call the hearing to order i'd like to welcome everyone here to the subcommittee on how hearing we are here today to talk about p t s d treatment and research in the department of veteran affairs post traumatic stress disorder is among the most common diagnosed i know says made by the veterans health administration of the approximately three hundred thousand veterans operation during iraqi freedom  access to v a health care nearly twenty percent sixty thousand veterans have received a pulmonary diagnosis of p t s d the v a also continues to treat veterans from vietnam and other conflicts who will continue to work with me in supporting p t s d research programs i look forward to hearing testimony today from several organizations that are working to provide a comprehensive and cutting edge working to provide treatment for p t s d recognizes that this is an important issue and one that will will be working well for some long time to come we are committed to ensuring that all veterans receive the best possible treatment when they go to the v a and that's one of the reasons why we're having this hearing today will have several more hearings dealing with p t s d because this is an important issue an issue that there are still a lot of unanswered questions so i look forward to the testimony here today and i would like to recognize mr brown for any opening statement he might have to thank mr chairman for a very prominent injury that our veterans endure that is precisely why today's hearing is so critical we must continue to focus on how to best strengthen research and rapidly disseminate affective clinical care in all settings so we can finally understand this illness break through it and move forward with complete recovery bringing relief to the many heroic veterans who still fight daily battles no less harrowing than the ones they fought in to our veterans and and your hard work we are fortunate to have this opportunity today to discuss the impact of p t s d and what is having on returning troops that are better and their families and i look forward to hearing the testimony of the expert to join us you know i want to thank them for i want to thank you colonel for your dedication to our service men and women and thank you for the service your service to our country i think an important part of our discussion today will be to hear about the research on p t s d cases in vietnam and the soldiers i think it's important to look at both individually and in comparison to one another i also look forward to hearing about the research that is done on exposure therapy innovative and new treatments are essential to the health of our veterans in our current forces are veterans deserve to know that once they leave the battlefield and return home that we have programs in place to take care of them mr chairman i want to chairman and thank you very much for holding this hearing today and i think the ranking member also for being here with us this morning today's the third hearing that this subcommittee has had examinee mental health for our veterans brave men and women who will not have access to the a treatment because they were discharged from the military because of a v a of a so called preexisting person ali disorder not p t s d from their service the secretary defense is today required to submit a report to the armed services committee evaluating the efficiency and fairness of this practice and as we talk about the different treatment and research being done i would ask all the members of this committee all the people here today all the panel members keep those soldiers in mind who are fighting their battle against p t s d alone without access to the benefit of v a health care they have earned i spoke to a young man  illinois who was had severe problems when he came back and was asked and ordered i should say to have his realism and bonus with interest paid back this is a young man who gave everything he had to this nation and is now because of the conditions that he has working two days a week at a subway sandwich place because he can't hold full time employment we can do much better that mr chairman for our veterans we owe it to them and as times prior to deployment and he does not have don't believe personality disorder preexisting conditions it was a terrible way to treat somebody and to think that there are twenty two thousand people like louis out there i think is a  o this committee recognizes finally and i think that our nation has truly ignored this issue for many many many years and for many many wars there are three thousand of the armed forces on active knowledge significant problem with substance abuse i don't think it is lost on anybody that our veterans need to receive the help that they need to deal with these  issues a constituent of mine and i've mentioned this before but lance corporal justin bailey returned from iraq with p t s d he developed a substance abuse disorder his family his loving parents improve the treatment and services provided by the department of veterans affairs to veterans with p t s d and substance abuse disorders in the interest of time i will not read the different sections of this bill but i would like to urge in my opinion and i had dinner last night with an old friend of mine from northern nevada who is a vietnam vet known him since we were high school different parts of the state being here i think this is my third testimony to this committee and i was thinking about what is news since the last time that i testified and wanted to share a little bit about the about three different efforts that we've recently published just in the last six months that have that answer some fundamental questions about the importance of p t s d in our service members coming  home i'm going to focus my comments on the wonderful work of my very dedicated team at walter reed army institute of research but i want to acknowledge upfront and thank you and other members of congress for the appropriation f y o seven appropriation of three hundred million dollars for p t s d and t b i research which is now in the process of being distributed through grant mechanisms managed by medical research and material command at fort dietrich to a variety the relationship of answers that they gave on the first assessment with the answers they gave on the second assessment and i think that you know we've clear really confirmed the importance of that second assessment particularly for our reserve component service members  between active component reserve not apparent when they first return they look exactly the same but about six months later you see this difference emerge there's a variety of possible reasons for that thing i'd like to comment on has to do with the multiple deployments and the dwell time we've just recently released our report the mental health advisory team this is an unprecedented afeard to  are that multiple deployments that there is a direct relationship between the number deployments and the psychological well being of service members those who are on their third deployment in iraq had a nearly to iraq so there's a clear linear relationship that's actually fairly hard it's a little bit more difficult to show that relationship after they return from deployment because there's an attrition there's an association of mental health second thing that we learned from the five was that those soldiers serving in afghanistan and brigade combat teams are experiencing rates of combat and mental health rates very comparable to those soldiers serving in brigade combat teams in iraq so that's a fairly new development in the last year the third study that i'd like to comment on briefly is the publication we just published january thirty first in new england journal of medicine having to do with the relationship of mild traumatic brain injury and there's i think been a bit of confusion and i want to clarify terminology mild traumatic brain injuries exactly the same thing as concussion what is often reported and news media for instance is up to twenty percent of service members coming back from iraq have traumatic brain injury and often seriously injured seriously brain injured individual and it's often not made clear that the vast majority of those soldiers and service members being labeled as having traumatic brain injury in fact have had concussions what soldiers refer to as getting their bell rung or athletes or for getting their bell rung a concussion is an injury where there's a blow to the head or a jolt to the head the results in brief loss of consciousness or a brief alteration or change in consciousness there may be a memory gap that lasts for a few hours  the expectation there is expectation of full recovery after concussion and that's very different than moderate and severe traumatic brain injuries which almost always result in evacuation from theater and  about potential long term effects of mild traumatic brain injury possibly in association with blast exposures and some of these types of the types of symptoms the service members are have coming back are things like headaches irritability concentration problems memory problems and so our study looked to see what the relationship of those types of symptoms when service members came home to having a concussion and theater and what we learned was that it was a somewhat surprising finding to us was that p t s d and depression was actually what was what we could attribute the symptoms to is very difficult to attribute the symptoms that alters with concussions directly to the  concussion what we found was that the vast majority of these physical health symptoms and post concussive symptoms occurred in soldiers with p t s d and there was a very strong relationship between having a concussion in iraq and developing p t s d our the unfortunate truth is that we really don't have a definitive diagnostic test that can tell us definitively who had a concussion or whether symptoms of soldiers are having in the post deployment period are in fact due to that concussion and that makes it very difficult to do screening and know with accuracy what the cause of the symptoms are the major implication are finding is th soldier coming back and getting post employment screening that there is a risk that they may get as having brain injury when in fact the real problem is post traumatic stress or depression p t s d depression i think a happening in iraq is when a soldier suffers a concussion that's a very life threatening experience in that context of a concussion on the battlefield that very life threatening traumatic experience then sets up the potential for p and depression and then p t s d and depression can lead to the physical health consequences for a variety of mechanisms i also just i guess i'm a little bit over time but i just wanted to mention that  of the issues with the multiple deployments dwell time on soldiers come back we've learned from the research that we've done the twelve months is not sufficient for soldiers to quote unquote reset and be ready to go those very things things that we label symptoms when they come home and get them in trouble and can interfere with their functioning when they come home and their relationships when they come home those symptoms of p t s d are in fact often necessary  adaptive mechanisms that they need in combat they need the sleep deprivation the ability to to the hyper alert state that they have to maintain for a long period of time so we're asking a lot of our service members when  they when we ask them to transition and sort of turn on and turn off these skills and it's i think a little bit unreal and in fact our data have shown that the rates of increase over the first year they don't decrease they do decrease for a certain percentage of individuals but then there's the other individuals who manifest the symptoms as the year goes on so i think that the  lessons that we've learned have to do with this relationship of p t s d and mild t b i some things about multiple deployments and dwell time and some lessons learned from post on the health assessment thank you very much for the opportunity to  discuss this with you thank you very much colonel for your testimony this morning in your rundown of current d o d p t s d research programs do you see any gaps in the gap in research has to do with clinical trials of the the efficacy of psychotherapy and medication trials and understanding exactly what the elements of psychotherapy are that are effective and what works what doesn't work establishing group therapy practices that are effective we've not been able to show necessarily the effectiveness of group therapy the way we have for individual therapy so there's a lot of questions within the psychotherapy and medication treatment arena that are huge gaps in that area and i think that  with helping soldiers to transition through educational program called battle mind and we showed that to be moderately effective particularly for those soldiers with with the highest levels of combat  experiences but it was it was not you know it was not it didn't have the effectiveness that we'd like to see and so we're working my team is working on developing an advanced version of that that we hope to be able to to test in a field trial and then in the coming time period i think that there's i actually don't know to what extent and how many clinical trials are going to be funded out of the  the appropriation the f y o seven appropriation that's being managed by m r m c but i know there are clinical trials included in that as well thank you mentioned about t b i screening   there were three three areas of recommendations that we made one pertain to two modifications to our post one and screening to assure that all health problems  mislabeling individuals as being brain injured and and so we provided some specific recommendations about how we might structure the postponement screening in a way to minimize those arrests the second set of recommendations pertain to risk communication or education it's how we communicate about the disorder and i think even just the term mild traumatic brain injury which which is a s concussion for some reason mild traumatic brain injury has sort of caught on as the as the term you know that is being most widely used i think that's unfortunate i think that soldiers and family members understand the word concussion much better and concussion is a lot less stigmatising than the term brain injury so i've advocated been advocating for communication strategies that promote there the education strategy that's most important is that soldiers learn that they need to come in and get seen when they have a concussion on the battlefield and not blow it off a soldier sometimes tend to do and athletes tend to do as well get them get them and get them seen right there on the battlefield because that's that's really the time to be evaluated once they come home it becomes a lot more murkier and difficult to sort out what the etiology of particular symptoms are because that i just hope that and i've no problem with trying to call it what it is my only concern is if you look at for instance where the v a when you look at disability ratings v a it tends to be higher than in th prevent the army from take care about men and women who served in uniform and i know is a concern with a lot of veterans out there is it just trying to shift the burden back on to the veterans themselves versus taking care of it and myself with many of the questions that you asked the witness because i think that we're all concerned and focusing from the same angle you mentioned three hundred million dollars that was appropriated and i was seven i'm interested in knowing couple of things  how are we doing we're spending the money lab or a little bit on the programs and this is this is a question that's loaded when i ask it but it wasn't enough and what else do we need to do sir i'm not really the person in position to comment on the expenditure of those funds because on on that the i run the research program the walter reed army institute of research and i'm not in charge of the program that's at a higher level so i'll have to take that for the record but that's certainly been information readily available and my understanding is you know that the the processes have been put in place too and to grant the grants are now in the only identifies a small percentage of individuals who will then go on to develop problems so we need that second assessment and there's about a two to three fold increase in rates of reporting mental health problems at that's that second assessment time point three to six months seems to be about right we could go as early as two months or you know as late as six months but somewhere in that range is certainly reasonable why would you i mean  think in the beginning of some of your testimony you're talking about a twelve month timeframe not having enough time to reset when they're redeployed and i'm i'm i'm wondering if six months is too soon or does there need to be  second risk assessment some some units are actually conducting the the second the sas and they're conducting the second assessment three to six months and then they're doing it again shortly before redeployment  theatre but i'm not i'm not sure i'm not advocating for that that that be done but i know that some units are are in the process do we have any any numbers that quantify that that second risk assessment all is there is there a spike between the six and the ten month or not not really the six month and twelve month figures are very very comparable to one another from from the data that we've seen in  different context we've studied soldiers with similar surveys that use similar instruments on them at at three and three six and twelve months and we've found that six and twelve months are very very similar in prevalence not receive treatment they don't they don't come in and get any help at all and we know that based on some of our survey data that the concerns about perceptions within their  perceptions by their leaders cetera are some of their concerns now we've been working ardently a sense to start a war to the stigmatize through education programs and battle the battle mind training for instance and other types of education programs and i think the word is getting out there we've seen a slight decrease in perceptions of stigma during this last visit to iraq to the team to the perception of sigma seem work that we've been doing it would seem to me one of one of the ways we could really handle this would be to in my state now i know i know particularly the guard ever returning person back is screened and you know i would hope we get to the point at fact one of the publications that we published in november when we looked at the relationship of referral or treatment for p t s d symptoms from the first screen when they initially come and the subsequent s ix months later we found very no direct relation an improvement in symptoms a lot of soldiers which was which was somewhat of a counterintuitive finding we were not expecting that  so part of that may and there's a lot of potential reasons for that mad to do with the inaccuracy of the screening these are these are not one hundred percent you know it's there's not there's no way to one hundred percent identify individuals and we have a lot better screening i can guarantee of for p t s d that we have for mild t b i but that's a kind of another topic so that's one inherent problem so a lot of and then when we identify problems it's still voluntary we can't force a soldier to receive mental health treatment and we can encourage them to we can we have a limited ability to to get a soldier help if there's overt threats to self or others but aside from that you know it's a voluntary process we can encourage individuals to go and get help and they can choose not to and that's an individual thing and and  then and then there's the stigma which isn't just in the military it's a stigma in society in general of receiving mental health treatment so there are certain stigma and there's barriers to the depending on where a person lives how close the clinic is how accessible the doctor is whether the you know in units for instance doctors rotate frequently and so sometimes there's a lack of stability for a person might develop a relationship with the physician and  then three months later the physicians been deployed and so that can affect the person's desire to continue with treatment so there are a lot of factors and it's a difficult it's a it's a tough question that you ask in terms of what's going to have and to these individuals because we you know this is part of the what you know sort of what we've recognized since the beginning  grant invitations to have a grant proposal submitted and then those are all peer reviewed and there's a peer review process that establishes which ones get funded based on the science and also based on the contributing to this research do they have also had their own grant funding mechanisms and so i know so they are and they are also actively involved  participated in the planning of the meetings that were held to prioritize how the money should be allocated and have also had the opportunity to apply for the  area because i'm not responsible for this but i know that they grant process spans the the domain of basic science and applied research and clinical trials  of those homeless veterans are fleeing from some form of mental disorder p t s d or some other form and hoping that we could find the end of the research that we could find a way to diagnose those people that maybe have the problem but then she will develop another problem later because the time they come with the with the problem they don't have the wherewithal to be able to find help and so i would hope as part of the in that hearing as well but let me remind my colleagues it takes a little bit of money to be able to care for these people let me ask you a couple of questions if i may something that you said  chord with me when you said that there have been studies that demonstrate that if people are called back up to service before a year or even a after a year that that's just not enough yeah that's what i said i what i what i what i said is that there's a is the twelve months isn't sufficient appears to be insufficient based on the data that we have now it's my understanding and correct me if i'm wrong that our armed forces are so stretched right now that people are being called back to duty in a far shorter time than twelve months twelve months is recommended but in many instances they have a ninety day stay at home and they are back in the theater of war is that your understanding is well i'm not that's i don't know actually what the you know how many units of rotate about before twelve months i'd have to find find that out i'd appreciate it as is my understanding that it's a much shorter period of time in many instances and i'm going to share with you another nevada story young man from nevada  had done his tour of duty he was back home and he had been raised by his grandmother back to his grandmother's home he was called back he did not want to go back told his grandmother he would rather kill himself than go back he was interviewed by a psychologist or a psychiatrist that determined that he was depressed and gave him prozac he was sent back he was on suicide watch and the day after he was taken off a suicide watch he killed himself it seems to me that we ought to be doing a better job of screening people and fully  person there's lots of answers to that and the first one that comes to mind is is simply that the only way to get better is to isn't it in part to have the desire  to do so and to make that commitment and there's no we can't force people to get better with psychiatric problems it's the most effective form of the reason why the when they do they're they're not necessarily willing or interested in treatment they also have other there are options available to them to get treatment through other means for instance military one source which is a separate track that isn't part of the medical system they can get care in the v a system or vet centers they can get help from chaplains is a huge amount of counseling that's provided by by chaplain so and and in a lot of people a lot of individuals actually do get taxed away from those who most need it and would be one for instance and also i just don't think that by and large if we force it we can't we can't simply can't ethically do that  personnel know mental health professionals at our remote locations thank you very much mr chairman i would hope that this committee or the full committee look into this issue of compensating the doctors or lack there simultaneous telecom subcommittee hearing going on colonel i was i was reading through your testimony as questions were being asked and the one thing that really sticks out here is for the first time you've had a sizable number of soldiers study that were on their third rotation to iraq and it it's really striking to see how the increased risk goes up with each deployment and i hope that's something that the department of defense is taking  look at what we're doing to these young men and women as we put them through third rotations and that should it should only be done when absolutely necessary ita couple representatives from the american legion in my office earlier and  heard you talk about the stigmatism being identified as someone with post traumatic stress syndrome or just having mental health issues and they brought up another interesting point on not just from the medical side but how it seems to be affecting our veterans on the employment side too that a lot of employers are a little bit nervous about maybe hiring people that are just coming back from this war because they're hearing so much in the media about you know traumatic brain injury and post traumatic stress syndrome and that it's also affecting our veterans on on the economic front so as you embark up amongst this campaign to educate people about p t s d so that they get treatment and help  i think it might also be you know a good idea the in some way can help educate lawyers as to the treatments that are available and that that these vets once they're treated you know shouldn't be stigmatized when they go look for a job just because they receive this treatment to that employers have a responsibility to take a look at our young men and women that serve the country and not use this as a reason not to hire them i know they wouldn't do that overtly but it seems like it's  causing some problems which which contribute to that the only question i have a maybe you could just educate me on this the representatives i had from american legion were talking about you know the distinguishment between regular military and  national guard and reserves with regards to treatment and they were under the impression i don't know if it's correct or not maybe you can can tell us that when you have somebody it's in the national guard and reserve and they have a mental issue coming back from contact p t s d or the like they can get treatment obviously they have a benefit to get treatment that their family members aren't available to receive counseling on a lot of time you know these issues are issues within the family all marriages breaking up we see the high divorce rate taking place in the national guard and reserve that seems to get worse is these young men and women are deployed multiple deployments and what assistance is there that's available to families of national guard and  strong focus on marital and family therapy so there's no difference available to families of national guard and reserves yes sir i believe i believe so i'm a little hasn't there but i guess i think i think that is that is  chairman the i appreciate your written testimony here today specifically referring to research projects most the time our discussion at this committee is about how to fund more research and we don't actually get much for a presentation about some of the results we have been told her all that there are an abundance of good research projects that could still be done out there if there was funding available for that do you agree with that david yes and again and in the clinical trials arena i think that's i think that's a true statement for sure like little trials meeting the kind of studies where you need to have five thousand or ten thousand or thirty thousand people participating which takes a lot of staff time and labor and record keeping is that the kind of trials you're talking about know what we need actually are are  therapy processes that work as effectively as individual therapy which would have implications in terms of resources and medications as a variety of new medication opportunities that need to be associated with a host of chemical changes in the body's hormonal system immune system and autonomic nervous system i just like you to amplify on that of in the remaining time i have because we have a lot of discussions here about somehow the division between mental health and physical health it comes up a lot of context is mental health parity bills that kind of thing but could you just take the remaining three or four minutes i have and just discuss it in more detail those kinds of changes that you're talking about i mean this is this is an distinction the fact the matter is that there are a host of changes it happened within the nervous system endocrine system even the immune system as a result of stress traumatic depression are much more likely to use medical services to miss work due to illness to have more pain to have more headaches even to have more post concussive symptoms in fact it's one of the strongest risk factors help people to understand that this is the other thing is that these are normal biological processes that are there adaptive unnecessary and combat being hyper alert as is is a survival mechanism that soldiers need in necessarily let go of that and it's their reactions that they have all other people may perceive them as being abnormal or in fact things that are adaptive that as soon as they go back into combat for their next rotation that to turn it all back on again  t we can we can look at some of these biological changes both in the context of what's normal reactions to stress and then also in the context of at what point do those reactions become abnormal and really interfere with a person's life and those are those are questions which are active focus is a very active focus of research now take my last fifteen seconds i think there's also a lot of  research going on now in young children who are raised as babies or born into very stressful environments whether it's a home of abuse or a home of poverty and that chronic stress month after month year after year leads to panel to come forward and while the coming forward we have carolyn who is the immediate past president of american occupational therapy association members of the subcommittee for giving me the opportunity behalf of the american occupational therapy association to discuss issues regarding post traumatic stress disorders you introduce me  war one occupational therapist helps wounded warriors return to their military responsibilities or transition into civilian life by helping them develop strategies to accomplish their goals and gain the skills that allow them to achieve the maximum level of participation in independent occupational therapy perhaps best known for its work in rehabilitation services after  plays a unique role in helping veterans recover from service members of the team that along with physicians and psychologists who use medication and counseling the occupational therapist employ performance strategies that support the veterans and success in their performance in daily activities actually it's in these daily activities that it's possible to observe the problems veterans are having with multitasking with sequencing of tasks with their safety with their judgment and actually identifying the cognitive which has a very important  need for consideration these are all problems that require strategies for individuals to overcome the effective treatment of p t s d and the return of veterans back into their work their family and community lives really requires an integrated system of care that includes assessment goal setting treatment and learning to self manage life with p rehabilitation does not stop when veterans are discharged from hospitals or medical care it must be provided along a continuum addressing community reintegration social reconnection and work accommodations all these are areas in which occupational therapist play an important role veterans with p t s d often have difficulty in their daily lives and avoid activities because they res or fear or even anger consider for example a soldier who's driving on retune routine patrol when a roadside bomb explodes upon returning home the veteran might experience flashbacks of that event triggered simply by driving the therapist simulated or virtual reality driving experiences or even actual driving experience in a controlled environment to help the veteran extinguish or restrain the negative stress reactions there but also work with veterans to help them manage to p t s d such as depression mild head injury or concussion and substance abuse by helping them develop strategies daily life that are meaningful them for them and their families having the families involved is particularly important because we know the importance of social support to individuals in recovering from the unique contribution of occupational therapy is highly valued by the army for their combat stress control the army model deserves additional attention from the veterans administration and the subcommittee because it fully recognizes occupational therapy as contribution as a member of the team by adding the performance component to the medication and counseling provided by other team members we recommend the v a consider and adopt the army model the veterans administration has made significant strides in preparing to meet the needs of veterans but work remains to be done the only seven hundred fifty occupational therapists in the entire v a system while both the veterans administration and the department of defense guidelines for p t s d exist and include occupational therapy it's the experience of our members that the inclusion of occupational therapist varies from site to site this variation does not ensure full access to effective treatments the american occupational therapy association encourages the committee to look at this issue from the consultation with a o t s members within the v a we have heard that they are struggling to maintain the quality of care for which they are known because of increase demand for rehabilitation services and gaps in staffing the most important issues to a sure that veterans receive the services they need to recover and re entered community life able to care for themselves and others able to work and make contributions to their families and communities if the v a has staffing problems they should look for and contract with community programs to provide the services that the veterans need just as you discussed earlier with colonel hope there is also a need to study the effectiveness of complex interventions medication counseling and i'd ask for consideration to add the third leg to the stool the importance of daily life performance research to understand the relationship of quality of life to p t s d symptoms of verity disability treatment outcomes and cost the problem begs for an interdisciplinary disciplinary translational clinical study mr chairman i've made additional recommendations in my written testimony but i want to highlight a couple issues for your subcommittees consideration to increase the numbers of occupational therapist within the veterans administration we would urge that the subcommittee consider expanding the student loan repayment program to ensure that the v a remains an attractive employment option because there is a real supply and demand issue right now and that would draw people to the v a services salaries in the v a appeared to be lower than other health care settings the bureau of labor statistics estimated in two thousand and six that the average salary in the california for occupational therapist was seventy three thousand dollars right now the palo alto poly trauma rehab center is offering fifty thousand dollars for two new positions that have been vacant since last july  and members of the committee my name is david director and professor of medicine at the center for clinical health policy research at duke university medical center and served as a member of the institute of medicine committee which produced the report treatment of  post traumatic stress disorder and assessment evidence this study was sponsored by the department of veterans of the v a charge the institute of medicine committee with several specific tasks to respond to its main task which is making conclusions regarding the committee develop method using generally accepted international standards for conducting a systematic qualitative review the committee's conclusions were ultimately based on its judgments of the sufficien y of the body of evidence for each category or class of treatment the committee was not asked to recommend what therapies clinicians should use or not use the committee's assessment went down the nearly two thousand eight hundred articles identified in our search to eighty nine randomized controlled trials thirty seven studies of treatment with medications such as selective serotonin re upping uptake inhibitors or s s r i eyes and any convulsions and fifty two studies of treatments with psychotherapy i'd be happy to provide details about the criteria the committee used and about how we evaluated the methodological quality of the studies we reviewed the evidence on pharmacotherapy in general was limited with relatively few studies meeting inclusion criteria and free of significant methodological limitations even among the s s r i as with the with the most substantial evidence base the committee was struck by an consistencies in the results and serious methodological limitations the committee found the evidence for s s r i's and all other drug classes for which randomized trials right down to five inadequate to conclude efficacy the committee reviewed studies on several types of psychotherapy the committee judged the evidence for exposure therapy sufficient to conclude advocacy exposure therapies or family of therapies and include confronting the trauma related memories or stimuli and may be used in combination with other therapeutic approaches the evidence for all but one of the remaining psychotherapy categories was inadequate to conclude efficacies the committee's conclusions of iniquity inadequacy regarding evidence for most treatment modalities should not be considered clinical practice guidelines finding that the evidence is inadequate is not a determination that the treatment does not work the committee recognizes that clinical treatment decisions must be made every day based on many other factors and considerations such as patient preference availability ethical issues and clinical experience that we were not asked address and we did not the committee was struck by the lack of evidence on treatment efficacy and one population compared to another the diagnostic and statistical manual criteria recognizes only one type of p t s d yet reasonable people might question whether all p t s d is the same and whether one can expect the treatment shown effective in one group for example earthquake survivors to also work for u s combat veterans however we found no evidence that p t s d is the same or that it's different in veteran or v a populations compared with civilian population a minority opinion in the report was based on the belief that there are subgroups and the evidence should be examined separately for them but the committee majority concluded otherwise the committee found that p t d needs more attention from high quality research including in veterans the committee highlighted several research related issues in the report including methodological quality investigator independence and special population we recommended research take steps to ensure that investigative investigators use methods to improve the internal validity of research for example the use of blinding and adequate patient follow up the committee also noted that the majority of drug studies have been funded by the farm by the pharmaceutical manufacturers and the majority of psychotherapy studies have been conducted by the individuals who develop the techniques or their close collaborators the committee recommends that a broad range of investigators be supported to kentucky replication and confirmation studies the research literature is not supportive on the issue of patients who have p t s d and other health problems such as substance abuse other anxiety disorders or traumatic brain injury or about special veteran population such as ethnic and cultural minorities women and people with physical impairments we recommend that the most important such populations be defined to design research around interventions tailored to their special needs finally the committee made to general recommendations about research veterans we recommend that congress require and ensure that resources are available quality research on the treatment of veterans with p t s d with involvement of all relevant stakeholders second we recommend that the v a take an active  identifying the high impact studies that will most efficiently provide clinically useful information the committee is grateful to have the opportunity to be of assistance to the v a and hopes that the department and congress find the report useful and moving ahead to strengthen p t s d research thank you for the opportunity to testify and i would be happy to address any questions the committee might have thank very much doctor  we are told would you hold please mr chairman members of the subcommittee i'm pleased to be here today to discuss a new and innovative technology currently undergoing testing in veterans administration and navy facilities that has  hospitals with requests from six additional facilities for the technology we've been treating patients with therapy for the past twelve years and have an overall success rate of ninety two percent this is defined as a reduction in symptoms improve work performance or the successful completion of a task which was previously impossible our centers and clinics have broad experience in treating patients that would be our therapy technology that my company and others have been studying is a virtual reality or virtual reality exposure therapy for p t research protocol works by allowing the therapist to gradually expose the combat veteran to distressing stimuli in the virtual scenarios in the study participants to regulate breathing and physiological arousal after a number of sessions the fight flight response to distressing stimuli is extinguished use of virtual reality technology helps veterans of the kerning to overcome their reluctance they have been coming forward for help virtual baghdad which is shown in exhibit a is a realistic environment consisting of a single map that allows the user to navigate seamlessly through a suite of different but magically connected virtual scenarios i can see myself in the village of the marketplace said one of the navy corpsman who participated in our study virtual reality exposure therapy is an investigative treatment modality for p t s d that has been in existence for about ten years is been used successfully with vietnam era veterans and was survivors of traumatic events such as motor vehicle accidents earthquakes bus bombings in israel and nine eleven survivors a panel of academic and government experts has published a consensus opinion that exposure therapy is the most appropriate therapy for p t s d while exposure may sound counterintuitive i necessary for treatment success in virtual reality patients who normally avoid reminders of the trauma are systematically exposed to combat related stimuli this allows for individually paced emotional processing and desensitisation to occur current research funded by the office of naval research is focused on determining the optimal treatment protocol for iraqi war veterans with different co morbidities for example those with mild traumatic brain injury investigators are currently conducting three months of visits to ensure that the treatment is lasting investigators also are also performing periodic physiological assessments to help design a study that would construct a profile of veterans who might do especially well with the art technology one of our systems is in iraq right now and could be used in such research in we just received stronger just from the navy in advancing research and just this context how or where here to speak about our experience and success with the v a and leave you with three additional advanced technologies which could significantly help improve the lives of veterans with p t s d first it is important to correlate the progress of the therapy not only with psychophysiology but also the brain imaging in collaboration with other researchers we postulated that there may exist an f m r i or functional brain imaging signature for p t s d the discovery of which could lead to more targeted treatment second we are can be used both alone or in combination with  protective agents such as antioxidants to conduct stress inoculation training is important track how well both technologies work to avert p t s d third v r may be an important piece of the puzzle as tools are developed i can assess and treat the many co morbid conditions that accompany p t s d for example virtual reality can be useful both in cognitive rehabilitation for t b i as well as physical rehabilitation for veterans with amputations mr chairman i thank you for the opportunity to present this important technology today please at this time to answer any questions you may have teams of professionals to address the issues that bring a patient therapist into that does bring that performance to the management of the patient's lives make you well first of all the research that should be funded should be focused on methodologically high quality studies so that at the end of the day whatever therapies are being evaluated that we can make reasonable inferences that these are going to work and who they're going to work for and that we also have understanding's of the context in which they work how long they should work so it's those kinds of issues that are really the specific therapies personally i have no opinion about i mean there are there are certainly promising some promising therapies out there but it's really more a question of how it's studied as opposed to what's being studied from my perspective but i think that the most important thing that could be done again in my opinion is that that they establish a coordinated effort that there is a lot there are a lot of questions that need to be asked and answered asking them in a coherent coherent way a systematic way allocating research so that you're maximizing your bang for the buck so to speak in the research endeavor making sure that that outcome measures and  radicals and chronic inflammation have been implicated in most of the serious psychological illnesses as well as dementia in fact very high levels of free radicals such as proxy night products of talked about a response mechanism is actually turned on this arousal response is turned on to get the effect of the v c r that turns on the glutamate pathway which is toxic to neurons and that can be blocked you mr chairman other members of the distinguished members of the subcommittee vietnam veterans of america thank you for the opportunity again to present our views on p t s d treatment and research moving ahead toward recovery a also thanks a subcommittee for its concern about the mental health care of our troops and veterans and your particular leadership in holding this hearing today however as we are gathered here today after troops have been are will be affected by their wartime experiences to be sure there have been attempts by the military services to address combat stress it deployment through cognitive awareness programs as colonel hogan mentioned such as battle mind and the innovative combat stress yet no one can really say how serious any individual soldier mental and emotional problems will become after actual combat exposure or the resulting impact that these wounds will have on their physiological health and general psychosocial readjustment to life away from the battles would like to ask furthermore despite the increased availability of behavioral health services to deployed military personnel the true incidence of p t s d among active duty troops may still be unreported as was hinted at earlier today as colonel mentioned a recent retrospective report documented what most in the military already know that of those who's a valuation were positive for a mental disorder only twenty three to forty percent complained or sought help for their mental health problems while still on active duty primarily because of stigma and discrimination no one really knows whether those  and treatment the psychological stresses of war will never really upon separation from active military service our mail and increasingly our female veterans are obstacles in the search for mental health  steps and employ methods would handle effectively problems that affect the quality of the results of these studies and that congress should ensure that resources are available for and other federal agencies to is seriously flawed because it provides treatment in the hope of reducing symptoms approximating some notion of normality when in reality normal is only participation which provide them a reason to get better in the first place and then to provide the treatment and support services along with that therefore the issue is not so much making them normal but helping them get their lives back together and other words recovery means living with the illness managing it and getting better recognizing there might be limitations most major psychiatric illnesses are episodic but chronic recovery involves both common coming to terms with the symptoms and finding a mean of meaningful life in the midst of these affective evidence based psychosis psycho social treatment programs as here the conflicts in afghanistan in iraq continuing and no immediate end in sight believes it's time to address the mr chairman on behalf of the iraq and afghanistan veterans of america and our tens of thousands of members nationwide i thank you for the opportunity to testify today regarding this important subject i would also like to point out today that my testimony as as director of government affairs for the iraq and afghanistan veterans of america and does not reflect the views or opinions of the marine corps reserve which i am currently a member of during the iraq and afghanistan wars american troops mental health injuries have been documented and analyzed as they occur and the rates are already comparable to vietnam but thanks to today's understanding of mental health screening and treatment the battle for mental health care non veterans need not be repeated we have an unprecedented opportunity to respond immediately and effectively to the veterans mental health crisis mental health problems among iraq and afghanistan veterans are already widespread the v a has given preliminary mental health diagnosis is to over one hundred thousand iraq and afghanistan veterans but this is the tip of the iceberg the v a special committee on p t s d concluded that fifteen to twenty expected to do more than eight times the number of residential rehab services the non enrollees with this massive influx of veterans seeking mental health treatment is paramount that we ensure the treatment they are receiving is the most effective and will pa path of recovery but before i speak about the specifics of p t s d treatment research i'd like to talk about two of the barriers that keep veterans from getting the proper treatment in the first place the first step to treating p t s d is combating the stigma that keeps troops from admitting they are facing a mental health problem as colonel mentioned approximately fifty percent of soldiers and marines in iraq who test positive for a psychological problem are concerned that they will be seen as weak by their fellow service members and almost one in three of these troops worry about the effect of mental health diagnosis on their career because of these fears those most in need of counseling will rarely seek it out recently my reserve unit took part in completing our post deployment health reassessment which includes a series of mental health questions while we underwent the training one of my marines asked me about post traumatic stress disorder he said and i quote if there is nothing wrong with it then why is it called a disorder i could not have agreed with him more to do the stigmatize the psychological injuries of war  recently partnered with the ad council to conduct a three year public service announcement campaign and to try and combat this stigma and ensure that troops who need mental health care get it our goal is to inform of its members and veterans that there is treatment available and then it does work a service member is willing to seek treatment the next step is assuring that they have convenient access to care on this front there is much more that must be done particularly for world veterans more than one quarter of veterans live at least an hour from a v are addressed however once a service member suffering from p t s d has access to care we also need to ensure they receive the best possible treatment currently a variety of treatments is available psychotherapy and what's a therapist helps the patient learn to think about the trauma without experiencing stress is an effective form of treatment this version of therapy sometimes includes exposure to the trauma in a safe way either by speaking or writing about the trauma or in some new studies through virtual reality some mental health care providers have reported address the root cause of the trauma itself very concerned that in some instances medications are being seen as a cure all that will somehow fix or replace the face to face counseling from a mental health professional that will actually help the service members cope affectively with their memories of war and i'll address this briefly to when i return from my second tour i faced the same reintegration issues that most service members face had a hard time sitting in class her brain and a very difficult time sleeping when i s assistance from my school health center i was given a whole slew of drugs that lasted about four days when i realized i was needing to take two pills for sleep two pills which i call super ritalin if you will for adults during the day did not effectively help me until it i was able to sit down and actually talk with someone and they told me the steps i could take to help get myself settled down it worked incredibly well the face to face treatment but there were finding from our membership a lot of issues with dealing with medication tr a recent institute of medicine study entitled treatment of prose dramatic stress disorder an assessment of the evidence that we've heard a lot about today outlined that many gaps in the current the many gaps in current recent research among the problems the identified many studies lack the characteristics of internal validity that means too many people are dropping out of these studies the samples were too small or follow up was too short the institute of medicine committee also identified serious issues with the independence of the researchers the majority of drug studies were funded by pharmaceutical manufacturers and many of the psychotherapy studies were conducted by individuals who developed the techniques finally the committee concluded that there were serious gaps in the sub populations assessed in these studies veterans may react differently to treatment treatment than civilians but few of the studies were conducted in the veterans populations there's also not enough research in to care for people suffering from co morbid disorders such as t b i or depression the solution is more and better research to respond to the i o m findings i wholeheartedly support more funding for research and other medical conditions affecting iraq and afghanistan veterans thank you for your attention and your work on behalf carthage illinois and illinois on the river veterans serve and there's a very difficult process to get those vets to the places where they can get the help so i couldn't agree with you more that we need to do more in terms of health care for veterans because these are people who serve this country and to not have the resources whether it's a box or whatever for them to go makes it pretty pretty hard to treat somebody when that when they have  first mr chairman thank you for asking the question there are significant significant differences in the types of warfare given even for decades between them the troops nowadays are  serving longer deployments and more frequently whereas in vietnam you served a twelve year tour if you were in any armed services unit with the exception of the brain core in which you served thirteen months  there are other significant differences in the makeup of the armed forces themselves today's armed forces of course are a volunteer service whereas a great number of the  women and men who served in vietnam were not only volunteers but the large majority of them were draftees lots of major differences but the fact of the matter is that when we came back and now i speak on behalf of vietnam veterans we didn't have some a lot of the resources available in fact there was a lot of stigma and discrimination directed against p t s d did not exist as we know it now at the time it became known of course as post vietnam stress syndrome it's been known for thousands of years but i mean given the nomenclature of lots of differences our principal concern is that with the lack of or reduced organizational capacity and i mean that across the board in terms of resources personnel  out we have lots of anecdotal information to indicate that's happening around the country where i just took a call last week from from a fellow out in southern california it said his vietnam veterans support group which is meeting in the b and there was a licensed clinical social worker that's been working with this group for over two years we're told they can no longer meet the  social worker was taken off the air because they don't have the resources to handle everybody at this time that's just outrageous and i'm sure as you indicated in your rural districts or the then had a one on one meeting with a counselor who then could give us a referral slip whether we needed to go see someone or find out what other resources were available at that point we then took all the marines lined them up and they registered with the v a right there on the spot they were given information to know what programs were available what resources were available then they took the marines and they lined him up they had approximately six representatives there from local washington d c area that centers to let them know what resources were available it was textbook i don't think we could do it any better the problem is that was my unit taking initiative it is not mandated that way and this was the first time that i've seen out of our three deployments that we've service members come back and had it organized in this fashion so until it is required for reservists and national guardsmen to when they return as they're conducting these assessments to have their as a resource we're going to continue to see people fall through the cracks and i'm very proud of my unit for what they did but again it is not it is not something that is done d o d or v a wide thanks very much doctor we all know we can't force people to seek medical attention and probably rightly so but how can be better reach out and find the people who need the most help well i'm not a marketing strategist by any means but i think that there has to be more marketing efforts directed at outreach efforts particularly in our rural areas i think that would have that would help a great deal i know that there are efforts being made around the country as part of the tap program the transition assistance program because i do participate in one myself where  ministre toure's from the v a occasionally show up to talk to the guard members and inform them of the services but it's not at least in the midwest it's not as widespread as i think it should be so i think it's more a marketing kind of thing in the sense of getting the word out plus i think also that there needs to be encouragement by their colleagues such a know if i may sir i notice highly unusual but i would like to recognize sergeant bauer for his not only his two tours in iraq but i learned today that he's been called up for a third time he's correct but i'm not going to the desert this time i'm going someplace relatively tropical but i don't think there will be any umbrellas in our drinks or anything else so it'll be a change of scenery but i will be leaving next month and it's with that that i thank this committee for opportunities you've provided me with testifying before you and i look forward to seeing you next winter thank you very much for your service we can find out where at maybe i'll bring up the number of persons i'll bring  coming mr chairman ranking member i'm pleased to be here today to discuss the treatment in research programs in p t s d i'm proud to be accompanied by dr matthew freedman c one hundred twenty thousand returning vets owens who have come to v a medical centers and clinics and been diagnosed with a mental health condition and the nearly sixty thousand who have been diagnosed with the sixty thousand figure makes p t s d the most common of the mental health problems but it's by no means the only one with depression a close second however is these numbers today they've provided care to an additional seven thousand returning veterans with p t s d and if our number greater number with readjustment problems without specific diagnoses as has been mentioned it's been since the vietnam war that we've learned about p t s d as a distinct mental health condition that we've developed criteria and strategies for diagnosis and have done research and established effective treatment to important to recognize that most of the four hundred thousand veterans seen for p t s d in the last year were vietnam era veterans returning veterans represent an opportunity to apply the lessons that we've learned since vietnam to prevent the chronic corps for p t s d that was all too common among vietnam veterans at the same time we can't lose sight of the ongoing need to develop better treatment for all veterans with and those from vietnam as well as other v a s responded to the challenge of returning veterans and to the opportunities created by scientific advances with dramatic and tour mental health programs the budgeting creased from two billion dollars in two thousand and one to over three point five billion dollars this year the number of mental health professionals has also grown over the past two and a half years we've hired thirty eight hundred new mental health status for a total of nearly seventeen thousand  establish p t s d specialty care programs in each of her medical centers and in many of her larger community based outpatient departments there were also major expanses in vet cent programs with ongoing increases and the number of centers from two hundred nine to thirty two v a approach to p eight to p t s d is to promote early recognition and treatment there is community outreach including collaboration's and virtually all of the post deployment health reassessment as well as screening for all veterans seen in our system when there are positive screens that arends are further evaluated and referred to mental health providers it's need evidence from research suggests that the most effective forms of treatment for are certain forms of psychotherapy specifically prolonged exposure and cognitive processing therapy it's been somewhat over a year since publication of findings from a landmark v a cooperative study demonstrating the effectiveness of the law and its the work of dr friedman and his colleagues for completion of this research was a major event however of comparable importance even before the findings were published the began lower scale training programs for mental health staff so they could deliver these treatments in real life clinical care the research is ongoing to specific projects or large scale clinical trials who've been mentioned earlier one follows up on early small scale studies by b in a investigators suggesting that privacy in an inexpensive generic drug already used by millions of americans for high blood pressure can improve sleep in reduce nightmares in p t s d currently a lowered scale multi fight trial is being implemented to evaluate its effectiveness another trial is based on both clinical experience and smaller clinical trials suggesting that newer anti psychotic medications may be effective in reducing symptoms in service related chronic p t s d v a is currently conducting a l randomized clinical trial to determine if this drug risperidone is affective in veterans with chronic p t s d who continue to have symptoms despite receiving standard medications nobbles therapeutics affective strategies for rehabilitation of those with persisting symptoms and new strategy for the delivery of care including another study of dr friedman looking at primary care management of p t s d well health is an important part of overall health v a is committed to providing the highest quality of care possible to our investigators clinical trials into patient care they are in fact is the primary goal of our research program thank you again mr chairman dr friedman and i will be pleased to of time what does that exactly mean i mean are there follow up appointments to assess the progression of the symptoms do you do it by phone calls or how do you watch over these folks yeah i'll  d some very obviously don't know many people are somewhere in between if they prefer to be treated they should be treated if they're reluctant we should keep an eye on and our attempts to provide treatment for veterans is that we know a lot more what to expect than we did following vietnam and i think as a result of the experience that we've had for the past several decades is we've been able to educate the public this is really a kind of a preventive public health approach trying to get information out to the veterans to their families to the communities to the er employers  that should there be difficulties readjusting reintegrating people will know what to look for what to expect as dr hogue emphasized the expectation is that most are going to have a few speed bumps along the road to reintegration but they're going to get past it i think that's why the the watchful waiting that dr katz mentioned is such a reasonable and important approach but for those people who do run into trouble and we know there's going to be a sizable minority that they'll know themselves their families will know their employers will know their loved ones will know and then we can get the information out where do you go for help this is a new development very important since experience with vietnam veterans and some of the research coming out of israel in the cage that the onset may be delayed for many many years and so as dr katz said we need to keep keep the word out there we need to keep our partnerships with the veteran services it in some way first of all there are the a d o d practice guidelines based on the best evidence and as the research continues and you've heard from many people at this table today  emphasize the importance of new research because we need and as the as the new results come in obviously the practice guidelines will need to be tailored accordingly again repeating some of the answers that some of the other people have said i think that there is a tremendous need for new research we do have as dr katz and others have emphasized we have a very very effective behavioral treatment dr support we are now out there training hundreds of practitioners in these new treatments so that when people come knocking we'll be able to provide the best treatment that's available these are going to be self sustaining programs  friedman for coming by the second and to all of our witnesses let me thank you and it's been a very informative hearing and at the end of the day i know that all of us want to do the very best we can to make sure that  not just the service person but but but their families you know get some some treatment and some relief from this they've given us everything and that's the bare minimum we can do and i appreciate all of you for being