SPEAKERS CONTENTS INSERTS Tables
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29–556
2006
[H.A.S.C. No. 109–64]
MENTAL HEALTH
HEARING
BEFORE THE
MILITARY PERSONNEL SUBCOMMITTEE
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
HEARING HELD
JULY 26, 2005
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MILITARY PERSONNEL SUBCOMMITTEE
JOHN M. MCHUGH, New York, Chairman
JO ANN DAVIS, Virginia
JOHN KLINE, Minnesota
THELMA DRAKE, Virginia
MICHAEL CONAWAY, Texas
JIM SAXTON, New Jersey
WALTER B. JONES, North Carolina
JIM RYUN, Kansas
ROBIN HAYES, North Carolina
VIC SNYDER, Arkansas
MARTY MEEHAN, Massachusetts
LORETTA SANCHEZ, California
ROBERT ANDREWS, New Jersey
SUSAN A. DAVIS, California
MARK UDALL, Colorado
CYNTHIA MCKINNEY, Georgia
JEANETTE JAMES, Professional Staff Member
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DEBRA WADA, Professional Staff Member
JENNIFER GUY, Staff Assistant
C O N T E N T S
CHRONOLOGICAL LIST OF HEARINGS
2005
HEARING:
Tuesday, July 26, 2005, Mental Health
APPENDIX:
Tuesday, July 26, 2005
TUESDAY, JULY 26, 2005
MENTAL HEALTH
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
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
WITNESSES
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
APPENDIX
PREPARED STATEMENTS:
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.
DOCUMENTS SUBMITTED FOR THE RECORD:
[There were no Documents submitted.]
QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD:
[There were no Questions submitted.]
MENTAL HEALTH
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.
OPENING STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE FROM NEW YORK, CHAIRMAN, MILITARY PERSONNEL SUBCOMMITTEE
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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STATEMENT OF HON. VIC SNYDER, A REPRESENTATIVE FROM ARKANSAS, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE
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.
STATEMENT OF HON. WILLIAM WINKENWERDER, JR., M.D., ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS
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.
STATEMENT OF HON. MICHAEL J. KUSSMAN, M.D., DEPUTY UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS
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.
STATEMENT OF LT. GEN. KEVIN C. KILEY, M.D., THE SURGEON GENERAL, U.S. ARMY
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.
STATEMENT OF VICE ADM. DONALD C. ARTHUR, MEDICAL CORPS, SURGEON GENERAL, U.S. NAVY
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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.
STATEMENT OF LT. GEN. GEORGE P. TAYLOR, JR., SURGEON GENERAL, DEPARTMENT OF THE AIR FORCE, U.S. AIR FORCE
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.
Dr. WINKENWERDER. Yes.
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?
Dr. WINKENWERDER. Yes.
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-