post-traumatic stress disorder

and traumatic brain injury as

 emerging tRENDs in Force and

veterans health

Hearing

before the

Committee on 

Veterans’ Affairs

House of Representatives

Subcommittee on Health

one hundred ninth congress

second session

SEPTEMBER 28, 2006

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 109-67

For sale by the Superintendent of Documents, U.S. Government Printing Office

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washington : 2007

30-385.PDF
Committee on Veterans’ Affairs

Steve Buyer, Indiana, Chairman

 Michael Bilirakis, Florida Lane Evans, Illinois, Ranking

 Terry Everett, Alabama Bob Filner, California

 Cliff Stearns, Florida Luis V. Gutierrez, Illinois

 dan burton, Indiana Corrine Brown, Florida

 Jerry Moran, Kansas Vic Snyder, Arkansas

 richard H. baker, Louisiana Michael H. Michaud, Maine

 Henry E. Brown, Jr., South Carolina Stephanie Herseth, South 

 Jeff Miller, Florida Dakota

 John Boozman, Arkansas Ted Strickland, Ohio

 Jeb Bradley, New Hampshire Darlene Hooley, Oregon

 Ginny Brown-Waite, Florida Silvestre Reyes, Texas

 Michael R. Turner, Ohio ShellEy Berkley, Nevada

 John Campbell, California Tom Udall, New Mexico

 BRIAN P. BILBRAY, California John T. Salazar, Colorado

James m. Lariviere, Staff Director

Subcommittee on Health

 Henry E. Brown, Jr., South Carolina, Chairman Michael H. Michaud, Maine

 Cliff Stearns, Florida, Vice Chairman Ranking

 Richard H. Baker, Louisiana Bob Filner, California 

 Jerry Moran, Kansas Luis V. Gutierrez, Illinois

 Jeff Miller, Florida Corrine Brown, Florida

 Michael R. Turner, Ohio Vic Snyder, Arkansas

 John Campbell, California

Jeffrey D. Weekly, Subcommittee Staff Director

(II)
CONTENTS

September 28, 2006

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Post-Traumatic Stress Disorder and Traumatic Brain Injury 

as Emerging Trends in Force and Veterans Health Care.......

OPENING STATEMENTS

Chairman Brown ........................................................................ 

Prepared statement of Chairman Brown ..................................

Hon. Michael H. Michaud, Ranking Democratic Member, 

Subcommittee on Health ........................................................

Prepared statement of Mr. Michaud ..........................................

Hon. Bob Filner ...........................................................................

Prepared statement of Mr. Filner ..............................................

Witnesses

Boswell, Hon. Leonard, a Representative in Congress from the 

State of Iowa ............................................................................

Prepared statement of Mr. Boswell ........................................... 

Cross, Gerald, M.D., Acting Principal Deputy Under Secretary 

for Health, Veterans Health Administration, U.S. Department of Veterans Affairs .........................................................

Prepared statement of Dr. Cross ...............................................

Hoge, Col. Charles W., M.D., Director, Division of Psychiatry 

and Neuroscience, Walter Reed Army Institute of Research, 

United States Army ................................................................

Prepared statement of Col. Hoge ...............................................

Pascrell, Hon. Bill, Jr., a Representative in Congress from the 

State of New Jersey .................................................................

Prepared statement of Mr. Pascrell ...........................................

Ritchie, Col. Elspeth Cameron, M.D., MPH, Psychiatry Consultant to the Surgeon General, United States Army ................

Prepared statement of Col. Ritchie ............................................

STATEMENTS FOR THE RECORD

U.S. Government Accountability Office, Laure E. Ekstrand, Director, Health Care .................................................................

(III)
 

Page

102

108

114

 123

125

133

260

STATEMENTS FOR THE RECORD (CONTINUED)

American Legion, Cathleen C. Wiblemo ....................................

Blinded Veterans Association, Thomas Zamperi ......................

Disabled American Veterans, Joy J. Ilem .................................

Iraq and Afghanistan Veterans of America ..............................

Vietnam Veterans of America, Thomas J. Berger .....................

POST-HEARING QUESTIONS FOR THE RECORD

Hon. Michael H. Michaud ..........................................................

Hon. Bob Filner (at the time of printing, the U.S. Department 

of Veterans Affairs had not responded to the questions for 

the record from Mr. Filner) .....................................................

(IV)
(1)

POST-TRAUMATIC STRESS DISORDER AND

TRAUMATIC BRAIN INJURY AS EMERGING

ISSUES IN FORCE AND VETERANS HEALTH

THURSDAY, SEPTEMBER 28, 2006

U.S. House of Representatives, 

Subcommittee on Health,

Committee on Veterans’ Affairs,

Washington, D.C.

 The Committee met, pursuant to call, at 10:00 a.m., in Room 334, 

Cannon House Office Building, Hon. Henry Brown [Chairman of the 

Subcommittee] presiding.

 Present: Representatives Brown of South Carolina, Moran, Michaud, Michaud, Filner, Snyder. Also Present: Representatives Boswell, Cantrell.

Mr. Brown. The Subcommittee will now come to order. Good morning, and welcome to today’s hearing on an issue that is very important to all of us. I am pleased to have assembled, with the help of 

Ranking Member Mr. Michaud, the panel that we have in front of us 

here today.

 As most of you here today know, much has been written and discussed relative to Post Traumatic Stress Disorder, or PTSD, since the 

beginning of Operations Enduring and Iraqi Freedom. We are fortunate to have before us some of those who are responsible for providing 

us critical data on this mental health condition, and I am eager to 

take this opportunity to learn more about the nature of the disorder 

and its prevalence amongst our returning servicemen and women.

 And while PTSD seems to have captured a majority of the headlines 

over the last few years, an equally challenging condition is being seen 

in increasing numbers at the VA; Traumatic Brain Injury, or TBI. 

Due to the concussive nature of many of the war-related injuries being seen in Iraq and Afghanistan, TBI can take many forms, ranging 

from quite mild, almost undetectable, to very dramatic.

 We will be interested in hearing how the VA is meeting the increased demand, how the four polytrauma centers are handling that 
2

workload, and what best practices are being shared with other VA

medical centers to ensure that the best care is being provided all 

around the nation for those who have suffered some form of TBI. In 

addition, we are going to examine some of the similarities between 

PTSD and TBI in terms of how the conditions manifest, how they are 

identified and ultimately how they are treated.

 The important point I would like to add to this is that these injured 

servicemembers, in particular those with PTSD, can be treated and a 

sense of normalcy can be attained. Having said that, in the absence 

of in-theater risk mitigation techniques, effective early identification, 

and aggressive outreach and treatment, normalcy and appropriate 

adjustment may be difficult to realize for some returning from theater.

 This is an important topic and I want to again thank those assembled before us today for taking the time to help us better understand 

some of the emerging health challenges that both DoD and VA will 

continue to face.

[The statement of Mr. Brown appears on p. 38]

Mr. Brown. I now yield to the Ranking Member, Mr. Michaud, for 

an opening statement.

Mr. Michaud. Thank you very much, Chairman Brown, for holding this very important oversight hearing. Fatalities to our troops in 

Iraq and Afghanistan from blast-related injuries are lower than in 

previous conflicts, due to improved protective combat equipment and 

advances in the delivery of medicine on the battlefield.

 However, those who survive blasts are at great risk for Traumatic 

Brian Injury, or TBI. Severe, moderate and even mild TBI can affect 

veterans and their families for the rest of their lives. Brain injuries 

can impair functions including short-term memory, concentration, 

judgment. As well, many TBI cases experience degrees of impaired 

vision. It can also affect a veteran’s ability to return to work.

 The emotional and behavioral changes that result from TBI can 

place a tremendous burden on families and friends. Many veterans 

with mild TBI may have their symptoms misdiagnosed as a mental health disorder. These veterans need targeted care to help them 

function better. Post traumatic stress disorder (PTSD) is also a 

wound that many of our returning veterans carry home.

 Unfortunately, the stigma of mental illness often leads veterans to 

ignore or deny that they had any problems, even when they see their 

relationships and lives crumble under the weight of the symptoms 

of PTSD. Untreated PTSD is linked with substance abuse, severe 

depression and unfortunately, even suicide. Sadly, we have already 

seen too many Vietnam veterans—and now veterans from Iraq—go 

down this tragic path.

 Access to VA’s mental health programs and TBI programs, and the 
3

quality of these programs depend on adequate funding. VA mental 

health care experts have recognized that VA’s program have gaps 

in quality. In response, Secretary Principi rightly adopted a mental 

health strategic plan with initiatives to address the gap in VA’s mental health care efforts. The Administration promised to commit $100 

million in fiscal year 2005 and $200 million in fiscal year 2006 to fund 

these mental health care initiatives.

 Last fall, Ranking Member Lane Evans and I asked GAO to study 

whether the administration fulfilled this commitment to fund the 

new mental health initiatives. Today, GAO’s testimony provides its 

preliminary findings of the study. Sadly, the Administration is far 

short of fulfilling its commitment. VA did not provide $100 million in 

fiscal year 2005 for new mental health care efforts. VA only funded 

approximately $53 million.

VA claimed to GAO that it also provided $35 million in funds generally distributed to VA hospitals and clinics. GAO found, and VA

concedes, that VA never told medical facility directors that the $35 

million was to be used to rebuild mental health services. GAO also 

found that some of the $53 million went unspent. The preliminary 

findings for fiscal year 2006 were also disappointing. VA allocated, 

at best, $158 million of the promised $200 million. Again, GAO found 

that some of this money might not be spent.

 Gaps in mental health care services remain. The mental health 

strategic plan is good. However, without real commitment to funding, the plan will not become a reality. Members on both sides of the 

aisle want and need to address this very important issue. We must 

keep our promise to our veterans and dedicate mental health care 

staff who want to help them recover from the psychological wounds 

of war.

 Funding and implementation of VA’s mental health plans will 

require vigorous oversight from this Committee. That is why I am 

pleased, Mr. Chairman, that we are holding this hearing. Further, 

it is my intention to continue to press for passage of Lane Evans’ 

Comprehensive PTSD Bill, H.R. 1588. It is also my intention to reintroduce an updated version of this legislation in Lane Evans’ name 

in the 110th Congress to ensure that his noble efforts are carried on 

in order to meet the critical mental health challenges that we face.

 So with that, Mr. Chairman, I want to thank you very much, and I

also would like to welcome both Representative Pascrell, and Representative Boswell. And I want to thank Chairman Brown for allowing them to join us at this hearing, because I know they have a deep 

commitment to veterans’ issues, and they definitely will add a lot to 

this discussion. So thank you very much, Mr. Chairman.

[The statement of Mr. Michaud appears on p. 41]

Mr. Brown. And thank you, Mr. Michaud, for the opening state-
4

ment. And I know both of the other gentleman from other committees, and they have got other responsibilities, so if it is the will of the 

Committee to allow them to speak out of order, and to speak for two 

minutes?

[No response.]

 Okay, without objection. Okay, Mr. Pascrell?

STATEMENTS OF HON. BILL PASCRELL, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW 

JERSEY, AND HON. LEONARD BOSWELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF IOWA

STATEMENT OF HON. BILL PASCRELL

Mr. Pascrell. Thank you Mr. Chairman and Ranking Member Michaud, and also Committee members, for dedicating so much of your 

time to this very critical issue. I salute the Veterans Committee. 

Your work many times goes unnoticed, I understand that.

 I would like to ask that my entire testimony be inserted into the 

record, if you would?

Mr. Brown. Without objection.

Mr. Pascrell. As a cofounder of the Congressional Brain Injury 

Task Force, I am committed to improving the lives of individuals with 

Traumatic Brain Injury, TBI. I would like to focus on an issue that 

has gained more and more publicity over the last year; dramatic brain 

injury in our nation’s servicemen and women, past and present.

Traumatic brain injury is defined as a blow or jolt to the head, or a 

penetrating head injury that disrupts the function of the brain. This 

has been called the “ silent epidemic.” A million five-hundred-thousand people are affected in the United States every year. When I first 

learned of this, seven years ago, and I want to tell you, Mr. Chairman, I was just shocked out of my wits. I never thought, until folks 

in my own district came to me, you know, we need to be educated on 

these things, and certainly members of Congress should be, if we are 

going to talk about it.

 Military duties increase the risk of sustaining TBI. For our armed 

forces, TBI is an important clinical problem in peace and war, and its 

consequences may extend for many years. Over 1500 military personnel involved in the global war on terror have been seen and treated by 

DVBIC. At Walter Reed alone, over 650 soldiers with brain injuries 

from Iraq and Afghanistan have been treated. That represents 40 

percent of all the troops evacuated to Walter Reed Medical Center so 

far. About 10 percent of the servicemembers in Iraq, 20 percent of 

the troops on the front lines returned from combat tours with concussions.

 DVBIC, the Defense and Veterans’ Brain Injuries Center, was es-
5

tablished in 1992, after Desert Storm. Until then, there was no overall systematic program for providing brain injury-specific care and 

rehab within the department of defense, or the Veterans Administration for that matter.

 The changing nature of warfare demands corresponding improved 

and specialized medical care. It has been estimated that 50 percent of 

all combat injuries are blast injuries. So as part of the recently-passed 

blast injury prevention and mitigation and treatment initiative, the 

DVBIC is leading the effort to illuminate patterns of brain injury 

from blasts including providing guidelines for the assessment.

I must say, Mr. Chairman, the last five years has seen more advancement in this area than probably in the past couple of hundred 

years, so that parts of the brain that have not been affected in a negative way can be developed, so that we can compensate.

 These are great times. You know, I tell kids in the schools, “ Don’t 

let your parents tell you, oh, for the good old days.” These are the 

times when we can address these very serious injuries in terms of 

modern warfare. The Defense and Veterans’ Brain Injury Center’s 

mission is to serve active duty military, their dependents, and veterans with TBI, through state-of-the-art medical care, innovative clinical research initiatives, and educational programs.

In order to better recognize TBI, the DVBIC has begun to employ 

improved diagnostics, increase brain injury training of battlefield 

medics, and clinical research on blast injury.

Now, what I want to emphasize in concluding, Mr. Chairman, is 

the need to improve and expand the Special Committee on Post Traumatic Stress Disorder. And the Committee on Care of Veterans with 

Serious Mental Illness recommended to the Veterans Administration, 

under the Secretary of Health, that VA establish a screening process 

to identify veterans with mild TBI. I recommend that we look into 

that screening process.

 Also noted was the need for the VA to establish a TBI registry that 

can be used to create more sophisticated evidence-based, cost-effective assessment and treatment strategies. We have passed general 

legislation to do this throughout the nation for civilian TBI. We need 

to do it in terms of the special situation that we face as Americans.

 In July 2006, the Veterans Administration Inspector General’s office reported on a lack of consistency in VA case management, citing 

that the effectiveness of case managers ranged from outstanding to 

inadequate. The Inspector General also reported on a major weakness in the VA’s TBI care, and its participation in the DVBIC program. The number of TBI beds—I was shocked to find this out—in 

head-brain injury treatment resources do not correspond to the scope 

of the problem. That was the case since 1999; it is the case today, 

also.

And very briefly, Mr. Chairman, I would ask you—beg you— to 
6

look at the funding. According to a recent study by researchers at 

Harvard and Columbia, the cost of medical treatment for individuals 

with TBI from the Iraq war will at least cost $14 billion over the next 

20 years. This is a sustaining situation; not going to be hit or miss. 

Without our support, DVBIC’s congressionally directed mission of coordinating clinical health care, executing research that will result in 

better characterization and management of the problem, and education of both military and civilian communities will come to a halt.

 This is one of TBI tasks force’s primary mission. As such, in conclusion, the task force along with other concerned members request an 

additional $12 million for the DVBIC in the Military Quality of Life, 

and Veterans Affairs Appropriations Bill for fiscal year 2007, for a 

total of 19 million.

 I know the Committee shares these sentiments, and I am absolutely thankful for the fact that you have let me testify.

[The statement and attachment of Mr. Pascrell appears on p. 45]

Mr. Brown. Well, let me also thank you, Mr. Pascrell for taking 

your time to be part of this discussion. We have got assembled a 

great panel that I am sure has listened very intently to some of your 

recommendations, and thank you for coming. You can stay for the 

whole meeting if you would like, but we wanted to afford you the opportunity to speak first.

 And Mr. Boswell, if you could take a couple minutes, so we can 

proceed.

STATEMENT OF HON. LEONARD BOSWELL

Mr. Boswell. I heard the “couple minutes,” and I will try to do 

that, sir.

 And I do thank you kindly, you and Mr. Michaud, for allowing us to 

do this. As Congressman Pascrell has already said, very kind of you. 

I have been respecting your work on this for a long time, and I salute 

you too, sir, because I know your heart is in this, you are focused, and 

we cannot thank you enough. There are probably over a hundred 

of us here in this room and otherwise that are veterans. And so we 

thank you. I feel very fortunate.

 I would like to share with you before I start, I have a veteran that 

is from Iraq that is on my staff, and I would like to introduce you to 

this veteran. She is standing right over there, Alexis Taylor; she has 

joined my staff, an Iraq veteran.

Mr. Brown. Glad to have you with us today.

Mr. Boswell. Again, Mr. Chairman, I would say this, that we all 

know it has been said that for more and more veterans are returning 

from tours of duty in Iraq and Afghanistan, there are many new issues and we have heard some of them. But it is an issue that I don’t 
7

think we can’t ignore, and I am not suggesting that we are.

 The number of veterans returning with post traumatic stress disorder is alarmingly high. A recent study found that 17 percent of 

soldiers and marines returning from Iraq screened positive for PTSD. 

Our men and women in uniform returning from combat are fighting a 

different type of war, and a different type of enemy. I thought maybe 

I had seen it all in Vietnam. It was different, and there is no front 

line there, either. I helped to put too many of our young men and 

women in body bags, and it makes a lasting impression.

 The National Center for PTSD found several things associated with 

individuals diagnosed with PTSD, such as physical pain, sleep disturbance, nightmares, substance abuse, self-harm, or suicide. I believe 

obviously there is a connection between PTSD and suicide. Some estimates have found that almost one thousand veterans receiving care 

from the Department of Veterans Affairs commit suicide each year, 

and research shows that one out of 100 veterans who have returned 

from Iraq have considered suicide. I find this very disturbing.

 Since March 2003, 80 individuals who have served in Iraq or Afghanistan have committed suicide. Our young men and women serving our country have kept us safe for so long, it is our job, as you 

know, to protect them. A few months ago I learned of a young man 

from my district, Joshua Omvig, who experienced undiagnosed PTSD

after returning from an 11-month tour in Iraq. His family and friends 

did not know how to help him. Goodness knows they tried. Then in 

December of last year Joshua tragically took his life. He was only 22 

years old.

 His parents were very close. They knew something wasn’t right, 

and they were trying everything they could think of. He was staying 

with them, going to work, and trying to get adjusted. And one morning, his mother felt the intensity, and she stayed right with him as 

he went out to get in his pickup to go to work, and he shot himself in 

front of his mother, in the pickup.

After I heard his story I was shocked to find one in a hundred Operation Iraq Freedom veterans have reported thinking about suicide. 

I knew something had to be done, as anybody would feel. That is 

why we have introduced H.R. 5771, the Joshua Omvig Veterans Suicide Prevention Act. This legislation will mandate the Department of 

Veterans Affairs to develop and implement a comprehensive program 

to regularly screen and monitor all veterans for risk factors for suicide within the Veterans Affairs system.

At any point in a veteran’s life, if they were found to have specific 

risk factors for suicide they would be entered into a tracking system; 

ensuring they do not fall through the cracks. Then they would be 

entered into a counseling referral system to make certain those veterans receive the appropriate help. It would provide education for 

all VA staff, contractors, and medical personnel who have interaction 
8

with the veterans. In addition, it would make available 24-hour mental health care for veterans found to be at risk for suicide.

Currently, the Department of Veterans Affairs regularly screens 

veterans for depression, PTSD, and substance abuse, but not suicide 

specifically. I am saddened by the circumstances that this legislation 

grew out of, but I know that if enacted, this program could save lives. 

We treat their physical injuries, which goodness knows we should. 

Now it is time to treat the wounds that are not visible. It is my hope 

that a comprehensive veterans bill will result from this hearing and 

that any bill considered will include provisions for the Joshua Omvig 

Veterans Suicide Prevention Act. This important issue cannot go 

another day without the attention it needs.

 And Mr. Chairman, I say this and I am looking you square in the 

eye, and I am very, very serious: it is not important to Leonard Boswell to have my name on that Bill. It is not. We are in the political 

season, and we know that. It is important that this need be taken 

care of, and I would be delighted if you, Mr. Chairman, Mr. Michaud, 

wanted to take this and make it your bill. I don’t care. I know there 

is a need, and I think we all know that. And that is the way I deeply 

feel about it.

 It unfortunately came to my attention the manner it did. We stayed 

very close to the family, very close. When we built this idea, we went 

and talked to them about it, because they have come out in a sense. 

They want to help others. They are in their grief, and their shock, and 

it will go on the rest of their lives, but they want to do something to 

help others.

 And so we felt like we could, so I very carefully, very quietly went 

and talked to them with staff that was working on it, and said this is 

what we had in mind, what would they think about it? And after a 

few tears, they said this would be wonderful. I said, “ Now, it is up to 

you. If allowed, I will name this the Joshua Omvig Bill.” And they 

looked at each other and they said that they would be honored. So 

that is the reason that it is on there.

 And I seriously don’t care who gets credit for sponsoring this bill. 

I want you to know that, Mr. Chairman. I say this in all sincerity: 

it needs action, and I have confidence that you and Mike will give it 

your attention.

 And I thank you very, very much for allowing me to make this testimony, and I will leave this for the record.

Mr. Brown. And we will certainly, with unanimous consent, allow 

the statement to be submitted for the record.

[The statement of Mr. Boswell appears on p. 60]

Mr. Brown. And Mr. Boswell, I really do appreciate you and Mr. 

Pascrell coming and being a part of this discussion. This has been 

a Committee hearing that has been late coming, and I am grateful 
9

for you all’s input. I know we have all got stories we can tell about 

personal involvement. I know last July, I had my appendix taken 

out in Bethesda on the fifth floor, and had a chance to interact about 

four or five days with those young men and women coming back from 

harm’s way. And you know, you could see some visible injuries, you 

know, if so many came back without an arm or a leg, those were easily identifiable.

 I went into a room for this young guy from Florence, South Carolina, and it had half of his skull actually blown away, and they have 

got the computer technology to replace the image of that skull, and 

they all could draft hair on it, you know, to make a kind of look back 

like it was normal. But you could tell, as you look at that young man’s 

eyes and you talked to him, that you knew that he was going to have 

a lasting problem with that brain injury.

 And so this is a major concern, and we are grateful for you all’s input. And you can stay as long as you would like, if you would like.

Mr. Boswell. Thank you what you just said. And you know, with 

today’s technology, we do the battery of tests when the young men 

and women leave the service. We have got the ability to see what is 

going on in their minds, and we have just got to do something about 

it. And we thank you. We wouldn’t ever think about doing something 

for the physical injury, as you well know.

Mr. Brown. Right.

Mr. Boswell. We would do everything we possibly could. And the 

mental injury is just as important.

Mr. Brown. That’s right. Thank you so much.

 And our Ranking Member, acting Ranking Member, do you have 

an opening statement?

Mr. Filner. Yes, I would like to submit my opening statement for 

the record.

 Let me just thank Mr. Pascrell and Mr. Boswell not only for your 

expertise, but for your passion. We need that energy, and I would 

say to the panel something I generally say after you all have testified: please don’t hide behind statistics and bureaucrat-ese and written statements. Let us know that you have some passion for doing 

this, for solving this issue. I think we want to hear that more than 

anything else; more than any defensiveness about what you’re doing, 

about things that you want to point out. We want to make sure that 

you have the passion that many of us have from personal experiences. I know you all do, too, but in these Committee hearings, it 

doesn’t always come out.

 And let me say, I think we are letting our veterans down today. The 

young men and women who are, as you have shown one of us here, 

Mr. Boswell, coming back, are the bravest young people in the world. 

And yet we are not giving them the attention or the expertise that we 

have as a society. We don’t do outreach sufficiently. We don’t make 
10

sure that the mental, as has been said here, is seen as important as 

the physical health. The mental scars will last probably longer or at 

least equally, and may have a deeper impact.

 And yet, when these young men and women come back, they don’t 

even know what they got. And when we have diagnoses of PTSD, the 

first thing the VA does, instead of saying, “ We have got to have more 

facilities, and more resources to deal with it,” the first thing they 

do is investigate why we have so many diagnoses of PTSD. That is 

disgraceful, that that is the response that these two men and women 

get, and the doctors who are dealing with him.

 And the tragedy, as I think both of our guests have said, is that we 

know how to deal with these issues today better than we ever have. 

And we watch the same things for these returning Iraqi vets that we 

saw in Vietnam, when we knew less. They come home without knowledge of what is going on. The family doesn’t have any idea. There is 

violence in the family, perhaps spousal abuse, kids run away, alcohol 

and drug abuse, loss of job, homelessness, suicide.

I think the figures that I have seen, Mr. Pascrell, are much higher. 

I have seen figures of several hundred suicides, and a much higher 

rate, as you point out, than either in the general veterans’ population, 

or in the general population. This is a tragedy. The administration 

says, “ Support our troops, support our troops, support our troops.” 

When they come home, we don’t have the outreach for them, we don’t 

have the resources for them. We know that whatever percentage it 

is, whether it is one-half or one-third of our veterans that have PTSD, 

we don’t have the resources to deal with it. I have been at the PTSD

clinics in San Diego. They are wonderful. We know how to deal with 

it. But we are not getting these services to all the people that need 

them. And we are not given the resources to make sure that we can 

handle them if we did.

 We even have now, as I think you pointed out, ways to perhaps—

knowledge of the brain that says we can physically identify who has 

certainly a higher risk of PTSD.

 So let us as a nation commit ourselves. We made a tremendous 

moral mistake by not dealing with these issues for Vietnam. It is not 

too late, by the way. Half of the homeless on the streets tonight are 

probably Vietnam vets, probably with intense mental situations. We 

need to bring them back, if we can. But let us not lose more, who are 

returning from Iraq, to this terrible situation.

 So we want to give you all the resources that you need as professionals, but we have to look at this in a passionate way like our two 

guests have shown, and we have to, as a nation, say we are going to 

support our troops, we are going to treat these mental illnesses with 

the knowledge that we have, and we are not going to let them be lost 

and unable to further contribute to our society.

 Thank you Mr. Chairman.
11

[The statement of Mr. Filner appears on p. 43]

Mr. Brown. Okay. Thank you, Mr. Filner.

 Dr. Snyder, do you have an opening statement?

Mr. Snyder. I do not, Mr. Chairman, thank you.

Mr. Brown. Okay, thank you very much.

 We are absolutely impressed that we have got such an outstanding 

panel before us today, and let me introduce our panel.

 I welcome Dr. Gerald Cross, the Acting Principal Deputy Under 

Secretary for Health at the VA. He is accompanied by Dr. Katz, the 

Deputy Chief Patient Care Services Officer for Mental Health, and 

Dr. Sigford, VA’s National Program Director for Physical Medicine 

and Rehabilitation.

 Representing the United States Army, we are pleased to have Colonel Elspeth Cameron Ritchie and Colonel Charles W. Hoge. Doctor 

Ritchie is the Psychiatry Consultant to the Surgeon General of the 

United States Army, and Doctor Hoge is the Director of the Division 

of Psychiatry and Neuroscience at the Walter Reed Army Institute of 

Research.

 They are accompanied by Colonel Labutta, the Chief of the Department of Neurosurgery at Walter Reed.

 We will now proceed with Dr. Cross.

STATEMENTS OF GERALD CROSS, M.D., ACTING PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS, ACCOMPANIED BY IRA R. KATZ, 

M.D., PH.D, DEPUTY CHIEF PATIENT CARE SERVICES

OFFICER FOR MENTAL HEALTH; BARBARA SIGFORD, 

M.D., PH.D, PROGRAM DIRECTOR, PHYSICAL MEDICINE

AND REHABILITATION SERVICES; COL. ELSPETH CAMERON RITCHIE, M.D., M.P.H., PSYCHIATRY CONSULTANT TO THE U.S. ARMY SURGEON GENERAL, UNITED

STATES ARMY; COL. CHARLES W. HOGE, M.D., DIRECTOR, DIVISION OF PSYCHIATRY AND NEUROSCIENCE, 

WALTER REED ARMY INSTITUTE OF RESEARCH, UNITED STATES ARMY, ACCOMPANIED BY COL. ROBERT J. 

LABUTTA, MC, CHIEF, DEPARTMENT OF NEUROLOGY, 

WALTER REED ARMY MEDICAL CENTER

STATEMENT OF GERALD CROSS, M.D.

Dr. Cross. Mr. Chairman and members of the Committee, good 

morning. I am accompanied by Dr. Arthur Katz, Chief Patient Care 

Services Officer for mental health, and Dr. Barbara Sigford, director 

of physical medicine and rehabilitation service.
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At first, let me say I can assure you, Mr. Chairman, we from VHA 

do have passion, and we have that passion in caring for our veterans.

 I would like to submit my written testimony for the record.

 In beginning my testimony, I would like to address an issue that I

know is of concern to many members. Recently, VA’s Inspector General issued a report on our ability to care for patients with traumatic 

brain injuries. While the report identifies areas in which we can improve on our performance, its executive summary is very clear. It 

states that our patients have very similar outcomes when compared 

with a matched group of TBI patients from the private sector.

 Given that our patients have more severe injuries than the average 

patient, and given that it takes longer for them to begin rehabilitation because of the complexity of their wounds, and because of the 

distance they must travel from the theater of war to begin treatment 

for those wounds; the fact that our patients do as well as those in the 

private sector demonstrates that we are doing an outstanding job in 

supporting their recovery, and that we are providing the exceptional 

care Congress and all Americans expect of our department.

VA is succeeding in treating many TBI patients with multidisciplinary approaches that include a sensitivity to the physical, cognitive, emotional, functional, and behavioral manifestations of brain 

trauma. Our polytrauma system of care includes four primary polytrauma rehabilitation centers, which provide exemplary care for veterans with multiple injuries, including brain injuries, and fully involves their families in their care and treatment.

 Twenty-one new polytrauma network sites are opening this fall, 

enhancing access, and ensuring lifelong coordination of care for these 

men and women. And a hotline for all polytrauma patients, and their 

families, is staffed 24 hours a day, seven days a week, 365 days a 

year.

 To ensure that we identify every veteran with TBI, VA clinicians are 

receiving additional training in recognizing both acute and delayed 

symptoms of brain trauma, and then providing the prompt identification, and multidisciplinary evaluation and treatment, which is essential for their successful recovery.

 We are improving our ability to coordinate the care of TBI patients 

by assigning a permanent social worker-case manager to every patient we have seen at our polytrauma centers. And we recognize the 

need for family support in caring for loved ones.

 Our intent is to restore every patient to his or her fullest possible 

level of functioning. We will not fail in that effort.

 Mr. Chairman, members are also concerned that we have the capacity and the funds to treat OIF-OEF veterans with PTSD. Let me 

assure the Committee that we do. Among our accomplishments, we 

have been adding 100 OIF-OEF veterans to our vet center staff to 
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provide clinical peer support. We have expended substantial funds 

to expand mental health services at our community-based outpatient 

clinics, and we have added tele-mental services to serve remote locations.

Altogether, VHA now operates approximately 200 specialized 

PTSD programs in addition to our 207 vet centers which, by the way, 

will increase in number to 209 by October of this year.

 Working closely with our colleagues in DoD and other federal agencies, our researchers are working on new pharmacological, psychological, and other treatments, and we are finding ways to harness 

these technologies to extend our ability to care for veterans with this 

illness. And we are placing a special emphasis on finding more effective ways to treat veterans—including women veterans—at risk for 

PTSD.

 Mr. Chairman, today’s veterans with PTSD and TBI are receiving 

state-of-the-art care throughout VHA. We are committed to improving our abilities to address TBI and PTSD, and to meet the specific 

needs of veterans returning from the global war on terror, who have 

earned and are receiving the best care available anywhere.

 Thank you for your time, sir.

[The statement of Gerald Cross, M.D. appears on p. 62]

Mr. Filner. Sure glad I gave that lecture on passion, Mr. Chairman.

Mr. Brown. Thank you very much, gentlemen, for being a part of 

this, and thank you for your passion and for your understanding, and 

for your expertise.

 And with that, I will ask Colonel Ritchie to testify.

STATEMENT OF COL. ELSPETH CAMERON RITCHIE

Colonel Ritchie. Mr. Chairman, distinguished members, Mr. Michaud, thank you for the opportunity to be here and to share with 

you our concern and our passion about taking care of our soldiers and 

veterans.

 Going to war affects all soldiers. The number of soldiers with Post 

Traumatic Stress Disorder, PTSD, has gradually risen. Since 911, 

the Army medical department has taken care of soldiers at the Pentagon during 911, in Afghanistan, in Iraq, and throughout the world. 

We take care of soldiers with physical wounds, and with psychological issues from combat.

 We are committed to providing and ensuring that all returning 

veterans receive the physical and behavioral health care they need. 

An extensive array of mental health services has long been available. However, since 911, we have augmented and improved behavioral health services throughout the world, especially at Walter Reed 
14

Army Medical Center and the other Power for Vets projection platforms and major army installations, where we mobilize, train, deploy, 

and demobilize army forces.

 We anticipate that the need for these services will not decrease. 

We are committed to providing the necessary help. The Army medical 

department has performed behavioral health surveillance in an unprecedented manner. There have been four mental health advisory 

teams, three previously in Iraq, one in Afghanistan, and currently 

one in Iraq at this time. Charles Hoge, Colonel Hoge, will present his 

research.

 We have also performed several epidemiological consultations, 

called EPICONs, at installations in the United States, such as the 

assessment following the cluster of suicide-homicides at Fort Bragg 

in North Carolina in 2002.

 There are numerous other initiatives for us to learn from the war. 

We held a workshop on updates in combat psychiatry at the Uniformed Services University of the Health Sciences, in 2004, where we 

gathered together those who had been in theater with academicians 

and policymakers. We have used the results of all of these assessments to improve the behavioral health services that we offer our 

soldiers.

 The Army Deputy Chief of Staff for Personnel, and the Army Surgeon General, share responsibility for the prevention and screening 

for PTSD for soldiers, both active and Reserve, from the global war 

on terror. Derived partly from the EPICON results from Fort Bragg, 

we have come up with a new deployment cycle support program that 

has been in place for several years to help our soldiers and their families.

 Since the beginning of the war, there has been a robust combat 

and operational stress control presence in theater. Today, more than 

200 behavioral health providers are deployed in Iraq, and another 25 

in Afghanistan. The mental health assessment team reports have 

demonstrated both the successes and some of the limitations of these 

combat stress control teams. As a result of learning of the limitations, we have improved the distribution of behavioral health providers throughout the theater. Access to care and quality of care have 

improved as a result.

 Before deployment, soldiers are screened for medical issues including family problems. Then, as part of the reintegration process, soldiers are briefed on what stressors to expect, the common symptoms 

of post-deployment stress, such as hyper-arousal, and ways to mitigate these symptoms.

 The post-deployment health assessment, when soldiers are coming 

home, is used to screen the soldiers again for physical complaints and 

psychological complaints. And then last year, the Assistant Secretary 

of Defense for Health Affairs directed an extension of the current pro-
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gram so that we now have a post-deployment health reassessment; 

and the army requires that all soldiers redeployed from combat zone, 

whether they are active or Reserve, complete this new PDHRA screen 

at three to six months following deployment. The PDHRA program 

was fully implemented in January of 2006.

 If a soldier has post traumatic stress disorder, or other psychological difficulties, they will be further evaluated and treated, using 

well-recognized treatment guidelines, including psychotherapy and 

pharmacotherapy.

 Traumatic brain injury is also a focus of our attention. TBI, as it is 

often called, is a broad grouping of injuries that range from mild concussions to penetrating head wounds. Many of these symptoms are 

similar to post traumatic stress disorder, especially the symptoms of 

difficulty concentrating, and irritability. I have Col. Labutta here, 

chief of neurology, with me today to answer any questions you may 

have on screening, diagnosis, and treatment of TBI.

We recognize that there is a perceived stigma. Therefore, we are 

moving to integrate behavioral healthcare into primary care, wherever possible. Our pilot program at Fort Bragg, Respect.Mil, has been 

very successful, and we are moving to implement it throughout the 

Army.

 There is a legitimate concern about our isolated Reserve component soldiers. The Army one-source program was put into place, and 

is now becoming the military one source to provide free confidential 

counseling. Our physically wounded soldiers have also been the focus 

of attention.

 Finally, we have been working on improving our suicide prevention 

programs. Every suicide is a tragedy. The DCSPER is the proponent 

for suicide preventions, while the chaplains conduct suicide prevention classes, and behavioral health is also doing surveillance. However, several years ago we leveraged a new report, the Army Suicide 

Event Report, the ASER, to improve our surveillance. All suicides 

and serious suicide attempts require this report to be filled out, and 

we are in the process of setting up a new suicide prevention office 

within the Army medical department.

 So continuing to assess the quality of our services, we learn. Lieutenant General Kiley is a co-chair of the Department of Defense Mental Health Task Force, with a report due in May of 2007.

 We are ongoing training of our leadership in numerous venues. You 

have already heard about after the soldier leaves and goes to the VA, 

it is critically important also that we provide education to our civilian 

providers; that they learn to ask, “ Are you a veteran?” and, “ Have 

you been exposed to a blast injury?” And we have numerous efforts.

In summary, we have been at war for five years. War challenges 

the psychological health of our troops and their families. We have 

been in continual process of improving our efforts. This is not just 
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an army issue, it is not just a VA issue, it is a national issue. We 

have the tools that we need to recognize and treat soldiers and their 

families.

 Thank you very much for your attention.

[The statement of Colonel Elspeth Cameron Ritchie appears on 

p. 72]

Mr. Brown. And I thank you, Colonel Ritchie, for your service. 

And at this time, we would hear from Colonel Hoge. 

STATEMENT OF COL. CHARLES HOGE, M.D.

Colonel Hoge. Thank you, Mr. Chairman and distinguished members. Thank you for inviting me here.

 I direct a research program focused on assuring that soldiers who 

serve in Iraq and Afghanistan get the best mental health services 

that we can provide. And since my testimony to this Committee in 

July of 2005, we have continued to collect data, and continue to try to 

refine our programs and improve our programs, based on the lessons 

learned from the data that we collected.

 Soldiers are remarkably resilient. They are doing heroic things 

day after day for a year or longer. Some of them are going back for 

their second or third rotation. They are working in highly dangerous and unpredictable environments. And it is normal to experience 

symptoms after these combat experiences. Most soldiers transition 

very well when they come home, and have resolution of those symptoms. Some need help, and that has been the primary focus of the 

research that we have been conducting.

 Based on the data from several sources, and we now have robust 

data from a number of different sources, we estimate that 10 to 15 

percent of Army soldiers develop post traumatic stress disorder after 

deployment to Iraq. Another 10 to 15 percent have significant symptoms of PTSD, depression, or generalized anxiety, and may benefit 

from care. Alcohol and family problems can add to these concerns.

 The Army has a comprehensive strategy to encourage soldiers to 

seek help early, before these symptoms become severe, or interfere 

with their lives, seriously interfere with their lives, such as the example that we heard earlier today.

 We learned that soldiers may not express mental health concerns 

until several months after they returned from deployment, and as 

a result, the post deployment health assessment now includes the 

reassessment that Dr. Ritchie discussed earlier. So far, over 60,000 

soldiers who have returned from Iraq have completed this health assessment. Of these, 35 percent reported some sort of mental health 

concern on general screening questions. And after speaking with a 

health care professional, about 18 percent were recommended to seek 
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assistance from one of the many mental health sources of care.

One new finding from post-deployment health reassessment program is that Reserve component soldiers—that is, National Guard 

and reservists—report higher rates of mental health concerns, and 

higher rates of referral, compared to active component soldiers. It 

is important not to misinterpret these data as suggesting that they 

are in some way less mentally healthy than the active component soldiers. Reserve component and active component soldiers have nearly 

identical rates of mental health concerns in theater and immediately 

post deployment. And these differences don’t appear to emerge until 

several months after they return home.

 We don’t know exactly why this is, but potential factors that could 

relate to this include concerns about ongoing access to health care 

among Reserve component soldiers after they have been home for 

some period of time, and the fact that active component soldiers stay 

with their unit, and they continue to work full time with their unit, 

with the peers who they have shared their combat experiences with, 

and that provides a very supportive environment for resolving symptoms when they have been home.

 So far, we are not seeing higher rates of mental health concerns 

among soldiers who are deployed more than one time to Iraq, compared to those who have deployed once. However, it is difficult to 

measure the effect of multiple deployments, because the rate of leaving military service is somewhat higher for those who have been to 

Iraq one time. Although we have data indicating that our efforts are 

working to encourage soldiers to get help for combat related mental 

health problems, our surveys indicate that many soldiers with mental health concerns still don’t seek care, and perceive that they will be 

stigmatized if they do; that is, viewed or treated somehow differently 

by their peers or leaders.

 The data on stigma have led to new approaches to improve the 

availability of mental health in primary care settings and training 

for soldiers and leaders to improve their recognition of mental health 

issues, reduce the perception of stigma, and assure successful transitions throughout the deployment cycle.

 In the area of training, my team has developed and tested a new 

training program called BATTLEMIND, with these goals in mind. 

This new training highlights the skills that help soldiers survive in 

combat, and how to transition the skills when they get home. The 

training has been incorporated into the army deployment cycle support program, and is being utilized in a variety of ways, including at 

VA facilities and VA vet centers. Further information on the training 

materials can be obtained at www.BATTLEMIND.org.

 Thank you very much for your continued interest in our research, 

and your support for the men and women who are serving in Iraq and 

have served in Iraq and Afghanistan, and other locations.
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[The statement of Colonel Charles W. Hoge appears on p. 79] 

Mr. Brown. Thank you, sir, for your testimony and for your involvement in this program.

My first question would be that understanding that the post deployment health assessment, and the post and limit health reassessment are self-reporting tools, are you personally convinced that they 

are powerful sufficient to be used as predictable tools? and if not, how 

can they be improved?

Colonel Hoge. The post-deployment health assessment and the 

post-deployment health reassessment include a self- report portion 

of the survey, but basically, all individuals sit down with a primary 

care professional to review the answers that they have put on those 

surveys. So in essence, the survey questions are really just prompts 

to help the primary care professional identify what issues need to be 

discussed further.

Colonel Ritchie. If I may add to that, it is also important to recognize that the soldiers have a number of other venues to seek help, and 

we encourage the unit—and I believe the unit leaders are very much 

doing this—to provide outreach and education. And then there is a 

number of other efforts, such as the combat stress control teams, to 

provide outreach, education, and treatment if necessary.

Mr. Brown. But I assume that all the young men and women leaving service are leaving the battlefield, they have this battery of tests, 

or this observation; and I guess the ones that show signs, I guess they 

are sort of put into the system. But is there a process to later go back 

and reevaluate the ones not detected early on after they leave the 

battlefields, to see if there is a later-developing problem?

Dr. Cross. Sir, that is one of the main reasons that the post-deployment health reassessment was established, to be done three to six 

months after the soldier has returned from combat. I think it is very 

important that we have numerous opportunities in our system and in 

the VA system for the soldier to seek treatment, because we do recognize that many soldiers will not seek treatment right away.

Mr. Brown. And if I might ask, how are the service chaplains being integrated into the theater-based assessment team? Do you bring 

those chaplains on board to help do the assessments?

Colonel Ritchie. If I understand the question correctly, you ask 

how the chaplains are integrated into theater, and also after the return home?

Mr. Brown. My question is just how are they integrated in the assessment of the troops after they leave the battlefields?

Colonel Ritchie. Chaplains are an integral part of our system. 

In general, each battalion has its own chaplain who will work very 

closely to the soldiers, and this is extremely important because it 

provides a non-stigmatizing, confidential way for the soldier to seek 
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help. Chaplains have also been part of our mental health assessment 

teams. In terms of after they come back, again, the chaplains will be 

present, and in every battalion. And as a result of the evaluations, 

the post-deployment health assessment or reassessment, the soldier 

can either seek out a chaplain or a behavioral health provider. So 

again, they are very well integrated, and we really could not do our 

mission without them.

Mr. Brown. Do you have some thing to add, Dr. Hoge? Do you have 

anything further to add on that question about the chaplains, or are 

you pretty satisfied?

Colonel Hoge. I agree completely. They are very well integrated, 

and a very important part of the well-being of soldiers in every unit.

Mr. Brown. Okay, thank you. We will probably come back for 

some other questions, and I will also offer the other members of the 

Committee to question later. But let me further my question to Dr. 

Cross and Dr. Katz, if I could.

 One of the biggest challenges that we continue to hear a lot about 

is the transitional rehab capacity of the VA for those with TBI. Dr. 

Cross, Dr. Katz, or Dr. Sigford, please describe the resources available to our men and women after they have been discharged from a 

VA facility.

Dr. Cross. If I understood your question, sir, it relates to the resources available to them after separated from the military?

Mr. Brown. Right.

Dr. Cross. For both PTSD and TBI, we have very significant programs available. I wanted to highlight particularly both in the programs that we have to address their needs, and in outreach, our vet 

centers. Our vet centers are a unique resource within our organization, and I wanted to point out a couple of things about them.

 As of August, counseled 16,933 outreach services for 111,000-plus, 

and also counseled with 1215 families. A unique resource, where the 

new veteran can just walk in, no wait, say “ hello,” be welcome, say “ 

Have a cup of coffee, take it easy, let’s talk,” and I think that is very 

important.

 We also have a comprehensive system of primary care. We are 

training our primary care providers to make sure that they understand, in addition to all of their other training, that they can recognize TBI or PTSD. We have put out this training manual, and an 

online course that we now mandate for our primary care providers 

working with polytrauma patients and others.

 And of course, our PTSD programs, 112 inpatient and over 200 specialty service programs. And I will ask Dr. Katz to expand on that.

Dr. Katz. The first task is to overcome the barriers to veterans getting into our systems. For that, their interactions with DoD, vet centers are also very important sources of outreach. In our medical centers and clinics, we also run outreach programs. Over recent years, 
20

we have funded 84 outreach providers to go out to the community, 

Reserve, and Guard units, and also to do in-reach; to work with the 

veterans in primary care, and rehabilitation programs after physical 

injury, to educate veterans and families about mental health conditions, and to give the message the treatment works. We are working 

very hard to get patients somewhere. The no-wrong-door theme that 

we have learned from the vet centers applies all over the system. Our 

goal is to get people in treatment, knowing the treatment works, and 

that it can prevent disability.

Mr. Brown. Let me follow up on that if I could. What type of collaborative arrangements exist with the DoD to providing continued 

care for these folks? The September 2004 GAO report stated that 

VA lacks the information it needs to determine whether it can meet 

an increasing the demand for VA PTSD services. VA stated that it 

planned to aggregate, at the national level, the number of veterans 

receiving PTSD services at VA medical facilities and vet centers, and 

share this information with GAO. Has this been achieved?

Dr. Cross. Sir, with regard to collaboration with DoD, we are making remarkable efforts in that area. We put our own staff in the eight 

military treatment facilities where returning service numbers are 

most likely to come. We are collaborating on information exchange 

to make sure that data that is found, obtained in the DoD system, is 

conveyed over to us.

 I have observed personally an interaction between our Tampa facility for polytrauma, Walter Reed in Bethesda, talking about a patient 

online on video teleconference, simultaneously with a doctor in Baghdad, who had actually treated that patient initially. A remarkable 

degree of communication.

Mr. Brown. Is that a seamless transferring of information, or is 

that a manual transfer of information? Do you have, like, is your 

computers compatible, and can you share those records electronically?

Dr. Cross. We are receiving electronic information from DoD, but 

we are also, on a patient-by-patient basis, making sure that we talk 

to each other, to compare notes.

Mr. Brown. Okay.

Dr. Cross. And we are talking about the very, very seriously injured polytrauma patients.

Mr. Brown. Right, okay. I thank you very much.

 Mr. Michaud, do you have some questions?

Mr. Michaud. Thank you very much, Mr. Chairman. Once again, 

I want to thank the panel for your testimony.

Colonel Hoge, your research shows real differences in how the National Guard members and reservists respond to PTSD screening 

questions three through six, most after deployment, as compared to 

active components of servicemembers. Is this because the National 
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Guard and Reserve members do not have the same access to mental 

health services, or support?

Colonel Hoge. Sir, we are not really sure. This is new data. The 

PDHRA program has just been implemented, and this is the first 

time we have seen this. To date, all of our data has shown very comparable rates between active component and Reserve component. So 

something is happening in terms of the level of concern rising in Reserve component soldiers, among Reserve component soldiers, after 

they have been home for several months. And I don’t know if that is 

concern that they may have issues that may be ongoing and whether 

they have concerns about getting health care on an ongoing basis.

 Also, we have a relatively small sample of Reserve component soldiers who have completed the post-deployment health reassessment, 

and that sample may not be representative of all Reserve component 

soldiers. So this these to be continued to be studied. But we were 

asked specifically about what we are seeing on the PDHRA, and I felt 

like it was important to share those data, even though they are fairly 

preliminary.

Mr. Michaud. Thank you.

 Dr. Cross, what challenges do you see in helping families of veterans with TBI to navigate the VA and the DoD health care systems? 

And what is the VA doing to help?

Dr. Cross. Sir, the greatest challenge that we have faced, in my 

opinion, is communication. It has been so very important for us to 

make those family members feel and actually be a part of the treatment care team, to be involved in making the decisions that will affect their loved one. We are learning to do that better and better, 

but this is something that we have really put a great deal of effort in. 

Communication I think is at the core of success; not only of treating 

the patient himself, but the family as well.

Mr. Michaud. Also, we have heard that mild TBI can go undiagnosed or misdiagnosed. What is VA doing to ensure that veterans 

with mild TBI are correctly diagnosed? Dr. Cross?

Dr. Cross. We are working with our primary care providers and all 

of our staff to deal with polytrauma in any of its forms, to make sure 

that in addition to their education that they already have, their medical education for instance, that they receive supplemental training to 

make sure that they understand those fine distinctions. Not just to 

recognize the severe cases, but the mild and moderate, as well.

Mr. Michaud. Okay. Why is it that VA is not using the brief traumatic brain injury screen development by the Department of Defense 

in the Veterans Brain Injuries Center to screen veterans for mild 

TBI?

Dr. Cross. We are vitally interested in screening. We take great 

interest in the work that DoD is doing with the screening in the Veterans Brain injuries Center. We want to make sure that any screen 
22

that we adopt is evidence-based and applicable to the population, the 

much larger population that we serve. We are following this with 

great interest, and we are doing research of our own.

Mr. Michaud. But Col. Labutta, has a brief traumatic brain injury 

screen been validated as a screen for mild TBI?

Colonel Labutta. The screening questions are validated to the 

point of the mid-80s, 85 percent or so, of sensitivity at this time. Some 

of those questions have been asked to redeployed returning units, 

and have not been wider applied until we know more about that, and 

to apply them both for more redeployed units, and to apply those or 

modified versions of those questions, into the VA system.

Mr. Michaud. So it has been 85 percent validated? That is a pretty 

high percentage. So why isn’t VA using it? Are you looking for a hundred percent?

Dr. Cross. We are not looking for a hundred percent. We are looking to make sure that it is applicable to the patient population that 

we serve. I have read the study that has been referred to—I believe 

it is one study—and as I said, we want to make sure that we don’t inappropriately label, that we don’t expose to imaging studies that are 

unnecessary. We want to make sure that we have a test that works 

for our population. Dr. Sigford?

Mr. Michaud. Are you testing it right now?

Dr. Cross. No, Sir. We are doing research on developing tests.

Mr. Michaud. And how long will that be?

Dr. Cross. We are expecting research grants on those subjects this 

year.

Mr. Michaud. So you will have some results on that research this 

year?

Dr. Cross. I can’t promise you that, sir. We will do the research 

this year.

Mr. Michaud. Okay. I know Dr. Ritchie made a statement that 

you have the tools. You might have the tools, for those that can access those tools. My concern is talking to a lot of veterans, they do 

not have access to those tools, and that is a big difference. The tools 

are no good if a veteran cannot access them. And that is my major 

concern, particularly for veterans that live in rural areas who have 

even a greater problem of accessing tools when you look at, under the 

CARES process, a lot of the recommendations have not even been 

implemented to make the tools available to rural areas.

 So I am really concerned with that. I am also very concerned that 

the VA did not provide the $100 million that Secretary Principi had 

talked about for fiscal year 2005 for new mental health care efforts. 

As well as the additional $35 million that VA said that they would 

be using, and they sent out to the VISNs; they never stipulated that 

it was for mental health care areas, which they can use to make up 

shortfalls in a lot of different areas.
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 And the other area that I am really concerned about is the fact 

that when you look at Iraq and Afghanistan veterans, and what is 

happening with them with TBI and PTSD; the war over in Iraq and 

Afghanistan is triggering effects of veterans from Vietnam. Will they 

be able to get the access, because they might fall into category eight? 

And because of the current war, it is really having a negative effect 

on them.

 These are a lot of concerns that I have, and when you mention that 

you have the tools, I beg to differ. Everyone does not have access to 

those tools, and we are not doing our job to make sure that they are. I

think it is incumbent upon each and every one of us here at this table, 

in Congress, and each and every one of you at that table, to make sure 

that we provide these services for our veterans.

I realize that you are in a different situation, that you have to get 

your statements approved, but I do not have to get my statements 

approved. I can tell you, having heard from veterans yesterday, and 

having heard from other veterans in the past, Blake Miller, Mrs. 

Pelkey, who lost her husband to suicide; veterans are not getting the 

help that they need. I would implore each and every one of you to do 

what you have to do to convince your boss and your superiors to do 

what they have to do to provide the resources, so our veterans can 

get it.

 This is a family values issues. It doesn’t affect only the veteran; it 

affects their families. And if you care about family values, and if you 

care about veterans, you will do everything in your heart and soul to 

convince your superiors to do what is right, and that is to take care 

of the veterans.

 Thank you Mr. Chairman.

Mr. Brown. Thank you, Mr. Michaud.

 Mr. Filner, do you have a question?

Mr. Filner. Yes, thank you. Thank you for your statement, Mr. 

Michaud.

Can anyone there tell me how many suicides we have had from 

returning Afghanistan-Iraqi troops?

Dr. Cross. Sir, I don’t have that number—

Mr. Filner. I’m sorry, can you speak a little louder?

Dr. Cross. Sir, I don’t have that number with me, but I will take it 

for the record and get you that information.

Mr. Filner. Give me a guess, Mr. Cross. Come on. You don’t have 

it with you? Is it in the thousands? Is it in the millions? Is it 10, is 

it 100? Come on.

Dr. Katz. We have requested information from the National Death 

Index, which records—

Mr. Filner. Nobody there knows how many suicides there have 

been from returning Iraqi soldiers? Nobody there knows? This is disgraceful. You guys are the experts. Many people have attributed sui-
24

cides—not everyone, but the connection between PTSD and suicide is 

very clear. Surely you would want to know how many suicides there 

are, to see if this is a problem or not.

Colonel Ritchie. Perhaps I can answer that question. I believe 

that the number of suicides in active duty soldiers after they have 

returned from Iraq is about 78. However, I will need to confirm that 

exact number.

Mr. Filner. I have seen higher, much higher estimates. I don’t 

know, you have—you have hedged it with “ active duty.” I don’t 

know what that means. I have seen in the hundreds. I have also 

seen—and if you dispute this, let me know—that the suicide rate is 

much higher in this population than in either the normal veteran 

population or the normal civilian population; is that true, or not?

Colonel Hoge. Sir, no, the suicide rate actually consistently has 

been lower in the military than civilian populations that are comparably matched in terms of the age and demographics.

Mr. Filner. I am saying the returning Iraqi- Afghanistan soldiers. 

Use my language. You take whatever I say and use your own language, and which gives all kinds of caveats and bureaucratic—I said 

one thing, you said “ the military.” That means everybody, now, in 

the military, including all the guys at the desks, right?

 So is the suicide rate of returning Iraqi and Afghanistan soldiers, 

Marines, and anybody who is involved there, even civilians, higher or 

not, than the general population?

Colonel Hoge. No, sir.

Mr. Filner. I have different information. I think that is at least a 

matter of debate.

 But, as I think Col. Ritchie said, any suicide would be important. 

Of course, you cloak that concern with all kinds of—suicidal events, 

what the hell is a “ suicidal event?” It’s an attempted suicide or a real 

suicide, probably, but the way you talk about them dehumanizes it, it 

takes the passion out, takes the emotion out.

 Okay, whatever the rate is, let’s say it is 83, somebody said 83 earlier. You said 78. I have seen hundreds. Have we done everything 

we could to prevent those, is what I want to know. Every one of you 

said what a great job we are doing. I don’t question that we are doing 

a lot. I don’t question your own commitment to this. I don’t question 

your own sincerity in this.

 But you have an opportunity here, in front of people who have said 

they are concerned and control the resources that you get. What do 

you need to do your job better? Tell us. What resources do you need? 

Not one person has said “ We need additional resources,” or “ We 

would like to have additional this.” You have said “ Everything is 

fine.” Col. Ritchie said, “ We have all the tools that we need.” Everybody else, “ Oh, we are doing such remarkable things.”

 How come every one of us here, and I’m sure you, too, have heard 
25

story after story after story that we are not doing our job? Because 

we are doing part of it, but we are not doing a lot. To whom much is 

given, much is required. We are the richest nation in the history of 

the world. If we can’t devote the resources we need to do this, to take 

care of every single person who needs the help, we are not doing our 

job.

 So what else do you need to do your job? Not one of you has said 

that to us. You have got some very sympathetic people here. We 

want to give you resources. What would you do? How would you do 

your job better? Every one of you, how would you do your job better 

if you have more resources?

Dr. Cross. Sir, we are committed to doing the best job that we 

can—

Mr. Filner. Oh, come on, Dr. Cross. Tell me what you need to do 

the job better.

Dr. Cross. I screen every single patient that we have for depression—

Mr. Filner. But as Mr. Michaud said, maybe half—we don’t know, 

maybe half the people aren’t even coming in to you. How do we reach 

out to them? Do you need any more outreach help?

Dr. Cross. We are making a tremendous effort in outreach.

Mr. Filner. I can’t believe you guys.

Dr. Cross. Can I tell you about some of—

Mr. Filner. I can’t believe you, all of you. We are giving you a 

chance to say what you need. Let us see, we have 150,000 troops in 

Iraq now, probably several hundred thousand have come back, probably another couple hundred thousand are going. I would say that 

adds up to maybe a million children of families. What are we doing 

for the children to tell them about PTSD when their daddy comes 

home and their mommy comes home? What do we tell them about 

the nightmares that their parents are going to have? What do we 

tell them about why they are being slapped in the face, or why their 

father tried to kill himself? What are we doing for the children?

Colonel Ritchie. Perhaps I can address that one. We have got a 

number of new educational products, which is part of the solution, 

but not all of the solution.

Mr. Filner. You held up a training manual, one of you. Where is 

the comic book that will help kids understand what is going on?

Colonel Ritchie. Well, there are those products out there. There 

is a new Sesame Street video for children of deployed families, there 

is a new “ Mr. Poe Goes to War” educational product—

Mr. Filner. Tell me about those. Those sound very interesting. Is 

everybody given one? How do they get them?

Colonel Ritchie. Okay. They are available in a number of sites 

from our Army community service—

Mr. Filner. Does anybody go to the families and deliver the—
26

Colonel Ritchie. The Army community service has been very active in outreach to families, and they are hung on a number of websites—

Mr. Filner. And everybody who would need this has gotten their 

hands on it? Would you say that?

Colonel Ritchie. No, I would not—

Mr. Filner. So what would you do to make sure that everybody 

gets access to them?

Colonel Ritchie. Well, I think we are in the process of doing that 

right now, but we are not there yet.

Mr. Filner. So what do you need to do the job better? How many 

times do I have to ask it?

Colonel Ritchie. I think, sir, if I could say in my personal opinion, 

my personal opinion—

Mr. Filner. I know, is not approved by OMB. That is what I would 

love to hear.

Colonel Ritchie. The area that I am very concerned about is the 

family members of the deceased, and the family members of the 

wounded. And the family members of the deceased in many cases 

move off our installations, off our posts. And I think we need to, as a 

system, continue to do more.

 Now, the vet centers do offer them counseling through their readjustment centers. But I am not sure if everybody knows about that. 

So that is one area where personally, I think we need to do more. 

Over the long term, not just the short term.

Mr. Brown. Mr. Filner, I think you much for your questions. Your 

time has expired.

Mr. Filner. Are we going to have another round, Mr. Chairman?

Mr. Brown. We will have another opportunity.

Mr. Filner. Thank you.

Mr. Brown. Okay. Mr. Moran, do you have a question?

Mr. Moran. Mr. Brown, thank you very much, Mr. Chairman. 

Thank you for convening this hearing. I think this topic is one that 

is of significant importance. And I apologize for not hearing your 

testimony, although I have read at least in part your testimony, and 

I apologize for not hearing the other questions.

 The reason that I wanted to make certain that I was here was this 

question in particular. I have been reading these statistics, the press 

stories of increased post-traumatic stress syndrome, that the numbers are growing, and which our servicemembers are suffering from 

this condition.

 My question is, is there any statistical evidence related to the 

length of deployment and the number of times that a serviceman or 

woman is deployed in Iraq or Afghanistan? One of the things that I

am greatly concerned about is the request that we are making of our 

servicemen and women to serve longer and longer periods of time, 
27

deployed in the war on terror, and the number of times that they are 

redeployed back to those theaters. And my question is, is there a 

relationship between the presence of post traumatic stress syndrome 

symptoms and the number of deployments, and the length of deployment?

Colonel Hoge. Yes, sir. In the early part of the war, there were 

combat units that were from the Army that were rotated into Iraq for 

varying periods of time. Some were there for less than six months. 

Others were there for longer, between six months and a year. And 

others were in fact there for longer than a year.

 Among those, looking at those data, we did see a linear increase 

in the rate of concerns of post traumatic stress symptoms, and other 

mental health concerns was increased for those who had been there 

longer. Now in the Army, most units are rotating for a year, so we 

really can’t look at that at this time.

Mr. Moran. What about the number of deployments? And this is 

perhaps more National Guard and Reserve units, but again, it appears to me that we are—no, it doesn’t appear; it is true—we are 

utilizing our Guard and Reserve in significant increases in number 

of deployments. And I know from time to time that our servicemen 

and women are returned home, they in some cases believe that they 

have completed their service in theater, and only a matter of a few 

weeks later, learned that they are being redeployed. Is there a mental health consequence to that redeployment, or that series of redeployments?

Colonel Hoge. We have some data from the post- deployment 

health reassessment, and from some of our other surveys that we 

have done, that actually shows that soldiers who have rotated two 

or more times to Iraq have similar rates of mental health concerns, 

compared to soldiers who have rotated only one time to Iraq.

But that is difficult to study, and that doesn’t really answer the 

question, because we also know that soldiers who have been to Iraq 

the first time, for one rotation, have a somewhat higher rate of leaving military service than soldiers who have in, for instance, to Afghanistan or other deployment locations. So there may be a multiple 

deployment effect that we can’t measure because there is a higher 

rate of attrition from service among those who have been to Iraq.

Mr. Moran. Well, commonsense, at least my commonsense tells me 

that there would be a relationship, and that being redeployed has to 

be a significant event in one’s life and their family’s life, with what 

I would think would be just necessary mental health components to 

that redeployment.

Colonel Ritchie. Sir, if I could add to that. We agree with your 

interest and concern, and we are looking at that closely. The Army 

leadership is very interested in that. I mentioned before that we 

have a mental health advisory team in theater again right now for 
28

the fourth time in Iraq, and they are looking at that very issue, the 

post- deployment health reassessment is looking at that. I expect 

that we will have more data emerge over time, as multiple deployments continue.

Mr. Moran. What kind of time frame do you think that you would 

have more data in which we could better analyze the answer to these 

questions?

Colonel Ritchie. In general, the results of the mental health assessment teams have been coming out yearly. We have the results 

from the mental health assessment team sometime this fall, the current MHAT three, the ones from MHAT four will probably be next 

summer or fall. So over time.

 In addition, we have the results of the post-deployment health reassessment, which is coming out continually. So I would say over the 

next year, there will be a number of different sources of data.

Mr. Moran. Anyone else? Thank you very much for your response. 

I just had a genuine concern about what we are doing to soldiers 

and their families, and today’s circumstances that they face. And my 

guess is this is one component, one symptom of the results of multiple 

deployments, and long periods of deployment. And any information 

that you garner in the short run which is of value to us in making 

decisions and encouraging the Department of Defense to do things 

differently—in other words, sooner knowing that information is better, before it is no longer relevant.

 Thank you very much. Thank you, Mr. Chairman.

Mr. Brown. Thank you, Mr. Moran. Dr. Snyder, do you have any 

questions?

Mr. Snyder. I do.

Colonel Ritchie, following up on your bringing up the family members, and I appreciate you bringing up the family members: if a base 

and a family, a spouse get notice—and they are living on the base—

that their active-duty member has died overseas, what is the time 

period in terms of notification, and having to be out of the housing 

and off the base?

Colonel Ritchie. I believe that the answer to that is one year. I

would need to double check for you. That doesn’t directly fall into 

the medical lane, but I believe that it used to be six months, and now 

it is extended to a year. And I will take that for the record, also, to 

confirm.

Mr. Snyder. Because we talk a lot about the support network, that 

they lose that support network, at some point.

 Dr. Hoge, on page nine of your written testimony, you say that 

there are gaps in mental health research. You say, quote, “ specifically, research is limited in the areas of establishing standardized 

treatment strategies for combat related PTSD, long-term longitudinal studies, and studies on the impact of deployments on military 
29

families,” end of quote.

 Why is the research limited? Do you all need more medical research 

dollars from us? Could you benefit from more medical research dollars? Do you have some estimate on how many additional dollars you 

need, or are there other factors? What is the limitation here?

Colonel Hoge. I am only speaking for research within DoD among 

our soldiers, among our men and women who are serving. And in 

general, I think we have done a good job with identifying the problems, and reducing stigma barriers to care, but I think there is a lack, 

a potential lack of standardization of the treatment that soldiers receive, in that soldiers really speak—there is a way of communicating 

with soldiers about mental health issues.

Mr. Snyder. So you are describing the problem, but what is it going 

to take to solve the problem? I appreciate what you are saying there, 

but what kind of money, or what is it that is keeping you from doing 

that kind of study?

Colonel Hoge. I hesitate to quote a specific dollar figure, because 

I don’t think I am allowed to do that. But I would take that for the 

record, and I would be happy to provide—

Mr. Snyder. We can read the First Amendment to you, Colonel. It 

applies in this building.

Without quoting a specific amount, would it be helpful if you had 

additional dollars?

Colonel Hoge. Absolutely. Absolutely. We really do not have 

any—we really have very few treatment studies within DoD that focus specifically on what medications are effective for troops in the 

combat environment; for instance, what are the best cognitive behavioral techniques that speak the language of the soldiers?

 And we are doing a lot. We know a lot. We know that pharmacological interventions are effective. We know that cognitive behavioral 

therapy are effective. And we rely on a lot of good research studies 

that have been conducted outside of DoD. But I think more could be 

done in the area of specific treatment studies for our soldiers, you 

know, within the military, before they leave service.

Mr. Snyder. Thank you.

 Dr. Cross, in your testimony, on page six of your written testimony, you talked about research collaboration between NIH and DoD, 

and you mentioned 55 proposals were received, and that “ those with 

merit are expected to start later this year.” Of the ones that you considered to have merit, were all of them funded? And again, obviously 

it is a bottom line question.

Dr. Cross. For this year, we plan to fund at least six new major scientific projects related to TBI in fiscal year 2007. Spending for fiscal 

year 2007, including research on polytrauma, neurotrauma, amputation, prosthetics, I would estimate to be approximately 75 million.

Mr. Snyder. That wasn’t my question. My question was, do you 
30

have proposals—of these 55—this is your statement, I am just reading from your statement.

Dr. Cross. Yes, sir.

Mr. Snyder. You said you have 55 proposals you received, and that 

those with merit are expected to start later. My question is, do you 

have funding to start all the ones that have merit? Or were some of 

those 35 not able to be started even though you considered them to 

have merit, because you did not have adequate funding? Could you 

have benefitted from some more research dollars?

Dr. Cross. We are going to fund them based on their methodology. 

We are not going to fund them all. Those that meet the criteria that 

we set, those are the ones that will be funded.

Mr. Snyder. I should have become a dentist. Sometimes you have 

to pull teeth around here, don’t you?

Dr. Cross. Sir, honestly I don’t know where the line is going to be 

drawn on that, in terms of the methodology.

Mr. Snyder. Is money part of your methodology? Is that on your—I

mean, we have had previous testimony. This is not a mystery. We 

have had previous testimony that there was not—matter of fact, it 

was in somebody’s written statement from the VA, I think, was it 

from the VA? That there was not enough money to fund all the traumatic brain injury studies. And that was several months ago, and I

am just trying to get a follow-up. We can’t help you if we don’t have 

information.

Dr. Cross. I have with me Dr. Kupersmith, who is heading our 

research effort. If I could introduce him?

Mr. Snyder. Sure.

Dr. Kupersmith. We often have a category of meritorious but not 

funded. I don’t have the numbers for you on that particular review. 

Our general funding rate is about 20 to 25 percent, and that is where 

we target the meritorious proposals. We work with people who are 

below those levels to try to upgrade their proposals, usually, and you 

know, we review them on the next round. But I don’t know in that 

particular review whether there was a category of meritorious but 

not funded. I will get that information for you.

Mr. Snyder. Yes, we would like it. We have had previous testimony to that effect, but more good work could have been done if there 

was adequate funding.

 Thank you, Mr. Chairman.

Mr. Brown. Thank you, Dr. Snyder. And we will entertain a second round of questioning, and I have got a question of Dr. Hoge.

 It is often reported that 30 percent of servicemembers returning 

from Iraq and Afghanistan suffer from PTSD. That is an alarming 

statistic. As a recognized leader in research in this area, what do you 

think—this is true incident rate of PTSD among those returning from 

OEF or OIF?
31

Colonel Hoge. I am sorry, I misunderstood the question, sir, the 

last part of your question?

Mr. Brown. Is 30 percent the right number, or is there some other 

number?

Colonel Hoge. Thirty percent is certainly the right number, at 

least for individuals who experience symptoms. But that doesn’t 

mean that they have the disorder of PTSD. Our estimates based on a 

variety of data sources is that about 10 to 15 percent of soldiers who 

return from Iraq have the disorder of PTSD, and need treatment. 

And then there are additional soldiers who experience symptoms to a 

varying degree, that may need some assistance but don’t necessarily 

reach the criteria for actually having the disorder.

Colonel Ritchie. And if I could add to that; by “ symptoms,” what 

we are seeing very commonly is hyper- vigilance, the increased arousal, nightmares, and sort of just being on edge all the time. And that 

should in most cases resolve on its own over time. The message we 

are trying to put out to our troops and our leaders is that if that 

doesn’t resolve, if it gets in your way with either your family life or 

your work life, come in and see us. And “ us,” we include is chaplains, 

behavioral health, primary care, military one-source. So we try to 

offer a really wide range of options, low-stigma ways that people can 

come and get the help that they need. In many cases, just the education that this is normal is helpful to the soldier.

 I would like to add, too, that I think an important push for us that 

we are doing right now with the aid of Colonel Hoge and his troops 

is BATTLEMIND training for spouses and family members, and parents of soldiers, how can we make sure they are educated in these 

symptoms?

 I had a mother of a soldier tell me a very eloquently how shocked 

she was when her son came home for R&R, and he was just not acting right. And she felt she needed more education on that issue, to 

realize their son might not a very nice guy when he came back for the 

R&R. So that again is part of our increased educational effort to the 

whole collective military family.

Mr. Brown. Do you find that most of the cases coming back, are 

they treated with medicine, or just by coming back in and having the 

community support and family support, that tends to help them overcome that, you know, that stress?

Colonel Ritchie. I think Committee support is absolutely essential. I do not have hard data for you on that, but anecdotally, it makes 

a lot of difference to have the uniform be recognized, to have people be 

thanked for their service. Tremendously important.

Mr. Brown. Then what percent would you say would have to be 

treated with some medicine, or—

Colonel Hoge. I think the question is, what percent need to be 

treated? Is that correct, sir?
32

Mr. Brown. Yeah. I know there are all sorts of treatments, and 

I guess going, having sessions, and—but I am just thinking, if there 

is some long-lasting treatment that would have to be on some, you 

know.

Colonel Hoge. Among the soldiers who have come back from Iraq, 

about a third have received some sort of mental health evaluation or 

treatment. A lot of this is preventative, educational type services, 

and not necessarily treatment for disorders. About 12 percent of the 

troops who come back from Iraq have been diagnosed with some sort 

of mental health problem. That is within the year of return, and 

within our military treatment facilities.

 Once they leave the military and go into the VA system, I think the 

VA has data as well on what percent of individuals who access the 

healthcare system at the VA receive a diagnosis of a mental health 

problem or presumptive diagnosis of a mental health problem. And 

their overall data that I have seen that has been made public, the 

overall rate of accessing care for mental health issues is actually fairly 

similar, though there is a lot higher use of mental health diagnoses.

 I don’t know if that is clear, but it is about a third of individuals access care, and somewhere in the neighborhood of at least 10 percent 

receiving a diagnosis of a mental health problem within the first year 

of coming home.

 Mr. Brown. Dr. Cross, is that a similar number with you? I am 

really just looking to see how many are long-term users of some kind 

of corrective medicine?

Dr. Cross. Sir, I would ask that Dr. Katz answer that, but if I 

might just—I wanted to say one word on how much I appreciate our 

BATTLEMIND technique that has been brought forward by DoD. 

We have adopted this. We are using it in our vet centers. We are 

finding it to be very practical, and very effective, and I want to thank 

my DoD colleagues for their work on that.

And now I will ask Dr. Katz to respond to your specific question.

Mr. Brown. Thank you, okay. Doctor?

Dr. Katz. In terms of the number of people we are seeing—VA sees 

about 31 percent or so of returning veterans—about a third of them 

have mental health concerns or diagnoses. 15 percent have PTSD. 

Other conditions, as Dr. Hoge suggested, like depression, anxiety, alcohol use problems, are also common.

 Information from our National Center for PTSD suggests that 

among those exposed to a significant trauma in military or civilian 

life, about 25 percent will exhibit significant symptoms over time. 

Most of them, though, will recover on their own, or with brief interventions. About eight to 10 percent will require more extended 

treatment. And about 60 percent of those that receive either medications—certain antidepressants, for example—or certain forms of 

psychotherapy, will respond.
33

Mr. Brown. Okay, thank you very much.

 Mr. Michaud, you have a follow-up question?

Mr. Michaud. Yes, thank you, Mr. Chairman.

 Dr. Cross, what happens to the mental health care initiatives that 

are supposed to be beefed up, VA resources for mental health care, 

when the allocated funds sunset? What happens to those initiatives? 

And when does it sunset?

Dr. Cross. The enhancement funds that I believe you are talking 

about? The enhancement funds?

Mr. Michaud. Yes.

Mr. Moran. We are still fully committed to using the full amount 

of those enhancement funds. Here is what we are doing: we want to 

make sure that every one of those dollars that are put forward for 

that is used appropriately. It is taking a bit longer to do that, but 

we want to make sure that those dollars go to the very best purpose, 

to actually make a difference for each of those veterans. So we are 

doing this carefully. We are taking some time, but we are doing it 

as expeditiously as we can, while making sure that it is used very 

effectively.

Mr. Michaud. So when those funds sunset, what happens to the 

initiatives? And when does it sunset?

Dr. Katz. We have been talking about 2008 funding. We can’t 

speak about funding until you speak about funding. I was hired four 

months ago to implement the strategic plan; and empowered to do it, 

we will do it.

 Programs are out there, but it is more than spending money. Implementing the strategic plan really involves culture change. Issues 

like Dr. Ritchie and Dr. Hoge were talking about, integrating mental 

health and primary care is a matter of money, but not just a matter of 

money. Reorienting the specialty mental health sector to provide rehabilitation and recovery-oriented care is a matter of cultural change 

that we are working intensively on. It will be done, but it will take 

time.

Mr. Michaud. Okay. Okay, actually I was just told that once the 

money runs out, then the facilities will have to pick up, so—

Dr. Katz. Yes. One of the conditions of the money going to a facility or a VISN, or regional network, is a commitment that staff hired 

will be permanent staff. And when designated funds run out—if they 

do—the programs and the positions will be continued by the facility, 

or the VISNs.

Mr. Michaud. So if a VISN is running low on money, and they see 

this program, then they probably will not want to accept it, knowing 

that they will have to pick up the cost.

Dr. Cross. Sir, for the VISNs on mental health, we are putting 

out enough money to make sure that they can carry out whatever 

program they need to carry out. Looking at 2005 to 2006, and on to 
34

2007, we are looking at about a 30 percent increase in funding for 

that period of time. The service enhancements are going to make a 

difference. We are going to carry them out. We are going to do good 

things for these veterans, and we are going to make sure that those 

programs that we fund are actually effective, and make a difference.

Mr. Michaud. Well, I respectfully disagree, because I know some 

VISNs that were supposed to have a CBOC within the VISN, they 

refused to submit a business plan because they know they don’t have 

the money to implement it. So I can’t see them doing this.

 What steps is the VA taking now to be able to release funds quickly 

for the new mental health initiatives for 2007?

 Are you doing anything now for the 2007?

Dr. Cross. Sir, we have already got a great deal of work done, 

and we are working on a mental health primary care initiative. You 

talked about stigma. We want to make sure that that is not an issue. 

People are comfortable in coming in to, usually, a primary care facility, and seeing people that they already know.

 What we want to do is to make sure that when we do detect any 

mental health condition, especially things like depression, we want to 

make sure that when we detect it, that we then follow through, and 

have the capability in those primary care clinics. So we have brought 

forward a mental health primary care initiative on which we are going to expand very substantial funds, over the coming years.

Mr. Michaud. And my last question is, how many and how much?

Dr. Katz. Our talk about the primary care initiative is roughly a 

$40 million program. We received 85 responses to requests for proposal, and we will be funding the overwhelming majority of them. 

Other plans for the year are to target specific needs, both in established programs where there are gaps, and also in new programs. 

For example, part of our plan for the year includes suicide prevention 

counseling very much like the ones that Mr. Boswell spoke about.

 Another plan is to put recovery and rehabilitation coordinators in 

the field, really to facilitate, at the local level, the transformations 

discussed in the strategic plan.

Mr. Michaud. Thank you. Thank you Mr. Chairman.

Mr. Brown. Thank you, Mr. Michaud. Mr. Moran?

Mr. Moran. Thank you Mr. Chairman.

 The issues surrounding brain rehabilitation, traumatic brain injury, what is the status of the ability for Bethesda and Walter Reed 

Army Medical Center to meet those needs of our military men and 

women? Do we have sufficient capacity?

Colonel Labutta. I think your question was, do we have the capacity to meet the rehabilitation needs at Walter Reed and National 

Navy Medical Center?

Mr. Moran. Yes, sir.

Colonel Labutta. Thank you. We could certainly do more inpa-
35

tient rehab at both those facilities for traumatic brain injury. I think 

that when we have a soldier there who has had a brain injury and is 

there for prosthetic care for a year, and also had a brain injury; the 

prosthetic care and the prosthetic rehab seems to take first place. 

When there isn’t another injury, what we usually do is try to have 

that soldier transferred to one of the VA polytrauma centers, where 

they have active traumatic brain injury rehab.

 So hopefully, to answer one of the questions of what is a need, there 

is a gap, if you will, for those soldiers who need some inpatient rehab during their acute care, while they are getting acute care, at the 

MTFs.

Mr. Moran. Is that gap caused by lack of dollars, lack of personnel, 

or lack of physical space?

Colonel Labutta. I think the answer to that question, sir, would 

be yes.

Mr. Moran. And I guess also what you are telling me, though, is 

aside from the inpatient treatment that is occurring during the immediate return and medical care and treatment at the Bethesda or 

Walter Reed; then, we are utilizing the VA system to help meet that 

gap in other circumstances?

Colonel Labutta. Yes, sir.

Mr. Moran. And the capacity within the VA?

Colonel Labutta. I am sorry?

Mr. Moran. Is there sufficient capacity within the VA for this 

treatment?

Dr. Cross. Sir, looking at our polytrauma treatment centers, the 

floor of them, 12 beds each; occupancy rate about 71 percent.

Mr. Moran. I thank you. Thank you Mr. Chairman.

Mr. Brown. Thank you, Mr. Moran. Mr. Filner?

Mr. Filner. Thank you Mr. Chairman. Thank you for having this 

hearing today, I think it is very important to our nation.

I am not going to get too much—with questions. Let me just briefly 

say I am more than a little disappointed from the testimony today. I

said in my opening statement that we are letting our veterans down. 

That judgment is based on representing San Diego, California, probably the biggest military and veterans community in the country. If 

not the biggest, one of the biggest. And I talk to my constituents 

every day. We had a lot of statistics from Dr. Katz. I appreciate 

that, but I assume those statistics are based on the patients that 

come in. I mean, two thirds of the almost 600,000 returnees from 

Iraq and Afghanistan don’t access that system, so I am not sure if 

you have—whatever your statistics are, we are missing an incredible 

amount of our population.

 And what saddens me is that we have the expertise—and I don’t 

question your expertise—we have the expertise and the resources not 

to let these young men and women—and some older men and wom-
36

en—down. We know that whatever your statistics say, the Guard 

and Reserve forces who are taking a much more prominent role, as 

you know, in this war; when they get those papers that they have to 

check boxes on, all they want to do is get home. And they can check 

anything that stops that, and if they had to go for a medical inquiry 

for two or three days, they ain’t going to check that box. And they are 

going to have those problems.

 Treating our veterans, as you know, should be seen as a cost of the 

war. We are spending $1 billion every 2 and a half days in Iraq. If we 

can’t take the money that you all need to do your job better, we ought 

to be ashamed of ourselves. We have the money.

 And Mr. Chairman, maybe you and some of the other leaders of the 

Committee could talk to their bosses—I hope they talk to their bosses. Talk to the Secretary of Defense, talk to the Secretary of Veterans 

Affairs. The rules under which you are here, and the kind of statements that you are allowed to make, are not helping our veterans. 

Personally, I know you want to help them. You are not doing it with 

this kind of testimony, and the way you responded to our questions. 

You are simply not doing the job that you can do, and if we have to 

change the rules, Mr. Chairman, and make those arrangements with 

their secretaries, we ought to do that. These people know a lot more, 

need a lot more, then they are telling us here. And you have lost an 

opportunity for our veterans. We have lost an opportunity to use 

your expertise. That saddens me, and I wish we could find a way to 

talk more freely, because as Dr. Katz says, you know, we have the 

money. You have the expertise. Let us join those two together. We 

want to give you the money. We want to make your arguments, but 

you are not helping us, and I wish you could find a way to do that in 

a better way.

 And I thank you, Chairman.

Mr. Brown. Thank you, Mr. Filner.

 Mr. Michaud, for a brief statement.

Mr. Michaud. Thank you very much, Mr. Chairman, once again for 

having this hearing. I also want to thank the panel, for your willingness to come here, and I look forward to working with you. I want to 

thank Mr. Filner, as well.

 In closing, Mr. Chairman, I just want to say that actually, Mr. 

Filner’s remark actually reminded me, yesterday, we actually heard 

from two veterans that came back from Iraq, and one of them, exactly 

how they answered the question, made a difference in whether or 

not they get home immediately or not. So it forced them to answer 

the question in such a way that they could go home to see their loved 

ones. So there are problems out there, and as Mr. Filner has mentioned, and others, hopefully that each and every one of you will look 

down deep in your heart, and really—because I know you know what 

is going on out there—and encourage your bosses to come forward 
37

and put forward an aggressive program that is funded. You have the 

tools, but we have got to make sure that each and every veteran has 

access to those tools, and that you don’t have to wait for services.

 So once again, I want to thank the panel for coming today. And 

thank you especially, Mr. Chairman.

Mr. Brown. Thank you, Mr. Michaud. And let me tell you, I want 

to thank you and Mr. Filner and the other members for their participation today, and certainly thank the panel for what you do with 

the resources that are available to you, for solving such a pressing 

problem, that we feel like we need to reach across all lines to help our 

young men and women in their time of need.

 Without further ado, I would like to ask unanimous consent that 

all members have five legislative days in which to submit an opening 

statement, or to revise the extent of their remarks.

 And with nothing further, the hearing stands adjourned, and 

thanks to you all again for your service.

[Whereupon, at 11:50 a.m. the hearing was adjourned.]
(38)

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Questions for the Record

The Honorable Bob Filner

Subcommittee on Health

House Committee on Veterans Affairs

September 28, 2006

Hearing on Post Traumatic Stress Disorder (PTSD) & Traumatic Brain Injury (TBI)

Question 1: VA has consistently claimed that it does not need additional staff to provide veterans and their families with family and 

marital counseling to help veterans and their families stay strong 

and resilient in the face of debilitating Post Traumatic Stress Disorder (PTSD) symptoms.

Question 1(a): In FY 2006, please state by each VISN how many 

veterans received treatment for PTSD. 

 Response: The number of unique veterans by Veterans Integrated 

Service Network (VISN) who received treatment for PTSD in fiscal 

year (FY) 2006 is provided in the chart below. Each veteran is counted only once: there were 345,844 unique veterans treated for PTSD

in FY 2006. 

VISN 1 19356 VISN 8 23456 VISN 17 18231

VISN 2 8856 VISN 9 16655 VISN 18 17733

VISN 3 12875 VISN 10 10761 VISN 19 12104

VISN 4 16570 VISN 11 10501 VISN 20 19685

VISN 5 7963 VISN 12 12909 VISN 21 17361

VISN 6 23488 VISN 15 12940 VISN 22 17522

VISN 7 27106 VISN 16 28521 VISN 23 11251

TOTAL 345,844

Question 1 (b): Of the veterans, who received treatment for PTSD

in FY 2006, please state how many received marriage or family counseling as part of their treatment for PTSD. 

Response: The Veterans Health Administration (VHA) does not 

have specific information on the number of veterans who received 

marriage or family counseling as part of their treatment for PTSD

in FY 2006. However, families are treated in a number of ways in 

addition to conjoint therapy. The treatment of families includes involving them as important participants in the care of veterans with 

PTSD, consistent with the patients’ preferences. Examples include 

the families working with the patient in seeking care; and providing 

the family information about the nature of symptoms, the associated 

disability, and the impact on quality of life. Families are involved 

260
261

with planning treatment and choosing between alternative therapies; evaluating the outcomes of care; and helping to decide when 

treatments should be modified or augmented. Families are also often involved as partners in psychosocial treatments. For example, 

family psycho-educational interventions have been demonstrated to 

be effective in other serious mental illnesses, and they are currently 

being extended to include patients with PTSD. The treatment of the 

family also includes involving them as an important part of the management of PTSD in primary care settings in the VHA. As provided 

in the Department of Veterans Affairs (VA)/Department of Defense 

(DoD) Clinical Practice Guideline for Management of PTSD in Primary Care, VHA primary care providers regularly assess family support and knowledge of PTSD and incorporate family skills training 

into the patient’s treatment plan, when indicated. In addition, assessments of family functioning and relationships are routinely conducted in both primary care and mental health specialty settings.

 Treating the families by involving them in these and other components of care is within the scope of practice for psychiatrists, psychologists, and social workers who are providing care for the patient. 

Continuity and coordination of care may be best accomplished when 

interactions with families are conducted by the same providers that 

are involved in other elements of care. 

Care within our medical centers and clinics extends beyond treatment to alleviate symptoms of PTSD to include rehabilitation to optimize functioning and role performance and promote hope, even in the 

face of persistent symptoms. With the consent of the veteran, families are involved in the process of rehabilitation, as they are in other 

forms of treatment. Their input and inclusions are, as a rule, coordinated through the psychiatrists, psychologists, and social workers 

involved in the planning, monitoring, and delivery of care. 

Care provided by our medical centers and clinics is part of a treatment plan directed toward meeting the veterans’ needs. In conjunction with care provided in VA medical centers (VAMC) and clinics, 

care within our Vet Centers is designed to facilitate readjustment to 

the family as well as the community for veterans affected by combat 

Vet Centers are authorized to address and frequently serve the readjustment and related needs of the family as well as the veteran. The 

services provided by Vet Centers are designed to promote continued 

strength and resilience of veterans and their families in the face of 

stress and stress-related illnesses. 

VA also notes that recently, Congress, under the Veterans Benefits, Health Care and Information Technology Act of 2006, Section 

201, Public Law 109-146 authorizes VA to hire marriage and family 

therapists and licensed mental health counselors and requires VA

to provide Congress with a report on marriage and family therapy 

workload for the treatment of PTSD. VA is currently working on de-
262

veloping a methodology for tracking the number of veterans diagnosed with PTSD receiving marriage and family therapy.

Question 2: Screening recent veterans for PTSD is a vital first 

step towards helping veterans become resilient and recover from the 

psychological wounds of war. Please provide a detailed breakdown by 

each VISN of: 

The number of OEF/OIF veterans who were screened for PTSD

Those screened for PTSD, the number who screened positive 

Those who screened positive, the number who received a followup mental health appointment 

Those OEF/OIF veterans who screened positive, the number who 

completed an initial follow-up mental health appointment. 

 Response: VA has not tracked the number of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who were 

screened for PTSD. Information from DoD indicates that 32.7 percent 

of the 14,467 referrals for positive Post Deployment Health Risk Assessment (PDHRA) screens were for mental health reasons (4731 individuals). Not all of these were specifically for PTSD and VA is in the 

process of sorting out how many of those referred actually came to VA

for care. VA does have the number of OEF/OIF veterans who received 

a provisional diagnosis of PTSD at VAMC, broken out by VISN, between FY 2002 through FY 2006, see chart below. It should be noted 

that a provisional diagnosis of PTSD simply indicates that the veteran responds positive to three of the four items on the screener for 

PTSD. It does not mean that the veteran has PTSD. Additional evaluation and testing would be required to render a diagnosis of PTSD. 

Also the data provided in the chart below have to be interpreted with 

caution because they only apply to OIF/OEF veterans who have 

accessed VHA health care due to a current health question. These 

data therefore do not represent all 631,174 OIF/OEF veterans who 

have become eligible for VA healthcare since FY 2002 or the approximately 1.4 million troops who have served in the two theaters of operation since the beginning of the conflicts in Iraq and Afghanistan. 

Program Evaluation 

VA’s goal is to measure and evaluate the outcome of PTSD screening and treatment methods. VHA currently screens all patients and 

collects data to identify potential PTSD patients. For patients with 

the definitive diagnosis of PTSD, symptom data on functional outcomes are collected. 

 The overall goal of PTSD treatment is based on the individual patient. A patient’s progress is measured in relation to the severity of 

their PTSD symptoms and their functional goals. Examples of these 

functional goals for patients include but are not limited to employment, increased social ability, reduction of anger responses, and reduction of PTSD symptoms. 

VA’s ongoing PTSD program evaluation series, The Long Journey 

•

•

•

•
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Home, reports symptom and functional outcomes of veterans of all 

service eras served by specialized PTSD programs. Preliminary data 

will become available starting in the 3rd quarter of 2007. 

 OEF/OIF Cohort

 When patients screen positive, VA clinicians are instructed to provide follow-up either in primary care or by referral to a mental health 

provider. At this time, VA is unable to provide the number of OEF/

OIF veterans who receive and complete a follow-up mental health 

appointment. VA will provide the numbers when they become available.

 As new programs are developed they are included in the data collection processes. Data for screenings and outcomes for PTSD are 

routinely reported back to a facility and/or program for quality assurance purposes. Data analysis is performed on a national basis to 

determine overall outcomes and needs for these patients. 

Number of OEF/OIF Veterans with Potential PTSD, using a 

VAMC

FY 2002 - FY 2006

Network Medical Centers and Clinics

Primary2 Any1

VISN 1 1732 2011

VISN 2 911 1011

VISN 3 1255 1412

VISN 4 1402 1643

VISN 5 794 900

VISN 6 1940 2227

VISN 7 2421 2763

VISN 8 1998 2378

VISN 9 1324 1603

VISN 10 922 1048

VISN 11 1029 1290

VISN 12 1034 1236

VISN 15 968 1144

VISN 16 2357 2714

VISN 17 1467 1729

VISN 18 1467 1666

VISN 19 1196 1411

VISN 20 1736 2009

VISN 21 1193 1491
VISN 22 1902 2276

VISN 23 1096 1269

Total Counts 1 29018 33754

1. The patient counts were generated by matching a cumulative roster 

of 633,867 unique OIF/OEF veterans, who had been separated from active 

duty as of August 31, 2006, with VA inpatient (PTF) and outpatient (OPC) 

databases for FY 2002, 2003, 2004, 2005, and through 4th Qt. FY 2006. The 

DoD Defense Manpower Data Center identified and provided the identity of 

these veterans to the VA Environmental Epidemiology Service on September 

29, 2006.

2. The number for “Primary” indicates the total number of unique veterans whose primary reason for the inpatient or outpatient visit was for treatment or evaluation of PTSD. 

3. The number for “Any” indicates the total number of unique veterans 

with PTSD, whether or not the primary reasons for the inpatient or outpatient visit was for treatment or evaluation of PTSD.

Question 3: Please identify in detail the systematic barriers VA

has identified to veterans receiving services for PTSD, depression, 

and high risk alcohol use. Please describe VA’s current and planned 

initiatives to overcome these systematic barriers to accessing mental 

health services. 

Response: Through extensive health services research, VA has 

identified potential barriers to veterans’ access to VA services for 

PTSD, depression and high risk alcohol use to include social stigma 

and lack of information. 

 Affordability is a barrier in other care systems but is less so in 

VA. In fact, veterans are able to receive psychological treatment and 

medications from VA at little or no out-of-pocket cost. In fact, VA provides cost-free care for combat-theater veterans for the first 2 years 

after their discharge or release from active military service. Vet Center services are always free for war zone veterans. Many VA mental 

health programs for returning veterans are adding evening or weekend clinic hours to facilitate care for working veterans.

 Other potential barriers to access to VA services are the potential 

social stigma attached to a diagnosis of mental illness and a lack of 

information about mental illness. VHA’s strategy to overcome these 

barriers includes campaigns addressing de-stigmatized mental illness and its treatment, public education, and the development of 

community leaders, primary care providers, chaplains, and others as 

“gatekeepers” supporting the delivery of mental health care. We are 

also providing outreach services from VA medical centers and clinics, 

as well as readjustment counseling centers to provide communitybased education about illness, services, and the effectiveness of care 

to returning veterans. 

 There are also potential provider-related barriers for veterans 

seeking access to VA services. Limited expertise in dealing with men264
tal disorders among some health care providers and the necessity to 

respond to the many other disorders presented by the patients are 

provider-level barriers to obtaining mental health care. VHA is responding to these barriers by including clinical reminders for annual 

screening for major depression, PTSD, and problem drinking, and for 

evaluating symptoms in those with ongoing treatment. To address 

these barriers at the level of primary care providers, VHA is implementing a major initiative to integrate mental health services with 

primary care and to provide both care management for common mental illnesses and alcohol-related problems and support for referrals, 

when needed. To address variability in knowledge, and clinical expertise in delivering, evidence-based psychotherapies, we are planning 

to fund several centers to provide training, supervision, and certification. Other programs will increase the availability of care for mental 

health and alcohol-related problems, both within primary care and 

mental health specialty services, including a national initiative to 

provide a suicide prevention coordinator (SPC) in each medical center. SPCs will work within the community to promote linkages with 

other mental health providers. 

Finally, there are potential system-related barriers. A significant 

system-level barrier that research shows often limits the treatment 

of mental illness in the private sector and other public health settings 

includes the lack of coordination between mental health and general 

health services. VHA is unique in its degree of and emphasis on service integration and provider collaboration. VHA’s integrated care 

teams and national electronic record system allow for consistent communication, consultation, and tracking so that veterans with mental 

illness appropriately receive the initial and follow-up treatment they 

need. Moreover, VHA is implementing a national initiative to integrate mental health and primary services, to further promote service 

coordination and reduce potential system-level barriers to care. 

Question 4(a): Has VA set a goal to increase the percentage of eligible National Guard members and Reservists who utilize VA health 

care in FY 2007? If so, what is the percentage, and how does VA plan 

to achieve that increased utilization goal? 

Response: VA’s goal is to treat all eligible and enrolled veterans, 

including eligible National Guard and Reservists. VA has made extensive efforts to ensure that information is available to returning troops 

about VA services and their eligibility. Ultimately it is each veteran’s 

decision regarding whether or where he or she will seek health care, 

but VA wants that decision to be based on ample information about 

VA and its programs for veterans. The following is a summary of efforts to reach out and educate veterans and their families: 

The Office of Seamless Transition has partnered with the National Guard Bureau to establish 54 transition assistance advisors (TAA), formerly State benefit advisors. A TAA is located in a.

265
every State and territory. The TAAs are National Guard Bureau 

staff that work closely with VAMCs and Vet Centers in outreach, 

education, and referral efforts. 

VA is actively reaching out to National Guard and Reserve members to increase their awareness of VA benefits and services. Since 

May 2005, with the signing of the memorandum of agreement 

(MOA) with the National Guard, VA now has access to National 

Guard troops at the unit drills, family programs, reunions and 

Freedom Salute events. This is a major step in closer collaboration with the National Guard soldiers and airmen. A similar MOA

is being developed with the US Army Reserve (USAR) Regional 

Commands and the US Marine Corps at the national level. The 

goal for these partnerships is to enhance access to VA services 

and benefits during the de-mobilization process and when service 

members return home to increase their education and awareness 

of VA services and benefits at the state and local level. 

VAMC and Vet Centers are heavily involved in DoDs post deployment health reassessment (PDHRA) program for National Guard 

and Reserve members. PDHRA is an outreach, education, identification, and referral program. Vet Center staff has participated 

in over 300 PDHRA screening events with National Guard and 

Reserve units. These screenings have resulted in over 10,000 service members, as of September 30, 2006, being referred to VA for 

follow-up care. In addition to providing this follow-up care, VA

staff actively enrolls National Guard and Reserve members in 

health care. 

Recently VA has agreed to assign 22 Army Wounded Warrior 

(AW2) staff to VAMCs to work with seriously injured soldiers/

veterans and their families. AW2 soldiers have all been medically 

discharged from the Army with 30 percent or greater disability 

ratings. Over 20 percent of the soldiers/veterans in this program 

have a PTSD disability. An AW2 staff will be located in each 

VISN (with two assigned in VISN 7). Seventeen AW2 staff members are currently in place, with five more scheduled to begin 

their assignments by the end of 3rd Quarter FY 07. The VA/AW2 

partnership is a major step in the outreach initiative that will 

help VAMC and Vet Center staff reach out to seriously injured 

soldiers/veterans and their families. 

The Office of Seamless Transition is actively working with the 

Army Reserve and the Marine Corps to develop memorandums of 

understanding (MOUs) to help promote outreach, education, and 

transition assistance. 

In response to the growing numbers of veterans returning from 

combat in OEF/OIF, the Vet Centers initiated an aggressive outreach campaign to educate returning service members of the VA

benefits available to them. The Vet Centers hired 100 Global War 

b.

c.

d.

e.

f.

266
on Terrorism (GWOT) veterans to enhance their outreach services to GWOT veterans. Since the beginnings of hostilities in 

Afghanistan and Iraq, the Vet Centers have seen over 177,000 

OEF/OIF veterans, of which over 134,000 were outreach contacts 

seen primarily at military demobilization and National Guard 

and Reserve sites, usually in group settings. 

Returning veterans outreach, education and clinical (RVOEC) 

teams (funded and monitored through the Office of Mental Health 

Services) collaborate with readjustment counseling services and 

with State veterans affairs offices to provide information about 

VA services. A primary goal of the RVOEC program is to promote 

awareness of health issues and health care opportunities and the 

full spectrum of VA benefits. Some VAMCs began these outreach 

activities before RVOEC teams were funded as local initiatives, 

and they continue these services, now using the RVOEC teams 

as their agents. 

The National Center for PTSD has a number of informational 

pamphlets for returning veterans and their families on their web 

site (http://www.ncptsd.va.gov/). The specific information appears 

prominently on the Web site: 

War in Iraq: Information

This section of the Web site contains the latest fact sheets 

and literature on the war in Iraq. Important links from the 

site are: 

The Iraq War Clinician Guide, 2nd Edition, and two new 

guides on Returning from the War Zone: A Guide for Military 

Personnel and A Guide for Families as well as the VA Operation Enduring Freedom and Iraqi Freedom Seamless Transition Web site. 

In addition, VA provides briefings on benefits and healthcare services at town hall meetings, family readiness groups, and during 

unit drills near the homes of returning Guard/Reservists. Return 

and deactivation of Reserve/Guard units presents significant 

challenges to VA because rotation is irregular and the service 

members spend short periods at military installations prior to release to their Guard or Reserve components. For this reason, VA

continues to refine and adapt traditional outreach efforts to meet 

the needs of those who are currently separating from service by 

focusing at the local armories or reserve centers in the months 

following deactivation. 

Since May 2005, as part of the Secretary’s Letter Writing Outreach Campaign, over 658,000 letters were mailed to veterans 

informing them of VA’s wide range of health care benefits and 

assistance to aid in their transition from active duty to civilian 

life. 

Question 4(b): Of the 326,862 National Guard members and Reg.

h.

i.

j.

267
servists who have separated or been discharged from service since 

FY 2002 through the 3rd quarter of FY 2006, how many are no longer 

eligible for VA health care under the two-year window as a Priority 

6 enrollment? 

Response: DoD’s OEF/OIF separation file shows 631,174 separations through August 31, 2006. Of these separations, 338,879 were 

National Guard members or Reservists. These data indicate that approximately 147,740 had a deployment* end date of at least September 

30, 2004 with 50,054 of these separated members having enrollment 

status with VA. This results in 97,686 or 66 percent of the 147,740 

known separated National Guard members or Reservists reviewed 

during the cited time frame as being no longer eligible for enhanced 

combat veteran Priority 6 enrollment. These individuals remain eligible to apply for VA health care benefits though they may be subject 

to eligibility criteria (e.g., income, service connection, etc.).

 It is important to note that those “combat” veterans who enroll with 

VA during the two-year post-discharge period of coverage remain enrolled at the end of that two-year period of eligibility. VA assesses 

the enrolled veteran’s individual eligibility factors at the end of this 

two-year post discharge period and places them into the appropriate 

priority group. This effectively “grandfathers” those combat veterans 

who are not subject to VA’s current enrollment restriction for new 

Priority 8 applicants. 

 Those combat veterans, who do not enroll with VA during the twoyear post discharge period, may be enrolled based on their individual 

eligibility factors such as service connection or level of income. They 

are subject to VA’s current enrollment restriction for new Priority 8 

applicants. 

*Note: The deployment end date for a National Guard and/or Reservist may not be the actual separation date. 

Question 5: The 2005 SMI Committee report, sent to the Committee on June 23, 2006, recommends that VA develop an initiative 

to address the needs of veterans with Traumatic Brain Injury (TBI). 

“This initiative should consider the development of an educational 

intervention for practitioners both primary care and mental health, 

consider the addition of data-driven and appropriate screening questions, establish a multidisciplinary task force, establish pilot programs 

through Request for Proposals, establish a TBI registry, establish a 

plan for cooperative relationships with DoD, assess the adequacy of 

VHA’s capacity to provide rehabilitation for both veterans with acute 

and chronic TBI, develop a population-based projection methodology, 

and issue RFPs to accelerate research in areas of TBI. 

Response: The following is VHA’s response to each of the 2005 

SMI Committee report recommendations: 

Recommendation 1 Develop an educational intervention for practitioners in both primary care and mental health settings to assist 

268
them in the identification of veterans with unrecognized mild, acute 

and chronic TBI. 

VHA has mandated completion of a 4-hour continuing education 

course, Veterans Health Initiative: Traumatic Brain Injury, for VA

clinicians in a position to provide services to eligible beneficiaries with 

TBI. Health care specialties included are: Physicians, Optometrists, 

Psychologists, Nurse Practitioners, Physician Assistants, Registered 

Nurses, Prosthetists, Orthotists, Social Workers, Audiologists, Blind 

Rehabilitation Coordinators, Speech Pathologists, Visual Impairment 

Services Team (VIST) Coordinators, Occupational Therapists, Physical Therapists, Kinesiotherapists, Recreation Therapists, and clinicians in Readjustment Counseling Centers. The Office of the Under 

Secretary for Health has mandated that the training be completed by 

March 31, 2007. Primary care providers and mental health providers 

are included in this group. New staffs are required to complete this 

education within 90 days of employment. 

The Office of Patient Care Services (PCS) established a work group 

to develop a TBI Information Letter (lL) on the cognitive, behavioral 

and affective disorders following TBI. The work group, co-chaired by 

the National Program Directors for Neurology and Physical Medicine 

and Rehabilitation Services (PM&RS) included VA central office and 

field mental health experts as well as others from the disciplines of 

rehabilitation, primary care, and neurology. The Defense and Veterans Brain Injury Center (DVBIC) also participated. On January 25, 

2006, IL 10-2006-004, Screening and Clinical Management of Traumatic Brain Injury, was released to the field. Following the release of 

the Under Secretary for Health’s IL, the PM&RS National Program 

Office participated in national conference calls to educate the field 

about the importance of screening and treatment of individuals with 

unrecognized brain injuries. 

Recommendation 2 Consider the addition of data-driven, appropriate screening questions to the current clinical reminder system that 

identifies those patients needing further assessment for TBI (i.e., the 

1-question screening from DVBIC [Defense-VA Brain Injury Center], 

Walter Reed). 

 Screening for TBI is currently in the evidence building stage. Research on TBI screening is a major focus for the Polytrauma/Blast 

Related Injury Quality Enhancement Research Initiative (QUERI) 

for fiscal year 2007. A literature review has been completed and a 

workgroup has been charged to develop a clinical reminder for the 

screening of OEF/OIF veterans for possible TBI. This group will identify appropriate follow-up for potential positive screens, and ensure 

the ability to tabulate statistics at the facility, network, and national 

levels on use of the screen, any referrals that result, and outcomes, as 

appropriate. The group recommendations are due to VHA in spring 

2007.

269
Recommendation 3 Establish a multi-disciplinary task force to 

1. Survey and report on the current evidence-based practices that 

would be appropriate in treating individuals with TBI, and 2. Create 

standards of clinical care for the treatment of psychiatric symptoms 

due to TBI. 

 A recent State of the Science Review was published in April of 2006 

that summarizes the evidence base for treating individuals with TBI 

(Gordon WA, et al, Traumatic Brain Injury Rehabilitation State of the 

Science, American Journal of Physical Medicine and Rehabilitation, 

85,343-382). This body of work updates the results from a National 

Institute of Health (NIH) Consensus Development Conference, which 

were published in 1999. The updated review used a methodologically 

sound process for evaluating all available research reports published 

since the NIH conference that met rigorous criteria for inclusion. This 

document has efficiently met the intent of this recommendation and 

will serve to provide evidence- based guidance in the development 

of treatment protocols adopted in VHA TBI rehabilitation programs. 

The above referenced review also addresses the State of the Science 

for psychiatric interventions that can contribute to clinical care of 

persons with TBI. 

 The Polytrauma/Blast Related Injury QUERI maintains a reference 

“library” of relevant research articles that can be accessed through 

the QUERI staff or website. This “library” currently consists of approximately 300 references and is updated quarterly. It will allow 

ongoing review of evidence-based practice relevant to specific treatment protocols or questions. 

Recommendation 4 Establish Pilot Programs (through RFPs) that 

implement cost-effective means of assessment and treatment trials 

identified from the task force report. 

 Findings of the above State of the Science Review will be shared 

with the Office of Research and Development for potential request for 

proposals (RFPs). 

Recommendation 5 Establish a TBI registry that can be used as a 

place for study of this condition in order to create a more sophisticated 

evidence-based, cost effective assessment and treatment strategies. 

VHA PM&RS has a mature national database, the Functional 

Status and Outcomes Database (FSOD), that is used system-wide 

to track active duty and veterans with TBI receiving rehabilitation 

services. The database is more comprehensive than a registry and includes information such as demographics, diagnoses, functional clinical outcomes, and cost. VA and non-VA researchers use the FSOD

database in conjunction with studies on this population.

 The Polytrauma/Blast Related Injury QUERI has developed additional variables that have been embedded in the FSOD software. 

These enhancements will allow additional data to be generated such 

as military demographics, mechanism of injuries, severity and com270
plexity of injuries. 

Recommendation 6 Establish a plan for cooperative relationships 

with DoD, VA primary care, and physical medicine/rehabilitation to 

assure that patients at risk for mild unrecognized TBI are followed 

for early interventions once symptoms appear. 

VA has established an OEF/OIF Clinical Reminder Work Group. 

This group has a time line that will result in a national clinical reminder ready for implementation by Spring 2007. This clinical reminder will cue primary care mental health and other providers to 

screen for individuals with mild to moderate TBI that has not as yet 

been recognized and diagnosed. It will be applied across all VHA facilities and will be mandatory. Clinicians familiar with TBI as well as 

the development and implementation of clinical reminders are participating on this group. In addition, there is active consultation with 

DoD clinical experts. 

VA is participating on a TBI Task Force commissioned by the Office of the Army Surgeon General to review the processes involved 

with the prevention, identification, assessment, treatment, rehabilitation, family support and transitions to civilian life, of service members with TBI. A report of the findings and recommendations is due 

no later than May 17, 2007. 

 The VA Polytrauma System of Care has established 21 Polytrauma 

Network Sites (one in each VISN) that have specially trained teams 

to accept referrals from primary care of individuals with mild TBI. 

These teams have been charged with outreach to providers in their 

facilities and VISNs to promote their services. 

 A joint VA and DoD national conference is scheduled for April 10-

12, 2007, “Evolving Paradigms: Providing Health Care to Transitioning Combat Veterans.” The target audiences for the conference are 

primary care providers and there will be sessions on the assessment, 

treatment and management of TBI. Many of the sessions will be recorded for future continuing education. 

Recommendation 7 Assess the adequacy of VHA’s capacity to provide rehabilitation for both veterans with acute and chronic TBI and 

recommend a regional approach to provide such capacity. 

VA developed the Polytrauma System of Care (PSC) to improve 

access to specialized rehabilitation services for polytrauma and TBI 

patients. PSC will also facilitate delivery of care closer to home, and 

to provide life-long case management services for OEF/OIF veterans 

and active duty service members. 

VA facilities participating in the PSG are distributed geographically throughout the country so as to facilitate access to specialized 

care closer to the home, and to help veterans and their families to 

transition back into their home communities. Interdisciplinary teams 

of professionals have been designated at these facilities to work together to develop an integrated plan of medical and rehabilitation 

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treatment for each veteran. In some cases, polytrauma may cause 

long-term impairments and functional disabilities. VA is committed 

to providing services and coordinating the lifelong care needs of these 

individuals. 

 The four components of the PSC include: 

Rehabilitation Centers (PRCs) - These four regional centers 

(Richmond, Virginia; Tampa, Florida; Palo Alto, California; Minneapolis, Minnesota) are fully operational. They provide acute 

comprehensive medical and rehabilitation care for complex and 

severe injuries and serve as resources for other facilities in the 

PSC. 

Polytrauma Network Sites (PNSs) - These twenty-one sites including the 4 PRCS, one in each of the VISNs, are also fully operational. Their role is to manage the post-acute effects of TBI and 

polytrauma and to coordinate life-long rehabilitation services for 

patients within their VISN.

Polytrauma Support Clinic Teams (PSCTs) - These teams are 

currently under development. They include local providers of rehabilitation services who have the expertise to deliver follow up 

services in consultation with regional and network specialists. 

Polytrauma Points of Contact (PPOCs) - All other facilities will 

provide local PPOCs. These are smaller facilities without the 

expertise or resources to meet the rehabilitation and prosthetic 

needs of the polytrauma patients. Each of these facilities ensures 

that at least one person is identified to serve as point of contact 

for consultation and referral of polytrauma patients to a facility 

capable of providing the level of services required. 

VHA is in the development stages of a comprehensive review of patients with TBI. Currently, all severely injured, polytrauma patients 

are followed for improvement in function overtime in the same manner as all rehabilitation patients. VHA has developed a newly implemented screen to assist in identifying patients with mild to moderate 

TBI. This screening is used for all OEF/OIF veterans. This has been 

implemented recently; therefore, no formal reports have been generated at this time. VHA is still in the planning stages of determining 

the best mechanism to track long term outcomes for patients with 

TBI.

 The goal in FY 08 is to have a measure for mild/moderate TBI of 

percent screened and of those who screened positive. For those who 

screen positive, a full evaluation will begin within 30 days. 

Recommendation 8 Develop a population-based projection methodology to predict distribution of additional and future needs, given 

the markedly higher percentage of TBI in the population of veterans 

returning from OEF/OIF. 

The PM&RS National Program Office is collaborating with the 

Rehabilitation Outcomes and Research Center on a research study, 

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Geographic Access to VHA Rehabilitation Services for OEF/OIF Veterans [and military personnel]. This study will assist PM&RS in planning for the future needs of veterans with TBI and other impairments 

sustained in combat. Funding for this study is provided through a 

Health Services Research & Development (HSR&D) grant. 

Recommendation 9 Issue RFPs to accelerate research in the area 

of traumatic brain injury in order to learn the specific mechanisms 

of action by which they cause mental illness and to develop new and 

better treatments for veterans. 

Prior to the current conflict in Iraq, the Office of Research and 

Development (ORD) established and maintained an active research 

portfolio in the area of brain injury. In response to the needs of our 

returning soldiers with unique injury patterns and polytrauma, ORD

issued Combat Neurotrauma RFP. This research initiative seeks to 

advance treatment and rehabilitation for veterans who suffer traumas from improvised explosive devices and other blasts, including 

TBI. The solicitation was written with input from various members of 

DoD. The solicitation is still active, and investigators are encouraged 

to submit proposals in this area. Applicants are asked to pay special 

attention to: 

Cooperative projects in TBI with DoD; 

Co-morbid conditions with TBI such as post-traumatic stress disorder and trauma to extremities; 

Screening and diagnostic tools related to mild TBI, especially 

field-based; and 

Continuity of TBI care between 000 and VA (i.e., treatment and 

case management over time) 

Col. Geoff Ling, MD, PhD, of the Defense Advanced Research Projects Agency (DARPA), chaired the review panel that included neurosurgeons on staff at the Walter Reed Army Medical Center. 

Multidisciplinary members of the TBI scientific peer review panel, 

including members from VA, DoD, NIH and various academic institutions in the areas of molecular neuroscience, neurosurgery, physical medicine and rehabilitation and neuropsychiatry specializing in 

TBI, have agreed to return to review resubmissions and to serve as 

an ad hoc advisory group for ORD. It is expected that advice from 

the scientific review board will lead to increased submissions in the 

areas of: 

Approaches to short- and long-term consequences of TBI that affect relationships, employment and reintegration; 

Intervention strategies for care giving and family coping; and 

Vocational Rehabilitation training for persons with mild to severe TBI

Proposals deemed meritorious through scientific peer review and, 

therefore, slated for funding include but are not limited to: 

The neurobiology of acute and chronic TBI, 

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Neuroprotection of TBI and effectiveness of interventions, 

Impact of rehabilitation strategies on neural plasticity following 

TBI, using imaging, neurobiological, and cognitive approaches, 

Primary and secondary drug trial interventions following TBI, 

Identification of factors influencing metabolic changes after TBI, 

and 

Treatment trials to enhance cognition and attention and to treat 

emotional, behavioral, and psychomotor conditions related to 

TBI

Scientific administrators from several federal funding agencies, including VA, NIH, DoD and the National Science Foundation, have 

self-assembled to prevent duplication and look for points of convergence and collaboration. 

 Also, ORD staffs are developing a Service-Directed Research project to explore how to improve methods of chronic care for returning 

OEF/OIF veterans with TBI or TBI-related injuries. In addition, 

ORD maintains a broad portfolio of research related to mental health 

issues that could be expected to inform clinicians about issues related 

to TBI. 

Question 6: For each year from FY 2002 through FY 2006, please 

provide us with the number of veterans who utilize the VA medical 

facilities and Vet Centers who a) attempted suicide and b) committed 

suicide. 

Response: VHA cannot provide the definitive quantitative information about rates of suicide, for the following reasons: 

Not all veteran suicides are documented as suicides. For example, 

when the cause of death is not immediately obvious to the coroner 

or medical examiner the death certificate may list another cause 

of death such as heart attack. 

Not all veteran suicides are reported to VA. A proportion of the 

events occur in the community and there is no requirement to 

report that information to VA. 

 Nonetheless, VHA is working on creating systems and procedures 

to obtain more complete information about suicides and suicide attempts in an ongoing manner as part of our efforts to develop an 

evidence-based approach to prevention, and to target care where it 

is most needed. Although VA does not have the systems in place at 

this time that would allow it to provide the requested information, 

it is working intensively to get more complete data, and to apply information on suicides and attempts in quality improvement, and, on 

attempts, in targeting care. 

 As part of VHA’s efforts at suicide prevention, we have implemented 

two important projects. First, to obtain the best available estimates 

for rates and risk factors for suicide together with their geographic 

variation, VHA has obtained data from the National Death Index of 

the cause of death for all veterans who have stopped receiving care in 

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recent years. This is intended to be a sustained activity, with data obtained each year to allow an evidence-based approach to suicide prevention. Second, VISN 19 has developed a systematic strategy for the 

identification of enrolled veterans who have attempted suicide. They 

have identified 170 attempts and 22 completed suicides in the past 2 

years. The ratio of attempts to completed suicides, approximately 8 to 

1, is within the range cited in an National Institute of Mental Health 

(NIMH) Fact Sheet (www.nimh.nih.gov/suicideprevention/suifact.

cfm), and is consistent with what is expected for a population that 

is predominantly male and middle aged or older; this is preliminary 

evidence for the validity of their approach to identifying cases. VISN

19’s methods for creating a listing of attempts are currently being 

replicated in other regions. The goal is to implement it broadly in late 

FY 2007 as a method for targeting care to those patients who may be 

at the highest risk for suicide, and those who have already made attempts to harm themselves. 

 The Vet Center program will be an integral part of VHA’s suicide 

prevention system. Currently, the Vet Center program is also moving 

in the direction of being more evidence-based and oriented towards 

prevention. In 2006, the Vet Centers initiated a suicide prevention 

program in conjunction with the University of Rochester, School of 

Medicine, based on the U.S. Air Force model. The Vet Center suicide 

prevention program is now in the second year of training Vet Center 

staff on a community approach to detecting and intervening in preventing suicides. 

Question 7: Please provide us with FY 2004 and FY 2005 suicide 

rates for each of the following groups of veterans who are enrolled in 

VA health care: Vietnam era veterans, Persian Gulf War veterans, 

and OEF/OIF veterans. 

Response: While that data is not currently available, VHA’s 

has developed an action plan that is included in the Mental Health 

Strategic Plan (MHSP) to develop the necessary data collection and 

policies to address it. As part of that plan, VA has funded a Mental 

Illness Research Education and Clinical Center in Denver to focus 

on suicide prevention, and supported it to develop and disseminate 

methods for maintaining a facility-by-facility “registry” of suicide attempts, and its use for both identifying veteran specific risk factors, 

and targeting enhanced care. VHA will designate suicide prevention 

coordinators in each of our medical centers. Their responsibilities will 

include implementing new policy and procedures developed as part of 

the MHSP. 

Question 8: Please provide a detailed update of VA’s efforts to 

implement the VA’s Inspector General’s recommendations in the report titled “Health Status and Services for Operation Enduring Freedom/Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation,” Report Number 05-0181-165, dated July 12, 2006. 

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Response: The Inspector General’s report included four specific 

recommendations, below is VHA response to each of the recommendations: 

Recommended Improvement Action(s) A: The Under Secretary for 

Health should improve case management for TBI patients to ensure 

life-long coordination of care. 

Case management has a crucial role in ensuring life-long coordination of services for patients with polytrauma and TBI, and is an 

integral part of the system at each polytrauma care site. PSC uses a 

proactive case management model, which requires maintaining routine contacts with veterans and their families to coordinate services 

and to address emerging needs. As an individual moves from one 

level of care to another, the case manager at the referring facility is 

responsible for a “warm hand off” of care to the case manager at the 

receiving facility closer to the veteran’s home. Every combat injured 

veteran with TBI is assigned a case manager at the polytrauma system of care facility closest to his or her home. The assigned case manager handles the continuum of care and care coordination, acts as the 

point of contact for emerging medical, psychosocial, or rehabilitation 

problems, and provides patient and family advocacy. 

The Office of Social Work (OSW) revised VHA Directive 2005-017, 

“Social Work Case Management in VHA” in May 2006 to completely 

describe the functions expected of Social Worker Case Managers, the 

requirement for after-hours coverage, and the requirement for transfer of case management functions to a case manager at the facility 

providing follow-up care. OSW is also collaborating with rehabilitation services in hiring and training social worker case managers at 

the PRCs and PNSs. Documentation templates for social work case 

management follow-up have been developed. 

Consistent documentation of case management follow-up in the 

medical record improves communication among professionals involved with the patients’ care. 

 A Polytrauma Telehealth Network (PTN) that links facilities in the 

PSC is available to support care coordination and case management. 

The PTN ensures that polytrauma and TBI expertise are available 

throughout the PSC and that care is provided at a location and time 

that is most accessible to the patient. The PTN allows provision of 

specialized expertise available at the PRCs and PNSs to be delivered 

at facilities close to the veteran’s home. 

Specialized rehabilitation care for patients with polytrauma and 

TBI requires a continuum of services that may include inpatient and 

outpatient rehabilitation, long-term care, transitional living and 

community re-entry programs, and vocational rehabilitation and employment services. The twenty-one PNSs have recently completed inventories of VA and non-VA TBI specific services within their VISNs. 

These are used to coordinate resources to meet individualized treat276
ment needs of patients closer to home. The case managers dedicated 

to the PSC are responsible for identifying and coordinating these services for the individual patient as close to home as possible. 

 During the August 2006 Polytrauma System of Care Conference, 

polytrauma social work case managers received training on expectations for proactive and continuing case management of active duty 

personnel and veterans with brain injury and polytrauma. Monthly 

conference calls are held to mentor and educate the PNS case managers. 

 The OSW, in collaboration with PM&RS, has established a social 

work case management work group. This group is developing a new 

model of social work TBI and polytrauma case management that will 

address the care coordination, psychosocial and family support issues 

of this special population across different sites, levels of rehabilitation, and health care service delivery. This group is also identifying 

training needs and will work with the Employee Education System 

on a variety of education initiatives. A one-hour training session was 

held in January 2007 via conference call to educate social workers 

concerning the signs and symptoms of mild to moderate TBI. 

VHA is publishing a new VHA Handbook on Transition Assistance 

and Case Management of OIF/OEF Veterans. The Handbook requires 

each VA medical center to appoint a master’s prepared nurse or social worker to serve as the OIF/OEF Program Manager to oversee 

all seamless transition activities, coordination of care for OIF/OEF

service members and veterans, and coordination of case management 

services for severely-injured OIF/OEF service members/veterans, including those with TBI. The Handbook also describes the functions 

of 100 new Transition Patient Advocates, who will be assigned to severely-injured service members/veterans, including those with TBI, 

and their families. Recruitment for the new positions is already underway. 

The Office of Seamless Transition (OST) implemented a seamless transition performance measure for fiscal year 2007. Severely 

injured OEF/OIF service members/veterans who are transferred by 

VA/DoD liaisons at the Military Treatment Facilities (MTFs) must 

be assigned a VAMC Case Manager prior to transfer. This VA case 

manager must contact the service member/veteran within 7 calendar 

days of notification of the transfer. OST developed a tracking system 

into which the VA/DoD social work liaisons stationed at the MTFs 

enter the patients transferring to VA. Starting October 10, 2006, the 

tracking system automatically generates an email to the receiving 

facility when the VA/DoD Liaison enters a potential transfer date. 

The receiving facility assigns a case manager in the tracking system 

and the case manager must contact the patient within seven calendar 

days of notification of the transfer. 

 The VA has partnered with the Army Wounded Warrior (AW2) 

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Program to assign an AW2 Soldier and family management specialist 

to 22 VA medical centers located in the VISN 21. The AW2 staff will 

integrate with existing polytrauma teams and will function as case 

managers for both soldiers and their families. They will work with 

soldiers, veterans and their families to ensure they are fully linked to 

VA care and benefits. Seventeen AW2 staff members are currently in 

place, with five more scheduled to begin their assignments by the end 

of 3rd Quarter FY 07.

Recommended Improvement Action(s) B: The Under Secretary for 

Health should work with DoD to establish collaborative policies and 

procedures to ensure that TBI patients receive necessary continuing care regardless of their active duty status, and that appropriate 

medical records are transmitted. 

 The revised DoD/VA MOA entitled, “Department of Veterans Affairs (VA) and Department of Defense Memorandum of Agreement 

Regarding Referral of Active Duty Military Personnel Who Sustain 

Spinal Cord Injury, Traumatic Brain Injury, or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services” is currently in the Office of the Assistant Secretary of Defense 

for Health Affairs. DoD is shifting billing and reimbursement under 

this MOA from the Military Medical Support Office to the three TRICARE regional offices. There are no changes that impact the transfer 

of clinical care between the two agencies. 

VA and DoD have developed the capability to share electronic medical records bi-directionally to coordinate the care of shared patients. 

The VA/DoD Bidirectional Health Information Exchange (BHIE) supports the real-time bidirectional exchange of outpatient pharmacy 

data, allergy information, lab results, and radiology reports between 

all VA facilities and select DoD host sites receiving large numbers 

of OEF/OIF combat veterans such as the Walter Reed Army Medical Center (WRAMC), the Bethesda National Naval Medical Center 

(BNNMC), and the Landstuhl Army Medical Center in Germany. All 

VA medical centers have the capability to view the DoD BHIE data. 

In addition to BHIE capability, VA and DoD have made significant 

progress toward sharing inpatient data. VA and DoD have developed 

the capability to permit the four VA regional polytrauma centers to 

view DoD inpatient data stored in DoD’s inpatient clinical information system (CIS). This capability provides unprecedented access 

to electronic DoD inpatient data by VA clinicians treating patients 

transferred from DoD and enhances continuity of care between DoD

and VA. This past quarter, VA and DoD also conducted successful 

testing of the bidirectional sharing of inpatient narrative and discharge summaries. 

Recommended Improvement Action(s) C: The Under Secretary for 

Health should develop new initiatives to support families caring for 

TBI patients, such as those identified by patients and family mem278
bers we interviewed. 

The Offices of PM&RS, Social Work, Seamless Transition, Mental 

Health, Spinal Cord Injury and Geriatrics and WRAMC provided a 

national satellite broadcast, “Serving our Newest Generation of Veterans” in May 2006. This live broadcast was repeated on multiple 

dates and times to provide VA staff opportunities for viewing. The 

continuing education program included presentations on understanding the military culture, providing appropriate care across the lifespan; addressing the needs of families of polytrauma patients through 

supportive services; educating patients, families and staff about polytrauma rehabilitation (which includes a video about the four PRCs), 

amputation care, cognitive issues, physical and recreation therapy 

needs of polytrauma patients; and transforming the rehabilitation 

environment to better meet the unique needs of young polytrauma 

patients. 

The PM&RS National Program Office identified a subject matter 

expert in the area of therapeutic support for families dealing with 

stress and loss. During the August 2006 “Polytrauma System of Care 

Conference.” Pauline Boss, Ph.D. provided an educational session on 

the impact of trauma on the family, assisting families with coping 

and strategies for VA providers. VHA is continuing to work with Dr. 

Boss as a consultant. She presented at a conference for Polytrauma 

Rehabilitation Center staff and VA leadership December 7, 2006. 

 The OSW has held four quarterly educational conference calls for 

VHA social workers on polytrauma and seamless transition. Each 

call stressed different aspects of assessing and meeting the needs of 

families of polytrauma and other OEF/OIF patients. 

VHA has hired seven clinical staff members who are assigned to 

the new Center for Intrepid Joint Services Rehabilitation Facility 

(Center) at Brooke Army Medical Center in San Antonio, Texas. VHA

staff will provide clinical services and seamless transition services to 

active duty service members undergoing rehabilitation at the Center and will offer supportive services for families. A memorandum of 

agreement for VA’s role in the operation of the Center was signed by 

Secretary Nicholson in September, 2006, and by the Secretary of the 

Army in January 2007. The Center for the Intrepid was dedicated 

on January 29, 2007 and will be receiving active duty and veteran 

patients for rehabilitation shortly. 

 The VHA PRCs at Minneapolis, Minnesota, and Palo Alto, California, have Fisher Houses to lodge the families of active duty service members and veterans undergoing polytrauma rehabilitation. 

A Fisher House is under construction at the James A. Haley VA

Hospital in Tampa, Florida, with an estimated completion date of 

April 2007. The Fisher House Foundation will break ground for a 

new Fisher House at the fourth VHA PRC in Richmond, Virginia, in 

Spring 2007, with an estimated completion date of Fall 2007. 

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 Each PRC and PNS has established a General Post Fund for family 

lodging and associated needs. Voluntary Service accepts donations 

made to the VA Medical Centers for family lodging into the Family 

Lodging General Post Fund. Social workers access the funds to help 

families defray the costs of hotel lodging, meals, and local transportation at facilities without Fisher Houses or when the Fisher House is 

full. 

 In FY 2006, the OSW helped arrange 48 free airline ticket vouchers 

through the Fisher House Foundation’s Hero Miles Program for the 

families of polytrauma patients so they could visit the patient at the 

PRCs. The Hero Miles Program will continue in 2007. 

 More than 200 VHA Social Workers attended the Uniformed Services Social Work & Seamless Transition Conference in August 2006. 

The VA hosted conference offered a seamless transition track with 

workshops on transferring care from DoD to VA facilities, meeting 

the needs of families, treating combat stress and PTSD, and working 

with veterans suffering from polytraumatic injuries. 

Recommended Improvement Action(s) D: The Under Secretary for 

Health should work with DoD to ensure that rehabilitation for TBI

patients is initiated when clinically indicated. 

 In April 2006, a DoD - VA TBI Executive Board was established. A

TBI Summit was held September 18-20 that brought together nonVA, DoD, and VA subject matter experts to discuss contemporary 

practice concerning the identification and treatment of individuals 

with brain injuries. Outcomes of this meeting included identification 

of priority issues, and building consensus across DoD and VA concerning case management, assessment and treatment. 

 A VA/DoD Rehabilitation Nurse liaison has been recruited and is 

currently assigned to WRAMC. This individual will monitor and follow the severely injured, assess readiness for rehabilitation, communicate closely with Rehabilitation Nurse Admission Case Managers 

at the PRCs, provide updates on medical status, functional status, 

recovery progress, and nursing care issues. The Rehabilitation Nurse 

liaison will have close contact with families, providing education concerning impairments, rehabilitation process, and orientation to the 

VA PRCs. 

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