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25–235 PDF 2017

S. HRG. 114–620 

THE CURRENT STATE OF RESEARCH, DIAGNOSIS, 

AND TREATMENT FOR POST–TRAUMATIC STRESS 

DISORDER AND TRAUMATIC BRAIN INJURY 

HEARING 

BEFORE THE

SUBCOMMITTEE ON STRATEGIC FORCES 

OF THE

COMMITTEE ON ARMED SERVICES 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

APRIL 20, 2016 

Printed for the use of the Committee on Armed Services 

( 

Available via the World Wide Web: http://www.fdsys.gov/ 

COMMITTEE ON ARMED SERVICES 

JOHN MCCAIN, Arizona, Chairman 

JAMES M. INHOFE, Oklahoma 

JEFF SESSIONS, Alabama 

ROGER F. WICKER, Mississippi 

KELLY AYOTTE, New Hampshire 

DEB FISCHER, Nebraska 

TOM COTTON, Arkansas 

MIKE ROUNDS, South Dakota 

JONI ERNST, Iowa 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

MIKE LEE, Utah 

LINDSEY GRAHAM, South Carolina 

TED CRUZ, Texas 

JACK REED, Rhode Island 

BILL NELSON, Florida 

CLAIRE MCCASKILL, Missouri 

JOE MANCHIN III, West Virginia 

JEANNE SHAHEEN, New Hampshire 

KIRSTEN E. GILLIBRAND, New York 

RICHARD BLUMENTHAL, Connecticut 

JOE DONNELLY, Indiana 

MAZIE K. HIRONO, Hawaii 

TIM KAINE, Virginia 

ANGUS S. KING, JR., Maine 

MARTIN HEINRICH, New Mexico 

CHRISTIAN D. BROSE, Staff Director 

ELIZABETH L. KING, Minority Staff Director 

SUBCOMMITTEE ON PERSONNEL

LINDSEY GRAHAM, South Carolina, Chairman 

ROGER F. WICKER, Mississippi 

TOM COTTON, Arkansas 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

KIRSTEN E. GILLIBRAND, New York 

CLAIRE MCCASKILL, Missouri 

RICHARD BLUMENTHAL, Connecticut 

ANGUS S. KING, JR., Maine 

(II)

C O N T E N T S 

APRIL 20, 2016

Page 

THE CURRENT STATE OF RESEARCH, DIAGNOSIS, AND TREATMENT FOR POST– 

TRAUMATIC STRESS DISORDER AND TRAUMATIC BRAIN INJURY ......................... 1 

Greenhalgh, Captain Walter M., MC, USN, Director for the National Intrepid 

Center of Excellence Directorate, Walter Reed National Military Medical 

Center .................................................................................................................... 3 

Colston, Captain Michael J., MC, USN, Director, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury ............................ 7 

Street, Amy E., Deputy Director, Women’s Health Sciences Division, National 

Center for Posttraumatic Stress Disorder .......................................................... 8 

Questions for the Record ......................................................................................... 32 

(III)

(1) 

THE CURRENT STATE OF RESEARCH, 

DIAGNOSIS, AND TREATMENT FOR POST– 

TRAUMATIC STRESS DISORDER AND TRAUMATIC BRAIN INJURY 

WEDNESDAY, APRIL 20, 2016 

U.S. SENATE,

SUBCOMMITTEE ON PERSONNEL, 

COMMITTEE ON ARMED SERVICES, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 2:36 p.m. in Room 

SR–222, Russell Senate Office Building, Senator Lindsey O. Graham (chairman of the subcommittee) presiding. 

Committee members present: Senators Graham, Cotton, Tillis, 

Sullivan, Gillibrand, Blumenthal, and King. 

OPENING STATEMENT OF SENATOR LINDSEY GRAHAM 

Senator GRAHAM. The hearing will come to order. 

We’re here to receive testimony on research, diagnosis, and treatment of post-traumatic stress and traumatic brain injury in the Department of Defense and Department of Veterans Affairs. 

The committee meets this afternoon to receive testimony from 

the Department of Defense and Department of Veterans Affairs on 

research, diagnosis, and treatment of post-traumatic stress and 

traumatic brain injury. This is an important hearing. We must do 

everything we can to help servicemen and women and veterans suffering from PTS [post-traumatic stress] and TBI [Traumatic Brain 

Injury]. 

We’re fortunate to have a distinguished panel of witnesses joining us today: Captain Walter Green—say it—— 

Captain GREENHALGH. Greenhalgh. 

Senator GILLIBRAND.—Greenhalgh, sorry about that—Medical 

Corps, United States Navy, Director for the National Intrepid Center of Excellence at Walter Reed National Military Medical Center; 

Captain Mike Colston, Medical Corps, United States Navy, Director 

of the Defense Center of Excellence for Psychological Health and 

Traumatic Brain Injury; and Dr. Amy Street, Deputy Director of 

the Women’s Health Division, National Center for Post-Traumatic 

Stress, Department of Veterans Affairs. 

Post-traumatic stress and traumatic brain injury have been 

called the signature wounds of the Afghan and Iraq conflict. Since 

2001, about 5 percent of the over 2.7 million servicemembers deployed in support of the wars in Afghanistan and Iraq were diagnosed with PTS. And from 2000 through September 2015, there are 

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over 339,000 TBI cases diagnosed, with most of these being mild 

TBI diagnosed in garrison locations. With the significant impacts 

that both PTS and TBI have made on our servicemembers and veterans, it is vitally important that we better understand, through 

well-developed medical research, the causes of PTS and TBI, and 

develop appropriate measures to treat and eventually prevent PTS 

and TBI. While both DOD [Department of Defense] and VA [Veterans Affairs] have made significant research investments to learn 

more about PTS and TBI leading to major advancements in diagnosis and treatments, more work must be done on prevention. 

Today, I want our witnesses to tell us what DOD and the VA are 

doing to prevent, diagnose, and treat PTS and TBI, and to give us 

an overview of promising treatments, therapies, and technologies 

that may be available in the near future. Finally, tell us what this 

subcommittee can do to help your department provide better care 

for servicemen and women and veterans who may suffer from PTS 

and TBI. 

Senator Gillibrand. 

STATEMENT OF SENATOR KIRSTEN E. GILLIBRAND 

Senator GILLIBRAND. Thank you so much, Chairman Graham, for 

your leadership. I’m so grateful I get to serve on this subcommittee 

with you. 

Senator GRAHAM. Thank you. 

Senator GILLIBRAND. It’s extremely meaningful, the work that we 

do. 

I want to welcome our witnesses. Thank you for your service, and 

thank you for the focus you have on the state of research, diagnosis, and treatment for post-traumatic stress disorder and traumatic brain injury. 

I’m pleased we have witnesses here, both from the DOD and the 

Department of Veterans Affairs. Both of these agencies are addressing significant caseloads of PTSD and TBI. I look forward to 

learning about how each agency responds to the challenges of research treating these conditions, and if there are different approaches in how to do this. Although PTSD and TBI are widely recognized as signature wounds of our recent conflict in Iraq and Afghanistan, we know that these conditions are more than just war 

injuries. We know that PTSD is triggered by a traumatic event. 

That traumatic event can be combat-related, but all too frequently, 

the trigger event can be military sexual assault. While we continue 

our efforts to rid the military of this scourge, we must provide 

world-class treatment to the survivors of this horrendous crime. 

I am particularly interested in learning more about PTSD that 

is caused by sexual assaults. Specifically, I would like to know if 

PTSD presents itself differently in male survivors versus female 

survivors, and how treatment for PTSD meets the unique needs of 

male survivors of sexual assault. 

I’d also like to hear more about the state of the art in diagnosing 

and treating PTSD and TBI, the interaction between the two, and 

the ongoing research to improve diagnosis and treatment of these 

conditions. Over the years, our understanding of PTSD and TBI 

has grown substantially; however, there remains much more to be 

learned. 

3 

Furthermore, we need to ensure that those who suffer from 

PTSD and TBI related to military service have access to a 

healthcare system that is able to meet their physical and mental 

healthcare needs. Our servicemembers, retirees, and their families 

deserve the highest-quality care. 

So, thank you each to our witnesses for the time and effort 

they’ve put into this important issue. 

Thank you. 

Senator GRAHAM. Well, one, thank you for the compliment, Senator Gillibrand. It’s been a pleasure working with you and your 

staff. 

Captain, please. 

STATEMENT OF CAPTAIN WALTER M. GREENHALGH, MC, USN, 

DIRECTOR FOR THE NATIONAL INTREPID CENTER OF EXCELLENCE DIRECTORATE, WALTER REED NATIONAL MILITARY MEDICAL CENTER 

Captain GREENHALGH. Well, good afternoon, sir. Thank you. 

Well, good afternoon, Chairman Graham, Ranking Member Gillibrand, and members of the subcommittee. Thank you all for the opportunity to discuss with you the Department of Defense’s efforts 

to prevent, diagnose, treat, and research traumatic brain injury, or 

TBI, and its associated psychological health comorbidities. 

As the Director for the National Intrepid Center of Excellence, or 

NICoE, at the Walter Reed National Military Medical Center in 

Bethesda, I lead a team of exceptional professionals whose mission 

is to improve the lives of patients and families impacted by TBI 

and psychological health issues. 

Through the generosity of the American people and the Intrepid 

Fallen Heroes Fund, NICoE opened in 2010 on the Walter Reed Bethesda campus, followed by five of the proposed nine Intrepid Spirit 

Centers, or NICoE satellites, to be build on military installations 

around the country. Together, we’ve created an integrated TBI care 

network. It’s a very important component of the military health 

system’s TBI pathway of care, as managed by the Defense and Veterans Brain Injury Center. 

This past year, NICoE officially transitioned into the Walter 

Reed National Military Medical Center command structure, becoming a directorate within the flagship of military medicine and formalizing research support and collaboration from the Uniformed 

Services University of the Health Sciences, also on the Bethesda 

campus. 

This completely integrated approach to our work, leveraging the 

expertise and resources of Walter Reed’s outpatient TBI programs, 

inpatient consultation service, and Uniformed Services University’s 

research capabilities allows us to serve our unique patient population in a seamless fashion, using the entire TBI care portfolio 

available on America’s Academic Health Campus in Bethesda. 

An important part of the Federal TBI continuum of care in the 

TBI research mission—is the TBI research mission. NICoE and the 

network of military health system TBI Care Centers, in collaboration with partners, including the Veterans Administration, National Institutes of Health, Uniformed Services University, and 

other Federal academic and private institutions, continue to push 

4 

the boundaries of innovation with cutting-edge translational research. 

One signature collaborative project is the congressionally mandated longitudinal 15-year study to comprehensively categorize 

servicemembers and their caregivers affected by TBI. Another example is the neuroimaging core research project, with over 1,000 

servicemembers affected by TBR thus far evaluated clinically and 

with state-of-the-art neuroimaging capability, collecting over 40,000 

imaging and clinical datapoints for study per patient. 

In addition to our high-tech research, NICoE is actively engaged 

in clinical research on our high-touch aspects of our program, such 

as our National Endowment for the Arts-supported Therapeutic 

Arts Program and our congressionally supported research on Kindergarten–9 assisted therapy. And by tracking both the short- and 

long-term outcomes of our programs, we are also able to rapidly assess and accelerate discovery more effectively using every taxpayer 

dollar by putting the research and its findings immediately to use 

at the deckplates amongst our patients. 

So, I’m grateful for the opportunity to represent the men and 

women working at NICoE, as well as the patients we’re honored to 

serve. I look forward to answering your questions today. 

Thank you. 

[The joint prepared statement of Captain Greenhalgh and Captain Colston follows:] 

JOINT PREPARED STATEMENT BY CAPTAIN MIKE COLSTON, M.D. AND CAPTAIN

WALTER GREENHALGH, M.D. 

Chairman Graham, Ranking Member Gillibrand and members of the Committee, 

we are pleased to discuss the Department of Defense’s (DOD) efforts to promote psychological health (PH) and prevent, diagnose, and treat traumatic brain injury (TBI) 

and behavioral health conditions. We are honored to be joined by Dr. Amy Street, 

the Deputy Director of the Department of Veteran Affairs’ (VA) National Center for 

Post-Traumatic Stress Disorder’s (PTSD) Women’s Health Sciences Division. 

We want to thank the Committee for its sustained leadership and support for the 

work we perform in the Military Health System (MHS) to care for our Nation’s 

Service members, veterans, and their families—especially those dealing with the 

complex issues of PH and TBI. Your investments in medical research have led to 

important advancements in care and a greater understanding of where future research should be targeted. 

Advances in combat medicine and protective equipment have saved the lives of 

countless Service men and women who would have died from their injuries in conflicts of the past. With that welcome increase in survival rates, however, comes a 

lifelong obligation to Service members whose road to recovery, both physical and 

mental, is long. By their nature, the signature invisible wounds of our recent wars— 

PTSD and TBI—demand greater sensitivity in identification of the injury or illness, 

as well as an ability to coordinate treatment with other injuries. 

Over the last 15 years over 300,000 Service members have suffered a TBI and 

over one million have been treated for behavioral health conditions. To meet these 

challenges, we have expanded the ability of our military hospitals, military clinics 

and network of civilian providers to treat these conditions, introduced new therapies 

to improve recovery, and generated a comprehensive portfolio of research efforts to 

advance the state of the science and drive evolution of care. 

Although our recent conflicts have added greater awareness and urgency to understanding PH and TBI, these medical conditions are not confined to military personnel alone. That is why the DOD has partnered with other government agencies, 

academic research institutions, and the private sector to share what we know and 

what we have learned, address our gaps in knowledge, and increase our collaboration on research. Many of the efforts and milestones that will be discussed today 

are a result of this ongoing collaborative work. 

5 

CURRENT STATE OF TBI/PH RESEARCH, TREATMENT, AND THERAPIES

TBI and PH research represent complex undertakings, as these conditions are 

heterogeneous and often associated with other medical conditions. Our research 

often involves differentiating comorbidities like PTSD, depression, substance abuse, 

and chronic pain—all factors which can complicate the prevention and treatment of 

other PH conditions and TBI. The best way to account for these comorbidities, and 

effectively identify treatments and therapies, is through the kinds of comprehensive 

and longitudinal research efforts we have undertaken. What we’ve learned about the 

brain over the past decade of PH and TBI research outpaces any advancement of 

knowledge to date—and only through continued effort will we reap the benefits of 

the research we have begun. 

The President’s Executive Order in 2012 directed Federal agencies to develop a 

coordinated National Research Action Plan (NRAP). This directive has accelerated 

the knowledge we have gained and strengthened inter-agency cooperation and coordination. The DOD, VA, and Department of Health and Human Services (HHS), 

responded to the Executive Order with a wide-reaching plan to improve scientific 

understanding, develop effective treatment, and reduce occurrences of PTSD, PH 

conditions, TBI and suicide. The NRAP represents the ten-year strategic blueprint 

for interagency research to identify and develop more effective diagnostic and treatment methodologies to improve outcomes for TBI and PH and we are eager to continue working with our inter-government partners to advance our understanding of 

these conditions. 

Specifically, two jointly funded VA and DOD consortiums are focused on priorities 

outlined in the NRAP: The Consortium to Alleviate PTSD (CAP), and the Chronic 

Effects of Neurotrauma Consortium (CENC). The CAP seeks to improve the psychological and physical health and well-being of Operation Enduring Freedom, Iraqi 

Freedom, and New Dawn Service members and veterans by developing and evaluating the most effective preventive, diagnostic, prognostic, treatment and rehabilitative strategies for combat-related PH issues and comorbid conditions. The CENC is 

dedicated to establishing a comprehensive understanding of the chronic sequelae 

that may be associated with mild TBI. Together, CAP and CENC ensure that high 

priority research areas are being addressed and efforts are not being duplicated 

across or within agencies. This collaboration supports a more unified vision for research within the federal community to better anticipate and respond to emerging 

medical requirements. 

In 2012, DOD funded an independent study to assess access to mental health providers for more than 1.3 million Service Members and their families who reside in 

rural and remote locations. Initial results of the study were released in January 

2015 and included a geospatial development tool to monitor locations of US military 

members, their families, and their distance from mental health care. Recommendations emerging from these findings included the increased use of telehealth and 

other technologies to improve access to care for remote populations. The Department 

is pursuing the study’s recommendations, including incorporating the increased use 

of telehealth and other technologies to improve access to care for remote populations. We recently updated our policies on telehealth and telemedicine to encourage greater adoption by both providers and patients and continue work to expand 

utilization of telemedicine capabilities. 

The Department has taken other steps to increase access to needed behavioral 

health services, and we monitor our performance in access and quality. We have 

eliminated the limit on inpatient behavioral health bed days in our TRICARE program, and we are finalizing our policies to ensure alignment with the Mental Health 

Parity Act in 2016. The MHS is a leader among US health systems in achieving 

high rates of timely outpatient follow-up visits for patients with PTSD or depression 

after psychiatric hospitalization for PTSD: 86 percent of patients who were hospitalized were seen as an outpatient within 7 days of discharge; 95 percent were seen 

within 30 days. Additionally, 91 percent of patients diagnosed with PTSD and 82 

percent of patients with depression received psychotherapy. 

The Department has also introduced new approaches to how we screen for TBI 

in Service Members returning from deployment. Improvements in TBI screening, including screening in theater, and changes in the post-deployment health assessment 

and re-assessment were based, in part, on evidence derived from DOD-funded studies. 

The use of integrated interdisciplinary treatment programs has also increased 

since 2007 due to evidence from DOD studies for management of severe TBI and 

a number of DOD-funded studies are cited by the Joint Theater Trauma System 

Clinical Practice Guideline Management of Patients with Severe Head Trauma. This 

6 

highly practical guidance is revised annually and directs care for severe and penetrating TBI sustained in theater. 

DOD continues to develop innovative technologies in areas of TBI care that improve recovery and reintegration. Examples of novel interventions for TBI under 

study include neurofeedback, biofeedback, the interactive metronome, computerbased cognitive rehabilitation, and non-invasive electrical stimulation devices. To 

identify objective TBI screening, diagnostic, and assessment tools, the DOD is studying the effectiveness of innovative technologies such as portable devices to measure 

the brain’s electrical activity, environmental sensors and other concussion detection 

systems, and neurocognitive assessment tools. 

Current progress in the upstream treatment of PH and TBI is exemplified by the 

inTransition program established in response to Executive Order 13625. The 

inTransition program pairs trained mental health professionals with Service members transitioning to new care teams in VA or in the local community. It has wide 

utilization—with over 10,000 calls per month and more than 15,000 extended coaching cases since its inception in February 2010. This number will continue to grow 

as all Service Members who are receiving mental health care and leaving military 

service are now automatically enrolled into the inTransition program. By enhancing 

coordination between referring and gaining providers, inTransition reduced the 

number of Service Members who disengage from mental health care during a period 

of change. 

In addition to the progress in PH and TBI treatment practices, our physical infrastructure has been expanded and improved over the past five years. The Defense 

and Veterans Brain Injury Center (DVBIC), National Intrepid Center of Excellence 

(NICoE), and other Intrepid Sites make up a network of treatment facilities across 

the world that focus on TBI care for Service members and their families. Located 

on military installations, providers at these facilities diagnose and initiate the treatment for patients referred with complex, comorbid PH/TBI conditions; conduct focused research, and deliver expert treatments to improve TBI and PH outcomes. 

These centers leverage their collective reach and provide comprehensive TBI care 

throughout the MHS.. Additional DVBIC sites located in VA Polytrauma Rehabilitation Centers extend the scope of members and their families. Located on military 

installations, providers at these facilities diagnose and initiate the treatment for patients referred with complex, comorbid PH/TBI conditions; conduct focused research, 

and deliver expert treatments to improve TBI and PH outcomes. These centers leverage their collective reach and provide comprehensive TBI care throughout the 

MHS.. Additional DVBIC sites located in VA Polytrauma Rehabilitation Centers extend the scope of members and their families. Located on military installations, providers at these facilities diagnose and initiate the treatment for patients referred 

with complex, comorbid PH/TBI conditions; conduct focused research, and deliver 

expert treatments to improve TBI and PH outcomes. These centers leverage their 

collective reach and provide comprehensive TBI care throughout the MHS.. Additional DVBIC sites located in VA Polytrauma Rehabilitation Centers extend the 

scope of 

FUTURE OF TBI/PH RESEARCH, TREATMENT, AND THERAPIES

Research has provided many answers and influenced improvements to care—however, gaps remain in the nation’s scientific knowledge about PH and TBI, gaps that 

we are working diligently to address. 

Coordinated research efforts to accelerate discovery of the mechanisms underlying 

behavioral health conditions, TBI, and other comorbidities remain a top priority. 

Understanding pathophysiology allows researchers to target treatment more efficiently and identify new targets for treatment. Our research plan outlines a timeline 

to work towards developing effective biomarkers that detect disorders early and accurately. Additionally, the NRAP work group is orchestrating better coordination of 

federal research strategies and investments. Major efforts include the Federal Interagency TBI Research (FITBIR) Registry to share research data, use of Federal RePORTER and other interagency databases to share research portfolio information, 

and a Joint Strategic Portfolio Reviews and Analyses to discuss current activities, 

priorities, and remaining gaps. 

In 2001 the DOD initiated the largest longitudinal study of Service Members, Veterans, and their families in US military history—the Millennium Cohort Study. This 

epidemiological study includes more than 200,000 participants across the globe, with 

a planned follow-up for 21+ years to evaluate the long-term impact of military experiences during and after the time of military service. The Millennium Cohort Study 

offers a unique opportunity to define the challenges that Service Members, Veterans 

and military families experience. This will serve to advance the understanding of 

7 

protective and vulnerability factors that can then be used to design training and 

treatment programs into the future. 

Our partnership programs also provide us with important insights. Working with 

the National Collegiate Athletic Association (NCAA), DOD created the Concussion 

Assessment, Research and Education (CARE) Consortium to conduct a large-scale, 

multi-site study of the natural history of concussion in both sexes across multiple 

sports. The aim of the study is to address current gaps in our knowledge, and shed 

light on the neurobiological mechanisms of concussion symptoms and the trajectory 

of recovery. It will provide information on a cohort of individuals with SRC, and contribute to other datasets for public use and drive a more informed public discussion 

about concussion care and policy. 

In addition to these advancements made in research, treatment, and therapies— 

the MHS is working internally to make PH and TBI efforts more effective, cost-efficient, and beneficial to Service Members, Veterans, and their families. DCoE estimates there are more than 200 programs receiving DOD funding to provide both 

clinical and non-clinical psychological health or TBI services for Service Members 

and family members. Such services account for more than $1 billion annually. DOD 

has begun a multifaceted approach to examine program effectiveness to review the 

value of these programs, ensuring they both are non-duplicative and informed by 

clinical evidence. 

Beginning in fiscal year 2015, DCoE implemented onsite program evaluations 

with current DOD-funded PH and TBI programs to measure program effectiveness 

and meet the intent of NDAA [National Defense Authorization Act] directives. 

DCoE’s program evaluation efforts are DOD’s primary mechanism to comprehensively document program efficacy within the MHS. 

CONCLUSION

Scientific progress is incremental and takes time, but Service Members and their 

families need solutions. The progress the Department—and the Nation—has made 

in the past 10 years has led to an expanded knowledge base and cutting-edge treatments that have improved the lives of our Service Members, Veterans, their families, and all Americans. Yet, we are neither complacent nor satisfied with our 

achievements. Our mission is urgent. We have a long-term plan to continue to improve our treatment of these very complex medical conditions. We are honored to 

represent the Department of Defense today on behalf of the men and women who 

conduct such vital research, and deliver care in support of such a special population. 

We are grateful for the ongoing support of this Committee and the Congress in supporting our efforts, and we look forward to answering your questions. 

STATEMENT OF CAPTAIN MICHAEL J. COLSTON, MC, USN, DIRECTOR, DEFENSE CENTERS OF EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND TRAUMATIC BRAIN INJURY 

Captain COLSTON. Chairman Graham, Ranking Member Gillibrand, members of the subcommittee, thank you for support of our 

Nation’s servicemembers, veterans, and their families. 

I’m pleased to share DOD’s efforts to foster research for PTSD 

and other psychological health conditions, TBI, and comorbidities, 

including substance-use disorders, pain disorders, and suicide. 

Last year, over a quarter of our servicemembers were treated for 

these conditions, so please allow me to discuss how we evolved to 

support the need. We reduced barriers to care, including stigma. 

We expanded access to care by tripling the size of our mental 

health infrastructure. We improved transition points in the continuum of care. And we improved our system’s ability to treat the 

sickest patients. All the while, we developed a comprehensive research portfolio to study PTSD, TBI, and suicide. 

DOD partners with other government agencies, academia, and 

the private sector in research. The centerpiece of our collaborative 

efforts is the National Research Action Plan, or NRAP. NRAP 

brings together DOD, VA, the Department of Health and Human 

Services, and the Department of Education, improving our underVerDate Nov 24 2008 15:20 May 03, 2017 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6602 C:\USERS\WR47328\DESKTOP\25235.TXT WILDA
8 

standing of TBI and PTSD. But, there are challenges. One challenge is ascertaining why PTSD, TBI, depression, substance-use 

disorders, and chronic pain all present together. Longitudinal research efforts, like the Millennium Cohort Study and the 15-year 

study on TBI, will aid our understanding, just as the Framingham 

Study helped elucidate factors in cardiovascular disease. 

PTSD treatment has a wide evidence base, with A-level evidence 

supporting the use of therapy and medications for PTSD survivors, 

irrespective of trauma, be it developmental, be it sexual, or be it 

from the ravages of war. We, nonetheless, face challenges in how 

best to structure our health system to support those interventions. 

Health systems research is imperative. Answering mandates 

from Congress in NDAAs ’13 and ’15, agency priority goals, and 

DOD’s Cost Analysis and Program Evaluation Office, my center, 

the Defense Centers of Excellence for Psychological Health and 

TBI, is halfway through a 5-year effort to evaluate psychological 

health in TBI programs for effectiveness, including outcomes and 

fiscal granularity. Cooperation with academia and federally funded 

research and development centers aids us in this effort, leading to 

analyses focused on results. 

With your continued support, I’m confident our discoveries will 

bear fruit in the years ahead. And I look forward to answering your 

questions. 

STATEMENT OF AMY E. STREET, DEPUTY DIRECTOR, WOMEN’S 

HEALTH SCIENCES DIVISION, NATIONAL CENTER FOR 

POSTTRAUMATIC STRESS DISORDER 

Dr. STREET. Good afternoon, Chairman Graham, Ranking Member Gillibrand, and members of the subcommittee. 

As a researcher whose work is focused on military sexual trauma, MST, and a psychologist with the Department of Veterans Affairs who works with veterans who have experienced MST, I am 

grateful for the opportunity to speak about the current state of research related to MST and the diagnosis and treatment of conditions associated with MST, with a particular focus on post-traumatic stress disorder. I’m also honored to be seated with my colleagues representing the Department of Defense. 

Research indicates that experiences of sexual harassment and 

sexual assault during military service are far too common. Data 

from the 2014 RAND [Research and Development] Military Workplace Study indicated that 1 percent of servicemen and 5 percent 

of servicewomen were sexually assaulted in the past year, impacting an estimated 20,300 Active Duty servicemembers. The majority 

of these assaults occurred in military settings or were perpetrated 

by military personnel. 

Experiences that constitute sexual harassment are even more 

common, with 7 percent of servicemen and 22 percent of servicewomen experiencing sexual harassment in the past year. My own 

research demonstrates that experiences of sexual harassment and 

sexual assault are common among troops deployed in support of 

military operations in Afghanistan and Iraq, raising the possibility 

that servicemembers may have been exposed to multiple types of 

severe traumatic stress during military operations in these countries. 

9 

MST is an experience, not a diagnosis. And servicemembers and 

veterans will vary in their reactions to MST. Our men and women 

in uniform are remarkably resilient after being exposed to traumatic events, but, sadly, many will go on to face long-term difficulties with mental health after experiencing MST. 

MST is strongly associated with a range of mental health conditions, but MST has a particularly strong association with PTSD. 

Research data from veteran samples indicates that experiences of 

MST are an equal or stronger predictor of PTSD, as compared to 

other military-related stressors, including exposure to combat. 

In my clinical experience, veterans who have experienced MST 

often struggle with feelings of betrayal, either by perpetrators 

whom they believed to be comrades in arms or by the military system that they believed should have protected them. MST survivors 

may also struggle to integrate a victim identity with the value they 

place on their own strength and self-sufficiency as former or current servicemembers. Others who felt that they had to leave military service prematurely may experience grief or anger at losing a 

military career due to the tangible and intangible injuries caused 

by their alleged perpetrators, or, in their view, inadequate action 

taken by their leadership to protect them from such harm. 

Many still think that only servicewomen experience MST, but 

servicemen do, too. Although the rates of sexual assault are lower 

among military men than among military women, in absolute numbers, more servicemen than servicewomen experienced sexual assault in the past year. 

Research on the mental health consequences of sexual trauma 

among men has lagged behind similar research among women, but, 

increasingly, the data suggests that the mental health consequences of MST may be more significant for male veterans than 

for female veterans. 

Fortunately, recovery is possible after experiences of MST. And 

VHA [Veterans Health Administration] has services spanning the 

full continuum of counseling, care, and services to assist eligible 

veterans in these efforts. Recognizing that many survivors of sexual trauma do not disclose their experiences unless asked directly, 

it is VA policy that all veterans receiving healthcare be screened 

for experiences of MST. Veterans who disclose MST experiences are 

offered a referral for mental health services. All VA counseling, 

care, and services determined to be necessary to overcome the psychological trauma of MST is provided free of charge. A veteran’s 

eligibility for MST-related care is entirely separate from the veteran’s entitlement to VA disability compensation for the same conditions. Every VA Medical Center provides MST-related counseling, 

care, and services. MST coordinators are available at every VA 

Medical Center to assist veterans in accessing these services. 

Issues related to brain health and head trauma transcend the 

veteran and military community, impacting all Americans. Today, 

Secretary Bob McDonald is participating in VA’s groundbreaking 2- 

day event focused on brain health, Brain Trust Pathways to Innovation. This first annual public-private partnership event is convening many of the most influential voices in the field of brain 

health, to include the Department of Defense, the sports industry, 

private sector, Federal Government, veterans, and community partVerDate Nov 24 2008 15:20 May 03, 2017 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6602 C:\USERS\WR47328\DESKTOP\25235.TXT WILDA
10 

ners, to identify and advance solutions for mild traumatic brain injury and post-traumatic stress disorder. The event will also serve 

as a showcase for many of the advancements that VA is pioneering 

to improve brain health for veterans, the military, and for the 

American public. 

Mr. Chairman, I appreciate the opportunity to appear before you 

today. And I’m prepared to answer any questions you or the committee may have. 

[The prepared statement of Dr. Street follows:] 

PREPARED STATEMENT BY DR. AMY STREET

Good afternoon, Chairman Graham, Ranking Member Gillibrand, and Members of 

the Subcommittee. Thank you for the opportunity to speak about the VA current 

state of research related to military sexual trauma (MST), and the diagnosis and 

treatment of mental health disorders associated with MST, with a particular focus 

on posttraumatic stress disorder (PTSD). 

VA uses the term ‘‘Military Sexual Trauma’’ to refer to psychological trauma, 

which in the judgment of a mental health professional employed by the Department, 

results from a physical assault of a sexual nature; battery of a sexual nature; or 

sexual harassment, which occurred while the Veteran was serving on active duty, 

active duty for training, or inactive duty training. For purposes of this program, sexual harassment means repeated, unsolicited verbal or physical contact of a sexual 

nature which is threatening in character. MST is an experience—not a diagnosis— 

and Servicemembers’ and Veterans’ will vary in their reactions to MST. Our men 

and women in uniform are remarkably resilient after being exposed to traumatic 

events; but, sadly, many will go on to experience long-term difficulties with mental 

health after experiencing MST. 

We know that experiences of sexual harassment and sexual assault during military service are far too common. Data from the 2014 RAND Military Workplace 

Study, using questionnaires that assessed incidents consistent with sex crimes 

under the Uniform Code of Military Justice, Article 120, indicated that 1 percent 

of Servicemen and 5 percent of Servicewomen were sexually assaulted in the past 

year, impacting an estimated 20,300 active component Servicemembers. The majority of these assaults occurred in military settings or were perpetrated by military 

personnel. Experiences that constitute sexual harassment are even more common. 

Using questionnaires that assessed incidents consistent with sex-based military 

equal opportunity (MEO) definitions of these offenses, seven percent of Servicemen 

and 22 percent of Servicewomen experienced sexual harassment in the past year. 

My own research demonstrates that experiences of sexual harassment and sexual 

assault are common among troops deployed in support of military operations in Afghanistan and Iraq, raising the possibility that Servicemembers may have been exposed to multiple types of severe traumatic stress during military operations in 

these countries. 

Experiences of MST are strongly associated with a range of mental health conditions. These mental health disorders can include depression and substance use disorders, but experiences of MST have a particularly strong association with PTSD. 

In fact, research data from civilian samples demonstrates that rape is the traumatic 

experience with the strongest predictive probability of PTSD. Research data from 

Veteran samples indicates that experiences of MST are an equal or stronger predictor of PTSD as compared to other military-related stressors, including exposure 

to combat. In addition, experiences of MST may be a stronger predictor of PTSD 

than experiences of sexual assault that occurred during childhood or occur during 

adult civilian life. In my clinical experience, Veterans who have experienced MST 

often struggle with feelings of betrayal, either by perpetrators whom they believed 

to be ‘‘comrades in arms’’ or by the military system that they believe should have 

protected them. MST survivors may also struggle to integrate a ‘‘victim identity’’ 

with the value they place on their own strength and self-sufficiency as a former or 

current Servicemember. Others who felt that they had to leave military service prematurely (for instance, because of actual or perceived health or safety issues related 

to their MST experience) may experience grief or anger at losing a military career 

due to the tangible and intangible injuries caused them by their alleged perpetrators or, in their view, inadequate action taken by their leadership to protect them 

from such harm. 

11 

1Gender differences in experiences of sexual harassment: data from a male-dominated environment. 

AE Street, JL Gradus, J Stafford, K Kelly—Journal of consulting and clinical psychology, 2007 

Ann Epidemiol. 2005 Mar;15(3):191–5. 

The role of sexual assault on the risk of PTSD among Gulf War Veterans. 

Kang H 1, Dalager N, Mahan C, Ishii E. 

J Trauma Stress. 2005 Jun;18(3):272–84. 

Deployment stressors, gender, and mental health outcomes among Gulf War I Veterans. 

Vogt DS1, Pless AP, King LA, King DW. 

Many still think that only Servicewomen experience MST, but Servicemen do, too. 

Although the rates (percentages) of sexual assault are lower among military men 

than among military women, more Servicemen in absolute numbers than Servicewomen experienced sexual assaulted in the past year. Further, men who are sexually assaulted are more likely than women to have been physically injured or to 

have been threatened with physical injury during the assault, and men’s experiences are more likely to involve multiple assailants. Research on the mental health 

consequences of sexual trauma among men has lagged behind similar research 

among women. However, the data increasingly suggest that the associations between experiences of MST and mental health disorders, while substantial for female 

Veterans, appear to be even stronger for male Veterans. 1

MILITARY SEXUAL TRAUMA-RELATED CARE IN VHA

Fortunately, recovery is possible after experiences of MST, and VHA has services 

spanning the full continuum of counseling, care, and services to assist eligible Veterans in these efforts. Recognizing that many survivors of sexual trauma do not disclose their experiences unless asked directly, it is VA policy that all Veterans receiving healthcare be screened for experiences of MST. Veterans who disclose MST experiences are offered a referral for mental health services. All VA counseling, care, 

and services determined to be necessary to overcome the psychological trauma of 

MST, including the clinical manifestation of related PTSD, is provided free of 

charge. A Veteran’s eligibility for MST-related counseling, care, and services is entirely separate from the Veteran’s entitlement to VA disability compensation for the 

same mental health disorder(s). That is, a Veteran’s eligibility for MST-related counseling and care is not conditioned on the Veterans Benefits Administration having 

adjudicated the MST-related mental health disorder to be service-connected. In addition, Veterans who meet the eligibility criteria of 38 U.S.C. section 1720D(a)(1) are 

able to receive MST-related counseling, care, and services, even if they are not eligible to be enrolled in VA’s health care system or receive other VA health care. Every 

VA medical center provides MST-related counseling, care, and services; MST Coordinators are available at every VA medical center to assist Veterans in accessing 

these services. Many community-based Vet Centers also have specially-trained MST 

counselors. 

EFFECTIVE TREATMENT OF PTSD

VA is strongly committed to delivering quality care to all Veterans with PTSD, 

including those whose PTSD results from MST. Advances in research have led to 

a range of effective treatments for PTSD that reduce symptoms and increase functioning and well-being. The VA/DOD Clinical Practice Guidelines, titled Management of Post-Traumatic Stress Disorder and Acute Stress Reaction (2010)), recommend trauma-focused cognitive behavioral therapy [such as Prolonged Exposure 

(PE), and Cognitive Processing Therapy (CPT)], Eye Movement Desensitization and 

Reprocessing, stress inoculation, selective serotonin reuptake inhibitors, and 

venlafaxine, a serotonin norepinephrine reuptake inhibitor, as primary treatments 

for PTSD. PE and CPT are among the most widely studied types of trauma-focused 

cognitive behavioral therapy. Evidence demonstrating their effectiveness is particularly strong. These treatments have great relevance for MST survivors as much of 

the early work developing and testing both PE and CPT occurred among sexual assault survivors in the civilian population. 

VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers 

and Clinics, requires that all VA medical centers provide access to either PE or 

CPT. VA has supported this requirement by training upwards of 7,000 therapists 

in these treatments as part of a broader initiative to disseminate evidence-based 

psychotherapy for mental health disorders. Uptake of PE and CPT across the VA 

health care system was rapid; by 2009, 96 percent of VA facilities were providing 

PE or CPT and 72 percent were providing both. VA also offers a range of treatment 

options to treat PTSD and associated symptoms and is using telehealth technologies 

to increase the availability of treatment for PTSD. VA remains open to new and inVerDate Nov 24 2008 15:20 May 03, 2017 Jkt 000000 PO 00000 Frm 00015 Fmt 6633 Sfmt 6621 C:\USERS\WR47328\DESKTOP\25235.TXT WILDA
12 

novative treatments for PTSD and supports research on these treatments as part 

of its portfolio on PTSD and related mental health disorders. 

CONCLUSION

Mr. Chairman, I appreciate the opportunity to appear before you today. I am prepared to answer any questions you or other Members of the Committee may have. 

Senator GRAHAM. Well, thank you all very much. 

I’ll start. And it was a excellent—— 

Dr. Street, if someone is a victim of sexual assault in the military, can they get a disability rating because of the PTS [Post-traumatic Stress]? 

Dr. STREET. So, a disability rating would be provided for PTSD. 

So, because military sexual trauma is the experience and not the 

diagnosis, it would be the diagnosis related to the experience—in 

this case, PTSD—that the disability rating would come from. And 

yes, they can. 

Senator GRAHAM. So, if someone has been assaulted, and they 

get PTSD, they qualify. 

Dr. STREET. That’s right. They would then go through the same 

process that a veteran who experienced PTSD related to combat—— 

Senator GRAHAM. Okay. 

Dr. STREET.—that same disability assessment process. 

Senator GRAHAM. Captain Greenhalgh, when—what’s the process 

we use when people return from the battle theater, in terms of 

evaluating them to make sure that we’re catching things that they 

may have experienced? 

Captain GREENHALGH. Yes, sir. Well, the—you know, if we’re 

talking about traumatic brain injury, for example, it actually 

doesn’t start after they leave the battlefield; it starts on the battlefield, with—not necessarily symptom-related evaluations and 

screening, but event-related. So, if a servicemember, for example, 

is involved in a—an IED [improvised explosive device]—if they’re 

within 50 meters of an IED blast, for example, or a rollover accident, it’s not up to, necessarily, the medical leadership to say they 

need to get screened; the line leadership, the battle buddy, will ensure that that person is screened on the battlefield or at the local, 

you know, forward medical unit. So, that’s when the screening does 

begin. 

Now, certainly if somebody falls through that crack or is not, you 

know, involved in a significant—— 

Senator GRAHAM. Right. 

Captain GREENHALGH.—injury or event, when they return from 

the battlefield, there is immediate post-deployment health risk assessments that are performed. Actually, a cycle of three of them 

are performed within—shortly after return, then 90 days later, 180 

days later. 

Senator GRAHAM. What have we—how old is this system? 

Captain GREENHALGH. Excuse me, sir? 

Senator GRAHAM. How old is this system that you’ve just described? 

Captain GREENHALGH. Well, I, myself, deployed about 4 years 

ago, and it had already been in effect several years before that. 

Now, it’s been modified, I think, you know, at—— 

Senator GRAHAM. Do you think it’s working? 

13 

Captain GREENHALGH. I think it’s as good as it can be right now, 

because we are—you know, we’re basically not waiting for the patients to come to us with—— 

Senator GRAHAM. Right. 

Captain GREENHALGH.—symptoms; we’re basically asking them 

about symptoms that maybe others wouldn’t necessarily associate 

with a traumatic brain injury, and they’re—— 

Senator GRAHAM. When it comes to prevention—I’m sure there 

are all kind of technical things we’re trying to do to protect the 

brain in a IED attack, but when it comes to PTS or—what kind of 

preventive measures are we employing? 

Captain GREENHALGH. With regards to the psychological health, 

sir? 

Senator GRAHAM. Yes. 

Captain GREENHALGH. I mean, I think that prevention begins 

long before they deploy, and it has to do with training and—being 

adequately trained and knowing their—you know, kind of knowing 

their algorithms. You know, we don’t want to overtrain people. You 

want—you know, when they’re in training, you would say, you 

know, ‘‘train like you fight,’’ but you want them to have adequate 

rest, let—to allow, you know, brain rest, as well. But, you know, 

sort of—— 

Senator GRAHAM. Are we teaching people what to watch out for 

in their buddies? 

Captain GREENHALGH. No, absolutely. I think there’s—just from 

the psychological health perspective, certainly, and from the traumatic brain injury perspective, as well, there’s a lot of training that 

goes on before they deploy. And then, depending on how long a 

servicemember is in theater, there’s mandatory screening that occurs if they’re there for more than 6 months, even if they’re not involved in any sort of any specific event. 

Senator GRAHAM. Do you feel you have adequate resources at the 

moment to do your job? 

Captain GREENHALGH. Well, sir, you know, we’d always love to 

have more. 

Senator GRAHAM. Right. 

Captain GREENHALGH. But, I think that, especially with a drawdown in commitments overseas, what we’re finding is that the resources aren’t necessarily needed for the Active, you know, returning-off-the-battlefield servicemember as much as they were just 3 

or 4 years ago. I think it’s more for the long-term commitment that 

we have to these servicemembers, some of whom were injured 

years ago, understanding that it’s not a, you know, patch ’em up 

and send ’em back out to the real world. Some of these—— 

Senator GRAHAM. Right. 

Captain GREENHALGH.—people suffer for years. And along with 

our, you know, VA colleagues, this is a long-term commitment, and 

that’s where I think the nature of the type of support that we need 

definitely changes. 

Senator GRAHAM. Do you think the handoff between DOD and 

the VA is working? 

Captain GREENHALGH. I think it’s working better than it ever 

has, sir. 

14 

Senator GRAHAM. Do you agree with that, Ms. Street—Dr. 

Street? 

Dr. STREET. I do. 

Senator GRAHAM. Captain Colston, you said that 25 percent of 

the force has been treated for—for what? 

Captain COLSTON. Yes, sir. So, one of the things that we actually 

do is, in transition, where we—when we do handoffs from DOD to 

VA, we look at who’s been treated in the last year. And it’s at 

about 20 percent for psychological health conditions, and then, for 

other conditions, such as substance-use disorders, pain disorders, 

depression, that kicks it over 25 percent. So, we have a large cohort 

of treated people right now, sir. 

Senator GRAHAM. So, from a DOD perspective, this is a problem. 

Captain COLSTON. Oh, absolutely, sir. And it’s one, certainly, 

that we’ve devoted a lot of resources to, that we have really made 

a number of turnarounds for. 

Senator GRAHAM. Well, just to stay within time, here—do you see 

any promising therapies in the future? Hyperbaric oxygen treatment, I’ve heard a lot about that. There’s a program, I think, in 

Myrtle Beach. People really believe in it. There are all kind of ideas 

out there. Could you tell me a little bit about that treatment and 

what you see coming in the future? 

Captain COLSTON. Well, I think hyperbaric oxygen treatment, 

we’ve done about seven studies on that right now. None of them 

failed to show any effect beyond a placebo effect. But, we have all 

kinds of innovative strategies, and we also have a number of Alevel evidence-based strategies for PTSD. I think innovations in the 

future are going to include biomarkers, neuroimaging, and, really, 

better ascertainment of the disease states of PTSD and TBI and 

the other things that run with it. 

Senator GRAHAM. Okay. Well, we’ll let the hyperbaric people— 

you’ll have your say. You can write us a report about it. 

Senator Gillibrand. 

Senator GILLIBRAND. Thank you, Mr. Chairman. 

Victims and experts have stated that the response to military 

sexual trauma is more similar to that of incest than other forms 

of sexual assault. How many survivors of MST go on to develop 

PTSD, is the first question? And for MST survivors who develop 

PTSD, how do they present differently from those with PTSD stemming from other kinds of traumatic events? 

Doctor? 

Dr. STREET. We know that experiences of sexual assault, including experiences of sexual assault during military service, are one 

of the strongest predictors of PTSD. It’s the type of event that’s associated with PTSD symptoms among both women and men, as I 

mentioned, even more strongly for men than for women. 

And the symptoms of PTSD related to MST look really quite 

similar than the symptoms of PTSD related to other forms of traumatic stress, although survivors of MST may report certain kinds 

of issues more frequently than other types of trauma survivors. So, 

for example, issues around intimacy and sexuality, issues around 

interpersonal relationships and boundaries, certainly issues around 

trust, issues around self-blame. Those are issues that come up, I 

15 

think, much more frequently in—when working with sexual trauma survivors. 

Senator GILLIBRAND. In the last report we got, 62 percent of the 

people who reported that they were sexually assaulted were retaliated against—from their perspective, some form of retaliation. How 

does the experience of not being believed or being retaliated 

against affect PTSD symptoms? 

Dr. STREET. It worsens it. I’ve done research indicating that a 

victim’s experiences in reporting, in the system, and how they feel 

about that experience—if they feel positively about it, if they feel 

like they were believed—that is a strong predictor above and beyond the traumatic experience of how they’re doing, years later, in 

terms of PTSD and depression symptoms. 

Senator GILLIBRAND. Last December, there was a study completed by the VA researchers that was published in the American 

Journal of Preventive Medicine on the link between military sexual 

trauma and death by suicide. The study found that MST was a significant risk factor for suicide among men and women, even controlling for other psychiatric disorders. What implications do these 

findings have for screening and treating patients with MST? 

And then, to Captain Colston, how do these findings inform 

screenings and treatment of servicemembers? And what kind of 

outreach do you encourage survivors of MST to seek care? 

Dr. STREET. So, we do, as I mentioned, screen every veteran for 

experiences of MST, in the VA, which that study would suggest is 

particularly important, because, unlike other types of traumatic 

events, the risk associated with MST for suicide doesn’t run fully 

through PTSD or depression; it exists separate from that. So, it’s 

just why it’s so important that we screen specifically for experiences of military sexual trauma, so that those patients can be followed up with, in terms of suicide risk, directly. 

Senator GILLIBRAND. Captain? 

Captain COLSTON. Yes, ma’am. I’d agree with—yes, ma’am, I’d 

agree with Dr. Street. Suicide risk is increased from sexual assaults, aside from PTSD. PTSD itself is not necessarily a robust 

risk factor for suicide. It does have a hazard ratio that suggests 

that it’s associated with suicide, but certainly sexual trauma is a 

really big factor. 

Developmental trauma, especially developmental sexual trauma, 

stuff that I’ve seen as a child psychiatrist, that’s a huge risk factor 

and something that actually affects the brain as it develops, makes 

you kind of check the horizon for if you’re safe all the time. 

Senator GILLIBRAND. Although the prevalence for military sexual 

trauma is higher among women, given the significantly larger portion of men in the Armed Forces, there are similar numbers of men 

and women who have survived sexual trauma. How do men differ 

in their response to MST? And how do VA services meet the unique 

needs of men who have survived MST? And are treatments for 

PTSD related to MST different for men and women? And, if so, 

how? And is there a detectable difference in male suicide rates? 

Dr. STREET. So, male and female survivors of MST look more 

similar than they do different, although men’s experiences may be 

exacerbated, in terms of symptomatology, although the symptoms 

themselves are the same. Men—male survivors do struggle uniqueVerDate Nov 24 2008 15:20 May 03, 2017 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6602 C:\USERS\WR47328\DESKTOP\25235.TXT WILDA
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ly with concerns about their masculinity, understanding what this 

says about their sexual orientation, a lot of self-blame, ‘‘Why was 

I targeted for this?’’ This isn’t something that men usually experience. 

In terms of treatments, the treatments look very similar. I think 

differences, in terms of male and female survivors, really comes in 

when we think about our social marketing and our outreach. We’re 

very careful to have outreach materials that are specifically targeted to male survivors, to include pictures of men on all of our 

outreach materials about MST, in addition to pictures of women, 

so that men can understand that our MST treatment services are 

there for them as well as those for women. 

Captain COLSTON. I’d say one of the things that we struggle 

with, the prevalence of sexual assault in women compared to men 

is probably about five to one. And Dr. Street’s data and Nate 

Galbreath’s data at SAPRO, and some of Ron Kessler’s data from 

Harvard, support that. 

One of the things that we struggle with is getting men into care. 

Men are less apt to engage in care for sexual assault. And, in fact, 

in therapy, that’s something that you may address way downstream. It’s not an initial or presenting problem. 

Senator GILLIBRAND. It’s why I have a concern that the suicide 

rate might be higher, because if—— 

Captain COLSTON. Well, I—— 

Senator GILLIBRAND.—male survivors won’t report, they don’t get 

any care. And, just anecdotally, I met a male survivor who attempted suicide, was not successful, paralyzed himself in his— 

shooting himself in the spine, and was paralyzed for the rest of his 

life. But, he couldn’t face his life, he couldn’t face his wife, he 

couldn’t face anything after it. And instead of seeking treatment— 

or, actually—he actually did, but, for many survivors, instead of 

seeking treatment, they just commit suicide. 

Captain COLSTON. There’s no question that it’s a trauma that’s 

very hard to overcome. And it’s very hard for us to get granular 

exactly about what the problem is. There’s—— 

Senator GILLIBRAND. Yeah. 

Captain COLSTON.—on the order of 300 risk factors associated 

with suicide. Certainly, sexual assault is one of them. PTSD is one 

of them. 

One thing is, I think, you know, with regard to VA care and 

some of the promising things, we see that veterans who have PTSD 

have lower suicide rates than other veterans. So, I think there are 

some promising developments in the treatment and in the turnover 

from DOD to VA. 

Senator GILLIBRAND. Thank you. 

Senator GRAHAM. For the record, Senator Cotton served a tour 

of duty in combat in Iraq. I think you were a platoon leader and— 

is that correct? 

So, Senator Cotton. 

Senator COTTON. Thank you, Chairman Graham. 

And I can say that the system that Captain Greenhalgh described has been in effect for at least 10 years, at least in the 

Army. 

17 

I want to talk briefly about the relationship between traumatic 

brain injury and post-traumatic stress. Does—one does not necessarily presume or infer the other. Is that correct? 

Captain GREENHALGH. Not necessarily, sir. I think, certainly, if 

someone has been exposed in a traumatic event downrange that resulted in a traumatic brain injury, I think the possibility is greater 

that they will also have comorbid post-traumatic stress along with 

that. I do believe that a history of TBI sort of predisposes someone 

to be more vulnerable to psychological health issues downrange, or 

down the road. And some of that has to do with the chronic effects, 

if that is a servicemember who has chronic effects of the TBI, developing some symptoms that are very suggestive also of psychological health issues. There’s a lot of overlap there, as well. 

Captain COLSTON. And I’d say patients often present to us in an 

undifferentiated state. They’ll present, maybe, with their—with a 

problem with suicidality, maybe a substance-use disorder, maybe a 

pain disorder. Sometimes it’s very hard for us to discern what the 

precipitant was. 

Dr. STREET. I have nothing to add. 

Senator COTTON. Is one easier to diagnose than the other? 

Captain GREENHALGH. From a—— 

Senator COTTON. To the extent that you can separate the comorbidity of the two. 

Captain GREENHALGH. Well—so, my background, sir, is primary 

care, so I would say, certainly, we see a lot of behavioral health in 

the primary care setting. But, given that, we have very strong 

CPGs for a lot of things that we take care of in the—you know, in 

military medicine and just medicine in general. 

When I see a patient who has a history that sort of fits within 

the clinical practice guideline description for certain kind of diagnosis, I find that, from the primary care perspective, the TBI is certainly an easy one to try and fit into that, you know, diagnostic 

realm. 

Captain COLSTON. Some of it has to do with the patients that 

present in front of us. For Walt, in a primary care setting, he’s 

going to see a different patient population than I’ll see in a psychiatric setting. One of the things that occurs to me is, the science 

for PTSD is probably more developed than the science is for TBI. 

Science for TBI is really in a nascent stage, so PTSD is a little easier to discern. It’s a little easier to discern from a child psychiatry 

standpoint with regard to developmental trauma, just because the 

prevalence of that is so high. 

Dr. STREET. And just to add, I concur that the research base on 

PTSD is a bit further along. And, as part of that, we have existing 

well-validated instruments for the screening and diagnosis of 

PTSD. And I think those instruments are being developed for TBI, 

but are not as far along, haven’t undergone as rigorous tests. 

Captain GREENHALGH. If I—— 

Senator COTTON. So, the science for PTS is further along than 

TBI. Is that simply because of the volume of patients that the medical world has seen with post-traumatic stress, as opposed to TBI? 

Captain COLSTON. I think it’s a number of factors. The science 

of TBI is—has been really hard to get a handle on, just from the 

standpoint of—you know, it took—I’ll give you an example, sir—it 

18 

took 20 years and $50 billion to get on top of HIV [Human Immunodeficiency Virus]. HIV has about a dozen genes and two 

serotypes. The brain uses about 20,000 of the 30,000 genes in the 

human genome. Understanding the way the brain works, especially 

a brain that’s traumatized, is extremely hard. 

With regard to PTSD, we at least have a long history of looking 

at people who were traumatized, and a long history of treatment 

interventions, so I think the science is more developed for that reason. The prevalences of both of those—in DOD, the prevalence of 

TB—of PTSD is about 2 percent; TBI, slightly lower. 

Dr. STREET. I think, from a historical perspective, we really became aware of PTSD, following the Vietnam War. And so, we’ve 

had that span of history to really think about the disorder, the diagnosis, and the treatment of the disorder. TBI is something that 

we’ve become so much more aware of, due to the recent conflicts 

in Iraq and Afghanistan. 

Captain GREENHALGH. And, if I could just add, sir. Again, from 

the primary care perspective, there have been versions of PTS, it 

seems, from conflicts centuries ago, as well, this—the idea of shellshock and things like that. I think we’ve gotten more of a handle 

on it after the Vietnam conflict. But, as Captain Colston alluded to, 

with technology, neuroimaging capacity, that really has just been 

a phenomenon of our generation. And so, I think there’s a lot of potential there. And again, from the primary care perspective, having 

neuroimaging support certain diagnostic criteria for traumatic 

brain injury, I think that’s where there’s a lot of potential for the 

science. But, I agree, I think we’ve been describing things like PTS 

for quite a lot longer than we have traumatic brain injury. 

Senator COTTON. One word I think I heard you use twice, maybe 

three times, was ‘‘longitudinal.’’ The root of that is ‘‘long,’’ which is 

a little worsened, given the number of people who suffer from PTS 

or TBI. Obviously, when you’re conducting a longitudinal study, it 

takes many years to get results. Is that something about which we 

should be concerned? 

Captain COLSTON. Yes, sir, but it’s the only way that we can do 

it, because these things don’t present in silos. PTS doesn’t present 

in a silo. TBI doesn’t present in a silo. So, we’ve got to get a handle 

on where the patients are. And we have a lot of efforts. We’ve got 

the millennium cohort study, we’ve got the 15-year TBI study. We 

have the STARRS [Study to Assess Risk and Resilience in 

Servicemembers] longitudinal study on suicide. So, we’re looking at 

several hundred-thousand patients now to get an idea of where patients are coming from. 

Captain GREENHALGH. And if I can add onto that, ‘‘longitudinal’’ 

doesn’t mean that we have to wait until the study is over to start 

gathering data, so the 15-year study, for example, has report-outs 

every 4 years. The next one is due next year. Not to mention the 

constant stream of data and research that is being formulated into 

papers and publications along the way. That’s just a small example. 

So, longitudinal really, I think, if anything, connotes a commitment to a long-term study of this, not to say that we’re going to 

not give you any answers for 15 more years, sir. 

19 

Senator COTTON. Can—do you, can you, would it be productive 

to expand the dataset to look at other occupations that might have 

similar risk factors, like, say, professional football, professional 

hockey, boxing? There may be others. 

Dr. STREET. Certainly, the brain trust meeting that I described 

that’s happening today and tomorrow is doing exactly that, and it’s 

bringing in a researcher from my institution who was one of the 

first to identify this issue among professional football players, and 

taking that information and then applying it to the military and 

veteran community. So, for sure, these public-private partnerships 

in which you can identify knowledge that’s been gathered in other 

places and applied to this population, I think are very promising. 

Senator GRAHAM. Senator Blumenthal. 

Senator BLUMENTHAL. Thanks, Mr. Chairman. 

Dr. Street, I think you’ve touched briefly on the transition from 

Active Duty out of service or into the Reserves or care of the Veterans Administration. How well do you think that transition is 

going these days, in terms of the computer compatibility, not only 

in records, but also in transition on pharmaceutical drugs, the prescriptions, and so forth? Maybe you can give us an overview, because I think you’re—you really are in a position to comment on 

that issue. 

Dr. STREET. Well, I’m happy to comment from my perspective, although my perspective may be a bit limited, so you may choose to 

hear from my colleagues, as well. But, in my perspective as a practicing clinician, that transition is going well. I think Captain 

Greenhalgh, earlier, said it’s going better than it ever has. And I 

know that there’s a lot of attention to this issue, a lot of new initiatives. And, in my experience as a practicing clinician, I haven’t encountered problems with that. 

Captain COLSTON. Sir, I’d say it’s DOD policy right now that we 

do a warm handoff from DOD to VA. And it’s really important, 

those transitions. One of the things that we’ve done is, we’ve established coaching, an in-transition program, where we actually look 

at people’s medical data and then go in and say, ‘‘Hey, can we help 

you with your follow-on appointments?’’ And I think that’s been 

used to good effect in the last year. 

Senator BLUMENTHAL. Well, it’s always been the policy. It’s not 

always been the executed policy. And so, for example, on the interoperability of computer programs, I don’t know whether you can 

give us an up-to-date perspective on how well that’s going. It’s been 

a continuing struggle, as you know. 

Dr. STREET. I don’t have an update on the status of that. I’m— 

but, I’m happy to take that question for the record, and we could 

get back to you with a more thorough answer on the updated status of that integration process. 

Senator BLUMENTHAL. I would appreciate that. And, as well, on 

the pharmaceutical drug issue, the transition there has been an 

issue for some time. 

Senator BLUMENTHAL. Let me shift to, again, the post-traumatic 

stress, military sexual assault trauma. Is that an area where you 

think more research, as well as clinical treatment, is necessary? 

Dr. STREET. I’m a researcher. I’ll always say that I think more 

research is necessary. But, I do think this is a case where underVerDate Nov 24 2008 15:20 May 03, 2017 Jkt 000000 PO 00000 Frm 00023 Fmt 6633 Sfmt 6602 C:\USERS\WR47328\DESKTOP\25235.TXT WILDA
20 

standing things that are unique about experiences of military sexual assault, ways in which those experiences differ when they’re in 

the military context from when they’re in a civilian context, and 

better understanding that has a lot of implications for recovery. So, 

I think our—research that helps us understand that process, as 

well as research more generally targeted to the disorder and treatment of the disorder, is extremely valuable. 

Senator BLUMENTHAL. And it may seem obvious—the answer 

may seem obvious. I think I have an idea about what the answer 

is, but maybe you can talk a little bit about what the differences 

are in the civilian-versus-military sexual assault trauma. 

Dr. STREET. Sure. Senator Gillibrand, earlier, referred to the fact 

that survivors of military sexual assault in some ways looked clinically more like survivors of childhood sexual abuse than they look 

like survivors of adult sexual assault in the civilian world. And I 

think there’s some truth to that, certainly in terms of the fact that 

survivors from military sexual trauma often talk about the experience of ongoing abuse in which they feel trapped and unable to escape because they’re not able to, sort of, leave their position, although there have been policy improvements to make that more 

possible. They’re also dependent, often, on their perpetrators for 

meeting their basic health needs or for this feeling that their perpetrators are those who are supposed to be watching their back 

and looking out for them. And I think those kinds of differences 

gives the survivor, sometimes, a little bit of a flavor for—that looks 

more like ongoing childhood abuse. 

Of course, also, we know that survivors of traumatic stress are 

often repeatedly traumatized over a lifespan. So, that earlier trauma increases risk for later trauma. So, many women and men who 

are survivors of sexual trauma in the military are also survivors 

of childhood sexual trauma or other interpersonal trauma, as well. 

So, then those experiences can exacerbate each other, in terms of 

the severity of the symptom presentation. 

Senator BLUMENTHAL. Thank you. 

My time is expired. But, I appreciate your taking my earlier 

questions for the record. Thank you very much. 

And thank you all for your service. 

Thank you. 

Senator GRAHAM. Thank you. I think Senator Tillis is on the 

way, but I—Senator Gillibrand, if you have any follow-up. 

Senator GILLIBRAND. One of the issues that some of us work on 

is rescheduling marijuana to become a Schedule 2 drug so more research can be done and so patients that have been prescribed the 

medication can get access to it more regularly. One of the concerns 

we’ve had is, because it’s a Schedule 1 drug, it, therefore, prohibits 

the VA from being able to prescribe it, even though that individual 

might have been prescribed in their State, where their State’s already passed a law. We’ve heard, anecdotally, from many veterans 

that marijuana can often be a very useful treatment for PTSD 

symptoms. Have you studied that issue? Do you have any insight 

into that issue that you’d like to share? 

Captain COLSTON. Ma’am, I can say DOD hasn’t ascertained the 

answer to that question, for the reason that you—— 

Senator GILLIBRAND. For the Schedule 1. 

21 

Captain COLSTON.—just asked earlier. 

One thing that I have seen, as a child psychiatrist, is, there’s 

risks and benefits to any intervention. And with regard to marijuana, one of the things that we struggle with is, it can precipitate 

psychosis in some people, especially younger people, people of a 

military age. So, that would be a concern that I would have as we 

press forward on this. 

Dr. STREET. I know that VA has ongoing studies looking at the 

effectiveness of marijuana for a treatment of PTSD, but I know 

that there have been issues that have come up related to the quality of the marijuana, the consistency of the marijuana, the strength 

of the marijuana, that’s made it—there are unique challenges, in 

terms of studying the effectiveness of that substance on the disorder. 

Senator GILLIBRAND. Would you recommend further study of it so 

that we could actually have drug companies study it and drug companies produce medicines that then can be tested? 

Dr. STREET. I’d like to see the results of the early studies, in 

terms of addressing the, sort of, cost-benefit analysis. If early studies looked promising, then I would make that recommendation. 

But, if early studies showed a lot of negotiate, unexpected effects, 

then I would be more cautious in that recommendation. 

Senator GILLIBRAND. Thank you. 

Senator GRAHAM. Senator Sullivan. 

Senator SULLIVAN. Thank you, Mr. Chair. And I appreciate you 

and the Ranking Member calling this hearing. It’s a very important 

topic. 

You know, appreciate the witnesses being here. One of the things 

I really like about this committee, it’s very bipartisan. And this 

topic comes up a lot in a very bipartisan way. You see members 

who actually really, really care about this. I certainly happen to be 

one of them. I think most people who have served in the military 

can recall more than one instances where a troop member of their 

squad or unit or—has succumbed to the—to depression and suicide. 

And I think it—it’s a searing experience, of course, for families, but 

for the troops and the leadership and everybody else who goes 

through that. So, it’s a topic that we need to do a better job at. 

I’m sure that’s probably already been covered to some degree, 

but—What authorities would you view, from our perspective, that 

you need from this committee or the Congress to do more to address some of the issues of the stigma PTSD or reducing the rates 

of suicide among our Active Duty and veteran populations? Is there 

anything more you need from us? 

Captain GREENHALGH. Well, sir, I think you talk about two 

things that are very closely related, which is reducing the rate— 

reducing the stigma and then attacking the problem, itself, which 

is suicide. And I think, with regards to reducing the stigma, we’ve 

made great strides over the last decade, I think, at least, in making 

it not just a, again, symptom-drive approach, the patient coming to 

the medical provider, looking for help. With our screening efforts, 

certainly everybody is asked whether they’re symptomatic or not. 

When we go through our annual health maintenance examinations, 

that comes up as a very prominent topic, that and TBI history, as 

well as a lot of the technology and, sort of, the apps that are availVerDate Nov 24 2008 15:20 May 03, 2017 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6602 C:\USERS\WR47328\DESKTOP\25235.TXT WILDA
22 

able, a lot of, you know, IT solutions, where the servicemember 

doesn’t—and their family—doesn’t necessarily have to go to a clinician to ask the question. They can get a lot of the information they 

need online. And I think that goes a long way towards 

destigmatizing, if they can at least get the answer to some of their 

preliminary questions in, sort of, a non-sort-of-clinical environment. 

I think that’s certainly one step. 

Captain Colston? 

Captain COLSTON. With regard to resources, I wouldn’t necessarily have anything to say about that. I would say that there 

is a robust relationship between suicide and depression. And certainly identification and management of depression, especially in a 

primary care setting, is a very important strategy, and one that we 

really want to focus on, really in public health. 

Senator SULLIVAN. Let me ask another question that relates to, 

kind of, my first one on authorities. There is a bill—and I’m having 

my team take a look at it—that I’ve been looking at. I believe it 

might be Senator Peters who has put this bill forward, that—and 

I don’t want to butcher it here, so we can make sure you get it for 

the record—but that is concerned about claims that there’s been 

thousands, maybe tens of thousands, of members of the military 

who have received discharges that are less-than-honorable discharges related to PTSD or brain-injury type of issues. And are you 

familiar with this bill, or are you familiar with—and the bill would 

ask the military to have a presumption, maybe, in favor of a honorable discharge. In my military career, have not really seen that 

issue, but I may have been missing something. Are you familiar 

with this bill? Are you familiar with the problem? And what’s your 

advice? Do you think there’s thousands, or even more, members of 

the military who have been discharged with other-than-honorable 

designation because of activities of undiagnosed PTSD, and that 

their discharge designation should be relooked at? And do you need 

authority to do that, from the Congress? 

Captain COLSTON. Sir, on the bright side, we’ve already had that 

authority, and we’ve used it. So, we’ve—we did a mental health review, where we looked at over 200,000 boards. We did a physical 

disability board review, where we looked at a number of boards for 

just that problem. And since 2007, patients that you are going to 

separate for means, be they disciplinary, be they for lack of performance, they need to be—PTSD issues and TBI issues need to be 

addressed before that can be done. 

And when we look at the numbers, we look at—we used to separate about 4,000 folks a year for personality disorder separations. 

That number is down to 300. So, that number is about 7 percent 

of what it was. There’s been a lot of attention to this issue. And 

certainly—about 3 years ago, I think we spent on the order of $10 

million looking at boards. And certainly, as Senator Blumenthal’s 

brought up in some previous correspondence with DOD, sometimes 

we’re going all the way back, so the boards of correction for military records have looked at cases from Vietnam veterans, cases 

even where PTSD didn’t exist as a clinical diagnosis. Of course, it’s 

hard to ascertain, you know, exactly what the circumstances were 

around something that happened a long time ago without records. 

Senator SULLIVAN. So, you—— 

23 

Sorry, Mr. Chairman. Just a follow-up. 

If you—so, you already have that authority. Have you seen this 

bill? And have you weighed in on it? And—it would be very useful. 

It’s, like I said, something that I’ve—I’m very sympathetic to. I 

don’t know what DOD thinks about the bill. At the same time, it 

sounds like you’re already—you already have the authority to do 

what the bill does. I don’t know if it has a presumption in favor 

of a honorable discharge or—again, I don’t know the specifics. I’m 

sorry, I should have brought it with me. But, have you weighed in, 

or do you need the authorities, or you think you’re good to go in 

addressing this—what you’re obviously saying is a problem? 

Captain GREENHALGH. Well, sir, I mean, I haven’t seen the bill. 

I haven’t been asked to weigh in. But, I echo what Captain Colston 

said, is that I don’t think it’s an issue of the type of discharge that 

a patient gets. I think it’s a matter of ensuring that they get the 

correct kind of care that they need prior to discharge, or even after 

discharge, with that warm handoff to our VA colleagues. Whether 

it’s honorable or dishonorable, I think, is—isn’t necessarily the 

driving point. 

Senator SULLIVAN. Mr. Chairman, if I may, maybe we can submit that bill. And if they had a view on it—— 

Senator GRAHAM. Yeah. Well, it sort of is the driving point, because you don’t want someone to have a UOTHC, other-than-honorable-conditions discharge, who had a medical condition that may 

have resulted in it. 

Senator SULLIVAN. Right. 

Senator GRAHAM. That’s the whole point. 

Dr. STREET. And this was particularly relevant or military sexual 

trauma survivors. They were often diagnosed with a personality 

disorder as part of their discharge after they had suffered a sexual 

assault. And with that discharge, they weren’t entitled to VA benefits. So, it was a huge problem for them—— 

Senator GRAHAM. Yeah. 

Dr. STREET.—because they have trauma, they’ve been—they’re a 

survivor, they need mental health care, and they don’t even have 

access to the VA anymore. So, that—we wanted those cases to be 

looked at again to say, Can we get this right? 

Senator GRAHAM. Yeah, we—we’ll upgrade the discharge if 

there’s a medical reason that was missed, or PTS suffering. 

Captain Colston, the reviews you’re familiar with, did you all actually change discharge designations? 

Captain COLSTON. Yes, sir. So, several servicemembers have had 

discharge determinations changed over the years. And several 

servicemembers have had their benefits changed. So, especially the 

Physical Disability Board of Review—— 

Senator GRAHAM. Could you do this? Could you have that 

group—and I applaud your efforts—give us the results? I mean— 

of the 200,000 reviewed, how many discharges were upgraded and 

how many benefits were restored? 

Captain COLSTON. Yes, sir. The executive agent for that was the 

Air Force and the Physical Disability Board of Review is right 

here—— 

Senator GRAHAM. Our crack staff—— 

Captain COLSTON.—inside the Beltway. 

24 

Senator GRAHAM.—will get on that, won’t you, crack staff? Absolutely. 

Senator King. 

Senator KING. Thank you, Mr. Chairman. 

[The information referred to follows:] 

DOD has undertaken three coordinated efforts to upgrade discharge characterizations, dating back to the Vietnam-era, from other than honorable characterizations, 

change administrative separations to military retirements, and otherwise scrub all 

disability boards started under a mental health claim since 2001, for a potential increase in benefits. These efforts are carried out by the Boards of Correction for Military Records (BCMRs). 

The results that you are inquiring about were from the review initiated in October 

2012, by order of the then-Secretary of Defense, Leon Panetta, requiring the existing 

Physical Disability Board of Review (PDBR) to conduct a comprehensive review of 

mental health diagnoses from September 11, 2001 to April 30, 2012, for Service 

members who completed a disability evaluation process and whose mental health 

diagnoses were changed during that process. The PDBR completed a review of 

200,000 cases where a disability board was started and then changed or stopped, 

for reasons such as change in diagnoses of post-traumatic stress disorder (PTSD), 

adjustment disorders, depression, anxiety or possible removal of diagnoses stemming from other factors, such as disciplinary proceedings. This effort was undertaken to audit the system in an analytically sound, non-bureaucratic, and actionoriented manner to mitigate the risk of bias toward diverting Service members away 

from compensable disabilities. 

No evidence of bias was found. Of the 200,000 cases processed by the Services for 

eligibility, about 5 percent (11,000) were found eligible for reconsideration using a 

permissive administrative filter. All eligible individuals received at least two, and 

most times three, mailings, with return receipts requested, that invited them to 

apply to the PDBR for consideration for changes to the military record. About 1000 

were returned by applicants. 100 of the cases either met the eligibility criteria for 

consideration (66 cases resulting in 10 medical retirements) or contained other discrepancies that accrued to the benefit of the applicants (34 cases). Those 34 cases, 

processed under the rationale that the PDBR application was nested within a 

Boards of Correction for Military Review (BCMR) application, resulted in 7 additional findings for medical retirements by the BCMRs. 

Subsequent to the above review, then-Secretary of Defense Chuck Hagel, issued 

a memorandum focused upon the petitions of Vietnam veterans to Military Department Boards for Correction of Military/Naval Records for the purpose of upgrading 

their discharges based on claims of previously unrecognized PTSD, as PTSD was not 

yet recognized as a diagnosis during this period of history. Thirty-eight percent of 

Vietnam-era petitioners have been granted relief, a figure that is significantly higher than that for standard discharge upgrade requests. The latest numbers indicate 

the Department has received 759 qualifying petitions, 273 of which have been adjudicated and 486 of which are still pending resolution. Of those that have been adjudicated, 103 were granted upgrades. 

Another effort currently underway by the DOD’s Physical Disability Board of Review (PDBR), is looking at 77,000 medical boards where combined disability ratings 

of 20 percent or less were assigned to Service members who were discharged between September 11, 2001 and December 31, 2009. Many of these cases stemmed 

from decrements in disability findings stemming from existence of non-compensable 

mental health conditions, such as personality disorders or adjustment disorders. In 

almost 25 percent of the cases reviewed by the PDBR, an applicant became eligible 

for a disability retirement. Members who prevailed in this forum were awarded 

monthly disability retirement pay and TRICARE eligibility for themselves and eligible dependents retroactive to the day of original disability separation. 

To ensure that mental health conditions are rightfully considered, the DOD has 

implemented section 521 of the Carl Levin and Howard P. ‘‘Buck’’ McKeon National 

Defense Authorization Act for Fiscal Year 2015, P .L. 113–291, by: 1) including the 

opinion of a clinical psychologist or psychiatrist if the review for correction of 

records includes a mental health disorder; and 2) including on the board a clinical 

psychologist, psychiatrist, or physician with training on mental health issues pertaining to post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) 

when there is a request for review by a Service member diagnosed with PTSD or 

TBI while deployed or with a mental health disorder while serving in the military. 

25 

Thank you all for your work in what is a really important area. 

We see it daily in Maine. 

Dr. Street, one of the issues we have in our State—it’s a very 

rural State, it’s large—large, long distances. How do we deal with 

the unique challenges facing veterans in PTSD and other mental 

issues who—it’s just almost impossible to drive a whole day, and 

drive back, and to have effective treatment. Talk to me about treating this problem in rural areas, and particularly about the possibility of using online resources, telemedicine, those kinds of things. 

Dr. STREET. Well, you’re—the things you suggest are exactly the 

kinds of things that we’ve been working with, really figuring out 

how we can harness technology to take what we know are effective 

treatments, but have used—been, historically, in a sort of face-toface setting in an office situation, and use technology to make those 

more widely available. So, certainly telehealth. But, increasingly 

now, we’ve also been developing and testing online technologies. So, 

for an example, a colleague of mine in Boston recently developed 

a online intervention for comorbid PTSD and alcohol abuse that’s— 

that, in early stages, is showing—shown to be quite effective. We 

are also harnessing the use of mobile apps that veterans can use, 

if they have infrequent appointments, in between appointments to 

help manage their symptoms and improve their process of recovery. 

So, we’re hoping that use of technologies, and really harnessing 

those technologies, can help address some of the issues with treatment among rural veterans. 

Senator KING. Just as sort of a parenthetical question, then I’ll 

get back to the technology. Do we know what works? Is—are there 

proven treatments to deal with this issue? 

Dr. STREET. There are. And it’s, I think, such an important message to get out there. So—because I think it provides hope for veterans. But, we have well-established, rigorously-tested treatments 

for PTSD, primarily psychotherapies in the cognitive behavioral 

realm that have been shown, in multiple settings, in multiple populations, to be very effective in reducing the incidence of PTSD. 

Senator KING. I think that’s important news out of this hearing—— 

Dr. STREET. Absolutely. 

Senator KING.—that this is not a hopeless situation, that there 

are—— 

Dr. STREET. Absolutely. 

Senator KING.—successful treatments. 

Dr. STREET. Absolutely. 

Senator KING. Well, I want to encourage you, in the strongest 

possible terms, to pursue these technological advances, because 

time is not on our side. And again, in many places in this country, 

people are in very rural areas—in Alaska—and they just don’t— 

they just don’t have access to a clinic or to a group. It’s very difficult. 

Dr. Colston, talk—let’s talk about substance abuse as it relates 

to this issue. Do you—I’m—from my anecdotal data from my staff 

in Maine, there’s a lot of overlap. A lot of people that have PTSD 

end up in a substance-abuse situation, either alcohol or drugs. Is 

that true? And how do we deal with that issue? 

26 

Captain COLSTON. Yes, sir. There’s about a 30-percent overlap 

between PTSD and substance-use disorders. And one of the really 

scary things that we’re facing right now is the scourge of opiate 

overdose deaths in this country. So, as people transition—— 

Senator KING. 47,000 a year. 

Captain COLSTON. Yes, sir. Just horrible. And certainly, as people have transitioned into heroin use, more heroin overdoses—— 

Senator KING. Do you think part of it is self-medication? 

Captain COLSTON. Yes, sir, no question. And we’ve seen that with 

alcohol. We’ve seen it with all kinds of illicit drugs. And, you know, 

certainly now, the drugs that are out there are just scary. They’re 

drugs that you can take once and end up dead. And that’s really 

where the change has been. We recognize that there is an overlap 

between those systems, so we have a lot of stepdown care in DOD, 

a lot of intensive outpatient treatment, where we great both your 

mental health issues, which—PTSD runs with other things. It runs 

with TBI, it runs with depression, it runs with substance-use disorders, it runs with pain. And we also treat your substance-use disorders. With regard to opiate-use disorders, we’ve got medicationassisted therapy. With regard to alcohol-use disorders, lots of new 

science that supports the use of things like acamprosate, which is 

a medication-assisted therapy for alcoholism, or other drugs that 

work really well, like naltrexone. 

Senator KING. So, you see this as an important area, that the comorbidity is a significant issue. 

Captain COLSTON. Oh, absolutely, sir. Dual-diagnosis work is 

really where most of our stepdown work is right now. And Walt, 

over at the NICoE, sees a fair amount of folks who are struggling 

in that regard, too. 

Senator KING. Dr. Street, are there any VA rules that, if you— 

if you’re suffering from PTSD, but you also have an—a drug-abuse 

problem, you can’t get treatment, or you’re excluded? There’s no— 

there are no barriers on—— 

Dr. STREET. No, no barriers. And, in fact, increasingly, we’re 

looking at treatments that can treat both of the disorders simultaneously, because we know that they are so interrelated. 

Senator KING. A final question. I know that a program was created in 2010 to help people moving out of the service into—called 

In Transition, I think it’s called. My question is, Is it working? And 

how do we know? 

Captain COLSTON. So, we’re collecting—that’s run out of my office, sir—we’re collecting data on it. We ramped up the program 

tenfold about a year ago. 

Senator KING. Good. 

Captain COLSTON. One of the things that we’re trying to do 

throughout DOD is get outcome measures. And, luckily, there 

hasn’t been, in this short period that we’ve been running the program, a suicide in any person who’s been coached in the program. 

Nonetheless, we want outcome measures with regard to things like, 

How depressed is this patient? What kind of PTSD symptoms does 

this patient have? How much healthcare is this patient utilizing? 

And I think, as our health systems evolve, and as we develop registry data, the ability to get a better idea of where patients are as 

27 

they move between DOD and VA, we’ll get much better answers 

with regard to outcomes. 

Senator KING. I think we should be applying the same level of 

resources, money and personnel, to transition out of the service 

that we put into recruiting in, because that’s where a lot of the 

slippage occurs, in that sometimes very difficult transition. And 

that’s been something I’ve—I just think that’s a—that’s a rule of 

thumb. Let’s spend as much helping people when they come out as 

we spend bringing them in, in the first place. 

Thank you very much for your testimony and for your work. 

Senator GRAHAM. Senator Tillis. 

Senator TILLIS. Thank you, Mr. Chair. 

Thank you all for being here. 

First off, I understand—I’m sorry I’m late. I had a competing— 

actually, I was just following Senator Sullivan through the committee, the concurrent committee circuit. So, I apologize for being 

late. If you’ve already answered these questions, I can just refer 

back to the record. 

One thing I wanted to underscore, I think that Senator Sullivan 

covered. It’s a bill that I support, the Fairness for Vets Act. I think 

you all got into a discussion here, so I won’t ask you to repeat it, 

but just underscore, I think it—I think it’s important, and I think 

it provides value. And I believe there’s at least consensus among 

the Department that you do, as well? Thank you. Any problems 

with it? 

Captain COLSTON. I haven’t looked at it yet, sir. 

Senator TILLIS. Okay. Okay. 

And I think Senator Cotton may have mentioned something 

about public-private partnerships. We go to the easy—the easy one 

to identify, which would be the NFL [National Football League]. 

Based on where I come from, I could argue NASCAR [National Association for Stock Car Auto Racing]. But, what other sort of network of private partners are out there? And what, specifically, are 

we doing to really bring in and collaborate, use their expertise, not 

reinventing the wheel? And, Dr. Street, maybe I should direct that 

to you. 

Dr. STREET. Yeah, there’s actually a 2-day summit going on 

today and tomorrow that’s really—the focus of it is public-private 

partnerships around the issue of TBI, and bringing in folks from 

VA, from DOD, the NFL, certainly researchers from the private 

sector who are familiar with those issues, to try to really garner 

innovative technologies from different sectors and apply them to 

this population. 

I think that’s a good general—this idea of public-private partnerships is a good general model, and one that VA is trying to do more 

and more of. 

Senator TILLIS. Have we gone into any of the, maybe, research 

universities that do a lot of work there, and found partnership opportunities with them? Is that another area you’re casting a net? 

Dr. STREET. Yeah, absolutely. I mean, where I hale from, in Boston, we have very close connections with Boston University. 

They’ve done a lot of work around chronic encephalopathy. And 

many of those investigators actually hold dual appointments in the 

academic institution and in VA so that we can really harness some 

28 

of the power of the best scientists in the country who are doing this 

kind of work. 

Senator TILLIS. Okay, thank you. 

Senator King mentioned the transition piece. I’m on Veterans Affairs Committee. And, obviously, a lot of the challenges we have 

after a man or woman comes out, they may have undiagnosed TBI, 

PTSD. And I’m trying to figure out how we do a better job of— 

there’s this handoff, and, you know, sometimes if you go in transition, you’ve got the younger soldiers that are in the back of the 

room with their headphones on, doing their duty, and then moving 

out there. They may be, in fact, people that should be listening. 

And what they’re thinking about is moving on. To what extent is 

the DOD—it necessarily becomes a VA role, but to what extent is 

the DOD making sure that—particularly for ones where you may 

have evidence to suggest that someone does have something that 

has not yet been effectively treated—make sure that those veterans 

get vectored into the care that they may need through the VA? 

Does that handoff actually occur, or is it a—just because of the finite nature of the transition—I’m trying to get some sense of how 

we do a better job of making—the VA may not know that there is 

someone out there that may—they may need to help. So, it’s—how 

do you kind of create an alert system—or does it already exist— 

to make sure there’s a good handoff? 

Captain COLSTON. Well, really, three things. First, there’s a separation health assessment, where we try to cover all of these issues. 

For patients who present with any kind of condition, we have an 

Integrated Disability Evaluation System with the VA. And then we 

have an in-transition system to coach folks who—and it’s an optout system, and it’s not an opt-in system—to help folks get that 

next appointment. 

I’d also say, for the sickest patients, we go all the way to—when 

I was at Great Lakes, if I had a 18-year-old patient with schizophrenia who was going to end up at the VA, one of my techs would 

get on the plane and bring him to Alabama or bring him to Texas. 

I mean, that’s the level of transition support that’s expected. 

Senator TILLIS. Do you think that we’re doing that consistently? 

Captain COLSTON. Sir, I can say we’re measuring it right now. 

Senator TILLIS. Okay. 

Captain COLSTON. And I could certainly take that question for 

the record as—with regard to how we’re doing. 

Senator TILLIS. Yeah, I would appreciate that. I mean, just to get 

some sense. 

[The information referred to follows:] 

In addition, August 2012, the Presidential Executive Order 13625 established the 

Interagency Task Force on Military and Veterans Mental Health (ITF) to implement 

mental health initiatives across the DOD, the Department of Health and Human 

Services, the VA, and other Federal agencies for Veterans, Service members, and 

their families. Specifically for Service members transitioning from the DOD to the 

VA system, one notable action has been the expansion of the DOD’s inTransition 

program from ‘‘opt-in’’ participation, typically at the Separation Health Assessment, 

to ‘‘opt-out’’ or automatic enrollment. This program provides specialized coaching 

and assistance to all Service members seen for a mental health concern during the 

12 months preceding their separation from military service. From inception in January 2010 and through March 2016, the inTransition program opened 16,484 new 

coaching cases and closed 13,821 coaching cases. Survey respondents continue to express high levels of satisfaction with inTransition, as 95 percent indicated the servVerDate Nov 24 2008 15:20 May 03, 2017 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6621 C:\USERS\WR47328\DESKTOP\25235.TXT WILDA
29 

ice met their needs, and 95 percent of the respondents indicated the assistance received from the program increased the likelihood of continuing treatment at the VA 

or with another clinical provider. 

The DOD/VA Interagency Care Coordination Committee (IC3) addresses the needs 

of the most seriously wounded, ill, and injured Service members/Veterans and their 

families or caregivers. IC3, established in 2012, is improving the way DOD and VA 

care coordinators collaborate to provide more synchronized care, benefits, and services to those who require complex care coordination. IC3’s synchronized efforts are 

supported by official policy in both Departments. Care coordination always includes 

point to point travel arrangements and by-name handoffs. This type of care is especially critical for the unfortunate Service members who develop serious life-long 

mental illnesses, such as schizophrenia or bipolar disorder. This high-needs population will require ongoing care regardless of the nation’s war footing, as about 3 

percent of the population develops these illnesses, with first presentations coinciding 

with typical age of military accession (18–25 years old). 

Finally, an Integrated Disability Evaluation System has markedly increased the 

ability of DOD and VA to meet patients where they are, shortening wait times for 

disability determinations, and giving veterans options regarding where to access 

their follow-on care. 

Senator TILLIS. You know, I’m from North Carolina. We’ve got a 

million veterans and a lot of folks who either serve at Fort Bragg 

or Lejeune that end up staying in North Carolina. And just want 

to make sure we’re getting them to the care that we think can help 

avoid other problems and complications. I work a lot with a drug 

treatment facility down in Raleigh-Durham that’s—about 60 percent of their clients are people who now have substance-abuse 

problems, but it’s not clear how they got there, what caused them. 

Some of them are rooted in PTSD. So, I’m very sensitive to this 

issue to make sure we’re capturing as many as possible and getting 

them in—into the appropriate sort of care setting. So, I would appreciate that. 

Thank you, Mr. Chair. 

Senator GRAHAM. Thank you. 

This has been a excellent panel. I think you’ve all acquitted yourselves well. 

Just to kind of summarize, one in four military members are affected by what we’ve been talking about today—trauma, PTS, drug 

abuse, alcohol-abuse problems. They’ve been treated for these problems. Is that correct? 

Captain COLSTON. Yes, sir. We do a DMDC data run, so—a Defense Management Data Center data run—for everyone that’s getting out, and look and say, ‘‘Have you been treated?′′ 

Now, one thing I can say is, we’re—we do a really good job with 

screening. And certainly, we’ve evolved to identify more of the illness that’s out there. I think, you know, we now have probably the 

most treated cohort in human history. So—— 

Senator GRAHAM. Yeah, I would think so. 

Captain COLSTON.—I think we’re doing a good job in that regard. 

Senator GRAHAM. Well, and that’s the whole point. We want— 

you know, somebody asked this, but, you know, as I wrap up here 

and let other people ask additional questions, please tell us what 

we can do. Because, you know, we’re trusting y’all guys. Everybody 

seems to be very focused that the veterans and those serving deserve this. About 80 percent of the cases are unrelated to being in 

combat. TBI—one thing about the movie—I haven’t seen it, but 

Senator Gillibrand was telling me—that you can’t look at a TBI inVerDate Nov 24 2008 15:20 May 03, 2017 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6602 C:\USERS\WR47328\DESKTOP\25235.TXT WILDA
30 

jury on a MRI [Magnetic Resonance Imaging]. It’s not like looking 

at a broken bone, right? 

Captain COLSTON. No, sir. There’s no neural imaging, no correlation. 

Senator GRAHAM. Only God knows how much of this we missed 

in past conflicts. 

Captain GREENHALGH. For the mild TBI, yes, sir. 

Senator GRAHAM. Okay. 

And I’ll just add with this and let members wrap up what they 

would like to ask. 

I’ve been to a bunch of refugee camps. And I’d bet most of us 

have. I can only imagine what the people in these refugee camps 

are going through. From Syria—I was one in Turkey not long ago— 

the children, the women, particularly, victims of sexual assault. So, 

one thing, as a Nation, as a world, we need to—there’s a—not a 

whole lot of treatment, the people who have been through conflict. 

And I just think they’re ticking timebombs if we don’t get ahead 

of this. So, one thing I’d like the Senate to understand is that, 

when we provide aid to the refugees, it’s more than just food and 

water and clothing. If we don’t have a mental health component, 

I think we’re making a huge mistake. 

So, anybody else? 

Yes, Senator Sullivan. 

Senator SULLIVAN. Just had a follow-up question. 

So, the bill is actually S. 1567, Fairness to Veterans Erroneously 

Discharged from the Military. That’s the name of the bill. So, if you 

could take a look at that to see if that’s providing you additional 

authorities that you think you need, which is obviously a issue that 

seems to be a pretty big issue if you’re looking at 200,000 cases. 

I just had another question. Like Senator Tillis, I’m on the Veterans Affairs Committee, and I asked the questions of some of our 

service organizations when they were testifying recently. On the 

designation PTSD, there’s been some discussion of—you know, we 

talk about the stigma, the ‘‘post-traumatic stress disorder.’’ And so, 

a ‘‘disorder’’ kind of comes with a little bit of, you know, implications. And so, some people have mentioned to me, ‘‘Well, maybe 

we—this should be referred to as post-traumatic stress injury.’’ So, 

if you receive this in combat and you were injured, obviously, that 

it’s like, you know, getting shot. Nobody calls a gut wound or a— 

getting shot a ‘‘disorder′′; they call it a ‘‘injury.’’ So—in some veterans groups think that might be a good idea; others don’t, for reasons that might have to do with benefits and how things are actually categorized in the VA. And if you don’t call it a ‘‘disorder,’’ you 

might lose a certain amount of—— 

Do you have any thoughts on that, Dr. Street? Any of you? Just 

on the—just the title, itself, which does have certain implications. 

I was just wondering what your thoughts are on that. 

Dr. STREET. I’m in favor of retaining the ‘‘post-traumatic stress 

disorder’’ title. I appreciate the concern about stigma, but I—I don’t 

believe that changing the title is the way to most effectively combat 

the stigma. 

Senator SULLIVAN. No, I don’t think it would at—I mean, I’m not 

saying it would, but it—you know, it might be—might help, right? 

31 

Dr. STREET. I mean, I think certainly—just to outline my specific 

concerns—I mean, there is—we’ve made so much progress, in 

terms of our ability to diagnose and effective treat the disorder. 

And, in part, that’s due to the fact that the symptoms of PTSD look 

so similar, regardless of the source of traumatic stress exposure, be 

that something associated with military service or something from 

the civilian sector. And I’m concerned that changing the name 

would introduce confusion that might negatively impact functioning. But, I agree that the issue of stigma is a concern and 

needs to be addressed. I’m just not sure that this is the most effective way to do it. 

Captain COLSTON. There is a good point to the use of that term, 

inasmuch as the normal course of being exposed to trauma is toward health, and a vast majority of people who are exposed do get 

healthy. Sebastian Younger, in Vanity Fair, about a year ago, 

wrote a very beautiful article about some of his exposures and, you 

know, the subsequent course, and some of the things that we’ve 

seen in the military. It’s tough to weather the vicissitudes of military life, especially when you’re coming out of combat, especially 

when you’re dealing with austere environments. But, I think that, 

you know, going back to where General Chiarelli was 5 years ago 

or so, when he used the term PTS as opposed to PTSD, there’s arguments on both sides of the ledger. 

I very much agree with Dr. Street’s assertion that we’ve got to 

call it a ‘‘disorder,’’ because we’ve got to get people services, we’ve 

got to get people support, and we’ve got to make diagnoses, to get 

paid, in the medical record. 

Senator SULLIVAN. Thank you. 

Senator GRAHAM. Yes, sir. 

Senator TILLIS. This is really just to reinforce what the Chair 

said. One of the things that I’m really intent on is challenging you 

all to tell us where past congressional decisions at the time may 

have made sense; they may not have made sense, they just had the 

votes; or times have changed. But, the sorts of things that we place 

on you, particularly in dealing with this—you know, may end— 

well-intentioned policies that do not add value, they add cost or 

constraints. We need your feedback so that we’re not only adding 

some new good ideas that maybe take the edge off of some of the 

old ones that are still in place, but really help us do reforms of 

any—you’ve got a very—you’ve got a changing environment. Your 

understanding of PTSD, how to treat it, how to transition, how to 

keep track of our vets and take care of them change over time. And 

I really want a committee where they come in here and you tell us, 

‘‘You need to change this, this′′—or call my office, or call the 

Chair’s office, and give us an opportunity to look at some of the 

things that you’re currently doing that are no longer value-added 

and could deploy resources to a better and higher use, in your professional opinion. 

Senator GRAHAM. Thank you. 

Anything else? 

[No response.] 

Senator GRAHAM. I move that all outside statements for the 

record received in advance of the hearing should be included in the 

official record. Without objection. 

32 

Senator GRAHAM. The hearing is adjourned. Well done. Thank 

you. 

[Whereupon, at 3:47 p.m., the hearing was adjourned.] 

[Questions for the record with answers supplied follow:] 

QUESTIONS SUBMITTED BY SENATOR RICHARD BLUMENTHAL

TRANSITION FROM DOD TO VA HEALTHCARE

1. Senator BLUMENTHAL. Captain Greenhalgh and Captain Colston: You state that 

the current policy of the Department of Defense (DOD) and Department of Veteran’s 

Affairs (VA) is to conduct a ‘‘warm hand-off’’ for servicemembers’ healthcare when 

they transition out of active duty service. What is the current status and effectiveness of the hand-off between the DOD and VA for servicemembers’ healthcare, particularly concerning electronic records and pharmaceutical prescriptions? 

Captain GREENHALGH and Captain COLSTON. Collaboration between DOD and the 

VA during the transition from DOD to VA health care has never been greater, and 

the two Departments are continuing their efforts to improve transition services. 

These services are mandated in policy and executed through intensive case management services, including an ‘‘InTransition’’ program to help Service members during 

the transition period. 

Regarding electronic records, the Departments have collaborated on two complimentary mechanisms—a file transfer system and an electronic viewer—together 

they ensure all of the essential information of the DOD Health Record is available 

for both benefits adjudication and continuity of care in the VA. In 2010 the Departments agreed on the definition of the Service Treatment Records (STR)—it is the 

composite of all digital information and paper documentation necessary for continuity of care and benefits determinations. The STR includes the Armed Forces 

Health Longitudinal Technology Application (AHLTA), the Military Health System 

(MHS) electronic medical record that was implemented in 2004, and the older information that was created or is still printed on paper. To better enable claims processors in the VA to request and receive an official electronic archive version of the 

STR, DOD accelerated fielding of the DOD Health Artifact and Image Management 

Solution (HAIMS), and established an automated interface with systems supporting 

the Veterans Benefits Administration (VBA). Since January 1, 2014, the record 

transfer has occurred electronically. The Services compile and scan all the paper 

documentation and upload the files into HAIMS. In addition, everything from 

AHLTA is rendered as a single, well organized, easily searchable portable digital 

format (pdf) file. All of these files are stored in HAIMS and automatically copied 

from HAIMS to the VBA’s system as soon as a claim is filed, completely eliminating 

the need to mail STR requests and printed copies of records between Departments. 

A July 2014, DOD Office of Inspector General report covered the period 6 months 

before and after the DOD HAIMS capability was put in place. The report compared 

the previous time preparing to mail a record with the current time to compile it into 

HAIMS, and did not highlight the time saved within the VA. Subsequent to this report, DOD and VA have significantly refined and improved on execution. The number of VA late pending STR requests, which was over 6,000 in August 2014, has 

been consistently less than 1,000 since May 2015, and most STRs for new VA requests are now provided within one day of the date requested. The Services track 

late STRs by name until the request is closed out with the VA. DOD has imposed 

aggressive targets upon the Services, and they report compliance weekly. 

The complimentary means of sharing the STR is through the electronic health information exchange that the Departments have been working on for a decade. Since 

December of 2013, everything from AHLTA has been accessible through the Joint 

Legacy Viewer (JLV), and constraints on system capacity were eliminated by the 

summer of 2015. JLV displays complete notes from AHLTA just as they appear 

when printed, a significant improvement over previous VA viewers. The viewer 

gives providers an integrated, chronological view of medical information familiar to 

clinicians of both Departments. It provides real-time electronic health record information from all DOD and VA facilities, as well as information received from a growing number of DOD and VA commercial health care partners. Today more than 

70,000 VA clinicians have access to this system, a number that increased more than 

60-fold in the past 15 months. 

All of these improvements in health information access apply equally to Reserve 

Component Service members, and the archival process for them includes collecting 

and scanning any documentation held at the unit level. 

33 

Regarding pharmaceutical prescriptions, a just-released GAO audit, ‘‘Actions 

Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices,’’ found no evidence to dispute a rigorous 2015 Veterans Health Administration 

study showing that 97 percent of transitioning Service members maintained clinically appropriate medication treatment through their transition from DOD to VA 

health care. 

Beginning on June 1, in accordance with the National Defense Authorization Act 

for fiscal year 2016, section 715, ‘‘Joint Uniform Formulary for Transition Care,’’ 

both the DOD and VA will be mandated to stock the same medications to treat pain, 

sleep, and psychiatric disorders, and any other conditions determined appropriate 

by the DOD and VA Secretaries. This synchronization will further ensure that patients leaving Active Duty have continuity of medication treatment during this transition. 

Finally, DOD has worked closely with VA and HHS, and the Executive Office of 

the President, including the President’s Office of National Drug Control Policy, to 

ensure that the President’s mandates, vis-&-vis the potential for medication misuse, 

in Executive Order 13625 and subsequent 2014 Executive Actions are carried out. 

DOD is a national partner in the important effort to stem the scourge of prescription opiate abuse and overdose deaths. Integrated and extensive prescription drug 

monitoring programs, an extensive research portfolio coordinated between agencies, 

and execution of recent mandates in state and federal law will help turn the tide 

on this urgent public health problem. 

VETERANS HEALTH ADMINISTRATION RESPONSE. The Department of Veterans Affairs (VA) has taken a number of actions in collaboration with the Department of 

Defense (DOD) to identify and track Servicemembers who are transitioning to civilian life and to ensure that those in need of care do not fall through the cracks. Enhanced health care information sharing has been accomplished through the DOD– 

VA Joint Legacy Viewer (JLV). JLV represents groundbreaking agency-to-agency 

interoperability. JLV combines and shares data and gives both VHA clinicians and 

Veterans Benefits Administration rating specialists a composite view of Veterans’ 

treatment history. 

VA’s ‘‘Pilot Evaluation of Medication Continuation for Veterans Transitioning 

from the Department of Defense Health Care System to the Department of Veterans 

Affairs Health Care System’’ validated VA’s long-standing practice of continuing 

medications for transitioning Servicemembers. This long-standing practice was institutionalized by VA with respect to mental health medications with the policy directive entitled, ‘‘Continuation of Mental Health Medications Initiated by Department 

of Defense Authorized Providers.’’ 

The link to the pilot evaluation is available at: http://www.pbm.va.gov/PBM/ 

vacenterformedicationsafety/othervasafetyprojects/DOD—VA—Medication—Continuation—Report.pdf 

The link to the VA Directive is available at: http://www.va.gov/vhapublications/ 

ViewPublication.asp?pub—ID=3075 

2. Senator BLUMENTHAL. Captain Greenhalgh, and Captain Colston: How do you 

plan to address the remaining shortfalls in the system? 

Captain GREENHALGH and Captain COLSTON. Aside from issues regarding electronic health records and prescription drugs—including opiate overdose deaths nationwide, another concern that Department of Defense (DOD) and the Department 

of Veterans Affairs (VA) face is suicide deaths in recently discharged Service members. 

The DOD’s National Telehealth and Technology Center, a component of its Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury 

(DCoE), expertly manages the DOD Suicide Event Report (DODSER), the most comprehensive database regarding death by suicide. Leaders at DCoE, in collaboration 

with VA researchers recently published a seminal article in the Journal of the 

American Medical Association regarding the relation of suicide risk to deployment 

and separation status. While deployment was not associated with the rate of suicide, 

separation from military service had a robust effect. The effect was pronounced in 

persons who separated with less than 4 years of military service or who did not separate with an honorable discharge. 

In an effort to mitigate suicide risks by translating research findings into practice, 

then-Assistant Secretary of Defense for Readiness and Force Management promulgated the DCoE researchers’ article to each of the Service’s Assistant Secretaries for 

Manpower and Reserve Affairs (M&RA), with guidance to commanders to ensure a 

warm handoff to the Department of Labor for Service members who receive a less 

than honorable discharge. This handoff includes employment services and integration into social service systems, as appropriate, in the local community. The handoff 

34 

is executed by name to ensure continuity between the commander, or his designee, 

and a Department of Labor representative at a specific American Job Center in the 

community. Additionally, inTransition is a free voluntary program to provide behavioral health care support to Service members and Veterans as they move between 

health care systems or providers. Personal coaches, along with resources and tools, 

assist participants during the transition period and empower them to make healthy 

life choices. 

Recognizing risks associated with early separation while balancing readiness imperatives, the DOD has endeavored to drastically reduce separations of first-term 

Service members under the rubric of personality disorder, which does not carry the 

benefit of medical retirement. After policy was implemented in 2007, personality disorder separations were reduced from over 4,000 per year to 300 per year in 5 years. 

Each of the Service’s Assistant Secretary for M&RA creates an annual report auditing the separation process for personality disorder; and the DOD has endeavored 

to listen to stakeholder’s concerns about this matter over the past decade, including 

Veterans Service Organizations and representatives from the Yale Law Clinic. The 

change in policy carries a requirement to treat in place more Service members who 

are less able to weather the routine vicissitudes of military life. As such, the effort 

requires ongoing leadership and judgment from commanders, as the cohort of retained Service members presents risks for poor outcomes, including suicide. Systemwide changes, such as the creation of service lines for mental health care and use 

of a behavioral health data portal, are designed to emphasize outcomes in the identification and management of those receiving mental health care. 

It is important to note that a growing body of research suggests that mental 

health issues, such as depression or personality disorder, are only one part of a complex interplay of risk factors related to suicide. Suicide is a culmination of complex 

interactions between biological, social, economic, cultural and psychological factors 

operating at individual, community, and societal levels. Risk and protective factors 

span across the fields of medicine, epidemiology, sociology, psychology, criminology, 

education, and economics. Research also shows that many Service members and 

Veterans who are at risk for suicide will not seek help from mental health providers. Therefore, despite the efforts to improve access to clinical approaches, a suicide prevention response exclusively based on a mental health approach will not address suicide prevention efforts relevant to most of the at-risk population. A holistic, 

community approach that relies on a variety of interventions is more likely to increase effectiveness of suicide prevention efforts. 

Defining suicide risk, and adequate treatment strategies, is an imperative in the DOD. Today, a $160 million military and operational medicine health research portfolio focuses on suicide. DOD integrates its suicide research efforts with other government agencies, especially VA and the Department of Health and Human Services 

(HHS), through the National Institute of Mental Health. A collaborative effort to improve understanding of suicide, along with Traumatic Brain Injury (TBI) and 

Posttraumatic Stress Disorder (PTSD), is focused in a National Research Action 

Plan (NRAP). The NRAP, mandated by an Executive Order in August 2012, created 

a roadmap to better coordinate and partition research portfolios to match agency expertise. 

Comorbidity in military populations is becoming better understood, and research 

shows that TBI, PTSD, depression, substance use disorders, and chronic pain, are 

risk factors for suicide. The public health approach acknowledges the role of these 

various factors in suicide, but recognizes that these diagnoses can often be a result 

of other factors; for instance, pain and hopelessness that arise from other variables, 

such as relationship, financial, and legal problems; difficult transitions; and feelings 

of isolation. Therefore, addressing suicide with both clinical and non-clinical approaches provides the necessary multi-prong approach to address the various interconnected causal factors. Longitudinal research efforts like the Millennium Cohort 

Study, the largest study ever created to ascertain the health effects of military service, are slowly aiding scientific understanding to this issue. 

There continues to be a comprehensive coverage of research portfolios across the 

DOD, VA, and HHS. Along with the epidemiological effort to collate and analyze annual suicide data in the annual DODSER, progress continues throughout the research continuum. While suicide prevention has been keenly focused upon by military leaders for many years, challenges still exist. One challenge is a low base rate 

for suicide, even in high risk groups making it difficult to target assistance to those 

who need it. Under the medical approach, the Army Study to Assess Risk and Resilience in Soldiers (Army STARRS) and its follow-on STARRS Longitudinal Study (efforts with projected outlays near $100 million), are attempting to enable clinicians 

to separate patients into risk cohorts, so interventions can be tailored according to 

risk. Additionally, randomized clinical trials under the auspices of a Military Suicide 

35 

Research Consortium are evaluating cognitive-behavioral suicide interventions in 

high risk groups, such as hospitalized patients. Another challenge is translating a 

vast body of research, containing a wealth of information about suicide prevention 

practices that have been tested and validated in different populations to the military. Using the public health approach, these practices are being reviewed, and 

some are piloted for implementation among Service members and Veterans. As an 

example, ‘‘Window to Hope’’ is an Australian program to reduce hopelessness that 

can lead to suicide after sustaining a traumatic brain injury. This program was recently adapted and evaluated for feasibility for U.S. military Veterans. Other studies have looked at components of post-traumatic stress disorder as a risk factor for 

suicide, finding that feelings of guilt and shame were underlying mechanisms of suicidal thoughts. Clinical trials now are underway to target these specific feelings. 

The urgency of the suicide problem, with some military rates exceeding age-adjusted civilian rates for the first time in recent years, continues to push the DOD 

and VA’s joint effort to develop effective prevention, intervention, and postvention 

strategies for suicide. It is necessary to maintain strong partnerships and collaborations during this process and ensure adequate communication. It is also crucial to 

use a public health approach in addition to addressing clinical factors related to suicide. The transition from active service is challenging and it is important to continue to forge the way in performing research, maintaining data, translating research findings into actionable outcomes and efforts, and measuring progress to address this vulnerable population and prevent suicides. 

VETERANS HEALTH ADMINISTRATION RESPONSE. VA has multiple programs in 

place to facilitate transition from DOD and is continuously working to ensure that 

we monitor and respond to potential shortfalls in order to best meet the needs of 

our Veterans. For example, VA and DOD transition assets and capabilities supporting continuity between the health systems include liaison and care coordination 

staff to facilitate a seamless transition process, as well as numerous interagency initiatives that support shared standards of care and interoperable processes for care 

delivery that facilitate transition between the systems. For example, VA has 43 Liaisons for Healthcare stationed at 21 Military Treatment Facilities (MTF). 

VA Liaisons for Healthcare, either licensed social workers or registered nurses, 

are strategically placed in MTFs with concentrations of recovering Servicemembers 

returning from Iraq and Afghanistan. VA Liaisons for Healthcare coordinate health 

care as Servicemembers transition from the MTF to a VA health care facility closest 

to their homes or the most appropriate location for the specialized services their 

medical condition requires. VA Liaisons are co-located with DOD case managers and 

provide onsite consultation and collaboration regarding VA resources and treatment 

options. VA Liaisons for Healthcare meet with Servicemembers directly to provide 

education about the VA system of care, the eligibility process, health care benefits, 

and services. They also assist in the understanding of the individual’s health care 

needs in order to coordinate initial health care. VA Liaisons for Healthcare connect 

with Transition and Care Management Program Managers to coordinate this initial 

care and to have a VA case manager assigned. 

VA Liaisons for Healthcare facilitate the connection between the DOD and VA 

case managers and treatment teams, ensuring that current health care needs are 

communicated. The expectation with each referral is that the Servicemember will 

leave the MTF registered for VA health care with a scheduled VA appointment. 

Since this connection has been made prior to leaving the MTF, the Servicemember 

is already engaged with Transition and Care Management Program Managers upon 

arrival home. This early connection with Servicemembers and their families/caregivers starts the process of building a positive relationship with VA and ensures 

early coordination of health care with VA. 

VA has also coordinated with DOD’s inTransition program to receive 

Servicemembers separating from the service who have been seen by a mental health 

provider while on Active Duty or who self-refer to the inTransition program. This 

DOD program provides coaching to assist Servicemembers who are transitioning between health care systems, status, or locations. inTransition’s mission is to support 

continuity of care for the Servicemember during transition. A transition coach provides support and guidance on psychological health concerns, resources, and healthy 

living, while motivating and assisting the Servicemember to connect with a treatment provider post-transition. In the second quarter of fiscal year 2016, 

inTransition opened 1,900 new coaching cases. From February 2010 to March 2016, 

the cumulative number of coaching cases opened by the inTransition program was 

16,509. Survey respondents expressed high levels of satisfaction with inTransition, 

with 89 percent indicating the assistance received from the program increased their 

likelihood of continuing treatment at the new location and 90 percent indicating 

that inTransition products and services met their needs. 

36 

The link to the inTransition program is available at: http://intransition.dcoe.mil/ 

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VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 

VA Cares About Military Sexual Trauma 

You can contact this facility’s 

MST Coordinator 

at 


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