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25–825 2017

[H.A.S.C. No. 115–39] 

POST–TRAUMATIC STRESS DISORDER AND 

TRAUMATIC BRAIN INJURY—CLINICAL 

AND RESEARCH PROGRAM ASSESSMENT 

HEARING 

BEFORE THE

SUBCOMMITTEE ON MILITARY PERSONNEL 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

HEARING HELD 

APRIL 27, 2017 
(II) 

SUBCOMMITTEE ON MILITARY PERSONNEL 

MIKE COFFMAN, Colorado, Chairman 

WALTER B. JONES, North Carolina 

BRAD R. WENSTRUP, Ohio, Vice Chair 

STEVE RUSSELL, Oklahoma 

DON BACON, Nebraska 

MARTHA MCSALLY, Arizona 

RALPH LEE ABRAHAM, Louisiana 

TRENT KELLY, Mississippi 

JACKIE SPEIER, California 

ROBERT A. BRADY, Pennsylvania 

NIKI TSONGAS, Massachusetts 

RUBEN GALLEGO, Arizona 

CAROL SHEA-PORTER, New Hampshire 

JACKY ROSEN, Nevada 

TOM HAWLEY, Professional Staff Member 

CRAIG GREENE, Professional Staff Member 

DANIELLE STEITZ, Clerk 
(III) 

C O N T E N T S 

Page 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Coffman, Hon. Mike, a Representative from Colorado, Chairman, Subcommittee on Military Personnel ........................................................................ 1 

Speier, Hon. Jackie, a Representative from California, Ranking Member, Subcommittee on Military Personnel ........................................................................ 2 

WITNESSES 

Colston, CAPT Mike, M.D., USN, Director, Defense Centers of Excellence 

for Psychological Health and Traumatic Brain Injury, U.S. Department 

of Defense ............................................................................................................. 3 

Ivany, LTC Christopher G., USA, Chief, Behavioral Health Division, HQDA, 

Office of the Surgeon General, United States Army ......................................... 6 

Johnson, CAPT Thomas M., M.D., USN, Site Director, Intrepid Spirit Concussion Recovery Center, Naval Hospital Camp Lejeune ...................................... 7 

Pflanz, Col Steven E., USAF, Deputy Director of Psychological Health, United 

States Air Force Medical Support Agency ......................................................... 4 

APPENDIX 

PREPARED STATEMENTS: 

Coffman, Hon. Mike ......................................................................................... 27 

Colston, CAPT Mike ......................................................................................... 28 

Ivany, LTC Christopher G. .............................................................................. 49 

Johnson, CAPT Thomas M. ............................................................................. 56 

Pflanz, Col Steven E. ........................................................................................ 40 

DOCUMENTS SUBMITTED FOR THE RECORD: 

[There were no Documents submitted.] 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Ms. Speier ......................................................................................................... 69 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

Mr. Coffman ...................................................................................................... 73 

Mr. Knight ........................................................................................................ 78 

Ms. Tsongas ...................................................................................................... 76 

(1) 

POST–TRAUMATIC STRESS DISORDER AND TRAUMATIC 

BRAIN INJURY—CLINICAL AND RESEARCH PROGRAM 

ASSESSMENT 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, SUBCOMMITTEE ON MILITARY PERSONNEL, Washington, DC, Thursday, April 27, 2017. 

The subcommittee met, pursuant to call, at 2:29 p.m., in room 

2118, Rayburn House Office Building, Hon. Mike Coffman (chairman of the subcommittee) presiding. 

OPENING STATEMENT OF HON. MIKE COFFMAN, A REPRESENTATIVE FROM COLORADO, CHAIRMAN, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Mr. COFFMAN. The hearing is now called to order. 

Good afternoon, and welcome. 

Today, the subcommittee will hear from the Department of Defense [DOD] and the military departments on their efforts to address the effects of post-traumatic stress disorder [PTSD] and traumatic brain injury [TBI] on our service members. 

For far too long, the real and proven effects of PTSD and TBI 

largely were ignored. Even worse, service members who demonstrated symptoms of PTSD were sometimes deemed weak or 

mentally unstable. Thankfully, we know better today and are taking aggressive steps to help those who have endured traumatic 

stress. 

As a nation, we have endured an extraordinarily long period of 

conflict with thousands of American troops deployed in harm’s way. 

Some, as a result of their combat experiences, suffer from posttraumatic stress or TBI. But PTSD and TBI are not limited to combat injuries. PTSD can arise from any traumatic event, such as 

sexual assault. We expect the Department to treat all those suffering from PTSD and TBI equally, providing the best appropriate 

care for each. 

For more than a decade, Congress has provided funding and legislative direction for the Department’s PTSD and TBI research and 

clinical approaches. In fact, relevant provisions of law are found in 

each of the last four NDAAs [National Defense Authorization Acts]. 

Today, our intent is to review our progress and determine where 

we need to go from here. Our witnesses are experts in the fields 

of mental health, and I look forward to hearing their views of our 

clinical and research progress. If they have any suggestions for the 

subcommittee, I welcome them. 

Before I introduce the witnesses, I would like to turn to Ranking 

Member Speier for any opening comments she would like to make. 
2 

[The prepared statement of Mr. Coffman can be found in the Appendix on page 27.] 

STATEMENT OF HON. JACKIE SPEIER, A REPRESENTATIVE 

FROM CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Ms. SPEIER. Thank you, Mr. Chairman. Let me join you in welcoming our witnesses here today. 

As post-traumatic stress disorder and traumatic brain injury 

began to emerge as prominent injuries from the conflict in Afghanistan and Iraq, and stories of service members facing difficulty in 

obtaining appropriate care became more frequent, Congress began 

to push the Department of Defense to be more and more proactive 

and increased resources for mental health prevention, treatment, 

and research. 

Since 2004, when Congress first directed the Secretary of Defense to conduct a study of the mental health services available to 

service members at the time, Congress has provided more than 

$1.5 billion in funding for PTSD- and TBI-related research. Of this, 

more than $800 million has gone to over 400 research projects related to psychological health of service members, including PTSD, 

suicide prevention, military substance abuse, resilience, prevention 

of violence within the military, and family-related research. 

We need to better understand how that money has been used; 

what, if any, results have come from that research; where are there 

potential breakthroughs, and what areas may not be as productive; 

what gaps may exist that should be addressed; and how should we 

begin to prioritize the demands that continue to grow in this area. 

One area that I believe requires more focus is the relationship 

between TBI and the development of chronic traumatic encephalopathy, an issue that has been getting a lot of attention in particular 

because of professional football. I look forward to hearing how the 

Department is taking a leadership role in researching this connection. 

Just as important as research is the care and treatment of service members. We continually hear about access challenges and the 

lack of available care providers. A huge concern to me is the stigma 

that persists among service members that leads to them not seeking care in the first place. 

As we heard at the subcommittee hearing on review board agencies earlier this year, the stigma can lead not just to long-term 

mental and physical health problems but also employment or financial difficulties, as discharge status may not take into account 

a service member’s PTSD or TBI history, even with liberal consideration guidance. 

I would like to learn more about what the services are doing to 

address these challenges, and I look forward to hearing your testimony today. 

Thank you, Mr. Chairman. 

Mr. COFFMAN. Thank you, Ms. Speier. 

I ask unanimous consent that non-subcommittee members be allowed to participate in today’s hearing after all subcommittee members have had an opportunity to ask questions. Is there objection? 
3 

Seeing none, without objection, non-subcommittee members will 

be recognized at the appropriate time for 5 minutes. 

We will give each witness the opportunity to present testimony, 

and each member will have an opportunity to question the witnesses for 5 minutes. We would also respectfully remind the witnesses to summarize, to the greatest extent possible, the high 

points of your written testimony in 5 minutes or less. Your written 

comments and statements will be made part of the hearing record. 

Let me welcome our panel. Our witnesses are mental health experts for the Department of Defense and the military services and 

are intimately involved in these issues across their respective organizations and the Department of Defense. 

They are: Captain Mike Colston, United States Navy, Director, 

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury; Colonel Steven Pflanz, United States Air Force, 

Deputy Director of Psychological Health, Office of the Air Force 

Surgeon General; Lieutenant Colonel Chris Ivany, United States 

Army, Chief, Behavioral Health Division, Office of the Army Surgeon General; Captain Thomas Johnson, United States Navy, Site 

Director, Intrepid Spirit Concussion Recovery Center, Camp 

Lejeune, North Carolina. 

With that, Captain Colston, you are recognized for 5 minutes. 

STATEMENT OF CAPT MIKE COLSTON, M.D., USN, DIRECTOR, 

DEFENSE CENTERS OF EXCELLENCE FOR PSYCHOLOGICAL 

HEALTH AND TRAUMATIC BRAIN INJURY, U.S. DEPARTMENT 

OF DEFENSE 

Captain COLSTON. Chairman Coffman, Ranking Member Speier, 

members of the subcommittee, thank you for your support of our 

Nation’s service members, veterans, and their families. 

I am pleased to share DOD’s efforts in research and program assessment for PTSD, TBI, and related conditions. Last year, about 

a quarter of service members were seen for PTSD, TBI, or a mental 

health condition. Allow me to describe our progress. 

First and foremost, we made PTSD and TBI leadership issues, 

with an emphasis on prevention. PTSD incidents decreased from 

17,000 to 14,000 from 2012 to 2015, and TBI incidents decreased 

from 31,000 to 23,000 over the period. 

With regard to mental health across the board, we expanded access to care by tripling our mental health infrastructure since 2001. 

A recent RAND study validated DOD’s progress, finding that DOD 

outperforms civilian health systems in outpatient follow-up after 

psychiatric inpatient care for PTSD or depression. 

One of our largest tasks is better understanding why PTSD and 

TBI often present with depression, chronic pain, substance use disorders, and suicide risk. Longitudinal research efforts, such as the 

15-year study on TBI, aid our understanding and provide a framework for creating effective rehabilitation and support programs. 

Advances from medical research accrue slowly in PTSD and TBI. 

On balance, it takes 15 years or more to take a medical discovery 

into clinical practice. Fortunately, with Congress’ support, my office, the Defense Centers of Excellence for Psychological Health and 

TBI, has developed a knowledge translation process for use in 

DOD. This capacity gives us a pathway for advances in PTSD and 
4 

TBI and comorbid conditions so that we can get them to clinics 

quickly and cost-effectively. 

I would like to touch upon program assessment. We have evaluated over 150 mental health, TBI, substance use, and suicide prevention programs over the last 5 fiscal years. This program evaluation has been invaluable. Publication of this 5-year study will be 

completed later this fiscal year and will help us progress on the 

vital work of ensuring our funding is tied to programs that work, 

such as the U.S. Army’s embedded behavioral health program and 

its associated Behavioral Health Data Portal. 

I would like to briefly discuss the public health success in DOD 

that no doubt accrued from our increase in infrastructure, from 

which we might draw lessons for our Nation in addressing a disturbing national trend. 

In 2015, there were over 52,000 overdose deaths in America. Opiate overdose death rate went up to 10.4 per 100,000 in 2015. The 

DOD rate was 2.7 per 100,000, about one-fourth of that. How was 

this accomplished? In short, through leaders’ focus on the wellbeing 

of service members and a focused, outcome-based effort on prevention—primary prevention, selected prevention, and indicated prevention—drug testing, provider training, pharmacy protections, and 

medication therapies. 

We hope to generalize some of the successes we have seen in 

PTSD and TBI incidents and opiate overdose deaths into other 

public health areas, such as suicide prevention and alcohol use disorders. With your continued support, I am confident that our research discoveries, clinical innovations, and relentless focus on 

readiness for PTSD and TBI will bear fruit in years ahead. 

I look forward to answering your questions. 

[The prepared statement of Captain Colston can be found in the 

Appendix on page 28.] 

Mr. COFFMAN. Colonel Pflanz, you are now recognized for 5 minutes. 

STATEMENT OF COL STEVEN E. PFLANZ, USAF, DEPUTY DIRECTOR OF PSYCHOLOGICAL HEALTH, UNITED STATES AIR 

FORCE MEDICAL SUPPORT AGENCY 

Colonel PFLANZ. Chairman Coffman, Ranking Member Speier, 

distinguished members of the committee, thank you for the opportunity to speak to you today about post-traumatic stress disorder 

and traumatic brain injury in the military and the ongoing leadership you have provided to the services regarding military mental 

health. 

The last decade has seen powerful advances in our understanding of evidence-based treatments for PTSD and TBI. I vividly 

recall standing outside the Air National Guard headquarters building in Cheyenne, Wyoming, on a crisp autumn evening in the fall 

of 2010. I had just completed my training in prolonged exposure 

therapy for PTSD. Thrilled with the excitement about the promise 

of this treatment, I literally said to myself in the parking lot, ‘‘I feel 

like I have been given the cure to cancer.’’ Growing up, there was 

no higher aspiration for medicine than that. That sentiment was 

not entirely hyperbole. Research has proven the tremendous efficacy of these therapies. 
5 

Roughly 1 year later, in Afghanistan, I had the opportunity to 

serve combat warriors coming off the battlefields. There, I understood the importance of having real answers for difficult problems, 

of greeting elite professionals with elite care. 

I have repeated this story many times over the years because it 

is so important to have effective therapies to offer our patients, 

who have given so much in the service of our country. 

Today, all Air Force mental health providers routinely receive 

training in one or more of the several evidence-based therapies for 

PTSD, and all airmen can be confident that they will receive stateof-the-art treatment when they enter an Air Force mental health 

clinic. 

Fortunately, PTSD and TBI rates remain low amongst airmen. 

Even so, we are excited about the successful translation of research 

into clinical practice, including requiring evidence-based therapies 

for PTSD, event-driven protocols for recognizing TBI, and the use 

of progressive return to activity in the management of concussion. 

Integrating behavioral health care into primary care clinics, embedding mental health professionals into operational units within 

highly stressed career fields, and comprehensive screening for 

PTSD and TBI following deployments and throughout an airman’s 

career are three additional developments that help us successfully 

identify and manage these conditions. 

On the horizon, the Invisible Wounds Clinic being established at 

Eglin Air Force Base in 2018 will be a powerful enhancement of 

our treatments for PTSD and TBI, both as a referral center and as 

a projection of treatment and expertise Air Force-wide. 

Likewise, research partners are helping us evaluate options to 

repackage the essential elements of evidence-based therapies for 

PTSD to fit existing delivery systems without losing efficacy. These 

emerging opportunities are every bit as exciting as the research already translated into practice. 

To be certain, there is much work still to be done. The Air Force 

partners with its fellow services and civilian academic institutions 

to constantly push the envelope of science so that our treatment 

techniques and systems delivery grow ever more efficacious. 

At the same time, we are studying our systems of care to close 

gaps in services. Currently, a multidisciplinary task force is identifying and resolving gaps in the continuum of care and the Integrated [Disability] Evaluation System for airmen suffering from invisible wounds, with work underway on 27 specific solutions, ranging from education and training to culture and policy. These solutions will translate directly into improvements in services for these 

airmen. 

I wish to thank the committee for its interest in this topic and 

for your dedicated support of the men and women in the armed 

services. I am grateful for the opportunity to appear before you on 

this matter of importance. 

[The prepared statement of Colonel Pflanz can be found in the 

Appendix on page 40.] 

Mr. COFFMAN. Lieutenant Colonel Ivany, you are recognized for 

5 minutes. 
6 

STATEMENT OF LTC CHRISTOPHER G. IVANY, USA, CHIEF, BEHAVIORAL HEALTH DIVISION, HQDA, OFFICE OF THE SURGEON GENERAL, UNITED STATES ARMY 

Colonel IVANY. Chairman Coffman, Ranking Member Speier, and 

distinguished members of the subcommittee, thank you for this opportunity to provide the Army perspective on providing behavioral 

health and traumatic brain injury care to our soldiers and their 

families. 

Health care is essential to readiness, which is the Army’s number-one priority. I know of no area of health care that has faced as 

many challenges, made as many changes, and has achieved as 

many advancements as in Army behavioral health care. 

Over the course of my career, I have personally witnessed the 

impact of behavioral health support for soldiers in countless situations. From small outposts across Baghdad to clinics and hospitals 

across this country, Army physicians, psychologists, clinical social 

workers, nurses, and technicians have helped soldiers deal with the 

consequences of combat. 

Just as importantly, I have seen healthcare providers supporting 

the families of those that have volunteered to serve this country, 

as Army spouses and children also confront and overcome mental 

illness. 

The history of Army behavioral health care has included many 

challenges. Early in the wars in Iran and Afghanistan, the Army 

realized that the size and the organization of its behavioral health 

force was insufficient to meet the needs of our beneficiaries. In response, it greatly increased resources and expanded the number of 

clinical programs to serve this population. 

Senior Army medical leaders also made a pivotal decision to centralize the oversight and direction of all clinical programs and constructed a small team of professionals within the Office of the Surgeon General to do so. That team set out to analyze the effectiveness of all clinical programs, identify the best practices, and replicate them across the force. 

Out of this process came many programs, like embedded behavioral health, which has reduced many barriers to care for soldiers 

in combat units and improved access and readiness. The embedded 

model places professionals in small clinics in close proximity to 

where soldiers live and work. Today, over 450 providers in 62 embedded behavioral health teams support every operational unit in 

the Army. Data has clearly shown that soldiers are receiving care 

earlier and needing less hospitalization to receive treatment. 

Other innovations were drawn from the civilian sector. For example, school behavioral health had shown clear promise in several 

school districts across the country. The Army embraced this approach and placed providers directly in schools on Army posts all 

over the world. Children in 60 schools on Army installations can 

now see a provider by simply walking down the hall from their 

classroom. 

In traumatic brain injury care, in partnership with the DOD and 

other services, the Army has implemented a clear set of clinical 

standards and delivers them in interdisciplinary clinics across the 

force. Clinicians have reduced unnecessary variance, a key step in 

improving quality of care. Simultaneously, the Army Medical Re-
7 

search and Materiel Command is advancing its state of the science 

through a gap-driven research portfolio. 

Finally, the Army recognized the need to accurately understand 

the true effect of each patient’s treatment. It developed an automated process to measure from the patient’s perspective how symptoms responded to the care. The Behavioral Health Data Portal is 

now in use in every Army behavioral health clinic and has been 

used over 2 million times. To my knowledge, it is the most widely 

used clinical outcome system for mental health care in the country. 

Soldiers with behavioral health conditions get better faster because 

of this technology. 

This transformation has been possible because the Department of 

Defense delivers the vast majority of the care for our soldiers with 

mental health conditions and a history of TBI. The civilian sector 

could not have adapted as rapidly or as completely to meet the 

challenges faced by soldiers and their families. As the Military 

Health System evolves to best care for its beneficiaries, it is vital 

that we continue to deliver the large majority of mental health 

care. 

While much has been done, many challenges still remain. Like 

the rest of the Nation, we continue to fight against stigma to seeking mental health care, we search for better ways to keep more soldiers engaged in care until they achieve a full clinical response, 

and we strive to find new technologies to assist our clinicians in delivering cutting-edge treatments. 

I am committed to ensuring we overcome these and other challenges to improve the health and readiness of the force. I look forward to working with Congress in this endeavor. I want to thank 

my partners in the DOD, my colleagues here on this panel, and you 

for your continued support. 

Thank you. 

[The prepared statement of Colonel Ivany can be found in the 

Appendix on page 49.] 

Mr. COFFMAN. And, Captain Johnson, you are now recognized for 

5 minutes. 

STATEMENT OF CAPT THOMAS M. JOHNSON, M.D., USN, SITE 

DIRECTOR, INTREPID SPIRIT CONCUSSION RECOVERY CENTER, NAVAL HOSPITAL CAMP LEJEUNE 

Captain JOHNSON. Chairman Coffman, Ranking Member Speier, 

distinguished members of the subcommittee, thank you for providing me with the opportunity to share my perspectives as the director of the Intrepid Spirit Concussion Recovery Clinic at Naval 

Hospital Camp Lejeune. 

Marine Corps Base Camp Lejeune and the surrounding area are 

home to approximately 50,000 warfighters and their families. 

Traumatic brain injury, or TBI, has been described as the signature injury of the wars of Afghanistan and Iraq. Approximately 80 

percent of all TBIs are classified as mild. Individuals who have sustained a mild TBI may only experience subtle changes in mood, 

memory, sleep, and balance. They have no visible signs of their injury but are often struggling to function at work, at home, and in 

the community. 
8 

I remember vividly when I met with a Marine sergeant and his 

wife in the clinic. I asked him about his medical issues. He told me 

that all he wanted me to do was fix his headaches so he could get 

back to his unit and deploy back to Iraq. 

I then asked his wife, ‘‘What was bothering you?’’ And there was 

this dramatic pause, and she burst into tears. And she told me that 

she felt that she hardly knew her husband since he had returned 

back from his last deployment, in which he had sustained a TBI. 

Tragically, the war does not end for those families when the service 

member comes home. It goes on and on every day, as they struggle 

heroically to overcome the trauma of war. 

The reality is that there is currently no diagnostic tool that is 

sensitive and specific for mild TBI. However, we have worked to 

overcome this by developing a holistic, integrated, interdisciplinary 

treatment model that employs a standard evaluation that includes 

physical, psychological, and spiritual dimensions. We then use this 

information to diagnose and treat each of our patients. 

We treat these service members like warrior athletes and employ 

both traditional therapies as well as complementary and integrative medicine to return them to the highest level of function possible after their injuries. We use a minimal amount of medication, 

almost no narcotics. And over 90 percent of them return to full 

duty upon completing our program. 

The great sacrifices made by warfighters and their families compel us to do everything in our power to support them on their road 

to recovery. Research in the prevention, diagnosis, and treatment 

of TBI is one way to fulfill this great obligation. The Military 

Health System, in partnership with civilian academic institutions, 

has a robust research portfolio to address gaps in knowledge and 

improve care for service members with TBI. 

For example, we have developed a progressive return-to-activity 

protocol that give providers guidelines on how to gradually increase 

activity in individuals in a way that maximizes recovery. 

We are committed to caring for people like the retired combatdecorated master chief petty officer who was a patient at Intrepid 

Spirit. He had been exposed to literally hundreds, if not thousands, 

of blasts during his career. After he retired, he noticed an insidious 

decline in his cognitive function, to the point where remembering 

where he was going when driving and then even driving itself became difficult for him. After an extensive workup in our clinic, it 

became apparent that he had a brain injury. 

To this point, the DOD has an ongoing longitudinal study on 

traumatic brain injury incurred by members of the Armed Forces 

in order to better understand what happens to individuals like the 

master chief so they get the treatment they need. 

Because Intrepid Spirit Camp Lejeune is located where the service members live and work, we are uniquely suited to support these 

important efforts. Every day, as we work with service members— 

sailors, marines, soldiers, airmen, and coastguardsmen—who have 

sustained a TBI, we are reminded of the urgency and importance 

of our mission. 

On behalf of the staff at Naval Hospital Camp Lejeune and service members like the Marine sergeant and the master chief that I 

mentioned earlier, we are grateful to the committee for your strong 
9 

support. Navy Medicine is privileged to work hard at something 

that is so important and so rewarding. 

I look forward to your questions. 

[The prepared statement of Captain Johnson can be found in the 

Appendix on page 56.] 

Mr. COFFMAN. Thank you, Captain Johnson. 

Captain Colston, I think you had mentioned that, on TBI, on 

numbers, that I think that you dropped from 31,000 to 23,000. In 

what period of time was that? I am sorry. 

Captain COLSTON. Between 2012 to 2015. 

Mr. COFFMAN. Okay. And so I suspect that this was enhanced 

safety, because, I mean, TBI is produced by trauma. So how would 

you—— 

Captain COLSTON. I think a couple things. I think the OPTEMPO 

[operational tempo] was pretty similar over those periods. So I 

know that there is a lot of leader intervention in regard to TBI and 

in regard to efforts that leaders make to tell people not to get 

TBIs—safety, other issues along those lines. 

As you know, sir, there are very few TBIs on the battlefield right 

now, something on the order of about 200. MVAs [motor vehicle accidents], sports accidents, and the like are where we are getting a 

lot of those, and prevention measures can be used in that regard. 

Mr. COFFMAN. Okay. Thank you. 

A question for all of you, each one of you individually. So I have 

a concern that a soldier, marine, airman, or sailor might be reluctant on Active Duty to go see a mental health professional or go 

see a neurologist about the consequences of a TBI for fear of what 

that may do to their career. 

I was a junior officer during peacetime, but I can remember deploying as a rifle platoon commander in the Marine Corps and then 

coming back. And if I look at the Marines, particularly during the 

height of Iraq and Afghanistan, that person in that same position 

that would have been in combat coming back and then, as a first 

lieutenant then, saying, ‘‘Oh, I want to see a mental health professional because I am concerned about post-traumatic stress,’’ and 

what the reaction for that command would have been; it wouldn’t 

have been positive. 

And so I want you to—and I was aboard a ship not that long ago, 

an aircraft carrier in the Persian Gulf, and ran into the chaplain. 

And the chaplain was informing me, the ship’s chaplain, that he 

would see a lot of the sailors that would prefer to see him versus 

see a mental health professional because there was no entry in 

their healthcare books, in the health record books. 

And so if each one of you can comment to me how significant this 

issue is today and what your branch of service is doing in response 

to it, to gain access for these military personnel. 

Captain Colston. 

Captain COLSTON. Yes, sir. Stigma is a huge issue. We suspect 

that perhaps even half of people who have a condition don’t come 

see us because of stigma. Some of it has to do with security background questionnaires, and certainly we have worked over the last 

number of years to allay that concern in folks. 

One of the things that I remember from when I deployed as an 

Army psychiatrist was you have to work with the chaplains. In es-
10 

sence, there needs to be a close relationship in a deployed setting 

between mental health providers and chaplains. 

There is a presumption of nondisclosure in mental health. I 

would never, as a mental health provider, run to a commanding officer with things that don’t have to do with the soldier’s readiness. 

I have never shared personal details about patients, recognizing 

that I need to make it as easy as possible. It is also DOD policy 

that there is a presumption of nondisclosure, and that policy 

speaks directly to commanding officers. 

It is obviously a leadership issue, and it is one that we need to 

address closely. And, obviously, GAO has looked at it over a number of years. 

Mr. COFFMAN. Colonel Pflanz. 

Colonel PFLANZ. Sir, I think all the services are moving to increasingly embed mental health resources closer to the soldiers, 

sailors, marines, and airmen. We are certainly doing that in the 

Air Force with our RPA [remotely piloted aircraft] community and 

our special operators, special tactics, and we are increasingly beginning to take that to maintainers on the units. 

You know, this proximity breeds familiarity, and with familiarity 

there is comfort. And as you get comfortable with individuals, you 

are willing to come and get care and get help. So the greater we 

bring care to them, the more likely it is we are going to break down 

those barriers and their reluctance to seek care. 

Mr. COFFMAN. Lieutenant Colonel Ivany. 

Colonel IVANY. Sir, I certainly agree with the previous two panelists here. This has been a key focus within the Army. I think we 

have made quite a bit of progress in this area. 

If you compare the number of mental health visits that were delivered in 2007 to all Army beneficiaries, it was about 900,000 at 

that time. Last year, 2016, we delivered 2.1 million visits to Army 

beneficiaries, more than double the number of people and number 

of times that we have been able to see people. 

So I think our data shows that this issue is getting better. The 

core of our approach has been to move health care further forward 

to eliminate barriers to that care, and we have seen soldiers and 

their beneficiaries use it more frequently. 

Mr. COFFMAN. Captain Johnson. 

Captain JOHNSON. Sir, we have changed the way we do business 

to meet this need. Specifically, we have provided education to service members about the signs and symptoms of TBI and PTSD and, 

moreover, that it is a real, important issue. We have provided education to healthcare providers. 

We have also changed the way we do business in theater. Historically, if a service member had a problem, they may or may not 

go to medical. Now, it is an event-driven process. If you are in the 

proximity of a blast, you are to go to medical, regardless of your 

symptoms, and then the healthcare provider then can get history. 

They have more training to determine if you did indeed sustain a 

TBI or have PTSD or other medical issues. 

In addition, at Naval Hospital Camp Lejeune, through the Intrepid Spirit, because of our holistic, integrated, interdisciplinary 

approach with a standard evaluation, individualized treatment, 

most of the service members return to duty, so 90 percent or so. 
11 

So their testimony when they tell other service members that they 

went to the Intrepid Spirit and that they had these symptoms and 

they got better is very, very powerful. And I think, ultimately, they 

are our greatest advocates that say that this is a real phenomena, 

it is treatable, and they should seek treatment. 

Mr. COFFMAN. Thank you, Captain Johnson. 

Ranking Member Speier. 

Ms. SPEIER. Thank you, Mr. Chairman. 

As I mentioned in my earlier comments, I am concerned about 

the relationship between TBI and CTE [chronic traumatic encephalopathy]. There was an international state-of-the-science meeting in 

2015 that agreed to six recommendations, the first of which was 

the creation of a coordinated brain bank and tissue repository system. 

So, Captain Colston, has the DOD created or coordinated for 

such a repository? And, if so, how are service members informed 

about their opportunity to register and to donate? 

Captain COLSTON. Yes, ma’am. We called Dan Perl at USUHS 

[Uniformed Services University of the Health Sciences] a couple 

days ago about this matter. He is up to 51 brains in his brain tissue repository at USUHS. Up at VA [Veterans Affairs] Boston, 

there are 98 brains of veterans. 

So we have moved up from about a dozen to 51 at USUHS in 

a pretty short period, I think in about a year. The Center for Neuroregenerative Medicine [CNRM] is leading this process for DOD. 

And the Chronic Effects of Neurotrauma Consortium [CENC] is 

leading it for VA, Dave Cifu down at—— 

Ms. SPEIER. So how are we informing veterans and/or those who 

are discharged from the military of the availability of this repository? 

Captain COLSTON. Right now, it is what you have on your driver’s license. I know that efforts are afoot to approach that issue. Of 

course, what we need is brains and histories. And getting the word 

out is a big part of the effort at CNRM and CENC right now. 

Ms. SPEIER. It sounds like we could do a better job at that than 

we are. 

Captain COLSTON. I think the brains versus pathology progress, 

ma’am, is something that we need to work on. And certainly I could 

take that for the record. 

[The information referred to can be found in the Appendix on 

page 69.] 

Ms. SPEIER. All right. 

I have been working on this issue from a different perspective for 

close to a decade, and I have become aware of a professor and 

Nobel Prize winner at UC San Francisco, Stanley Prusiner, who 

was the first to identify the tau protein, which is related to mad 

cow disease and, as a result, also related to TBIs. And he sent me 

this letter, which I want to read parts of it and then get your comments. 

‘‘Seemingly mild TBIs can initiate progressive nervous system 

degeneration involving aggregation of the tau protein into tangles 

within the frontal lobes of the brain. As many as one in five soldiers deployed in Iraq and Afghanistan were within the distance of 

an IED [improvised explosive device] blast and suffered one or 
12 

more mild concussive episodes. Drugs must be developed to treat 

such individuals. 

‘‘Combat-related TBIs exhibit disinhibited behaviors, including 

depression, insomnia, drug addiction, alcoholism, and suicide. 

These symptoms of central nervous system dysfunction are indistinguishable from those seen in CTE patients in whom modified 

tau proteins aggregate. Lowering the level of tau delays the onset 

of neurodegeneration. 

‘‘Large numbers of service members deployed in recent conflicts 

will develop CTE, which is one of the subset of conditions known 

broadly as post-traumatic stress disorder. Hence, the identification 

of such drugs is an urgent medical, societal, and national security 

issue. The development of such medicines and that the Congress 

continues to fund annual research and development in the Department of Defense budget to undertake this important work is key.’’ 

So I guess my question to each of you—and I have 1 minute and 

15 seconds left—is: What are we doing in terms of seeking out 

medicines, and to what degree do you concur with Dr. Prusiner on 

his conclusions? 

Captain COLSTON. Ma’am, I was honored to meet Dr. Prusiner in 

the Assistant Secretary’s office. Right now, he is working on a 

novel drug discovery compound, looking at about 20,000 compounds 

that have to do with tau aggregation. As you know, he is an expert 

in mad cow disease. There is a question about protein scaffolding 

and the progress. 

The clinician in me says there probably is some nexus between 

TBI and CTE. But I also need to say, as a scientist, that that nexus 

is not fully established right now. 

Ms. SPEIER. And the idea that we need a drug in order to try and 

address this condition in our service members? 

Captain COLSTON. I think Dr. Prusiner’s work is high-risk/highreward. If, in fact, protein scaffolding is what causes CTE, I think 

his work will bear great fruit. As a Nobel laureate, those are the 

kind of people we want on high-risk/high-reward projects, and I 

think he is the perfect person for that job. 

Ms. SPEIER. Yes, Captain Johnson. 

Captain JOHNSON. At Camp Lejeune, we are making efforts to 

make service members more aware of the brain bank by having 

discussions with some of the medical leaders, both at MARSOC 

[Marine Corps Forces Special Operations Command] and in the 

MEF, the Marine Expeditionary Force, and the Special Operations 

Command. 

In addition, I personally am donating my brain to that brain 

bank. And, again, I think that is one way to get the message out, 

that I think it is so important that I want to participate in it. 

I also heard a story that I think merits discussion. There was a 

service member who donated his brain to the brain bank, and the 

family members said they felt that their son was still serving the 

country even after death by donating his brain to the brain repository. 

So we are doing everything we can, and we support it 100 percent. 

Ms. SPEIER. Colonel Pflanz. 
13 

Colonel PFLANZ. The Air Force is very concerned about the impact of recurrent, chronic, or severe TBI on its airmen and other 

service men and women. I agree with Dr. Colston that, you know, 

the research on the link between blast injuries and chronic traumatic encephalopathy is unclear. And, more importantly, what do 

we do with it once we make that link? 

And so the Air Force and the other services are falling back clinically now on our DOD/VA clinical practice guidelines. Those are 

our bibles. You know, the latest literature, as it emerges, is incorporated into those clinical practice guidelines so that the physicians 

working in the trenches are using the best knowledge, best possible 

treatments. 

Ms. SPEIER. Lieutenant Colonel Ivany. 

Colonel IVANY. Ma’am, the Army recognized this as a key issue 

and is fully supportive of all research efforts in this area. And we 

feel, again, great motivation here. The Army is the lead service for 

the NCAA–DOD [National Collegiate Athletic Association–Department of Defense] Grand Alliance, which is a big part of the broader 

research assessment and following soldiers and athletes over time. 

And there are many other research efforts ongoing. 

We feel that it is very important to continue a broad research 

base in this area, because the clear connections from TBI to CTE 

are not yet fully established. And so we feel it is important to keep 

many research options on the table so that we have the best chance 

of developing care. 

Ms. SPEIER. Thank you. I yield back. 

Mr. COFFMAN. I recognize Mr. Bacon for 5 minutes, and then we 

will have to break or recess for three votes, and then we will return 

to finish the hearing. 

Mr. Bacon. 

Mr. BACON. First of all, thank you for treating our service men 

and women and taking good care of them. I know, as someone who 

has commanded five times, the importance of what you are doing, 

because we have seen the impacts of when folks come back home. 

I would like to ask you briefly, do you feel like you have been 

adequately resourced and funded to treat PTS [post-traumatic 

stress] and TBI? 

We will start with Captain Colston. 

Captain COLSTON. Yes, sir. The Defense Centers of Excellence for 

Psychological Health and TBI has a $125 million annual budget. I 

feel that is more than sufficient to meet our need. And it has 

helped us to do really, I think, what we need to do, which is translate theory into practice. 

Mr. BACON. Thank you. Our three service reps? 

Colonel PFLANZ. Sir, I would agree that we are adequately 

resourced to address these issues. The services are leading the way 

in the adoption of evidence-based therapies for PTSD. The Air 

Force is at 80 percent using these in treatment of PTSD, whereas 

many of our civilian communities are somewhere between 10 and 

40 percent. 

And so certainly we are being resourced—the funding that is 

going to Fort Detrick and our military research is tremendous. 

That is helping us find the cutting-edge science to advance our 

treatments in the field. 
14 

Mr. BACON. Great to hear. 

Colonel IVANY. Sir, the Army does feel that we have good resourcing in this area. We feel that the major struggle is not in having enough resources but in finding qualified mental health professionals across the country to come work with the Army at many 

bases that are in places that are not necessarily highly desirable 

to live. 

So things in the area of a stable civilian hiring environment, lack 

of CRs [continuing resolutions] and hiring freezes and those types 

of things help very much with the Army to be able to use the resources that are provided to bring providers into the clinics to care 

for our soldiers. 

Mr. BACON. Thank you. Captain Johnson. 

Captain JOHNSON. We would ask for you to continue with your 

leadership, your guidance, and your commitment to helping all of 

us take care of the service members and their family. 

Mr. BACON. Thank you. 

Here is another question. I know earlier it was harder to find effects of PTS, and I think we are trying to be a lot more aggressive 

in finding it early. Do you have analysis that shows that we are 

seeing a lot more earlier reporting, earlier success at finding PTS 

when folks come back from deployment? 

I will just start off again with Captain Colston. 

Captain COLSTON. Well, sir, I think one of the first things, the 

way that we approach that problem is by screening. So we do do 

person-to-person mental health assessments within 90 days of the 

deployment and then within 90 days after, 6 months to a year and 

a half, and 11⁄2 years to 21⁄2 years after. 

We are studying it right now. For instance, we are studying from 

the standpoint of the disability evaluation system. We are studying 

it from the standpoint of the prevalence of the condition. But I 

don’t have a final answer, because we really don’t know what the 

final answer is. 

Mr. BACON. Uh-huh. 

Colonel PFLANZ. Sir, I don’t know that we can say that we are 

doing a better job of identifying it earlier, but with our serial 

screening, we are certainly giving airmen, soldiers, sailors, marines 

an opportunity, multiple opportunities, to tell medical professionals 

that they are suffering from these symptoms. 

And if they are reluctant when they are first coming back from 

deployment because they are worried that perhaps they might be 

delayed, they have another opportunity 6 months later, and they 

have another opportunity—— 

Mr. BACON. Right. 

Colonel PFLANZ. So this serial screening is so important in giving 

these airmen multiple opportunities, and that has to give us an advantage in treating these earlier. 

Mr. BACON. Thank you. 

Colonel IVANY. Sir, within the Army, again, this has been a 

major area of focus, to try to identify these conditions as early as 

possible. Screening is key. And we feel like moving care forward 

has been another very important step. As I mentioned, we have 

seen many more soldiers, almost twice as many, twice as fre-
15 

quently on the outpatient side and have far fewer soldiers needing 

hospitalization for those same conditions. 

So, for us, that is an indication that we are getting to see soldiers 

earlier in the course of the illness, prior to major crisis events 

which lead to them going into the hospital and having very negative career events. 

Mr. BACON. Thank you. Captain Johnson. 

Captain JOHNSON. I can just echo what my colleagues have said. 

There are more robust screening tools that are in use to identify 

service members who have TBI or PTSD earlier. The Navy has also 

moved forward by embedding mental health in more forward positions. So what that does is that increases access and decreases stigma. 

And, finally, in our clinic, because we use a holistic, interdisciplinary, integrated approach, frequently a service member may initially say they have TBI, but then, as you get more history, PTSD 

due to whatever causes will become more apparent. 

Mr. BACON. Well, thank you very much. I yield back my 13 seconds. 

Mr. COFFMAN. Thank you, Mr. Bacon. The hearing will resume 

following the vote series. 

[Recess.] 

Mr. COFFMAN. This hearing is now called back to order. 

I am still concerned about the issue of access to care and the 

stigma that might be—and I know you all have essentially said 

that access has dramatically increased, that the culture of the military has changed to where there is—you can’t say no stigma, but 

you say—I mean, if someone is in a line position of leadership, particularly in a combat military occupational specialty, and they have 

got issues related to stress or TBI that they want to seek treatment 

on, you know, that is—that is a hard one. 

And let’s go back to the culture. At least I am outdated here. 

But, you know—but I remember, say, back when I was a junior officer, I mean, in a rifle infantry company in the Marine Corps, 

where if I had an appointment of any kind, the company commander was made aware of that appointment where I was leaving 

the company to go do something on Mainside. 

So tell me about how that infantry rifle platoon commander who 

is expected to be—to act appropriately in a stressful environment, 

in a combat environment, leading marines in this particular instance, where that is not a stigma for that junior Marine officer to 

go to seek treatment. And it would be the same for a platoon commander of the United States Army infantry or anything in combat 

arms, in any—a pilot—a fighter pilot, or somebody involved in a 

stressful situation—in the United States Air Force or positions in 

the Navy. I mean, you know, if someone’s a SEAL [Sea, Air, Land] 

team member or somebody, you know, in any kind of a combat role. 

I mean, what is their access to care, and is there a stigma associated to it? And do you have any ideas where legislatively we could 

look at changing the administrative process in terms of how somebody’s healthcare record is kept and how somebody—I think you 

mentioned privacy issues. 

So let’s go back now, starting with you Captain Colston, and talk 

about where we are today, access today. And what can we do to im-
16 

prove it if, in your estimation, there needs to be something to improve access to where someone doesn’t feel that there is a stigma 

associated with receiving care? 

Captain COLSTON. Yes, sir. Well, first of all, I think you hit the 

nail on the head. Junior officers, and I remember my time as a junior officer, there wasn’t any discussion of mental illness or suicide 

or anything along those lines. And also, the senior enlisted folks 

really do act as gatekeepers for health care. That has been one of 

the things that we have recognized over the years. 

So the first thing is policy. So we wrote a DOD policy 6490.04 

that says, it is DOD policy that mental health care is the same as 

a rash. Commanders need to make sure that folks view mental 

health care just like the sergeant coming up to you and say, hey, 

get that rash taken care of. 

Obviously, at the unit level we need to make sure that happens. 

And that is where I think the embedded providers come in, the 

OSCAR [Operational Stress Control and Readiness] providers in 

the Marine Corps, the embedded behavioral health providers in the 

Army, the psychologists on aircraft carriers. I think that is where 

the role is. I think it is really—I think with regard to policy, I 

think we are there. 

There has been talk of making all mental health care confidential. I don’t know that that necessarily best balances the interests 

of what we need to do as a warfighting entity and meet the needs 

of our soldiers, sailors, airmen, and marines. But it is certainly 

something that we have explored and something that we have 

looked at in research. 

One of my predecessors, Chuck Engel, has the view that that is 

where we should go. I think when we have kind of been through 

the SF–86 Question 21 with other agencies, DNI [Director of National Intelligence], those folks, I think where we are going to end 

up is somewhere in the middle. And I don’t know what that middle 

is. 

Mr. COFFMAN. In the civilian world, certainly in Colorado law, if 

a therapist has a patient who is a threat to his or herself or to 

someone else, then there is a reporting requirement for that. 

Captain COLSTON. Yes, sir. That is commonly known as the 

Tarasoff warning. I am required as a psychiatrist, whether I am in 

the military or in the civilian world, where I have also practiced, 

I am required to tell folks, tell authorities if someone is a harm to 

themselves or others. 

There has been some thought of saying, well, that is really where 

we should cut it off. I think when we look at it from the security 

standpoint, we need to be a little bit higher in DOD, though. 

Mr. COFFMAN. Okay. Colonel Pflanz. 

Colonel PFLANZ. Sir, American culture is changing about mental 

health care. The military culture is certainly changing as well. The 

challenge we have is that perception is ninth-tenths of reality and 

what airmen, soldiers, sailors, marines believe is true mobilizes 

their behavior. What they see is, you know, the 1 airman in 10 that 

goes out with a medical evaluation board, and 9 out of 10 that 

come back, they saw me, they had satisfactory care, they don’t 

raise their hand and say, you know, I had a great experience with 

mental health. 
17 

So it is our messaging, it is our training, you know, continuing 

encouraging help-seeking behavior, educating airmen through suicide prevention training, resiliency training, other sorts of things 

that mental health care is a good thing. It doesn’t have the negative outcomes, sometimes, but not usually, that they perceive it to 

have. And then embedding mental health closer and closer so that 

they are familiar with this, and the false notions that they have, 

they will start to learn are untrue. So again, changing perception 

is the most important thing. We are moving the dial, but we are 

not there yet. 

Mr. COFFMAN. Do you think confidentiality, though, should we 

enhance confidentiality requirements for the patient? 

Colonel PFLANZ. What I found in 22 years working with my patients is that the confidential dial is titrated to the right level. 

Most of my patients that I interact with that I then speak to commanders, I am an advocate for that individual. They are appreciative of that communication. And for the 95 percent of patients 

that I never speak to their commander, they are appreciative of 

that as well. 

I think changing that will impair—if we make it more confidential, it will impair my opportunities to be that patient’s advocate 

with a commander, to help that commander understand the mental 

illness, how it impacts the mission, and also help that commander 

understand that this airman with treatment is going to be a fullblown asset once we’re done. 

Mr. COFFMAN. Under current regulations, do you have to receive 

permission from the patient, the airman being treated, to be able 

to discuss the issue with, say, that person’s commanding officer? 

Colonel PFLANZ. I do not need the airman’s permission for things 

that impact duty performance, safety, mission safety, those sorts of 

things. 

Mr. COFFMAN. Lieutenant Colonel Ivany. 

Colonel IVANY. Yes, sir. I think the key here is two things. One 

is a trusting, working relationship between a small number of mental health providers and then line leaders. If line leaders trust and 

know and understand who it is they are going to talk to themselves 

or who it is they are sending their soldier to talk to, they are much 

more likely to use that care. If we just ask them to go up to the 

hospital to a nameless or faceless entity and clinic and just walk 

in and say I need help, that is a much, much harder sell than us 

saying, look, please come down to the clinic two blocks down from 

where you work to see Dr. Johnson who has seen all your soldiers 

and your unit for the past, you know, couple of years and worked 

with you on many different issues. 

So if you have a trusting working relationship, that changes the 

thought process, because that leader doesn’t have to necessarily 

think differently about mental health care in general, they just 

have to think differently about at least one mental health provider 

that is there to help them and their unit. So I think that is one 

of the keys. 

The second is that while we want to make sure that we offer as 

much confidentiality as possible, we have to balance readiness. So 

when we identify a readiness impairing issue, it is in the best interest of the unit, of the leader, and ultimately the soldier them-
18 

selves to make sure that is known to the appropriate people so that 

we can form a community to help that soldier to get better or to 

help them take the next steps in their life. 

Mr. COFFMAN. Captain Johnson. 

Captain JOHNSON. We have found that education of the service 

members, as well as healthcare providers, is one way to decrease 

stigma. In addition, when service members are referred to the Intrepid Spirit Concussion Recovery Clinic and when they recover 

and when they return to full duty, that is a testimony to the fact 

that TBI and PTSD are real issues and they are also treatable. 

And it encourages service members. It gives them hope to step forward, to seek treatment, and then return and get back into the 

fight. 

Mr. COFFMAN. Thank you very much. 

Ms. McSally, you are now recognized for 5 minutes. 

Ms. MCSALLY. Thank you, Mr. Chairman. And thank you, gentlemen, for your service and your care for our troops. 

I am a big proponent of integrated medicine and—for myself and 

really from a public policy point of view. And alternative options 

are just sometimes challenging because they are not recognized 

often in the medical community. So can you speak a little bit more 

about—you know, I have talked to organizations that are involved 

with helping our troops, this is mostly with vets, hyperbaric oxygen 

therapy, or another organization our community is involved in, 

take and choose for PTSD on, you know, doing scuba-related underwater therapy, or service animals, other nontraditional things that 

there is, again, outside organizations that are already doing things 

like this. Sometimes it is tougher for a big bureaucracy to accept 

some of these alternative things that they say can’t be proven. 

So just talk to me about some of the things that you might be 

working on or you think that may be useful. I have seen it in some 

of your testimony, Captain Johnson. Any other perspectives on 

these other treatments. Some of them, again, may be psychological, 

but also there is some physiological elements, I think, of a cortisol. 

And I am not a doctor, but other things related to the potential 

benefits for those that are suffering from PTSD and TBI. 

Captain JOHNSON. You have hit on a very important issue. Just 

to break down your question to the components, in regards to 

hyperbaric oxygen therapy, currently, the FDA [Food and Drug Administration] has I believe it is 13 approved indications for the use 

of hyperbaric oxygen therapy. The Navy and the DOD provides 

clinical care for these approved uses of hyperbaric oxygen therapy. 

So our use of hyperbaric oxygen therapy is in alignment with the 

FDA and the Undersea and Hyperbaric Medical Society. Having 

said that, there is always more to learn, and we certainly are open 

to discussion to explore research and other projects that involve 

hyperbaric oxygen that can help service members and their families. 

In regards to complementary and integrated medicine, we have 

found at Camp Lejeune that service members are very receptive to 

it. They are hesitant about taking a pill. We use a lot of acupuncture, yoga, various meditation techniques, Alpha stimulation, 

audio-visual entrainment, and various other tools. We have found 
19 

that this results in a decreased need for medications, in particular, 

narcotics. It is a central part of our treatment plan. 

Ms. MCSALLY. Are you bringing in experts from off base in order 

to partner with that or are you building expertise within the 

service? 

Captain JOHNSON. Both. 

Ms. MCSALLY. Okay. 

Captain JOHNSON. For example, myself and one of my colleagues 

in the clinic has completed training in acupuncture. But we also 

have relationships through our NICoE [National Intrepid Center of 

Excellence] and Intrepid Spirit’s network to discuss the latest and 

newest innovations in complementary and innovative medicine. 

Ms. MCSALLY. Great. Thanks. Captain Colston, did you have 

something to add? 

Captain COLSTON. Yes, ma’am. We welcome complementary and 

alternative medicine in DOD. And, in fact, given the national opiate scourge, I think especially for pain disorders it is important to 

have yoga and acupuncture and mindfulness and other therapies 

available for patients. And I think—if I were to look at family practice docs across the board right now, lots of them are trained in 

battlefield acupuncture where we really are using it. 

Ms. MCSALLY. Yeah. Is there also, as you are—maybe again this 

breaks up our thinking on some traditional mindsets, right, 

transitioning that to the VA, are you—I mean, are we seeing 

partnering with the VA to make sure, if you guys are all using this 

and it is working, as they are transitioning, they are not dealing 

with similar bureaucracy saying, sorry, that is not approved, we 

don’t do that here? Anybody else want to jump in? 

Colonel PFLANZ. I think that, you know, all the services are interested in the emerging research, and our partnership with the 

VA and our clinical practice guidelines is one of our great 

strengths. It makes us, despite our size, a very nimble organization 

as new research emerges. And almost all of our research projects 

are partnered with civilian institutions, so we have the best minds 

out there assisting us. And as this new research emerges, it is incorporated relatively quickly into our clinical practice guidelines. 

The one on PTSD is being updated as we speak, and that allows 

our practitioners in the field to have the cutting-edge tools to treat 

airmen, soldiers, sailors, marines in those clinics with the best possible science that has emerged. 

Ms. MCSALLY. You have got to believe there is skepticism within 

the traditional medical community, right, on some of these things? 

I deal with it all the time. Right? So how are you overcoming that? 

Lieutenant Colonel Ivany, is that how you say it? Do you want 

to jump in? 

Colonel IVANY. Yes, ma’am. I think that the more that we put 

these alternative approaches out in clearly defined clinical practice 

guidelines, which is the clear state of the science that is a joint 

DOD/VA work, then more and more people out there in each individual clinic will see that this is clearly beneficial and this is not 

a competition. It is an augmentation to what they are doing to help 

their patients. 

Ms. MCSALLY. Great. Thank you. I am over my time. I appreciate 

all of your work, gentlemen. Thank you. I yield back. 
20 

Mr. COFFMAN. Thank you, Ms. McSally. 

Ranking Member Speier. 

Ms. SPEIER. Thank you. I just have a couple of quick questions. 

Lieutenant Colonel Ivany, you referenced in your statement that 

one of your biggest problems was hiring, that you have a 15 percent turnover rate with your specialists who provide the services. 

And I can see for the service member having to redevelop a relationship with yet another behavioral specialist has got to be problematic. What can we do to fix that? 

Colonel IVANY. Ma’am, I think the biggest thing that we can do 

is to make sure that the healthcare providers who have options to 

work with us or work elsewhere have trust that there is a stable 

hiring environment within the U.S. Government and within the 

Army. So that—for instance, the recent hiring freeze, you know, as 

we identify and try to bring providers on, we had to have many of 

those providers wait. And they weren’t able to come onboard to our 

clinics until we have worked through the steps to resolve the hiring 

freeze to get them through the gate. 

So they are hesitant to hear about sequestration. They hear 

about continuing resolutions, and it makes many hesitant. So I 

think that is the single most important thing at the national level 

that would help us at the clinical level. 

Ms. SPEIER. All right. Captain Johnson, you talked about some 

of those suffering from TBIs or PTSD self-medicating. I am presuming this is alcohol and drugs, unrelated to their condition. Is 

that right? 

Captain JOHNSON. That is correct. 

Ms. SPEIER. I have a lot of biotech in my district. And I was 

speaking to one of my CEOs just last night who said that they are 

close to finding a genetic marker for PTSD. Are you looking at that 

at all in the research that is being undertaken? And if not, why 

not? 

Captain COLSTON. Yes, ma’am. In fact, we have protocols underway right now to look at genetic loci for PTSD. I just say there are 

far more than one, and that is one of the things that we find across 

mental illness, across PTSD, depression, autism spectrum disorders. But we have funded research and we are looking at that 

closely. 

Ms. SPEIER. My colleague had to leave, but Congresswoman 

Shea-Porter is from New Hampshire where the opioid crisis has 

been particularly severe. And she got the impression from your testimony, and maybe it was you, Captain Colston, who talked about 

the success you are having. And she wants to know if there are certain procedures or policies or programs you have undertaken that 

has been particularly successful, could you share them with us? 

And if you could do that for the record, that would be helpful. 

Captain COLSTON. Yes, ma’am. Well, I would start with it is my 

opinion, but I think the fact that our death rate is 2.7 per 100,000, 

and the national death rate is 10.4 for 100,000, for opiates, is obviously a significant difference between populations. Universally, we 

have random drug testing, which is, of course, not available to most 

people. You know, in regard to civil rights that you have when you 

are an Active Duty service member, there is a difference between 

being a civilian and in the military. 
21 

I do think secondary prevention efforts are really where we have 

excelled with regard to pharmacy interventions, a prescription drug 

tracking system, various issues with regards to sole provider programs. And then goalkeepers, to be quite honest with you, ma’am. 

One of the things that I do as a psychiatrist, that I have a buprenorphine waiver. So I can give medication-assisted therapy for people who are addicted to opiates, give them a drug that they can’t 

overdose on, give them a drug that they can’t snort and, hence, die. 

I think that has been useful. And, of course, we have put naloxone 

into the hands of first responders. And in New England, New 

Hampshire, Vermont, Governor—I know the Governor in Vermont 

made the entire state of his governorship address one year on opiate overdose deaths. 

This is the single biggest public health crisis that we have faced. 

It is 55,000 overdose deaths a year. Car accidents, 38,000; gun 

deaths, 36,000. AIDS was never this big. It is a huge issue. And 

frankly, it is a doctor-created problem and it is on us to fix it. 

Ms. SPEIER. Last question I have. To what extent are we now 

tracking those who have been diagnosed with TBI over the course 

of the rest of their lives to see what conditions they acquire that 

we would attribute to TBI? 

Captain COLSTON. So we have two studies underway. We have 

the 15-year longitudinal TBI study, which we are 7 years into. And 

I think that is going to talk an awful lot especially about how 

PTSD and TBI and suicidality and chronic pain and substance use 

all overlap. And we will learn a lot more about that. We also have 

an IMAP [Improved Understanding of Medical and Psychological 

Needs in Veterans and Service Members with TBI] study. In regard to the here and now, how do we look at—how do we look at 

TBI. Well, we have a very robust surveillance network with regard 

to TBI, and we look at scientifically something called incidence, 

which is new incidents and prevalence. In other words, how people 

are—if people aren’t recovering from TBI. 

Most TBI is self limiting. Most mild TBI just gets better. It 

doesn’t matter if you saw a doctor, it doesn’t matter what you do. 

What we need to get on top of are the chronic cases, and we need 

to learn about those. 

Ms. SPEIER. So do you think the studies are going to provide you 

with that? 

Captain COLSTON. Yes, ma’am. I think longitudinal studies are 

really the way to go. The Framingham study, really, we learned a 

ton about coronary artery disease. I think the Army’s STARRS 

[Study to Assess Risk and Resilience in Servicemembers] study in 

regard to suicide is going to yield great benefit. I think longitudinal 

studies like the Millennium Cohort Study, which in essence is a 

study that looks at what does military service do to you healthwise—I think they are all extremely important. 

Ms. SPEIER. Okay. Thank you. Thank you, Mr. Chairman. 

Mr. COFFMAN. Thank you, Ms. Speier. 

I wish to thank the witnesses for their testimony this afternoon. 

This has been very informative. 

There being no further businesses, the subcommittee stands adjourned. 

[Whereupon, at 4:12 p.m., the subcommittee was adjourned.] 

A P P E N D I X 

APRIL 27, 2017 

PREPARED STATEMENTS SUBMITTED FOR THE RECORD 

APRIL 27, 2017 

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WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

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RESPONSE TO QUESTION SUBMITTED BY MS. SPEIER 

Captain COLSTON. The Department of Defense (DOD) is working to inform veterans and those discharged from the military of the brain tissue repository (BTR). 

Brain Injury Awareness month, supported by connected health efforts (e.g., internet, 

apps) and outreach events, advertises the crucial need for brain tissue donations to 

this repository. Service members can declare their desire to donate to a brain repository after death through a will or power of attorney. If no such documents exist, 

next-of-kin may also make a determination regarding donation. Donations will remain voluntary: ethical considerations forbid compelling the donation of brain tissue. DOD is also partnering with the Organ Procurement Organizations (OPOs) to 

establish a Memorandum of Understanding and Institutional Review Board approvals to obtain such specimens, since OPOs can reach out to individuals interested in 

brain donation. DOD plans similar outreach for the 15-year longitudinal study participants. [See page 11.] 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING 

APRIL 27, 2017 

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QUESTIONS SUBMITTED BY MR. COFFMAN 

Mr. COFFMAN. As we know, traumatic brain injury (TBI) is a significant health 

issue that affects service members and veterans during times of both peace and war. 

In addition, there is growing evidence that TBI is associated with a variety of shortand long-term adverse health outcomes that may include the acceleration of the 

onset of brain disorders that may result in dementia and other disorders that affect 

memory, movement and mood. 

Given this emerging link between mild, moderate and severe TBI and dementia, 

what initiatives are being undertaken by the Department and service surgeons general to advance research? How might the Department and services use public-private partnerships to advance their research, particularly as it relates to the link between TBI and dementia? 

Captain COLSTON. The Department of Defense (DOD) recognizes the importance 

of following Service members diagnosed with Traumatic Brain Injury (TBI) for an 

extended period in order to define risk factors associated with the delayed onset of 

dementia or chronic traumatic encephalopathy. DOD currently conducts and supports multiple clinical research studies to diagnose TBI earlier and to better understand the progression of TBI symptoms. The Department also collaborates with several private and academic groups. Of the many research initiatives supported or 

conducted by DOD, three are of note. The first is the congressionally-mandated 15- 

year longitudinal study exploring the natural history of TBI. The study intends to 

improve our understanding of TBI through neurobehavioral, neurocognitive, neuroimaging, blood specimen, sensory, and motor data from Service members and veterans injured since October 2001. It will document long-term outcomes and identify 

long-term, chronic effects of TBI. The second, one of several large-scale studies researching the relationship between TBI and neurodegenerative conditions, is the 

Chronic Effects of Neurotrauma Consortium, a DOD and VA collaboration exploring 

the long-term effects of mild TBI. The third, the DOD-sponsored National Collegiate 

Athletic Association Grand Challenge, targets collegiate athletes—including those at 

the military service academies—to ascertain the sequelae from concussion. DOD has 

played a key role in developing and supporting the Federal Interagency Traumatic 

Brain Injury Registry, which allows for data sharing across the entire TBI research 

community and for collaboration among research programs in the DOD, NIH, and 

academia. Additional DOD research includes efforts to better understand chronic 

traumatic encephalopathy (CTE). Two recent studies are noteworthy. One study examined postmortem brain specimens from eight military cases with chronic and 

acute blast exposure: this study found a distinct and previously undocumented pattern of brain scarring that could account for aspects of the behavioral symptoms of 

CTE. Beyond the results of these 8 brains, the repository includes approximately 80 

samples and continues to accumulate more over time. The other study sought a 

premorbid test for CTE: this study, which used positron emission tomography (PET) 

scans, represents an important step toward identifying CTE in living Service members thought to be at risk. 

Mr. COFFMAN. The medical-scientific literature indicates there is a paucity of data 

for women affected by brain injuries particularly in the armed services. Although 

there are clear historical reasons, thinking into the future, how is DOD making an 

effort to accumulate more data on female service members as related to issues of 

brain injuries? 

Captain COLSTON. Given that sixteen percent of Service members are women, the 

Department of Defense (DOD) is working to accumulate more data on female Service members diagnosed with Traumatic Brain Injury (TBI). DOD has recently published on, and continues to investigate, gender differences in TBI. DOD is supporting several longitudinal studies designed to determine gender differences for the 

risk for TBI, differential clinical effects of TBI, intersex differences in symptom reporting, and differences in short- and long-term outcomes between sexes. Two of the 

largest studies are the congressionally-mandated 15-year longitudinal study and the 

Improve Understanding of Medical and Psychological Needs in Veterans and Service 

Members (IMAP) study. The 15-year study explores the natural history of TBI. The 

IMAP study investigates health care, mental health care, and the rehabilitation 
74 

needs of female Service members after they complete inpatient treatment in DOD, 

the Department of Veterans Affairs, or both. It focuses on the needs of concussed 

female Service members, as well as on the health and behavioral needs of disabled 

Service members’ caregivers, who are primarily women. The DOD-sponsored National Collegiate Athletic Association Grand Challenge Partnership and the Concussion Assessment, Research and Education Consortium also address gender differences. 

Mr. COFFMAN. As we know, traumatic brain injury (TBI) is a significant health 

issue that affects service members and veterans during times of both peace and war. 

In addition, there is growing evidence that TBI is associated with a variety of shortand long-term adverse health outcomes that may include the acceleration of the 

onset of brain disorders that may result in dementia and other disorders that affect 

memory, movement and mood. 

Given this emerging link between mild, moderate and severe TBI and dementia, 

what initiatives are being undertaken by the Department and service surgeons general to advance research? How might the Department and services use public-private partnerships to advance their research, particularly as it relates to the link between TBI and dementia? 

Colonel PFLANZ. The Department of Defense has multiple ongoing initiatives to 

advance research into our understanding of TBI. Specifically, the ongoing, congressionally mandated 15-year longitudinal study is intended to increase our understanding and awareness of both short and long-term outcomes of TBI. This would 

include cognitive and behavioral changes that would be expected to occur in TBIrelated dementia or chronic traumatic encephalopathy (CTE). The Chronic Effects 

of Neurotrauma Consortium (CENC) is a public-private, multi-center collaborative 

effort between DOD, VA, civilian academic institutions, and private research entities. The CENC mission is to foster research to better understand the long-term 

neurodegenerative outcomes following TBI in Service members and to find effective 

treatments. In addition, CENC aims to find ways to identify the Service members 

most susceptible to these adverse long-term outcomes. The DOD has also partnered 

with the National Collegiate Athletic Association (NCAA) in sponsoring the NCAA– 

DOD Grand Alliance. This $30 million project is intended to research and prevent 

concussions by investigating sport-related mild TBI (mTBI). The United States Air 

Force Academy and the sister Service academies are all participating sites for this 

ongoing research. Finally, DOD has been involved in the development and support 

of the Federal Interagency Traumatic Brain Injury Registry (FITBIR). This system 

is intended to foster sharing of data amongst those performing TBI research, including entities within DOD, other governmental agencies such as NIH, and civilian research centers. 

Mr. COFFMAN. The medical-scientific literature indicates there is a paucity of data 

for women affected by brain injuries particularly in the armed services. Although 

there are clear historical reasons, thinking into the future, how is DOD making an 

effort to accumulate more data on female service members as related to issues of 

brain injuries? 

Colonel PFLANZ. The ongoing, congressionally mandated 15-year longitudinal 

study of the natural history of TBI will allow meaningful comparisons between 

males and females exposed to TBI. In addition, the Improved Understanding of 

Medical and Psychological Needs in Veterans and Service members with Chronic 

TBI (IMAP Study) is another DOD and VA collaborative effort supported by the 

Services. Among other goals, this study is investigating the unique needs of female 

service members in terms of health care, mental health, and rehabilitation following 

TBI exposure. 

Mr. COFFMAN. As we know, traumatic brain injury (TBI) is a significant health 

issue that affects service members and veterans during times of both peace and war. 

In addition, there is growing evidence that TBI is associated with a variety of shortand long-term adverse health outcomes that may include the acceleration of the 

onset of brain disorders that may result in dementia and other disorders that affect 

memory, movement and mood. 

Given this emerging link between mild, moderate and severe TBI and dementia, 

what initiatives are being undertaken by the Department and service surgeons general to advance research? How might the Department and services use public-private partnerships to advance their research, particularly as it relates to the link between TBI and dementia? 

Colonel IVANY. As the scientific evidence emerges on potential associations between TBI and dementia or other disorders which may affect memory, movement 

and mood, the Department of Defense (DOD) and Surgeons General seek answers 

through a research portfolio cultivated to evaluate the spectrum of injuries. The 

DOD achieves this by grooming a research strategy including focal areas such as 
75 

understanding the neuropathophysiology (brain damage at the cellular level) in living and deceased models, identifying assessment and diagnostic techniques that correlate with structural brain changes, developing treatments to slow or reverse the 

progression of disease, and monitoring the natural progression of TBI. Importantly, 

the DOD’s current Combat Casualty Care-Neurotrauma Research Portfolio includes 

104 open studies ($483M), effectively covering the spectrum of TBI by severity of 

injury (mild to severe), location in the injury/care continuum (point of injury, rehabilitation, or longitudinal study), and technology readiness level (time until it is a 

viable product). This DOD strategy, in combination with active program management, ensures a diversified, yet gap-driven, portfolio which is most likely to deliver 

solutions relevant to Service Members with TBI. Moreover, the DOD recognizes the 

importance of interdepartmental coordination and public-private partnerships in 

order to successfully advance understanding of TBI and the state of the science. One 

DOD supported effort looking at the natural progression of TBI is the Chronic Effects of Neurotrauma Consortium (CENC). The CENC is a joint DOD and Department of Veterans Affairs (VA) effort addressing the long-term consequences of mild 

TBI in Veteran, Active Duty, Reserve, and National Guard populations. It is part 

of a larger collaboration stemming from Executive Order 13625, which initiated the 

National Research Action Plan (NRAP) for Improving Access to Mental Health Services for Veterans, Service Members, and Families. Additionally, the DOD portfolio 

includes other longitudinal studies that seek unique but complimentary results in 

military relevant populations. The Department expects the CENC, National Collegiate Athletic Association (NCAA)-DOD Grand Alliance (Concussion Assessment, 

Research and Education Consortium), and the DOD/VA 15 year longitudinal study 

of TBI (including a neurological/neurobehavioral clinical data, blood specimens, and 

psychosocial impacts) collectively will inform the natural progression and long-term 

effects of TBI in sports, military, and civilian populations. For optimal outcomes 

from the research investments, the DOD supports public-private partnerships within the TBI portfolio. One example is the TBI Endpoints Development (TED) study, 

which in coordination with the National Institutes of Health (NIH), leverages 

datasets containing thousands of TBI subjects to harmonize and curate data into a 

large meta-dataset. The project seeks to validate this dataset and enter into FDA 

qualification processes to become acceptable ‘‘standard measures’’ for clinical trials. 

The DOD strategy also supports the NRAP requirement to place all federally funded 

study data into the Federal Interagency Traumatic Brain Injury Registry (FITBIR), 

a secure, centralized informatics system developed to accelerate analysis. As of 30 

APR 2017, the FITBIR maintains data from 60 studies include over 1.5 million 

records from 42,500 subjects. 

Mr. COFFMAN. The medical-scientific literature indicates there is a paucity of data 

for women affected by brain injuries particularly in the armed services. Although 

there are clear historical reasons, thinking into the future, how is DOD making an 

effort to accumulate more data on female service members as related to issues of 

brain injuries? 

Colonel IVANY. The Army and Department of Defense (DOD) recognize there is 

a limited amount of scientific literature specific to female Service Members affected 

by brain injuries. Historically military-related mild TBI (mTBI) studies did not include high numbers of women because of the relatively low prevalence of the injury 

to women in combat. Recognizing the increasing role of women across the range of 

military operations, and increased exposure to combat situations, the DOD has 

made a concerted effort to evaluate potential gender differences in incidence, symptoms, and outcomes after Combat and Non-Combat-Related mTBI. The Congressionally mandated 15 year longitudinal study of TBI, required on Section 721 of the FY 

2007 NDAA, is already producing results specific to gender difference which should 

help inform clinical practice and future study design. The NCAA–DOD Grand Alliance (Concussion Assessment, Research and Education (CARE) Consortium), as well 

as a parallel study of non-NCAA Service Academy Cadets, seek enrollment of all 

women at the Service Academies, and will surely add to the body of literature. However, other studies seeking enrollment of women have faced continued challenges 

due to a low prevalence. The DOD effort to mitigate that limitation is leveraging 

data to look at the gender differences in healthcare utilization, and provide insight 

into TBI-related comorbidities, long-term consequences, and health care costs specific to women. Additionally, the DOD funds a number of studies that have set out 

to examine how gender impacts TBI outcome in Service Members or Veterans. 

Mr. COFFMAN. As we know, traumatic brain injury (TBI) is a significant health 

issue that affects service members and veterans during times of both peace and war. 

In addition, there is growing evidence that TBI is associated with a variety of shortand long-term adverse health outcomes that may include the acceleration of the 
76 

onset of brain disorders that may result in dementia and other disorders that affect 

memory, movement and mood. 

Given this emerging link between mild, moderate and severe TBI and dementia, 

what initiatives are being undertaken by the Department and service surgeons general to advance research? How might the Department and services use public-private partnerships to advance their research, particularly as it relates to the link between TBI and dementia? 

Captain JOHNSON. 1. The Intrepid Spirit Camp Lejeune, in partnership with 

Princeton University and Wayne State University are in the early phases of ‘‘A Prospective Study of the Effects of Repetitive Low Level Blast Exposure (RLLBE) on 

Fitness for Duty in SOCOM Warriors.’’ Follow on efforts include the development 

of validated baseline testing tailored for individual warfighters that can be repeated 

after subsequently sustaining a TBI. This baseline testing would be used to determine what effects the exposure had on their performance, how long their recovery 

was, and when they were fit enough to return to duty. Additionally, the development of individualized baseline testing will allow providers to detect subtle changes 

in cognitive function throughout their life. Partnering these types of tools with clinical history contributes exponentially to a longitudinal study on the long term effects 

of TBI. Due to the nature and frequency of exposures, the Special Operations community would serve as the initial community that this may prove best suited. 

2. The Surgeon General of the Navy has made partnerships one of his strategic 

priorities for Navy Medicine—Readiness, Health and Partnerships. As part of our 

initiative towards expanding and strengthening our partnerships to maximize readiness and health, we see significant potential for public-private partnerships as it relates to the advancement of research in TBI and dementia. In our pursuit to partner 

with academic, public, and private institutions, we are strategically assessing the 

landscape for future opportunities, removing barriers, and remaining vigilant that 

our partnerships are in alignment with our objectives. Intellectual sharing through 

partnerships can be a more cost effective and yet very impactful way to advance research. 

Mr. COFFMAN. The medical-scientific literature indicates there is a paucity of data 

for women affected by brain injuries particularly in the armed services. Although 

there are clear historical reasons, thinking into the future, how is DOD making an 

effort to accumulate more data on female service members as related to issues of 

brain injuries? 

Captain JOHNSON. It is my understanding that the Department of Defense is pursuing a number of longitudinal studies to gain a greater understanding of the risk 

profile, long-term effects, clinical differences, and outcomes for female service members impacted by TBI. Specifically, the Intrepid Spirit Camp Lejeune has presented 

at a national meeting on TBI in female service members. In addition, we are in the 

process of finalizing the publication of a retrospective study of approximately 300 

service members, four of which are women, seen at Intrepid Spirit Camp Lejeune 

who had a reported history of TBI due to blast exposure. It is my observation that 

a shared data base between the Intrepid Spirit Center Camp Lejeune and other 

military treatment facilities would significantly increase the data collection on 

women impacted by brain injuries in the Armed Forces. For this reason, the Intrepid Spirit Camp Lejeune is establishing the final parameters under which a 

Memorandum of Understanding (MOU) could effectively operate a shared database 

with the National Intrepid Center of Excellence (NICoE). 

QUESTIONS SUBMITTED BY MS. TSONGAS 

Ms. TSONGAS. What are the current screening mechanisms that the services use 

to identify post-traumatic stress disorder (PTSD) for warfighters returning from deployment? What screening or monitoring measures are taken with service members 

who have suffered from PTSD before they are approved for a future deployment? 

Captain COLSTON. The Department of Defense (DOD) screens Service members for 

symptoms of Post-traumatic Stress Disorder (PTSD) at multiple points within the 

deployment life cycle, including annual, pre-deployment, and post-deployment 

health assessments. Service members deployed in connection with a contingency operation are assessed for PTSD and depression symptoms, suicide and violence risk, 

and substance use disorders using person-to-person interviews at four different periods before and after deployment. These interviews, conducted by trained health care 

providers, expand upon self-reported survey responses and include a review of 

health records. Service members are then referred for follow-up evaluation and 

treatment, as needed. In accordance with DOD policy, health care providers notify 

a Service member’s Commander regarding concerns (e.g., risk of harm to self or oth-
77 

ers, mission impairment). Service members are not cleared for subsequent deployments unless they are free of deployment-limiting mental health conditions. 

Ms. TSONGAS. How are the services screening for PTSD in service members as a 

result of non-combat deployment related causes—such as military sexual trauma 

that may not have been previously reported, for example? Specifically, please address how the FY15 NDAA requirement for annual mental health screening of service members has been implemented and what is covered in the screening. 

Captain COLSTON. The Department of Defense (DOD) leverages a Primary Care 

Medical Home model, using an evidence-based screening instrument, to screen Service members for Post-traumatic Stress Disorder (PTSD). The Post-Traumatic Stress 

Checklist screens for trauma at multiple points regardless of deployment status. 

Screening is conducted for all new patients, existing patients annually, and any patients for whom it is clinically necessary. Patients with PTSD who receive ongoing 

mental health treatment are screened periodically until the end of their treatment. 

During intake for all mental health appointments, in accordance with health care 

accreditation standards, providers ask Service members a number of questions related to whether they have experienced trauma. DOD complies with the National 

Defense Authorization Act for Fiscal Year 2015. As part of annual periodic health 

assessment, Service members receive annual mental health screening. This assessment includes the use of evidence-based screening instruments that produce a selfreport of depression symptoms, posttraumatic stress, alcohol misuse, and overall 

functioning. The annual assessment includes a follow-up interview with a trained 

health care provider to further assess identified symptoms, review medical documentation, and provide referrals for applicable treatment and evaluation. 

Ms. TSONGAS. What requirements exist for mental health screening as service 

members leave active duty to ensure that PTSD and other mental health issues are 

identified during service and there is a warm handoff to the VA? 

Captain COLSTON. During military separation, Service members must complete a 

separation health assessment that includes a review of medical history, medical concerns, and current health status. This assessment may be completed at a Department of Defense (DOD) or Department of Veterans Affairs (VA) facility—each entity 

shares results with the other. Service members currently receiving mental health 

care are automatically enrolled in the inTransition program during separation from 

the military. Service members can elect to opt out if they desire. The inTransition 

program supports a warm hand-off between the DOD and the VA for Service members who are in treatment for psychological health conditions by enhancing coordination between referring and gaining providers. Since the launch of the automatic 

enrollment requirement in April 2014, the inTransition program has completed 

50,314 assessments in support of care transitions. 

Ms. TSONGAS. We’ve heard in recent years of the development of new technologies 

that use physiological measurements to predict and help address the onset of PTSD 

episodes. What is the current research portfolio of technologies for the screening or 

monitoring of PTSD? Do the services see the measurement and use of physiological 

indicators as a way to provide even more comprehensive care to service members 

suffering from PTSD? What are the limitations in currently existing technologies? 

Captain COLSTON. Efforts to predict or treat Post-traumatic Stress Disorder 

(PTSD) using physiological measures are in incipient stages. Investigations regarding the possible utility and functionality of biosensors are underway. Biosensors 

have the potential to aid screening, monitoring, and treatment of many psychological health conditions. The Department of Defense (DOD) is currently studying 

biosensors that look and feel like Band-Aids, ‘‘Fitbits,’’ ‘‘Smartwatches,’’ and other 

wearable technologies. These tools take physiological measurements and link to 

smartphones that collect data. While these innovative biosensors are not yet effective in clinical applications for PTSD treatment, they will likely be a part of PTSD 

management in the future. Studies continue to establish efficacy and then effectiveness in the field. Currently, DOD relies on evidence-based screening tools for the 

assessment and diagnosis of PTSD. For instance, the Post Traumatic Stress Checklist (PCL) is a series of questions that a patient answers and a provider scores. Providers integrate screening results with other clinical information to determine if patients meet criteria for PTSD. Since 2013, DOD has used a software platform and 

computer technology to create an electronic database, the Behavioral Health Data 

Portal, where patients’ PCL responses are stored for providers to monitor. There are 

no predictive or diagnostic technologies beyond the research stage in DOD’s current 

portfolio; several promising endeavors, however, are in progress. These include studies on Heart Rate Variability, attention bias biomarkers, brain imaging, and voice 

analysis. DOD is working to integrate technology into clinical care and apply technology to prevention efforts. Mobile applications for self-care tools that supplement 

treatment for Service members and veterans suffering from PTSD have been devel-
78 

oped for use across the Services, DOD, and the Department of Veterans Affairs. Examples of these apps include PTSD Coach, PE Coach, and Dream EZ. Studies on 

the PTSD Coach indicated both high rates of perceived helpfulness and acceptability 

and also a reduction in some PTSD symptoms when combined with clinical treatment. While the measurement and use of physiological indicators (i.e., data that 

these apps help to collect) have not yet been incorporated into clinical care, substantial interest exists and research is underway to do so in the future. One challenge 

in developing technology to advance psychological health screening and treatment 

in DOD is privacy. Most applications use the internet to operate. It is difficult to 

interact digitally across the internet without attending to privacy issues. Additionally, technologies that support psychological health screening and treatment are 

new, so we are still learning how they can best aid Service members with PTSD. 

Finally, our understanding of the safety and effectiveness of the use of technology 

to support PTSD screening or treatment over time is limited. This is a challenge 

that merits further research. 

QUESTIONS SUBMITTED BY MR. KNIGHT 

Mr. KNIGHT. I am aware that Tinker Air Force base is currently conducting clinical trials on magnetic EEG/EKG-guided resonance therapy. Can you elaborate on 

the clinical trials and their results thus far? Are there any plans in the Department 

of Defense to expand these trials? Also, has Tinker AFB conducted clinical trials 

using repetitive transcranial magnetic stimulation (rTMS)? 

Colonel PFLANZ. One study is underway on magnetic EEG/EKG-guided resonance 

therapy at Tinker AFB. The study is in its early stages, having completed the intervention with eight subjects so far; it is too early to draw any substantive conclusions. We are not aware of any plans for the Department of Defense to expand these 

trials. Tinker AFB has not conducted any clinical trials using repetitive transcranial 

magnetic stimulation (rTMS). 

Æ