The Department of Defense and

Department of Veterans Affairs: 

The Continuum of Care for Post

Traumatic Stress Disorder

Hearing

before the

Committee on 

Veterans’ Affairs

House of Representatives

one hundred ninth congress

first session

July 27, 2005

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 109-19

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22-708.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

 Tom Udall, New Mexico

JAMES M. LARIVIERE, Staff Director

(II)
CONTENTS

July 27, 2005

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Department of Defense (DOD) and Department of Veterans 

Affairs (VA): The Continuum of Care for Post Traumatic 

Stress Disorder (PTSD) .............................................................

OPENING STATEMENTS

Chairman Buyer ......................................................................... 

Hon. Lane Evans, Ranking Democratic Member ....................

Prepared statement of Mr. Evans .............................................

Prepared statement of Mr. Snyder ...........................................

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

Witnesses

Pelkey, Stephanie, Spring, Texas .............................................

Prepared statement of Mrs. Pelkey ..........................................

Hoge, Charles W. COL, M.D., Chief of Psychiatry and Behavoir Sciences, Division of Neurosciences, Walter Reed 

 Army Institute of Research, United States Army ................

Prepared statement of COL. Hoge ...........................................

Engle, Jr., Charles C., LTC, M.D., MPH, Chief, DoD Deployment Health Clinical Center, United States Army .............

Prepared statement of LTC Engle ............................................

Friedman, Matthew J., M.D., Ph.D., Executive Director, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs ......................................................

Prepared statement of Dr. Friedman .......................................

Batres, Alfonso R., Ph.D., MSSW, Chief, Office of Readjustment Counseling, Department of Veterans Affairs .............

Prepared statement of Dr. Batres ............................................

Keane, Terence M., Ph.D., President, Association of VA Psychologist Leaders, VA Boston Health Care System .............

Prepared statement of Dr. Keane .............................................

Kilpatrick, Michael E., M.D., Deputy Director, Deployment

Health Support Directorate, Office of the Deputy Assistant

 Secretary of Defense, Department of Defense ......................

Prepared statement of Dr. Kilpatrick ......................................

(III)
Kussman, Michael J., BG, M.D., MS, MACP, (U.S. Army

 Ret.), Deputy Under Secretary for Health, Veterans Health

 Administration, Department of Veterans Affairs ................

Prepared statement of BG Kussman ........................................

Testimony for the Record

Sommer, John, Executive Director, The American Legion .....

Weidman, Richard, Government Relations Director, Vietnam

Veterans of America ...............................................................

Scully, Jr., James H., M.D., Medical Director, American

 Psychiatric Association ..........................................................

Faenza, Michael, President and CEO, National Mental Health

 Association ..............................................................................

POST-HEARING QUESTIONS FOR THE RECORD

Chairman Buyer ..........................................................................

Ranking Member Lane Evans, and Ms. Berkley .....................

 

(IV)

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(1)

The Department of Defense (DoD) and Department of Veterans Affairs (VA): The Continuum of 

Care for Post Traumatic Stress isorder (PTSD)

Wednesday, July 27, 2005

U.S. House of Representatives, 

Committee on Veterans’ Affairs,

Washington, D.C.

 The Committee met, pursuant to notice, at 10:27 a.m., in Room 

334, Cannon House Office Building, Hon. Steve Buyer [Chairman of 

the Committee] presiding.

 Present: Representatives Buyer, Burton, Miller of Florida, Boozman, Evans, Filner, Michaud, Herseth, Strickland, Hooley, Berkley, 

and Udall.

 Also Present: Hon. Ted Poe of Texas, Hon. Grace Napolitano of 

California, and Committee Counsel Linda Bennett.

 The Chairman. The full Committee hearing on the House Veterans’ 

Affairs Committee July 27th, 2005 will come to order.

 Today the Committee is meeting to examine efforts of the Departments of Defense and Veterans’ Affairs to identify recent combat service members at risk for post-traumatic stress disorder, referred to as 

PTSD, including Reserve and National Guard members, and to assess 

their capabilities to meet an increase in demand for PTSD-related 

services from Operations Enduring Freedom and Iraqi Freedom.

 The wounds of wartime service are not always as visible as those 

caused by a bullet or shrapnel. Wounds to the mind and spirit, however, are just as serious and demand every bit as much care and attention.

 We have, since the days when it was called “shell shock,” learned 

much about PTSD. Yet we have much more to learn so that we can 

accurately diagnose and effectively treat it. Perhaps there are ways 

that we can prepare our young warriors before they deploy so that 

they will be less vulnerable to the trauma.

 These are things we must learn about so that we can take appropriate action.
 Recently, the VA Inspector General report indicated that waiting 

times for health care appointments have been underreported, and 

we owe our veterans better, regardless of the burdens of their service 

that they bear.

 So I want to bring this up. I also will note, I read your statements 

last night, and I’m hopeful that the witnesses today will address this 

in your testimony. This recent IG report that was examining the 

state variances in VA disability compensation payments noted some 

really significant numbers. And that is rather alarming, and I welcome the comments from the experts here today.

During fiscal years 1999 to 2004, the number and percentage of 

PTSD cases increased significantly. Now this is from the IG report 

dated May 19th, 2005. While the total number of all veterans receiving disability compensation grew by only 12.2 percent, the number of 

PTSD cases grew by 79.5 percent, from 120,265 cases in Fiscal Year 

1999 to 215,871 cases in Fiscal Year 2004. During the same period, 

PTSD benefit payments increased 1248 percent from $1.7 billion to 

$4.3 billion.

Compensation for all other disability categories only increased by 

41 percent. While veterans being compensated for PTSD represented 

8.7 percent of all compensation recipients, they’re receiving 20.5 percent of all compensation payments. That’s a “wow.” It’s a distortion 

also in the compensation system. I don’t understand the reasons for 

what’s happening out there, and I welcome the input from the experts on this today. And we may even have to do follow-up with 

regard to this.

 I now yield to my Ranking Member, Mr. Evans, for his opening 

remarks.

Mr. Evans. Thank you, Mr. Chairman, for holding this hearing. It’s 

really important to hear from these witnesses today. I hope we can 

move forward quickly on legislation to ensure that the VA and DOD

are taking steps to address mental health care needs for returning 

servicemen and women.

 I also want to thank Mrs. Stefanie Pelkey for her service to our 

country in the Army Reserve and for her husband Michael’s honorable service. We owe so much to you that we can never repay for 

what you have suffered, what you have lost.

 She told her husband’s story in her written statement, and it indicated to me the truth of the perception among veterans that the 

war’s outcome doesn’t end when they come home. Their service to 

this country demands that they get the health care they need, the 

compensation, pension programs and educational benefits and the GI 

Bill benefits they need.

 So, thank you, Mr. Chairman. I appreciate your yielding and your 

time.

[The statement of Hon. Lane Evans appears on p. 69]

2
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The Chairman. Thank you. Our colleague from Texas, Judge Ted 

Poe, wanted to be here to introduce his constituent who will testify 

next, and if you would indulge me, rather than take his statement 

and submit it, if I my read the introduction of his constituent, our 

first witness. This is the statement on behalf of our colleague, Ted 

Poe, of Houston, Texas. Quote: “I want to thank Chairman Buyer 

and Ranking Member Lane Evans for holding this important hearing 

on a problem that impacts all of our communities. Stefanie Pelkey 

is a constituent of mine from Spring, Texas. She was a captain in 

the Army where she served with her husband, Captain Michael John 

Pelkey. Today, Stefanie Pelkey will tell you the story of her husband, 

a man whom she loved who and loved his country and how he was 

a changed man when he came back from Iraq. She will talk about 

their experience as they tried to deal with her husband’s emotional 

turmoil, and she will talk about how post traumatic stress disorder 

hurt both the patient and everyone within their circle of friends and 

families. Her story is an important story as it serves to underline 

an important and growing problem as more and more of our armed 

forces members return from combat with injuries, not all of which are 

physical, and turn to the VA and DOD for assistance.” Ms. Pelkey, 

you are recognized and may take as much time as you like.

STATEMENT OF STEFANIE PELKEY, SPRING, TEXAS; ACCOMPANIED BY MS. SHERRY FORBISH

STATEMENT OF STEFANIE PELKEY

 Ms. Pelkey. Mr. Chairman, Ranking Member Evans, and other 

members of the Committee, my name is Stefanie Pelkey and I am a 

former captain in the U.S. Army. This testimony is on behalf of my 

husband, CPT Michael Jon Pelkey, who died on November 5th, 2004. 

Although he was a brave veteran of Operation Iraqi Freedom, he did 

not die in battle, at least not in Iraq. He died in a battle of his heart 

and mind. He passed away in our home at Fort Sill, Oklahoma from 

a gunshot wound to the chest. My Michael was diagnosed with post 

traumatic stress disorder, PTSD, only one week before his death, by 

a licensed therapist authorized by TRICARE.

The official ruling by the Department of Defense is suicide. However, many people, including myself, believe it may have been a horrible accident. We also believe that he would not have been sleeping 

with a loaded weapon if it weren’t for PTSD.

 When I met my husband, he was responsible and hardworking. He 

loved life, traveling and having fun. He hailed from Wolcott, Connecticut and was one of six siblings. He received his commission from 

the University of Connecticut. Being a soldier was a childhood dream 

for him.
4

We were married in November 2001, and our journey as a military 

family began. Michael deployed for Iraq with the 1st Armored Division in late March of 2003, three weeks after our son Benjamin was 

born. He left a happy and proud father. He returned in late July 

2003. It seemed upon his return that our family was complete and 

that we had made it through our first real world deployment. He 

seemed so happy to be home.

 A few days after returning to Germany, he reported to his primary 

care physician on July 28, 2003, as part of a post-deployment health 

assessment. He expressed concerns to his primary care physician 

that he was worried about having serious conflicts with loved ones. 

The physician referred him to see a counselor. However, the mental 

health staff on our post was severely understaffed with only one or 

two psychiatrists. Michael was unable to get an appointment before 

we moved from our post in Germany to Fort Sill, Oklahoma.

 He noted several concerns on his DD Form 2796, post-deployment 

health assessment. However, the most worrisome notation from this 

form was the admission of feeling down, depressed and sometimes 

hopeless. He also noted that he was constantly on guard and easily 

startled after returning from his deployment.

 When we got to Fort Sill, we both settled into our assignments. Everything seemed normal for a while. Six months later, the symptoms 

of PTSD started to surface, only we did not know enough about PTSD

to connect the dots.

When my husband returned from Iraq, there were no debriefings for 

family members, service members, or forced evaluations from Army 

Mental Health in Germany. As a soldier and wife, I never received 

any preparation on what to expect upon my husband’s return. I believe that it is crucial that spouses be informed about the symptoms 

of PTSD. Spouses are sometimes the only ones who will encourage a 

soldier to seek help. Most soldiers I know will not willingly seek help 

at any military mental facility, for fear of repercussions or even jibes 

from fellow soldiers.

 After months arriving in Oklahoma, there were several instances 

in which I would find a fully loaded 9mm pistol under Michael’s pillow or under his side of the bed. I could not seem to get through 

to him that having this weapon was not necessary and it posed a 

danger to our family. Michael finally agreed to put his pistols away. 

I thought the situation was resolved. As a soldier myself, I could understand that having a weapon after being in war might somewhat 

be habitual for him.

 Little by little, other symptoms started to arrive, including forgetfulness, chest pains, high blood pressure and trouble sleeping. Remembering to mail bills and recalling simple things became a great 

problem for him. One of the greatest tests PTSD posed to our marriage was that Michael began to suffer from erectile dysfunction, 
5

which would cause him to break into tears. He did not understand 

what was happening. I did not know what was happening to my 

husband.

 On other occasions, he would overreact to simple things. One night 

we heard something in the garage. It was still light outside. Michael proceeded to run outside with a fully loaded weapon and almost 

fired at a neighbor’s cat. These overreactions occurred on several occasions.

 These symptoms would come and go to a point that they didn’t 

seem like a problem at the time. There were times that everything 

seemed just right in our home, and he seemed capable enough. He 

was succeeding in his career as the only captain in a research and 

development unit at Fort Sill. It was a job in which he was entrusted 

with researching and contributing to the Army’s latest in targeting 

developments.

 We soon bought a new house, and he was so proud of it. We were 

finally getting settled. Finally, the nightmares began. this would be 

the last symptom of PTSD to arise, and it was the one symptom that 

I feel ultimately contributed to my husband’s death. These nightmares were so disturbing that Michael would sometimes kick me in 

his sleep or wake up running to turn on the lights. He would wake 

up covered in sweat, and I would hold him until he went back to 

sleep. He was almost child-like in these moments. In the morning, 

he would joke around, and, sadly, we both laughed it off.

 However, at this time I do want to point out that Michael was seeking help for all of these symptoms I have discussed. He was put on 

high blood pressure medication. He also complained of chest pains 

and was seen on three occasions in the month preceding his death. 

He even sought a prescription for Viagra to ease marital tensions. 

However, no military physician who ever saw Michael could give him 

any answers. No doctor ever asked him about depression or linked 

his symptoms to the war.

 Michael tried to seek help from the Fort Sill mental health facility 

but was discouraged that the appointments he was given were sometimes a month away. So he called TRICARE and was told that he 

could receive outside therapy if it was family therapy, so we took it. 

Family therapy, marital counseling, or whatever they wanted to call 

it, we were desperate to save our marriage. After all, the symptoms 

of PTSD were causing most of our heartache.

 In the two weeks prior to his death, we saw a therapist as a couple 

and individually. This therapist told Michael that he had PTSD and 

that she would recommend to his primary care provider that he be 

put on medication. He was so excited and expressed to me that he 

could see a light at the end of the tunnel. He finally had an answer 

to all of his problems and some of our marital troubles. It was an 

exciting day for us, not to mention two weeks before his death, he 
6

interviewed for a position in which he would be running the staff of a 

general officer. He was beaming with pride.

 He met with the therapist on a Monday. Tuesday we celebrated 

our third wedding anniversary. It was a happy time. I felt hope 

and relief with the recent positive events. Michael must have felt 

something else. Friday my parents were visiting. I was at a church 

function, and my father returned from playing golf to find Michael. 

He looked as if he were sleeping peacefully, except for the wet spot 

on his chest. His pain was finally over and his battle with PTSD was 

won. No, he wasn’t in Iraq, but in his mind, he was there day in and 

day out. Although Michael would never discuss the details of his experiences in Iraq, I know he saw casualties, children suffering, dead 

civilians and soldiers perish. For my soft-hearted Michael, this was 

enough. Every man’s heart is different. For my Michael, it may not 

have taken much, but it changed his heart and his mind forever.

 My husband served the Army and his country with honor. He was 

a hard worker, a wonderful husband and father. He leaves behind 

a 28-month-old son, Benjamin. One day I would like to tell my son 

what a hero his father was. He went to war and came back with an 

illness.

 Although PTSD is evident in his medical records and in my experiences with Michael, the Army has chosen to rule Michael’s death a 

suicide without documenting this serious illness. I have been told by 

the investigator that PTSD diagnoses must be documented by Army 

mental health psychiatrists to be considered valid. At the time Michael sought help, he knew it was an urgent matter and was not 

willing to wait a month or even a few days. We accepted the help 

TRICARE offered us, and now Michael is not going to get the credit 

that he deserves. Why pay outside mental health providers to care 

for our soldiers if their diagnoses are not considered valid? He is a casualty of war. I have heard this spoken from the mouths of two generals. He came home with an injured mind. And to let him become 

just a suicide is an injustice to someone who served their country so 

bravely. He loved being a soldier and he put his heart into it.

I will be submitting petitions to have PTSD officially documented 

and to have my husband put on the official Operation Iraqi Freedom 

Casualty of War list. There are so many soldiers who have committed suicide due to PTSD in Iraq and received full honors and benefits without an official PTSD diagnosis. Michael deserves the same 

honor.

 If only the military community at that time had reached out to 

family members in some manner to prepare them for and make them 

aware of the symptoms of PTSD, my family’s tragedy could have been 

averted.

 So many soldiers are suffering from this disorder, and so many 

families are suffering from the aftermath of this war. I don’t want my 
7

Michael to have died in vain. He had a purpose in this life, and that 

was to watch over his soldiers. I intend to keep helping him do so by 

spreading our story. He suffered greatly from the classic symptoms 

of PTSD. It is plain to see in retrospect. His weapon became a great 

source of comfort for him. He endured sleepless nights due to nightmares and images of suffering that only Michael knew.

 My husband died of wounds sustained in battle. That is the bottom 

line. And the war does not end when they come home.

 Thank you.

[The statement of Stefanie E. Pelkey appears on p. 76]

 The Chairman. Mrs. Pelkey, thank you for sharing your story. It 

takes courage for you to sit there and share publicly, but I know you 

do that on behalf of your husband. Actually you’re telling his story, 

and I think it’s extremely important.

 Sitting to your left is your congressman, Congressman Ted Poe. 

And he was with the President, but I’m glad he’s now arrived. I want 

you to know, Congressman Poe, I read your introduction of your constituent into the record, but I’ll yield to you for any comments that 

you may have.

 Mr. Poe. Thank you, Mr. Chairman, and thanks for having this 

hearing. Besides the fact that Mrs. Pelkey is a constituent of mine, a 

little more background about her.

 She graduated with an Associate degree from the New Mexico Military Institute in Roswell, New Mexico back in 1996 and went on to 

graduate and receive her commission as a second lieutenant from 

the New Mexico State University in Las Cruces, New Mexico. And 

then graduating officer’s basic course, Mrs. Pelkey received her first 

assignment as the battalion chemical officer for the 1st 94th Field 

Artillery Battalion in Germany. It is important to note that she was 

the first woman to serve in this field artillery battalion and one of the 

first three women in Germany to ever be placed in an all-male combat 

arms unit.

 After she met her husband, they were married on November they 

were married on November 2, 2001, and their son Benjamin was born 

on March 15, 2003 in Germany. Her second assignment was as the 

brigade chemical officer for the 75th Field Artillery Brigade at Fort 

Sill, Oklahoma.

 She left the Army and ended her time in service in September of 

2004. And her husband Michael died on November the 5th, 2004.

 And I want to thank you, Mr. Chairman, for having this hearing, 

and I also want to thank Mrs. Pelkey for her moving testimony.

 I yield back. Thank you.

 The Chairman. Thank you very much. Mrs. Pelkey, your pain will 

last for some time, and I think as those of us here listening to your 

story, we seek to empathize and sympathize with your position. I
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could not help reflect upon my best friend, who was 16, and took his 

own life with a pistol. His baseball cap sits behind my desk so I can 

look at it every day. And a lot of people walk into my office and they 

think probably it’s my baseball cap, but it’s my best friend’s. And, you 

know, I have for the last 27 years, when I think of him, thought of 

why, and what could I have done to prevent it. And it’s going to 

happen to you, you’re going to ask in your mind, “Did I do all that I

should have done?” Now when you do that, what is important for us, 

though, is for you not to place that burden so much upon yourself. 

You’re going to. I do, and will continue to ask, “What could I have 

done?”

 But let me shift it. You touched on the fact that your husband 

sought treatment, but there was an access problem. Can you develop 

that a little more for us to understand? Because here, for those of us 

who have oversight over the VA, the reason we’ve asked the military 

to come here is that these soldiers transition, as you know, from the 

military to veteran status. The VA also cares for some of the active 

duty in our system and then they transition back and VA gets reimbursed for that care.

 For this transition, we are trying to make sure that that health 

care is seamless, so that help is available when you find yourself in a 

position that is very challenging. Help us understand when you play 

this back in your mind, where did the system break down, and where 

should the help have been?

 Ms. Pelkey. I want to point out that at this time that my husband 

was redeployed back to Germany was in the very early stages of them 

even bringing people back from Iraq. I think they were more, or the 

Army was more on a level of preparing for units to come back at that 

time and not individual soldiers.

 They did have the post-deployment health assessment in place, 

and the doctors did refer him to see mental health. But I think the 

breakdown in the system overall for my husband was the lack of staff 

at the mental health facility in Germany at that time. And I know 

there have been improvements since.

 But also, when he was seen at Fort Sill, there was no system in 

place for when these symptoms arise for the primary care providers, 

the nurses, the doctors, to recognize these symptoms. They should be 

able to trigger some kind of post traumatic stress disorder diagnosis, 

you know, or referral when they see some of these symptoms, and 

that’s just not in place, to my knowledge. And I think that’s where 

my husband really, really lost out was that they just didn’t recognize 

the physical symptoms.

The Chairman. So when the doctors were treating the physical 

symptoms, they were being very narrow rather than taking it to a 

PTSD level?

Ms. Pelkey. Right.
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The Chairman. How many doctors did he see, do you recall? How 

many different medical doctors at Fort Sill?

Ms. Pelkey. He saw his primary care provider, who consulted with 

the same physician each time. And I can tell you there were about 

seven or eight different visits for chest pains, high blood pressure, 

erectile dysfunction and even noted depression.

 The Chairman. At any time did you think of or suspect PTSD?

 Ms. Pelkey. No, I did not suspect PTSD. I didn’t really know anything about it at that point. I think that my husband and I thought 

that we were just going through marital problems.

 The Chairman. So when was the first time you heard about PTSD?

Ms. Pelkey. I heard of PTSD shortly before my husband died, when 

he was diagnosed, by his outside provider.

 The Chairman. And who was the outside provider?

Ms. Pelkey. She was a therapist. Her name was Joanie Sailor, 

and she was an off-post provider that generally TRICARE sends the 

soldiers to for treatment.

 The Chairman. So she’s a civilian therapist. Is she a doctor?

Ms. Pelkey. She’s a civilian therapist. She’s an MA. She’s a licensed therapist.

The Chairman. So at Fort Sill -- well, maybe this is a question for 

others -- do you know how many referrals there were -- were there 

others that you knew who were being referred to TRICARE?

Ms. Pelkey. I know that, I mean, from general knowledge, that the 

Army as a whole is having problems with marriage in general, divorce rates and everything. So I can imagine that there are plenty of 

people that are being seen -- 

The Chairman. That’s right. You got there through family therapy 

as the access, because you weren’t getting that access from the military?

Ms. Pelkey. Yes sir. We had the opportunity to, but like I said, 

my husband was not willing to wait. I think at that point he knew 

that we needed to do something immediately, and he was not willing to wait the amount of time which was given to him, which was a 

month.

The Chairman. You know, in the military we talk about the Army 

family, right, the Army of One. And somewhere in there was a breakdown in the family to help take care of our own. I mean, that’s my 

sense by your story here. And that’s very bothersome to me.

 Let me yield at this time to Mr. Filner for any questions he may 

have. You’re now recognized for five minutes.

Mr. Filner. Thank you, Mr. Chairman. And thank you for having 

this hearing, and thank you for scheduling Mrs. Pelkey here with us. 

I know we were all affected, Mrs. Pelkey. I appreciate your courage 

and your willingness to testify in public. It’s very important. I’m glad 

there are people from the DOD and VA here to hear it. I don’t know 
10

if you’ve tried to talk to them, go up that chain of command, but I’m 

glad they heard it.

 We talk a lot, we argue about numbers here. Is a billion dollars 

enough, two billion? But it gets down to whether we have the services for people like you and your husband, and we simply don’t. It 

comes down to being able to get the needed help; appointments not 

being available, and veterans having to wait. It’s not just statistics, 

it’s human beings, and you’ve pointed that out.

 First of all, you made a very powerful statement about families 

being educated. I mean, that’s rather an obvious and fairly simple 

thing in essence, if the Army, and other defense agencies recognized 

it.

 We’ve seen it with our atomic veterans, our Agent Orange from 

Vietnam, PTSD. At first, nobody wanted to recognize the truth. They 

said it’s only just, as the Chairman said, shell shock or it’s in your 

head. And it looks to me, there’s an institutional dynamic to deny illnesses, maybe because it’s going to cost money, or they don’t want to 

admit mental problems on behalf of our brave young men and women.

 But the outreach to families, the outreach to soldiers coming back 

has to be incredibly expanded. I think you would agree with me that 

if you had known this from the beginning, you could have pressed for 

the proper attention. And even if you press for that, by the way, I can 

tell you there’s not enough resources now. And for some reason, the 

VA is still messing around with a mathematical model to tell us how 

many people are going to have mental health problems.

It just doesn’t seem to me they’re recognizing it still. You have an 

important role to play. I hope we can work with you to do that.

 Even with your knowledge now of PTSD, if your husband was not 

diagnosed as PTSD service-connected, there’s no provision for services, is there? If something happened, let’s say two years, more than 

two years down the line, if these symptoms became graver then, he 

would have had the same problems. Is that your sense of it?

 Ms. Pelkey. He would have had the same problems, but I do want 

to make very clear that I have seen with my own eyes that, after my 

husband’s death, that the Army became very proactive on the Fort 

Sill community. They started a program there that has just grown, 

and they’re not waiting around for any models to come out. They’re 

trying to see what works for the soldiers. And they have some very 

low budget programs that are working wonderfully for the soldiers.

 There are group therapies. There are things out there that are 

working that don’t cost a whole lot of money. And they’re working. 

Soldiers don’t want to see PowerPoint presentations. They don’t 

want to see videos. They want to be in a safe environment.

They want to talk with one another, just as I know in my experience 

talking to Vietnam veterans and other war veterans, that they feel 
11

safe amongst themselves talking about it, and this is what they’ve 

done at Fort Sill.

 They’ve modeled the program to integrate the soldiers wherever 

they’re comfortable. They go into motor pools wherever they have to, 

and they’re talking to the soldiers, and then the soldiers that have 

apparent problems are put into group sessions and they talk, they 

joke around, and then they really get down to the problems that they 

have. And this is what’s working, from what I’ve seen.

 So there are things out there that are being done.

Mr. Filner. I think we know how to deal with it if we put the resources in. Do you think the families, whether it’s the spouses or the 

children are getting -- while the service member is deployed, that’s 

when some education should be done. Is that being done also at Fort 

Sill?

Ms. Pelkey. They are -- they have a very strong pre- and post-deployment there now. I mean, yeah, it did take a loss or maybe even, 

you know, a couple of losses. But the command has been very proactive there. They now brief spouses, and they’re starting a program 

for children where they even sit the children down and tell them, you 

know, these are the things that scare mommy or daddy. These are 

the things, slamming doors and -- they try to educate the children 

and they’re trying their hardest, but it’s crucial I think to educate the 

spouses, because spouses, whether they’re male or female, are ultimately the ones that are going to push their spouse to go and get help, 

whether it’s because of marital tension or, you know, just they’re the 

ones. They’re the ones that are going to urge the soldier to go.

Mr. Filner. Yes. I’ve sat in some of the PTSD discussions. They’re 

very powerful. I just hope what you’re describing at Fort Sill keeps 

going even after a change of command. Sometimes these things are 

personally driven as opposed to institutionally driven. And what 

you’ve taken as your job and which we want to support is to get all 

this institutionalized, provide whatever money is needed. We’ve seen 

what happens in Vietnam if you don’t treat the mental state. You 

know, half of the people on the streets today are Vietnam vets, and 

that’s partially because we didn’t take it very seriously.

The Chairman. Thank you.

 Mr. Filner. And we see it happening again, and I appreciate your 

efforts.

 The Chairman. Thank you, Mr. Filner, for your contribution. I now 

recognize Mr. Michaud. Ma’am, he’s the Ranking Member on our 

Health Subcommittee. He’s from the State of Maine.

Mr. Michaud. Thank you very much, Mr. Chairman. I’d ask unanimous consent for my full opening statement to be submitted for the 

record.

 The Chairman. Hearing no objection, so ordered.
12

[The statement of Hon. Michael Michaud appears on p. 74]

Mr. Michaud. Also, Mr. Chairman, I’d ask that testimony from the 

National Mental Health Association be entered into the record.

 The Chairman. We have an entire list when I get to the end that will 

be submitted. They are on the list.

 Mr. Michaud. Okay. Great. Thank you, Mr. Chairman. Mrs. 

Pelkey, first of all, I want to thank you for your courage and your willingness to come before this Committee and share your experience. 

It is tragic what happened to your husband, but your willingness to 

speak out will help many other families who will face the challenges 

of caring for family members with PTSD.

 Many American military families are in your debt for your testimony here today, and for that, I want to thank you for that testimony 

because, unfortunate that it happened, but I think hopefully we’ll 

learn from it and be able to help others.

I just have one question. In your testimony, you indicated that you 

would like your husband to be recognized as a casualty of combat. 

Has the Army explained to you the process by which you can petition 

to have your husband acknowledged as a casualty of war?

 Ms. Pelkey. The fact that it’s not being recognized in his file, in his 

case file, is one reason that the subject has never come up between 

myself or a casualty officer. So it hasn’t been discussed yet. It’s 

something I would like to do, because I believe that it will open the 

door to this being recognized as a wound of war and for them to be 

recognized as casualties.

 And they’ve already done so in recognizing one soldier that I know 

of. His name is Master Sergeant Koontz from Katy, Texas. His family submitted a petition to have him recognized as a casualty of war. 

He committed suicide at Walter Reed in their outpatient -- I don’t 

believe it was a care facility. It was like a motel room, outpatient 

living quarters. And they successfully had him put on the Casualty 

of War list.

 They have opened the door for this to be recognized, and I would 

like to have my husband also on the Casualty of War list because I

truly with all my heart believe that I have the medical evidence and 

just my own experiences that he suffered from this disorder. And it 

will open the door further for other soldiers to be recognized and for 

the illness to be taken seriously.

 Mr. Michaud. Okay. But as of yet, you have not asked and they 

have not offered that process to you as of yet?

 Ms. Pelkey. No one has offered to explain the process. But I also 

have not inquired about the process.

Mr. Michaud. Okay. Thank you.

Mr. Filner. Mr. Michaud, would you yield for a minute?

Mr. Michaud. Yes.
13

Mr. Filner. I do have some legislation aimed at Vietnam, that I

think could be expanded here. If you are a casualty but not from the 

battle itself in Vietnam, your name can’t be on the wall at the Vietnam War Memorial. And this seems to be the same problem.

 In other words, we do not recognize the heroism because of some 

bureaucratic sense that, you didn’t die in battle. We need to work 

together to make that happen both for previous wars and for this.

Mr. Michaud. Thank you, Mr. Filner. At this time I’d yield back 

my time.

 The Chairman. I’ll be more than generous to give you time which 

Mr. Filner had taken from you. All right. Ms. Herseth.

Ms. Herseth. Thank you, Mr. Chairman, and I apologize for arriving late to hear your testimony, but I’ve had a chance to review your 

written statement for the record, and I’d like to echo the thoughts of 

my colleagues here today.

The Chairman. You know what, Ms. Herseth? I apologize. You 

need to stand down.

 Ms. Herseth. We should defer to other of my colleagues who have 

been here a while.

The Chairman. We would request that you would defer to your -- 

 Ms. Herseth. That’s what I will do. Thank you.

 The Chairman. Thank you. Ms. Hooley I think is next.

 Ms. Hooley. Thank you, Mr. Chair. First of all, Mrs. Pelkey, thank 

you so much for taking your time to be here. Your story reminds all of 

us that we need to have a comprehensive approach to addressing the 

mental health needs of our men and women of the armed services.

 With soldiers returning from Iraq and Afghanistan, it places a 

greater burden and demand on our VA hospitals. And I know that it 

is incredibly important that we have the means necessary to treat our 

soldiers that are returning.

 I’m from Oregon, and from our VA hospital, we have had, because 

of budget freezes, we’ve had to reduce the number of therapists. For 

example, we’re about 25 percent short of needed therapists in the 

Portland VA hospital. They’ve been asked to cut their sessions down 

from 50 minutes to 30 minutes. They’ve been asked to have a greater 

length of time between sessions. It used to be well, can you deal with 

this in ten sessions? Well, we all know when you have mental health 

problems, some of those sessions, I mean, sometimes you can deal 

with it fine, sometimes it’s going to take 35 or 50, whatever it takes is 

what we need to be doing.

 One of the things -- because in Oregon we don’t have a base, we 

have a lot of soldiers returning from the military, but a lot of them 

are Guard and Reserve. So one of the things we did because we knew 

this was going to be a problem, and we brought everyone involved in 

the military together with employers.

 We brought our mental health workers together and said we need 
14

to do more than just a debriefing when the soldiers return. We need 

to make sure their families are included, and that we do this not 

just the first time when they return, but we do it three months, six 

months, because a lot of these problems don’t come up until much 

later. I mean, sometimes it happens six months later, sometimes it 

happens a year later.

 My question is, what kind -- I mean, you talked a little bit about 

what resources were available and if you wanted to get in sooner 

than a month, he had to go off base. But is there now any place for a 

spouse to go or a soldier that’s returning to just say, hey, something’s 

wrong here? I don’t know what it is, but something’s wrong. Is there 

someplace you can go now?

 Ms. Pelkey. Yes. And I apologize for only being able to use Fort Sill 

as a resource, but -- 

Ms. Hooley. Right. That’s what you know.

 Ms. Pelkey. -- that’s near and dear to my heart and they have done 

an excellent job in trying to reform their program, and they have also 

really started to focus on the spouses there.

I know that just recently, a group of drill sergeants that returned 

from Iraq were counseled, and out of about 50 drill sergeants, 12 of 

those needed referrals, as well as they had a session with just the 

wives of the drill sergeants, and it was just kind of a closed, informal 

discussion. And that’s the way they’re approaching it at Fort Sill is a 

comfortable setting. These spouses all had a chance to say, you know, 

I feel the same way. I feel like my husband is not here anymore, or 

he’s disconnected. He doesn’t love me. I don’t feel pretty any more. I

don’t feel wanted by my husband. And they realized, hey, this is not 

just some kind of divorce phenomenon, it’s for a reason.

 And that’s the approach they’re taking there. Another point I wanted to make is that the consistency with the care providers, whether 

they be primary care providers, physicians, or mental health physicians, the soldiers have even said, I see a different person every time. 

I’d like to see the same person for at least six months, for at least a 

year, the same person who will be able to recall some of the things 

that I’ve spoke about, some of the things, the deep personal things 

that I’ve shared with them.

 And the armed services, they’re having a problem keeping these 

contracted people to stay there for that length of time. And they need 

to support, they need the money to keep that consistency, to keep 

those providers there for up to a year to follow up with these soldiers. 

And they do need a system of checks and balances.

 And there are also hotlines that have been set up where even some 

soldiers can talk directly 24 hours a day to the on call mental health 

physician there. And they have actually intervened 20 suicide attempts.

Ms. Hooley. That’s really good news The thing that bothered me 
15

most is that if you have to see a different person every time, it seems 

to me you’re telling your story over and over and over again and not 

making forward progress.

 Did your husband when he came back, or did you -- did they talk 

about what signs to look for, for PTSD?

Ms. Pelkey. They did not talk to me as a spouse about it.

 Ms. Hooley. Did they talk to him about what you need to look for? 

Do you know if that happened?

Ms. Pelkey. The only counseling my husband got when he came 

home was like I said, in the post-deployment health assessment, but 

they mostly talked about backaches, knee pains. She made a referral to see a mental health physician, but like I said, in Germany at 

that time, there was only one or two psychiatrists for the whole community.

 Ms. Hooley. How long did it take before you or your husband recognized that this was a serious problem after he came back? Was it 

a week, a day, two months?

Ms. Pelkey. Well, initially, he showed signs of anxiety, appetite 

loss, but these all subsided within weeks. When we got back to the 

United States, it seemed like they were almost all gone and everything was back to normal. And six months later, everything started 

to surface in small increments.

 The pistol, him sleeping with the pistol or carrying a loaded pistol 

around lasted for, you know, one to two months until I finally thought 

it was resolved. He put it in a high place in his closet. And I thought, 

okay, well, that’s done. Then, you know, a couple of months later, he 

started having problems with his blood pressure, chest pains, erectile 

dysfunction, and -- thoughts. Okay, well, he has a problem with blood 

pressure. He got it physically treated with blood pressure medication. The erectile dysfunction caused marital problems.

Ms. Hooley. Right.

 Ms. Pelkey. But they are also noted physical symptoms of post 

traumatic stress disorder. And I truly believe with all my heart that 

that was the root of our marital troubles, family problems. And as a 

spouse, if I had been informed about these things and I had talked to 

other women or just a counselor about these things, I think that not 

only would I have understood what was going on, I would have urged 

my husband to get help more quickly, and I would not have had the 

reactions that I did to my husband’s problems.

 When he would forget things, I would yell at him. I would say how 

can you forget to mail a bill? You’re a captain in the Army. I just don’t 

understand. You are not -- this is not the same person that left. But 

if I thought something else was wrong with him, I would have never 

labeled it or known that it was post traumatic stress disorder. And 

with the intimacy issues, it’s very personal, but it needs to be said. A

lot of the soldiers are suffering from intimacy issues with their wives, 
16

and I believe it’s directly related to the high divorce rate. Because 

that is one of the symptoms, and it does cause problems when you 

are so consumed with what you saw over there that you can’t function with your wife and with your family. Some of the soldiers have 

even noted that they come home and they send their children to their 

rooms. They don’t want to interact with their families.

The Chairman. Thank you, Ms. Hooley.

Ms. Hooley. Thank you so much for taking your time and your 

testimony.

 The Chairman. Thank you. I now recognize Ms. Berkeley. Ma’am, 

she’s our Ranking Member on Disability Assistance and Memorial 

Affairs from the State of Nevada.

 Ms. Berkley. Thank you, Mr. Chairman. Mrs. Pelkey, I want to 

thank you very much for coming here and sharing what is a very intimate tragedy with all of us and with our country. People need to hear 

these things. While you were speaking and when I read your testimony last night, I was trying to put myself in not only your husband’s 

place but in your place. You never know how you’re going to react to 

something unless you’re actually thrust into the situation.

 I grew up during the Vietnam War. I was in high school and college. And so many of the kids that I went to school with that went 

to Vietnam came back dramatically changed, and it seems like those 

that were the most quiet and the most sensitive were the ones that 

were most dramatically affected by what they saw and experienced 

over there, and I suspect it’s very similar in Iraq right now.

 What astounds me now as a member of Congress is that knowing what transpired in Vietnam with our veterans that returned and 

knowing the mental problems that they experienced, and knowing 

that so many of our homeless in this country are veterans of the Vietnam War, and I meet with my homeless veterans quite often in Las 

Vegas. They’re my contemporaries. And, you know, you think if not 

for the grace of God. They went to war as kids, 19, 20, 21 years old, 

and they came back changed forever.

 I would have hoped by now that we would not put such a stigma 

on mental illness as to pretend it doesn’t exist or to avert our eyes or 

don’t put the necessary resources in so that we can truly holistically 

treat these men and women that are coming back and help to educate 

the families that are here so they could recognize the symptoms and 

get help.

 So it seems to me from what you were saying and from what I feel 

is that we need a multi-pronged approach to this, but we need to 

provide resources so we can counsel the families before their loved 

ones return so you know what to expect, and then put the necessary 

resources in so we can hire the right amount of professional people 

that deal with mental illness.

 Because you are quite right. Taking care -- providing medication 
17

for high blood pressure or providing Viagra for erectile dysfunction is 

just superficially treating symptoms that aren’t really going to get to 

the core of the problem.

 So I again want to thank you for being here and for all of your 

sacrifice on behalf of this country. And let’s make sure that your husband’s death is not in vain and that we help hundreds of thousands of 

other Americans that are coming home and are suffering needlessly. 

And if there’s any way that we can help and support them, we should 

be in this with both feet.

 So thank you very much. And perhaps if I can suggest it, I’m sure 

your member of Congress already has this in the back of his mind, 

perhaps you can work with him and make sure that your husband is 

recognized appropriately. I think we would all be very happy when 

that happens for you.

 Thank you very much for being here.

Ms. Pelkey. Thank you.

The Chairman. Thank you, Ms. Berkley. Congresswoman Grace Napolitano, please come on up here and you may sit on the other side of 

Ms. Berkley. That’s where Mr. Udall sits. You may join us here on 

the dias.

 She is Co-Chair of the Mental Health Caucus, and we welcome you 

to the Committee. With no objection, we’re pleased for you to join 

us.

 Okay. Ms. Herseth, we’ve been waiting for this.

[Laughter.]

 Ms. Herseth. Well, I appreciate that, Mr. Chairman. And in deferring to my colleagues who have certainly shared with our witness 

today our concern, our empathy for the situation that you face and 

our appreciation for your courage and your willingness to share your 

experiences and how that guides this Committee and other members 

of Congress.

Congresswoman Napolitano and the hard work that she’s doing 

with many of our colleagues with the Mental Health Caucus to eradicate the stigma that Ms. Berkley indicated is a shame still exists. 

And in your written statement, you had indicated that you sensed 

particularly perhaps in the military environment on the base how 

that may or may not be exacerbated when one returns and what that 

means for one’s career and the fears that perhaps your husband had 

in that regard.

 So I appreciate you being here and working with us to address this 

issue as a matter of sufficient resources, but also how we go about 

allocating various resources in ways that are not only going to get at 

the heart of the problem but help us to identify what symptoms are 

becoming manifest sooner so that we can seek treatment that is going 

to be unique and particular to each individual based on what he or 
18

she may be suffering.

Just a couple of questions. The first is, some military treatment 

facilities are using nurses to help manage patients’ care. Do you believe that a person whose job it is to look at the whole picture of the 

patient’s care may have helped your primary care doctor to connect 

the dots of your husband’s symptoms and led to an earlier and better 

treatment of the PTSD from which he suffered?

Ms. Pelkey. Yes I do. And I believe that it is of tremendous importance for not only -- I know we’ve been talking about educating the 

families and the spouses and the children, but something has to be 

done also for the medical profession to also help them because they’re 

overwhelmed. It’s not -- it’s a lack of education too there and a lack of 

time and a lack of funding there also.

 They do the same thing with pregnant women on most military 

posts. I know when I was in Landstuhl, Germany, I saw a different 

provider every time, a different health care provider every time I was 

given a screening for my pregnancy. And it’s the same thing that’s 

going on with these soldiers. They’re seeing some one different every 

time. They need to see one person that’s in charge of everything and 

that’s keyed onto these physical symptoms also.

 Ms. Herseth. So your sense is that if we’re addressing the issue of 

turnover and the need for the continuity of care, but at the same time 

looking at individuals that are providing health care to our veterans, 

perhaps nurses, where we may or may not have as much turnover 

based on which facility the soldier may be getting treatment, that 

if we at least in the short term while we address these issues going 

forward more effectively that there needs to be one person that you 

get to see on a more ongoing basis rather than, as you just described, 

someone different each time you come in, each week, each month, each 

three months, however frequently one is going to seek the care?

 Ms. Pelkey. Yes. Consistency is -- 

Ms. Herseth. And then the last question is, when you completed 

your service, were you briefed on your VA benefits and resources for 

your family? Were you aware that the vet centers offer bereavement 

counseling, and has the vet center in your area been of help to you 

and your family during your time of grief following your loss?

 Ms. Pelkey. When I exited the service of course my husband was 

not deceased, but I was given a very intense briefing on my benefits. 

And I also had help with my disability, with my application for disability. And, yes, I have used the grieving services with the VA.

Ms. Herseth. I’m pleased to hear that. And, Mrs. Pelkey, thank 

you very much for being here today. I yield back, Mr. Chairman.

The Chairman. Thank you very much. And I yield to Mr. Udall.

 Mr. Udall. Mr. Chairman, thank you very much, and I appreciate 

very much the Committee focusing on this very important issue.

 Mrs. Pelkey, thank you for your testimony. Clearly, it’s very dif-
19

ficult, as all of us can see, for you to tell your husband’s story here 

today. But rest assured, I think with your courage and the courage of 

others and all of you stepping forward and talking about this, I think 

it really makes a difference in terms of moving the cause forward, 

and not only do we hear it, but I think the word spreads to many, 

many others.

 I was struck by what you talked about in terms of the contrast between the military and TRICARE. And I think what I heard is that 

it was in TRICARE where this was discovered and was starting to be 

dealt with.

 And that tells me a couple of things. One is that the military were 

not focusing enough, although there’s very hopeful things you’ve talked about in terms of Fort Sill and the involvement that’s going on 

there. But tell me a little bit about the TRICARE situation and what 

enabled them to discover what was going on? And did you feel that 

they were on the right path at the time?

Ms. Pelkey. I believe the reason that my husband and I had to seek 

help from TRICARE is that the military, and especially the medical 

facilities, are not receiving the funding and the help that they need 

to make these diagnoses, have the consistency that I’ve been talking 

about.

 TRICARE offered marriage or family counseling for my husband 

and I. And like I said in my testimony, we took it, because we felt 

at that point that our marriage was falling apart, and we wanted to 

save it. And whatever you want to call it, TRICARE sent us to an off 

care provider for quote/unquote “family therapy.” That’s what it was 

coded as.

 And I think that’s where the problem is, is that a lot of these soldiers are having family problems and family issues connected to post 

traumatic stress disorder which you can directly link to the divorce 

rates and the suicides.

 But TRICARE does have off post providers, and she did immediately recognize the symptoms of post traumatic stress disorder. I have a 

letter that she’s written. And I just really feel that the military medical community is overwhelmed with not only post traumatic stress 

disorder, but with everything that goes along with that; the families, 

the stress in the families. I mean, so many things.

 I know as a soldier myself, I could get a same-day appointment to 

see a military medical doctor. But the problem is, is that with post 

traumatic stress disorder, they just need some help with connecting 

the dots there, some kind of system of checks and balances.

 Mr. Udall. What was the time period from when he finished his 

service in Iraq until the actual family therapy and you started discovering what the problem was?

Ms. Pelkey. Well, the symptoms started arising about six months 

after he came back from Iraq, and the family therapy started only one 
20

week before his death. So it was a little over a year.

 Mr. Udall. And one of the things that I think you said that was 

striking about what they’re doing at Fort Sill now involving group 

therapy and having the soldiers talk with each other. And then the 

essence of that is really them not feeling that they’re alone in these 

kinds of mental health issues that are coming up.

 Do you think that knowing what they’re doing now and kind of 

seeing what is happening there at Fort Sill as a result of what they 

saw happen with your husband, that if he’d had that kind of support, 

that might have been a much different situation for him? That if they 

had spotted it early and given him the opportunity to visit with other 

soldiers and have a chance to share the things that he was feeling 

inside, do you think there would have been a different outcome?

Ms. Pelkey. I feel like there would have been a different outcome, 

because like I said, I think the soldiers that have served in Iraq in Operation Enduring Freedom, they have a comfort level amongst each 

other that is unlike being in front of a counselor, or unlike discussing 

it with your spouse who has no connection. I mean, even though I

was an Army captain myself, I hadn’t been to Iraq. So the comfort 

level still wasn’t there between my husband and I.

 And what they’ve done at Fort Sill is provide a comfortable environment. I don’t even know if this matters, but they’ve provided, you 

know, comfortable furniture, just kind of like a living room environment for these soldiers to sit down and share their thoughts on it. 

And there’s a moderator for this in which afterwards the soldiers, 

after they feel comfortable, can come up to that provider and ask 

for a referral, and that’s how they’re identifying most of the patients 

there is in these group therapy sessions that are being moderated. 

And then afterwards, they all stand in line and, you know, take a 

questionnaire.

 But I do feel like this can be brought on on a bigger scale. I mean, 

a facility to deal with post traumatic stress disorder in the same kind 

of comfortable environment. I can see it on a bigger scale.

 Mr. Udall. Mrs. Pelkey, thank you very much for your testimony, 

and we really appreciate you stepping forward on behalf of all veterans that are in a similar situation. Thank you.

 Ms. Pelkey. Thank you.

 The Chairman. I thank the gentleman for his contribution. I ask 

unanimous consent from the members that Grace Napolitano of California, not a member of the Committee, would be recognized at end 

of all members of the Committee having asked questions, and if she 

would like to ask any questions, she would be recognized at this moment.

Mrs. Napolitano. Thank you, Mr. Chair, and yes, I would.

The Chairman. Hearing no objection, so ordered. You are now recognized.
21

Mrs. Napolitano. Thank you, Mr. Chair, and thank you to the 

members. I’m very interested in the issue of PTSD for a number of 

reasons.

 It has been something that has been a long-standing issue with city 

members of councils throughout the United States, simply because a 

lot of our soldiers from previous wars have not been able to deal with 

the issue of PTSD and end up being homeless, and therefore being 

found under freeway overpasses and in many areas of, especially cities like Los Angeles, where everybody thinks they’re just crazy, and 

there’s no way that anybody has been able to address the problem, 

wrap their arms around it, and be able to really identify what has 

happened to the individuals who have had a long-standing, 20, 30 

years of dealing with mental health issues.

 That said, I have been to both Bethesda and Walter Reed and have 

visited with some of soldiers that have returned with disabilities and 

asked the surgeons in charge whether or not they provide mental 

health services to the people they’re treating. The answer is yes, 

very, very good services. They also have on the third floor the ability 

to have drop-in, day care, if you will, or big clinics rather.

My concern has been that only those that are identified or selfidentified get help. Others go home thinking they can deal with it, 

that it is something that they can withstand, and eventually it begins 

to rear its ugly head. Just recently I was traveling to Washington, 

sitting in an airport next to an individual who wore a pin that I recognized, and we got into a conversation.

 And he indicated to me, because he asked me what Committees I

sat on and what I was doing in Washington, and I indicated I was cochair of the Mental Health Caucus, and he told me a story that kind 

of set me back, and that was that he was a Vietnam veteran and had 

17 jobs in 20 years. Something is wrong, that we are not helping our 

soldiers be able to cope with it.

 And, besides that, the most important thing, if a soldier is going 

home to a family, how is that family going to learn how to identify? You’re a captain. You were able to understand because at least 

you’ve served with part of it, or you’ve been exposed to it. What about 

the families that have not? Those that take irrational behavior as 

something they can no longer tolerate. And so then that individual 

either gets thrown out, or the family moves away, and they are left to 

their own devices.

 I have had individual VFW groups approach me that now they’re 

seeing soldiers returning, needing help and asking them for help at 

the VFW and American Legion posts.

 We are not dealing with it. And my concern has been that we need 

to not only deal with the actual service to the service individual, 

but also their family so that they can have a strong support system 

that can recognize and be able to refer them to adequate assistance, 
22

whether through the VA or a local, like a TRICARE, especially if the 

wife has additional insurance. Notwithstanding the fact that our 

medical institutions do not train doctors to recognize depression and 

areas that need to be recognized at any level, whether it’s a soldier 

or an individual who has suffered trauma, which also is classified as 

PTSD.

 So I’m thankful that you’re here, and I’m sorry -- thank you, Mr. 

Chair. It’s of grave importance to all of us. And I think that we need 

to stress the need to expand beyond that scope of service that we are 

now rendering our servicepeople. And I thank you so very much for 

being here and for being so open about your testimony.

 Thank you, Mr. Chair.

 The Chairman. I thank the gentlewoman for her contribution. I’d 

like to thank you for coming. And before you leave, would you please 

introduce the lady who is accompanying you to your right?

 Ms. Pelkey. This is my dear friend, Sherry Forbish, who is actually 

the moderator of my grief group through my church in my home town, 

and she’s been a tremendous support to me as well as my Christian 

church community. And she’s a wonderful friend.

 The Chairman. At any time did you ever turn to the chaplaincy 

corps of the Army?

 Ms. Pelkey. Yes. We did receive or go for marriage counseling twice 

to a chaplain. However, I do want to say that he was a family friend. 

So some of the things we were sharing with him were, you know, on a 

very personal level and just more personal than we would have been 

with just a counselor I think.

 The Chairman. People know their boundaries, right?

 Ms. Pelkey. Yes.

 The Chairman. Whether it’s the chaplaincy, whether it’s therapists, 

whether it’s psychiatry, whether it’s an MD or internal medicine, 

everybody knows their boundaries, but they also then do referrals, 

right? When they know it presses the bounds, then they do that referral. But did referrals occur here from the chaplaincy?

 Ms. Pelkey. No. We again saw him for two sessions, and there of 

course were other things discussed.

The Chairman. Right.

Ms. Pelkey. And I think it’s a good point too that the chaplains 

need to be educated on this, because a lot of soldiers do feel very 

comfortable with turning to the chaplains. But you also have to remember that chaplains are few and far between, and they’re very 

short-handed on chaplains also.

The Chairman. The point is, there are many different entries.

 Ms. Pelkey. Yes.

 The Chairman. Let me conclude with this, ma’am. You have within 

your rights to make an appeal through the Surgeon General of the 

Army with regard to your husband’s case, and you have a very able 
23

and compassionate Member of Congress there to your left who can 

also be of assistance to you in that appellate right. And I would encourage you to do that.

 Mr. Filner. Mr. Chairman?

 The Chairman. Mr. Filner.

 Mr. Filner. I just want to follow up on that if I may.

 The Chairman. Sure.

Mr. Filner. Have you met with the Secretary of VA or Secretary of 

Defense, or have you requested that?

 Ms. Pelkey. No sir, I haven’t.

Mr. Filner. Mr. Chairman, I think this Committee should work 

with Mrs. Pelkey to try to get those appointments. I think it would 

be very helpful. As you saw, she’s an incredible source of knowledge 

and compassion. And I would hope that we could help her get those 

appointments.

 I thank you for yielding.

The Chairman. If I may finish, ma’am, I would encourage you to 

work with your congressman, who understands this process. You are 

here as a witness of this Committee. We will work with him. You do 

not need an appointment with the Secretary of Defense or with the 

Secretary of the Army. There are processes for this to occur, and we 

will work with you to do that.

 I think what would be helpful here also is if I invite you to stay, 

because we have two more panels that are going to testify, and we’re 

going to hear from the Army. We’re going to also hear from experts. 

And I’d like for you to listen to what they have to say, and then I’d 

like to come back and speak with you afterwards about your thoughts 

on what you hear. Will you be helpful to us in that fashion?

 Ms. Pelkey. Yes. I would be proud to.

The Chairman. All right. Thank you very much. We appreciate 

your testimony.

 Ms. Pelkey. Thank you.

 The Chairman. Thank you. You are now excused.

 The second panel would please come forward. And when they step 

up from their seats, ma’am, you can occupy one of theirs. First is 

Colonel Charles W. Hoge, M.D., who currently directs collaborative 

research programs to enhance resiliency and reduce the impact of 

mental disorders among soldiers and their family members. He directs the WRAIR Land Combat Study designed to assess the mental 

health impact of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), and identify new prevention and intervention strategies.

 Next we will hear from Colonel Charles C. Engel, Jr., M.D., MPH. 

He is the Assistant Chair of the Department of Psychiatry at the 

Uniformed Services University and the Director of the Department of 

Defense Deployment Health Clinical Center at Walter Reed in Wash-
24

ington, D.C. He was the 1st Cav Division Psychiatrist during the 

1991 Gulf War and since then has served as a DOD medical adviser 

on post-war physical and mental health, particularly as it relates to 

post-war idiopathic physical symptoms, physical health concerns, 

and the improvement of post-deployment clinical services.

 We’ll then hear from Matthew J. Friedman, M.D., Ph.D. He is 

the Executive Director of the U.S. Department of Veterans’ Affairs 

National Center for Post-Traumatic Stress Disorder, and Professor 

of Psychiatry and Pharmacology at Dartmouth Medical School. He 

has worked with PTSD patients as a clinician and researcher for 30 

years, and has published extensively on stress and PTSD, biological 

psychiatry, psychopharmacology, and clinical outcome studies on depression, anxiety, schizophrenia, and chemical dependency.

 We’ll then hear from Alfonso R. Batres, a Ph.D. MSSW. He is the 

Chief Officer of the Department of Veterans’ Affairs Readjustment 

Counseling Service. He has direct oversight of the 206 Vet Centers 

providing readjustment counseling service to war zone veterans nationally. He is recognized as a national and international leader in 

pioneering the development and provision of services for veterans 

with combat-related trauma. Dr. Batres serves on the VA’s National 

Leadership board and is currently extensively working in the VA’s 

response to the needs of returning combat veterans of Iraq, Afghanistan and the Global War on Terrorism.

 We’ll then hear from Terence M. Keane, Ph.D. Dr. Keane is a Professor and Vice Chairman of Research and Psychiatry at Boston University of Medicine. He is also the Chief of Psychology and Director of 

the National Center for PTSD at the VA Boston Healthcare System. 

The past President of the International Society for Traumatic Stress 

Studies, Dr. Keane has published three books and over 140 articles 

on the assessment and treatment of PTSD. His contributions to the 

field have been recognized by many honors, and we appreciate you 

being here today.

 At this point, I will now yield to Dr. Hoge. You are recognized.

STATEMENTS OF COLONEL CHARLES W. HOGE, M.D., CHIEF

 OF PSYCHIATRY AND BEHAVIOR SCIENCES, DIVISION

 OF NEUROSCIENCES, WALTER REED ARMY INSTITUTE

 RESEARCH, UNITED STATES ARMY; ACCOMPANIED BY

 LTC CHARLES C. ENGEL, JR., M.D., MPH, CHIEF, DOD

 DEPLOYMENT HEALTH CLINICAL CENTER, WALTER REED

 ARMY MEDICAL CENTER, UNITED STATES ARMY; 

 MATTHEW J. FRIEDMAN, M.D., PH.D., EXECUTIVE

 DIRECTOR, NATIONAL CENTER FOR POST-TRAUMATIC

 STRESS DISORDER, DEPARTMENT OF VETERANS’ AF-

 FAIRS; ALFONSO R. BATES, PH.D., MSSW, CHIEF, OFFICE

 OF READJUSTMENT COUNSELING, DEPARTMENT OF VET-
25

 ERANS’ AFFAIRS; AND TERENCE M. KEANE, PH.D., PRESI-

 DENT, ASSOCIATION OF VA PSYCHOLOGIST LEADERS, VA

 BOSTON HEALTH CARE SYSTEM

STATEMENT OF DR. CHARLES W. HOGE

Dr. Hoge. Thank you, Mr. Chairman, and members of the Committee. It’s a great honor -- 

The Chairman. If you could pull the mic closer to you and turn it on. 

Thank you.

 Dr. Hoge. It’s a great honor to be here and I thank you for the opportunity to discuss the Army’s research on PTSD and other mental 

health issues associated with deployments to Iraq and Afghanistan.

 I’m also grateful for the opportunity that I had to be here for the 

moving testimony of Mrs. Pelkey and the subsequent questions from 

the Committee.

 I’m Colonel Hoge. I’m Chief of Psychiatry and Neurosciences at 

Walter Reed Army Institute of Research. The Army and Department 

of Defense have taken a proactive approach to understanding and 

mitigating the mental health concerns associated with deployments 

to Iraq and Afghanistan. We’ve made it a priority to learn as much as 

possible and adjust programs as the war is ongoing to meet the needs 

of our service members and their family members. And your interest 

in this matter along with previous support from Congress has greatly 

enhanced the body of scientific knowledge.

 Mental health symptoms are common and expected reactions to 

combat, an the research following other military conflicts has demonstrated that combat exposure confers considerable risk of mental 

health problems, to include PTSD, major depression, substance abuse 

and social, family, and occupational problems, as we’ve heard previously.

 However, virtually all studies that have assessed the mental health 

effects of prior combat in prior wars, including the first Gulf War, we 

conducted years after soldiers returned from the combat zone. To 

address these concerns, a team of Walter Reed Army Institute of Research, which I’m privileged to lead, initiated a large study in January 2003 with support from senior Army medical and line leaders and 

Marine line leaders as well, to assess the impact of current military 

operations on the health and well being of soldiers and their family 

members.

 This study is ongoing, and we have collected over 20,000 surveys to 

date from soldiers from multiple brigade combat teams deploying to 

Iraq and Afghanistan, both active component and National Guard, as 

well as personnel from Marine Expeditionary Forces.

 We have conducted assessments now out to 12 months after returning from deployment. We’ve published results of our initial find-
26

ings from three months post-deployment in July of 2004. We have 

also conducted similar assessments in theater as part of the mental 

health advisory team efforts.

Our studies confirm the importance of PTSD and other mental 

health concerns associated particularly with deployments to Iraq. 

Overall, based on our latest findings, 15 to 17 percent of service 

members surveyed three to twelve months post-deployment met the 

screening criteria for post traumatic stress disorder, and 19 to 21 percent met criteria for depression, PTSD and anxiety. In parallel with 

our survey-based data, there has also been a substantial increase in 

military health care utilization and use of military heath services in 

military treatment facilities among our OIF veterans.

 Alcohol misuse, which is strongly associated with PTSD, also has 

increased post-deployment. Other outcomes that we’re looking at include aggression in family functioning, and preliminary data indicates that there are likely deployment-related effects in these areas 

similar to what previous studies have shown. The strain of repeated 

deployments on soldier and family well being is evident in some units 

anecdotally.

One of the most important findings of our research is what we’ve 

learned about barriers to care in the military, particularly stigma. 

Our studies showed that soldier and marines are not very likely to 

seek professional help if they have a mental health problem, and they 

are concerned that they may be somehow treated differently if they 

do. Our data has helped us to focus on approaches to facilitate access 

to care.

We’re conducting a number of ongoing research projects to improve 

identification and intervention, reduce stigma and barriers, and our 

primary focus really is on improving access to care. And we’re also 

attempting to evaluate programs that are being implemented, such 

as the Department of Defense post-deployment health assessments.

 Our research has shown that soldiers are much more likely to 

report their mental health problems three to four months or subsequently after coming home than immediately on their return. And as 

a result, DOD has expanded the post-deployment health assessment 

program to include a survey now at three to six months post-deployment. We are also evaluating interventions such as psychological 

group debriefings, and we’re developing standardized training modules for soldiers, leaders, and health care providers.

Considerations for improving assess to care include co-locating 

mental health services in primary care clinics. And we heard this 

morning discussion about the fact that soldiers, virtually all soldiers 

access primary care, and this is obviously one portal for soldiers to 

get help.

 We want to improve awareness among primary care professionals 

of depression, PTSD evaluation and treatment, and it’s important 
27

to ensure that there’s adequate resources to support continued services in the operational setting in Iraq and Afghanistan as well as to 

ensure that service members who are identified through our screening programs or who refer themselves receive timely evaluation and 

treatment.

 One of the most important aspects of our work is to provider the 

best interventions within the medical model of care while conveying 

the message to our service members that many of the reactions that 

they experience after combat are common and expected. Helping to 

normalize these reactions is a key to stigma reduction and early intervention.

 Thank you very much.

[The statement of Dr. Charles W. Hoge appears on p. 84]

The Chairman. Thank you very much for your testimony. Colonel 

Engel, you are now recognized.

STATEMENT OF DR. CHARLES C. ENGEL

Dr. Engel. Mr. Chairman, members of the Committee, I appreciate 

the opportunity to appear before you today and discuss the ways that 

the Departments of Defense and Army are working proactively to 

identify and help military personnel with mental illness after service 

in Iraq and Afghanistan. We appreciate Congress’s interest in this 

topic and this Committee’s consistent support of DOD and VA mental 

health.

 I have three main points. First is the need to bring safe, accessible and confidential care to service members rather than waiting for 

them to seek care. Second, primary care affords an excellent opportunity for early recognition and care. And third, many DOD efforts 

are currently underway to reach out to providers, service members, 

families, the severely ill and wounded.

 I am privileged to direct a unique DOD center of health care excellence called the Deployment Health Clinical Center. We began caring for Gulf War veterans in 1994 at Walter Reed. In 1999, we were 

designated the Deployment Health Clinical Center, and our mission 

expanded to include provision and improvement of tri-service postdeployment medical care.

 We have provided care for over 15,000 service members with health 

concerns following service in various deployments, including Iraq and 

Afghanistan. We have helped those with both physical and mental 

wounds. Colonel Hoge tells us mental illness occurs to one in four of 

those returning from Iraq, with rates rising.

A study of injured soldiers evacuated through Walter Reed led 

by CPT Tom Grieger, Colonel Steve Cozza, shows that about half of 

those with initial PTSD and depression quickly improve, but overall, 
28

rates rise two- or three-fold in the next few months.

 What should we do abut this? First, we must provide, safe, confidential and continuous care. We cannot diagnose mental illness 

simply by looking, and there are no laboratory tests. We must build 

trust so service members offer frank accounts of their mental state 

and we can do accurate screening and provide proper care. Without 

protection from adverse career actions, mental illness is driven underground. Soldiers keep problems private until they balloon out of 

control, and we miss opportunities to prevent tragedies and threats 

to mission success.

Second, Colonel Hoge’s data reinforced civilian findings that most 

people with trauma-related mental illness don’t receive care. Misconception, stigma and local barriers to care are prevalent. These 

data compel is to bring services to soldiers rather than waiting for 

them to seek it.

 Third, mental illness occurs on a spectrum of severity, and we must 

provide care to the whole spectrum. A mild definition of PTSD yields 

rates of pre-war PTSD of nearly 25 percent, and post-war rates over 

50 percent. This tells us that many are distressed after war, and 

most distressed is not severe. Only 5 to 10 percent of military personnel seek specialty mental health care every year, but over 90 percent 

use primary care. The impact will be great if we improve the mental 

health of those getting primary care.

 Deployment Health Clinical Center has partnered with the MacArthur Foundation, Dartmouth, Durham VA, and Indiana University in a Fort Bragg Primary Care Improvement Initiative. The goal 

is successful implementation of VA-DOD mental health guidelines. 

The program is called “RESPeCT-MIL” and builds on a scientifically tested approach for depression developed by Allen Dietrich at 

Dartmouth. Use of RESPeCT-MIL improves continuity, maximizes 

existing primary care resources, and frees mental health providers 

to practice specialty care. We look for broader implementation and 

evaluation in the future.

Many with PTSD may benefit from psychosocial approaches offered 

in primary care. Our investigators have collaborated with Brett Litz 

of the Boston VA and the National Center for Post Traumatic Stress 

Disorder, Richard Bryant in Australia to develop an NIH-funded 

computer-assisted therapy tool called DESTRESS. DESTRESS offers anonymity and a scientifically valid approach that primary care 

doctors can prescribe to patients in need. Many will obtain relief, and 

for others, DESTRESS may reduce stigma.

 We are also pushing information to clinicians through the Deployment Health Clinical Centers pdhealth.mil website and Uniformed 

Services University’s Courage to Care program. pdhealth.mil gets 

over 700,000 hits a month. Thirteen hundred providers receive our 

daily science and news e-mail digest, and we have distributed 10,000 
29

deployment health tool boxes to primary care providers across the 

services. We also run toll free telephone and e-mail help line for providers, service members and families.

Providing care for the severely wounded and ill is a fulfillment of a 

scared trust, the promise every combat medic makes to assist injured 

comrades. Walter Reed’s Psychiatry Consultation Service led by Hal 

Wain follows ever wounded soldier. Deployment Health Clinical Center serves as a worldwide referral center for severe post-deployment 

illness. We have run nearly 120 cycles of two different specialized 

care programs, one for unexplained illness and another for PTSD.

 We published the unexplained illness approach in JAMA, the Journal of the American Medical Association, after a 20-site VA cooperative studies program study.

 Mr. Chairman and members of the Committee, I hope I have communicated my three main points. First, we must bring safe and confidential mental health care to service members rather than waiting 

for them to seek it. Second, primary care is an excellent opportunity 

for doing just that. And third, many DOD efforts are underway to 

reach providers, service members, families, the severely ill and the 

wounded.

 The Deployment Health Clinical Center and its devoted staff are 

privileged to assist the inspiring men and women who serve our nation. We owe our success to an unwavering support from Congress, 

DOD, Uniformed Services University and the Army Medical Department. Thank you for allowing me to appear before you today. I would 

be pleased to respond to any questions from members of the Committee.

[The statement of Dr. Charles Engel appears on p. 91]

The Chairman. Thank you very much for your testimony. I now 

recognize Dr. Friedman.

STATEMENT OF DR. MATTHEW J. FRIEDMAN

Dr. Friedman. Mr. Chairman, distinguished members of the Committee, I am Matthew Friedman. I am the Executive Director of VA’s 

National Center for PTSD, Professor of Psychiatry, Pharmacology 

and Toxicology at Dartmouth Medical School.

 I’ve been a VA psychiatrist for over 30 years and spent much of that 

time treating men and women who have developed PTSD and other 

problems as a result of their service in combat areas.

 I’ve been asked to comment on the PTSD syndrome itself, and I’ve 

submitted extensive information about that in my written testimony 

which I will not cover in my oral comments.

 I would like to emphasize, however, as have the previous speakers, 

that most people who return from a combat zone do not have psychi-
30

atric or psychological problems. A large number of them who do, have 

transient problems, adjustment disorders, from which they recover 

quite quickly. But there is a significant minority, an important minority, who will develop recurring and sometimes totally incapacitating psychiatric problems, of which PTSD is the most symptomatic.

 I’ve been asked to comment about the comparisons between the 

current situation and the post-Vietnam era in which I cut my teeth 

as a clinician. And I think the news is good. I want to emphasize two 

points in particular. First of all, when our men and women returned 

from Vietnam, they returned to a hostile public, a public that did not 

reward or recognize their courage. That’s not the case today, and I

think it’s very important. We know that social support is a key factor 

in whether or not people are going to readjust successfully after their 

combat experiences. Hopefully it is a very good sign that we’re having these hearings today which may help our returnees from the OIF

and OEF deployments.

 The second news is also good, and that is that there has been a 

great deal of scientific progress in the past 30 years. When we were 

first faced with the Vietnam veterans, we didn’t have any evidencebased treatments. We didn’t really know what to do for them. It was 

really a bootstrap, seat-of-your-pants type of an operation. Now we 

have medications that work, two of which have FDA approval. We 

have psychosocial treatments that are very, very effective.

Last year there was a joint VA-DOD practice guideline process to 

develop state-of-the-art, evidenced-based treatments for PTSD. And 

now the VA has made an institutional commitment to support that 

effort through a best practices project through which PTSD will be 

the pilot project to disseminate this information so all VA clinicians 

can provide the best care for people who come into our offices.

 The problem is, will they come? Will the stigma that Dr. Hoge’s 

research has indicated keep them away? Will they know, as Mrs. 

Pelkey did not know, what’s available, what the signs of PTSD are, 

what kinds of services are available should they recognize a treatable 

problem among a loved one or within themselves? I think that the 

challenge of dissemination of information to families and to servicemen and to veterans is a great one and a very, very important one.

 Unlike our DOD colleagues, we VA clinicians do not have a mandate to provide direct services to families. I think that’s a disadvantage, with the glaring exception -- or the wonderful exception of the 

Vet Centers that Dr. Batres will comment on, we clinicians can only 

see families as adjunctive to treatment of our veterans. I think that 

were our mandate changed and there were appropriate resources to 

serve that mandate, we could do a much better job and perhaps prevent some of the problems that might otherwise develop.

 In addition to my concern about stigma, I’m worried about the 

Guard and reserves. And I’ve commented on that in two “New Eng-
31

land Journal of Medicine” editorials. They really fall into the cracks. 

Will they recognize what’s available in the VA hospitals? Will they 

know about their eligibility? I don’t know. I think we need to make 

every effort to inform them. To get the word out.

 Other concerns are military sexual trauma, which is even more 

toxic than combat trauma, in terms of producing PTSD. I’m concerned about the men and women returning from these deployments, 

who will have severe medical problems. A loss of limbs, loss of eyesight. Other kinds of persistent problems. They’re a very high risk 

for PTSD, and we need to be able to monitor and provide the best 

treatment that we can.

 We need to recognize that we have a new, young cohort of people 

seeking our treatment, with fresh trauma problems, and we need to 

be able to provide the best services. In short, the VA has the best expertise, the most sophisticated clinicians, the best spectrum of treatment in the world. We need to make sure, and cherish what has been 

accomplished, and have our services available, so that we can help 

those who seek our help.

My final comments, which I’ll run through quickly, concern collaborations between the National Center and the DOD. You’ve heard 

about three of them. We’ve been working with Colonel Hoge, in terms 

of the de-briefing study which was done in Kosovo and which will be 

repeated with OIF/OEF troops. We’re working with Dr. Engel on the 

Web-based treatment at Walter Reed, as well as the pilot project at 

Fort Bragg, integrating primary care and mental health care, which, 

I think, had it been accomplished, might have helped Mrs. Pelkey 

and her husband.

 We’re looking at doing brain imaging, with troops from Fort Drum, 

as well as drug studies. We’re doing a major post-deployment study 

of 17,000 troops. And so, I would like to close by just thanking the 

Committee for its attention and concern, and thanking all the support that we’ve received from VA and DOD. Thank you.

[The statement of Matthew J. Friedman appears on p. 103]

 The Chairman. I thank the gentleman for his testimony. And could 

we pause to ask Colonel Hoge, Colonel Engel, Dr. Friedman, Dr. Batres, Dr. Keane -- do each of you have written testimony? And would 

each of the witnesses like that to be submitted for the record? All 

witnesses have answered in the affirmative. 

Hearing no objection, it will be so ordered.

 We’ll now recognize Dr. Batres.

STATEMENT OF DR. ALFONSO R. BATRES

 Dr. Batres. Thank you, Mr. Chairman and Committee members, 

for the opportunity to present on services provided by the program 
32

that I am privileged to head, to returning veterans from Operation 

Enduring and Iraqi Freedom.

I just wanted to add a few brief points to the comments I submitted 

to the Committee with my written testimony. The VA program that 

I represent, was initiated by Congress 25 years ago, to address readjustment challenges in Vietnam combat veterans. Matt Friedman, to 

my right, was one of the field docs who actually was instrumental in 

putting up one of very first Vet Centers, at that time.

The Vet Center is the first of its kind, and represents the foundation from which VA became the world leader in providing these 

services to war veterans. The Congress subsequently extended these 

services to all our combat veterans and their families. Therefore, any 

veteran who served in a combat zone, is eligible. Not unusual to find 

a World War II veteran alongside with a Korean War veteran, and 

now, an Iraqi Freedom veteran, at our Vet Centers.

 The heart of our program is veterans and their families. The 207 

Vet Centers dispersed nation-wide are staffed, primarily, by veterans, 

many of whom have served in a combat zone, and who understand 

the culture of the military, and the sacrifices that service members 

make to this country.

 On a personal note, I want to put into the record that my dad was 

a World War II veteran, as well as his five brothers. They all served 

in World War II. I am a Vietnam combat veteran, and I have a son 

who served in the Persian Gulf, with the 82nd Airborne. I am typical 

of the employees in the Vet Center program.

 The Vet Center program is a VA gold standard in veteran and family satisfaction. 99 percent of our clients and families not only rate us 

highly, but they would recommend us to other veterans. We are also 

the gold standard in VA, for employee satisfaction. We are located in 

easy-to-access locations within their community, and we have minimal bureaucratic barriers to accessing care.

 A veteran will be seen when they walk in -- we have no waiting list 

-- along with their families. The program laid the foundation for outreach services to combat veterans in our great country, characterized 

by a focus on providing a safe, confidential environment, where veterans who have been traumatized, or have gone through experiences, 

can come in, and receive timely and friendly services.

 In Fiscal Year 2003, with a few months of war under our belts, we 

saw about 1,900 OEF/OIF veterans. In Fiscal Year 2004, we saw over 

9,600. And for this year, we’re projecting over 14,000 new OEF/OIF 

veterans walking through our Vet Centers. They currently represent 

about 10 percent of our client workload.

 We do not include in this count, the growing number of veterans 

and their families, to whom we provide education, de-briefing, and 

outreach services to beam-up sites, and National Guard and Reserve 

locations all over this country. In order to get a better handle on that, 
33

we just did a survey for the month of June in this Fiscal Year, in 

which we documented 5,000 servicemen and women in that particular month, who received services in that category.

 Included in that are family members of National Guard and Reserve folks, who have deployed, but are currently not eligible for VA

services, because their family member is an active military member. 

We are reaching a fair amount of these veterans, but I have to honestly say that we have a lot of work to do, in making sure that we are 

providing comprehensiveness to all these veterans.

 The Secretary of VA, and my bosses, Dr. Kussman and Dr. Pearlin, 

authorized the hiring of 50 veterans from Operation Enduring Freedom and Iraqi Freedom, to become outreach workers for my program, 

approximately a year ago. Again, these are recently-returned combat 

veterans, many of them disabled, who have recently returned from 

their tours in Iraq and Afghanistan.

 The initial 50 program proved so successful, that the underSecretary has authorized an addition 50 FTEE positions for this year. 

These veteran employees continue the program emphasis -- our program emphasis on hiring veterans into the VA.

 As you have read in my written testimony, we have initiated a bereavement program for family members of those who died while on 

active duty. In coordination and referral from DOD casualty assistance officers, we have provided services to well over 400 families in 

the last year and a half. The majority -- over 300 of them -- coming 

from KIAs in Iraq.

 Our standard is to offer services directly to the family, within two 

days of the notification, in the community in which they reside. We 

will be conducting an analysis of our year-and-a-half worth of work 

with DOD, to see if we can improve on our services, and get feedback 

from our consumers, about how we can move to improve these types 

of services.

 We are very cost effective in that. As a rough benchmark, the VA

reported OEF/OIF veterans who have been seen for comparable mental health services within the VA. Our numbers are about 50 percent 

of those that have been seen. It’s not including in the ones we provide 

outreach services to. 

 The Vet Centers continue to provide a unique service, that is integrated with traditional mental health services, and adds value to 

serving veterans and their families. I don’t want to confuse what we 

do, with what the VA medical centers do. We only provide one component of the services, primarily focused on outreach, assessment, and 

treatment of veterans who are closer to home, and may not require 

the extensive services that VA offers.

 The DOD concepts of having mental health services available to 

soldiers while in the combat area, represent a major investment in 

dealing with the social and psychological psycholi of combat service. 
34

The study by Colonel Hoge, and the work done by Dr. Engel -- Colonel 

Engel -- are really instrumental in providing a continuum of care for 

the soldiers.

 The soldiers are going to face a transition, where when you blink, 

you go from a very supportive community environment, back into 

civilian life. And I think they need all the assistance that we can 

provide to them, to make that step into civilian life. And to keep 

them healthy, and connected. And quite frankly, to provide a varied 

assortment of service, to include employment issues. Benefit kinds of 

things, that is critical, not only to the soldier, but to their family, in 

an integrated fashion.

 Yesterday, I heard a presentation by the surgeon general of the 

Navy, I believe VADM Arnold, who described their Marine Corps OSCAR teams, and how they operate. Along with the Army combat 

stress teams, I think the Marine Corps has done an exceptional job -- 

both of them have -- in developing these types of interventions within 

the combat zone.

 The OSCAR teams are embedded in their unit, and are not a separate component, or a medical unit, therefore, promoting an integration into the Marine Corps unit, for functioning. This is an exact 

model of how Vet Centers operate. We are embedded in your local 

communities, and geographically located outside of VA medical centers.

 This goes a long way to avoid the stigma of accessing care, and promotes the normalization of issues that will arise in most of our veterans, that being the recognition that serving in a combat zone presents 

challenges to any soldier. And that the integration of these types of 

services, as has been indicated before, is really critical. Thank you.

[The statement of Alfonso Batres appears on p. 111]

The Chairman. Dr. Batres, on behalf of this Committee, let me extend an appreciation to your family, for their service to their country, 

not only including your uncles and your father, but yourself and your 

son.

Mr. Batres. Thank you, sir.

The Chairman. Dr. Keane, you’re now recognized.

STATEMENT OF TERENCE M. KEANE

 Dr. Keane. Thank you, Mr. Chairman. And thank you, too, members of the Committee, for permitting me to testify here today, with 

my distinguished colleagues. Today, I am representing the Association of VA Psychologist Leaders. And while I’ve spent some 28 years 

in the Department of Veterans’ Affairs, in three different VA medical 

centers, as chief of psychology, my comments today represent that 

group of VA psychology leaders.
35

 The VA represents the best in mental health systems in the world. 

This has been touted in both the “New England Journal of Medicine,” 

as well as in the “Lancet” in the past two years. With expertise in 

post-traumatic stress disorder, schizophrenia, the neuro sciences, 

geropsychiatry, and substance abuse, we address the full range and 

spectrum of combat-related psychological problems.

 With reference to today’s hearings, I do want to say that as a professor and faculty member at Boston University, one of the largest 

health care systems in the City of Boston, there is not a single expert 

in the area of post traumatic stress disorder on faculty. Not one. It 

would seem hard for me to fathom how private-sector resources could 

be marshalled to provide the kinds of care that’s provided by VA, 

in the Vet Center program, and in the many different installations 

across the country.

 I do want to comment, for a moment, about the VA’s leadership role 

in the President’s New Freedom Commission. The VA has established 

an outstanding action agenda. And with the current administration, 

there is tremendous support for moving forward, and implementing 

many of the ideas represented, and creatively developed, by the VA

mental health care employees.

 There are many examples of VA’s tremendous support for the 

returning OEF and OIF veterans. But there are also some important issues for us to discuss here today. Our group -- and that is the 

AVAPL VA psychologist leaders -- fully supports the notion of a fully-resourced President’s New Freedom Commission agenda. These 

resources should be implemented. They should be evaluated, they 

should be monitored.

 And the question that remains for us, is how will these resources, 

and a system that is strained for resources -- how will these resources be protected, to ensure that they deliver the kind of care that is 

intended? With the growing numbers of mental health needs, we 

also, in VA, need to employ the most contemporary, the most creative 

methods of delivery of services.

 This will require that our aging workforce be re-tooled, and retrained, with a major educational initiative. And what direction 

should this take? This should be training in the use of tele-health, 

already one of Dr. Pearlin’s major initiatives. This should be directed 

in the area of mental health, so that services can be provided. As 

well, Web-based interventions should be prioritized, so that patients 

can get needed education, and needed support, when and where they 

need it.

 We have information that the availability of Internet is quite strong, 

among younger generations, and we should make use of this resource 

for the delivery of whatever services are viable in that modality. As 

well, continued collaborations with the Department of Defense, in 

integrating care and conducting research on these newest veterans, 
36

needs to continue to be the highest priority.

 Our organization also supports, as many of my colleagues have already stated, the changes in eligibility that have already been made, 

and would like to see increased eligibility, again, for families, for 

spouses, for partners, affected by activation, deployment, injury, of 

death. As well, we support the completion of the National Vietnam 

Veterans’ Longitudinal Study.

 We support the completion of this study, not only for what it will 

tell us about Vietnam veterans, the largest cohort of veterans that 

exists in VA today, but as well, what it will tell us about the current 

group of the newest veterans. Our group also supports an increase 

in the research budget that’s allocated to study mental health and 

behavioral health problems.

 It is, indeed, the case, that the behavioral science, the mental health 

research workforce, is graying in VA. There needs to be a concerted 

effort to support junior people, to study the problems associated with 

military service, and combat trauma. But as well, and perhaps, most 

importantly, from my perspective, behavioral health services, psychiatric and psychological, need to be paired with physical rehabilitation, in order to maximize and optimize the outcome.

VA is one of the world’s leaders in the area of physical rehabilitation. We suggest that combining mental health services, at significant levels, with the outstanding physical rehabilitation, will yield 

the best possible outcomes for the people who are so injured. There 

are many other recommendations reflected in my written report. I’d 

be happy to answer any questions, and thank you all for the opportunity to speak with you here today.

[The statement of Terence Keane appears on p. 118]

The Chairman. Thank you very much for your testimony. I would 

like to exercise a cautionary counsel to my colleagues, with regard to 

Mrs. Pelkey’s testimony from the first panel. Only she has the right 

to privacy, and if she waived the right to privacy, with regard to her 

comments regarding her husband’s case, we now know that she has 

an interest in filing an appeal with the surgeon general of the Army.

 So, I would exercise caution, and I think it would be inappropriate 

to ask any of the experts on this panel or the next panel to comment 

directly upon her husband’s case. But obviously, process and procedures are open. And that would be my counsel to my colleagues.

 Where do new doctors turn in the private sector, and in military 

settings, to gain awareness and then develop an expertise with regard to how to deal with PTSD? Because it’s not just those who serve 

in the military. You’re also dealing with police officers, after gun battles. You’re dealing with firefighters. You know, the first responders 

in our society.

 We also have teams that will arrive upon the scenes of tornadoes, 
37

hurricanes, and traumatic events. So, how are we doing as a country, 

and where is this really being generated? I’ll just open it up. Anybody that would like to comment.

 Dr. Keane. I’ll begin. I’m sure there’ll be others who will speak. It 

is a major initiative of ours at the National Center for PTSD, to try 

to influence the education and training programs, in both psychiatry 

residency training programs, as well as in psychology. Clinical psychology training programs.

 We have engaged in this initiative for the full 16 years, that we’ve 

been involved in this work. We’ve been supported by the National Institute of Mental Health, in providing education and training, at the 

most advanced levels, for some 12 years, now. And it’s through these 

mechanisms, that we have actually conducted, I think, significant 

education and training, both in our own institutions, but as well, in a 

variety of different places across the country.

 It is solving a problem -- given that PTSD’s really only widely 

recognized since 1980, it’s been solving a problem for this country, 

that has taken some of our time. How do you create and generate a 

whole cadre -- a whole cohort of people, who can take care of people 

who have been sexually assaulted? Or the other kinds of events that 

you’ve mentioned?

 It has not been easy to do this. There are not experts at every 

medical school in the country. There are not experts at every clinical psychology training program in the country, in these areas. Yet, 

it’s actually a vastly-improved situation today, than it was when I

entered the field 28 years ago.

 The Chairman. Dr. Friedman?

 Dr. Friedman. I appreciate your question, Mr. Chairman. I think 

that you’re right on target, that although PTSD treatment and research began in VA, I think that we have really been a major force in 

influencing the civilian sector in many, many different ways.

In addition to our -- our graduates, and people who’ve benefitted 

from our programs, and people who come into VA, and gone on to 

influence the training programs in psychiatry, psychology, social 

work, and nursing throughout the United States, and certainly in 

the developed nations, as well, there has been recognition that sexual 

trauma, that disaster trauma, the recent tsunami, to be one of many 

examples, call for the kind of expertise that was first developed for 

treating veterans with PTSD.

One of the things that the National Center, and the field in general, 

has done, has moved from the VA, as the spawning ground, and taken 

the same technologies, the same conceptual tools, the same clinical 

tools, and used them with women who’ve been sexually traumatized, 

with disaster victims. The National Center has had a five-year collaboration with SAMHSA, with the emergency disaster branch of 

SAMHSA. And we were major players in the post-9/11 recovery.
38

In terms of what’s happened institutionally, within the field in general -- there have been independent efforts, with a lot of overlap and 

collaboration with VA practitioners, to develop evidence-based practice guidelines from other organizations. The International Society 

for Traumatic Stress Studies, of which Dr. Keane and I are both past 

presidents, actually developed the first practice guideline for PTSD, 

which was published in 2000.

 Since then, there have been two other practice guidelines. One 

was the American Psychiatric Association’s practice guideline, which 

came out last year. And the joint VA/DOD practice guideline, which 

I mentioned in my testimony. So, perhaps that’s responsive to your 

question.

 The Chairman. With regard to the seamless transition, medical records. DOD to VA, VA back to DOD. Are these occurring electronically, or is this paper? What’s happening, out there, right now? Does 

anybody know?

 Dr. Keane. Most of the -- most of the -- the hand-offs are by paper, 

and by phone. And it actually, at least, by my report, in my experience, it’s actually working very well, in many, many, many instances. 

So, we’re very pleased about how this integration has occurred. I

think you were asking -- 

The Chairman. What about the post-deployment health surveys? 

Do you get those? Is the VA getting those?

Dr. Keane. No.

 The Chairman. Great. You know, we put a lot of effort into this. I

wrote the law for a reason. For you to do these as pre-deployments, 

and post-deployments, and then, to make sure they get to the VA. So, 

if DOD doesn’t care about them getting to the VA, are they getting 

there? Let me turn to DOD. Tell me what’s happening.

 Dr. Engel. If I may. There are a number of challenges in the data 

sharing area, not the least of which is -- are the HIPPA laws.

 The Chairman. No, no, no. You can’t pull HIPPA on me. Uh-uh.

Dr. Engel. Sir -- 

The Chairman. No, you can’t pull HIPPA, no, no, no, no. You can’t 

do that. We, Congress, say you can move that data. So, go to the next 

comment. You can’t pull HIPPA on us.

 Dr. Engel. Well, sir, I’m really not trying to pull -- 

 The Chairman. Right. Well, I’m just saying, -- 

 Dr. Engel. I -- 

 The Chairman. Just erase HIPPA.

Dr. Engel. I -- 

The Chairman. Now, go to the next -- 

Dr. Engel. -- the level at which I operate, these are challenges that 

we -- that we are -- that we -- 

 The Chairman. HIPPA’s a challenge, but it’s not a challenge with 

regard to the sharing of information, and how we get it from DOD to 
39

VA. That’s the only point I want to make. 

Dr. Engel. Yes, sir. I mean, I think we’ve made enormous strides 

in taking the post-deployment health assessment data. It’s all in a 

data repository, where it can be analyzed in near-real time. And I

think that we, as an organization, would welcome the opportunity to 

share that data with the VA, and do so rapidly.

The Chairman. All right. Mr. Filner.

 Mr. Filner. Thank you, Mr. Chairman. Just for the record, I wish 

you were not so defensive about anything that comes from this side 

of the aisle. But if I were you, I would walk Mrs. Pelkey over to the 

Secretary of Defense, and the Secretary of Veterans Affairs, and have 

her talk to them. Maybe we can help her do that.

 What amazes me, gentlemen, when I hear people from various bureaucracies talking, doing their studies, and working hard -- it’s almost as if you’re working in a vacuum, outside the real world. You 

all have just heard an incredibly emotional and moving testimony by 

Mrs. Pelkey. I didn’t hear one statement reacting to that. I didn’t 

hear any passion about “oh, we’re going to correct that, and here’s 

what we need.”

 You read your statements, that you wrote earlier. You make incredible claims, like Colonel Hoge said we have a distinctly pro-active 

approach. That’s demonstrably false, at least in terms of the vast 

majority of our soldiers. We don’t have a pro-active approach, and I 

don’t know how you can say that. Everybody there is Pollyanna. You 

haven’t made one suggestion for change!

 I thought we would hear from you after listening to the testimony, 

“what do we have to do, and how much money do we need to do it?” It 

seems to me, that that’s what you ought to be reacting to, on a human 

scale, and not on your bureaucratic studies. I have a Ph.D. I understand research. But Colonel Hoge, you told us nothing meaningful.

Mrs. Pelkey could have told you all that, just by sitting down with 

the interviewer and telling her experiences. And a lot of spouses 

could have done the same thing. I hope you’re going more than a year 

out, but that’s all you talked about. And we know these symptoms 

occur later on.

 And even within the context of your own testimony, which was so 

Pollyannish, I don’t understand how you can not sit there and be angry about what we are doing as a nation to meet these needs. I think 

Colonel Hoge, or as Colonel Engel said, your center had seen 1,500 

post-Iraq servicemen. 1,500, out of the tens of thousands? You said 

in your own testimony, there’s 700,000 hits a month on your Web site. 

And that means -- that’s an incredible number of people interested in 

what we are doing. And we’re meeting only a few.

 Your one-in-four statement, after 12 months, I don’t understand 

why you would stick to that, when we know these things first, come 

up after 12 months. And second, how difficult it is for people to admit 
40

this kind of situation, or to even get data on it, as we have heard so 

movingly in the testimony. CPT Pelkey wouldn’t have been in one of 

your statistics, and yet, there he was, very sick. Very ill.

 I appreciate Dr. Friedman saying, the only suggestion I really 

heard from you, is that you don’t have a mandate in the VA to deal 

with families, as opposed to the individual veterans. That’s an important statement, and we ought to remedy that. And I appreciate 

you saying that. But we could have heard 25 things, probably, from 

you all who are experts, to tell us what we had to do. And I didn’t -- all 

I hear is, we’re doing everything right.

 The statement that the Vet Center had gone up from a few thousand to 14,000 in last year, that shows what you’re trying to do, and 

the need. I don’t think there’s been a great increase in the number 

of staff there, to serve this incredible increase. You need to say, we 

went from 3,000 to 14,000, and our staff had too few people to deal 

with that.

 That’s what we have to know. What do we have to do, to meet the 

needs? And all I hear is that everything is fine. Everything is not 

fine. We have suicides, we have divorces, we have domestic violence, 

we have crime, we have homelessness. Let’s get passionate about 

these problems.

 The fact that a veteran is not being helped, and commits suicide, or 

is on the street, should get everybody angry, as an American citizen, 

about this issue. We know how to treat these illnesses. We know 

how to do it. We’ve advanced that far. And yet, we’re not getting the 

services that veterans need.

 So, I’m very disappointed by all your testimony. You are locked 

in these studies, and your journals. Go out and talk to veterans and 

their families, and you’ll get all the information you need. I just want 

to know, how much money does it cost to do the kind of work that 

Mrs. Pelkey laid out? We know we have to deal with the families. We 

know we have to spread the information to all the service providers. 

We know we have to have peer discussions.

Just tell me how much that’s going to cost, and let’s do it. Thank 

you, Mr. Chairman.

Dr. Hoge. Sir, if I may -- 

Mr. Burton. [Presiding] Go ahead. Respond.

 Dr. Hoge. -- respond to that. I think that the - the critical -- if I

understand your question, sir, the critical element is, given the research, which shows that there is a significant risk of mental health 

problems, particularly PTSD, are the resources sufficient to take care 

of our servicemembers coming back, and -- 

 Mr. Filner. That was a great translation of my emotion, into bureaucratic language. I don’t know why you have to talk that way. 

Talk as a human being, and not, you know, “the study based on,” 

and “we have to get the resources conditioned on” -- I mean, come 
41

on. These are people who are suffering. I want to know how much 

money do we need, to make sure they stop suffering? That’s all you 

have to do.

Mr. Burton. Okay. I think he understands this. Let him respond.

 Dr. Keane. I would just like to add, if I can, that there are approximately 10 very specific recommendations in my written testimony, 

that, I think, warrant consideration by the group. And I’d be happy 

to elaborate on them, if given the opportunity.

Mr. Burton. Since I’m sitting in for the Chairman, and he’s not 

yet returned -- I’m interested in some of the comments from my colleague. In the last couple of years, there’ve been, as the chief of staff 

was just pointing out here, that there have been about 100 people 

added to take care of the need. Is that sufficient in the Vet Centers.

 Mr. Batres. We just got an additional 50. The original 50 -- 

 Mr. Burton. Yes, I understand that. He just told me that, too. But 

if what my colleague has said is correct, there was 15,000 last year? 

Is that what you said? 14,000? Are 100 new people in the last couple 

of years sufficient to deal with that problem? And I’d also like for 

you to elaborate a little bit more on what he was asking about the 

families. Is there a mechanism for these families, to get the kind of 

assistance that they need as well?

 You know, I know some people that were in Vietnam. And when 

they came back, there was a great deal of stress upon them, but also 

on their families, because the adjustment to these people was really 

substantial. You know when they have a loved one that goes, that’s 

a pretty warm, fuzzy guy, and when he comes back, he’s a hardened 

veteran, who’s seen some of the worst atrocities, and tragedies that 

you can imagine. And the family has to adjust. Is there any provision, as well, for the family members? And if not, should there be?

 Mr. Batres. A point of clarification. And I don’t think you were 

here when it was said. My program -- 

Mr. Burton. Well, I apologize for that. Go ahead.

 Mr. Batres. -- does have eligibility for family members. So, we see 

family members. We see these significant others, and the children. 

In our bereavement program, the whole aim is to treat the whole family, because DOD only treats one individual. Usually, the significant 

other. We’ve expanded our services to the entire family of operation. 

And we’ve been doing that for awhile.

 The other thing is that you’re exactly right. We became very proactive, early on, to get those 50 FTEE authorized, so we can begin to 

do the outreach mechanisms. Before this operation, we had no experience with the number of National Guard and Reserve folks that are 

being activated, and some of them doing their second and third tours, 

right now.

 So, in anticipation for that, we designated those folks, and we hired 

from within, the returning soldiers, to do the outreach. And to pro-
42

vide access to care for the VA. And they’re bringing in a significant 

number. I suspect that the next 50 will also be equally as effective, in 

doing that. I think we need to assess, and see if 100 is enough. And 

if it’s not, I think we should get more, or I would certainly advocate 

for more resources, through my particular avenue.

 I do want to dispel the perception that we’re not passionate. I’m a 

disabled Vietnam combat veteran, and I take my job seriously, as I 

think most VA folks do. And we are working very pro-actively, to do 

what we can for our fellow veterans, and I think that I would extend 

that to a good number of our folks in our program.

The problem is, from my perspective, that, you know, figuring out 

what would be appropriate for the increasing numbers, when you 

don’t know what they’re going to be initially. And then, as you go 

along, developing those, and then, quickly staff them. I am -- I feel 

very fortunate to have the additional 100 FTEE, and I’ll guarantee 

you, they’re being put to very good use.

 Dr. Friedman. I’d like to comment, also, in response to some of the 

earlier statements. It’s a new ballgame. I think that looking, and 

trying to project resources based on traditional accounts of people 

that come through the turnstiles, to VA clinics, or Vet Center clinics, 

is only a piece of it.

 As Mrs. Pelkey indicated, and as some of us indicated in our testimony, there are new initiative. New kinds of things that we really are just beginning to get our heads around. The collaboration 

between the VA and the DOD is unprecedented, in my experience. 

It’s very, very welcome. The fact that I’m doing a number of projects 

with these two gentlemen, as well as many other people in uniform, 

is something that hasn’t happened until very, very recently.

 Much of the effort, I think, has to be about prevention, about education. As Dr. Keane said, using Web-based technologies. We’ve 

developed -- and I gave four CD-ROM copies to the Committee -- in 

conjunction with Walter Reed Army Medical Center, the Iraq War 

clinician guide, which is a state-of-the art manual on how to treat 

these people. It’s available on the Web, it’s available by CD-ROM. 

Prevention. Outreach to families.

Costing that out, I think, is something that we’re really unfamiliar 

with.

Mr. Burton. Well -- 

 Dr. Friedman. And I think we need to do it, because it’s a major part 

of what has to be done.

Mr. Burton. Well, we have a Vietnam veteran sitting there, next to 

you. And with the experience in Vietnam and Korea, and the other 

conflicts with which we’ve been involved, it strikes me as unusual 

that you’re saying you don’t have the experience to deal with some 

of these problems. I mean, we’ve had war after war after war in our 

history. And each one of those wars gave information to the various 
43

agencies on how to deal with these stressful problems that are created.

 And I mean, you know, they had horrible things in World War I

and II, trench warfare, and Korea and Vietnam. And from what I’m 

gathering from you folks is that you’re experiencing something new, 

because maybe the National Guard’s involved. They’re still military 

personnel who are involved in combat. It seems to me that the statistical data that you’ve had from previous conflicts could be a real 

benefit.

I just don’t understand why you seem, I don’t know, somewhat bewildered, because this is something new. I don’t think it is anything 

new, is it?

 Dr. Friedman. May I clarify?

 Mr. Burton. Sure. I’d like to know. 

 Dr. Friedman. I thought I covered some -- 

 Mr. Burton. You’d better turn your mike on.

 Dr. Friedman. I thought I covered some of that in my testimony.

 Mr. Burton. Well, I apologize. I wasn’t here. 

Dr. Friedman. What’s certainly new, are evidence-based treatments. And as I said, we didn’t have the kind of treatments 30 years 

ago for the Vietnam vets, that we have now. And we’re learned a 

great deal from Vietnam.

 What is new, is the immediacy and the collaboration with the DOD. 

It was 10, 15, 20 years after people returned from Vietnam, before VA

had the capacity and offered the eligibility so that Vietnam veterans 

could come to VA. What’s new, now, is the fact that there are families 

out there, with returnees who’ve just come in a day or two ago. That’s 

new.

 It’s new for VA, and it’s an important opportunity. It’s an opportunity that we welcome, so it’s not about being bewildered. It’s about 

recognizing the problem, identifying it, and trying to be as pro-active 

as possible.

 Mr. Burton. Well, how long will it take before you know how many 

additional personnel you’re going to need to deal with this large number of people who need attention and care? I mean, I think you said 

14,000? Is that correct? 14,000?

Dr. Friedman. I think it’s very hard to make projections. I’ll defer 

to Dr. Hoge. I mean, it’s very early in the game. The data we have on 

Vietnam veterans, we obtained in the mid-1980s.

Mr. Burton. Okay, based upon the data you had back then, how 

long would it take to take care of 14,000 people and give them the 

attention they need? And how much would you need additional personnel for that?

Dr. Hoge. Sir, I think there’s ample data available for us to project service utilization needs, and resource needs. And I would like 

to take the question for the record, and get back to you on specifics 
44

of exactly what resources we would like to request, to best serve our 

service members.

Mr. Burton. So, what you’re saying is, from the experience you’ve 

had in the past, Colonel, that you could project the need fairly accurately.

Dr. Hoge. Yes, sir. I -- 

Mr. Burton. Why hasn’t that been done before now? I’m just curious. 

Dr. Hoge. Well, I think that the combined data of what we -- 

Mr. Burton. I mean, the war’s been going on, there, for over two 

years.

Dr. Hoge. Yeah.

Mr. Burton. And we also had Desert Storm before that. Why hasn’t 

there been some statistical data, showing what the need would be before now?

Dr. Hoge. Virtually every study that was conducted in prior wars, 

sir, were done literally years, sometimes decades after servicemembers came home. This is the first war where we’re actually collecting 

data in real time, and calculating rates. But we now have two years’ 

worth of data. And I think that’s sufficient to make reasonable -- you 

know, maybe not the most accurate, but I think reasonable projections -- 

Mr. Burton. How long would it take for us to get that here on the 

Committee? I know the Chairman and others would like to have 

that.

Dr. Hoge. Well, I’m a researcher, and I -- and I will do the -- my 

very best, to go to my leadership, and get that answer for you, as 

quickly as possible, sir.

Mr. Burton. You can’t give us any timeframe? A month? Two 

months? Two weeks?

Dr. Hoge. I don’t see any reason why it can’t be done in the next 

month, or so. I mean, I’m -- I can’t speak for my leadership, but it’s 

-- it’s something which we have been wrestling with. What are the 

resource needs, for instance, with the upcoming post-deployment reassessment, that’s going to be done at three to six months?

Mr. Burton. Uh-huh.

Dr. Hoge. That reassessment is going to generate a large number of 

soldiers coming in for care. And there’s a lot of serious questions being asked about what are the resources that are necessary to provide 

the services for those servicemembers that identified. And my -- 

Mr. Burton. Well, let me just say, because I know the Chairman’s 

going to be back here in a minute, I would personally, as a member 

of the Committee and one who’s been on and off this Committee for 

about 20 some years, like to have not only the statistical data on how 

many people you would need to take care of those who are coming 

back, but also, if you could project out how many people you would 
45

need, based upon past experience, to deal with some of the family 

members that are suffering from the results of the stress caused by 

the conflict on these soldiers.

 So, you don’t have to be precise. I don’t think anybody expects you 

to be precise. But we’d like to know what the need is. Congress can’t 

authorize or appropriate the resources necessary to take care of a 

problem, unless we’ve got some pretty good data.

Dr. Hoge. Yeah.

Mr. Burton. And if people are vague about that, you know, we go 

to the authorizing Committee, and they say, well, how much do you 

need, and why? And if nobody has an answer, then they can’t authorize. And the appropriators are very difficult to deal with, if you can’t 

give them some pretty clear-cut information. So, if you could get that 

for us, you said you think maybe within a month, you could get it, 

that would be great.

Dr. Hoge. I’ll work with the leadership at the surgeon general’s office, and DOD, to try to get those -- those more specific estimates of 

resource needs, to the Committee.

 Mr. Burton. So, for the record, do you think you can get that within 

a month, maybe?

 Dr. Hoge. I -- I shouldn’t promise that -- 

 Mr. Burton. Will you try to get it within -- 

 Dr. Hoge. I will -- I will do the best I can, to nudge the system 

along, to -- do that. Yes.

 Mr. Burton. Okay. Thank you, Colonel, very much. I see the Chairman’s back. I’ll turn the chair back over to him.

The Chairman. [Presiding] Mr. Udall.

 Mr. Udall. Thank you, Mr. Chairman. Thank you all, for your 

testimony here, today. Many of the veterans that return, come from 

rural areas. And I don’t -- at least, from my own experience, in my 

Congressional district, in my state, it seems like they’re disproportionately from rural areas.

 And I was wondering, the -- in terms of the services that each of 

you have talked about, and what’s being provided now, do we have 

the capability to deal with veterans that are two, and three, and four 

hundred miles from the large hospitals -- are rural veterans treated 

differently, because they live so far from those facilities? I mean, 

what is being done to deal with that kind of situation?

 And any of the members of the panel that can speak to that.

 Dr. Engel. Sir, if I may. I would like to say that CPT Pelkey’s terrible story is, for me, a sober reminder of the overwhelming charge 

that we have, to care for our own. At the Deployment Health Clinical 

Center, what we are doing with Respect Mil study, and as Dr. Friedman mentioned, we’re collaborating with the National Center on this, 

and exploring ways to go broader, within DOD.

 This is a potential -- has the potential to maximize services for peo-
46

ple who are in outlying places. People who are otherwise, maybe falling through the cracks. So, I think that again, the -- the opportunity 

to afford good mental health care, through primary care, is a way of 

reaching out to rural communities. And if we can bolster continuity 

in primary care, people will not fall through the cracks, and we won’t 

experience the sorts of terrible tragedies that we’ve heard about today.

Mr. Udall. And do you think they’re getting the training they need, 

out in these primary care facilities, to recognize PTSD, and -- 

 Dr. Engel. Sir, one of the -- in the Respect Mil effort, we have developed a primary care education module, for primary care docs, that 

speak to them at their level of understanding of post-traumatic stress 

disorder, and facilitate care, and improve the structure of primary 

care, by allowing them to use good screening tools, and tools that 

measure the severity of patients’ illness.

It’s not just a knowledge issue. There are also important structural 

changes that have to take place in the clinic, so that patients who 

struggle with these sorts of challenges, get the intensive time and 

attention that they need.

 I would also add too, that Uniformed Services University’s department of psychiatry and its Center for the Study of Traumatic Stress 

is a leader in creating educational materials through its Courage 

to Care program for communities that are dealing with disaster or 

terrorism, and our PD.mil website has extensive information about 

the clinical practice guidelines for post-traumatic stress disorder, for 

depression and other mental health conditions. We make specific 

efforts to design that site so that primary care clinicians can access 

them quickly.

 As a mental health practitioner who has worked in a rural area all 

of his professional life, I thank you for your question. I think that the 

challenges of any health delivery, especially mental health delivery 

in rural areas are very unique and very important.

 I think that within VA there are a number of options. Certainly 

the vet center program is one of them and Dr. Batres can describe 

that. There are also community-based outreach clinics or outpatient 

clinics where VA practitioner and VA clinics are set up in places at 

a distance from the flagship hospital, so the transportation and road 

condition programs that often are barriers to access in rural areas 

can be overcome.

 There are also partnership with community mental health centers 

that have been done in certain areas.

 In addition -- this is kind of traditional stuff, but I think that given 

the information age, the internet, the tele-health capability, this is 

really -- and this is one of the things I have been wanting to address 

in some of my answers or my initial comments is this is a very good 

way to reach rural practitioners.
47

 The national center’s website, which is getting 65,000 unique users 

a month, is one way that people can access the latest on treatments 

and download it no matter where they are. We have even been able 

to do this with people providing help in the tsunami-stricken areas.

 We are working on a state-of-the-art curriculum. We call it PTSD

101, which will be a web-based production.

 In partnership with the Uniformed Services University health sciences, we have proposed a very, very ambitious and extensive educational initiative, which will be using tele-health and web-based technologies as well as face-to-face to upgrade the skills of DOD and VA

practitioners, so I think that there are many, many options that we 

have available, and we need to make good use of them.

Mr. Udall. Any other comments from the panel?

 Dr. Batres. I just wanted to briefly say a few things.

 One of the ways we extend our services is our contract for a fees 

program within the Vet Center program where we contract with private providers in rural areas. Although limited, we have found that 

that particular program is very effective if we can find the providers 

with the skills and the training to provide the services.

 We have also established outreach centers that are what we call “ 

outstations.”

For example, we have five vet centers on Native American land. 

These are very rural areas, places like Hopi and Navajo and other 

reservations we have gone out and established an outstation in the 

particular reservation to provide services closer to their communities.

For example, if you were a Hopi or Navajo, as you well know, you 

have to drive a long way to get to Phoenix or to Albuquerque. So we 

promote services and are local and attempt to do that.

 The other thing that we are doing, especially with the National 

Guard and Reserve, is working very closely with General Blum and 

the National Guard registry as well as the reservists. We are establishing, and I think the National Guard will be rolling out a plan 

that is state-based where we are creating coalitions of all community 

resources and coordinating the services, and I think that will help to 

improve our services to rural areas, but I want to also say what Matt 

said, and that is that is a challenge, when veterans are dispersed all 

over a great geographical area and getting the appropriate services 

to them.

 Those are some of the things that we have enacted.

 Mr. Burton. [Presiding] Mrs. Napolitano -- 

Mr. Udall. Thank you.

Mrs. Napolitano. Has he finished?

Mr. Burton. Are you finished? Do you have a follow-up question?

 Mr. Udall. No, I didn’t have a follow-up. My time was out, but I

noticed Dr. Keane wanted -- 
48

Mr. Burton. Oh, sure. Proceed. Sure, that’s fine. Thank you.

 Dr. Keane. I just want to concur that these are complicated matters 

when you have a centralized system, but the CBOCs, the communitybased outpatient clinics, is one important answer, as are the many 

programs that Dr. Batres has put into place.

 The issue with CBOCs, however, is the extent to which there is 

specialized care, and among the concerns that many of us have is that 

primary care doctors are already extraordinarily busy and very hardworking, and to take on the burden of both diagnosing and treating 

combat related problems becomes a burden that may just be too much 

for them to bear.

 The question of course is at what point can we have and how can we 

have mental health services in these clinics, and this is being actively 

debated and discussed and in many places implemented, but I think 

we could likely do more there.

Mr. Udall. Thank you very much.

Mr. Burton. If I might follow up before we yield to Mrs. Napolitano, 

could not be included in the information that I requested earlier some 

kind of analysis on how much revenue would have to be requested 

from the government to take care of the need for these people in the 

rural areas who need psychiatric help. If you could give us that. As 

I said before, I think one of the problems with this Committee and 

every Committee in Congress -- I was Chairman of the Government 

Reform Committee for six years -- is that we don’t get enough information from the various bureaucracies to be able to ascertain how 

much money we need to spend and how many people are going to be 

needed to do the job, so if you could try to get that along with Colonel 

Hoge?

Dr. Hoge. Yes, sir.

 Mr. Burton. We would really appreciate it. I mean he has already 

said he could get all this done in about two weeks -- or did you say 

four weeks?

[Laughter.]

 Dr. Hoge. Sir, I said I would go to my leadership and pass on your 

request for -- 

 Mr. Burton. Well, we’ll call your leadership and tell them you made 

a hard commitment for a week, how’s that? As quickly as you can get 

it done. I’m sorry. Does that answer your question?

 Mrs. Napolitano.

 Mrs. Napolitano. Thank you, Mr. Chair, and I have listened with 

great interest because PTSD has been something that I have been 

very interested in, very involved in since my days in state assembly 

in California.

 Some of the questions -- one of the answers that Dr. Batres gave 

in regard to the treatment, I believe you said it was bereavement 
49

only. What happens with treatment to the families or assistance to 

the families and those that have not lost a member? Because that 

is important. It isn’t just those that have lost a loved one, but it is 

a family whose member has gone through these atrocities, who has 

been injured -- not necessarily dead -- and cannot deal with because 

they don’t know how.

 So does that include also services to the families?

 Dr. Batres. We would cover that. Any problem that is related to 

their military service we would cover, so it is not limited to just bereavement.

 Mrs. Napolitano. So the resources needs would be for the service 

individual and the family?

Dr. Batres. Correct.

Mrs. Napolitano. Is the family aware of the services? Is it something that is given to them, talked about, sent to/mailed to them, 

emailed? How do you get that information to them?

 Dr. Batres. We get the information out through the typical formats. It is on our website. We inform folks. We do our debriefings at 

the demob sites and wherever we interact with the military we pass 

out that information to them, that they are eligible.

 And they have been eligible for 25 years. It’s not a new eligibility. 

We have always included the families as part of our treatment.

 Mrs. Napolitano. Okay, but that still does not -- many families 

don’t have access to computers so they can’t access the website. Is it 

possible then that you might include in writing when the VA sends 

information to a veteran to remind them that these services are available, that their families might seek help in instances where there is 

an issue of PTSD that may not recognize it’s PTSD.

I am trying to figure out a way to be able to get information to the 

family itself as to how they can help it. They may not recognize it. 

They may not know what PTSD is.

 Also you indicated that you have a website. Can you share the 

website so members of Congress -- I’d love to have on my website the 

ability to link some of my veterans’ organizations and say “Go” because I am being asked now what do we send these -- you know, we 

are starting to get these youngsters coming in, asking for help at the 

local VFW and American Legion.

 How do we tell them here is a place for you to go or refer them to? 

I’m sure somebody at the VFW has an access to a computer, but assistance to them at that level, because you can’t do it all, but how do 

we know what you are doing and how we can lend a hand in that?

Dr. Friedman. Our web address is in my testimony. The National 

Center has sent its annual report to this Committee every year. We 

have a section devoted to the web, with the web address, telling you 

all the bells and whistles and stuff. If you would like more information, I would be delighted to tell you about our website.
50

 Mrs. Napolitano. I’m sorry. I don’t have your testimony. Maybe I

missed it, because I am not a member of the Committee. I did happen 

to pick up stuff from outside, but I will look for it.

 Any other website that you gentlemen might have?

 Dr. Engel. If I may, our website is pdhealth.mil -- m-i-l -- and the 

other comment I would make, ma’am, is that if you have a constituent friend or otherwise that needs assistance I would be glad to bring 

the full resources of my center to assist. We are taking care of patients directly at my center. Certainly the numbers that we take care 

of are nowhere near the total number of people who are injured, but 

we come face to face with these folks every day and we are trying to 

develop innovative programs, and I assure you if you refer anyone to 

me and my center, we will take good care of them.

 Mrs. Napolitano. Thank you for the offer. I will take you up on it 

if I need and my staff needs it. But Mr. Chair, may I ask that you 

include in your request for information from Colonel Hoge how best 

to get information out to families on PTSD. That might take some 

doing, whether it is advertisement -- we have done it for the recruitment of personnel for the armed forces. Why cannot we start making 

some kind of inroads in indicating that there is help for those individuals who may be -- and their families for that matter -- who may 

need help, services that you can provide.

 Again, this will take money and this is something that maybe this 

Committee might be interested in working with you.

 Going to primary care, primary care is TRICARE, I am assuming?

 Dr. Engel. Ma’am, primary care is a treatment setting before specialty care. There is primary care within TRICARE. There is primary 

care within the VA and there is primary care within the Department 

of Defense.

 Mrs. Napolitano. My concern has been because in my area I had 

one clinic for my veterans, and I have a high percentage of veterans 

in my area, they were going to close it down. This was about six years 

ago. We have had a new clinic open, but it is outsourced. I am being 

told by the physicians that they cannot give certain services because 

they are not reimbursed for them.

 That creates a problem for me, because if veterans are going in, indicating that they have PTSD and they are required to -- how would 

I say -- prove that it happened during a wartime, whether it was 

Vietnam, whether it was a prior war, and these individuals are having problems. I am just telling you what problems I face in my area, 

so I am concerned about how can we get veterans who might not be 

identified as possible PTSD, that they can then go to an individual, 

whether it is a private servicer or VA, and say to them we need some 

mental health services.

 I’m sorry, but this macho thing prevents a lot of my veterans from 

admitting that they do have a problem. Unfortunately, we just need 
51

to be able to de-stigmatize so that it is something that they know they 

can be treated for and get help for. Question?

 Dr. Friedman. The primary care initiative is really an important 

one from a number of perspectives. I think that in the case of Mrs. 

Pelkey’s husband, where he did see a primary care practitioner, that 

was a missed opportunity. I think that just to take that particular 

example, not knowing any of the other details, one of the goals -- 

and Dr. Engel has been in front on that -- Dr. Gerald Cross, head 

of VA’s primary care has been very, very supportive in this regard 

-- is to acknowledge that because of stigma, other issues, and associated medical problems, veterans or Guardsmen, et cetera, with PTSD

aren’t recognized by primary care practitioners. This, unfortunately, 

is often the case. This needs to change since the first clinical port of 

call will often be the primary care clinic.

 That is the reason why we are so committed to trying to develop 

integrated primary behavioral health models of care which have been 

shown to be successful with depression.

A project that we are doing in collaboration with Dr. Engel at Fort 

Bragg is testing this model. Dr. Cross has been very enthusiastic in 

supportive about this. Indeed, every veteran who comes to a primary 

care clinic will receive a PTSD screen annually so that -- 

 Mrs. Napolitano. Sir, I’m sorry, but what if they don’t go to the 

primary care on PTSD? What if they just go for an issue? Can that 

primary care provider be able to identify that there is an issue with 

mental health?

 Dr. Friedman. That is the point of the screening. That is exactly the 

point of the screening.

Mrs. Napolitano. But are they trained? That’s my point. Are they 

given that?

 Dr. Friedman. That is an initiative that is underway.

 Mrs. Napolitano. That is why we are asking for the funding to be 

able to additional trained personnel so that we can then say we have 

enough people to address what we perceive is a growing issue.

 Dr. Engel. Ma’am, as part of this program that Dr. Friedman is 

speaking to that we are piloting at Fort Bragg, there is an education package for the primary care doctor, and there is a sort of clinic 

design that is put in place. It is called the prepared practice for recognizing people. The dissemination of that is something that we look 

forward to the opportunity to do.

Mrs. Napolitano. So it’s still in progress. One more follow-up, just 

very quickly -- 

The Chairman. [Presiding] I have been very patient.

Mrs. Napolitano. Thank you so much. Very quickly -- go ahead, 

never mind. Just go on.

The Chairman. Go ahead. Make it quick.

Mrs. Napolitano. It’s gone -- went in one ear and out the other.
52

 The Chairman. Thank you. We have votes coming up and we have 

another panel. That was the only reason, ma’am, that -- 

 Mrs. Napolitano. Thank you.

The Chairman. The last thing, Dr. Hoge, we really haven’t talked 

about your study, and you put a lot of time into this. Mr. Burton 

asked a question about data and getting that information to the Committee. In order for that to ever occur, how predictive are the results 

of your study?

 Dr. Hoge. I think the results of our study are predictive, and we 

have additional analysis that we have conducted, such as looking at 

how many servicemembers who have come back from OIF have accessed services, what percent have seen mental health, what are the 

reasons that they have accessed services. So we know, I think we can 

predict with some degree of accuracy what percentage of our servicemembers are in need of services, mental health services, and then 

obviously the second question to that is are the resources adequate.

That is something I just can’t comment directly on in my position 

-- 

The Chairman. Is the data being shared with the VA?

Dr. Hoge. Excuse me?

The Chairman. Is it being shared with the VA?

Dr. Hoge. Yes, sir. Yes, sir. All of our data, and that is one of our 

primary missions is to get the information out in a timely manner so 

that it can influence policy directly.

 The Chairman. Well, we recognize that the President in his budget 

increased $100 million in the VA for mental health.

 Dr. Friedman, I want to thank you for the team you sent to Newark 

city immediately after September 11th on behalf of the country. Your 

response to that and help is noted.

 I would like to thank this panel. You have invested a great deal 

of your life into these studies and being able to help our soldiers and 

the families.

 We know we have got them in the military but we don’t pause and 

say why? You know, we train them to kill and break things, when 

you think about it, and there are some mental consequences from 

warriors doing such things, and we train them to be rough and tough, 

but they are also someone’s cuddly son, right? Cuddly spouse? And 

they do have a warm, compassionate side to that warrior spirit, and 

when that veil gets pierced there are real consequences, and that is 

where you as professionals step in.

 At some point in time though, through PTSD and a diagnosis, 

through treatment, they can get better, can they not?

Dr. Hoge. Yes, sir.

 The Chairman. It is a curious matter with regard to the escalation 

of 100 percent PTSD disabilities and how people get worse, and all of 

a sudden when they get a 100 percent disability rating, then they get 
53

better. So I think what we are going to have to do is when we come 

back we may have to do a secondary hearing with regard to the IG report, because it is pretty alarming with what is happening out there. 

We want to make sure that the precious resources we have, that the 

care and attention go to individuals that need it and not to individuals who are perhaps using some form of excuse for bad behavior.

 It is a delicate matter and a delicate issue but it’s one we have to 

confront, and I know that you were able to sit here and listen to the 

testimony from the first panel witness and I am glad you were here 

and could hear that.

 There are reasons we call certain circumstances a tragedy, and 

we label them a tragedy because when you go back and you do an 

analysis of it, there are failures all around. This member of the army 

family didn’t get the support that he needed, and every port of entry 

for access or referral wasn’t there. I mean that is why we call it a 

tragedy, and so I imagine that perhaps there are some other cases 

out there, but I appreciate your leading forward, and this panel is 

now excused.

 The third panel will please come forward.

 Michael E. Kilpatrick, M.D., is deputy director of the Deployment 

Health Support, office of the Deputy Assistant Secretary of Defense 

(Force Health Protection and Readiness). Dr. Kilpatrick is responsible for providing assistance to Gulf War veterans and facilitating the 

operational support for Force Health Protection initiatives and the 

coordination of health-related deployment issues between the Office 

of Assistant Secretary of Defense for Health Affairs and the military 

departments.

 We will also hear from Brigadier General Michael J. Kussman, 

M.D., MACP, who is U.S. Army, Retired. He was appointed Deputy 

Under Secretary for Health for the Veterans Health Administration, 

of the Department of Veterans Affairs on May 29, 2005, and in this 

capacity he leads the clinical policy and programs for the nation’s 

largest integrated health system.

 If both of you would introduce who you have accompanying you, 

and then I would then yield to Dr. Kilpatrick.

 Dr. Kilpatrick. Mr. Chairman, I have Dr. Jack Smith with me. 

He is head of the Clinical and Program Policy in Health Affairs for 

DOD.

The Chairman. Very good. Thank you. You are now recognized. If 

you have a written statement, both of you gentlemen? You do?

 I ask unanimous consent that it be submitted for the record. Hearing no objection, it shall be entered. Dr. Kilpatrick, you are now recognized.
54

STATEMENTS OF DR. MICHAEL E. KILPATRICK, DEPUTY DI-

 RECTOR, DEPLOYMENT HEALTH SUPPORT DIRECTORATE, 

 OFFICE OF THE DEPUTY ASSISTANT Secretary OF DE-

 FENSE, Department of Defense; ACCOMPANIED BY

 DR. JACK W. SMITH, DIRECTOR OF CLINICAL AND PRO-

 GRAM POLICY INTEGRATION, OFFICE OF THE ASSISTANT

 Secretary OF DEFENSE FOR HEALTH AFFAIRS, Department of Defense; DR. MICHAEL J. KUSSMAN, DEPUTY

 UNDER Secretary FOR HEALTH, VETERANS’ HEALTH

 ADMINISTRATION, DEPARTMENT OF VETERANS’ AFFAIRS;

JOHN E. BARILICH, OPERATIONS OFFICER FOR VISN 110,

 DEPARTMENT OF VETERANS’ AFFAIRS; AND DR. MARK

 SHELHORSE, DEPUTY CHIEF PATIENT CARE SERVICES

 OFFICER FOR MENTAL HEALTH AND CHIEF MEDICAL

 OFFICER FOR VISN 6, DEPARTMENT OF VETERANS’ 

 AFFAIRS

STATEMENT OF DR. MICHAEL E. KILPATRICK

 Dr. Kilpatrick. Mr. Chairman, distinguished members of the Committee, thank you for the opportunity to appear before you today and 

discuss the Department of Defense’s efforts to prevent, identify and 

treat post-traumatic stress disorder.

 I would like to provide some brief opening comments.

I would first like to start by thanking Ms. Pelkey for her courageous 

testimony today. I would like to also express my sincere condolences 

to her for her loss.

 I am going to be talking about policies and health in the Department of Defense and then the ultimate evaluation policies that must 

be evaluated and how well they serve and support our men and women in uniform who serve. When that doesn’t happen, then we need to 

take a look at is there an issue with the policy, is there an issue with 

the implementation, and I think that those are areas where we must 

continue to learn as an organization and as a society.

The Department of Defense is firmly committed to safeguarding 

the health and fitness of our active and reserve component servicemembers both before, during and after deployments, and this includes emotional health.

 The department’s ongoing education programs for military health 

providers focus on prevention programs and early intervention for 

behavior and health issues. You have heard about those education 

programs. They’re still early. We need to have similar education programs for our military leadership, the operational leadership, so that 

they can support their soldiers, sailors, airmen, Marines getting help 

early when they need it.

 We need to make sure that that education program reaches out to 
55

touch the families so they are part of this issue on bringing to bear 

early intervention and then finally our servicemembers must understand that they have a safe haven to come to seek that health care.

 I believe we have made great progress in the areas of prevention, 

identification and care for stress-related health risks such as anxiety, depression, and acute stress reaction and we are really focusing 

now on post-traumatic stress disorder. These conditions are part of 

a continuum of mental health issues that are caused by operational 

stressors and combat trauma.

 The Department of Defense is making a sincere effort to screen our 

people for mental health problems annually as part of their preventive 

health assessment. Servicemembers attend briefings about the psychological challenges of deployment during pre and post deployment 

processing, often with family members. They learn what to expect on 

homecoming and how to reduce anxiety and family tensions. They 

also learn to recognize when and how to seek professional help.

 From the beginning of the current Operation Iraqi Freedom deployment we employed medical and environmental surveillance to 

monitor possible health risks. We deployed combat stress teams to 

provide education and address specific member concerns. At the 

request of the OIF leadership, the Army sent a 12p-person mental 

health advisory team to Iraq and Kuwait. This was the first time we 

have ever assessed behavioral health care in the field.

 Based on the advisory team’s recommendations we deployed additional combat stress teams for the OIF deployed force. In additional 

to the medical support, members of the chaplaincy provide counseling before departure, in the theater, and after troops return.

 Upon their return, servicemembers receive a post-deployment 

health assessment, with a face to face discussion with the primary 

care health provider. The assessment includes specific questions 

about behavioral health issues associated with deployments. If the 

individual’s responses indicate a risk of behavioral health issues, he 

or she is referred for medical consultation if PTSD or other behavioral health issues can be identified.

 Of the 138,000 troops who returned in calendar year 2004 and received a post-deployment health assessment, 16 percent were subsequently seen by mental health providers for evaluation.

 We are now implementing the new post-deployment health reassessment program to identify and recommend treatment for deployment-related health concerns that may arise three to six months after deployment. We are reaching out to veterans three to six months 

after they have returned to provide a proactive wellness check to see 

how they are doing, especially those servicemembers transitioning 

from active duty to inactive or civilian status.

 The reassessment begins with a questionnaire that includes questions designed to highlight possible stress-related issues. Important-
56

ly, the questionnaire is followed by a one on one consultation with a 

primary health provider. Again the professional administering the 

reassessment will refer individuals to follow up evaluation when it 

is indicated.

 This program certainly requires that education of the primary 

health care providers so they understand the program, making sure 

leadership understands this.

Dr. Winkenwerder yesterday testified that the Department of Defense has committed $100 million to do this program this year and 

next fiscal year for the servicemembers who will be in that three to 

six month window. After servicemembers return from deployments, 

military and VA providers provide a jointly-developed post-traumatic 

stress clinical practice guideline and a post-deployment health clinical practice guideline to provide focused health care on post-deployment health problems and concerns. There are really algorithms for 

the care providers to follow to make sure that those issues are appropriately addressed.

 Military members and their families can also proactively seek 

health care through Military OneSource, a 24-hour, seven-day a week 

toll-free family support service accessible by telephone, internet and 

email. Military OneSource offers information and educational services, referrals and face to face counseling for individuals and families. This confidential service is especially helpful for those who are 

not sure if their symptoms merit medical attention. Their going to 

Military OneSource does not get reported to the military leadership. 

If needed, counselors can refer the individuals for suitable care.

 OneSource is provided in addition to local installation family support services. The National Guard Bureau has recently signed a 

memorandum of understanding with the Department of Veterans’ 

Affairs to promote a seamless transition from DOD to VA. The DOD

provides timely data regarding a demobilization of National Guard 

troops so the VA can provide those individuals with information regarding available care and support. This includes the use of Vet Centers which provide professional readjustment counseling and are a 

link between the veteran and the VA.

 The department recognizes that stress-related health risks are 

ongoing threats to our servicemembers and that we must continue 

to improve our efforts to safeguard their emotional and behavioral 

health. Our education programs for military and family members 

and leaders and health care providers have been well received. Our 

early intervention programs, combat stress teams and health assessments have proven to be effective. All of this has been done in 

partnership with the VA, bringing us closer to our ultimate goal of a 

seamless transition from DOD to VA care.

 Mr. Chairman, I thank you again for inviting me here today. I am 

pleased to answer your questions.
57

[The statement of Dr. Kilpatrick appears on p. 124]

The Chairman. Dr. Kussman.

STATEMENT OF DR. MICHAEL J. KUSSMAN

 Dr. Kussman. Thank you, Mr. Chairman. Let me introduce, on 

my immediate left is Mr. Barilich and then Dr. Shelhorse to his left. 

Both of these gentlemen have been critically important to us and 

have been heroes in developing our mental health strategic plan and 

the implementation of our mental health processes, and I am very 

proud to have them with me today.

 Before I get to my remarks, I’ll make a few comments. I also had 

the opportunity to stop and talk to Mrs. Pelkey, and obviously told 

her how much I appreciated her courage and dedication and conviction and told her how sorry I was for her loss. I mean clearly it is a 

case where, as you articulated, that we should learn from, both DOD

and the VA.

Sir, just one other thing. I have been in this position since 29 May 

but as you know I was acting in this position for over a year, so I

would like to say I am no longer acting but I am still pretending.

[Laughter.]

 Dr. Kussman. Mr. Chairman and members of the subCommittee, 

I appreciate the opportunity to be here today. Nearly every servicemember who actively participates in combat comes away with some 

degree of emotional distress. Some have short-term reactions but 

thankfully the majority do not suffer long-term consequences from 

that experience and we have heard that from the previous panel.

Current efforts at early identification of emotional stress by DOD 

and VA clinicians increases the possibility of lowering the incidence 

of long-term mental health problems through a concerted effort at 

early detection and care. With DOD’s help, the VA regularly compiles a roster of servicemembers who have separated after active duty 

in the Iraq and Afghanistan theaters.

VA medical centers have treated over 100,000 of the close to 400,000 

OIF/OEF veterans who have separated from active service. Two of 

the most common diagnoses of health problems that have been cited 

so far are musculoskeletal ailments and dental problems. However, 

as was mentioned, we have a drop-down menu, so that when the person comes for whatever the issue is, a menu drops down and stimulates the primary care provider to do a mental health assessment to 

include PTSD.

 So of the people we have seen, the over 100,000, 24,000 have been 

diagnosed with potential mental health disorders including adjustment reaction, substance abuse, psychoses, as well as PTSD.
58

 Over 14,000 of this group, OEF/OIF veterans, have sought VA care 

at both Vet Centers and VA medical centers for issues associated to 

their adjustment reactions, such as PTSD.

VA’s approach to treating these servicemen and women is guided 

by an emphasis on the principles of health promotion and preventive 

care and is compliance with the President’s New Freedom Commission on Mental Health. We focus on providing the patient and the 

patient’s family education about good health practices and behaviors. 

We believe that education and destigmatization will go a long way in 

helping people get care and benefit from that.

VA is engaged in a number of activities to inform veterans and their 

families of the benefits and services available to them. In collaboration with DOD we have emphasis on outreach to returning members 

of the Reserve and National Guard, and this is of special concern to 

us, and has expanded significantly.

In Fiscal Year 2003, VA briefings reached nearly 47,000 Reserve 

and Guard members. So far this year, we have briefed more than 

68,000 Reserve and Guard members. In addition, both departments 

have developed a brochure together, which is entitled, “A Summary 

of VA Benefits for National Guard and Reserve Personnel.” The VA 

has distributed over a million copies of this brochure.

 In the interests of time, I was going to comment on the Vet Centers 

and the Global War on Terrorism counselors that we have hired, and 

there were 50 for the first year. We have increased now to hire another 50, and Dr. Batres commented on that, so I won’t reiterate his 

comments.

 OIF/OEF returning servicemembers seek out and enter the VA care 

from a variety of sources, including referral from military treatment 

facilities, Transition Assistant Program briefings, Vet Centers, and 

home town community service providers. When OEF/OIF veterans 

present to VA clinicians with mental, emotional, or behavioral complaints, they are assessed both for the symptoms, functional problems and total clinical needs. Treatment plans may include referral 

to mental health and Vet Centers for specific treatment of mental 

health issues.

 So, as was discussed by the previous panel, there is a tiered approach that people can get to us through our 157 facilities, our 206 

Vet Centers, as well as our 850 CVOCs that are distributed all around 

the country.

 The goal of the VA’s public health approach is to decrease the incidence of serious mental disorders. There is evidence from VA’s initial activities in the field that these approaches are accepted both by 

clinicians and the veterans they serve. They may well decrease the 

incidence of chronic mental disorder for veterans. For those who do 

develop mental disorders, decreasing the stigma or receiving care by 

teaching the public about the effect and efficacy of evidence-based 
59

treatment can increase the beneficial use of these services whose goal 

is the restoration and preservation of optimal social and occupational 

functioning.

 In conclusion, the VA will continue to monitor and address the 

mental health needs of OIF/OEF servicemembers. We are prepared 

to provide state-of-the-art evidence-based care to all those who come 

to see us.

 Now Mr. Chairman, that concludes my statement and I would be 

happy to answer any questions you have

[The statement of Dr. Kussman appears on p. 131]

The Chairman. I would like for you to explain a little bit more about 

this 24,000 of 100,000. You’ve got to break that number down. That 

is like saying one in four. Something just doesn’t fit right, feel right. 

Come on. We have all worn the uniform here. We know what it is 

like to go over there. We know what it is like to come home. We know 

what the mental adjustments are.

 It is hard for me to look at my soldiers and say one in four have 

what?

 Dr. Kussman. Oh -- let me try to answer a little more thoroughly 

than I did. As I hope I was getting across, and the message that we 

are all saying, is that almost everybody who serves has some kind of 

readjustment or reintegration problem. Most of the time it’s not illness. It is normal reactions to abnormal conditions, and to label this 

as “mental illness” would be inappropriate -- 

 The Chairman. Thank you.

 Dr. Kussman. -- clinically and would be inappropriate for the servicemembers and their family. It’s just not a true statement. But of 

that 100,000 who came, 24,000 had a diagnosis that would be consistent with adjustment reaction beyond what I just described to you.

 The Chairman. Take the next step. Of the 24,000, then what happens?

 Dr. Kussman. Of those 24,000 there’s 14,000 of them that have actually got a diagnosis of a mental health thing and there’s a gamut 

of that diagnosis. Some are adjustment reactions, of which PTSD is 

one of the adjustment reactions. There can be substance abuse, pure 

psychoses, acute stress reactions, and they fall into that 14,000 who 

actually do get a diagnosis under the ICD code.

 The Chairman. You have to break this down a lot farther for me. I

don’t want there to be any confusion.

 Of that 14,000 then, however you’re coding that, break them out 

into all the categories, because if you are including alcoholism, drug 

abuse, narcolepsy, sleep disorders -- just go down the list. What are 

we talking about?

 Dr. Kussman. Sir, Dr. Shelhorse will get that list. It’s by percentage. I believe that -- and he will get that out of the lists for you. Just 
60

a second.

 Sir, what I have is the actual, most updated, and the number is 

15,000 versus 14,000. I wasn’t trying to be disingenuous. What I put 

into the statement came before the latest number.

 Of the numbers of patients who have -- and you can have more than 

one -- and it is entitled, “The Frequency of Possible Mental Disorders 

among Iraqi and Afghanistan Veterans,” adjustment reactions, which 

is ICD code 309. I would be happy to give this to you for the record.

There were 15,000 of them, who had a potential adjustment reaction, of which -- and this is administrative data, as you know, sir, 

and so you would have to go back and look at the charts to determine whether they really end up having PTSD or not, or what kind 

of adjustment reaction because you could put down as a primary care 

internist, if somebody came to me and I was evaluating for whatever 

their physical thing was as well as their full evaluation, I might put 

down “Rule out PTSD” or “Rule out adjustment reaction” and that 

gets coded and gets picked up on these numbers.

 But then you would have to go back and look at the chart and see 

whether “rule out” actually turned out to have PTSD, as may have 

referred them to a mental health provider to actually make that diagnosis.

 But in the administrative data, about 15,000 people have the adjustment reaction, but under the 24,000 -- the total people who have 

come that might have mental illness -- under that are nondependent 

drug abuse -- there’s 10,000 people who could have had an adjustment 

reaction and drug abuse. Depressive disorders are 8,000. Affective 

disorders, 7,000. Affective Psychoses, 4,000. Alcohol dependency 

syndrome, 1,000. Sexual deviation disorder -- sounds awful -- 1,200. 

Special symptoms that are classified -- I’ll leave it to Dr. Shelhorse to 

describe that -- about1,100. Acute reaction to stress, 945. And drug 

dependency, 740.

The Chairman. Thank you for the breakout. Ma’am?

Mrs. Napolitano. Thank you, Mr. Chair. Quickly, what was the 

100,000 basis? Is that actually identified? Out of how many?

 Dr. Kussman. We categorize people who come that were OIF/OEF

veterans. There were 100,000 people who have come to us so far that 

had served in the two theaters.

 Mrs. Napolitano. Self referred?

 Dr. Kussman. Well, there is a mix of those. Some of them are transfers of care that are, as you may or may not know -- the Chairman 

knows this very well -- that we have a lot of seriously injured people 

that are case managed with the DOD, particularly at Bethesda Walter Reed, Brook, Eisenhower, and we have also branched out into Fort 

Hood and Fort Carson and some Navy basis, Marines as well, where 

we case manage those cases, so they are in that 100,000 as well.

 Most of them -- that is a relatively small number -- most of them 
61

have come to us for whatever they want, because they are veterans 

and they have a DD-214.

 Mrs. Napolitano. But have you done any outreach to those veterans from the Afghanistan war?

 Dr. Kussman. Oh, yes, ma’am. The outreach is a very critical thing 

for us, both in mental health and whatever the disease may be, because, as we have heard from the previous panel, you can have all 

the infrastructure you want, but if people don’t avail themselves of 

it or know it’s there, it is not very productive, and this is particularly 

challenging in mental health issues because of society’s stigma, and 

we are not immune to that and people are reluctant to go.

What we have tried to do is be sure through briefings, the BDD process, the TAP, and all these different things, be sure that the separating individual, whether they go back to being a Reserve or a National 

Guard person, or they just get out of the active duty and no longer 

serve, have as much information as possible, understand what the 

websites are, the 800 numbers.

 As we all know, people remember and keep track of a very small 

percentage of what you tell them in briefings, especially when you 

have come back from a place like Iraq and Afghanistan, and they 

want to get home. Indeed, as we have learned, it is not required for 

the National Guard or Reserve to actually go through the process, 

so a lot of them actually leave their demobilization site, whatever, 

without ever getting the thing. So what we have tried to do is be sure 

that we have videotapes.

 We have partnered with the National Guard and Reserve, the 

states, to go their sites, where they get back together, to have our VBA

and VHA counselors go under our seamless transition office chaired 

by Colonel (Retired) John Brown and Major General (Retired) Matthewson-Chapman who work for him. She has been a leader and a 

point person on the National Guard and Reserve.

 But one of the things that we have done is these pocket cards. You 

know, people lose everything that we give them, but we are hoping 

that -- people don’t usually lose their wallets, so we could give them 

a pocket card that they could stick in. If it is six months later or a 

year later, when they are having problems or their spouse is having 

problems, somebody might remember.

 Do you remember that pocket care we gave you?

 Mrs. Napolitano. I don’t want to stop you -- 

 Dr. Kussman. I’m sorry?

 Mrs. Napolitano. -- but at my age I am losing it before I can get to 

the next question, which has to do with exactly what you are talking 

about.

 In regard to the National Guard, because they are National Guard, 

and just recently I think we were considering a measure whereby 

they would only be given three months of TRICARE services. If they 
62

are not identified at the time they are mustered out or had not sought 

help for mental health treatment, does that preclude them from getting treatment at a VA hospital or any other institution that will help 

them? There’s no record of it.

Dr. Kussman. Let me say that we are potentially mixing two things. 

I mean they get their TRICARE benefit as having served on active 

duty, and the Department of Defense has extended that to be sure 

there was more time for them and their families to get care, but there 

is a two year window after you leave, if you have served in combat, to 

come to the VA for anything that came up during that period of time 

when you served, and with no co-pays.

 You are categorized as a Category 6 person, so it doesn’t make any 

difference what your income is or anything like that, and you have 

that two year window.

 After that they have a DD-214, and they are veterans, so they can 

come to us any time that they have for whatever they may need.

 Mrs. Napolitano. But it wasn’t identified prior to their being released and being mustered out of service or they’d been still eligible, 

and I am thinking of one veteran who didn’t recognize he was suffering from PTSD until 20 years later, until he had a group, a mentoring group of other veterans, who were rendezvousing, had been going 

through the same feelings and he was not alone, and then he sought 

help. But what happens to that veteran?

 Dr. Kussman. Well, we don’t just -- I mean with the enrollment 

management change that took place in the 1990s, 1996 I believe, we 

changed it to you don’t have to have a service-connected illness to 

come to the VA. Now having said that, there is one priority that we 

have, the decision was made if you are a Priority 8, and that is developed on an economic basis, but short of that you don’t have to prove 

connection to be seen.

 What you might have to prove is connection to get comp and pen, 

but we still would take care of the person.

 Mrs. Napolitano. Thank you, Mr. Chairman.

 The Chairman. Thank you. Dr. Kussman, what DOD data would be 

most helpful to the VA as you attempt to assess future mental health 

workload? What would be helpful to you?

Dr. Kussman. Well, as I mentioned in my testimony, we are working very closely with DOD to get as much information as we can as 

early as we can, and the comment was made about the post-deployment screen, and I would leave that to Dr. Kilpatrick, but I believe 

that they are scanning those and trying to make them electronic and 

then forwarding them to us, and there has been a great deal of progress on that. It’s not perfect.

 Other piece of information that we would like to have, whether it 

is mental health or anything else, is that we have learned clearly 

with our outreach at Walter Reed and Bethesda with the individuals 
63

that have what we describe as polytrauma, that if we are going to be 

effective in our ability to make this as seamless as possible, and god 

knows we still have a way to go, but I believe in my heart that we are 

much better than we were two years ago in what we are doing.

 We would like to know who entered the disability process and when 

they entered it so we could then determine if they choose to use the 

VA -- and as you know, sir, if the individual gets medically separated 

or discharged, particularly medically discharged, they have different 

options. They can continue to use the military system. They can use 

TRICARE or they could come to the VA But if they do want to come 

to the V.A, the sooner we can find out that information, get their 

comp and pen exam done, and get them appointments at the VA so 

when they leave they don’t fall through the cracks and have to tumble 

along themselves.

 And as you know, sir, the V.B.A. has been reasonably good in the 

past about trying to make sure that at TAP and BDD there was education on non-health care benefits. The VA in the past has not been 

as aggressive as we would like to be, and the servicemember had to 

show up and knock on the door.

 But we have changed that and we are actually partnering and being sure that not only do they get their comp and pen evaluation 

but, if appropriate, they get the appropriate appointments and get 

enrolled in the VA long before they actually get their DD-214.

 As you know also, we can’t provide them anything or give comp and 

pen to anybody until they are a veteran. They have got to get that 

DD-214, but the thrust is that everything is in place when they actually get the DD-214 and there isn’t a long gap.

The Chairman. Well, I accept your testimony about progress. I remember Dr. Winkenwerder being over here two years ago talking 

about this, so please convey this to Dr. Winkenwerder. He was invited to come here. He came to the Armed Services Committee, and 

chose not to come here. He sent you instead and I still haven’t seen 

the progress, so you can tell him that for me, okay?

Dr. Kussman. Yes, sir.

The Chairman. I yield to counsel for the limited purpose of three 

questions.

 Ms. Bennett. Thank you, Chairman. I am looking at VA’s own 

data, in which they look at evaluation of programs. I believe that is 

your NEPEC Center, the Northeast Evaluation Program Center, that 

looks at the mental health service projections.

They show that from the first half of ‘03, fiscal year ‘03 to now the 

first half of fiscal year ‘05 that the VA’s seen at least a 10 percent 

increase in the number of veterans for just the very limited area of 

outpatient by the special PTSD clinical teams.

 Those veterans then have generated a 21 percent increase in the 

number of visits.
64

VA has been working on a mental health model to do projections for 

capacity, to identify gaps in services.

Did your model accurately project in just even that narrow area a 

10 percent increase?

 Dr. Shelhorse. PTSD symptoms, PTSD diagnoses are actually 

wrapped into a group within the model and they are combined with 

compensated work therapy and some other specialized programs. In 

hindsight, it would have been advantageous for us to separate PTSD

out as a separate entity from that group so we could begin to make 

the accurate comparisons that you are mentioning, and that will indeed be something we do in a future iteration.

 So as it stands right now, I cannot tell you that the model predicted 

“x” percentage of PTSD diagnoses versus what we actually experienced because it’s actually blended with these other diagnostic entities within the group and in the model.

 Ms. Bennett. In VA’s model that you created basically to identify 

these gaps, that model does have implications for VA’s budget.

The first iteration of the model identified deficiencies in mental 

health service capacity that would require roughly at least $1.6 billion to address the chasm between the demand and the capacity for 

mental health services, including substance abuse, PTSD, depression, and a range of mental health care issues.

The model was then revised and re-projected. There was a significant drop in the gaps that were identified.

In the revision of the model, it was estimated that roughly $700 

million, or less than half of the original projection, would be needed 

to close the gaps by fiscal year 2007.

Did the model include projections for OIF and OEF veterans that 

are coming, and does it -- are you now revising it to take into account 

Colonel Hoge’s research and the outcoming research of increasing 

need for mental health services from returning soldiers?

 Dr. Kussman. Let me take a stab at the first part of your question.

 Yes, it’s true that the original assessment was in the numbers that 

you have described. However, when we looked at it critically and 

reviewed it -- and by the way, this wasn’t done in a vacuum, it was 

done with our subject matter experts including people who work in 

the NEPC and our seriously mental ill and all the other groups found 

that there were serious flaws in the design to look at that that didn’t 

take into account reliance, age cohorts, and things like that, because 

clearly mental health resources potentially we have seen from historically the Vietnam veteran needs more than the World War Two 

veteran, so that got revised on the $700 million.

 It was agreed upon and appreciated by all the people inclined, and 

as you know, our mental health providers and advocates are not shy 

and they certainly would have held us to a much level if they didn’t 

agree with that number that was projected.
65

 I’ll ask Mark about the second part of the question.

 Dr. Shelhorse. The model is essentially run off of data that is three 

years old, so ‘05 would be run off ‘02 actuals; ‘06 would be run off ‘03 

actuals, so by ‘02 and ‘03 we would have seen very little of the influx 

of patients that we might be seeing at present from OIF, OEF. The 

next year’s run will take into account ‘04 data, and so it probably will 

be a better approximation of the information that you are asking for 

about what the impact of OIF and OEF will be.

 Mr. Barilich. And if I could also add, in addition each year the 

model is revised and refined. Speaking with Barbara Manning this 

morning, who is one of the people who works on this, these type of 

things come up and need to be projected into the future obviously that 

weren’t known at the time of the baseline year.

 Also along with that, I think it is important to note, too, that one of 

the other things that is included in that model is what is referred to 

as “vet pop” and what that is is the list of discharges from service of 

our potential veteran population, so that information is also blended 

into these models.

 Ms. Bennett. Just to follow up, have you yet revised your ‘07 projections, because that was a $700 million number that did not take into 

account OEF, OIF, or the intensity of their usage of mental health 

services from VA

Are you revising it for your ‘07 budget?

 Dr. Kussman. Let me try to answer that by saying that we believe 

that that $700 million was an iterative thing over the course of our efforts to -- of the strategic plan, and as you know, the underSecretary 

to kick-start that put $100 million toward that goal in ‘05 and it will 

be continued in ‘06. We are developing the ‘07 budget right now.

 The Chairman. There was a DOD collaborative effort to provide clinical practice guidelines to be useful tools. Are they being utilized?

 Dr. Kilpatrick. On the DOD side, the use is not what we would 

like to see. What we are seeing at this point is about one to three 

percent of people coming back coming in to primary care on answering, “Yes. I am here today with a concern that may be related to a 

deployment.”

 With the numbers of folks coming back, I would expect that that 

ought to be a lot higher and so we are taking a look at, with the services drilling down, to say how is this being used?

 Some places you swipe your ID card and you have to electronically 

answer, “Have you returned from a deployment? Is this a deployment 

related issue?”

 That data is very robust. In some areas people are actually not 

asked that, so the policies there, the implementation, is not as robust 

as we would like. But currently we are seeing about three percent of 

people coming in to primary care are indicating this is for a deployment-related issue.

The Chairman. Dr. Kussman?

Dr. Kussman. Sir, as I mentioned to you, when anybody comes to us 
66

and comes to enroll and needs an appointment, part of the protocol 

is to ask, “Are you OIF?” “Oh, yes.” Because we were giving and are 

giving them top priority to get in for access to whatever, to be sure 

that they get in within 30 days, obviously faster if it is urgent or 

emergent.

 Also I mentioned that in our electronic health record, if you come, 

even if you come for your back pain or headache or arm pain, the primary care provider who sees you, a drop down menu automatically 

forces the individual practitioner to ask questions related to potential 

deployment.

 We also have a very robust employee education system, as you 

know, that is geared toward educating not only patients and we also 

have a very robust employee education system, as you know, that is 

geared toward educating not only patients but our staff, both doctors, 

nurses, nurse clinicians, PAs on the best approaches to PTSD and 

mental health in general, because, quite frankly, nationally there 

aren’t enough mental health providers to provide the full need that 

the country needs, and so you couldn’t rely on the number of psychiatrists and psychologists in the job. You have to rely on your primary 

care people to provide appropriate level of mental health care as part 

of their full service care to their patients.

When I was a practicing internist, that was part of my job, to evaluate my patient for mental health, and if I didn’t think or by the guidelines I was using if that was inappropriate for me to do it, they needed 

more advanced, then I would refer them on, but you can’t treat the 

full patient without assessing the mental health as well, but again it 

is hard to get people to admit that they have got problems and we go 

back to the stigma. The particular issue with mental health is that 

if the individual doesn’t recognize that they have a problem, it’s particularly challenging to treat them because if they keep denying the 

problem it is hard to force people to get help.

The Chairman. Dr. Kussman, I think we are going to have to come 

back and maybe do it for another day, and that is I want you to, I am 

going to ask of you to become intimate with the IG report, because 

trying to separate out of all of this -- as soldiers and as we are matriculated into a system, a value system, an ethos -- we don’t understand 

how some would then try to seek to use the system and do fraudulent 

claims and we don’t like to talk about that.

 It’s sort of like the big elephant in the room that everyone wants to 

ignore that there would actually be someone who would deface that 

value and then try to file fraudulent claims, and the IG has identified 

a practice going on out there and websites, and here is how you file 

your claims and if you get denied in this particular region, then start 

forum shopping.

 And we have this huge mushroom, an explosion now, of claimants, 

and what we want to do is make sure that we take care of people who 

particularly need it, right? There is a challenge that we are confronting here, are we not?
67

 Dr. Kussman. If I could comment -- 

 The Chairman. Yes.

 Dr. Kussman. -- because you asked for that in your opening remarks. 

Obviously, as you quoted, it is a delicate issue and we are truly sensitive and aware of that problem. It is a combined VA/VBA/VHA issue 

of benefits as well as making the diagnosis.

 As you know, the Secretary is acutely aware of this, but we are not 

unique, by the way, in our interaction with our fellow countries that 

practice medicine and provide benefits like we do. The Brits, the 

Canadians, the Aussies and the New Zealanders are actually seeing 

the same type of problem exploding with a lot of benefits, particularly 

mental health benefits, and they are struggling the same way that 

we are.

 The Secretary has charged us to look at that critically and make 

some recommendations to him and that is what we are starting to 

do, sir.

 The Chairman. When someone receives a 100 percent disability rating for PTSD, can’t they continue to receive treatment and get better, 

so the disability rating could actually go down?

 Dr. Kussman. Yes, sir.

 The Chairman. The system doesn’t prevent -- 

 Dr. Kussman. Oh, no, sir, it doesn’t prevent them from doing it. We 

encourage them. I mean obviously if somebody has a 100 percent 

disability for any kind of mental health thing, we would presume 

that ongoing therapy would be a good thing and that they drop out of 

service. Obviously we can’t admit -- I mean impact on the course of 

their events.

 The Chairman. Once they get their check, and they get their 100 

percent disability rating, and now they drop out of treatment, they 

have achieved a particular goal.

 Dr. Kussman. You could, sir, suggest that there are perverse incentives here.

 The Chairman. Well, that is what the IG report is indicating with 

this explosion. It is something we need to look at.

 Dr. Kussman. Yes, sir, we are.

The Chairman. Let me ask this one to professionals, and I’m sure 

that is the other panel.

 Is there a reluctance among the practice of psychiatry to really 

give that second opinion about someone else’s diagnosis or not? Is it 

pretty free-flowing?

 Dr. Kussman. I don’t think so, but I will turn to my psychiatrist 

here.

 The Chairman. I am just curious.

 Dr. Shelhorse. Not to my knowledge. I, in fact, did these exams for 

many, many years and we had many remands where we had second 

opinions or even third opinions. A panel would be required. They 
68

were quite common. No reluctance, no hesitation to give a second 

opinion even if it was a different opinion than the original examiner.

 The Chairman. Okay. Well, that’s good.

 Well, please convey my earlier remarks to Dr. Winkenwerder. I

mean the reason I came up with pre- and post- deployments was from 

the lessons learned coming out of the Gulf War and the synergies of 

my service on the Armed Services Committee and here, and so we 

put a lot of people through these, and then if that data is not being 

referred on to the VA, then we’ve got problems, so I just want you to 

know that it is very bothersome to me that this is continuing to occur.

 I want to thank you for your work that you are doing out there 

and continue to remain vigilant. And this hearing is now concluded. 

Thank you.

[Whereupon, at 1:57 p.m., the Committee adjourned.]
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