do have a shortage of mental health workers in the TRICARE system, but it is an issue that you are looking at and working on. Am I correct on that?

    General KILEY. My sense is that the adequacy of mental health resources both on our installations and in the communities that surround and support our installations frankly waxes and wanes due to a couple of issues. One is the ebb and flow of soldiers coming and going with their families. The second is that small numbers make a big difference, so that if we were to have a couple of additional psychologists in a community or a couple fewer psychologists, that can have a big impact on a community.

    I think it reflects the larger issues in the nation. If you go back 10 or 15 years and you look at how mental health has come to the forefront and mental health services have come to the forefront from the pharmaceuticals that went into the readiness of the American people to act to seek and gain some mental health resources, and then you look at the numbers of soldiers who have deployed over these last few years in combat operations, and our aggressive recognition of the likelihood that they have been impacted by that deployment, particularly tough combat, you come to the conclusion that there is a hidden population out there that still needs health care that we have to identify.

    We are doing that with our post-deployment reassessment, and now hopefully with my re-set we will even get to the point where everybody gets a little bit of it.
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    I cannot put my finger on one location, for example. I cannot put my finger on a subset, either the psychiatrist or psychologist or social workers who are or are not sure, but it requires constant monitoring and management, both at hospitals and at our regional commands and with the Department of Defense and Dr. Winkenwerder, and clearly Dr. Kussman at the VA. All of us are leaning forward on this to be alert.

    Mrs. DAVIS OF VIRGINIA. I take it you will come back that DOD has a plan in place?


    Mrs. DAVIS OF VIRGINIA. DOD has a plan in place so that we will not end up with a lot of potential problems in the future with the fine men and women in the military who are doing a dynamite job.

    And with that, General Kiley, let me ask you this. I know we have the OSCAR program in effect for the Marines. Is there any embedding program in the others services or is it just in the Marines?

    General KILEY. The Army has a very robust combat stress control operation with a whole series of teams. As I said in my opening comment, we have over 200 mental health providers who are in fact on special mental health teams. I visited one in Baghdad, and they are dispersed within the divisions and within the corps across both Iraq and Afghanistan.

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    I even have some numbers on that, a very significant number. They are numbered units, combat stress control teams, 30 to 40 personnel to include psychiatrists, psychologists, social workers and mental health technicians, our 91-xrays. They are very well embedded and have been in our Army inventory for going on 20 years now.

    What the MHAT–I showed and what we talked about a little bit earlier was their assessment was we needed more, and we put more in there. We sourced more into theater, sent more teams in, reserve and national guard and active. The results have been that they have made a big difference. They are very busy. In fact, their own mental health sometimes is something we have to keep an eye on. The divisions all have division psychiatrists on their staffs also, in the mental health division.

    So there is a lot of infrastructure in the battlefield talking to soldiers and leaders and first sergeants on a routine basis. Frankly, they drive the streets. They put themselves at risk sometimes getting from point A to point B. Very robust, yes, ma'am.

    Mrs. DAVIS OF VIRGINIA. My time is running out here. I know in the civilian world, the firefighters and police officers have to be debriefed after there are casualties or deaths or what have you. I know it has to be totally different in the military because you see a lot more death. Do you require the debriefings?

    General KILEY. I am not sure ''required'' is the right term, but I know that the CSCs and the mental health assets in our combat support hospitals in our divisions are very aggressive in doing exactly that, be it an accident, with a death in an accident; being it a tough firefight; and IED-type operation; very aggressive on a routine basis. Yes, ma'am.
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    Mrs. DAVIS OF VIRGINIA. Thank you. My time is up, gentlemen.

    Thank you, Mr. Chairman.

    Mr. MCHUGH. I thank the gentlelady.

    The gentleman from Massachusetts, Mr. Meehan?

    Mr. MEEHAN. Thank you, Mr. Chairman. Thank you very much for putting this hearing together. Obviously this is an extremely important issue to this panel, but to our men and women in uniform.

    There has been a lot discussed about the July 1, 2004 New England Journal of Medicine report. What struck me in the report is that of the soldiers deployed and Marines deployed in Iraq and Afghanistan, only 23 percent to 40 percent of those who tested positive for mental health disorder actually sought help. We have been talking today about, this morning about ways to get servicemembers at risk to seek help.

    Mr. Chairman, I worked with you and Mr. Snyder to include language in the defense authorization bill, fiscal year 2006, that would authorize the secretary of defense to initiate a mass media campaign to change attitudes within the armed services regarding mental health and substance abuse treatment, with the idea of lessening the stigma associated with addressing such problems.

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    I was struck by Admiral Arthur's comment that part of it is to get the leadership to say, look, I have had counseling. I am wondering if, number one, Dr. Winkenwerder, what your view is, how this media campaign above and beyond the Military OneSource, the confidential hotline, above and beyond that, what kind of a media campaign do you envision?

    Number two, I am interested, Admiral, as to whether or not the leadership training taking place to get leaders to say ''I have had counseling; we have to do it.'' It seems to me that that is a big step even for the leadership.

    Dr. WINKENWERDER. Let me take the first part of that question.

    We would welcome a media campaign. In fact, we are hoping to have such a campaign in the coming weeks to focus on the post-deployment health reassessment effort. Really, I would like to see it in USA Today and the papers that are on main street America, because we want to reach out to everybody, family members, all across the U.S.

    I think a great way to do that is with examples of individuals, the way in which reaching out helped them or what they needed to do or what they did not do. We are rolling into the implementation of this program. We have one Marine expeditionary force, a 12,000 group in California, that has just begun in the last couple of weeks, and another unit of Navy-Marine personnel at Great Lakes. We want to make sure we get some of the kinks worked out here over the next few weeks, but I would envision a campaign that would really reach out broadly.

    We would welcome anything you could do to help us. You asked what you could do to help. That would be something I would really welcome because we want to get the word out on this particular program, and I think that is maybe a window into talking about the issue more broadly.
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    You had another part of your question.

    Mr. MEEHAN. I am just wondering, Admiral, in terms of leadership whether there is any specific training to get leadership to come forward.

    Admiral ARTHUR. Absolutely. These embedded teams train the leaders as well as the junior troops. These embedded folks are not part of our medical department. They belong to the Marine Corps and it is the Marine Corps line establishment that established those embedded teams and are supporting them. So they well recognize the issues and what we need to do.

    There is one thing that bothers a lot of the Marines that I talk with after they return home, and that is the publicity that the effort in Iraq and Afghanistan gets. We see bombings every day and we see attacks on our forces. What we do not see is the sanitation and irrigation projects, the hospitals, the homes that are rebuilt and the stabilization efforts that are ongoing over there, and how we are rebuilding the country. Many of them say to me, you know, we are doing so much good work over there. We are building the country and all we see are the negative aspects of the war. I wish someone would recognize what I did with a shovel, not just with my M–16.

    Mr. MEEHAN. Dr. Kussman, you had indicated how Congress has been helpful with the VA, but in February of 2005 the GAO reported that officials at six of seven VA medical centers that it surveyed stated that they may not be able to meet the increased demand for PTSD services, and further the VA's own special advisory committee on post-traumatic stress disorder to improve mental health care for servicemembers returning from Iraq and Afghanistan, in its 2004 annual report noted that the VA's capacity to provide PTSD services had steadily eroded prior to the military operations beginning in Iraq and Afghanistan.
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    This committee also noted that PTSD services are lacking in many VA medical centers and are severely limited at community-based outpatient clinics. I am wondering, with more and more soldiers returning home in need of this care, obviously this is disturbing to see the GAO has concluded the VA not being prepared for this. Has progress been made since this GAO report was released? And what needs to be done to be in a position to meet the obviously high demand for these services?

    Dr. KUSSMAN. Yes, sir. Thank you.

    As I mentioned earlier when the chairman asked me, there was some controversy about that report. We believe, although we will not deny that there are some challenges obviously with things, the report did not take into account a lot of other resources within the VA including our rehabilitation counseling centers that provide a great deal of service with that. It was only a relatively narrow review of what services are available.

    Having said that, we always continue to assess what we are doing, took it to heart, and have increased with the undersecretary's leadership and in 2005 put another $100 million in for that. This will be continued in 2006 and 2007, to try to look at some of the gaps and particularly in the community-based outpatient clinics, we have put new performance standards in consistent with many of the same people, the seriously mental ill, the PTSD committees that made recommendations.

    They have been appreciative of what we are doing in that realm where depending on the size of the clinic, but if they have at least 1,500 people seen in that clinic, we want to be sure, and it is a rough measure, but that at least 10 percent of the workload there is identified as being mental health-related. That is a performance standard that has to be met by VISN. We are watching that and filling in the gaps and trying to hire people to meet that deficiency, as you noted.
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    Mr. MCHUGH. The time of the gentleman has expired.

    We do have a number of votes coming up. Dr. Snyder mentioned that he had another question or two. Maybe we can fit that in before the bells ring for the votes.

    Dr. SNYDER. Thank you, Mr. Chairman.

    Dr. Kussman, did I hear you right that you gave assurance to the committee that for Afghanistan and Iraq veterans that for the primary care appointment and then for any specialist appointment they are being seen within 30 days?

    Dr. KUSSMAN. Well, yes, that is the direction and the policy is that they are high priority and we will meet our standards. Obviously, if it is urgent or emergent, they will be seen in whatever the clinical situation dictates. But our goal, and we believe we are doing that fairly well, is to meet that requirement for that group of patients.

    Dr. SNYDER. That is a little bit different, when you said we are doing it fairly well and that is our direction and our policy, if I get a report in my office that somebody has come back and cannot get an appointment for 45 days.

    Dr. KUSSMAN. I never say ''always,'' but we believe that we are meeting that standard. We monitor that and I believe it is in the 90-some-odd percent range that is adhered to. I do not remember exactly what the number is for people that need appointments within that access standard.
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    Mrs. DAVIS OF VIRGINIA. Excuse me. Mr. Chairman, would you yield for a second?

    In getting that data, could you also supply us with information on follow-up visits? Because sometimes the initial visit they might get, but then it is very difficult to get the follow-up visits, and that would be helpful to see.

    Dr. KUSSMAN. We would be happy to.

    Mrs. DAVIS OF VIRGINIA. Thank you.

    Dr. SNYDER. Dr. Kussman, I want to understand how this process is supposed to work. Let's suppose I am at either the end of my tour in Iraq or I am going to be close to the end of my time in the military when I get back. I am going to be discharged from the service, but I know that I have some ongoing issues, some kind of health issue going on. I am in the process of arranging for my follow-up at my local VA hospital.

    So it is 2 1/2 months before my discharge date. I pick up the phone and call the VA or make some kind of contact with the VA. What is going to happen from that point on?

    Dr. KUSSMAN. Well, you know, obviously, sir, we do not see nonveterans. And so the person who is not a veteran would be a challenge to get that done prior to getting the DD–214. Having said that, we have a very robust benefits delivery at discharge and transition programs. A lot of services are available to the separating individual at that time to both get their benefits that they would get started on the paperwork process of getting the benefits that they may need when they leave through the process, getting appointments for their compensation and pension exams.
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    Dr. SNYDER. But haven't you just given an example of how we are not a seamless system? My example is I am somebody who knows I have health problems, and I have been told by my military doctors I need to be seen not in 45 days or 2 months. As soon as you get home, go see your doctors, go get established with a doctor at the VA. What you just told me is you are not going to look at anything until somebody walks in the door with a DD–214, which means they are disconnected from the service and they do not have a doctor and have not made an appointment for one.

    Why can't the system be that I call up two months early, or Dr. Taylor's or Dr. Arthur's designees call up the VA and say, I have this guy; he is going to be discharged in six weeks; we need him to have regular whatever. He needs to be seen that first week, and when can I tell him? I have to put an appointment in his hands so I know he is going to be seen. You are going to tell him, no, we will see him as soon as he gets his DD–214. That is not seamless care, if I understood what you are saying. That is what you say in your written testimony, too.

    Dr. KUSSMAN. Let me try to be a little more specific. Clearly, people who have entered the disability process and are being medically separated or discharged with medical conditions, we are outreaching as best we can to get those people enrolled early in anticipation of the discharge. The most specific that we have done with our seamless transition office and task force previously is to look at people who are significantly injured. We intend to expand that program and make it institutional where everybody who gets into the Physical Evaluation Board (PEB) process would have that same case management.

    If you are talking about the average soldier who just gets out of the military and is not medically separated or discharged, who wants to come to the VA, I mean, just the people who are medically separated and discharged is in the range I believe of 18,000 or 20,000 people a year. There are literally hundreds of thousands of people, I am not sure what the number of people is who separate from the military every year, to be sure that if they want an appointment it would be a great challenge to do that. But people who need it and that are being medically separated or discharged, it is our intent to provide that seamless transition for them.
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    Dr. SNYDER. Thank you, Mr. Chairman.

    It sounds like there is a bit of a seam there that I do not understand.

    Mr. MCHUGH. That is why we are here. I appreciate the gentleman's insight, and obviously as a physician, his particular expertise on the perspective.

    Gentlemen, thank you for being here. I appreciate it. As I said earlier, I think all of us have come to the agreement that is a universal understanding of the importance of this challenge, but I think as well there are some efforts that still need to be done to close the seams that are perhaps understandable, but necessary to be breached. We are looking forward to working with you.

    I would ask, as we have for most of you who have been kind enough to appear before the subcommittee in the past, that we will undoubtedly submit some written questions. We would deeply appreciate your most timely response to those so we can incorporate those into the record.

    With that, I will thank you one last time and allow you to go about your important day-to-day work, which is critical and we deeply appreciate that effort you put on behalf of the brave men and women in uniform and the veterans who have served so nobly.

    What timing. Thank you all very much.

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    Dr. WINKENWERDER. Thank you, Mr. Chairman. Thank you for your support.

    Mr. MCHUGH. At the risk of stating the obvious, obviously we are being called for votes. We are in pretty much agreement that we have been told that we will have four votes. I would say to the folks on the second panel, if you want to run down and grab some lunch, because they are 15-minute votes. This is probably going to be a half-hour, maybe a little bit more. I apologize, but we will be back. I thank you for your accommodation. Unfortunately, they do not ask us about scheduling votes. They just do it.

    If we can stand in recess until the return after the last vote.


    Mr. MCHUGH. The hearing will come back to order.

    I thank you all for your patience, particularly our panelists who have already spent quite a bit of time here since 11 o'clock this morning just waiting for this moment. We deeply appreciate your patience but also, more to the point, your willingness to come here today and to share your stories with us. We are very anxious to hear it.

    I know you all, I believe, had the opportunity to hear the first panel, those who are charged with providing the kinds of services and within the systems that you have first-hand experience. Your perspective on this is extraordinarily valuable to us. We all deal in theories and plans and program design and we do the best job we can there, but that far from guarantees access, far from guarantees effective service and such. So we are anxious to hear from you.
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    With that, let me just for the record introduce the second panel: Colonel Virgil Patterson, chief, Soldier and Family Support Branch, Army Medical Department Center and School.

    Thank you for being here.

    Captain K.C. Hughes, C Company, First Battalion, 46th Infantry, Fort Knox, Kentucky.

    Good to see you.

    Samantha Hughes, military spouse, Fort Knox, Kentucky, who shares a last name with Captain K.C. Hughes and it is not a coincidence. They are husband and wife. As I mentioned earlier, spouses are a critically important part of this team and in their own very important way they serve as well.

    So thank you for joining us.

    And also Specialist Stephanie Stretch, 233rd Military Police Company, Illinois National Guard.

    Very nice to see you, Specialist. Thanks for being here.

    With that, we do I believe have all of your formal statements. We do. And, without objection, they will all be entered into the record in their entirety, and we will leave it to you to present those statements in the way that you are most comfortable doing that.
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    So why don't we start in the order in which we introduced you and start with Colonel Patterson.

    Colonel, welcome, and thank you for being here, sir.


    Colonel PATTERSON. Thank you, Mr. Chairman.

    Mr. Chairman and distinguished Members of the committee, I wish to thank you for the opportunity to testify before you today about the extremely important topic of mental health of our armed forces. I am Colonel Virgil J. Patterson, social work consultant to the Army surgeon general, and team chief of the mental health advisory team that has deployed into Kuwait and Iraq twice and into Afghanistan.

    The Army surgeon general chartered the mental health advisory team for OIF–II in July of 2004 as a follow-up to the first team that went into Kuwait and Iraq in the summer of 2003. We were chartered to go back and re-look at the issues that we had found in the first iteration, as well as to assess the behavioral health needs, the training needs and how we were delivering the services within the theater. Also, we were asked to follow up and look at the implementation of the Army suicide prevention program in the OIF–II theater.

    The MHAT found that OIF–II soldiers, just like OIF–I soldiers, were experiencing numerous combat stressors. However, noncombat deployment stressors related to the quality of life had shown considerable improvement since OIF–I. Deployment length remained the leading concern about our soldiers in OIF–II. We found that the mental health and well-being of our soldiers in OIF–II had been significantly improved over OIF–I, reflected by a lower screening rate for mental health problems among the soldiers in OIF–II relative to OIF–I.
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    In OIF–II, we had 13 percent of our force screen positive for mental health disorders, i.e. anxiety, depression or acute stress reaction or PTSD symptomotology. In OIF–I, that was 18 percent. Our behavioral health care system had significantly improved compared with OIF–I. Our behavioral health providers were very actively involved in proactive outreach. We had, as General Kiley said in this morning's testimony, we increased the number of providers in-theater so that the number of providers, as well as the ratio of providers to soldiers had increased.

    Our providers were more evenly distributed so that access was easier in the theater. Forty percent of our soldiers who screened positive for a mental health problem reported having received professional help while in-theater. This was a significant improvement over the 29 percent that had received help who had screened positive for a mental health problem who had received help in OIF–I.

    Stigma and organizational borders to receiving care remain a concern for soldiers. Over half of our soldiers reported concerns with those issues. Over two-thirds of our soldiers reported that they had received training in handling the stressors of deployment. That was 69 percent, although only 41 percent felt that the training was adequate for mission needs. The good news message in that is that this is significantly higher than the 29 percent of the soldiers who reported receiving adequate training in OIF–I.

    Part of our mission was to follow up and see if the recommendations in OIF–I had been implemented. The majority of OIF–I mental health advisory team recommendations have been implemented or are in the process of being implemented. However, opportunities for improvements still exist in the OIF–II behavioral health system. The majority of these lie in the area of training for our personnel, access in removing barriers and stigma.
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    During the same 7-month period, 1 March through 30 September, 23 percent fewer soldiers were evacuated for psychiatric or behavioral health reasons during 2004 as there were in 2003, OIF–II versus OIF–I. We found that the community-based Army suicide prevention program objectives have been adopted and a unit suicide prevention program is evident at all OIF major commands of the combat units in Iraq, as we had recommended. The January through December 2004 suicide rate for soldiers deployed in OIF–II was 10.5 per 100,000 soldiers. That is lower than the calendar year 2003 rate for OIF–I and the recent Army historical rate over approximately a decade of 12 per 100,000 soldiers.

    Following our visit, we made a number of recommendations to the theater. We recommended that the OIF theater continue to improve awareness of mental health issues, access to care, and efforts to reduce stigma. We also recommended that the Army develop and assess the effectiveness of standardized training modules to prepare soldiers to handle the psychological demands of deployment- and combat-related stressors throughout the entire deployment cycle, pre-deployment, deployment and redeployment.

    We recommended that the Army Medical Department continue to support behavioral health services to soldiers by continuing forward-deployed outreach to our soldiers, ensuring that all behavioral health people can provide the full range of behavioral health services.

    We also recommended that the Army continuously assess how well the behavioral health needs of families are met in the rear.

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    I wish to thank you again for the opportunity to testify here today. I want to thank the committee and Congress for their interest in the well-being of our soldiers. I would like to emphasize that Army medicine is committed to ensuring that appropriate and accessible mental health care is available to all of our combat veterans. We will continue to seek improvement and do everything in our power to support our soldiers and their families. I thank you very much for the privilege of being here.

    [The prepared statement of Colonel Patterson can be found in the Appendix on page 118.]

    Mr. MCHUGH. Thank you very much, Colonel, for being here and your work, particularly as part of the MHAT team.

    Next, Captain K.C. Hughes, C Company, Fort Knox, Kentucky.

    Captain, thank you for being with us.


    Captain HUGHES. Thank you, Mr. Chairman. Thank you for giving Samantha and I a chance to share our experiences with you today.

    In April 2003, I deployed to Iraq as a scout platoon leader for the Third Armored Cavalry Regiment. My squadron was given the area of responsibility of Ar Ramadi and Fallujah later. On May 27, my platoon was attacked at the checkpoint and two of my soldiers were killed. Six more were wounded, including myself.
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    We were evacuated back to the U.S. and I was treated for a little while at Evans Army Community Hospital. When I was well enough, the Army allowed me to convalesce at my parents' home in Florida. It was in Florida when I began to notice that I had some problems. I began having sleepless nights and bad dreams. I began to feel depressed and guilty over my survival.

    After a month, I returned to Fort Carson and became the executive officer of our rear detachment. I also went to the behavioral health clinic to seek help for my depression. In August, I started talking to Samantha and I finally felt as if I had someone who could relate to how I was feeling. Samantha had had cancer and experienced some of the same guilt and depression issues that I was dealing with.

    After about a month, I really felt a lot better, but my nightmares continued. To make matters worse, when Samantha would try to wake me up, I would lash out at her physically and not remember anything.

    I felt that it was important that I get back to my unit, so in November I returned to Iraq. I was still bothered by bad dreams and growing concern that I would hurt Samantha. So I spoke to the squadron's combat stress team. They advised me to tell Samantha not to wake me up in the evenings, and if she noticed that I was having a dream, to go sleep somewhere else.

    In March 2004, I redeployed back to the states. Samantha and I got married and we moved to Fort Knox, Kentucky. My bad dreams continued and shortly after moving I had a real bad episode, so Samantha and I went to see behavioral health at Ireland Army Hospital at Fort Knox together. We were told not to shy away from the problem and speak more about it.
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    In an effort to do so, I wrote an article for Armor magazine and began to speak about the night of the attack. This has really helped me and Samantha out, and to date we have not had any more problems. I have never been criticized or chastised for my problems and seeking help has not been an issue for me or my career.

    I appreciate your listening to us today and our experiences, and I look forward to answering some of your questions.

    [The prepared statement of Captain Hughes can be found in the Appendix on page 126.]

    Mr. MCHUGH. Thank you very much, Captain.

    Mrs. Hughes, do you have something you would like to share with the subcommittee?

    Mrs. HUGHES. I could add a few details.

    Mr. MCHUGH. We would be delighted to hear them.


    Mrs. HUGHES. Thank you very much.
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    Good afternoon. K.C. summed up our story pretty good, but I will fill you in on a few details.

    Again, K.C. and I met in August 2003, shortly after he was wounded. At the time, he was struggling with his survivor's guilt. Because of my history with cancer, I had dealt with and experienced survivor's guilt and bouts of depression as well.

    I was able to recognize this in K.C. as well as relate with him on what he was going through. K.C. would occasionally have bad dreams. I knew he was having bad dreams because he would toss and turn, grit his teeth, breathe heavily, talk in his sleep. In an attempt to stop the dream, I would try to wake him, not knowing that he would act aggressively toward me. This happened a few times before K.C. redeployed to Iraq.

    When K.C. was in Iraq the second time, I was living with family in Cleveland, Ohio and I did not seek support from military services or family readiness groups at the time. K.C. and I decided that if the dreams continued, we would seek help together upon his return to the states. Once K.C. returned, the dreams continued. We started to notice that they were often provoked by triggers, perhaps talking about the event in great detail or watching a graphic program about the war.

    When K.C. was in Iraq, he spoke with the combat stress team and they suggested that I no longer wake K.C. during his nightmares. Instead, I should allow them to play out and remove myself from the situation. This helped us greatly and it seemed as if the problem was diminishing. Things were going well and dreams were fewer and far between. However, when we moved to Fort Knox, K.C. had two episodes that were far worse than anything he had experienced thus far.
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    K.C. began to walk and talk through his dreams. He had just as much strength in his sleep and he would in his waking hours. I was five months pregnant at the time and I felt the need to protect myself and my unborn child. K.C. and I felt that it would be best to seek counsel together at this time. We made appointments with the behavior health clinic at Fort Knox. We received good care and in fact they almost treated us immediately. Because of the counseling we have received, we have a better understanding of PTSD and how we can cope with it.

    Thank you very much.

    [The prepared statement of Mrs. Hughes can be found in the Appendix on page 132.]

    Mr. MCHUGH. Thank you.

    Again, thank you both for being here and your willingness to share your story with us.

    Specialist Stephanie Stretch, 233rd Military Police Company, Illinois National Guard.

    Specialist, thank you for being here.

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    Specialist STRETCH. I want to start off by thanking you for allowing me to come here and speak, not just for myself but for everybody in my unit at home.

    The year I spent in Iraq was an eye-opening event and life-changing experience. Months of heavy combat were stressful and an experience like no other. Combat takes a toll on soldiers, sleep becomes a luxury because of long hours at work and endless nightmares during the night. Loud noises, trash on the road and incoming fire from combatants become an everyday fear.

    Perhaps the most devastating incident I will ever witness was my own platoon leader hit by a roadside bomb. There was no help over there for us. There were no counselors for us to talk to. Nobody in our unit was trained. We did not receive training before we went over there on how to respond to these sorts of events.

    After our tour of duty, I returned home with anxiety and depression problems. After receiving an evaluation at the VA clinic, I was diagnosed with PTSD. This has been a debilitating diagnosis because I have trouble going to class because I am so tired from not sleeping for days. I cannot go out in large crowds without getting extremely nervous and having to be aware of all my situations.

    It took me about two months just to get into the VA clinic. That was two months of paperwork, calling them, finally getting in. After receiving my first appointment, I was diagnosed and they told me due to high volume of soldiers coming in, I probably would not be seen for months afterwards. I went downstairs and made an appointment and my first appointment was in February. I was not going to be seen again until June.
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    So I took it upon myself to go to a civilian doctor and spend my own money, realizing that going every few months was not going to help my situation at all. It is very expensive to go to a civilian doctor. I am a college student. I cannot afford TRICARE. I am using my parents' health insurance so I have to still pay a copay, but the VA hospital is not willing to help you with any of the expenses, like chiropractic bills. They do not offer chiropractic work at the VA hospital, so we have to pay for that out of our own hands, too.

    Due to the struggles of the VA hospital, it is kind of saddening because they want to help and they have good doctors, but you can't even get in to see the doctors. It is not just a problem that I have. It is a problem that about 100 percent of my unit has, whether they have to drive for hours just to get to the hospital and find out their appointment has been cancelled and drive all the way home. Or they just get there, they see a doctor once, and they cannot get in for another three months.

    I think that it needs to change and it can be improved, because they do have good medical to offer, but it is a serious, serious problem.

    I thank you for hearing me out.

    [The prepared statement of Specialist Stretch can be found in the Appendix on page 138.]

    Mr. MCHUGH. Thank you.

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    I want to start with our last two presenters, the captain and specialist. It seems we have kind of a different experience here. If we look at the data, clearly there are two different circumstances afoot. One is the 40 percent of those in-theater who felt they had adequate training as to availability, as to this stress disorder and what to be vigilant for, and those remaining who did not.

    Captain, I assume, but I do not want to so therefore I will ask, did you feel that your training on this issue was adequate? It seems in listening to your presentation, you were pretty well aware, and I commend you for making the determination that you needed help. That had to be a very difficult point to get to, in your own mind and that of your wife. But also, you were pretty much apprised both in-theater and back home as to what you could do and who was there to talk to and help, were the need there. Am I being accurate in that?

    Captain HUGHES. Yes, sir. Anytime there was an event that happened, a good firefight or something like that, combat stress would come down and speak to the unit on a small level. Specifically after my event, they came down and spoke to my platoon one by one. But anytime there was something like that, they let it be known that they were there and if anyone needed any help, that you could approach them over there for those problems.

    Additionally, the chaplain was always around to listen to the soldiers when they needed him. Then when we redeployed back to the United States, besides just the classes we got for redeployment on PTSD and integrating yourself back into your family, we were given contact information and 24-hour hotlines that you can call if you needed help. And the spouses get the same kind of classes back in the states at the FRG meetings.

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    So that stuff was readily known to myself at the time. When I came back the first time after being hurt, I was in the hospital system, so chaplains were always available to me. They were always informing me of where I can seek help, or if I needed to talk to someone, who I could talk to.

    Mr. MCHUGH. In both you and your wife, and I believe, Captain, you said this, felt that when you determined you wanted counseling and wanted someone to talk to, unlike what Specialist Stretch just said, you did not have one appointment then a four-month delay or an interminable wait to get that first appointment. The access was pretty immediate.

    Captain HUGHES. Yes.

    Mr. MCHUGH. At least immediate enough to your needs.

    Captain HUGHES. Yes, sir. I actually, when we made the call, for the second time when we went to Ireland Community Hospital at Fort Knox, I was at the captain's course so I was in class. We had talked about it that morning together, saying look, let's make an appointment. We need to figure this thing out. I said, Samantha, call and make us an appointment. She tried to call to make an appointment for me. She could not do it due to privacy issues, of course. So when I called, they said do you want to come in now, because you can just walk in, or we can schedule an appointment. I chose to schedule an appointment at the time, but had I wanted to I could have just walked in.

    Additionally, when we actually went in for the appointment together, the social worker felt I needed to see a psychologist that day. As soon as he was done with our session, I went out and sat in the waiting room for about five or ten minutes, and then was seen immediately by a psychologist right there at the behavioral health clinic.
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    Mr. MCHUGH. And you commented on this as well, but I think it is important to make sure the record shows it clearly. You heard us in the first panel talk a lot about the stigma of needing treatment for post-traumatic stress disorder and the unknowns of it. You do not feel there has been any kind of retribution, any kind of barriers put up against your career because of the challenges you faced and faced up to? I commend you for that.

    Captain HUGHES. No, sir. Actually, I said it in my statement, I actually wrote an article in the Armor community magazine saying, look, this is me. This is what I had. Commanders need to be aware that this issue is out there. Even though you are good in your classes, this is a fellow commander saying I have the issue. Your soldiers have the issue and it needs to be known.

    My battalion commander sat us down about a month-and-a-half ago, all the OIF and Afghanistan vets, sat us in our classroom and we sat down in a circle and he opened up saying, look, this is what happened when I was in Grenada and this is how I felt when I got home. When I redeployed to Afghanistan, this happened to me, too, and this is how I felt when I came home.

    Captain Hughes, do you have something to add? And I gave my testimony in front of all the soldiers. And then one of the other commanders gave his testimony and it was a very open environment for people to speak out and say look, this problem is here.

    Mr. MCHUGH. I really commend you for that article and for your articles, because that is what it takes. It takes an understanding to demystify it and to understand as well that it is treatable and understandable as long as there have been armies on the battlefield. There are things that can and should be done, and I compliment you.
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    Specialist, it sounds a little bit different than your experience.

    Specialist STRETCH. Yes, sir.

    Mr. MCHUGH. I am going to assume, and again I do not want to assume it, but you were one of the 59 percent to 60 percent of deployed soldiers who did not get adequate training as to this disorder and what resources were available. Is that a fair statement?

    Specialist STRETCH. Yes, sir. I do believe that it may have something to do with active duty and national guard. They see the advertisements for help because they have access to the channels and the newspapers. We do not. When we are overseas, if we needed help, they would go find a chaplain from a unit that wasn't even really, you know, just any available chaplain to come over and speak to us.

    Nobody in our unit was specifically trained to assist us with that. We were not necessarily trained going over there for anything like that. So we just do not, I think, have as much access to help and know as much information as the active Army does.

    Mr. MCHUGH. When you had your predeployment regular meetings, when you go for your weekend drills and your summer training et cetera, did anybody at anytime during a unit meeting say, you know, we ought to talk a little bit about health care and combat stress? Was that part of your training at all?

    Specialist STRETCH. Every now and then, like once a year, a spokesperson for TRICARE might come in for one of our drills.
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    Mr. MCHUGH. Right. Did that also mean might not?

    Specialist STRETCH. Yes.

    Mr. MCHUGH. Okay.

    Specialist STRETCH. And it is not really my unit's fault. It is who is in charge of getting this stuff done. Once we got to our mobilization station, they talked to us about health care and things like that. After we got back from being deployed, they also told us about health care and stuff, but they were not very clear. They told us about the VA hospital, but they did not tell us where to go, what benefits. They were not so clear.

    So a few months after being home, they actually scheduled somebody from the VA hospital to come to one of our drills to speak to us, just because people were not getting help because they were not sure where to go.

    Mr. MCHUGH. You heard the captain say a few moments ago, when they had a particular event while on patrol in-theater, someone would come over and talk to them. I will assume again, when the very understandably traumatic experience of seeing your unit commander lost to an IED, did anybody come unsolicited and talk to the unit?

    Specialist STRETCH. No. The chaplain talked to us, and our company commander, and people within my platoon, we tried to talk to each other, but we were all dealing with the same problem. While you were trying to support somebody else, it is hard to do that and be strong for yourself. So we just did not have access to the help that other people had.
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    Mr. MCHUGH. Thank you.

    Colonel, any comments on what you just heard?

    Colonel PATTERSON. Yes, sir. We found I guess two items that would be related to what she was just saying. You were in an MP company in the Army Reserve?

    Specialist STRETCH. Yes, sir.

    Colonel PATTERSON. When we looked at our data in OIF–II, we did break it down by type of unit and by component. We found that the prevalence of acute stress and PTS symptomotology among support units in the national guard and the Army Reserve was significantly higher than any other component across the board, even higher than in our combat arms, either in the reserve, national guard or active force. If we looked at screening for any mental health problem, anxiety, depression or PTSD symptomotology, that relationship remained the same.

    Having seen that data, we then went back and tried to ascertain if there were a training issue, something that we could differentiate based upon the data that we had, not that all the data that had would be the definitive answer, but just in what we had was there a difference that we noticed. We found that the perception of the support units in the national guard and in the Army Reserve of the level of training they had to prepare them for this particular deployment, for going to war, their perception of the level of training was lower than any other category, significantly lower within their own component or within any other component.
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    So the support units in the national guard and the support units in the Army Reserve felt that their training level, only 29 percent or 28 percent respectively, rated their level as high relative to the rest of the force, which was in the 50's and 60 percent.

    So we found those elements, and her story lends some support to that, that the training to prepare her unit to go into combat she felt was inadequate, and a significant portion of her colleagues in those types of units shared that view.

    Mr. MCHUGH. This is the MHAT–II study, not MHAT–I?


    Mr. MCHUGH. Did you have a specific recommendation in that study to address this issue? I have to tell you, I think you said they had the perception they were untrained. I think perception equals reality in this case. If that is their perception, obviously it is manifest.

    Colonel PATTERSON. I am trying to be very cautious——

    Mr. MCHUGH. I understand.

    Colonel PATTERSON [continuing]. To what the data says that I have and not draw conclusions for you.

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    Mr. MCHUGH. I will do that. You don't need to do that.

    Colonel PATTERSON. Thank you, sir.

    Our recommendation to the Army was to go back and look at the training that those components were receiving, how one trains, what one does to train. It was in transportation and support units in the national guard and reserve that we saw this pattern. In Iraq, transportation units, although they are not combat arms units, they are combat service support units, those units are experiencing very high rates of small arms fire, rocket fire and IED and car bomb explosions.

    Those are very traumatizing to the young transportation soldiers. Learning how to drive a truck, which was in the past part and parcel of what the MOS training for that specialty would have been, is not adequate to prepare them for that field.

    I cannot speak specifically about how that training has been modified. General Kiley addressed that this morning, that in the basic training that they all receive, convoy operations are part of that. I can address the training difference that the United States Army Training and Doctrine Command implemented at the beginning of this fiscal year. Before anyone deploys into theater, they have to have a train-up period. Even my team had to have a train-up period. As we deployed into Iraq twice, we iterated that training, which lasted a week, refresher training for us. That was in August of 2003 and 2004.

    By the time we returned to go to Afghanistan in January, the policy had changed and the training had doubled, and that entire second week of training was given with this type of training in mind, convoy operations, what to do in the case of an attack, emergency medical, et cetera.
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    So just from my personal experience, I have noticed that the Army did undertake significant effort to change the training. I am aware that they have changed the entry training, but I could not speak to that. Others will have to address that directly.

    Mr. MCHUGH. First, a point. Your comments certainly underscore the new challenges associated with an asymmetrical battlefield, because combat support is almost a misnomer anymore. Technically, you are supporting combat arms, but in many cases you are right side by side with them. I think Specialist Stretch's experience kind of underscores that.

    You did a follow-up as to an assessment of the Army's implementation of the recommendations under MHAT–I. It was pretty thorough and it was pretty favorable.

    Colonel PATTERSON. Yes, sir.

    Mr. MCHUGH. Are you going to do a similar completion on MHAT–II recommendations at some point?

    Colonel PATTERSON. Yes, sir. We on a quarterly basis monitor the progress on the recommendations that we have made and report that to the surgeon general.

    Mr. MCHUGH. And that is going to continue for some period?

    Colonel PATTERSON. Yes, until the recommendations are completed.
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    Mr. MCHUGH. Okay. Thank you.

    Dr. Snyder.

    Dr. SNYDER. Thank you, Mr. Chairman.

    The four of you were here this morning during the first panel. Do any of you have any comments about anything that you heard from the other folks? They are not here now, so they are not going to know what you said. Anything you want to amplify on or add a personal experience to or disagree with or agree with?

    Specialist STRETCH. I disagree with pretty much everything they said. All the help they are talking about getting while overseas, I had never heard of any of it, like the Web site they were talking about and the hotline to call. I never heard of it. They said that there were stress teams that came over to help you, and they not only helped you with your stress, but improved your morale. I never saw those. They talked about the VA sending a letter to everybody that had been overseas. I never got a letter. I don't know if they were just generalizing or maybe my unit is special or something, but I did not know about half the stuff they were talking about.

    Dr. SNYDER. Specialist, where are you at now? Are you still on active duty?

    Specialist STRETCH. I am in the national guard, so we just still drill one weekend a month.
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    Dr. SNYDER. You are still drilling. So when did your activation end?

    Specialist STRETCH. April of 2004.

    Dr. SNYDER. In 2004.

    Colonel Patterson, the issue about the level of training in anticipation of this, and the percent that said it was satisfactory and the percent that didn't. Two-thirds got the training, which means that one-third did not get any training. And then of that, a substantially smaller number said that the training was adequate.

    Isn't it a fair statement to say, we are never going to hit 100 percent on this kind of a thing? You are trying to prepare people for the horrors of war. How can you compare Captain Hughes losing two of his buddies, his friends. The training is important, but I do not see how any person is going to come out of that kind of experience and say I saw these terrible events and was hurt myself, but hey, you know what, that training we got back at Fort Benning was adequate. I do not see that happening. Do you?

    Colonel PATTERSON. I do not believe that any human experience prepares one for the horrors of war. Anyone who has been a live combat situation sees things that you do not see in the normal walk of life.

    Dr. SNYDER. I think that we ought to, we all need to acknowledge that reality. One of these guys in here talked about, someone had a phrase something like combat has some inherent stressors which I think is a way of saying war is hell and it is very hard to prepare for that kind of hellacious experience that people have gone through.
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    I was going to ask about seamlessness. I think the specialist answered that. Mr. Chairman, she saw a lot of seams in her experience there.

    Mrs. Hughes, I want to be sure I understand about this appointment that you could have made. We deal with you all as a family as much as we can, but I also understand the importance of medical privacy. It is not clear to me why you were calling and they said no, he would have to make the appointment.

    You obviously had things going on in your life, and that you could not have said okay, here is the deal. Let me make the appointment. I am going to make it for Samantha Hughes. And by the way, I might bring my husband along if I can drag his butt out of here with me. I mean, that would not have been a violation of medical privacy. Would that not have been a reasonable way to handle it, or am I missing something here?

    Mrs. HUGHES. I actually attempted that. They would not allow me to make the appointment. I even went as far as to say, well, it is for myself and I am going to bring my husband along. He is having some PTSD issues and we would like to talk about it together. They referred me to marriage counseling, but would not allow us to come to the behavioral health clinic at that point. So he actually needed to make the appointment on his own because of privacy issues, which I do understand.

    I make a majority of his health appointments because he is very busy in his command and it is easy for me to call during the day, being at home, but this was an exception.
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    Dr. SNYDER. But you are also entitled to your medical privacy. I guess I don't understand why you would not have been able to make an appointment and bring along your spouse.

    Mrs. HUGHES. I am not sure exactly why. Fortunately for me, my husband admits that he has a problem with this and it was okay for him to call and say, okay, I am going to make that appointment for both of us to come in and speak. So I am very thankful that he admits this, but I am assuming, and I think I am assuming correctly, that there are probably many wives out there where their husbands do not admit that they have a problem and are unable to make an appointment for the both of them to go in and speak with a psychiatrist or psychologist about this issue.

    My recommendation is, and I am sure that these already exist and I am unaware of them, that maybe there is some sort of support group or something where the family could call on behalf of the soldier.

    Dr. SNYDER. Captain Hughes and Specialist Stretch, where are you all at in your military careers?

    Captain HUGHES. I am a company commander right now for a basic combat training unit, sir. I have been in for four years. I have a very successful career right now. I am a four-year commander.

    Dr. SNYDER. Are you planning to make it a career?
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    Captain HUGHES. I have not decided that yet, sir.

    Dr. SNYDER. How about you, Specialist?

    Specialist STRETCH. I have also been in for four years. I just switched over to our headquarters, part of our MP unit, so I work directly with the commander now. If we got redeployed, I would be a driver or——

    Dr. SNYDER. My last question, would each of you comment just from your experience of being part of the military family. We have not talked much about drug and alcohol addiction today. Would you all comment about, just from your personal experience, and recognizing that at least three of you are not medical or mental health professionals, about whether you think that is a problem within the military today, addictions?

    Colonel PATTERSON. Whether we think addiction is a problem?

    Dr. SNYDER. Addictions, yes.

    Colonel PATTERSON. I think we have a number of soldiers in the force who abuse alcohol and other drugs. Even with our urine testing, we have a very small percentage, even as heavily as you have in the urine testing program, there is still a very small percentage that will test positive for illegal drugs. We have a very active substance abuse treatment program for people who have problems.

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    Captain HUGHES. Sir, I think in my opinion the Army is a good picture of the community as a whole. Personally, every community is going to have problems with drugs and alcohol addiction. I don't personally see that being any different than the problems that are in the community itself.

    Mrs. HUGHES. I am unaware. It is not in our household, so it is hard to say how it is in everybody's household. It is behind closed doors.

    Specialist STRETCH. I pretty much agree with those, too. It is maybe not a prevalent problem, but someone is always going to have that problem. So I think you are going to run into that anyway.

    Dr. SNYDER. Thank you all for being here. We appreciate your contribution.

    Mr. MCHUGH. I thank the gentleman.

    The gentlelady from Virginia, Ms. Drake?

    Mrs. DRAKE. Thank you, Mr. Chairman.

    I would certainly like to thank each one of you for being here and for having the courage to share your stories and to come forward. So thank you very much for that. I think it is really compelling the difference between panel one and your panel. You must be sitting there thinking, boy, what they think is happening really is not happening at all. That is sort of the feeling that I take away from it.
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    But, Captain Hughes, to start with, and your wife pointed it out, part of what my first question was to the first panel was about people that do not seek help or will not admit that they have a problem. You have just heard that she could not even arrange an appointment. But if you will remember, the answer to me was very lengthy talking about everything the military does to seek men and women out, where Captain Hughes in your written testimony, you said in the end it is up to the soldier to seek it out. So you apparently did not feel they were seeking you out.

    Did you or Specialist Stretch, did you do any of these surveys that they kept talking about, a survey before you go? So you did fill those out.

    Captain HUGHES. Yes, ma'am. I filled it out twice, when I was in the fleet hospital in Rota, Spain because I took a different route to the states. I did not go to Landstuhl and then back. While I was in the hospital bed, I filled one out and it sent red flags up like crazy because I had just come from a traumatic event. As soon as I turned it in, about ten minutes later there was a chaplain next to my bed, and shortly after that a psychologist standing next to my bed as well.

    And then on the way back, I had the privilege of acting as the squadron's personnel officer, so I was personally responsible for making sure I was able to manifest all 1,000, and it was 900-something soldiers in the squadron, and get them back. Part of that process was a Deployment Soldier Readiness Program (DSRP) process of meeting all these requirements. They had to go and attend a number of briefings. The mental health questionnaire was one of them. The family advocacy briefings and all these other things were all part of the DSRP process, so I know that while I personally filled it out myself, I know that all the 900 and however many soldiers in my squadron also filled that out. It was a mandatory requirement to redeploy.
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    Mrs. DRAKE. But even though you sent up red flags, it sounds like you really put a real effort into getting the help you eventually got. And you didn't get it right then?

    Captain HUGHES. No, I did seek. I immediately spoke to a chaplain there and they sat down with me and sat next to me and we talked about things. He educated me on what PTSD was and when I get back to my unit back in the states, you should go talk to behavioral health and look for things that bother you. If they bother you, if you need to avoid them, avoid them, those kinds of things. So he sat down, but I was only going to be in Rota, Spain for two or three days until I moved on to the next hospital on my way back to the states.

    Mrs. DRAKE. Specialist, how did yours go with surveys?

    Specialist STRETCH. Our survey was a little different. We had to fill one out after we got back from overseas.

    Mrs. DRAKE. Not before you went?

    Specialist STRETCH. I believe we filled one out while we were overseas, like kind of middle of the way, but then we had to fill one out when we got back. A lot of people lied on the survey because they told us, please tell us if you are having problems; no repercussions are going to come out of this. Yet if you were to say you had a mental or emotional problem, you were going to be held at the mobilization station for two to three months until they thought you were better. As an MP, we had the possibility of losing our security clearance. They would take your weapons away. I mean, they basically secluded you.
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    We had all been gone for a year. Nobody wanted to stay there for two more months. They knew they had a problem, but it was something they could get taken care of. So instead of putting down that we had problems on the survey, we usually just kind of looked over it and say I will deal with this when I get home because I am not going to spend three more months here and probably not get the help I need.

    Mrs. DRAKE. I kind of wondered how effective a survey would be if the people did not want you to know that there was a problem.

    Specialist STRETCH. Right.

    Mrs. DRAKE. Where, Captain Hughes, I think you were honest with your answers.

    Colonel Patterson, I understand your answer about training was different for Captain Hughes and for Specialist Stretch, but why was there such a difference about having professionals embedded to help them with mental health issues? It sounds like there was a lot of support in Captain Hughes's situation, but we had a major event and a leader killed with Specialist Stretch, and I am sure that medical people came, but obviously no one came to help them with mental health issues. We heard a lot about people being embedded in-theater, so I did not know why someone was not moved in to help them.

    Colonel PATTERSON. I do not know that I can answer that question specifically. I know that in the force structure not all units have embedded mental health assets within them.
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    Mrs. DRAKE. No, but wouldn't you have people available in-theater that could be moved into help a unit with this problem?

    Colonel PATTERSON. Yes, ma'am. We have our combat stress control units. Most of our tactical combat units have embedded mental health assets within them. Our divisions have a mental health section composed of a psychiatrist, a psychologist, a social work officer and six or eight 91-xrays or mental health specialists. Most of our separate brigades have a mental health officer and a mental health specialist assigned to them, but not all of them have that structure.

    To augment where there is a shortage, our combat stress control units have a geographical or an area responsibility to reach out. So yes, ma'am, there should have been.

    Mrs. DRAKE. Can you find out for us why they had no one and just let us know in the future? I would appreciate that.

    Thank you, Mr. Chairman. I yield back. I am sure my time is up. Thank you.

    Mr. MCHUGH. I thank the gentlelady.

    The gentleman from North Carolina just stepped out. I am not aware that he will be back.

    Well, Colonel, you mentioned that you did do an analysis on combat support unit perceptions versus active in the combat arms. So I am assuming that your data does not just take across-the-board 60-plus percent were trained; 40 percent adequately. You actually discerned the differences between all of the various segments, active, guard, reserve, combat, combat support, et cetera. Is that correct? Obviously, you did one category.
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    Colonel PATTERSON. Yes, sir. In some categories, we did, as we were analyzing the data, and the screening positive for mental health disorders is an example. In the aggregate, there was no significant difference between the active and the reserve component, but our curiosity was spiked and we wanted to see if we looked at type of unit, which would explain the type of experiences.

    Our data shows that combat experiences are those experiences that correlate with screening positive for mental health problems. The more frequent and the more that one has, the higher the risk of having a mental health problem. So we wanted to see if, based upon type of experiences by type of unit, if that hypothesis held and we found that it did. What surprised us was our transporters and support personnel, and that is when we began digging in and seeing if we could identify what were the factors that led to that anomaly of what we were not expecting.

    Mr. MCHUGH. So it is consistent in the combat support regardless of if you are active versus reserve?

    Colonel PATTERSON. No, sir. The rates were not different in the combat support among the active, but among the national guard units.

    Mr. MCHUGH. Only the national guard.

    Colonel PATTERSON. There is a fairly lengthy discussion of that in the report itself.
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    Mr. MCHUGH. Do you have any observations or perceptions as to accessibility through the VA for people like the specialist when he or she redeploys back home? You may have heard the question to the secretary on the first panel. The biggest concern we hear repeatedly is that the VA does not have sufficient professional staff available to see folks like Specialist Stretch in a timely manner upon need. You heard the response to that, but do you have any perspective on that?

    Colonel PATTERSON. Not beyond Dr. Kussman's.

    Mr. MCHUGH. I am sorry?

    Colonel PATTERSON. Not beyond what Dr. Kussman has said. No, sir, I am sorry.

    Mr. MCHUGH. That is all right.

    Colonel PATTERSON. In all honesty, I live in San Antonio, Texas. My wife works at Audie Murphy Veterans Hospital. The access there, we have several military bases and we have a VA hospital there. When you have that type of resources, access is not an issue. Where the specialist is located, access becomes an issue. In all honesty, from my perspective and the Army Medical Department, it is a major concern we have is the access to care for our reserve and national guard soldiers who return home and then may not have those resources readily available to them.

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    Mr. MCHUGH. Which also goes back to the fact that the TRICARE standard, which is what many of them use, we do not have a good assessment data-wise as to how many professionals are actually available. Dr. Winkenwerder and I kind of discussed that. So we do have a ways to go.

    Specialist, where are you stationed versus where is the VA center?

    Specialist STRETCH. The VA hospital I go to is actually only about ten minutes from my house. But I know in our state, I think there are only five or six VA hospitals and they are all relatively big. I know at the hospital we go to, we have people coming in from hours away because it is the closest one to them. So maybe it is overpopulated because they have so many people coming, but then again, I do not know.

    Mr. MCHUGH. Can you give me the name of the VA?

    Specialist STRETCH. It is in Marion, Illinois.

    Mr. MCHUGH. Marion, Illinois. Okay. Thank you.

    Dr. Snyder, do you have anything further?

    Dr. SNYDER. One comment I might make, Mr. Chairman, which is consistent with what you have said many times before, which is, Colonel Patterson pointed out that the improvement in morale related to predictability of deployment. You have been talking for some time about the need for additional troops. I think part of what we have been hearing today is, some of the things we have heard today is probably consistent with the fact that we went to the well too often with some of these troops so they did not have the predictability we would like to have had in getting back to their families.
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    Thank you.

    Mr. MCHUGH. I thank the gentleman.

    It is always tempting to look for an overall total panacea. Neither I, nor do you, want to portray troops and end-strength in that way, but clearly its ugly head keeps raising itself for a variety of these issues, and I think this is another one as well.

    Let me just say to Captain Hughes, Mrs. Hughes and Specialist Stretch, is there anything that you think we could do, and forget jurisdictions and does the legislature or Congress have the power. I think it is pretty obvious what the specialist would like to see happen, given her rather less than stellar exposure. Clearly, we do need to do some things there. But as good as you felt the programs were, is there anything that you would have preferred work better?

    I suspect Mrs. Hughes would say, you know, I ought to be able to make my own appointment and bring my husband along, because I suspect if you were the military member, Mrs. Hughes, and you made that call and said I am going to bring my husband along, and he were a civilian, that would be okay. I do not know that, but I bet it would. So that is probably a complaint.

    Don't you like how I ask you a question and then I answer it. If you do, we would appreciate hearing that.

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    Captain HUGHES. I think Vice Admiral Arthur stated a really good point earlier about the command climate. It is really important in this kind of topic. If your command climate is informal to the point where you can say I have a problem, then there is no issue with PTSD because these soldiers will seek the care. But if you are in an environment where your command does not make that an open topic, then soldiers will seek to do it other ways, or not seek to do it, and that is obviously the wrong thing to do.

    If I had chosen to be quiet about this, I could have been quiet about this and everything would have been completely confidential about my care. I just chose because I realized the problem with PTSD is that it is something that unless the soldier himself or herself claims that they have it and goes and seeks help, nothing will be done.

    So I think Vice Admiral Arthur, his point about command climate is very important. It probably, in my opinion, is the most important part of fixing the Army's problem with PTSD.

    Mr. MCHUGH. A point well taken.

    Now, both of you bring a shared and largely good news perspective in that, as you just said, Captain, and as the specialist's presence here suggests. Good folks like you are willing to step forward and talk about it, the demystification again, and all of us thank you very, very much for having the courage to do that. It does take some courage. It shouldn't, unfortunately, but it does.

    The other is that you are kind of a tale of two cities in that you and the colonel and the captain and Mrs. Hughes show the better news side, and how it can work, and for soldiers and sailors and airmen and Marines out there to know that that help is there through your experiences, that is positive. On the other hand, the specialist shows that we have a lot of work to do. My own perspective is particularly for the guard and reserve component. I think it was very important that you be here to help us focus on that as well.
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    Colonel, thank you for that. I commend the Army and I commend you as a leader in the MHAT process of stepping forward and taking up a very difficult issue that obviously, as no one knows better than you, Colonel, needs to be addressed, and to the extent your service does that we need that as well.

    So thank you all for being here. There may be, not that you do not have enough to do in your lives, but there may be some written questions that we are in a position to send those along to you. To the best of your ability, we would appreciate your responding so that we can fill out the hearing record. If you have any further thoughts in the future, let us know. We deeply appreciate your service and we are honored by your being here today.

    Thank you for helping us try to do our job a little bit better.

    With that, the subcommittee is adjourned.

    [Whereupon, at 2:15 p.m., the subcommittee was adjourned.]



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Table 1