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45–652 PDF 2008

S. HRG. 110–631

THE FINDINGS AND RECOMMENDATIONS OF THE

DEPARTMENT OF DEFENSE TASK FORCE ON

MENTAL HEALTH, THE ARMY’S MENTAL

HEALTH ADVISORY TEAM REPORTS, AND DEPARTMENT OF DEFENSE AND SERVICE-WIDE

IMPROVEMENTS IN MENTAL HEALTH RESOURCES, INCLUDING SUICIDE PREVENTION,

FOR SERVICEMEMBERS AND THEIR FAMILIES

HEARING

BEFORE THE

SUBCOMMITTEE ON PERSONNEL

OF THE

COMMITTEE ON ARMED SERVICES 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

SECOND SESSION

MARCH 5, 2008

Printed for the use of the Committee on Armed Services

(

COMMITTEE ON ARMED SERVICES 

CARL LEVIN, Michigan, Chairman 

EDWARD M. KENNEDY, Massachusetts 

ROBERT C. BYRD, West Virginia 

JOSEPH I. LIEBERMAN, Connecticut 

JACK REED, Rhode Island 

DANIEL K. AKAKA, Hawaii 

BILL NELSON, Florida 

E. BENJAMIN NELSON, Nebraska 

EVAN BAYH, Indiana 

HILLARY RODHAM CLINTON, New York 

MARK L. PRYOR, Arkansas 

JIM WEBB, Virginia 

CLAIRE McCASKILL, Missouri 

JOHN MCCAIN, Arizona 

JOHN WARNER, Virginia, 

JAMES M. INHOFE, Oklahoma 

JEFF SESSIONS, Alabama 

SUSAN M. COLLINS, Maine 

SAXBY CHAMBLISS, Georgia 

LINDSEY O. GRAHAM, South Carolina 

ELIZABETH DOLE, North Carolina 

JOHN CORNYN, Texas 

JOHN THUNE, South Dakota 

MEL MARTINEZ, Florida 

ROGER F. WICKER, Mississippi 

RICHARD D. DEBOBES, Staff Director 

MICHAEL V. KOSTIW, Republican Staff Director 

SUBCOMMITTEE ON PERSONNEL

E. BENJAMIN NELSON, Nebraska, Chairman 

EDWARD M. KENNEDY, Massachusetts 

JOSEPH I. LIEBERMAN, Connecticut 

JIM WEBB, Virginia 

CLAIRE McCASKILL, Missouri 

LINDSEY O. GRAHAM, South Carolina 

SUSAN M. COLLINS, Maine 

SAXBY CHAMBLISS, Georgia 

ELIZABETH DOLE, North Carolina 

(II) 

C O N T E N T S 

CHRONOLOGICAL LIST OF WITNESSES 

THE FINDINGS AND RECOMMENDATIONS OF THE DEPARTMENT OF DEFENSE TASK

FORCE ON MENTAL HEALTH, THE ARMY’S MENTAL HEALTH ADVISORY TEAM REPORTS, AND DEPARTMENT OF DEFENSE AND SERVICE-WIDE IMPROVEMENTS IN

MENTAL HEALTH RESOURCES, INCLUDING SUICIDE PREVENTION, FOR SERVICE- MEMBERS AND THEIR FAMILIES

MARCH 5, 2008

Page

Boxer, Hon. Barbara, U.S. Senator from the State of California ........................ 2

Arthur, VADM Donald C., USN (Ret.) Co-Chair, Department of Defense Task 

Force on Mental Health ....................................................................................... 19

MacDermid, Dr. Shelley M., Co-Chair, Department of Defense Task Force 

on Mental Health ................................................................................................. 19

Hoge, COL Charles W., USA, Director, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research; Accompanied by COL 

Carl A. Castro, USA, Research Area Director, Military Operational Medicine Research Program ........................................................................................ 121

Schoomaker, LTG Eric B., USA, Surgeon General of the United States Army 

and Commanding General, United States Army Medical Command .............. 129

Robinson, VADM Adam M., Jr., USN, Surgeon General of the United States 

Navy and Chief, Bureau of Medicine and Surgery ............................................ 134

Roudebush, Lt. Gen. James G., USAF, Surgeon General of the United States 

Air Force ............................................................................................................... 143

Sutton, COL Loree K., USA, Special Assistant to the Assistant Secretary 

of Defense (Health Affairs), Psychological Health and Traumatic Brain 

Injury .................................................................................................................... 148

(III) 

(1)

THE FINDINGS AND RECOMMENDATIONS OF 

THE DEPARTMENT OF DEFENSE TASK 

FORCE ON MENTAL HEALTH, THE ARMY’S 

MENTAL HEALTH ADVISORY TEAM REPORTS, AND DEPARTMENT OF DEFENSE 

AND SERVICE-WIDE IMPROVEMENTS IN 

MENTAL HEALTH RESOURCES, INCLUDING 

SUICIDE PREVENTION, FOR SERVICEMEMBERS AND THEIR FAMILIES 

WEDNESDAY, MARCH 5, 2008 

U.S. SENATE, 

SUBCOMMITTEE ON PERSONNEL, 

COMMITTEE ON ARMED SERVICES, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 2:35 p.m. in room 

SR–232A, Russell Senate Office Building, Senator E. Benjamin 

Nelson (chairman of the subcommitee) presiding. 

Committee members present: E. Benjamin Nelson, Lieberman, 

and Graham. 

Committee staff member present: Leah C. Brewer, nominations 

and hearings clerk. 

Majority staff members present: Gabriella Eisen, counsel; and 

Gerald J. Leeling, counsel. 

Minority staff members present: Diana G. Tabler, professional 

staff member, and Richard F. Walsh, minority counsel. 

Staff assistants present: Jessica L. Kingston and Ali Z. Pasha. 

Committee members’ assistants present: Frederick M. Downey, 

assistant to Senator Lieberman; Andrew R. Vanlandingham, assistant to Senator Ben Nelson; Jon Davey, assistant to Senator Bayh; 

Clyde A. Taylor IV, assistant to Senator Chambliss; and Andrew 

King, assistant to Senator Graham. 

OPENING STATEMENT OF SENATOR E. BENJAMIN NELSON, 

CHAIRMAN 

Senator BEN NELSON. Our ranking member, Senator Graham, is 

on his way. He’ll be a little late, but he has suggested we go ahead 

and start the subcommittee hearing this afternoon, so we can give 

Senator Boxer an opportunity to address us on a series of very important issues. 

2

Let me start by saying the Personnel Subcommittee hearing will 

come to order. I have a short initial statement which I’ll read and 

then, Senator Boxer, it’ll be our pleasure to have your testimony. 

The subcommittee meets today to receive testimony on the findings and recommendations of the Department of Defense (DOD) 

Task Force on Mental Health, the Army’s Mental Health Advisory 

Team (MHAT) reports, and DOD and Service-wide improvements 

in mental health resources, including suicide prevention, for 

servicemembers and their families. 

This subcommittee is responsible for the most important aspect 

of the United States military system, our men and women and 

their families who volunteer to serve our great Nation. The repeated and extended deployments and the intensity of the conflicts 

in Iraq and Afghanistan are taking a toll on the mental health of 

our troops and their families. This hearing will help us to understand more clearly what help is currently available to them and, 

importantly, what more is needed. 

It’s been an honor to be able to work alongside my ranking member, Senator Graham. We’ve switched positions a time or two. We 

continue to work well together because there is nothing partisan 

about the mental health of our military. 

Perhaps the most important piece of what we’re about today in 

looking after the mental well-being of our Armed Forces and their 

greatest support, their families, is an opportunity to learn more 

about what is being done, but also what more should be done. 

We’re pleased here in the first panel to have Senator Boxer, who 

for years has been a tireless advocate for our servicemembers. She 

has taken the lead on this issue of mental health and offered the 

amendment to create the DOD Task Force on Mental Health, 

which was included in the National Defense Authorization Act for 

Fiscal Year 2006. She is here to discuss her efforts in this area. So 

we thank you for being with us today. 

I’ll talk one second about our second panel. We’re honored to 

have several experts on the subject of mental health care and treatment in the military environment. They’re here to share with us 

the findings and recommendations of the DOD Task Force on Mental Health, as well as the findings of the other reports. I’ll introduce them when the second panel convenes. 

The third panel will consist of the DOD official charged with implementing the recommendations of the task force and the surgeons general from each of the Services. They’re here to discuss the 

programs, plans, and initiatives that the Services and DOD have 

in place already or plan to put in place to respond to the findings 

of the Army’s MHAT reports and to implement the task force’s recommendations. I’ll introduce them when we begin the third panel. 

So we look forward to the testimony today and we’ll ask Senator 

Graham to make his statement when he is able to join us. In the 

mean time, Senator Boxer, thank you very much for being here. 

STATEMENT OF HON. BARBARA BOXER, U.S. SENATOR FROM 

THE STATE OF CALIFORNIA 

Senator BOXER. Senator Nelson and Senator Lieberman, I’m very 

honored to be before your subcommittee. If we remember back, 

with the gracious help of this committee, Senator Lieberman and 

3

I working together, were able to include language establishing the 

Mental Health Task Force in the National Defense Authorization 

Act for Fiscal Year 2006. 

At that time, we were roughly 2 years into the Iraq war and we 

were beginning to hear countless stories that showed we did not 

have an adequate mental health care system in place. I can’t tell 

you how many phone calls I got from nameless families who said: 

We’re just scared. 

Over a 1-year period, the task force took a comprehensive and a 

very thoughtful look at the state of mental health care and services 

for our servicemembers and their families. Frankly, what they 

found, Mr. Chairman, was simply not good. In particular, the task 

force found that—and I’m quoting—‘‘Significant gaps in the continuum of care for psychological health exist,’’ and that ‘‘the military health system lacks the fiscal resources and the fully trained 

personnel to fulfill its mission to support psychological health.’’ 

In response to those findings, the task force developed a series 

of 95 comprehensive recommendations to dramatically improve the 

way that the DOD both views psychological health in general and 

provides treatment and care for those who need it. 

I am tremendously proud of their work and I have told them so, 

and particularly I am proud of the outstanding leadership of the 

two co-chairs, who will testify next: Vice Admiral Donald Arthur 

and Dr. Shelley MacDermid. 

It is my understanding that the DOD elected to adopt all but one 

of the task force recommendations. I am here today to both commend the work of the task force and to ask that you as the Senate 

committee charged with overseeing military health care, and particularly this subcommittee, provide the DOD with all of the resources and support necessary to implement these far-reaching 

changes. I am sure that you all agree, and from listening to the 

chairman’s heartfelt opening, you all agree that we have a big 

problem on our hands that is only going to get worse if we don’t 

do something big now, something that really fills the void. 

According to a study published in the Journal of the American 

Medical Association on November 14, 2007, 20 percent or one in 

five of all Active Duty Army soldiers and 42 percent of all Reserve 

component soldiers, including Army Reserve and Army National 

Guard, who served in Iraq are reporting that they need mental 

health treatment for a range of problems—one in five. This means 

that tens of thousands of men and women need and deserve the 

best mental health care that we can provide. 

I have to say, Mr. Chairman and Senator Lieberman, in all the 

years that I’ve been in Congress, and for a period of time in the 

1980s I served on the Armed Services Committee, I saw that when 

the military decides to do something they do it right and they do 

it as a model for the rest of the Nation. I don’t care whether it’s 

child care or health care or whatever it is. So I am so optimistic 

that with the resources that we can make sure they can really not 

only solve the problems that we’re facing in the military, but send 

a very clear signal to the civilian community of what the civilian 

community must do. 

Too many servicemembers have been discharged for preexisting 

personality disorders when they actually had mental health probVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
4

lems from their combat experience. Imagine, they were discharged 

for preexisting conditions when they had mental health problems 

from their combat experience. That’s wrong, because those people 

are not going to get the help they need. 

Too many servicemembers have turned to drugs and alcohol, and 

the number of DUIs has risen at bases across this Nation. Too 

many servicemen and women have attempted or committed suicide. 

In 2007 alone, 121 soldiers committed suicide and another 2,100 attempted suicide, a six-fold increase since 2002. This is tragic. I 

know you agree with me because I’ve talked to you about these 

things. 

If we don’t act soon, we will see more devastating consequences 

of these wounds play out in the years to come on our streets with 

homeless and substance abuse. I still, when I talk to the homeless, 

find homeless vets from the Vietnam era. 

Senators, we can’t have this continue. We see homelessness. We 

see substance abuse. We see violence. We see divorce, and that’s 

why we have to do more to confront these challenges today. 

I am so proud of the work that we have done together, particularly with my colleague Senator Lieberman. We have successfully 

passed legislation to establish a center of excellence for military 

mental health and traumatic brain injury (TBI). We have helped 

to set standards for deployment for servicemembers with diagnosed 

mental health conditions and to examine issues involving women 

and combat stress. 

But there is much more to be done. That is why I am continuing 

to work on legislation with Senator Lieberman to address mental 

health workforce shortages and to address the issue of suicide 

within the armed services. 

We also must shatter the stigma associated with seeking mental 

health care that says a soldier, sailor, airman, or marine is weak 

if he or she wants to talk with a mental health professional about 

experiences in Iraq or Afghanistan. We must ensure that we have 

adequate numbers of uniformed mental health providers who can 

train and deploy with our troops and be there when they’re needed. 

It doesn’t help them if they can’t find help quickly. We must give 

our servicemembers the tools they need to be able to cope with the 

stress upon them and the experiences that many of them face each 

and every day. 

That is why it is so important that this subcommittee fully supports the recommendations of the DOD Mental Health Task Force. 

Mr. Chairman, it’s rare that Members of Congress look at a special committee that was set up to work within the DOD and say 

you’re right on every count, you have done your work well. We are 

of one mind on this. Now, I know there are differences about the 

war in Iraq. There are bitter differences, difficult differences. But 

I know that all of us agree, regardless of how we feel about the 

war, we all feel the same way about the warriors. We honor them, 

we trust them, we want to stand by their side. 

I think today, Mr. Chairman, with your leadership and that of 

Senator Graham and Senator Lieberman, who I’m so pleased is 

here, I really think we can take some bipartisan actions to ensure 

that our troops are treated. 

5

In conclusion, let me say when we do this right it’s going to help 

our military in the long run. It’s going to enable us to attract more 

people when they know that if they do have this type of problem 

they’ll be cared for, they’ll be made whole, and it will help us recruit the best people and keep the best people. 

Thank you so very much for this chance to speak to you. 

[The prepared statement of Senator Boxer follows:]

PREPARED STATEMENT BY SENATOR BARBARA BOXER

Mr. Chairman, with the gracious help of this committee, I was able to include language establishing the Mental Health Task Force in the National Defense Authorization Act for Fiscal Year 2006. 

At that time, we were roughly 2 years into the Iraq war and beginning to hear 

countless stories that showed we did not have an adequate mental health care system in place. 

Over a 1 year period, the task force took a comprehensive and thoughtful look at 

the state of mental health care and services for our service men and women and 

their families. What they found was not good. 

In particular, the task force found that ‘‘significant gaps in the continuum of care 

for psychological health’’ exist, and that the ‘‘Military Health System lacks the fiscal 

resources and the fully-trained personnel to fulfill its mission to support psychological health.’’

In response to their findings, the task force developed a series of 95 comprehensive recommendations to dramatically improve the way that the Department of Defense both views psychological health in general, and provides treatment and care 

for those who need it. 

I am tremendously proud of their work, and particularly the outstanding leadership of the two co-chairs who will testify next, Vice Admiral Donald Arthur and Dr. 

Shelley MacDermid. 

It is my understanding that the Department of Defense elected to adopt all but 

one of the task force recommendations. 

I am here today to both commend the work of the task force and to ask that you—

as the Senate committee charged with overseeing military health care—provide the 

Department of Defense with all of the resources and support necessary to implement these far-reaching changes. 

I am sure that you all agree that we have a big problem on our hands that is 

only going to get worse if we don’t do something big now. 

According to a study published in the Journal of the American Medical Association on November 14, 2007, 20 percent (or 1 in 5) of all Active Duty Army soldiers 

and 42 percent of all Reserve component soldiers, including Army Reserve and Army 

National Guard, who served in Iraq are reporting that they need mental health 

treatment for a range of problems. 

This means that tens of thousands of men and women need and deserve the best 

mental health care that we can provide. We can and must do better. 

Too many servicemembers have been discharged for pre-existing personality disorders when they actually had mental health problems from their combat experience. 

Too many servicemembers have turned to drugs and alcohol, and the number of 

DUIs has risen at bases across the Nation. 

Too many service men and women have attempted or committed suicide. In 2007 

alone, 121 soldiers committed suicide and another 2,100 attempted suicide, a sixfold increase since 2002. This is tragic. 

If we don’t act soon, we will see more devastating consequences of these wounds 

play out in the years to come—homelessness and substance abuse; violence and divorce. That is why we can and must do more to confront these challenges today. 

I am proud of the work I have been able to do so far, much of it with my colleague 

Senator Lieberman. We have successfully passed legislation to establish a Center 

of Excellence for Military Mental Health and Traumatic Brain Injury. We have 

helped to set standards for deployment for servicemembers with diagnosed mental 

health conditions, and to examine issues involving women and combat stress. 

But there is more to be done. 

That is why I am continuing to work on legislation with Senator Lieberman to 

address mental health workforce shortages and to address the issue of suicide within the Armed Forces. 

6

We also need to shatter the stigma associated with seeking mental health care 

that says a soldier, sailor, airman, or marine is weak if he or she wants to talk with 

a mental health professional about experiences in Iraq or Afghanistan. 

We need to ensure that we have adequate numbers of uniformed mental health 

providers who can train and deploy with our troops and be there when they are 

needed. 

We must give our servicemembers the tools they need to be able to cope with the 

stress of combat and the experiences that many of them face each and every day. 

That is why it is so important that this subcommittee fully support the recommendations of the Department of Defense Mental Health Task Force. 

I know that there are different views about the war in Iraq on this committee 

and in the Senate. But all of us agree that we should honor the service of the brave 

men and women of our military. We can and must come together to serve them as 

well as they have served us. 

I look forward to continuing to work with you on this most important issue.

Senator BEN NELSON. Thank you, Senator. 

Senator Lieberman, I understand you may have an opening 

statement you’d like to make. I didn’t mean to pass over you so 

quickly. 

Senator BOXER. I would love to hear it. 

Senator LIEBERMAN. Just very briefly, I’m going to put my statement in the record. 

Thank you for convening this hearing. Thanks, Senator Boxer. 

We’ve formed a partnership in shared concern, as you quite rightly 

said, about the warriors, even though we had differences of opinion 

about the war, and that’s something that I think expresses the 

unity that the American people feel. 

There’s been a lot of work done on this. I’m very proud of the 

mental health care for our Wounded Warriors Act, which was in 

the National Defense Authorization Act for Fiscal Year 2008. I appreciate the work that is being done within the health services in 

the military. 

I just want to focus for a moment on the two pieces of legislation 

you mentioned that we’re working on, because the work is obviously not done. First, we’ve noted in all these Services a real shortage of uniformed behavioral health providers. That’s why Senator 

Boxer and I are working on legislation that will increase and improve incentives for recruitment and training and retention of such 

providers. We’re talking about psychologists, psychiatrists, social 

workers, and mental health nurses. 

The need for uniformed providers cannot be overemphasized 

when one considers their dual missions to not only deploy to combat zones, but staff garrison military treatment facilities (MTFs) 

across the globe. 

Incidentally, one of the things that Senator Boxer and I know 

you, Mr. Chairman and Senator Graham, understand is that a soldier, sailor, marine, or airman who is mentally fit is going to be 

a better fighter and is going to be a better team member with those 

in his or her unit. 

One of the interesting things that we’ve learned in our work on 

this, Senator Boxer and I, is that uniformed mental health professionals are critical. You can buy civilian services on a contract 

basis, but in the work that we’ve done and our staffs have done it’s 

very clear particularly those returning from combat strongly prefer 

receiving care from a fellow servicemember. That’s what this piece 

of legislation that Senator Boxer and I are offering focuses on. 

7

It’s not going to be easy, particularly because of some very practical problems that some of our military installations are in places 

that are not, shall we say, in the middle of cosmopolitan metropolitan areas. Would those in uniform agree with that? Yes, and some 

of the mental health professionals prefer to be in such places. 

So we have to figure out ways to attract people. 

Second, suicide rates have become alarming. In the past year 

there have been a number of disturbing reports concerning suicide 

rates, particularly in the Army. In 2007—higher than at any other 

time since the statistic had been tracked by the military; higher 

also than the suicide rate in the civilian population. 

So the legislation Senator Boxer and I are working on would in 

short create a new across-the-Services prevention program modeled 

on a highly successful aircraft incident prevention program, which 

is run by the Air Force. I hope that my colleagues will look at both 

of these pieces of legislation and ideally, as you were kind enough 

to include the previous legislation in the National Defense Authorization Act for Fiscal Year 2008, perhaps we could include these 

two in the National Defense Authorization Act for Fiscal Year 

2009. 

I thank you, Mr. Chairman, for your leadership, and again I 

thank Senator Boxer for her leadership here. Senator Graham, I 

don’t want to leave you out. This is a real bipartisan concern, and 

you’ve been right at the leadership of those trying to do something 

about it. 

Thank you very much. 

[The prepared statement of Senator Lieberman follows:]

PREPARED STATEMENT BY SENATOR JOSEPH I. LIEBERMAN

Chairman Nelson, thank you for convening this important hearing on the status 

of the Department of Defense’s mental health reforms. 

Soon after the conflicts in Iraq and Afghanistan began, the ‘‘hidden injuries’’ resulting from the war began to surface. The statistics are not new to anyone here. 

An estimated one in six Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) servicemembers has a diagnosable condition of post-traumatic stress disorder and 1 in 10 has suffered a traumatic brain injury. Over one-third of OIF/OEF 

veterans treated by the Veterans Administration has been diagnosed with a mental 

health condition, including post-traumatic stress disorder, depression, and substance 

abuse, among others. 

These realities have motivated this committee, and others including Senator 

Boxer, to work on a number of initiatives to improve our servicemembers’ access to 

high quality behavioral health care. Numerous commissions and study groups have 

also contributed significantly to the effort and influenced our work on this committee. Specifically, I would like to applaud the seminal work of the Mental Health 

Task Force. The Task Force, led by Vice Admiral Arthur and Dr. MacDermid, has 

been critical in providing a blueprint for building a true continuum of care for psychological health, and I look forward to their testimony. 

I would also like to thank the committee for working with Senator Boxer and myself to include our legislation, S. 1196, the Mental Health Care for Our Wounded 

Warriors Act, in the National Defense Authorization Act for Fiscal Year 2008, which 

authorizes the establishment of a Defense Center of Excellence on psychological and 

brain injuries. This center will provide critical leadership to the Department’s efforts to conduct research, develop treatments, and disseminate best practices on psychological health and brain injuries. I look forward to supporting the new Defense 

Center of Excellence and applaud Colonel Sutton in her efforts to bring critical leadership to this issue. The task ahead will not be easy—to not only fulfill the mandates passed in the National Defense Authorization Act for Fiscal Year 2008, but 

to implement many of the recommendations of the Mental Health Task Force. We 

ask that you come to this committee when you require additional resources or authorities to accomplish these goals. 

8

This hearing is very timely because we now have: a more comprehensive understanding of the psychological injuries affecting servicemembers, increasing research 

evidence to support the design of new interventions and models for delivering preventive and treatment services, and the political willpower to provide current and 

future servicemembers with the best behavioral health care. Therefore, we must 

now marshal our resources to implement long-term solutions that provide effective 

prevention and treatment services to those in uniform now and will promote resilience and early intervention and treatment for our future forces as well. 

First, we will not be able to increase access to behavioral health services to those 

in need now, and to inoculate against, or provide early treatment for psychological 

injuries if we do not increase the number of uniformed behavioral health service 

providers in each of our Services. That is why Senator Boxer and I are introducing 

legislation to increase and improve incentives for the recruitment and retention of 

uniformed behavioral health providers, including psychologists, psychiatrists, social 

workers, and mental health nurses. The need for uniformed providers cannot be 

overemphasized in light of their dual missions to not only deploy to combat zones, 

but staff garrison military treatment facilities across the globe. We have also 

learned that uniformed mental health professionals are critical because many of 

those returning from combat strongly prefer to receive care from a fellow servicemember. As we learn more about the mental health conditions that arise from repealed tours of duty, we must have the uniformed workforce in place to meet the 

demands of our returning servicemembers and the long-term challenges facing the 

Department to improve both the access to and the quality of mental health care. 

I believe this is critical to not only addressing the Department’s immediate behavioral health care needs, but also in strengthening the resilience of our forces in the 

future. 

I will also be introducing a second piece of legislation focusing on suicide prevention. Our military’s most valuable resource is the people who serve our country in 

uniform. In the past year, there have been a number of disturbing reports in the 

news concerning the Army’s suicide rate, which was higher in 2007 than any other 

time this statistic has been tracked by the military, and significantly higher than 

in the civilian population. We must reverse the current trend. My legislation will 

create a new prevention program, modeled on the Air Force’s highly successful aircraft accident prevention program, at the Department of Defense to investigate all 

suicides. An independent body, assembled by a four-star general, would produce a 

confidential report, including recommendations to address any recognized deficiencies. We must have the protocols in place to make sure we are able to determine 

when a servicemember needs help or immediate attention, and I believe my proposal will go a long way in preserving our most valuable resource—our men and 

women in uniform. Too much of our current debate on suicide has focused on whether or not there are statistically significant differences in suicides rates from 1 year 

to the next or when in comparison to those in the general population. Instead, I 

urge the Department to work with this committee and focus efforts on establishing 

protocols to investigate all suicides to determine causes and contributing factors, 

procedures to take immediate corrective action when necessary, and track the implementation of all Service-wide and force-wide recommendations emerging from such 

investigations. 

We can all agree that providing the best behavioral health care to our servicemembers is a priority for the current and future health of our force. I look forward 

to working with my colleagues on both sides of the aisle this year to tackle the challenges before us. We have asked our servicemembers to accept near-impossible trials 

and tribulations on the battlefield. The least we can do is to provide them with the 

best possible care and the attention they deserve.

Senator BEN NELSON. Thank you. 

Senator BOXER. Thank you, Senators. 

Senator Graham, while you were gone I just said thank you so 

much for giving me this opportunity, because I think that this legislation is really needed and we would be so thrilled to have it included in the next DOD bill. Thank you very much. 

Senator GRAHAM. Thank you, Senator. I agree with you. 

Senator BEN NELSON. Thank you, Senator. Senator Graham, do 

you have an opening statement? 

Senator GRAHAM. Very briefly. When Senators Lieberman, Boxer, 

Nelson, and hopefully Graham can come together, that’s a big day 

9

for the Senate. The topic brings us together, and I would just like 

to say to the witnesses, who are going to testify about the stress 

on the force, thank you for coming and telling us about what’s 

going on out there. I think I have somewhat of an understanding 

how stressful it may be, but there have been so many acts of bravery and kindness of our troops in incredibly hostile circumstances 

and a lot of people have gone back more than twice, and it has to 

wear on them and their families. 

The only thing I can tell you in the opening statement is that if 

I could be king of the world, bad people would not do bad things. 

We’re in a world where bad people have a desire to disrupt life for 

the rest of us, and we can sit on the sidelines and hope they go 

away or we can go fight them. We’re going to go fight them, and 

we’re going to take care of those who are doing the fighting. But 

there’s no other option as far as I see it. What happened in Afghanistan should be a wakeup call for all of us. The consequences of losing in Iraq are enormous, and so those who are willing to leave 

their families and go to far-away places with strange-sounding 

names to make us all safe, God bless. You’re needed. What you’re 

doing is noble and we’re going to help you and your family the best 

we can. But I can’t promise you an end to this, because the evil 

we’re fighting will not be compromised with; it has to be defeated. 

Senator BEN NELSON. Thank you, Senator Graham. 

Before we ask the second panel to step up, I ask unanimous consent that the statements submitted by outside organizations that 

the staff has already compiled be included in the record. 

Without objection, so ordered. 

[The prepared statements of the National Military Family Association and Sam D. Toney, MD, follow:]

PREPARED STATEMENT BY THE NATIONAL MILITARY FAMILY ASSOCIATION

Chairman Nelson and distinguished members of this subcommittee, the National 

Military Family Association (NMFA) would like to thank you for the opportunity to 

present testimony today on the mental health services for the military and their 

families. We thank you for your focus on the many elements necessary to ensure 

quality mental health care for our servicemembers, veterans, and the families within the Department of Defense (DOD) health care system. 

NMFA will discuss several issues of importance to servicemembers, veterans, and 

their families in the following subject areas:

Mental Health 

Wounded Servicemembers Have Wounded Families 

Who Are the Families of Wounded Servicemembers? 

Caregivers 

MENTAL HEALTH

As the war continues, families’ needs for a full spectrum of mental health services—from preventative care and stress reduction techniques, to individual or family 

counseling, to medical mental health services—continue to grow. The military offers 

a variety of mental health services, both preventative and treatment, across many 

helping agencies and programs. However, as servicemembers and families experience numerous lengthy and dangerous deployments, NMFA believes the need for 

confidential, preventative mental health services will continue to rise. 

Recent findings by the Army’s Mental Health Advisory Team (MHAT) IV report 

stated current suicide prevention training was not designed for a combat/deployed 

environment. Other reports found a correlation between the increase in the number 

of suicides in the Army to tour lengths and relationship problems. ‘‘Armed Forces 

Suicide Prevention Act of 2008’’ is a bicameral proposal calling for a review of existing suicide prevention efforts and a requirement for suicide prevention training for 

all members of the Armed Forces, including the civilian sector and family support 

10

professionals. NMFA is especially appreciative of the spouses and parents of returning servicemembers’ provisions: providing readjustment information; education on 

identifying mental health, substance abuse, suicide, and traumatic brain injury 

(TBI); and encouraging them to seek assistance when having financial, relationship, 

legal, and occupational difficulties. NMFA supports this proposed legislation. 

It is important to note if DOD has not been effective in the prevention and treatment of mental health issues, the residual will spill over into the Veterans Administration (VA) health care system. The need for mental health services will remain 

high for some time even after military operations scale down and servicemembers 

and their families’ transition to veteran status. DOD and the VA must be ready. 

DOD must partner with the VA in order to address mental health issues early on 

in the process and provide transitional mental health programs. Partnering between 

the two agencies will also capture the National Guard and Reserve population who 

often straddle both agencies’ health care systems. 

The Army’s MHAT IV report links the need to address family issues as a means 

for reducing stress on deployed servicemembers. The team found the top non-combat 

stressors were deployment length and family separation. They noted that soldiers 

serving a repeat deployment reported higher acute stress than those on their first 

deployment and the level of combat was the key ingredient for their mental health 

status upon return. The previous MHAT report acknowledged deployment length 

was causing higher rates of marital problems. Given all the focus on mental health 

prevention, the study found current suicide prevention training was not designed for 

a combat/deployed environment. Recent reports on the increased number of suicides 

in the Army also focused on tour lengths and relationship problems. These reports 

demonstrate the amount of stress being placed on our troops and their families. Are 

the DOD and VA ready? Do they have adequate mental health providers, programs, 

outreach, and funding? Better yet, where will the veteran’s spouse and children go 

for help? Many will be left alone to care for their loved one’s invisible wounds left 

behind from frequent and long combat deployments. Who will care for them now 

that they are no longer part of the DOD health care system? NMFA encourages this 

Subcommittee to talk with their VA committee counterparts on these important 

issues. We can no longer be content on focusing on each agency separately because 

this population moves too frequently between the two agencies, especially our 

wounded/ill/injured servicemembers and their families. 

DOD’s Task Force on Mental Health stated timely access to the proper mental 

health provider remains one of the greatest barriers to quality mental health services for servicemembers and their families. NMFA and the families it serves have 

noted with relief more providers are being deployed to theaters of combat operations 

to support servicemembers. The work of these mental health professionals with 

units and individuals close to the combat action they experience has proven very 

helpful and will reduce the stress that impedes servicemembers’ performance of 

their mission and their successful reintegration with their families. However, while 

families are pleased more mental health providers are available in theater to assist 

their servicemembers, they are less happy with the resulting limited access to providers at home. DOD’s Task Force on Mental Health found families are reporting 

an increased difficulty in obtaining appointments with social workers, psychologists, 

and psychiatrists at their military hospitals and clinics. The military fuels the shortage by deploying some of its child and adolescent psychology providers to the combat 

zones. Providers remaining at home stations report they are frequently overwhelmed treating active duty members who either have returned from deployment 

or are preparing to deploy. They are also finding it hard to fit family members into 

their schedules, which could lead to compassion fatigue, create burnout, and exacerbate the problem. NMFA hears from the senior officer and enlisted spouses who are 

so often called upon to be the strength for others. We hear from the health care providers, educators, rear detachment staff, chaplains, and counselors who are working 

long hours to assist servicemembers and their families. Unless these caregivers are 

also afforded respite care, given emotional support through their command, and effective family programs, they will be of little use to those who need their services 

most. 

Access for mental health care, once servicemembers are wounded/ill/injured, further compounds the problem. Families want to be able to access care with a mental 

health provider who understands or is sympathetic to the issues they face. The VA 

has readily available services. The Vet Centers are an available resource for veterans’ families providing adjustment, vocational, and family and marriage counseling. Vet Centers are located throughout the United States and in geographically 

dispersed areas, which provide a wonderful resource for our most challenged veterans and their families, the National Guard and Reserves. These Centers are often 

felt to remove the stigma attributed by other institutions. However, they are not 

11

mandated to care for veteran or wounded/ill/injured military families. The VA 

health care facilities and the community-based outpatient clinics have a ready supply of mental health providers, yet regulations restrict their ability to provide mental health care to veterans’ caregivers unless they meet strict standards. NMFA supports the Independent Budget Veterans Service Organizations recommendations to 

expand family counseling in all VA major care facilities; increase distribution of outreach materials to family members; improve reintegration of combat veterans who 

are returning from a deployment; and provide information on identifying warning 

signs of suicidal thoughts so veterans and their families can seek help with readjustment issues. However, NMFA believes this is just a starting point for mental 

health services the VA should offer families of severely wounded servicemembers 

and veterans. NMFA recommends DOD partner with the VA to allow military families access to these services. We also believe Congress should require Vet Centers 

and the VA to develop a holistic approach to care by including families in providing 

mental health counseling and programs. 

NMFA has heard the main reason for the VA not providing health care and mental health care services is because they cannot be reimbursed for care rendered to 

a family member. However, the VA is a qualified TRICARE provider. This allows 

the VA to bill for services rendered in their facilities to a TRICARE beneficiary. 

There may be a way to bill other health insurance companies, as well. No one is 

advocating for care to be given for free when there is a method of collection. However, payment should not be the driving force on whether or not to provide health 

care or mental health services within the VA system. The VA just needs to look at 

the possibility for other payment options. 

Thousands of servicemember parents have been away from their families and 

placed into harm’s way for long periods of time. Military children, the treasure of 

many military families, have shouldered the burden of sacrifice with great pride and 

resiliency. We must not forget this vulnerable population as the servicemember 

transitions from active duty to veteran status. Many programs, both governmental 

and private, have been created with the goal of providing support and coping skills 

to our military children during this great time of need. Unfortunately, many support 

programs are based on vague and out of date information. 

Given the concern with the war’s impact on children, NMFA has partnered with 

the RAND Corporation to research the impact of war on military children. The report is due in April 2008. In addition, NMFA held its first ever Youth Initiatives 

Summit for Military Children, ‘‘Military Children in a Time of War’’ last October. 

All panelists agreed the current military environment is having an effect on military 

children. Multiple deployments are creating layers of stressors, which families are 

experiencing at different stages. Teens especially carry a burden of care they are 

reluctant to share with the non-deployed parent in order to not ‘‘rock the boat.’’ 

They are often encumbered by the feeling of trying to keep the family going, along 

with anger over changes in their schedules, increased responsibility, and fear for 

their deployed parent. Children of the National Guard and Reserve face unique 

challenges since there are no military installations for them to utilize. They find 

themselves ‘‘suddenly military’’ without resources to support them. School systems 

are generally unaware of this change in focus within these family units and are ill 

prepared to look out for potential problems caused by these deployments or when 

an injury occurs. Also vulnerable, are children who have disabilities that are further 

complicated by deployment and subsequent injury. Their families find this added 

stress can be overwhelming, but are afraid of reaching out for assistance for fear 

of retribution on the servicemember. They often choose not to seek care for themselves or their families. 

NMFA encourages the DOD to partner with and reach out to those private and 

non-governmental organizations who are experts in their field on children and adolescents to identify and incorporate best practices in the prevention and treatment 

of mental health issues affecting our military children. At some point, these children 

will become children of our Nation’s veterans. We must remember to focus on preventative care upstream, while still in the active duty phase, in order to have a solid 

family unit as they head into the veteran phase of their lives. 

Family readiness calls for access to quality health care and mental health services. Families need to know the various elements of their military health system are 

coordinated and working as a synergistic system. NMFA is concerned the DOD military health care system may not have all the resources it needs to meet both the 

military medical readiness mission and provide access to health care for all beneficiaries. It must be funded sufficiently so the direct care system of military treatment facilities (MTF) and the purchased care segment of civilian providers can work 

in tandem to meet the responsibilities given under the TRICARE contracts, meet 

readiness needs, and ensure access for all military beneficiaries. 

12

National provider shortages in this field, especially in child and adolescent psychology, are exacerbated in many cases by low TRICARE reimbursement rates, 

TRICARE rules, or military-unique geographical challenges (large populations in 

rural or traditionally underserved areas). Many mental health providers are willing 

to see military beneficiaries in a voluntary status. However, these providers often 

tell us they will not participate in TRICARE because of what they believe are timeconsuming requirements and low reimbursement rates. More must be done to persuade these providers to participate in TRICARE and become a resource for the entire system, even if that means DOD must raise reimbursement rates. 

Many mental health experts state that some post-deployment problems may not 

surface for several months or years after the servicemember’s return. We encourage 

Congress to request DOD to include families in its Psychological Health Support 

survey; perform a pre and post-deployment mental health screening on family members (similar to the PDHA and PDHRA currently being done for servicemembers as 

they deploy into theater); and sponsor a longitudinal study, similar to DOD’s Millennium Cohort Study, in order to get a better understanding of the long-term effects 

of war on our military families. 

NMFA is especially concerned at the lack of services available to the families of 

returning National Guard, Reserve members, and servicemembers who leave the 

military following the end of their enlistment. They are eligible for TRICARE Reserve Select, but as we know Guard and Reserve are often located in rural areas 

where there may be no mental health providers available. We ask you to address 

the distance issues families face in linking with military mental health resources 

and obtaining appropriate care. Isolated Guard and Reserve families do not have 

the benefit of the safety net of services provided by MTFs and installation family 

support programs. Families want to be able to access care with a provider who understands or is sympathetic to the issues they face. NMFA recommends the use of 

alternative treatment methods, such as telemental health; increasing mental health 

reimbursement rates for rural areas; modifying licensing requirements in order to 

remove geographical practice barriers that prevent mental health providers from 

participating in telemental health services; and educating civilian network mental 

health providers about our military culture. 

Mental health professionals must have a greater understanding of the effects of 

mild TBI in order to help accurately diagnose and treat the servicemember’s condition. They must be able to deal with polytrauma—Post-Traumatic Stress Disorder 

(PTSD) in combination with multiple physical injuries. We need more education for 

civilian health care providers on how to identify signs and symptoms of mild TBI 

and PTSD. Military families also need education on TBI and PTSD during the entire cycle of deployment. NMFA appreciates Congress establishing a Center of Excellence for TBI and PTSD. For a long time, the Defense and Veterans Brain Injury 

Center (DVBIC) has been the lead agent on TBI. Now with the new Center, it is 

very important DVBIC become more integrated and partner with other Services in 

researching TBI. 

Because the VA has as part of its charge ‘‘to care for the widow and the orphan,’’ 

NMFA is concerned about reports that many Vet Centers may not have the qualified counseling services they needed to provide promised counseling to survivors, especially to children. DOD and the VA must work together to ensure surviving 

spouses and their children can receive the mental health services they need, 

through all of VA’s venues. New legislative language governing the TRICARE behavioral health benefit may also be needed to allow TRICARE coverage of bereavement or grief counseling. While some widows and surviving children suffer from depression or some other medical condition for a time after their loss, many others 

simply need counseling to help in managing their grief and help them to focus on 

the future. Many have been frustrated when they have asked their TRICARE contractor or provider for ‘‘grief counseling’’ only to be told TRICARE does not cover 

‘‘grief counseling.’’ Available counselors at military hospitals can sometimes provide 

this service while certain providers have found a way within the reimbursement 

rules to provide needed care. However, many families who cannot access military 

hospitals are often left without care because they do not know what to ask for or 

their provider does not know how to help them obtain covered services. Targeted 

grief counseling when the survivor first identifies the need for help could prevent 

more serious issues from developing later. The goal is the right care at the right 

time for optimum treatment effect. The VA and DOD need to better coordinate their 

mental health services for survivors and their children. 

The National Defense Authorization Act for Fiscal Year 2008 authorized an active-duty TRICARE benefit for severely wounded/ill/injured servicemembers once 

they are medically retired, but their family members were not mentioned in the 

bill’s language. A method of payment to the VA for services rendered without finanVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6621 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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cially impacting the family would be to include the medically retired servicemember’s spouse and children. NMFA recommends an active duty benefit for 3 

years for the family members of those who are medically retired. This will help with 

out-of-pocket medical expenses that can arise during this stressful transition time 

and provide continuity of care for spouses, especially for those families with special 

needs children who lose coverage under the Extended Care Health Option program 

once they are no longer considered active duty dependents. 

WOUNDED SERVICEMEMBERS HAVE WOUNDED FAMILIES

Transitions can be especially problematic for wounded/ill/injured servicemembers, 

veterans, and their families. NMFA asserts that behind every wounded 

servicemember and veteran is a wounded family. Spouses, children, parents, and 

siblings of servicemembers injured defending our country experience many uncertainties. Fear of the unknown and what lies ahead in future weeks, months, and 

even years, weighs heavily on their minds. Other concerns include the wounded 

servicemember’s return and reunion with their family, financial stresses, and navigating the transition process from active duty and the DOD health care system to 

veteran and the VA health care system. 

The two agencies health care systems should alleviate, not heighten these concerns. They should provide for coordination of care, starting when the family is notified that the servicemember has been wounded and ending with the DOD and VA 

working together, creating a seamless transition as the wounded servicemember 

transfers between the two agencies’ health care systems and eventually from active 

duty status to veteran status. 

NMFA congratulates Congress on the National Defense Authorization Act for Fiscal Year 2008, especially the Wounded Warrior provisions, in which many issues affecting this population were addressed. We also appreciate the work DOD and the 

VA have done in establishing the Senior Oversight Committee (SOC) to address the 

many issues highlighted by the three Presidential Commissions. Many of the Line 

of Action items addressed by the SOC will help ease the transition for active duty 

servicemembers and their families to their life as veterans and civilians. However, 

more still needs to be done. Families are still being lost in the shuffle between the 

two agencies. Many are moms, dads, siblings who are unfamiliar with the military 

and its unique culture. There is certainly more work to be done by DOD and the 

VA. We urge Congress to establish an oversight committee to monitor DOD and 

VA’s partnership initiatives, especially with the upcoming administration turnover 

and the disbandment of the SOC early this year. 

WHO ARE THE FAMILIES OF WOUNDED SERVICEMEMBERS?

In the past, the VA and the DOD have generally focused their benefit packages 

for a servicemember’s family on his/her spouse and children. Now, however, it is not 

unusual to see the parents and siblings of a single servicemember presented as part 

of the servicemember’s family unit. In the active duty, National Guard, and Reserves almost 50 percent are single. Having a wounded servicemember is new territory for family units. Whether the servicemember is married or single, their families 

will be affected in some way by the injury. As more single servicemembers are 

wounded, more parents and siblings must take on the role of helping their son, 

daughter, sibling through the recovery process. Family members are an integral 

part of the health care team. Their presence has been shown to improve their quality of life and aid in a speedy recovery. 

Spouses and parents of single servicemembers are included by their husband/wife 

or son/daughter’s military command and their family support and readiness groups 

during deployment for the global war on terror. Moms and dads have been involved 

with their children from the day they were born. Many helped bake cookies for fundraisers, shuffled them to soccer and club sports, and helped them with their homework. When that servicemember is wounded, their involvement in their loved one’s 

life does not change. Spouses and parent(s) take time away from their jobs in order 

travel to the receiving MTF (Walter Reed Army Medical Center or the National 

Naval Medical Center at Bethesda) and to the follow-on VA Polytrauma Centers to 

be by their loved one. They learn how to care for their loved one’s wounds and navigate an often unfamiliar and complicated health care system. 

It is NMFA’s belief the government, especially the DOD and VA, must take a 

more inclusive view of military and veterans’ families. Those who have the responsibility to care for the wounded servicemember must also consider the needs of the 

spouse, children, parents of single servicemembers and their siblings, and the caregivers. We appreciate the inclusion in the National Defense Authorization Act for 

Fiscal Year 2008 Wounded Warrior provision for health care services to be provided 

14

by the DOD and VA for family members as deemed appropriate by each agency’s 

Secretary. According to the Traumatic Brain Injury Task Force, family members are 

very involved with taking care of their loved one. As their expectations for a positive 

outcome ebbs and flows throughout the rehabilitation and recovery phases, many 

experience stress and frustration and become emotionally drained. The VA has also 

called for recognition of the impact on the veteran when the caregiver struggles because of their limitations. NMFA recommends DOD and VA include mental health 

services along with physical care when drafting the NDAA fiscal year 2008’s regulations. 

NMFA recently held a focus group composed of wounded servicemembers and 

their families to learn more about issues affecting them. They said following the injury, families find themselves having to redefine their roles. They must learn how 

to parent and become a spouse/lover with an injury. Each member needs to understand the unique aspects the injury brings to the family unit. Parenting from a 

wheelchair brings on a whole new challenge, especially when dealing with teenagers. Reintegration programs become a key ingredient in the family’s success. 

NMFA believes we need to focus on treating the whole family with programs offering skill based training for coping, intervention, resiliency, and overcoming adversities. Parents need opportunities to get together with other parents who are in similar situations and share their experiences and successful coping methods. DOD and 

VA need to provide family and individual counseling to address these unique issues. 

Opportunities for the entire family and for the couple to reconnect and bond as a 

family again, must also be provided. 

The impact of the wounded/ill/injured on children is often overlooked and underestimated. Military children experience a metaphorical death of the parent they 

once knew and must make many adjustments as their parent recovers. Many families relocate to be near the treating MTF or the VA Polytrauma Center in order to 

make the rehabilitation process more successful. As the spouse focuses on the rehabilitation and recovery, older children take on new roles. They may become the caregivers for other siblings, as well as for the wounded parent. Many spouses send 

their children to stay with neighbors or extended family members, as they tend to 

their wounded/ill/injured spouse. Children get shuffled from place to place until they 

can be reunited with their parents. Once reunited, they must adapt to the parent’s 

new injury and living with the ‘‘new normal.’’ Brooke Army Medical Center has recognized a need to support these families and has allowed for the system to expand 

in terms of guesthouses co-located within the hospital grounds. The on-base school 

system is also sensitive to issues surrounding these children. A warm, welcoming 

family support center located in Guest Housing serves as a sanctuary for family 

members. Unfortunately, not all families enjoy this type of support. The DOD could 

benefit from looking at successful programs like Brooke Army Medical Center’s 

which has found a way to embrace the family unit during this difficult time. NMFA 

is concerned the about the impact the injury is having on our most vulnerable population, children of our military and veterans. 

CAREGIVERS

Caregivers need to be recognized for the important role they play in the care of 

their loved one. Without them, the quality of life of the wounded servicemembers 

and veterans, such as physical, psycho-social, and mental health, would be significantly compromised. They are viewed as an invaluable resource to DOD and VA 

health care providers because they tend to the needs of the servicemembers and the 

veterans on a regular basis. Their daily involvement saves VA health care dollars 

in the long run. According to the VA, ‘‘ ‘informal’ caregivers are people such as a 

spouse or significant other or partner, family member, neighbor or friend who generously give their time and energy to provide whatever assistance is needed to the 

veteran’’. The VA has made a strong effort in supporting veterans’ caregivers. The 

DOD should follow suit and expand their definition. 

So far, we have discussed the initial recovery and rehabilitation and the need for 

mental and health care services for family members. But, there is also the long-term 

care that must be addressed. Caregivers of the severely wounded, ill, and injured 

servicemembers who are now veterans, such as those with severe TBI, have a long 

road ahead of them. In order to perform their job well, they must be given the skills 

to be successful. This will require the VA to train them through a standardized, certified program, and appropriately compensate them for the care they provide. The 

time to implement these programs is while the servicemember is still on active duty 

status. 

The VA currently has eight caregiver assistance pilot programs to expand and improve health care education and provide needed training and resources for careVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6621 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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givers who assist disabled and aging veterans in their homes. These pilot programs 

are important, but there is a strong need for 24-hour in-home respite care, 24-hour 

supervision, emotional support for caregivers living in rural areas, and coping skills 

to manage both the veteran’s and caregiver’s stress. DOD should evaluate these 

pilot programs to determine whether to adopt them for themselves. Caregivers’ responsibilities start while the servicemember is still on active duty. These pilot programs, if found successful, should be implemented as soon as possible and fully 

funded by Congress. However, one program missing from the pilot program is the 

need for adequate child care. Servicemembers can be single parents or the caregiver 

may have non-school aged children of their own. Each needs the availability of child 

care in order to attend their medical appointments, especially mental health appointments. NMFA encourages DOD and the VA to create a drop-in child care for 

medical appointments on their premises or partner with other organizations to provide this valuable service. 

NMFA has heard from caregivers of the difficult decisions they have to make over 

their loved one’s bedside following the injury. Many don’t know how to proceed because they don’t know what their loved one’s wishes were. The time for this discussion needs to take place prior to deployment and potential injury, not after the injury had occurred. We support the recent released Traumatic Brain Injury Task 

Force recommendation for DOD to require each deploying servicemember to execute 

a Medical Power of Attorney and a Living Will. We encourage this subcommittee 

to address this issue. 

NMFA strongly suggests research on military families, especially children of 

wounded/ill/injured Operation Iraqi Freedom/Operation Enduring Freedom veterans; 

standardized training, certification, and compensation for caregivers; individual and 

family counseling and support programs; a reintegration program that provides an 

rich environment for families to reconnect; and an oversight committee to monitor 

DOD’s and VA’s continued progress toward seamless transition. 

DOD must balance the demand for mental health personnel in theater and at 

home to help servicemembers and families deal with unique emotional challenges 

and stresses related to the nature and duration of continued deployments. We ask 

you to continue to put pressure on DOD to step up the recruitment and training 

of uniformed mental health providers and the hiring of civilian mental providers to 

assist servicemembers in combat theaters and at home stations to care for the families of the deployed and servicemembers who have either returned from deployment 

or are preparing to deploy. Spouses and parents of returning servicemembers’ need 

programs providing readjustment information, education on identifying mental 

health, substance abuse, suicide, and TBI. 

DOD should increase reimbursement rates to attract more providers in areas 

where there is the greatest need. TRICARE contractors should be tasked with stepping up their efforts to attract mental health providers into the TRICARE networks 

and to identify and ease the barriers providers cite when asked to participate in 

TRICARE. Congress needs to address the long-term continued access to mental 

health services for this population. 

NMFA would like to thank you again for the opportunity to present testimony 

today on the mental health needs for the military and their families. Military families support the Nation’s military missions. The least their country can do is make 

sure servicemembers, veterans, and their families have consistent access to high 

quality mental health care in the DOD and VA health care systems. Wounded 

servicemembers and veterans have wounded families. DOD and VA must support 

the caregiver by providing standardized training, access to mental health services, 

and assistance in navigating the health care systems. The system should provide 

coordination of care and DOD and VA working together to create a seamless transition. We ask this subcommittee to assist in meeting that responsibility. 

PREPARED STATEMENT BY SAM D. TONEY, M.D. 

Chairman Nelson, Ranking Member Graham, and distinguished members of the 

subcommittee, thank you for the opportunity to present this written submission in 

lieu of a personal testimony, regarding the need for improved mental health access 

and treatment programs, including suicide prevention, for servicemembers and veterans within the VA and Military Health Systems. 

Challenges with mental health management are well documented and include, 

among other issues, social stigma and access for patients who reside in rural locations. Additionally, the demand for mental health services has been on the rise, parVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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1Grembowski, 2002; Colton & Manderscheid, 2006; Maciejewski, et. al, 2007

2Mojtabai, 2005 

3 Hutschemaekers, Tiemens, & de Winter, 2007; Kovess-Masfe ́ty, et. al, 2007; Younes, 2005 4Satcher, 2000; Hogan, 2003 

5Goldney, Phillips, Fisher, & Wilson, 2004

6 Ciechanowski, Katon, & Russo, 2000; DiMatteo, Lepper, & Croghan, 2000

7 Ismail, 2002; Milliken, Aucherlonie, & Hoge, 2007; Ijff et. al, 2007

8Liu, Maciejewski, & Sales, 2005

9Weeks, et. al, 2004

10Satcher, 2000; Rost, Nutting, Smith, Elliott, & Dickinson, 2002; Katon et. al, 2005 11Maizels, Saenz & Wirjo, 2003

ticularly over the last few years.1 Studies suggestive of improvements in access as 

a result of an increased number of individuals with psychologic distress having contacted mental health professionals are misleading in that as recently as 2002 approximately two-thirds of adults with significant psychologic distress received no 

professional mental health care.2 The extent of this issue is one of global proportions. Several European studies, for example, examine the diminished use of mental 

health care services and explore the determinants of help-seeking interventions for 

mental health problems along with the factors that potentially influence treatment 

options.3 Here in the United States reports from the surgeon general and the President’s New Freedom Commission on Mental Health have concluded that the mental 

health system is fragmented and that evidence-based treatments are insufficiently 

used with less than optimal results.4 Additionally, many studies have focused on adherence to treatment plans including an examination of co-morbidities and elements 

that might be predictive of frequent hospitalization.5 Mental health disorders such 

as depression, for example, have been shown to impact one’s inability to adhere to 

disease management treatment protocols thus worsening the course of the co-morbid 

state.6

Much of the veteran centric research in mental health examines problems specific 

to combat with a general focus on Post Traumatic Stress Disorder (PTSD).7 While, 

veterans have access to a health care system unavailable to most Americans, the 

Veterans Health Administration (VHA), research demonstrates that utilization patterns in this population are suboptimal as compared to the general population. In 

2002, the VHA provided care to approximately 4.5 million veterans in a total veteran population estimated at that time to be 25.3 million (10 percent of the total 

population).8 Furthermore, veteran centric data reports that rural-urban disparities 

across regional delivery networks exist in the veteran population.9 Such disparities 

exist in terms of optimal, effective treatment and what individuals in general receive in actual practice settings.10 This results in functional impairments that continue to drive medical costs upward. 

We have found that undiagnosed/untreated or suboptimal treatment of mental 

health conditions adversely affect the volume and levels of utilization of health care 

services overall. There are a number of barriers relative to the effective management of mental health conditions, including social stigma and the availability of psychiatric/psychotherapeutic providers in rural communities. The use of state of the 

art, population based predictive modeling/risk stratification methodologies in addition to traditional telephonic screening will enhance proactive identification of high 

risk veterans. These approaches coupled with a specialized telephonic mental health 

care coaching and consultation liaison program will serve to benefit those veterans 

who would otherwise not seek or have access to mental health care. 

The first step toward addressing and effectively managing these veterans with 

mental health needs is accurate identification and risk stratification. This is a step 

that goes beyond current efforts to screen the population for a variety of mental 

health conditions (such as depression and PTSD) for a number of reasons. First, 

screening efforts typically focus on a limited number of definitive behavioral conditions with an emphasis on identifying and addressing the mental health issues. This 

does not take subclinical conditions or psychosocial/personality traits into consideration. More importantly, these efforts do not typically evaluate the clinical status/

utilization or risk of co-morbid medical conditions. Finally, predictive modeling and 

risk stratification methodologies utilizing data mined from electronic medical 

records can provide for an efficient evaluation of the entire population in the system 

and does not rely on the ‘‘participation’’ of the veteran during screening campaigns. 

We believe this predictive modeling/risk stratification approach can be an adjunct 

to current screening processes both from a volume and content perspective. 

Telephonically delivered, education-based, disease management programs can facilitate the care patients receive from their physicians, particularly on the primary 

care level.11 Furthermore, population-based disease management programs ‘‘provide 

education for a broad population, enabling contact with far more patients than 

17

12Feifer, et al., 2004, p.101 13Osterberg & Blaschke, 2005 14 Ismail, 2002; Milliken, Aucherlonie, & Hoge, 2007; Ijff et. al, 2007 15Weeks, et. al, 2004 16 (Satcher, 2000; Rost, Nutting, Smith, Elliott, & Dickinson, 2002; Katon et. al, 2005). 

would be feasible by other means and at a lower per-patient cost than more intensive programs.’’ 12

Providers may not fully comprehend why their patients do not respond to management of chronic conditions despite best efforts to follow standards of care in treatment protocols. Poor adherence to medication regimens is the most common example 

of this.13 While it is acknowledged in the literature that physician practices and patient behaviors contribute to gaps in care, recognizing psychologic distress as the potential source of non-adherence to treatment plans is difficult without the benefit 

of adequate predictive profiling and risk stratification for a large segment of the 

population suffering from chronic conditions. Much of the veteran centric research 

in chronic conditions including mental health examines problems specific to combat 

with a general focus on PTSD.14 The VHA research demonstrates that utilization 

patterns in this population are suboptimal as compared to the general population. 

As referenced above, this may be secondary to social stigma or geographic challenges, given the facilities based VA care delivery model. Furthermore, veteran centric data reports that rural-urban disparities across regional delivery networks exist 

in the veteran population.15 Such disparities exist in terms of optimal, effective 

treatment and what individuals in general receive in actual practice settings.16 This 

results in functional impairments that continue to drive all aspects of medical costs 

upward. 

It is widely recognized that access to care by rural veterans is a significant issue. 

While the VA system continues to improve by streamlining the appointment 

verification process, the distances many of our veterans are being asked to travel 

does not always seem feasible. In rural settings such as some parts of Nebraska or 

South Carolina, asking veterans to travel hundreds of miles each way does not seem 

appropriate. The VA has done an admirable job trying to accommodate as many veterans as possible but perhaps it is time to think ‘‘outside the box’’ to implement innovative and creative options, that extend beyond the VA’s facilities based delivery 

paradigm, to address these geographic issues. 

Following the identification of a target population within the VA system through 

the use of predictive modeling and risk stratification, and telephonic screening, we 

believe that individual veterans within this group should be contacted proactively 

through a unique and tested telephonic outreach campaign, and managed in an integrated program as follows:

• Engage Members

An enrolled veteran is defined as an individual who has been identified as eligible 

and appropriate for the program as described above and has agreed to enroll in a 

care coaching program. Veterans should be contacted for program engagement and 

enrollment using specially developed, individualized communications tools and techniques. Based on communications sciences, the tools are designed to quickly convey 

the value of the program, address and remove barriers to enrollment and active participation and ease the veteran into the program.

• Assess and Create Personal Intervention Plan

We believe that behavioral health clinicians (RNs and masters level therapists, 

supported by MDs and PhDs) should be the primary care coaches for veterans who 

agree to participate in an integrated management program. These clinicians telephonically conduct a comprehensive veteran assessment (BioPsychoSocial (BPS)) 

that includes a number of behavioral health screens such as the PHQ–9 and PCL–

17 as well as proprietary assessment criteria such as present conditions or health 

risks, depression history, condition knowledge, communications skills, health literacy, psychosocial barriers, motivation/readiness to change relative to depression 

and any other care gaps or barriers to treatment. The assessment criteria is used 

to develop a Personal Intervention Plan, specify the intervention level which defines 

the intensity and frequency of interventions, and to set care coaching goals focused 

on improving self-efficacy and sustaining behavior change. In addition, conditionspecific modules (e.g. PTSD, depression) assess individual treatment plans against 

evidence-based guidelines, measure individual symptom severity, quality of life, productivity, treatment plan adherence rates and condition-specific knowledge. Specific 

mental health assessments also enable care coaches to identify risk factors for suicide and to effectively intervene with preventive measures which include 

psychoeducational techniques, reframing, clinical alerts, and medical director conVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6621 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
18

sultation. Medical directors (Board Certified Physicians with specific VA experience 

and training) review each case monthly for consistency in treatment plans as well 

as potential underlying psychopathology not yet identified or treated. Medical directors may engage in a collaborative telephonic consultation with the VA practitioner 

to assist in the diagnosis and further enhancement of the particular treatment plan.

• Follow Personal Intervention Plan

A Personal Intervention Plan is oriented towards ‘‘graduation’’ from the program 

when the veteran has reached their care coaching goals, achieving sustained behavior change, treatment adherence and desired levels of self-efficacy. The intervention 

plan strategy includes Care Coaching, which involves motivational interviewing, 

working with tools to sustain behavior change, and follow up to assess and achieve 

progress towards goals. The second element to graduation is ensuring that all treatment plan interventions are consistent with evidence-based guidelines. As veterans 

are enrolled into an integrated program their initial assessment and individual psychosocial issues are communicated to the VA practitioner in a standardized reporting format.

• Measure Relevant Outcomes

Because programs such as these are driven by outcomes, they are developed to 

measure and report key relevant metrics to demonstrate the impact of the program. 

For individual veterans, this includes behavior modification milestones and achievement of ‘‘graduation’’ criteria. Across the population, this provides reporting on the 

activity and progress for every aspect of the program. 

Again, I would like to thank the subcommittee for this opportunity and welcome 

the opportunity to serve as a resource to the subcommittee in the future.

Senator BEN NELSON. With that, will the second panel please 

come forward as your name placard is being put forward. While 

that’s happening, I did mention, Senator Graham, how we have 

worked together on this subcommittee for some time when you 

were chair and now that you’re ranking member, and we’ve reversed our roles, but there’s nothing partisan about mental health 

care for our troops. 

On our second panel we are honored to have Admiral Don C. Arthur, United States Navy, Retired; Dr. Shelley M. MacDermid, who 

are the Co-Chairs of the DOD Task Force on Mental Health, which, 

as I stated earlier, was a congressionally-mandated task force referred to by both Senator Boxer and Senator Lieberman. The task 

force, as indicated, was charged with conducting an assessment of 

and making recommendations for improving the efficacy of mental 

health services provided to members of the Armed Forces by the 

DOD, to include access to mental health care providers, the reduction or elimination of stigma in regards to seeking mental health 

care, and coordination between the Department and civilian communities with respect to mental health services, among many other 

things. 

We’re also fortunate to have with us today Colonel Charles W. 

Hoge, United States Army, who is the Director of the Division of 

Psychiatry and Neuroscience at the Walter Reed Army Institute of 

Research. Colonel Hoge is well known in the medical community 

for his extensive work in the area of mental health care in the military. 

Accompanying Colonel Hoge is Colonel Carl A. Castro, United 

States Army, who is the Research Area Director of the Military 

Operational Medicine Research Program. Both colonels have participated in elements of all five of the Army’s MHAT reports, so 

they’re quite familiar with those reports. 

Let me say that I commend the Army for starting these MHAT 

studies on its own initiative. 

19

We look forward to hearing from each of you, and we will start 

first with Admiral Arthur—would you like to begin? 

STATEMENT OF VADM DONALD C. ARTHUR, USN (RET.) COCHAIR, DEPARTMENT OF DEFENSE TASK FORCE ON MENTAL HEALTH 

Admiral ARTHUR. Senator Nelson, Senator Graham: Thank you 

very much for inviting us to this panel. It’s a great honor. Indicative of the teamwork that went into the Mental Health Task Force 

report, I would actually like to turn it over to Shelley MacDermid 

for a moment, and we will tag team our presentations if that’s 

okay.

STATEMENT OF DR. SHELLEY M. MACDERMID, CO-CHAIR, DEPARTMENT OF DEFENSE TASK FORCE ON MENTAL

HEALTH

Dr. MACDERMID. Thank you. The full report of the Task Force on 

Mental Health is being submitted for the record and I thank you 

very much for inviting both of us to speak today. I’m honored to 

be here and I’m honored to be among the very distinguished speakers that you will hear from today. 

The report presented an achievable vision for supporting the psychological health of military members and their families. The task 

force recommended building a culture of support for psychological 

health throughout DOD in order to combat stigma, shortages of 

staff and training, and procedural and policy barriers that were 

interfering with access to quality care. 

The task force also made recommendations aimed at ensuring a 

full continuum of excellent care for servicemembers and their families. Because of specific gaps that were found during its investigations, the task force recommended increases in resources and staff 

and changes in staff allocations in order to address shortages that 

were impeding adequate care. 

Finally, the task force recommended that leadership be created 

and empowered to ensure consistent attention to and advocacy for 

the psychological health of military members and their families. 

I will now turn to Admiral Arthur. 

Admiral ARTHUR. Thank you. 

Sir, this is the report. It’s titled ‘‘An Achievable Vision’’ and it’s 

titled ‘‘An Achievable Vision’’ because we can get there. 

I would like to talk about the three pillars of mental health as 

concentrated on by this report: prevention, mitigation, and treatment. In the prevention, we focused on establishing a culture in 

the military Services that looks at mental health as part of an 

overall health policy, looking at mental health fitness with the 

same degree of concern that we have for physical fitness. Today we 

measure mile runs and pushups and pullups, but we don’t really 

measure how psychologically fit or resilient people are to the very 

difficult stresses of military service. We feel that vulnerability can 

and should be assessed in our military members and that we accept military members, officers and enlisted, who already have significant issues of stress in their lives, that we can measure and 

mitigate those stresses that they come to us with. 

20

We can measure their vulnerability to stress, and we can do two 

things with those measures. One is if we know that someone is vulnerable we can hopefully design programs, which will increase 

their resilience. We know that some are more resilient than others, 

and the more resilient the leaders, the less post-traumatic stress 

they have, and the men and women who serve them have. 

So first we can recognize vulnerability and try to mitigate it. Second, we can tell people who are extraordinarily vulnerable that, for 

example, it would be nice if you could be a jet mechanic, a perfectly 

good military occupational specialty, but not necessarily put them 

into the stressful situations that may permanently harm their psychological well-being, such as walking down the streets of Fallujah 

breaking in doors. Those things can be for the more resilient. 

This can also apply to a national level. You can see from the 

earthquake in Oakland and Hurricane Katrina in New Orleans 

that those two areas of the country dealt very differently with the 

environmental trauma, and I think that there could be some lessons learned from those two catastrophes and others; what is it 

that makes a community resilient and another community not as 

resilient, and try for the next time to build them up. 

My last point on prevention is that the families are very significantly affected by military service. Military service is tough during 

the best of times, but in combat it is very stressful for the spouses 

and especially the children. Congressman Walter Jones tells the 

story of going to Camp Lejeune to a grade school, talking with the 

kids there and saying: Is your mom or dad in the Marine Corps? 

One child said: ‘‘Well, yes, my daddy is in Iraq, but he is not dead 

yet.’’ To think of the impact on the families by that innocent statement really speaks to the fact that we must do everything we can 

to build up the families of our veterans. 

The second is mitigation. That is, to try to prevent the effects of 

combat, which is an absolutely abnormal state. Everyone who 

comes back from combat suffers post-traumatic stress because that 

is a normal reaction. We can mitigate this by embedding psychological professionals into our clinics, into our deploying medical 

support, so that when you have a psychological issue, a soldier, 

sailor, airman, or marine, does not have to go to someone else, to 

the hospital, and become labeled as going to seek psychiatric help. 

He or she can see someone in the battalion, in the company, who 

understands exactly what the mission of that company is and dayto-day is prepared to mitigate those effects. 

We need to screen and train our military leaders that physical 

fitness—that tactics of battle—are no less important than the psychological fitness of the men and women who go into combat, and 

that taking care of that psychological fitness is just as important 

as the maintenance that we would do on high-priced aircraft, 

tanks, and Humvees. 

The last point I would like to make on mitigation is that we have 

many ‘‘volunteers’’—and I put that in quotes—organizations, such 

as the key volunteers of the Marine Corps, the ombudsmen of the 

Navy, and there are other organizations of spouses and other concerned people who support the families. These are volunteers. 

They’re unfunded. I think that these programs ought to be in some 

21

way formalized, funded, so that every family member has a uniform degree of support. 

The last pillar is treatment. It requires a recognition and a 

destigmatization of mental health issues when people come back 

from combat or even from non-combat, but extraordinarily stressful 

deployments. Our military service is like no other service, not like 

working third shift at Kmart. There are stresses that people need 

to recognize as normal and celebrate it when we can put someone 

back into service. 

I was in Operation Desert Storm and was with a medical unit 

who had a battalion commander who was diagnosed with combat 

stress and admitted to us as an inpatient in Saudi Arabia. In 2 

weeks he was returned to his battalion, in time to engage in 

ground combat evolution. That was a battalion commander returned to function by not taking him out of the field, but addressing the issues and it was General Krulak who did this in the field. 

He said: ‘‘Everybody’s stressed; take care of that battalion commander and put him back in place. We have recruited, trained, and 

equipped the right people; now support them.’’ We did. 

Again, the embedding of psychological professionals is important 

so that you don’t have to go somewhere else to get care. You’re getting care essentially from your military family. 

Access to MTFs, the Veterans Administration (VA) community 

assets, and other ways of getting the treatment that you need 

when you need it and where you need it is very, very important. 

One of the recommendations in the task force report is to have recruit stations be access points for people who are reservists or people who get out of the military and just pass by a recruit station 

and say: I have a problem; I was in Operation Desert Storm, or I 

was in Iraq, and I’ve had these feelings, these paranoia, these 

thought streams; can you give me some help? Yes, they would have 

a book, they could make appointments; they could get you into the 

VA. I think that’s a great access point. 

Last on treatment is the continuum from the field to the clinic 

to the hospital, with the family-centered care, to the VA and beyond, is extraordinarily important. 

Underscoring all of this, as Senator Boxer well said, is the funding issue. The funding must be risk-adjusted, population-based. 

That is, to know what type of funding, what type of personnel assets you have to have based on the requirement; and it must be 

sufficient and predictable. 

With that, let me turn it back over to Shelley. 

Dr. MACDERMID. Thank you. 

The task force made 95 recommendations, almost all of which 

were endorsed by the Secretary of Defense, who submitted a detailed implementation plan to Congress in September 2007, several 

months in advance of its statutory deadline. I know that many 

dedicated individuals within DOD and the military Services have 

been working very hard to improve support for mental health and 

several of the recommendations already have been fully implemented. Many remaining recommendations are targeted for complete implementation by May 2008. 

You have many experts here today who can tell you about what 

is being done and what has been done. So all that I will do in my 

22

remaining remarks is to identify three areas where I am eager to 

hear about positive progress. 

The first issue I would like to address is TRICARE. The task 

force recommended several specific changes needed to ensure that 

the TRICARE system could provide adequate care for the psychological health of military members and their families who cannot 

receive their care at MTFs. Some of these changes have been made. 

For example, TRICARE Reserve Select has been simplified to be 

more accessible and efforts have been made to make it easier to 

find mental health providers. 

I’m aware of little progress, however, on some of the other recommended changes. Let me give you one example which pertains 

to intensive outpatient services, a highly utilized benefit in most 

health plans and a cost-effective treatment of choice for many patients with substance abuse or other serious psychological problems. 18 months ago the task force heard testimony from staff in 

the TRICARE Management Activity and representatives of the 

TRICARE contractors that cumbersome TRICARE rules resulted in 

intensive outpatient care not being covered under TRICARE. They 

asked for change. We made a recommendation to correct the deficiency. 

Yet little progress appears to have been made. These services are 

offered and heavily used in VA, available at many MTFs, and are 

a frequently utilized service in Medicaid and Medicare. Thus, military members and their families whose primary source of health 

care is the TRICARE system have no access to care that is available to the poor, the elderly, veterans, and their military brothers 

and sisters who are fortunate enough to receive care at MTFs. On 

its face, this seems quite inequitable. 

The second issue I would like to address is the supply of professionals who are well-prepared to provide the prevention, assessment, treatment, and follow-on of services to military members and 

family members who require care. The task force made several recommendations aimed at increasing the number of such providers 

and I think several efforts are underway in this area. I’m especially 

eager to learn about progress in the area of recruiting and retaining mental health professionals. 

The task force received numerous indications that it is difficult 

to get and keep highly qualified mental health professionals, especially when there are already shortages in the civilian community 

and DOD must compete with the VA and others for staff. But as 

the cumulative load of deployments on the force mounts there is no 

question that the need to support psychological health is only becoming more urgent. I hope that the importance of individuals who 

do that work is being recognized by very strong efforts to recruit 

and retain them. 

Also in the area of staffing, I’m eager to hear about changes in 

contracting procedures. The task force made site visits to 38 installations, where we heard over and over again that contracting mechanisms were cumbersome; temporary staff already in place often 

could not be retained because it wasn’t possible to give them timely 

information about whether their contract would be extended; hiring 

and processing procedures for new temporary staff took so long 

that the funds were gone before the person could begin work; critVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6602 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
23

ical GS positions lay empty for long periods even when a qualified 

and willing person had already been identified. 

These procedural problems were significant hurdles in the race 

to meet the needs of servicemembers and their families. I’m eager 

to hear how they have been addressed. 

While Congress has been helpful in allocating funds, I am eager 

to hear whether the right mix has been provided. For example, 

substantial funds have been allocated on a nonrecurring basis, 

which makes it difficult to address infrastructure issues and makes 

it difficult to hire the best staff. 

The task force report emphasized that the shortcomings we observed in the military mental health system were not caused by the 

protracted conflicts in which the United States is now engaged and 

are unlikely to disappear when the conflicts end. Nonrecurring 

funds, while helpful, do not allow the fundamental challenges to be 

addressed. 

Finally, as someone who has devoted her life to studying and advocating for families, I will close by saying that I am especially 

eager to learn how services for family members have been improved since the task force submitted its report. We made several 

specific recommendations in this area. For example, we wanted to 

be sure that parents or others caring for wounded or injured 

servicemembers could easily get access to installations, care managers, and other services. Because they have no official status within the military system, parents sometimes face barriers which systematically disadvantage young unmarried servicemembers. 

We also recommended that the substantial delays many children 

were experiencing in accessing care be addressed, and we recommended that inequities between families who were nearby and 

could receive treatment at MTFs and families who were far away 

and had to rely on TRICARE be eliminated. I’m eager to hear 

about progress in all of these areas. 

In conclusion, Mr. Chairman and distinguished members, I appreciate your sustained attention to these issues. I also very much 

appreciated the prompt and detailed plan submitted by the Secretary of Defense. But many weeks have elapsed and I know the 

strong sense of urgency which we all feel pales before the daily 

struggles that confront families dealing with depression, substance 

abuse, children’s disorders, or post-traumatic stress disorder 

(PTSD). I’m very much looking forward to the day the plan is fully 

implemented. 

That concludes my remarks and I thank you for your attention 

and turn it back to Admiral Arthur. 

Admiral ARTHUR. Sir, because a veteran is a complex organism 

and post-traumatic stress is not the only thing that affects them 

in combat—it is also TBI; they come home and add some alcohol 

to it, they have family strife—it’s very difficult to tease apart what 

is a mental health issue and what are some of the other social 

issues. So I’d like to conclude our portion by talking about TBI, 

which I think is a very big issue in this combat arena. 

I would like you to understand the fundamentals of how it differs 

from TBI that we see in the United States. First is the mechanism. 

In the United States, and all over the world, we have traffic accidents, we have football injuries, we have domestic violence, and 

24

they are relatively low velocity injuries. Something strikes the person’s head and the brain moves, the skull moves, and it causes a 

bouncing and you get an injury where the strike was and an injury 

on the other side, and it’s a relatively low velocity injury. 

That is not what is being seen in Iraq in blast injuries. This is 

not a tenth of a second, but a microsecond insult to the brain. The 

brain and the skull do not move as a unit. There tends to be a jiggle effect, in other words. The brain is not a solid piece of tissue 

that has uniform density. It has many different structures within 

it that are different densities, and at the density gradients you get 

a shear effect. 

It’s more global than just a single injury to one part of the brain, 

and that’s why, because of that diffuse mechanism, you get many 

symptoms that are not well localized. They are not often predictable. They can be individual as each person is affected differently. 

One of the things that we asked for in DOD when I was head 

of the TBI Task Force was for an omnidirectional blast indicator, 

something that you could wear into combat, and you could put on 

vehicles. Now we ask people, what was your blast exposure? They 

will say: ‘‘Well, I was 100 feet from a blast.’’ We don’t really know 

how far 100 feet is in combat. We don’t know whether they were 

in a vehicle, outside of the vehicle, behind a wall, in front of the 

wall. We don’t know what the insult was to the individual soldier, 

sailor, airman, or marine. 

So we’ve asked the blast industry to construct an omnidirectional 

indicator that we can use, that will allow us to tell what the exposure has been, correlate that with the symptomatology and with 

treatment efficacy, and even give the VA an ability to base compensation on actual environmental exposure. 

Senator GRAHAM. Where is that at? 

Admiral ARTHUR. I don’t know, sir. That would be something you 

would have to ask my Service colleagues now. Since I left 4 months 

ago, I have not kept pace with where that is. 

We also would like a baseline cognitive test. Football players, 

soccer players, already have that. If we had a baseline cognitive 

test going into combat or even coming into the Service, we could 

in the field assess an individual’s exposure and the resultant cognitive effect and have some idea on the extent of their injury. 

When I had my TBI 21⁄2 years ago, the psychologist gave me a 

whole battery of tests, and—in the air he drew a line—he said: 

‘‘But you’re normal; you are here on the battery of tests, you score 

very high.’’ I said: ‘‘I know, but I did not start there; I started at 

some other level.’’ 

I think you know of General Manny and his struggles. I talked 

with him just this last week. A general officer, a judge in his local 

constituency down in Florida, did not start at a baseline average 

American intellect. So we have to have, I think, individual baseline 

testing. 

Third, we have to have recognition and treatment with research, 

and the recognition won’t come from people presenting and saying: 

‘‘I have TBI.’’ They will come with people saying: ‘‘You know, I can’t 

remember things, I can’t remember faces, I can’t find my way out 

of Home Depot. My wife says that I forget her anniversary, and I’m 

blaming it on TBI.’’ [Laughter.] 

25

‘‘I can’t calculate how much to give on a tip at a restaurant. 

These are abnormal for me.’’ So people will present with a myriad 

of symptoms that are not normal behavior for them and must be 

recognized and treated. 

Senator Boxer brought up the incidence of behavioral issues, of 

people going to non-judicial punishment because they’ve acted out 

of the context of what they had, or they’re discharged for psychological issues existing prior to entry, when really it may be our failure to recognize TBI. 

Last is prevention. There are many things that we can do to prevent some of these TBIs. Let me give you one example of technology, and again I don’t know where this one is either. But I was 

up in Massachusetts at Mass General in a collaboration between 

Harvard and MIT on these design issues of mitigation strategies. 

I talked to the head of the physics department at MIT and he said: 

We have this gel, which is very much like the gel you would use 

on a bicycle seat or something like that. You put your hand in it 

and it forms an impression. We can change the characteristic of 

that gel by adding electricity, and the amount of electricity we add 

to that gel will make it harder or softer. It will change the shape 

of the polymers, the molecules, and make it hard or soft. So it 

might be soft as a nice helmet liner when you have a motor vehicle 

accident and you’re bouncing your head inside of a motor vehicle, 

but for a blast injury you may want it to have a different consistency, maybe a little harder, and the blast indicator could send a 

message to a microprocessor and provide an amount of electricity 

to that gel which would change its polymorphic configuration to be 

more blast-attenuating. 

So there are many things we could do, and the solution to TBI 

isn’t just in the treatment or recognition; it’s in the technology to 

prevent and mitigate. 

Senator Nelson, Senator Graham, thank you very much for this 

opportunity. It’s a true honor to be able to come back and testify 

before you, and thank you for your attention that you’re paying to 

this very important issue. 

[The prepared statement of Dr. MacDermid follows:]

PREPARED STATEMENT BY SHELLEY M. MACDERMID, MBA, PH.D 

Chairman Nelson, Senator Graham, distinguished members of the subcommittee, 

other distinguished Members of Congress, ladies and gentlemen, good morning. I am 

honored to be in the company of the distinguished speakers who are here to discuss 

with you today the mental health resources available to military members and their 

families. I completed service several months ago as the co-chair of the Department 

of Defense Task Force on Mental Health, and I am very pleased to be here with 

my co-chair Admiral Arthur today. 

The full report of the Task Force on Mental Health is being submitted for the 

record. The report presented an achievable vision for supporting the psychological 

health of military members and their families. The task force recommended building 

a culture of support for psychological health throughout DOD in order to combat 

stigma, shortages in staff and training, and procedural and policy barriers that were 

interfering with access to quality care. The task force also made recommendations 

aimed at ensuring a full continuum of excellent care for servicemembers and their 

families, because of significant gaps that were found during its investigations. 

Third, the task force recommended increases in resources and staff, and changes in 

staff allocations in order to address shortages that were impeding adequate care. Finally, the task force recommended that leadership be created and empowered to ensure consistent attention to and advocacy for the psychological health of military 

members and their families. 

26

The task force made 95 recommendations, almost all of which were endorsed by 

the Secretary of Defense, who submitted a detailed implementation plan to Congress in September 2007, several months ahead of its statutory deadline. I know 

that many dedicated individuals within DOD and the military services have been 

working very hard to improve supports for mental health, and several of the recommendations already have been fully implemented. Many remaining recommendations are targeted for complete implementation by May 2008, a few short weeks 

from now. You have many experts here today who can tell you about what is being 

and has been done, so all that I will do in my remaining remarks is to identify three 

areas where I am eager to hear about positive progress. 

The first issue I would like to address is TRICARE. The task force recommended 

several specific changes needed to ensure that the TRICARE system could provide 

adequate care for the psychological health of military members and their families 

who cannot receive their care at military treatment facilities (MTFs). Some of these 

changes have been made, For example, TRICARE Reserve Select has been simplified to be more accessible, and efforts have been made to make it easier to find 

mental health providers. I am aware of little progress, however, on many of the 

other recommended changes. 

Let me give you one example, which pertains to intensive outpatient services, a 

highly utilized benefit in most health plans, and a cost-effective treatment of choice 

for many patients with substance abuse or other serious psychological problems. 

Eighteen months ago the task force heard public testimony from staff in the 

TRICARE Management Activity and representatives of the TRICARE contractors 

that cumbersome TRICARE rules resulted in intensive outpatient care NOT being 

covered under TRICARE. They asked us for change. We made a recommendation 

to immediately correct this deficiency, yet little progress appears to have been made. 

These services are offered and used heavily in VA, available at many MTFs, and 

are a frequently utilized service in Medicaid and Medicare. Thus, military members 

and their families whose primary source of health care is the TRICARE system have 

no access to care that is available to the poor, the elderly, veterans, and their military brothers and sisters who are fortunate enough to receive care at MTFs. On its 

face, this seems quite inequitable. 

The second issue I would like to address is the supply of professionals who are 

well-prepared to provide the prevention, assessment, treatment and follow-up services to military members and family members who require care. The task force 

made several recommendations aimed at increasing the number of such providers 

within the military, and I think several efforts are underway in this area. 

I am especially eager to learn about progress in the area of recruiting and retaining mental health professionals. The task force received numerous indications that 

it is difficult to get and keep highly qualified mental health professionals, especially 

when there are already shortages in the civilian community and DOD must compete 

with the Department of Veterans’ Affairs and others for staff. But as the cumulative 

load of deployments on the force mounts, there is no question that the need to support psychological health is only becoming more urgent. I hope that the importance 

of the individuals who do that work is being recognized by very strong efforts to 

recruit and retain them. 

Also in the area of staffing, I am eager to here about changes in contracting procedures. The task force made site visits to 38 installations, where we heard over and 

over again that contracting mechanisms were cumbersome. Temporary staff already 

in place often could not be retained because it was impossible to give them timely 

information about whether their contract would be extended. Hiring and processing 

procedures for new temporary staff took so long that the funds were gone before the 

person could begin work. Critical GS positions lay empty for long periods even when 

a qualified and willing person had already been identified. These procedural problems were significant hurdles in the race to meet the needs of servicemembers and 

their families—I am eager to hear how they have been addressed. 

While Congress has been helpful in allocating funds, I am eager to hear whether 

the right mix has been provided. For example, substantial funds have been allocated 

on a non-recurring basis, which makes it difficult to address infrastructure issues, 

and makes it difficult to hire the best staff. The task force report emphasized that 

the shortcomings we observed in the military mental health system were not caused 

by the protracted conflicts in which the United States is now engaged, and are unlikely to disappear when the conflicts end. Non-recurring funds, while helpful, do 

not allow the fundamental challenges to be addressed. 

Finally, as someone who has devoted her life to studying and advocating for families, I will close by saying that I am especially eager to learn how services for family 

members have been improved since the task force submitted its report. We made 

several specific recommendations in this area. For example, we wanted to be sure 

27

that parents or others caring for wounded or injured servicemembers could easily 

get access to installations, care managers, and other services. Because they have no 

official status as family members within military systems, parents sometimes faced 

barriers which systematically disadvantaged young unmarried servicemembers. We 

also recommended that the substantial delays many children were experiencing in 

accessing care be addressed. We recommended that inequities between families who 

were nearby and could receive treatment at MTFs and families who were far away 

and had to rely on TRICARE be eliminated. I am eager to hear about progress in 

all of these areas. 

In conclusion, Mr. Chairman and distinguished members, I appreciate your sustained attention to these issues. I also very much appreciated the prompt and detailed plan submitted by the Secretary of Defense. But many weeks have elapsed 

and I know the strong sense of urgency we all feel pales before the daily struggles 

that confront families dealing with depression, substance abuse, children’s disorders, 

or post-traumatic stress disorder. I am very much looking forward to the day the 

plan is fully implemented. That concludes my remarks, and I thank you for your 

attention.

[The Report of the Department of Defense Task Force on Mental 

Health dated June 2007 follows:]

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Senator BEN NELSON. Thank you, Admiral. Thank you, Dr. 

MacDermid. 

Colonel Hoge? 

STATEMENT OF COL CHARLES W. HOGE, USA, DIRECTOR, DIVISION OF PSYCHIATRY AND NEUROSCIENCE, WALTER REED 

ARMY INSTITUTE OF RESEARCH; ACCOMPANIED BY COL 

CARL A. CASTRO, USA, RESEARCH AREA DIRECTOR, MILITARY OPERATIONAL MEDICINE RESEARCH PROGRAM 

Colonel HOGE. Senator Nelson, Senator Graham: I have a very 

brief statement for both Colonel Castro and myself regarding the 

MHAT assessments that we’ve conducted annually in Iraq, also 

called MHATs. So I may use that acronym. 

The MHAT missions were established by the Army Surgeon General at the request of the Commanding General, Multinational 

Force-Iraq and U.S. Central Command. They’ve been conducted annually in Iraq since the start of Operation Iraqi Freedom, and 

we’ve also conducted two assessments in Afghanistan in 2005 and 

2007. The MHATs are part of an ongoing scientific effort to understand the mental health impact of deployment to Iraq and Afghanistan and then utilize this knowledge to improve the care that we 

deliver to the servicemembers in the deployed environment and 

post-deployment. 

This effort is unparalleled compared with previous wars, where 

mental health issues really weren’t addressed until years and 

sometimes decades after servicemembers came home. 

The MHATs have maintained a consistent focus on soldiers and 

brigade combat teams or, in the case of Marine units, regimental 

combat teams. We’ve looked at both Active and National Guard 

units and units that have directly supported those brigade combat 

teams. The in-theater MHAT assessments have utilized the same 

methodology that we’ve utilized in some of our studies post-deployment that we published in the New England Journal of Medicine 

and other top-tier journals. 

The results of these investigations have shown that 15 to 20 percent of combat troops deployed to Iraq experience significant symptoms of acute stress, PTSD, or depression, and 15 to 20 percent of 

married servicemembers experience serious marital concerns. The 

MHATs have shown that longer deployments, multiple deployments, greater time away from the base camps, and combat frequency and intensity all contributed to higher rates of mental 

health problems. 

The most recent MHAT V report is in the process of being released, but one of the key findings concerns the cumulative effects 

of deployment, because this was the first time we were able to look 

at servicemembers who were on their third rotation to Iraq, compared with two rotations or their first rotation. What we found was 

that mental health problems rose with each cumulative deployment, reaching nearly 30 percent among those soldiers on their 

third deployment to Iraq. 

The MHAT V effort also showed that soldiers deployed to Afghanistan are now experiencing levels of combat exposure and 

mental health rates equivalent to levels in Iraq and substantially 

122

higher than they were experiencing in 2005 during our last assessment. 

The data from the MHAT missions have led to a number of important policy changes. Most importantly, the findings have led to 

revised doctrine and combat stress control procedures that we use 

in the theater, an improved training and distribution of behavioral 

health personnel. They’ve assured that there’s sufficient mental 

health personnel deployed in theater and are providing support to 

soldiers at remote locations. 

The MHATs have demonstrated the critical role of strong leadership in maintaining the mental health of combat units, and it’s led 

to the development and testing of new interventions, such as the 

training program called Battlemind, which is now being implemented Army-wide. 

Thank you very much for your continued interest in our research 

and your support for our servicemembers. We look forward to answering your questions. 

[The prepared statement of Colonel Hoge follows:]

PREPARED STATEMENT BY COL CHARLES W. HOGE, USA 

Chairman Nelson and distinguished members of the committee, thank you for the 

opportunity to discuss the Army’s Mental Health Advisory Team (MHAT) assessments. I am Colonel Charles W. Hoge, M.D., Director of Psychiatric Research at 

Walter Reed Army Institute of Research. Accompanying me today is Colonel Carl 

A. Castro, who is Director of the Military Operational Medicine Research Program, 

Medical Research and Materiel Command. We have both participated in and supervised elements of all five of the MHATs. 

The MHAT missions were established by the Army Surgeon General at the request of the Commanding General, Multinational Force-Iraq, and U.S. Central Command. The MHATs have been conducted annually in Iraq since the start of Operation Iraqi Freedom and twice in Afghanistan in 2005 and 2007. The mission of the 

MHATs has been to assess the mental health and well-being of deployed forces, examine the delivery of behavioral health care in theater, and provide recommendations for sustained and improved mental health services to theater commanders. 

Some of the MHATs have also included assessments of morale, the effect of multiple 

deployments, the status of training in behavioral health, and battlefield ethics. 

The MHATs are not representative of all soldiers deployed throughout Iraq or Afghanistan, but have maintained a consistent focus on soldiers in brigade combat 

teams (BCTs), to include Active and National Guard BCTs, as well as units that 

directly support these BCTs. Marine Regimental Combat Teams were studied 2 

years ago. The assessment methods have included surveys of soldiers, focus group 

interviews, and surveys of behavioral health providers, unit chaplains, and primary 

care professionals. 

The results of these investigations have shown that rates of mental health have 

remained consistent from year to year among soldiers in Iraq; 15–20 percent of combat troops deployed to Iraq experience significant symptoms of acute stress, posttraumatic stress disorder (PTSD), or depression, and 15–20 percent of married 

servicemembers experience serious marital concerns. The MHATs have shown that 

longer deployments, multiple deployments, greater time away from the base camps, 

and combat frequency and intensity all contribute to higher rates of PTSD, depression, and marital problems. The full report on the findings of MHAT V will be released soon. However the initial review shows that rates of mental health problems 

rose significantly with each deployment, reaching nearly 30 percent among soldiers 

on their third deployment to Iraq. The 2007 effort also showed that soldiers in brigade combat teams deployed to Afghanistan are now experiencing levels of combat 

exposure equivalent to levels in Iraq, and that mental health rates are now comparable between Iraq and Afghanistan. Suicide rates have increased compared with 

baseline rates prior to Operation Iraqi Freedom. The data collected from the MHAT 

missions have also been compared with data obtained in the post-deployment period. 

These studies have shown that 12 months is insufficient to reset the mental health 

of soldiers, and that rates of mental health, particularly PTSD, remain elevated and 

even increase somewhat during the first 12 months after return from deployment. 

123

The last two MHAT missions have shown that combat experiences, such as losing 

a team member, and mental health problems are associated with approximately a 

two-fold elevated risk of reporting ethical mistreatment of non-combatants, such as 

damaging Iraqi property when it was not necessary or hitting or kicking an Iraqi 

non-combatant when it was not necessary. All of the MHATs have shown that good 

unit leadership is vital in sustaining mental health and well-being among combat 

troops, as well as reducing the likelihood of ethical mistreatment of non-combatants. 

The data from all the MHAT missions have led to a number of important policy 

changes. The data have been used to improve the training and distribution of behavioral health personnel in theater. They have assured that sufficient mental health 

personnel (credentialed providers and mental health technicians) are deployed in 

theater and are providing support to soldiers at remote locations. The MHAT findings were the impetus for revising the Combat and Operational Stress Control doctrine and training that behavioral health personnel receive. All behavioral health 

professionals deploying to theater are now mandated to take the new Army Medical 

Department Combat and Operational Stress Control Course. The MHAT assessments have also led to the implementation of new Army-wide mental health training, called Battlemind, for all soldiers and leaders, as well as improved training in 

battlefield ethics and suicide prevention. When the findings of the most recent 

MHAT are released, we will further refine our policies to meet the mental health 

needs of soldiers. 

Thank you very much for your continued interest in our research and your continued support for our servicemembers. We look forward to answering your questions.

Senator BEN NELSON. Colonel Castro, do you have anything to 

add? 

Colonel CASTO. No, I do not, sir. 

Senator BEN NELSON. Thank you very much for your testimony 

here today. 

I’m going to ask a question about what we can do for mental 

health care in the rural areas that are not in close proximity to a 

base or may not even have a large city within a certain distance. 

Dr. MacDermid, did you find any protocols in place or that could 

be put in place to ensure that you could still have adequate mental 

health services? I’m thinking primarily of national guardsmen and 

reservists, who are by comparison stranded in other areas, not necessarily close to a base or other location for an operation. 

Dr. MACDERMID. Thank you for your question. We made a number of recommendations about ways to reach National Guard and 

Reserve folks, one of which was to simply increase the infrastructure within those organizations, because, for example, in each State 

there’s not necessarily someone who has the responsibility to oversee and monitor and take action about psychological health issues. 

I think it is also the case that the TRICARE system has to be 

functional for Guard and Reserve members, and the VA has also 

been increasing resources in that area. I think it doesn’t make 

sense in my mind to try to create something new when there are 

services already out there, but it’s not clear that those services are 

working effectively. We recognized, for example, that we were told 

on many installations that even in those areas the TRICARE network records did not appear to be very accurate, and that is likely 

to be similar and even more problematic in areas where there is 

not an installation. 

Senator BEN NELSON. Did you encounter anything having to do 

with confidentiality, or were you able to look at all of the records? 

Dr. MACDERMID. We did not look at medical records, sir. That 

was not something that we had the authority to do. Our conversations were with leaders of health care facilities, with patients, and 

with community providers. 

124

Admiral ARTHUR. Senator, may I add. There’s an even more vulnerable population. That’s the people who come back and are no 

longer affiliated with the Active, Reserve, or Guard component, 

those people who’ve gotten out of the Service. They go back to work 

and back in their community, where people really don’t understand 

what they have been through and don’t have any context for some 

of their mental health issues. 

One of the programs that I think is very successful is the Marine 

for Life program, where the marines have people all over the country who are retired or who have just done one or two tours in the 

Marine Corps and feel it is their obligation, their responsibility, to 

take care of marines who have gotten out. I think that population 

really is the unseen population for us. 

Senator BEN NELSON. In terms of the family that would be experiencing this vicariously, what have your thoughts been about how 

we might deal with the family members, particularly if they’re in 

a stranded location far away from a base or another provider? 

Dr. MACDERMID. There are substantial shortages in the civilian 

community for a variety of medical specialties, and it is a problem. 

That’s true for Active folks as well. When they have to go to communities to find specialists, they have trouble, too, which is one of 

the reasons why we put as much emphasis as we did on uniformed 

providers. 

I think in many cases the solutions for families are the same as 

the solutions for reaching National Guard and Reserve members, 

because it’s families that are out there in communities and that is 

where they have to get most of their care, and there’s a lot we 

could still do to try to make sure those communities are well prepared to receive them. 

These policy issues we identify that have the effect of impeding 

access to care I think might be low-hanging fruit. There probably 

are things I don’t understand. I’m sure that there are. But on their 

face, when it’s a matter of changing a policy that looks to be a good 

target for something that might open up quite a bit of access fairly 

quickly; I’m happy to be told that I’m wrong about that, but I think 

it’s certainly worth a look. 

Admiral ARTHUR. We also need to provide access for the families 

where they can receive the assistance, the social assistance, not 

just where it’s convenient for us. One of the things we talked about 

in the report is even going down to school counselors and teachers 

to educate school counselors and teachers about the particular 

stresses of the military and allow them to assist the children right 

in their schools. 

So there are a lot of things that we can do, but we shouldn’t 

make the families necessarily come to us when they have a problem. We should be accessible to them before they have a problem. 

Senator BEN NELSON. If you were to identify as a percentage of 

shortage, percentage shortage of the providers, the care providers 

that would be available to help, do you think we’re 50 percent 

below where we should be, or are we more than that, or do you 

have an opinion? 

Dr. MACDERMID. This is Admiral Arthur’s favorite question, sir. 

Admiral ARTHUR. I mentioned the population-based risk-adjusted 

model, and that speaks to assessing what the risks are. The risk 

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for a deploying combat battalion might be more than for a non-deploying motor transportation battalion, for example. So I think we 

have to assess what the risks are, the number of people, and then 

provide an appropriate number of resources and the appropriate 

kinds of personnel. It is not just psychiatrists. We tend to focus on 

the physician issues, but it’s really the sociologists, the social workers, the psychologist, the mental health practice nurses—anyone 

who can be involved, at the lowest level possible. 

Senator BEN NELSON. So do you have an opinion about how adequate we are in terms of numbers? Is it say 50 percent, 40 percent? 

Any estimate of that sort? 

Admiral ARTHUR. I would like to leave that up to my Service colleagues, because I think they’ve done a lot more assessments recently, and I actually don’t know where we are in the full contracting and the supplying of people for battalion support, particularly in the field. So if I may I would leave that for my Active Duty 

colleagues. 

Senator BEN NELSON. There have been a lot of questions raised 

about the length of deployment and then how much time should 

lapse between deployment number one and deployment number 

two; in other words, how much time back home should there be. 

I think we’re looking at trying to make the number the same or 

something similar to that. I think the longer the time at home that 

a soldier has or an airman or a marine probably the better. But 

I don’t know that statistically I can prove that. 

It seems self-evident that that time back would be very helpful 

and be required. But is that an assumption on our part that is 

founded on anything that you’ve been able to determine in your 

studies? 

Admiral ARTHUR. I think that’s a very valid conclusion. It also 

matters greatly where you are in the combat arena. If you’re right 

up front in combat operations day after day, or you’re in convoys 

day after day with the threat of adverse combat action, then you’re 

much more stressed and need more time back at home. 

If you’re in a rear echelon or a headquarters element in some 

place like Bahrain or other rear locations, then you may not need 

as much rest. 

The greatest concern I have are for the Special Forces people in 

the Army, the SEALS in the Navy, and the recon people in the Marine Corps, who have an incredibly high operational tempo and a 

very high degree of mental health issues in themselves and their 

families when they return. 

Colonel HOGE. Sir, if I may answer that question as well. We 

have good data that after a 12-month deployment, 12 months back 

home is not sufficient to reset. We actually see rates of mental 

health concerns rise slightly during that 12-month period. They 

certainly don’t go down. 

Senator BEN NELSON. Would it be fair to say, though, that the 

shorter the time in between, it wouldn’t be better; it would be 

worse? In other words, is there an optimum time, or is each case 

an individual case? Or have you been able to establish what would 

be an optimal timeframe in between? 

Colonel CASTRO. Sir, it is important to also keep in mind the 

length of deployment. For example, the Army deploys much longer 

126

and probably then it would require much longer in-between deployments. For the Marine Corps, which deploys the shorter amount of 

time, 7 months, then their recovery time probably doesn’t need to 

be as long. But as Admiral Arthur points out, it’s very critical to 

look at what exactly is happening to the servicemember, the warrior, while they’re over there. 

One of the key findings from the MHAT IV is that those soldiers 

and marines who are in day-to-day combat operations day-in and 

day-out, their mental health rates were two to three times higher 

than the overall force. So it’s very important to look at all of the 

variables that we know are related to and impacting on the psychological health of the servicemember. But we certainly know, as 

Colonel Hoge points out, a year is not long enough if you’re deployed for a year or longer. But perhaps if you deployed shorter, 

it’s not as long. 

But the bottom line is we don’t know because our soldiers deploy 

so frequently we have never been able to give you an exact time. 

Senator BEN NELSON. That raises some obvious questions about 

the dwell time, as you say, depending upon whether you were forward deployed or where you were in the deployment. It’s hard 

enough to try to get something that is uniform across the board for 

each branch the way it is. I imagine it gets a little byzantine if you 

try to make it a pattern or tailor it to each individual case. 

So 15 months may not be long enough. Do you have a recommendation just overall, a one-size-fits-all type of dwell-time recommendation? 

Colonel CASTO. One of the recommendations we made in the 

MHAT IV report was 18 to 24 months dwell time. But that was 

quite a controversial recommendation. 

Senator BEN NELSON. I imagine it was, yes. 

Senator Graham? 

Senator GRAHAM. Thank you, sir. Mr. Chairman, thanks for having the hearing. This has been fascinating. When it seems on the 

money front you expand TRICARE to include mental health services available in the civilian community, that would be a great 

start. It seems we’re going down that road. 

The investment in technology to understand the brain injury situation better—I am fascinated by some of the ideas out there and 

we will follow up and see where this monitoring device is at. I 

know I just want America to know we do spend a lot of money trying to find out what is the best equipment, what’s the best way to 

prepare our folks for war, and it’s always an ongoing endeavor. 

You said about 30 percent, I think, Colonel Hoge, of people who 

have gone back for the second or third time are having some mental health-related problems, is that right? 

Colonel HOGE. Yes, sir. 

Senator GRAHAM. Is it affecting retention rates? 

Colonel HOGE. I can’t answer that. I don’t have access to that. 

I haven’t looked at that particular outcome. 

Senator GRAHAM. Is it affecting the ability to go back to duty? 

Are these incapacitating problems? 

Colonel HOGE. They aren’t necessarily incapacitating to the point 

of not being able to do their duty. But that 30 percent rate is based 

on self-report survey data, where we ask a series of questions about 

127

what types of mental health problems the soldier is experiencing, 

and they have to report a substantial number of symptoms to meet 

that threshold. So it is not just a few symptoms. They have to report a fair number of symptoms. 

Senator GRAHAM. I guess what I’m asking is what kind of impact 

does it have on retention? What kind of impact does it have on 

being able to go back to duty? If you could maybe explore that a 

little bit and get back with us. 

Colonel HOGE. Yes, sir, I’d be happy to do that. 

[The information referred to follows:]

The Army’s retention database does not include any data that may indicate if a 

soldier has a mental health issue. Consequently, we do not have retention data that 

can be used to assess the impact of mental health problems. However, the Walter 

Reed Army Institute of Research (WRAIR) proactively approached this issue by 

looking at Post-Deployment Health Assessments (PDHA). Researchers from WRAIR 

conducted population-based analyses of over 300,000 Army soldiers and marines 

who completed a PDHA between May 2003 and April 2004. Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) deployers with a mental health 

problem who self-identified on the PDHA were over 30 percent more likely to leave 

military service within 1 year than OIF and OEF veterans who did not report a 

mental health problem on the PDHA. These findings have been published in the 

March 2006 edition of the Journal of the American Medical Association.

Senator GRAHAM. Civilian contractors—we have 130,000 folks 

over there. Has anybody looked at the civilian contracting force? I 

see some heads nod. To be asked later, I guess, in the next panel. 

We will do what money can do. We will try to grow the Army. 

I think that’s one of the goals, is to grow the Army to make sure 

the rotation schedules are not so onerous. 

Admiral, you had something? 

Admiral ARTHUR. Sir, I’d like to make a comment about the 

money. We’ve talked about money and TRICARE and modifying 

the TRICARE benefit. I’d just like to put a plug in that the reason 

we have such a wonderful save rate or resuscitation rate of combat 

injuries and so much attention that can be paid to our veterans in 

the field is because we have maintained an Army, Navy, and Air 

Force medical system that has not only taken care of our 

servicemembers and their families, but has maintained a state of 

readiness over so many decades and is ready to do whatever the 

Nation calls on it, and that requires that the Services and their 

medical functions be properly funded to train and equip for their 

combat role as well as their normal health care role. 

Senator GRAHAM. That’s well said. I think some of the unsung 

heroes of this war are the men and women in the medical services. 

If you could make it through the door of a hospital in Iraq, they 

say you have about a 90 percent survival rate, which is phenomenal. But these injuries are solid. They have to be detected, 

having your buddies understand what to look for, having commanders be sensitive. 

What you’re doing is good work for the country. War is a terrible 

thing. Just listening to this—my dad went off to World War II before I was born, but a lot of people went away for 4 years, never 

saw their family. 

Admiral ARTHUR. For the duration. 

Senator GRAHAM. For the duration. So America’s been through 

these tough times before. But this war is unique and we need to 

make sure that we’re stepping up to the plate and providing all of 

128

the services possible, and retention and recruitment are amazingly 

good to me. The one thing I hear from these beds in hospitals when 

I go visit, like Senator Nelson, is the number one comment I get 

is: ‘‘I want to go back to be with my buddies,’’ which just astonishes 

me. 

So I think our force needs to be protected and nurtured. But 

we’re blessed to have them. So thank you. 

Senator BEN NELSON. We certainly don’t have to work that much 

harder on creating a team concept in the military, because that is 

the reaction that you pick up from a wounded warrior, a feeling of 

guilt that they’re no longer able to be there with their comrades. 

If we can establish stronger mental health care and recognition of 

challenges at the time for prevention or intervention, it seems to 

me that we’ll be doing what needs to be done. 

The suicide rate, is there any comment that any of you would 

like to make about what is an alarming suicide rate for our military personnel today? 

We can take that up with the next panel. But I’m also thinking 

perhaps from your standpoint you may have some thoughts about 

it from the reports that you’ve been involved with. 

Colonel HOGE. Yes, sir. We’ve looked at suicide rates in theater 

with every one of the MHATs and we have seen consistently for the 

last couple of years a higher rate than the expected baseline rate 

of suicides. I think the factors that generally drive suicides, there’s 

an element of impulsivity. The soldier may, in an impulsive moment, make a decision that he wouldn’t make when he’s back 

home. 

Then a lot of times these things are precipitated by relationship 

problems that the soldier is having, that type of thing. 

Senator BEN NELSON. Any connection that you could draw between the length of deployment or the number of deployments or 

the short timeframe for dwell-time tied to suicide? 

Colonel HOGE. Sir, we haven’t been able to make a direct link because suicides are still quite rare events. We can make that kind 

of link for overall mental health concerns, mental health problems. 

We know there’s a relationship between mental health problems 

and suicide, and so we could make the link in that way. But we 

haven’t been able to make it in a direct way. 

Senator BEN NELSON. Thank you very much. We appreciate what 

you’re doing and thanks for being here today. [Pause.] 

Last, but certainly not least, on our third panel we welcome: 

Lieutenant General Eric Schoomaker, United States Army, Surgeon General of the Army and Commanding General, United 

States Army Medical Command; Vice Admiral Adam M. Robinson, 

Jr., United States Navy, Surgeon General of the Navy and Chief, 

Bureau of Medicine and Surgery; Lieutenant General James G. 

Roudebush, United States Air Force, Surgeon General of the Air 

Force, and a resident of Gearing, NE. We appreciate that connection, General. Also with her is Colonel Loree K. Sutton, United 

States Army, Special Assistant to the Assistant Secretary of Defense for Health Affairs on Psychological Health and TBI. 

Colonel Sutton, we congratulate you on your recent selection for 

promotion to brigadier general. Colonel Sutton is responsible for, 

among other things, implementation of the DOD Centers of ExcelVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00132 Fmt 6633 Sfmt 6602 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
129

lence for PTSD and TBI, which were mandated by the Wounded 

Warrior Act in the National Defense Authorization Act for Fiscal 

Year 2008. 

General Roudebush, I understand you received both your bachelor of medicine and doctor of medicine degrees from the University 

of Nebraska, another fine institution. So we have high expectations 

for you as a result of your stellar education. 

I know that, General Schoomaker, you have a brother living in 

Omaha, NE. As your brother, the other general, has told me on so 

many occasions, he’s had more than one good steak in Omaha. 

So we look forward to hearing your assessments today of Service 

and DOD-wide plans to implement all of the findings and recommendations we’ve just heard about in great detail. So with that, 

General Schoomaker, the platform is yours. 

STATEMENT OF LTG ERIC B. SCHOOMAKER, USA, SURGEON 

GENERAL OF THE UNITED STATES ARMY AND COMMANDING 

GENERAL, UNITED STATES ARMY MEDICAL COMMAND 

General SCHOOMAKER. Chairman Nelson, Senator Graham, distinguished members of the Personnel Subcommittee: Thank you for 

this opportunity to discuss the Army’s efforts to improve mental 

health care for soldiers and family members. Our Army Secretary, 

Pete Geren, our Chief of Staff of the Army, General George Casey, 

and the rest of Army leadership strongly support our efforts to improve the quality and access to mental health services and are also 

actively leading and remain engaged in our efforts to eliminate the 

stigma associated with seeking mental health care. 

The stigma is not just found in the military community. It is a 

national concern and should really be addressed in all communities. 

Our soldiers and our Army are doing amazing work in an Army 

that is demanding and has an extremely high operational tempo 

that you have heard spoken about by our previous two panels. But 

our soldiers and families are stressed. The global war on terror has 

placed increased operational demands on our military force. We 

know that repeated and extended deployments, as you’ve heard 

from the group that has performed our MHAT surveys, are experiencing increased stress, family difficulties, other psychological effects of war, such as depression, anxiety, withdrawal, and social 

isolation, and symptoms of post-traumatic stress, which, if not 

identified and treated promptly, may evolve into a more resistant 

psychological injury known as PTSD. 

The Army is absolutely committed to ensuring all soldiers and 

families are healthy both physically and psychologically. We have 

embraced the recommendations of the DOD Task Force on Mental 

Health and commend its authors. We are striving to provide the 

best mental health care for our soldiers and families. From the 

time a soldier enters the Army to the time that they depart, they 

are assessed, trained, and offered treatment for mental health care 

should they need it. This includes their families as well. 

Much of our efforts are concentrated on the activities associated 

with deployments, whether that’s building resiliency through training and awareness prior to deployment or assessing, training, and 

treating while being deployed. We then follow soldiers very closely 

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upon redeployment and several months after redeployment to ensure that the mental health needs are assessed and are being met. 

I’ll only touch on a few of the many programs that we have that 

address the recommendations of the Task Force on Mental Health. 

I hope it shows that we are taking significant action in line with 

each of these six key objectives that are described in the task force 

report and in their testimony. Let me just expand on a few. 

As described by Colonels Hoge and Castro just a moment ago, 

the MHATs are a groundbreaking achievement. Never before has 

a military force studied the psychological strains of combat as intensely during the conflict. This work of our best and brightest 

minds is published year after year in the world’s leading medical 

journals, like the New England Journal of Medicine and the Journal of the American Medical Association. 

I was pleased to hear Senator Boxer in her comments actually 

refer to one of those published studies. The authors of that study 

were sitting here in front of you a moment ago. 

Based on these assessments, we make changes, some immediately, to make our work and things work better. Sometimes it is 

not pleasant to hear what they found. Self-assessment is often not 

pleasant, but it is important we hear their unvarnished feedback 

so we can take the necessary steps to improve. 

The Army’s unprecedented Leader Chain Teach was a powerful 

initiative started at the top of the Army by the Secretary and by 

the Chief, that simultaneously and powerfully addressed leadership 

culture and advocacy. The program has now trained over 800,000 

soldiers in a massive education effort in the summer and fall of last 

year, and has now been incorporated into various soldier and leader training programs throughout the Army. 

Our Battlemind training program, which is the brand that we essentially call all of our resiliency and recognition and prevention 

programs in the Army, is an outgrowth directly of the MHAT assessments. It focuses on building fitness and resilience, which Admiral Arthur talked about. MHAT V findings indicate that 

Battlemind training is hitting the target and making soldiers less 

susceptible to combat stress. 

The Chief of Staff of the Army and Secretary of the Army have 

challenged us to incorporate all of this training and prevention and 

early recognition of the psychological consequences of deployment 

and family separation and combat. We’re doing so throughout the 

career of every soldier and every leader. Excellent quality care is 

being addressed throughout through improved and expanded training courses, like the new combat operational stress control course 

which is now mandatory for all deployed behavioral mental health 

providers. 

Under my predecessor, Major General Gale Pollock, we have 

launched an initiative to hire over 300 behavioral health providers, 

of which we have now hired 149 in the United States. These will 

have direct and lasting impact on access. 

Finally, we’ve taken the recommendation of the task force to 

heart and have incorporated access and enhancing skills through 

primary care providers through a program called RESPECT–MIL. 

This program had a pilot at Fort Bragg and was so successful we 

have now expanded this to 15 other installations. 

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I enumerate these initiatives, not to assert that we are 100 percent or that we have a 100 percent solution here, but to make the 

point that the Army takes reasoned, focused action everywhere we 

see the opportunity to make a difference. 

I applaud Senator Boxer and Congress for standing up the Task 

Force on Mental Health in 2006. I applaud Congress in 2007 for 

directing the establishment of the Centers for Excellence for Psychological Health and TBI being directed by my colleague, Dr. 

Loree Sutton. She is absolutely the right person, as I think you will 

see, to lead that organization and generate the kind of results that 

you, Congress, are seeking. 

This committee, along with the leaders of the DOD and the 

Army, is troubled by some of the negative trends that are related 

to the psychological health of our force. I’m very conscious of these 

reports. I know we will address some of these issues in these hearings. But I’m also heartened to see the terrific effort and the energy being applied to reverse these trends, and I am confident that 

with continued strong support from this committee and from Congress, we will provide the care and support that our warriors and 

their families deserve. 

Thank you again for holding this hearing. Thank you for the 

privilege of being here and responding to your questions. 

[The prepared statement of General Schoomaker follows:]

PREPARED STATEMENT BY LTG ERIC B. SCHOOMAKER, M.D., PH.D., USA 

Chairman Nelson, Senator Graham, and distinguished members of the Personnel 

Subcommittee: thank you for the opportunity to discuss the Army’s efforts in improving the mental health care for our soldiers and their family members. We are 

committed to getting this right and providing a level of care and support to our warriors and families that is equal to the quality of their service. Secretary Geren, General Casey, General Cody, and the rest of the Army leadership actively support our 

efforts in improving the access to and quality of mental health care services. They 

are also actively engaged in changing the culture and eliminating the stigma associated with seeking mental health care that not only our Army, but our Nation, experiences. 

We all recognize that the increased operational demand of our military force to 

fight the global war on terror has stressed our Army and our families. The Department of Defense (DOD) and the Army have made a concerted effort to proactively 

research the effects of this conflict through the DOD’s Mental Health Task Force 

as well as the Mental Health Advisory Team’s annual assessments. We know from 

this research that repeated and extended deployments have led to increased distress, family difficulties, and other psychological effects of war, such as symptoms 

of post-traumatic stress as well as post-traumatic stress disorder (PTSD). The Army 

is absolutely committed to ensuring all soldiers and their families are healthy, both 

physically and psychologically. We have made a concerted effort to mitigate risks 

and enhance mental health care services through various programs and initiatives 

which directly align with the DOD’s Mental Health Task Force Report’s four major 

recommendations: 1) Build a culture of support for psychological health; 2) Ensure 

a full continuum of excellent care for servicemembers and their families; 3) Provide 

sufficient resources and allocate them according to requirements; 4) Empower leadership. 

Enhancing, protecting, and improving the mental health for our soldiers and families starts from the time a soldier enters the Army, through various stages of their 

service, which includes getting ready for deployment, being deployed, and returning 

from deployment (often referred to as the Army Force Generation (ARFORGEN) 

cycle) as well as departure from Service. 

From the moment they start Basic Combat Training and at every successive assignment, soldiers and their families have access to a wide range of support services—the Installation’s Army Community Service program, the Chaplain’s network, 

Leadership and Family Readiness Groups, and of course health care at either the 

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military facilities on post or the extensive TRICARE network of providers in the civilian community. 

During a soldier’s service it is very likely that he or she can be called to deploy 

to a remote location of the world away from their families for various and sometimes 

extensive lengths of time. The Army has wisely recognized that building soldier and 

family resiliency to this stressor is key to maintaining their health and welfare. We 

developed ‘‘Battlemind’’ products to increase this resiliency and have several different training programs available for pre, during and post-deployment. These programs are designed for soldiers and their families, including children as young as 

pre-school aged to teens, and they are distributed throughout the force. These programs are also available online anytime at www.behavioralhealth.army.mil. 

In a parallel effort to both raise awareness and reduce the stigma associated with 

mental health care, the Secretary of the Army and Chief of Staff of the Army initiated a leader chain teaching program to educate all soldiers and leaders about posttraumatic stress and signs and symptoms of concussive brain injury. This was intended to help us all recognize symptoms and encourage seeking treatment for these 

conditions. All soldiers were mandated to receive this training between July and October 2007, during which time we trained over 800,000 soldiers. We are now institutionalizing this training within our Army education and training systems to continue to share the information with our new soldiers and leaders and to continue 

to emphasize that these signs and symptoms are a normal reaction to a stressful 

situation and it is absolutely acceptable to seek assistance to cope with these issues. 

During deployments, the Army found tremendous value in providing mental 

health treatment far forward in the operational areas. Our primary method of providing both preventive and required mental health treatment was through Combat 

Stress Control Teams. From the beginning of combat operations, there has been a 

robust Combat Stress Control presence in theater, with approximately 200 deployed 

behavioral health providers to Iraq alone. These combat stress control assets are 

heavily utilized to monitor and mitigate the effects of multiple and extended deployments. This is now a joint effort, with the Air Force assisting us in Iraq and Afghanistan and the Navy in Kuwait. The Army has also done unprecedented work in surveillance of soldiers, both in the combat theater and back home. The Mental Health 

Advisory Teams (MHATs) have gone to theater every fall since 2003 and surveyed 

soldiers, care providers, chaplains, and others. Their findings on epidemiology of 

symptoms, access to care, and stigma, have led to direct and immediate improvements in the way that we deliver care. The fifth MHAT report is due to be released 

soon. 

Upon redeployment, we continue to gather information about physical and psychological health symptoms on the Post-Deployment Health Assessment. Through our 

use of scientific studies to drive evidence-based practices, such as the work of the 

MHATs, we developed the Post-Deployment Health Reassessment to screen soldiers 

again during a later stage of the reintegration and post-redeployment period. Typically we find the signs and symptoms of post-traumatic stress are not fully apparent 

until after a 60–90 day readjustment period. In addition to these two event driven 

assessments, we have also implemented an annual screening tool, the Periodic 

Health Assessment, to further supplement our information. 

As expected, through our efforts to reduce stigma, raise awareness, and assess the 

health, to include mental health, of our soldiers, the need for behavioral health care 

is increasing. We do have gaps at some locations in meeting behavioral health care 

demand, but we are diligently working on solutions. The Army developed a program 

titled the Army Family Covenant, which formally commits us to improving access 

to high quality behavioral health for soldiers and families. Through Congressional 

Supplemental Funding targeted at caring for psychological health, we have been 

able to focus resources on hiring behavioral health providers. So far, we have been 

able to hire and put in place 138 providers of about 340 identified requirements in 

a very competitive hiring environment. We are also pursuing the hire of an additional 40 substance abuse counselors and over 50 marriage and family therapists 

and have added about 90 social workers to our Warrior Transition Units (WTUs). 

My medical treatment facility commanders tell me that these hires are making a 

difference. We also have numerous long-term efforts to enhance recruitment and retention of uniformed behavioral health providers. 

This committee is familiar with RESPECT–MIL, a program designed to decrease 

stigma and improve access to care by providing behavioral health care in primary 

care settings. Because of the success of this program, we have initiated further efforts to train primary care providers and integrate behavioral health with primary 

care. The combination of ongoing education and improved access to care through numerous portals should again help encourage soldiers to seek care early. 

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As part of the Army Medical Action Plan, we’ve developed a program for our warriors in transition called the Comprehensive Care Plan which is implemented across 

our 35 WTUs. The continuum of care that a soldier receives while in the WTU culminates in a care plan which integrates the more conventional medical and surgical 

interventions we administer to our wounded, ill, and injured warriors with efforts 

to optimize the soldiers’ return to uniformed service or transition into successful life 

as a veteran. These insights were derived from our experiences over the last year 

and have now been institutionalized under the direction of my Assistant Surgeon 

General for Warrior Care and Transition, Brigadier General Mike Tucker. Soldiers 

in the WTUs are expected to be physically, mentally, socially, and spiritually 

strengthened. They are vocationally enabled and a life-care plan is established for 

each of them. This program sets the conditions for a successful transition to the VA 

or society. 

As the Army Surgeon General, I am compelled to remain extremely cognizant of 

the toll that this demand has placed on my health care providers. The Army’s uniformed behavioral health providers are among the most highly deployed of any of 

our specialties. We use numerous recruitment and retention initiatives to encourage 

them to join and stay in the Army, including increased bonuses for psychologists 

and increased educational opportunities for social workers. As part of our detailed 

force management review being led by Major General Gale Pollock, we are assessing 

our manpower requirements and will recommend changes to the force structure as 

needed. We also developed Provider Resiliency Training to mitigate burn-out for not 

only our medical providers, but also for Army Chaplains and other specialists who 

are in the business of serving our soldiers and families. 

Although we have had many successes, there are also areas of concern. These include the increasing suicide rate, accidental deaths due to overdose, and public perceptions that soldiers are being inappropriately discharged from the Army for personality disorder when in fact they may actually have PTSD or mild traumatic brain 

injury (TBI). 

Unfortunately, Active Army suicide rates have increased over the last 7 years. Although the Active Army suicide rate is comparable to the demographically-adjusted 

civilian population rate, it is at an all-time Army high and we are taking action to 

address it. Over the last 2 years, there has been a concerted effort to improve suicide prevention. The Army G–1 is leading this effort with support from the medical 

and chaplain communities. The Army Medical Department’s Army Suicide Event 

Report continues to offer surveillance and perform analysis. Recent analyses of suicides have resulted in concrete recommendations, which are currently being implemented, both in theater and on our installations. 

We have also chartered a General Officer Steering Committee to address suicide 

prevention. We will develop an action plan focused on five areas of emphasis: 1) develop life-coping skills; 2) maintain constant vigilance; 3) encourage help-seeking behaviors and reduce stigma; 4) maintain constant surveillance of behavioral health 

data, and 5) integrate and synchronize unit and community programs. We must develop actionable intelligence that provides our leaders an analysis of each suicide 

or attempted suicide that includes lessons learned, trend data, and potential factors 

to monitor. The intent is to modify leader behavior towards soldiers who are impacted by stressors and are at risk of harming themselves. 

On the issue of accidental overdoses, I recently chartered a multi-disciplinary 

team of 17 dedicated professionals (psychologists, psychiatrists, physicians, nurses, 

unit commanders, first sergeants, and sergeants major) to analyze and develop risk 

mitigation strategies to reduce the number of accidental deaths and accidental drug 

overdoses within our WTUs. This team recommended 71 risk mitigation strategies 

to focus on improving identification, training, and monitoring systems. We have already adopted 26 of those recommendations. The Army will improve its capability 

to identify high-risk soldiers. We will also improve the training of our clinical staff, 

leaders and soldiers on risk reduction measures. We have changed policies and procedures to facilitate these risk-reduction measures and we will improve our capability to monitor and track accidental deaths, and accidental drug overdoses. 

Finally, there has been a perception that soldiers are being inappropriately discharged for personality disorder. All soldiers discharged for personality disorder are 

required to receive a mental status evaluation as per Army Regulation 635–200. A 

new policy was implemented in August 2007, requiring a review by the installation’s 

behavioral health chief of all personality disorder discharge recommendations. We 

are implementing an update to this policy mandating PTSD and mild TBI 

screenings for any soldier being discharged for misconduct. This change in policy 

will mitigate the risk of discharging soldiers with a health condition that was acquired while serving their country. 

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I greatly appreciate the privilege to command the United States Army Medical 

Command and the opportunity to report on the progress we have been making on 

providing quality mental health care to our soldiers and families. We appreciate 

your support as you interact with service men and women and their families in your 

states in communicating our strategic successes in this area. We also appreciate 

your help in influencing the mental health care providers in your areas to accept 

TRICARE patients which will expand our behavioral health care capacity. 

In closing, I’d like to share with you a quote from the DOD Mental Health Task 

Force Report: ‘‘In the history of warfare, no other nation or its leadership has invested such an intensive or sophisticated effort across all echelons to support the 

psychological health of its military servicemembers and families as DOD has invested during the global war on terrorism.’’ Thank you for holding this hearing and 

giving us the opportunity to share our accomplishments and to reaffirm our 

unyielding commitment to provide the best care to all our soldiers and their families.

Senator BEN NELSON. We thank you, General. 

Admiral Robinson? 

STATEMENT OF VADM ADAM M. ROBINSON, JR., USN, SURGEON GENERAL OF THE UNITED STATES NAVY AND CHIEF, 

BUREAU OF MEDICINE AND SURGERY 

Admiral ROBINSON. Good afternoon, Chairman Nelson. Thank 

you very much. I appreciate the opportunity to share with you 

Navy medicine’s efforts in preventing, diagnosing, and treating psychological health issues affecting our Active Duty and Reserve sailors, marines, and their families. As the provider of medical services 

for both the Navy and the Marine Corps, we have to be prepared 

to meet the needs of these similar and yet unique military populations. Navy medicine is continuously adapting to meet the shortand long-term psychological health needs of servicemembers and 

their families before, during, and after deployments. 

We are well aware of the fact that the number and length of deployments have the potential to impact the mental health of 

servicemembers, as well as the well-being of their families. The 

Navy and Marine Corps operational tempo in support of the global 

war on terror is unprecedented. We need to remain vigilant of the 

potential long-term impact our mission requirements will have on 

the physical and mental health of our sailors and marines and 

their families. 

To accomplish this, Navy medicine engages at several levels 

along the continuum of care, from commanding officers to small 

unit leaders to individual servicemembers, and of course with their 

families. Our goal is for psychological health services to be available to all who need them, when they need them. 

The same way physical conditioning prepares sailors and marines for the rigors and challenges of high tempo operational deployments, we are psychologically preparing servicemembers and 

their leaders to build resiliency, which will help manage the physical and psychological stresses of battle. We do this by preventive 

education programs introduced at every career training point, 

which help educate servicemembers on the importance of psychological health, in an effort to decrease the stigma often associated 

with being given a mental health diagnosis and receiving mental 

health services. 

Command involvement, together with dedicated and embedded 

stress management teams comprised of mental health providers 

and other professionals, are critical in helping sailors and marines 

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become comfortable with the concept of building resiliency and decreasing stigma. 

Our experiences in previous conflicts, most notably Vietnam, suggest that delays in seeking mental health services increase the risk 

of developing mental illness and may exacerbate physiological 

symptoms. 

We are attacking the stigma in a variety of ways to ensure 

servicemembers receive full and timely treatment. This also is a 

critical component in our efforts to decrease the number of suicides 

among sailors and marines. Although suicide rates in the Navy and 

Marine Corps have not significantly fluctuated in recent years, our 

efforts to improve leadership’s understanding and acceptance of the 

importance of treating mental health conditions is as important as 

preparing servicemembers to deal with the stresses of military life. 

Both the Navy and the Marine Corps have published leaders’ 

guides for managing marines/sailors in distress. These products are 

available in various formats and are part of a greater effort to ensure front-line supervisors, including junior leaders, are able to 

identify when others in their unit may need help. The Marine 

Corps’ Marine Operational Stress Surveillance and Training 

(MOSST) program includes briefings, health assessments, and tools 

to deal with combat and operational stress. The MOSST program 

includes warrior preparation, warrior sustainment, warrior transition, which happens immediately before marines return home, and 

warrior resetting. 

Navy medicine, in coordination with the line leaders in the Navy 

and the Marine Corps, is building on current training programs for 

leaders and our own caregivers. The curriculum focuses on combat 

stress identification and developing coping skills. Our goal is for 

members dealing with combat stress to be as comfortable in dealing with it as any other medical issue. 

For the servicemember, the predeployment health assessment is 

one way to become aware of potential psychological health needs 

and the health care services available. The symptoms of a mental 

health condition may not necessarily make an individual nondeployable, but this assessment helps emphasize the importance of 

psychological health as part of physical health and may decrease 

any delay in seeking treatment. 

Since the late 1990s, Navy medicine has embedded mental 

health professionals with operational components of the Navy and 

the Marine Corps. Clinical psychologists have been regularly embarked aboard all of our aircraft carriers and have become a valuable member of ship’s company. Not only have mental health assets 

helped crews deal with stresses associated with living in isolated 

and unique conditions, but medevacs and administrative discharges 

for conditions typically managed by mental health personnel have 

decreased. Having a mental health professional who is easily accessible and going through many of the same challenges has increased 

operational and battle readiness aboard these floating platforms, 

saving lives as well as hundreds of thousands of dollars in operational cost. 

For the Marines, Navy medicine division psychiatrists stationed 

with the Marines developed Operational Stress Control and Readiness (OSCAR) teams which embed mental health professionals as 

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organic assets in operational units. OSCAR teams provide early 

intervention and prevention support through all of the phases of 

deployment. The same team providing care in garrison also deploys 

with the units, which improves cohesion and helps to minimize 

stigma. 

Since the beginning of Operations Enduring Freedom and Iraqi 

Freedom, mental health-related medical evacuations for marines 

have been significantly lower among units supported by OSCAR, 

and currently there is strong support for making these programs 

permanent and ensuring they are resourced with the right staff 

and funding. 

Before returning from the operational theater, sailors and marines are typically provided a series of briefings that familiarize 

them with issues related to combat stress, as well as how to manage their expectations after returning home. 

The post-deployment health assessment measures the health status of returning servicemembers and must be completed within 30 

days before or after redeployment. Navy and Marine Corps post-deployment health assessments are being accomplished in theater, 

during warrior transition, and at Navy Mobilization Processing 

Sites. 

Warrior transition, initiated during OIF and expanded each year, 

has now become an inherent part of the sailor’s redeployment process home. Recognizing the hardest part of going to war is reconciling the experience inclusive of one’s losses, mental health professionals and chaplains assist servicemembers to reflect, recall, and 

reconcile the enormity of their deployment before returning home. 

Warrior transition is now mandatory for all seabees, individual 

augmentees, and soon our SEALs. 

Since 2005 Navy medicine has been administering the post-deployment health reassessment (PDHRA), as directed by Health Affairs. Implementing this program was a joint effort between the 

Navy ’s Bureau of Medicine and Surgery, the Bureau of Navy Personnel, Headquarters Marine Corps, and the Deputy Commandant 

of the Marine Corps for Manpower and Reserve Affairs. 

The PDHRA extends the continuum of care, targeting servicemembers for screening at 3 to 6 months post-deployment. Navy 

medicine played a critical role from the program’s inception to 

sustainment and coordinated implementation in line units. Beginning in 2006, Navy medicine established deployment health centers 

to serve as non-stigmatizing portals of entry in high fleet and Marine Corps concentration areas, and to augment primary care services offered at the MTFs or in garrison. 

Staffed by primary care providers and mental health teams, the 

centers are designed to provide care for marines and sailors who 

self-identify mental health concerns on the post-deployment assessment and reassessment. We now have 17 such clinics, up from 14 

last year. 

In urgent or extraordinary situations, Navy medicine meets the 

psychological health needs of sailors and marines and their communities by deploying Special Psychiatric Rapid Intervention Response Teams (SPRIRT). These teams have been in existence over 

15 years and provide short-term mental health and emotional supVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00140 Fmt 6633 Sfmt 6602 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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port immediately after a disaster, with the goal of preventing longterm psychiatric dysfunction or disability. 

The team may provide educational and consultative services to 

local supporting agencies for long-term problem solutions. Never 

before has the mental health and well-being of sailors and marines 

deployed to a war zone been as intensely studied. In order to establish comprehensive psychological health services throughout Navy 

and Marine Corps and to evaluate and provide recommendations 

on the needs of deployed sailors and marines, Navy medicine has 

developed the Behavioral Health Needs Assessment Survey 

(BHNAS). 

The BHNAS was adapted from the Army’s series of MHAT surveys. Recently, Navy received funding for creation of a Navy-Marine Corps Center for the Study of Combat Stress, to be located at 

the Naval Medical Center in San Diego. This center is strategically 

located to work closely with our new comprehensive combat casualty center, our C–5, to better understand the impact upon Navy 

and Marine Corps families. 

I have commissioned the Center for Naval Analyses to conduct 

a wide-ranging study of combat and operational stress control, impact and attitudes. 

This survey, unlike the anonymous BHNAS, will target over 

15,000 randomly selected families and provide the most comprehensive determination as to the cumulative effect of the global 

war on terror. 

Reinforcing a culture which values psychological health will require an enduring commitment to the mental health needs of 

servicemembers, their families, and those who provide their care. 

It requires a commitment to ensuring psychological health services 

are available and accessible in the operational environment. Expanding surveillance and detection capabilities, equipping our providers with the best possible training, and minimizing the stigma 

associated with seeking treatment, we will underscore a culture 

that recognizes and embraces the value of enhancing our resilience 

to deal with the increasing stresses of military life and understands 

that in the end it may be less a question for medical science than 

a challenge for every leader to accept. 

Chairman Nelson, Navy medicine continues to rise to the challenge of meeting the psychological needs of our brave sailors and 

marines and their families. I thank you very much for your support 

to Navy medicine and look forward to answering your questions. 

[The prepared statement of Admiral Robinson follows:]

PREPARED STATEMENT BY VADM ADAM M. ROBINSON, JR., MC, USN 

Chairman Nelson, Ranking Member Graham, distinguished members of the committee, I appreciate the opportunity to share with you Navy Medicine’s efforts in 

preventing, diagnosing, and treating psychological health issues affecting our Active 

Duty and Reserve sailors and marines, and their families. 

As the provider of medical services for both the Navy and the Marine Corps, we 

have to be prepared to meet the needs of these similar, and yet unique military populations. Sailors and marines often serve side-by-side, and they also serve under 

very different conditions—aboard ships, as boots on the ground, or as individual 

augmentees (IAs). As a result, these servicemembers face different physical and 

mental stressors and challenges during deployments. At the same time, their families may be also impacted by the unique stresses and demands of military life in 

slightly different ways. Navy Medicine is continuously adapting to meet the shortVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00141 Fmt 6633 Sfmt 6621 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
138

and long-term psychological health needs of servicemembers and their families before, during, and after deployments. 

We are well aware of the fact that the number and length of deployments have 

the potential to impact the mental health of servicemembers, as well as the wellbeing of their families. The Navy and Marine Corps operational tempo in support 

of the global war on terror is unprecedented. At the same time, Navy Medicine is 

playing an increasing role in Humanitarian Assistance and Disaster Relief missions. 

We need to remain vigilant of the potential long term impact our mission requirements—past, present, and future—will have on the physical and mental health of 

our sailors and marines. 

CONTINUUM OF CARE

Navy Medicine ensures a continuum of psychological health care is available to 

servicemembers throughout the deployment cycle—pre-deployment, during deployment, and post-deployment. We are also making more mental health services available to eligible family members who may be affected by the psychological consequences of combat and deployment. 

To accomplish this continuum of care, Navy Medicine engages at several levels—

from Commanding Officers, to small unit leaders, to individual servicemembers, and 

of course, with their families. Our goal is that necessary psychological health services will be available to all who need them—when they need them. 

PREVENTION AND STIGMA REDUCTION

The same way physical conditioning prepares sailors and marines for the rigors 

and challenges of high tempo operational deployments, we are working to psychologically prepare servicemembers and their leaders to build resiliency, which will 

help sailors and marines manage the physical and psychological stresses of battle 

and deployments. Preventive education programs introduced at each career training 

point help educate servicemembers on the importance of psychological health in an 

effort to decrease the stigma often associated with being given a mental health diagnosis and receiving psychiatric care. 

Command involvement, together with dedicated stress management teams comprised of health care providers and other professionals, are critical in helping sailors 

and marines become comfortable with the concept of building resiliency and seeking 

mental health support and care when necessary. Our experiences in previous conflicts, most notably Vietnam, suggest that delays in seeking mental health services 

increase the risks of developing mental illness and may exacerbate physiological 

symptoms. These delays can have a negative effect on the health of the 

servicemember, jeopardize a servicemember’s career and permanently alter their 

family situation. That is why we are attacking the stigma associated with getting 

help for mental health and stress-related conditions in a variety of ways to ensure 

servicemembers receive full and timely treatment—before deployment, in theater or 

after returning from deployment. 

The reduction of stigma to seeking mental health services is a critical component 

in our efforts to decrease the number of suicides among sailors and marines. Although suicide rates in the Navy and Marine Corps have not significantly fluctuated 

in recent years, our efforts to improve leadership’s understanding and acceptance 

of the importance of treating psychiatric conditions is as important as preparing 

servicemembers to deal with the stresses of military life. Both the Navy and the Marine Corps have published Leaders Guides for Managing Marines/Sailors in Distress. These products available in various formats are part of a greater effort to ensure frontline supervisors, including junior leaders, are able to identify when others 

in their unit may need help. 

The Marine Corps created the Marine Operational Stress Surveillance and Training (MOSST) Program, which includes briefings, health assessments, and tools to 

deal with combat and operational stress. The MOSST program includes warrior 

preparation, warrior sustainment, warrior transition (which happens immediately 

before marines return home), and warrior resetting. Warrior resetting, the final 

phase of the program includes medical screenings and briefings about the prevention of drug and alcohol abuse, anger management, and handling financial difficulties. 

BEFORE DEPLOYMENT

Navy Medicine, in coordination with line leaders in the Navy and the Marine 

Corps, is building on current training programs for leaders and our own caregivers. 

The curriculum focuses on combat stress identification and developing coping skills. 

From the Navy’s ‘‘A’’ Schools, to the Marine Corps Sergeant’s course, and in officer 

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indoctrination programs, we are ensuring that dealing with combat stress becomes 

as comfortable as dealing with any other medical issue. 

Before a unit deploys, there are several opportunities for sailors, marines, and 

their families to become acquainted with the types of resources available to help 

them cope with the stresses of deployment. Pre-deployment briefs include information about everything from legal services, pay fluctuations, chaplain services, as well 

as family support assets available in the military community organizations, and the 

medical facilities at the base. Representatives from each of these organizations detail when and how to access these services. 

For the servicemember, the Pre-Deployment Health Assessment is one way to become aware of potential psychological health needs and the health care services 

available. The symptoms of a mental health condition may not necessarily make an 

individual nondeployable, but this assessment helps emphasize the importance of 

psychological health as part of physical health and may decrease any delay in seeking treatment. 

Because IAs do not deploy as part of a larger unit, providing them with information presents unique challenges for Navy Medicine. There is an increasing number 

of sailors who are serving as IAs and the Navy Expeditionary Combat Readiness 

Center’s IA Family Readiness Program has been a step in the right direction in 

reaching out to these servicemembers and their families. These centers have proven 

to be a critical asset in assessing the health of returning IAs, as well as in coordinating their transition for additional care at the Department of Veterans Affairs 

(VA), or out into the community. Reserve component and IAs also receive 

debriefings, medical assessments, and information on access to care as they mobilize 

and demobilize through the Navy Mobilization Processing Sites. 

DURING DEPLOYMENT—ABOARD SHIPS AND IN-THEATER

In 1999, the Department of Defense directed the establishment of Combat Stress 

Operational Control programs within the services and the combatant commands to 

ensure appropriate management of combat and operational stress and to preserve 

mission effectiveness and war fighting capabilities. 

Before 1999, the Marines relied upon chaplains and a very small organic mental 

health footprint for prevention and early intervention of operational stress with 

more definitive care provided by the nearest Navy Medical Treatment Facilities. 

Hospital medical services were not always well coordinated with commands and 

during large-scale deployments medical battalions relied upon the use of mental 

health augmentees who had limited orientation and connections to the units they 

were called upon to support. 

Since the late 1990s Navy Medicine has embedded mental health professionals 

with operational components of the Navy and the Marine Corps. Since 1998, clinical 

psychologists have been regularly embarked aboard all of our aircraft carriers and 

have become a valuable member of ship’s company. Not only have mental health 

assets helped crews deal with the stresses associated with living in isolated and 

unique conditions, but medevacs and administrative discharges for conditions typically managed by mental health personnel (e.g., personality disorders), fell precipitously. Tight quarters, long work hours, and the fact that many of the staff may 

be away from home for the first time, present a situation where the stresses of 

‘‘daily’’ Navy life aboard ship may prove detrimental to a sailor’s ability to cope. 

Having a mental health professional who is easily accessible and going through 

many of the same challenges has increased operational and battle readiness aboard 

these floating platforms, saving lives as, well, hundreds of thousands of dollars in 

operational costs. 

For the marines, Navy Medicine division psychiatrists stationed with marines developed Operational Stress Control and Readiness (OSCAR) Teams which embed 

mental health professional teams as organic assets in operational units. OSCAR 

teams provide early intervention and prevention support through all of the phases 

of deployment. The same team providing care in garrison also deploys with the 

units, which improves cohesion and helps to minimize stigma. These teams provide 

education and consultation to commanders, entire units and individual marines. 

Battlefield debriefings address the topic of combat and operational stress and provide units and individual servicemembers with the skills to recognize and cope with 

the unique stressors of combat. Types of stress-related injuries are discussed, as 

well as how these injuries may manifest physically and mentally. The briefings also 

provide an opportunity to prevent combat stress situations from deteriorating into 

disabling conditions. Since the beginning of Operations Enduring Freedom and Iraqi 

Freedom (OEF/OIF), mental health related medical evacuations for marines have 

been significantly lower among units supported by OSCAR and currently, there is 

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strong support for making these programs permanent and ensuring they are 

resourced with the right staff and funding. 

AFTER DEPLOYMENT

Before returning from the operational theater, sailors and marines are typically 

provided a series of briefings that familiarize them with issues related to combat 

stress, as well as how to manage their expectations about returning home. The presentations focus on whatever experiences the sailors and marines have encountered 

while in theater and how these may affect their daily lives post deployment. In addition, since 2001, Navy Medicine has been providing Post-Deployment Health Assessments (PDHAs) to measure the health status of returning servicemembers. This 

global screening must be completed within 30 days before or after redeployment. 

The criteria for a PDHA vary and depend on where an individual deployed and for 

how long. Current guidance states that a PDHA is required if the servicemember 

was involved in land based operations for 30 continuous days to overseas locations 

without a fixed Military Treatment Facility (MTF) or by Command decision based 

on health risk. Navy and Marine Corps PDHAs are being accomplished in theatre, 

during Warrior Transition, and at Navy Mobilization Processing Sites. Warrior 

Transition, initiated during OIF and expanded each year, has now become an inherent part of a sailor’s redeployment process home. Recognizing that truly the hardest 

part of going to war is reconciling the experience—inclusive of one’s losses—mental 

health professionals and chaplains located in Kuwait assist servicemembers to reflect, recall and reconcile the enormity of their deployment before returning home. 

Warrior Transition accomplishes this by providing 3 days of facilitated decompressing; This preparation being the psychological equivalent of the ‘‘long boat ride 

home’’. Warrior Transition is now mandatory for all Seabees, IAs, and soon SEALs. 

Of the PDHAs completed in the Navy, there is an overall referral rate for additional health care services of 10 percent, with a 2 percent referral rate for mental 

health issues. The rate is currently the same for Active or Reserve component (AC/

RC) sailors. For the marines, the overall referral rate following the assessment is 

16 percent, with a mental health referral rate of 3 percent. This rate is also the 

same among Active and Reserve component marines. 

Since 2005, Navy Medicine has been administering the Post-Deployment Health 

Reassessment (PDHRA) as directed by the Office of the Assistant Secretary of Defense for Health Affairs (ASD(HA)). Implementing this program was a joint effort 

between the Navy’s Bureau of Medicine and Surgery (BUMED), the Bureau of 

Naval Personnel (BUPERS), Headquarters Marine Corps (Health Services), and the 

Deputy Commandant of the Marine Corps for Manpower and Reserve Affairs 

(USMC(M&RA)). The PDHRA extends the continuum of care, targeting 

servicemembers for screening at 3 to 6 months post-deployment. 

Currently, BUMED provides PDHRA program management and oversight and 

management of global war on terrorism funds. In addition, in consultation with 

ASD(HA), BUMED develops directives, procedures and protocols for supporting program implementation. Navy Medicine also serves as the liaison with the Navy and 

Marine Corps Public Health Center to provide technology and training for the electronic completion, storing and reporting of PDHRA data. Navy Medicine played a 

critical role from the program’s inception to sustainment and coordinated implementation in line units. 

Beginning in 2006, Navy Medicine established Deployment Health Centers 

(DHCs) to serve as non-stigmatizing portals of entry in high fleet and Marine Corps 

concentration areas and to augment primary care services offered at the MTFs or 

in garrison. Staffed by primary care providers and mental health teams, the centers 

are designed to provide care for marines and sailors who self-identify mental health 

concerns on the Post-Deployment Health Assessment and Reassessment. The centers provide treatment for other servicemembers as well. We now have 17 such clinics, up from 14 since last year. From 2006 through January 2008, DHCs had over 

46,400 visits, 28 percent of which were for mental health issues. 

The Navy and Marine Corps are working to improve their PDHRA completion 

rates. To date, for sailors who have completed their PDHRAs, the follow-on medical 

care referral rate is 26 percent (AC 21 percent, RC 34 percent). Of the 26 percent 

of referrals, 6 percent are for mental health issues. For the Marines, of the PDHRAs 

completed, the overall Marine Corps referral rate is 28 percent (AC 24 percent, RC 

48 percent) with a 7 percent referral rate for mental health (AC 6 percent, RC 9 

percent). 

Since February 2007, Command Navy Reserve Forces assumed responsibility for 

overseeing implementation of the PDHRA program in the Navy Reserve component. 

With strong leadership support they are actively engaged in program execution, as 

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reflected in their high compliance rate. For the AC, BUMED is still working with 

line leadership on the transition of program oversight and execution to the appropriate line organizations. In addition, we are advocating on behalf of a single integrated database and reporting system for identification, notification and documentation of compliance by eligible members. 

Since April 2007, USMC(M&RA) assumed management oversight for program 

execution for the marines. With BUMED support, USMC(M&RA) developed and implemented an aggressive plan to contract $4.5 million for mobile surge teams to 

complete 50,000 PDHRAs. 

ACCESSING MENTAL HEALTH SERVICES

Whether a servicemember is identified as needing mental health services through 

a health assessment tool or through self-referral, our personnel at Navy MTFs are 

prepared to provide high quality mental health services. In addition, sailors, marines and eligible beneficiaries seeking services can access a wider range of providers to meet their needs through various organizations such as Military 

OneSource, Navy’s Family Support Centers, Marines’ Corps Community Services, 

and the Navy’s Chaplains Corps. All of these of entry points allow beneficiaries to 

select the type of mental health services they feel most comfortable to help them 

deal with their situation. 

While Navy Medicine is making a concerted effort to ensure psychological health 

care for active duty members is available in the direct care system whenever possible, personnel shortages in psychological specialties make that a challenge. 

TRICARE network resources may be available; however, there is some concern that 

those providers may be less familiar with the unique demands placed upon active 

duty members. 

There are significant shortfalls in our Active Duty mental health community. 

Navy uniformed psychiatry and psychology communities continue to experience 

manning shortfalls. Our psychiatry community is at 90 percent manning, our clinical psychology community is at only 77.5 percent manning. The roles of the Navy 

social work community are being expanded and increases in the Psychiatric Nurse 

Practitioner community are also being explored to meet the growing needs for mental health services, both in theater and in garrison. Uniformed mental health providers are critical in our efforts to provide preventive and clinical services to marines and sailors. We must continue to develop mechanisms, including changes to 

accession and retention bonuses and special pays, to ensure an adequate complement of uniformed mental health providers. 

Providing services to Reserve sailors and marines is a continuous challenge as 

mental health problems may not emerge until the end of their benefit period. Furthermore, other problems, such as substance abuse, family discord or vocational dysfunction, may not present until after their benefits expire. Another challenge in 

meeting the needs of reservists is that many of them, unlike the Active-Duty Forces, 

do not reside in large fleet or military concentration areas and return from deployments to sites where they lack access to medical services or support networks. We 

will continue to strengthen our partnership with the Department of Veterans Affairs 

so that these servicemembers will be able to access psychological health services as 

close to their homes and families as possible. 

Coordination of care is being provided by a myriad of agencies and our commitment to ensure quality health care for reservists and their families remain in the 

forefront. The demands of providing services to these veterans, particularly in high 

fleet and Marine Corps concentration areas, is closely monitored to ensure sufficient 

capacity is available in our system. Our goal is to establish comprehensive and effective psychological health services throughout the Navy and Marine Corps. This effort requires seamless programmatic coordination across the existing line functions 

(e.g., Wounded Warrior Regiment, Safe Harbor), and we are working to achieve 

long-term solutions to provide the necessary care. 

Navy Medicine is also paying particular attention to de-stigmatizing psychological 

health services, the continuity of care between episodes and the hand-off between 

the direct care system and the private sector. We are developing a process to continuously assess our patient and their families perspectives so that we cam make 

improvements when and where necessary. 

CONTINUING EFFORTS TO MEET THE MENTAL HEALTH NEEDS OF SAILORS AND MARINES

In order to evaluate and provide recommendations on the needs of deployed sailors and marines, Navy Medicine has developed the Behavioral Health Needs Assessment Survey (BHNAS). BHNAS was adopted from the Army’s series of Mental 

Health Advisory Team surveys, which started in 2003, of land warfighters. 

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Preliminary results of the BHNAS show that Navy’s contributions to the global 

war on terrorism are diverse and substantial. The impact of OIF-related deployments appears to vary according to type of assignment and degree of exposure to 

direct combat. Sailors who had seen the most combat were more likely to screen for 

a mental health problem. As a matter of fact, Navy corpsmen showed the highest 

incidence of mental health problems among Navy personnel surveyed. Sailors reporting a strong sense of unit cohesion and leadership were half as likely to report 

mental health issues as those in less-stable command environments. These findings 

highlight an additional burden on the IA population because IAs do not enjoy the 

same level of command integrity, ethos and camaraderie. Phase II analysis of our 

BHNAS which focuses exclusively on our IAs, a study now which now has evaluated 

more than two thousand Sailors, is near completion. 

Recently Navy Medicine received funding for creation of a Navy/Marine Corps 

Center for the Study of Combat Stress to be located at the Medical Center San 

Diego. This center is strategically located to work closely with our new Comprehensive Combat Casualty Care Center (C5). The concept of operations for this first-ofits-kind capability is underway, as is the selection of an executive staff to lead the 

Center. The primary role of this Center is to identify best Combat and Operational 

Stress Consultants (COSC) practices; develop combat stress training and resiliency 

programs specifically geared to the broad and diverse power projection platforms 

and Naval Type Commands; establish provider ‘‘Caring for the Caregiver’’ initiatives; and coordinate collaboration with other academic, clinical, and research activities. As the concept for a DOD Center of Excellence develops, we will integrate, as 

appropriate, the work of this center. The program also hopes to reflect recent advancements in the prevention and treatment of stress reactions, injuries, and disorders. 

Never before has the mental health and well-being of sailors and marines deployed to a war zone been as intensely studied. To better understand the impact 

upon Navy and Marine Corps families, I have commissioned the Center for Naval 

Analysis to conduct a sweeping study of Combat and Operational Stress Control impact and attitudes. This survey, unlike the anonymous BHNAS, will target over 

15,000 randomly selected families and provide the most comprehensive determination as to the cumulative effect of global war on terrorism. Navy Medicine will continue to build upon and expand our efforts of assessing their mental health needs 

as a result of their service. Among the recommendations by the first BHNAS are 

to: continue developing stress resiliency programs; adopt a consistent ‘‘Caring for 

the Caregiver’’ program; fully implement the Psychological First Aid (self-aid and 

buddy-aid); and assess differential COSC burden on RC and IAs and their families. 

Implementing the recommendations of the BHNAS is the responsibility of Navy 

Medicine’s COSC. These two individuals are dedicated to addressing mental health 

stigma, training for combat stress control, and the development of non-stigmatizing 

care for returning deployers and support services for Navy Caregivers. The COSC 

assigned to Navy Medicine serves as the Director of Deployment Health, and he and 

his staff oversee Pre- and Post-Deployment Health Assessments, as well as the 

PDHRA. In addition, this position oversees Substance Abuse Prevention and Treatment, Traumatic Brain Injury diagnosis and treatment, and a newly created position for Psychological Health Outreach for Reserve Component Sailors. Navy Medicine is also establishing psychological outreach programs at the Navy Operational 

Support Centers (NOSC) throughout fiscal years 2008 and 2009. These programs 

will provide outreach to Reserve servicemembers and their families for psychological 

health, including high risk concerns such as PTSD and TBI, as well as post-deployment reintegration issues. Psychological Outreach Coordinators will work directly 

with Reserve servicemembers and their families as a liaison to the NOSCs and Military Treatment Facilities, the Department of Veterans Affairs, and other Service organizations. 

As Navy Medicine champions multi-disciplinary efforts in preventing, identifying, 

and managing stress, we continue to expand and strengthen our collaboration with 

a variety of community resources such as Navy Chaplains, the Navy Fleet and Family Support Centers and Marine Corps Community Services. Another example of 

strategy to create solutions for pressing problems is the implementation of Project 

Families Overcoming and Coping Under Stress (FOCUS). Project FOCUS is a prevention/very early intervention program consisting of 10 to 12 sessions with a team 

of specially trained counselors. In the initial pilot, this service—which can be arranged by direct contact from the family at risk—will positively impact 1,200 families. 

Reinforcing a culture that values psychological health will require an enduring 

commitment to the mental health needs of servicemembers, their families, and those 

who provide their care. It requires a commitment to: ensuring psychological health 

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services are available and accessible in the operational environment; expanding surveillance and detection capabilities; equipping our providers with the best possible 

training, and minimizing the stigma associated with seeking treatment. We need to 

underscore a culture that recognizes and embraces the value of enhancing our resilience to deal with the increasing stressors of military life, and a culture that understands that in the end, it may be less a question for medical science than a challenge for every leader to accept. 

Chairman Nelson, Ranking Member Graham, distinguished members of the committee, Navy Medicine continues to rise to the challenge of meeting the psychological health needs or our brave sailors and marines, and their families. I thank 

you for your support to Navy Medicine and look forward to answering any of your 

questions.

Senator BEN NELSON. Thank you, Admiral. 

General Roudebush? 

STATEMENT OF LT. GEN. JAMES G. ROUDEBUSH, USAF, 

SURGEON GENERAL OF THE UNITED STATES AIR FORCE 

General ROUDEBUSH. Yes, sir. First, Chairman Nelson, thank 

you. I know you are the driving force that brings us here today to 

discuss this and the information that has been shared already, that 

will be shared, and the questions that have been asked. The concerns raised I think underscore the importance of this. So thank 

you for giving us the opportunity to come at this in a way that I 

think is very meaningful for us all within the Air Force. 

I would first like to lay out the challenge and the opportunity, 

and then I will talk a bit about how we in the Air Force are approaching this. We clearly have airmen in harm’s way, as do our 

sister Services, perhaps not in the magnitude, but certainly within 

the intensity. We have airmen serving in the battlefield that are 

out there in the joint warfight, doing that mission every day, and 

we must take care of them. 

In addition to that, we have an incredibly high operational 

tempo. As I believe you would agree, we’ve been at war 18 years. 

We did not come home after the Gulf War. We continued operations, and that has caused stress, strain, and wear on our forces 

and our equipment that we simply must attend to. 

Now, we in the Air Force come at this in a way that is very coherent and resonant with our Air Force culture of accountability, 

caring for each other, a wingman culture, if you will. You always 

take care of your wingman. You protect their six. You make sure 

that nothing is below or behind that could be injurious, and that’s 

how we succeed. We succeed as a team very much the same in the 

way that we approach the challenges for our airmen. We medics 

support our line directly in doing this. 

We are accountable for a fit, healthy force that’s able to do the 

mission in some very demanding circumstances, both at home station and deployed, because every Air Force base is an operational 

platform whether we’re providing global deterrence from F.E. Warren in Cheyenne, WY, or global strike from Knob Noster, MO, or 

global mobility from Charleston. Every base is an operational platform, and we medics support our line in doing that, first by providing a healthy, fit force, but also by taking care of families, providing resilience and families that are able to support these warriors as they go in harm’s way and take on these intense and very 

demanding missions. 

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In addition to that, we provide constant surveillance, understanding, and attending to the health of our forces, so that 

rotationally and repeatedly and heroically we can deploy and do 

the mission, wherever that mission is found. When illness or injury 

occurs, we are there with the right care, to take care of those injuries and illnesses and, in support of our joint warfighters, to take 

care of those injuries and illnesses forward, stabilize them, and 

bring them home safely for definitive care here in the States. 

The best care that we can provide, though, we believe is often 

preventive. If there is not an injury or an illness, that is the best 

outcome. That’s economy of force. That’s preserving health, and we 

think that is the best outcome right up front. But again, if illness 

or injury occurs, we’re there to take care of it. 

Now, we support the line in doing this. Within our Air Force culture, the line is very much accountable and responsible for the 

health and well-being of the forces. I mentioned the wingman culture. The wingman program, if you will, wherein we take care of 

each other and we work to reduce the stigma—there is no stigma 

in needing help or asking for help. Certainly it can be uncomfortable, but sometimes that very uncomfortable conversation is the 

one that needs to happen: I need help or you need help. That’s the 

best place for it to begin. 

In addition to that, we have a suicide prevention program which 

is very much a line program. This was initiated in 1996 and serves 

as a model both for the military and for the Nation. During that 

time we’ve reduced our suicide—the incident of suicides, 28 percent. Any suicide is too many. However, to the full extent that we 

can prevent suicide we believe that that’s very important to do. 

That’s a community-based program, but it requires attention every 

day. It requires training, and it requires buy-in that in fact we do 

take care of each other and there is no stigma in seeking or needing help. 

Lastly, for those who are significantly wounded we have the Air 

Force Wounded Warrior Program, wherein a family liaison officer 

is assigned to every severely injured airman to administratively assist the family, and to assure that all medical issues are attended 

to as well, and that injured or ill individual is properly taken care 

of. 

So through this constellation of programs, both the medical and 

line, we are every day attending to our airmen to assure that we 

can repeatedly, heroically be there to support the mission, accomplish the mission, to dominate the domains, air space and cyber 

space, in support of our sovereign options, and do it without fail. 

Sir, I appreciate this opportunity to talk to you about Air Force 

medicine and I look forward to your questions. 

[The prepared statement of General Roudebush follows:]

PREPARED STATEMENT BY LT. GEN. (DR.) JAMES G. ROUDEBUSH, USAF 

Mr. Chairman and esteemed members of the committee, it is my honor and privilege to be here today to talk with you about the Air Force Medical Service (AFMS). 

The AFMS exists and operates within the Air Force culture of accountability wherein medics work directly for the line of the Air Force. Within this framework we support the expeditionary Air Force both at home and deployed. We align with the Air 

Force’s top priorities: Win Today’s Fight, Take Care of our People, and Prepare for 

Tomorrow’s Challenges. We are the Nation’s Guardian—America’s force of first and 

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last resort. We get there quickly and we bring everyone home. That’s our pledge to 

our military and their families. 

WIN TODAY’S FIGHT

It is important to understand that every Air Force Base is an operational platform 

and Air Force medicine supports the war fighting capabilities at each one of our 

bases. Our home station military treatment facilities form the foundation from 

which the Air Force provides combatant commanders a fit and healthy force, capable of withstanding the physical and mental rigors associated with combat and other 

military missions. Our emphasis on fitness, disease prevention and surveillance has 

led to the lowest disease and non-battle injury rate in history. 

Unmistakably, it is the daily delivery of health care which allows us to maintain 

critical skills that guarantee our readiness capability and success. The superior care 

delivered daily by Air Force medics builds the competency and currency necessary 

to fulfill our deployed mission. Our care is the product of preeminent medical training programs, groundbreaking research, and a culture of personal and professional 

accountability fostered by the Air Force’s core values. 

The AFMS is central to the most effective joint casualty care and management 

system in military history. The effectiveness of forward stabilization followed by 

rapid Air Force aeromedical evacuation has been repeatedly proven. We have safely 

and rapidly transferred more than 48,000 patients from overseas theaters to stateside hospitals during Operations Enduring Freedom and Iraqi Freedom. Today, the 

average patient arrives from the battlefield to stateside care in 3 days. This is remarkable given the severity and complexity of the wounds our forces are sustaining. 

It certainly contributes to the lowest died of wounds rate in history. 

TAKE CARE OF OUR PEOPLE

We are in the midst of a long war and continually assess and improve health services we provide to airmen, their families, and our joint brothers and sisters. We ensure high standards are met and sustained. Our Air Force chain of command fully 

understands their accountability for the health and welfare of our airmen and their 

families. When our warfighters are ill or injured, we provide a wrap-around system 

of medical care and support for them and their families—always with an eye towards rehabilitation and continued service. 

The Air Force is in lock-step with our sister Services and Federal agencies to implement the recommendations from the President’s Commission on the Care for 

America’s Returning Wounded Warriors. The AFMS will deliver on all provisions set 

forth in the National Defense Authorization Act (NDAA) for Fiscal Year 2008 and 

provide our warfighters and their families help in getting through the challenges 

they face. As we will discuss today, the AFMS is committed to meeting the mental 

health needs of all our airmen, whether deployed or at home, and we are very grateful for your support in these areas. 

Psychological Health 

Psychological health means much more than just the delivery of traditional mental health care. It is a broad concept that covers the entire spectrum of well-being, 

prevention, treatment, health maintenance and resilience training. To that end, I 

have made it a priority to ensure that the AFMS focus on the psychological needs 

of our airmen and identify the effects of operational stress. 

Prevention 

The Air Force has enhanced mental health assessment programs and services for 

airmen. We identify mental health effects of operational stress and other mental 

health conditions, before, during and following deployments through periodic health 

assessments (PHAs). We begin with the annual PHA of all personnel to identify and 

manage overall personnel readiness and health, including assessment for post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). 

Before deployment, our airmen receive a pre-deployment health assessment. This 

survey includes questions to determine whether individuals sought assistance or received care for mental health problems in the last year. It also documents any current questions or concerns about their health as they prepare to deploy. The responses to these questions are combined with a review of military medical records 

to identify individuals who may not be medically appropriate to deploy. 

The Post-Deployment Health Assessment (PDHA) and Post-Deployment Health 

Reassessment (PDHRA) contain questions to identify symptoms of possible mental 

health conditions, including depression, PTSD, or alcohol abuse. Each individual is 

asked if he or she would like to speak with a health care provider, counselor, or 

chaplain to discuss stress, emotional, alcohol, or relationship issues and concerns. 

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New questions were added to the PDHA and PDHRA to screen for TBI. Quality assurance and programs evaluations are conducted to assess implementation effectiveness and program success. Treatment and follow-up are arranged to ensure continuity of care by building on Department of Defense (DOD) and Veterans Affairs 

(VA) partnerships. 

The Air Force integrates these prevention services through the Integrated Delivery System (IDS). The IDS is a multidisciplinary team that identifies and corrects 

gaps in the community safety net. Leaders from the chapel programs, mental health 

services, family support centers, child and youth programs, family advocacy and 

health and wellness center are involved at each installation. They promote spiritual 

growth, mental, and physical health, and strong individuals, families, and communities. 

Post Traumatic Stress Disorder 

The incidence of PTSD is low in the Air Force, diagnosed in less than 1 percent 

of our deployers (at 6 month post-deployment). For every airman affected, we provide the most current, effective, and empirically validated treatment for PTSD. We 

have trained our behavioral health personnel to recognize and treat PTSD in accordance with the VA/DOD PTSD Clinical Practice Guidelines. Using nationally recognized civilian and military experts, we trained more than 200 psychiatrists, psychologists, and social workers to equip every behavioral health provider with the latest research, assessment modalities, and treatment techniques. We hired an additional 32 mental health professionals for the locations with the highest operational 

tempo to ensure we had the personnel in place to care for our airmen and their families. 

Traumatic Brain Injury 

We recognize that TBI may be the ‘‘signature injury’’ of the Iraq war and is becoming more prevalent among servicemembers. Research in TBI prevention, assessment, and treatment is ongoing and the AF is an active partner with the Defense 

and Veterans Brain Injury Center (DVBIC), the VA, the CDC, industry and universities. The AF has very low positive screening for TBI—approximately 1 percent 

from Operation Iraqi Freedom and Operation Enduring Freedom. 

Screening for TBI occurs locally in theater, before transport of wounded 

servicemembers stateside, and again at stateside hospitals as indicated. The Military Acute Concussive Evaluation tool is administered in accordance with the Joint 

Theater Trauma System TBI Clinical Practice Guideline. U.S. Transportation Command policy dictates that all servicemembers be screened for the signs and symptoms of TBI prior to transportation out of theater at either Landstuhl Regional Medical Center or at U.S. Air Forces Europe Aeromedical Staging Facilities. Follow up 

care for those with positive screens is conducted at U.S. military treatment facilities 

and/or DVBICs. The 59th Medical Group, Lackland Air Force Base, TX, is one of 

three DOD DVBIC Regional Centers that cares for TBI patients. 

The Air Force is involved in several cutting edge research initiatives involving 

TBI. One in particular is the collaboration between the Air Force Research Laboratory and the University of Florida’s Brain Institute. This research is focusing on the 

presence of biochemical markers in spinal fluid that is associated with TBI. Another 

is the Brain Acoustic Monitor, which detects mild TBI injuries and replaces invasive 

pressure monitors used to measure brain pressure for severe TBI cases. 

TBI is an expanding area of study requiring close cooperation among the Services, 

the Department of Veterans Affairs, academic institutions and industry. It is vital 

that we better understand this disorder and clarify the long-term implications for 

our airmen, soldiers, sailors, and marines. 

Suicide Prevention 

The Air Force suicide prevention program is a commander’s program. It has received a great deal of national acclaim and has achieved a 28 percent decrease in 

Air Force suicides since the program’s inception in 1996. We continue to aggressively work our 11 suicide prevention initiatives using a community approach, and 

this year released Frontline Supervisor’s Course. The course further educates those 

with the most contact and greatest opportunity to intervene when airmen are under 

stress. We conducted suicide risk assessment training for mental health providers 

at 45 Air Force installations throughout 2007 to ensure Air Force mental health providers are highly proficient in evaluating and managing suicide risk. 

Air Force prevention efforts are centered on effective detection and treatment. Recurring suicide prevention training for all airmen is a central component of this risk 

recognition. As part of our Chief of Staff’s and Secretary’s new Total Force Awareness Training initiative, we recently released revamped computer-based training. 

This effort incorporates suicide prevention education into the CSAF’s core training 

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priorities, ensuring suicide prevention will continue to receive the appropriate priority and attention. 

In 2008, the Air Force Suicide Prevention Program will monitor the Frontline Supervisors Training and the new computer-based suicide prevention training to ensure these initiatives effectively meet the training needs of airmen. Every Air Force 

suicide will be studied for lessons learned to prevent future suicides. These lessons 

will be shared in the annual Air Force Suicide Lessons Learned Report that is distributed Air Force-wide. 

The best approach to preventing Air Force suicides is continued emphasis on the 

data-proven Air Force Suicide Prevention Program. Each of the 11 initiatives in the 

Air Force Suicide Prevention Program represents an important tool for commanders. 

These initiatives focus on leadership involvement; suicide prevention in professional 

military education; community preventive services; community education and training; Critical Incident Stress Management and others. Since September 2006, every 

base commander must ensure all 11 initiatives are fully implemented on their installation using the annual Air Force Suicide Prevention Program Assessment Process and Checklist. There is no single, easy solution to preventing suicide. It requires 

a total community effort using the full range of tools. 

The Air Force Suicide Prevention Program was added to the National Registry of 

Evidence-based Programs and Practices (NREPP) in 2007, and is currently 1 of only 

10 suicide prevention programs listed on the registry. NREPP is a searchable database of interventions for the prevention and treatment of mental and substance use 

disorders. Operated by the Substance Abuse and Mental Health Services Administration, NREPP was developed to help people, agencies, and organizations implement effective mental health programs and practices in their communities. This listing demonstrates the military’s ongoing pivotal leadership role in suicide prevention 

within the United States and around the world. 

PREPARE FOR TOMORROW’S CHALLENGES

We’re looking forward to the fiscal year 2009 deployment of our Tele-mental 

Health Project, which will provide video teleconference units at every mental health 

clinic for live patient consultation. This will allow increased access to, and use of, 

mental health treatment to our beneficiary population. Virtual reality equipment 

will also be installed at six Air Force sites as a pilot project to help treat patients 

with post traumatic stress disorder. Using this equipment will facilitate desensitization therapy by recreating sight, sound and smell in a controlled environment. We 

are excited about these initiatives, not only for our returning deployers, but for all 

of our servicemembers and their families. 

In the months ahead, we will continue to implement enhanced AFMS psychological health and TBI programs made possible by fiscal year 2007 supplemental 

funding. These programs promote greater focus on access to care, quality of care, 

resilience, and surveillance. The funding will allow us to hire 97 additional mental 

health specialists over the next several months. We are indebted to Congress for 

your support. 

We will continue to work closely with the Office of the Secretary of Defense and 

our sister Services to implement the recommendations of the DOD Mental Health 

Task Force and the wounded, ill, and injured provisions of the NDAA for Fiscal 

Year 2008. 

CONCLUSION

In closing, Mr. Chairman, I am intensely proud of the daily accomplishments of 

the men and women of the United States AFMS. Our future strategic environment 

is extremely complex, dynamic and uncertain, and therefore we will not rest on our 

success. We are committed to staying on the leading edge and anticipating the future. With your help and the help of the committee, the AFMS will continue to improve the health of our servicemembers and their families. We will win today’s fight, 

and be ready for tomorrow’s challenges. Thank you for your enduring support.

Senator BEN NELSON. Thank you very much, General. 

Colonel, General-to-be? 

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STATEMENT OF COL LOREE K. SUTTON, USA, SPECIAL ASSISTANT TO THE ASSISTANT SECRETARY OF DEFENSE (HEALTH 

AFFAIRS), PSYCHOLOGICAL HEALTH AND TRAUMATIC 

BRAIN INJURY 

Colonel SUTTON. Good afternoon, Chairman Nelson. Thank you 

so much for inviting me. We thank you also for your kind remarks 

in your introduction. 

Let me just say for the record, sir, that my grandmother, Volga 

Bell Ward, graduated from Union College in Lincoln, NE. I just 

wanted to establish that. [Laughter.] 

Senator BEN NELSON. Great connection. 

Colonel SUTTON. Today, Mr. Chairman, I’m here to provide an 

update on the military health system improvements in psychological health and TBI, with a particular emphasis on what is happening with the Defense Center of Excellence for Psychological 

Health and TBI. Let me start out by saying I’m heartened by the 

optimism expressed by Senator Boxer and certainly shared by yourself and members of your committee, and Admiral Arthur and Dr. 

MacDermid. 

I’m deeply indebted to the Mental Health Task Force and to their 

emphasis on culture, on leadership, on the continuum of care, as 

well as the resources needed, particularly to reach those very tough 

populations that are particularly at risk, such as our Reserve components. 

I would also like to share with you some of my excitement, sir, 

in terms of what’s going on with the Defense Center of Excellence. 

We are becoming the front door for the Department for all matters 

of concern related to psychological health and TBI. I am pleased to 

report to you, sir, that we are on the verge of requiring a name 

change already, because Secretary Peake at my first meeting with 

him in January, he said: ‘‘Loree, what you really need is you need 

a deputy for your center from the VA.’’ I assured him that such an 

addition would be welcome, at which point we’ll need to change our 

name from the ‘‘Defense Center of Excellence’’ to, I would propose, 

the ‘‘National Centers of Excellence.’’ 

We opened our doors for initial operations on November 30, 2007, 

which meant that on December 1, we had a phone number, we had 

a receptionist, and we had a dugout in Rosslyn with a part-time 

chief of staff, a couple of contractors, and, fortunately, we are harnessing also the power, the momentum, and the achievements of a 

number of centers. 

So I would think of the Center of Excellence at this point, sir, 

as a center of centers. We are so pleased to be able to bring in the 

efforts and the track record, the achievements, of the Defense and 

Veterans Brain Injury Center with their 16 years of research, education, and treatment. They were named in fact as the number one 

treatment and research network for TBI in the country in 2005. 

We’re also bringing in, led by David Riggs, the Center for Deployment Psychology, which will really help boost our efforts, not just 

to reach out to psychologists, but to mental health professionals, 

health professionals within our direct care system, as well as 

throughout the country, because we realize those 800,000 soldiers, 

sailors, airmen, and marines who’ve already served are out there 

as veterans in various areas of the country. 

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We’re bringing in the efforts of the Deployment Health Clinical 

Center, led by Colonel Chuck Engel, as well as working very closely 

with the Center for the Study of Traumatic Stress at the Uniformed Services University, led by Dr. Bob Ursano. 

Sir, we are also so blessed to be working with Mr. Arnold Fisher 

and the Intrepid Fallen Heroes Fund. Mr. Fisher has pledged to do 

for psychological health and TBI what he and his fund have already done for the care of amputees with the Center for the Intrepid. 

We just recently convened our first strategic planning conference 

last week, sir. We had 160 folks that came together, a combination 

of military, VA, and advocacy groups. We had folks such as Meredith Beck from the Wounded Warrior Project, Ted and Sarah 

Wade, Barbara Cohoon from the National Military Family Association. It was just a tremendous effort coming together to really get 

our first initial traction. This will be a quarterly conference and I’ll 

look forward to reporting to you our ongoing results. 

We are in the process of launching a national awareness campaign, building upon the efforts that the National Institute for 

Mental Health had several years ago: Real Men, Real Depression. 

We are now looking to harness the power of stories that come from 

real warriors, real battles, and real strength. 

Sir, having said all of that, yes, we have done a lot. We are working on the issues of concern that were earlier addressed. I can certainly provide more details on that, and we have much more work 

ahead of us. We must continue to fully implement the Mental 

Health Task Force recommendations, redouble our efforts for suicide prevention, build that global network that will include not only 

DOD and the Services, but also the VA, our civilian colleagues. 

Yes, we’ve already been contacted and are in collaboration with 

folks in Israel, Great Britain, Australia, Canada, and we seek to 

add to that global network. 

We’re opening a clearinghouse and a call center which will really 

facilitate that communication between us and those that we serve. 

We want it to be two-way. The 18th of March this month we will 

initiate what will become a monthly video teleconference that will 

reach out to not only our folks within the Services, but to anyone 

who wants to join our regular communication, followed by a newsletter coming out in April. We’re also looking for ways to harness 

the power of not just 800 numbers and websites and newsletters, 

but YouTube and MySpace and podcasting and all of the ways that 

our generation of warriors and their families communicate. 

Sir, we are also very, very interested in working on what really 

was emphasized first and foremost by the task force and has been 

mentioned by so many others this afternoon. That is the importance of culture. We can work the implementing of all of the task 

force recommendations. We can come up with the best strategy, 

plans, programs, and policies. But unless and until we transform 

the culture that undergirds our efforts, we will fall flat. 

So that is a particular area of focus coming out the gate. We are 

partnering with the National Institutes of Health. We have the 

CDC, the Institutes of Medicine, the Substance Abuse and Mental 

Health Services Administration. We are working with a group of 

founding Federal partners, working with the Federal Steering 

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Group to initiate a priority working group to address the reintegration needs of our veterans, servicemembers, and families that will 

be co-chaired by Toni Zeiss who is also on the task force. So clearly 

it’s time for us to do a little less talking and a whole lot more action here, sir, and we’re after it. 

We thank you so much for your support. We thank you for your 

sustained collaboration. We have a lot of work ahead, but I assure 

you, sir, we’ll keep after it. 

[The prepared statement of Colonel Sutton follows:]

PREPARED STATEMENT BY COL LOREE K. SUTTON, USA 

Mr. Chairman, distinguished members of the committee, thank you for inviting 

me. Today, I will provide an update on the Military Health System (MHS) improvements in Psychological Health and Traumatic Brain Injury (TBI). You asked that 

I address implementation of the Mental Health Task Force recommendations, implementation of the Department of Defense Center of Excellence (DCoE) for Psychological Health and TBI, and information on suicide rates and risk factors. 

The Psychological Health programs in the MHS continuum of care encompass:

• Resilience, prevention, and community support services; 

• Early intervention to reduce the incidence of potential health concerns; 

• Deployment-related clinical care before, during, and after deployment; 

• Access to care coordination and transition within the Department of Defense (DOD)/Department of Veterans Affairs (VA) systems of care; and 

• Robust epidemiological, clinical, and field research. 

DOD MENTAL HEALTH TASK FORCE

The Department is grateful for the hard work and dedication of the members of 

the DOD Mental Health Task Force (MHTF). In September 2007, DOD responded 

to the Task Force’s report accepting 94 of the 95 recommendations for implementation. 

As of today we have completed five of the recommendations offered by the MHTF. 

We have initiated actions on all other recommendations. Some will be completed by 

May of this year and others will be completed at a later date, due to longer term 

implementation requirements. Finally, some will continue, based on the requirement of the recommendation. We will conduct a broad evaluation of our progress 

in May to gauge our status and reprioritize as needed to maintain our momentum. 

The one recommendation that DOD did not accept recommended actions that are 

taking place through programs that are currently operating, such as Military 

OneSource. Further initiatives could serve to confuse our warriors and their families 

as well as duplicate successful programs. 

DEFENSE CENTER OF EXCELLENCE

Our approach in developing a culture of leadership and advocacy began with the 

creation of the DCoE. The Assistant Secretary of Defense for Health Affairs appointed me as the DCoE Director in September 2007 and the DCoE opened its doors 

on November 30, 2007. The Center serves as the Department’s ‘‘front door’’ for all 

issues pertaining to Psychological Health and TBI. 

This Center will lead clinical efforts toward developing excellence in practice 

standards, training, outreach, and direct care for our military community with Psychological Health and TBI concerns. It will also provide research planning and monitoring in these important areas of knowledge. 

The DCoE will provide intensive outpatient care for wounded Warriors in the National Capital Region and importantly, it will instill that same quality of care across 

the country and around the world. We will accomplish this by establishing clinical 

standards, conducting clinical training, developing education and outreach resources 

for leaders, Families and communities, along with researching, refining and distributing lessons learned and best practices to our military treatment facilities (MTFs) 

and to the TRICARE provider networks. We will work together with our colleagues 

at the VA, National Institutes of Health (NIH) and elsewhere to create these clinical 

standards. 

The DCoE staff will build and orchestrate a national network of research, training, and clinical expertise. It will leverage existing expertise by integrating functions currently housed within the Defense Veterans Brain Injury Center (DVBIC), 

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the Center for Deployment Psychology (CDP), and Deployment Health Clinical Center (DHCC). 

To date, the DCoE is engaged in multiple projects that respond to the recommendations of the MHTF, including:

(1) Mounting an anti-stigma campaign projected to begin this spring 

using input from the Uniformed Services University of the Health Sciences, 

NIH, VA, the Substance Abuse and Mental Health Services Administration, 

our coalition partners, and others in the public and private sectors; 

(2) Establishing effective outreach and educational initiatives, including 

an Information Clearinghouse, a public Web site, a wide-reaching newsletter, and a 24/7 call center for servicemembers, family members, and also 

for clinicians; 

(3) Promulgating a Telehealth Network for clinical care, monitoring, support, and follow-up; 

(4) Conducting an overarching program of research relevant to the needs 

of servicemembers in cooperation with other DOD organizations, VA, NIH, 

academic medical centers, and other partners—both national and international; 

(5) Providing training programs for providers, line leaders, families and 

community leaders; and 

(6) Designing and planning for the National Intrepid Center of Excellence 

(anticipated completion in fall 2009), a building funded by the Intrepid Fallen Heroes Fund that will be located in Bethesda adjacent to the future Walter Reed National Military Medical Center.

The Department has allocated more than $83 million toward DCoE functions. 

That total includes amounts allocated specifically to telehealth infrastructure, Automated Behavioral Health Clinic, Defense Suicide Event Registry and DVBIC functions. An additional $45 million was allocated to research and development projects. 

A vital responsibility of the DCoE is quality of care. The quality of care initiative 

relies on developing and disseminating clinical guidance and standards, as well as 

training clinicians in clinical practice guidelines (CPGs) and effective evidence-based 

methods of care. 

DCoE is moving forward on these projects, as it continues the relentless momentum to reach full operational capability in October 2009. Each of the Services has 

initiated quality of care functions, including essential clinician training. For mental 

health, each Service is training mental health providers in CPGs and evidencebased treatment for Post Traumatic Stress Disorder (PTSD). The Services are training primary care providers in mental health CPGs. Regarding TBI, we sponsored 

a TBI training course attended by more than 800 providers, including VA providers 

from over 30 disciplines. We will repeat this training in 2008 to provide a basic level 

of understanding of mild TBI to as many health care providers as possible. Over 

the coming months, the DCoE will consolidate and standardize these training efforts. 

Severe TBI is easily observed. Similar to other severe trauma conditions, severe 

TBI is treated using well-established procedures. Usually, moderate TBI is clearly 

recognizable with an event-related period of loss of consciousness and observable 

neurocognitive, behavioral, or physical deficits. On the other hand, mild TBI, while 

more prevalent, is more difficult to identify and diagnose on the battlefield, just as 

it is in civilian scenarios. Our index of suspicion must be high to ensure that we 

appropriately evaluate, treat, and protect those who have suffered mild TBI. Military medicine has established a strategy to improve the entire continuum of care 

for TBI and published a DOD policy on the definition and reporting of TBI. This 

policy guidance serves as a foundation for shaping a more mature TBI program 

across the continuum of care and sets the stage for the mild TBI CPG to follow. 

The Army Quality Management Office—the DOD executive agent for Clinical 

Practice Guidelines—is creating a formal CPG for mild TBI. Guidelines generally 

require 2 years to develop; however, we have expedited that process and will have 

the CPG completed in 1 year. The Department will collaborate with VA on the development of this CPG to assure a standard approach to identification and treatment of mild TBI. 

Having standard guidelines and trained staff represent only part of the quality 

requirement. Equally important is proper equipment for the provision of care. Operations Iraqi Freedom and Enduring Freedom have placed our servicemembers at 

highest risk for potential brain trauma. Therefore, DOD acquired equipment to enhance screening, diagnosis, and recovery support for these warriors. 

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ACCESS

Our ability to deliver quality care depends, in part, on timely access. Access, in 

turn, depends on the adequacy of staff to meet the demand in line with acceptable 

standards for appointment wait times. We also must provide the services in a location or manner in which the service or family member can meet with the provider 

or interface with the system without undue hardship or long travel times and distances. 

In October 2007, the Department issued a new policy stating that patients should 

have initial primary psychological evaluations scheduled within 7 days of their request, with treatment to follow within normal access standards. Emergency evaluations are addressed right away. 

In addition to this enhanced access, we have begun moving Psychological Health 

functions into primary care settings. The Services will hire Psychological Health 

personnel for both mental health clinics and primary care clinics. In the primary 

care setting, Psychological Health providers can consult with primary care providers 

to identify mental health conditions and to make appropriate referrals for treatment. Alternately, behavioral health providers can manage the patient’s care in the 

primary care setting when appropriate. This arrangement also enables us to provide 

care for behavioral aspects of more traditionally physical health problems, such as 

pain and sleep problems that cause patients to seek care. 

To ensure ready access to mental health and TBI care in our MTFs, we are increasing staff using a number of approaches.

• For TBI, we developed a standard capabilities model of multi-disciplinary 

staffing and management; capabilities we are now assessing for use across the 

military Services. This model offers the basis for a site certification pilot program that the Army has undertaken to ensure that soldiers with TBI receive 

care only at those facilities with established capability to care for them. 

• Deployment-related health care has proven most effective when integrated 

with total health care. The Institute of Medicine advocated this position and the 

Department codified it in the DOD/VA Post-Deployment Health Evaluation and 

Management Clinical Practice Guideline. Telehealth technology will help to integrate this care particularly in the more remote locations. The DCoE will coordinate and integrate telehealth activities and capabilities across the Department; meanwhile, the Services have begun demonstration projects to assess how 

best to leverage telehealth technology to increase care for TBI patients in remote or underserved locations. 

• For mental health, we developed a population-based, risk-adjusted staffing 

model to more clearly inform us of the required number of mental health providers. The Department contracted with the Center for Naval Analysis to validate the model and expects results later this year. Using that validated model, 

the Department will adjust the requirements and disposition of mental health 

providers in the next fiscal year.

• United States Public Health Service (USPHS). Mental health providers 

are in short supply across the country—complicated by hard-to-serve areas, 

such as remote rural locations. To increase providers in these areas, we 

have initiated a partnership with USPHS, which will provide uniformed 

mental health providers to the MHS. The USPHS has committed to sending 

us 200 mental health providers of all disciplines. The military Services will 

place those providers in locations with the greatest needs. 

• Civilian and contract. We will employ civilian and contract providers to 

increase our mental health staff by more than 750 providers and approximately 95 support personnel. Additionally, the MTF commanders have hiring authority and may increase their staffs to meet unique demands. 

• TRICARE network. In the past few months, our managed care support 

contractors have added more than 3,000 new mental health providers to our 

TRICARE network across the three regions. In addition, they have reached 

out to thousands of non-network providers to identify clinicians who would 

be available to take on new patients if a network provider could not be 

identified within the established access times. 

• Military. As always, we must recruit and retain military providers. These 

men and women serve critical missions as an integral part of our deploying 

force. 

RESILIENCE

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riers so that those seeking care receive it at the earliest possible time and in the 

least restrictive setting, including nonmedical settings, such as chaplains, first sergeants, and counselors. 

I mentioned our anti-stigma campaign earlier. An important part of reducing stigma is education. The DCoE proposes a standardized curriculum for Psychological 

Health and TBI education for leaders, servicemembers, and family members. In the 

interim, each Service will implement training across its leadership spectrum that 

adheres to our overarching principles and is adaptable to the culture of its own 

Service. 

For families, we have implemented and expanded a number of education and outreach initiatives.

• The Mental Health Self-Assessment Program is accessible at health fairs 

as well as in a Web-based format. We expanded this program to include our 

school-aged family members. 

• The Signs of Suicide Program, an evidence-based prevention and mental 

health education program in our DOD Educational Activity schools, will expand to public middle and high schools in areas with high concentrations 

of deployed forces. 

• For our younger children, the proven-successful Sesame Street Workshop 

will expand with our cooperation to address the impact of having a deployed parent come home with an injury or illness. This program will be 

added to the original Workshop educational program and distributed widely 

across the Department. It is scheduled for completion and kickoff in April 

2008 to coincide with the Month of the Military Child.

For our servicemembers, we have taken a number of steps to prevent and identify 

early psychological issues.

• We will incorporate baseline neurocognitive assessments into our lifecycle 

health assessment procedures from entering the service through retirement. 

As we progress in that objective, we will continue to provide pre-deployment 

baseline assessments. 

• We added questions to both the Post-Deployment Health Assessment and 

Post-Deployment Health Reassessment to facilitate TBI screening. We also 

support initial identification teams at high-density deployment locations to 

ensure consistent screening and to further evaluate and treat those who 

screen positive. 

• Screening and surveillance will promote the use of consistent and effective assessment practices along with accelerated development of electronic 

tracking, monitoring, and management of Psychological Health and TBI 

conditions and concerns. We will incorporate screening and surveillance 

into the lifecycle of all servicemembers. 

• We must remember that our health care and community support caregivers may develop compassion fatigue. To help with that, the DCoE will 

develop a new curriculum of training or validate existing training to alleviate and mitigate compassion fatigue. 

DOD–VA TRANSITION

We must effectively establish a patient- and family-centered system that manages 

care and ensures a coordinated transition among phases of care and between health 

care systems. Transition and coordination of care programs help Wounded Warriors 

and their families make the transition between clinical and other support resources 

in a single location, as well as across different medical systems, across geographic 

locations, and across functional support systems, which often can include nonmedical systems. 

In terms of transition, we seek better methods to ensure provider-to-provider referrals when patients move from one location to another or one health care system 

to another, such as between DOD and VA or the TRICARE network. This is relevant most especially for our Reserve component members. 

Care coordination is essential for TBI patients who may have multiple health concerns, multiple health providers, and various other support providers. Frequently, 

they are unsure of where to turn for help. Proactively, the DCoE Clearinghouse, Library, and Outreach staff will offer accurate and timely information on benefits and 

resources available. Meanwhile, Army and the Marines have established enhanced 

care coordination functions for their warriors. 

Newly hired care managers will support and improve transition activities. The 

Marine Corps created a comprehensive call center within its Wounded Warrior Regiment to follow up on Marines diagnosed with TBI and Psychological Health conditions to ensure they successfully maneuver the health care system until their full 

154

recovery or transition to the VA. The Navy is hiring Psychological Health coordinators to work with their returning reservists, and the National Guard is hiring Directors of Psychological Health for each State headquarters to help coordinate the care 

of Guardsmen who have TBI or Psychological Health injuries or illnesses related to 

their mobilization. The other Reserve components are looking closely at these programs to obtain lessons learned as they set up their own programs. 

Information sharing is a critical part of care coordination. DOD and VA Information Management Offices are working to ensure that information can be passed 

smoothly and quickly to facilitate effective transition and coordination of care. 

RESEARCH

Research and development provide a foundation upon which other programs are 

built. Our intent is to rely on evidence-based programs; our assessment identifies 

the need to develop a systematic program of research that will identify and remedy 

the gaps in Psychological Health and TBI knowledge. To that end, we have established integrated individual and multi-agency research efforts that will lead to improved prevention, detection, diagnosis, and treatment of deployment-related Psychological Health issues and TBI. 

We will fund scientifically meritorious research to prevent, mitigate, and treat the 

effects of traumatic stress and TBI on function, wellness, and overall quality of life 

for servicemembers and their caregivers and families. Our program strives to establish, fund, and integrate both individual and multi-agency research efforts that will 

lead to improved prevention, detection, diagnosis, and treatment of deployment-related Psychological Health and TBI. 

SUICIDES

Let me now offer you an update on our suicide rates and risk factors. 

The DOD’s confirmed and suspected suicide rates increased in 2006 and 2007. 

Even with these increases, the aggregate suicide rates for DOD remain comparable 

to the demographically-adjusted civilian population rates. Risk factors for suicide remain unchanged:

• Failing relationships 

• Legal/occupational/financial problems 

• Alcohol abuse

Early intervention and prevention programs include pre-deployment education 

and training, suicide prevention training, Military OneSource, the Mental Health 

Self Assessment Program, National Depression and Alcohol Day Screening, and 

health fairs. To increase the awareness of DOD’s outreach and prevention programs 

available to the Reserve component members, DOD formed a partnership with the 

VA and other Federal agencies as well as professional advocacy groups. 

DOD also provides a broad array of support systems and services to the military 

community. Services available at military installations include health and wellness 

programs, stress management, family readiness and community support centers, 

family readiness groups, ombudsmen, volunteer programs, legal and educational 

programs, and chaplains, among many other community programs. 

CONCLUSION

Mr. Chairman, distinguished members, thank you for caring and for understanding the needs of our warriors and their families. Thank you also for providing 

the resources and support to design and implement programs to meet these needs. 

I look forward to working with you as we continue to build the Center of Excellence 

and implement the MHTF recommendations for Psychological Health and TBI. I am 

honored to serve with you in support of our warriors and families. There simply is 

no greater privilege!

Senator BEN NELSON. Thank you very much, and I believe you 

will. 

I’m concerned about how you transform the culture and how you 

identify the condition in such a way that it doesn’t have stigma associated with it. Now, General Schoomaker, we were talking the 

other day. You made it clear, and I think most everybody would 

recognize this, that the stress associated with the warriors is not 

something brand new; from the beginning of time stress has been 

associated with conflict. Perhaps our knowledge of it is more reVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00158 Fmt 6633 Sfmt 6602 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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fined today, and we’re working to refine it even more as we move 

forward. 

As we do that, is there really an expectation that we can somehow move from what is a macho attitude toward a recognition that 

we’re really trying to build people’s resiliency? Are there softer 

ways to talk about the situation, or does that even help? 

General SCHOOMAKER. Sir, I think it goes without saying that 

the U.S. military is a microcosm—a subset of the American society 

as a whole, and reflects the attitudes of society as a whole. The 

problems that we encounter in stigma within the uniformed Services is reflected in society at large. As I said in my opening comments, I think that this is an issue that needs to be addressed by 

all communities. 

Having said that, I think that this is done not by medics, it’s not 

done by people sitting at this table, but, as I think all my colleagues have emphasized, this is a problem for line leadership right 

down to the smallest unit leader and fellow soldiers, sailors, airmen, marine, coast-guardsmen, who in a sense give license to the 

view that the human dimension of combat and the human dimension of deployment and separation from families involves stressors 

that are going to be manifesting symptoms that may make them—

as you said in your opening comments and as Senator Graham 

said—less than completely engaged warriors. 

That’s how we have to look at this. I think that our leadership 

has taken a very assertive role in doing exactly what you describe. 

Senator BEN NELSON. Colonel, maybe I can ask you in terms of 

that, the cultural change in the way we think of this. In the training, basic training, building people into warriors requires building 

up self-confidence, teamwork, everything that we want to have 

somebody be combat prepared. How far can we go at the beginning 

to build up that resiliency to, if not eliminate the possibility, which 

is unlikely, but reduce the impact of the stress? 

Is there some tie to that where people would be less stressed 

with more training, more specific training, more directed training 

toward that, so that maybe we can get ahead of it rather than have 

to treat it after the fact? 

Colonel SUTTON. I couldn’t agree more with you, Mr. Chairman. 

In fact, I would say that the process of building resiliency for soldiers, sailors, airmen, marines, coasties, and their families has to 

start at day one. It starts not only with the tough training that 

challenges our young folks to go beyond that which they believe or 

know about themselves. Of course, it’s always fun to go to a basic 

training graduation where, after 12 weeks, when the buses come in 

it looks like they’ve scooped up folks from the shopping malls of 

America, with purple hair and rings and all of the rest. Twelve 

weeks later, the parents walk right by them and don’t even know 

who they’re seeing. 

It’s a transformation, and it starts with day one. I think we also 

need to look toward baseline cognitive screening when folks come 

in at accession, as well as perhaps imaging. We’re looking at that 

right now because, although we’re currently focused on the deployment cycle, we know that we need to prolong that. We need to extend that over the life cycle of a young troop and her family member being with us. 

156

It also has to do with the tough training that you mentioned. I 

would take issue with your comment earlier as to whether we need 

a softer approach. In fact, I would go back to a couple of weeks ago 

in the Washington Post newspaper; there was an article with a 

young female, as it turns out, Cobra pilot. When she was asked at 

the end, how do you cope with the stress of doing your job and engaging in combat, and she says: ‘‘Don’t ask me, how do I cope. That 

makes it sound like I have to get over something. Because when 

somebody’s shooting at my marines, this is my job; this is what I’m 

trained to do and I’m proud to do it.’’ 

I think it’s that kind of pride, buttressed by the confidence that 

can only come from tough training, as well as the framework of 

education to help folks understand what are the normal consequences of exposure to trauma, to killing, to losing one’s buddy, 

and what are the support systems; what are the tools. 

This generation wants tools. They don’t see themselves as disabled or weak or needing help. They want tools to be able to keep 

themselves going and performing. So I think that’s part of it. 

Two other examples I would point to, sir, as already positive 

signs of this transformation in culture that we’re aiming for. Several weeks ago in Tom Rick’s Inbox in the Washington Post once 

again, he gave the story of a young marine staff sergeant; and Staff 

Sergeant Travis Twigg, who came back from his third deployment 

and had a tough time, lost several of his men, and was not readjusting well. 

His sergeant major brought him in and said: ‘‘Sit down, Twigg; 

do you know why you’re here?’’ No, Sergeant Major. ‘‘You’re here 

because you have PTSD. Do you know why I know? Because I have 

it, and you’re going to get help.’’ 

He got Staff Sergeant Twigg to Bethesda, where he was hospitalized. He had a tough course of treatment, but did very well. He’s 

back in the Corps today, and in the article Staff Sergeant Twigg 

says: ‘‘Listen, here’s my phone number, here’s my email; I want to 

help anyone else who has these problems.’’ I’m going to be contacting young Staff Sergeant Twigg here and bringing him on our 

team. 

But think of what that says. The chain of command saw a problem, and didn’t say: ‘‘Ah, Twigg’s weak; he’s messed up; he can’t 

hang.’’ No. They recognized that this young staff sergeant needs 

help, and said I’m going to get it to him, and he’s going to be back 

in the force. That expectation of recovery, of performance, of resilience, whether it’s in the classroom or the battlefield, it’s paramount for our leaders to understand that we must prepare our 

troops; we must give them the tools that will allow them to gain 

the confidence and the expectation of recovery. 

Lastly, sir, I would point to as another sign of this transformation in culture that is just really getting started, has to do 

with Secretary of Defense Gates, his leadership in saying that, 

question 21 on the security clearance questionnaire, we need to 

change that. I’m proud to say that there’s been a lot of interagency 

work on that, but that is nearing fruition, and I think that’s going 

to be a real improvement that will help our troops understand that 

the Department’s stance toward seeking help, whether it be for 

mental or for physical health issues, is absolutely a sign of strength 

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and we want folks to feel like they can go forward without fear for 

their careers. 

Senator BEN NELSON. Now, we as a society at large have stigmatized seeking help by the very question about have you ever had 

this. People get over appendicitis, I guess, when the appendix is removed and other conditions, but there isn’t necessarily an indication that that condition has been removed with or without treatment. So we’ve probably done society as a whole a great disservice. 

We have to move beyond that. 

General Roudebush, maybe you can give us your perspective 

from the Air Force. 

General ROUDEBUSH. Yes, sir, and I think it does go that form 

follows function. We train individually. We select people for their 

capabilities and we train them in a particular area of expertise, 

and we expect them to execute in that particular area. But in reality we execute as a team. We very seldom ever execute individually. You’re always reliant on a team member for some portion. 

We execute as a team, but quite literally, we take care of each 

other as a family. Now, we have the family that the good Lord gave 

us, but we have the family that we’re issued, and they’re both really good families. I think that is at the essence of taking care of 

each other. 

Stigma is both self-perceived and outwardly or externally perceived. The individual may feel some reticence to say, ‘‘I need 

help,’’ and may suspect or assume that the others in the unit will 

think less of them because they did in fact need some assistance. 

But if you break down those barriers and say, yes, we execute and 

we succeed as a team and we take care of each other as a family, 

those barriers become less noticeable and less onerous. 

Now, I will tell you, it is far from perfect. I think the recommendations that the task force made are right on target, both 

in terms of assisting us in positioning the right resources and in 

prioritizing the right activities, policies, and issues. So I think we 

must do it better. 

But at the end of the day it’s going to be that accountability to 

each other and the willingness not to inflict stigma or assume stigma that I think will allow us to get to the other side. Once we get 

by that, and if you can get to a problem sooner, when it’s this big, 

as opposed to later when it’s this big, the whole process is enhanced. A better result, less time out; and frankly, it helps us deal 

with some very trying and demanding circumstances. 

In our theater of operations, everyone has PTS. There is nothing 

normal about that circumstance. It’s preventing that from becoming PTSD that we need to concentrate on. 

Senator BEN NELSON. We don’t have to establish the disorder associated with every PTS. It’s the extent of the PTS, I assume, that 

then establishes whether it’s a disorder or not. 

General ROUDEBUSH. Yes, sir, and getting to it sooner, in a 

proactive fashion, mitigating it early, is clearly the preferred way 

to do this. But it does take a team to do that. 

Senator BEN NELSON. In the case of Active Duty, when following 

the deployment the unit comes back and it stays pretty much intact. When you get to Guard and Reserve in stranded situations, 

where a reservist comes back from a deployment and goes back 

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into society, which probably does not have him or her associated 

with the team that they were with during the deployment, is there 

a greater risk of PTS becoming a disorder as time goes by if they 

don’t get some care for that up front? Is there a greater risk with 

that group, and is the probability higher that they will have a 

greater problem than somebody that will stay with the unit? 

General ROUDEBUSH. Sir, I can give you the Air Force statistics. 

Our statistics as we have gathered them, and they are far from as 

complete as we would rather or they need to be, but we continue 

to make progress in that regard. Our findings for our Guard and 

Reserve members are not significantly different than our Active 

Duty. 

Now, the challenges for us is getting to those folks in a way in 

terms of both surveilling and screening to assure that that happens. To that end, certainly their line and their unit counterparts 

are instrumental in assuring that we don’t lose track of them, as 

are their families; and sensitizing the families that if something 

does not seem right, if something is amiss, to ask the question 

much sooner than later, as both an ally and a resource, is helpful 

in that regard. 

But it is more challenging with the Guard and Reserve, there is 

no doubt about that. 

Now, when we find it we very aggressively go after it and treat 

it, either using uniformed capabilities or using our TRICARE networks if that’s more appropriate, because keeping these folks close 

to their home of record and at home with their families we believe 

is an important part of reintegrating them and successfully taking 

care of these folks. 

But yes, sir, it is a challenge. 

General SCHOOMAKER. Sir, this is a great question and it’s one 

that all of us are very concerned about, and I’m going to lean on 

what we’ve learned from the MHAT studies. I think I could say 

without fear of contradiction that we know there are several factors 

that contribute to raising the risk of post-traumatic stress symptoms and other stress-related symptoms, like isolation and depression. 

First is intensity of combat. The variability of combat teams, marine and soldier teams, the variability in their self-reported symptoms is a function of the intensity of combat. 

Second is the coexistence of concussive or mild TBI or severe injury. We think there is now some work done by Dr. Hoge that was 

recently published that suggested it might be the context in which 

that concussive injury occurred. In contrast to the sport field, when 

it’s in combat concussive injury is often associated with a lifethreatening event, maybe associated with the loss of friends and 

the like. 

The third is deployment length and frequency of deployment. 

These are all associated with a higher risk of stress. 

Let me say one other thing that I think is very important that 

you’ve touched on in your last series of questions, and that has to 

do with stigma. I think one of the very positive effects of reexamining and rescreening soldiers, sailors, airmen, and marines, anyone who’s been deployed, not just at reintegration, because we’ve 

learned through the MHAT studies that the excitement of reVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00162 Fmt 6633 Sfmt 6602 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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integration, the desire to get home and to be fully incorporated into 

home and family and job if you’re a reservist or a national guardsman overwhelms what may be symptoms. 

The MHAT studies have very closely shown us that you need to 

go back and reexamine at the 90- to 180-day period, and that is a 

challenge for the distributed Reserve and National Guard. 

Finally, I’d say in regard to stigma, and this is Eric 

Schoomaker’s opinion, the assumption of a stigma to oneself I think 

is attributed in part to fear. Part of that fear is that I am self-identifying a serious illness, a mysterious illness, one that may never 

end. One of the things that can be reassuring about our studies is 

that, with screening and identification of the early symptoms of 

post-traumatic stress, we can do things symptomatically that improve the individual soldier or marine’s state and eliminate, as you 

said, their emergence into or maturation into a disorder, especially 

if we can keep them away from alcohol and drugs and family discord and violence and all the other things that may characterize 

the establishment of a well-established PTSD. 

So I think one of the clues and one of the keys to removing stigma for that individual is improved education about the fact that 

your having these symptoms does not label you with a permanent 

disability, that in fact we can treat these and we can prevent a 

much more long-lasting disability. 

Admiral ROBINSON. Mr. Chairman, I would also like to add, just 

to the stigma question, I agree with what General Schoomaker said 

and also what General Roudebush said. Stigma is going to be a factor because it’s a factor in our country. The keys to success that 

I think the Navy and Marine Corps have shown are leadership, 

number one, education number two, education from boot camp all 

the way through War College. It’s a continuous process and there 

has to be education amongst the buddies that are caring for one 

another, the shipmates that are there, the leaders that are there, 

the small units that are there. 

Additionally—and this is very important, and I think this may 

be one of the keys—to embed mental health resources in the units 

means that when you go see the chaplain, who could be part of 

that, but when you go see the psychologist, the psychiatrist, or the 

social worker who is a part of your unit and who has been living 

with you day-in and day-out, it becomes less of an issue of stigma; 

it becomes more an issue of, that’s one of my shipmates, that’s one 

of my buddies, I have to go see him, I have some issues. 

So that together helps from the culture point of view. If at the 

same time families are given the opportunity to have deployment 

counseling, to have ombudsmen, to have different people who are 

available and units who are available to provide that mental health 

or that support that they need, so that they can in fact understand 

what their loved one’s going through while away on the deployment 

and they can also build up their resiliency and psychological 

health, it becomes a synergistic effect and it becomes very effective 

in terms of not only reducing the stigma, but also realizing that 

mental health and mental illnesses are as real as physical illnesses. 

You said it yourself: If I break my leg, no one cares that I come 

in with a cane and have a limp. But if I’ve had some sort of mental 

160

issue, then everyone looks at me as if I’m not capable of ever functioning again, which is completely untrue. 

Senator BEN NELSON. General? 

General ROUDEBUSH. Chairman Nelson, if I might add one thing. 

We’ve been focusing a great deal on mental health capabilities, psychiatrists, psychologists, social workers, and all the technical support that surrounds that. But as a family physician I can tell you 

that I was trained to anticipate and expect that upwards of twothirds to perhaps even more of the issues that I would face as a 

family physician will have an emotional aspect to it or a psychological aspect to it. 

So I think it’s important, while we focus on the pure mental 

health resources or the more specifically focused, that we also pay 

very close attention to the whole constellation of care capabilities 

that we have, both primary care as well as specialty and subspecialty, to provide them training, as in fact we all have, to focus 

on getting the right kinds of diagnostic training and sensitization, 

if you will, to look for TBI, to look for PTSD, while you may be 

treating something that is a very visible issue relative to an injury 

or an illness, to look for those things that may not be quite so visible. 

So we can really leverage the entire care capability that we have 

to further focus on this and assure that we’re not overlooking those 

injuries that we ought to be paying attention to. 

General SCHOOMAKER. General Roudebush is right on target. In 

fact, I think that that is the main thrust of the military’s respectmilitary effort. It’s to further arm primary care providers of all 

kinds—nurse practitioners, physician assistants, general internists, 

family medicine doctors, whoever that primary care provider is—

with the tools and skills necessary to screen and do first-line treatment. 

Admiral ROBINSON. That’s the plan for the deployment health 

centers that the Navy now has, so agreed. 

Senator BEN NELSON. The screening that you do I suppose prior 

to somebody’s joining one of the branches is important in trying to 

ferret out existing conditions of some sort of mental condition or 

perhaps identifying people that might have a greater potential for 

stress, as I think was indicated, put somebody as a mechanic as opposed to out in the front line if there’s something that could be 

identified that might be predisposed to stress. 

Then before they’re sent to theater there’s another screening. Do 

the screenings take it up to where you can really catch the people, 

somebody that might be more predisposed than someone else? Or 

can the person being screened hide it from the screening process? 

Colonel Sutton, do you have a thought? 

Colonel SUTTON. Sir, this is an important area. I think screening 

does play a role both at accession and certainly predeployment and 

ongoing during deployment and after they return, as well as the 

post-deployment reassessment of health. I would say, though, that 

rather than thinking of, for example, at accession this being a process designed to screen out, I would argue that this ought to be a 

process designed to screen in, that is to identify strengths as well 

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ership and our approach to help that troop really reach his or her 

potential. 

When 3 out of 10 of our 18- to 25-year-olds qualify for military 

service, I would argue that we already have an elite force, and so 

I would argue to screen at the beginning and then as we go 

through the process—and this, by the way, is something that in 

light of Colonel Hoge’s recent article and other emerging reports in 

the last year that have come out, we are relooking our screening 

process right now. We want to make sure that we are absolutely 

asking the right questions to elicit the information that we’re after. 

To do that, we’re bringing in not only experts from DOD and the 

VA, but we’re also going to bring in civilian experts from around 

the country, in fact around the world. We will be coming forward 

with recommendations to the senior leadership within the next 6 

to 8 weeks. But the screening process, the one that we had in place 

now, is a good one. I think that, armed with our latest knowledge, 

we can improve it even further. 

General SCHOOMAKER. But sir, with respect, I would say that the 

present state of what we have still centers around self-identification. 

General ROUDEBUSH. Exactly. 

General SCHOOMAKER. This dovetails very clearly with your earlier line of questioning around stigma, that in a society that stigmatizes a mental health or behavioral health problem, it is the 

tendency for some of our soldiers to obscure or to withhold information that is sensitive. 

I failed to mention one other stressor, one other factor that predisposes to post-traumatic stress, and I defer to my colleague the 

psychiatrist at the other end of the table to validate this. That is 

preexisting experiences prior to coming into the Service. Severe 

trauma prior to coming into the Service represents another predisposing element to development of symptoms while in service. If 

that’s obscured or withheld, then it does become a challenge to us. 

Senator BEN NELSON. Thank you for what you’re doing. It seems 

just even gratuitous for me to say how important it is, but I think 

we all recognize the mental well-being of our men and women in 

uniform is critical, not only to performance, but to quality of life 

and to our society. So I really do appreciate what you’re doing and 

I hope that we’ll continue to learn more about what will help us 

in not only identifying but treating these different areas. 

I’m encouraged by the fact that there’s not just one category that 

everything falls into. The more that we’re able to distinguish between various different degrees of post-traumatic stress is, I think, 

critically important to being able to do the job right and get the 

best result for our servicemembers and their families. So I commend you for what you’re doing. 

Colonel, thank you for taking the leap into a new area. We wish 

you the very best. Of course, we want to be responsive to the needs 

in terms of what financial resources and other resources will be 

necessary for us to be able to do this. 

Working to have the VA together with DOD, with a new name, 

in your area and in so many other situations, such as retirement, 

and disability determination, is extremely important to our memVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00165 Fmt 6633 Sfmt 6602 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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bers as well. So I hope that we’ll be able to cross the lines to VA 

and DOD generously and not get blocked in that process. 

Of course, General Schoomaker, we all appreciate your stepping 

into the breach with the Walter Reed situation and your willingness to take that, make that an opportunity and give us more confidence that, as you have, that the military really does care from 

the top down about the people who have the need for care of any 

kind. Our wounded warriors deserve no less than the best, and we 

thank you for providing it. 

The hearing is adjourned. 

[The following appendices will be retained in committee files:]

Appendix A: Mental Health Advisory Team (MHAT–I) Report, Operation Iraqi 

Freedom, 16 December 2003

Appendix B: Mental Health Advisory Team (MHAT–II) Report, Operation Iraqi 

Freedom, 30 January 2005

Appendix C: Mental Health Advisory Team (MHAT–III) Report, Operation Iraqi 

Freedom, 29 May 2006

Appendix D: Mental Health Advisory Team (MHAT–IV) Report, Operation Iraqi 

Freedom, 17 November 2006

Appendix E: Mental Health Advisory Team (MHAT–V) Report, Operation Iraqi 

Freedom/Operation Enduring Freedom, 14 February 2008

[Questions for the record with answers supplied follow:]

QUESTIONS SUBMITTED BY SENATOR JOSEPH I. LIEBERMAN

MENTAL HEALTH TASK FORCE REPORT

1. Senator LIEBERMAN. Vice Admiral Arthur and Dr. MacDermid, I thank you 

both again for your work on the Mental Health Task Force. Your report issued critical findings and recommendations that provide a blueprint for the Department to 

build a true continuum of care for psychological health (PH). In fact, your report 

issued over 90 findings, many of which can be accomplished administratively and 

others which will require statutory changes. If you can, please provide specific recommendations you regard as priorities that you feel our committee should act on 

in the National Defense Authorization Act (NDAA) for Fiscal Year 2009. 

Vice Admiral ARTHUR and Dr. MACDERMID. The Task Force made 95 recommendations, 94 of which were endorsed by the Secretary of Defense. The testimony by the other panelists made it clear that many actions are being undertaken 

to respond to the recommendations. I am not a legislative expert, so there may have 

been progress of which I am unaware, but my impression is that there may be action yet required related to the recommendations of the Task Force regarding 

TRICARE. I list four specific recommendations below. The background and justification for each of these recommendations is provided in the task force report, which 

was submitted for the record.

5.3.4.6 .......... DOD should modify TRICARE regulations to permit updates as new treatment approaches for 

psychological disorders emerge (e.g., intensive outpatient services). Policies should parallel those currently in place for medical conditions. 

5.3.4.7 .......... TRICARE should accept accreditation of residential treatment facilities for children by any 

nationally-recognized accrediting body, as is the norm in the civilian sector. 

5.3.4.8 .......... TRICARE should allow outpatient substance abuse care to be provided by qualified professionals, regardless of whether they are affiliated with a day hospital or residential treatment program, including standard individual or group outpatient care. 

5.3.4.5 .......... DOD should ensure TRICARE reimbursement rates for mental health services are competitive 

with local rates paid by other major payors to ensure military families are given priority 

by area providers. 

As I indicated in my testimony, the shortcomings in the PH system identified in 

the task force report were revealed but not caused by the current war. A long period 

of relatively constrained conflicts (though their frequency was increasing rapidly) 

led to the development of a system that been streamlined, downsized, and 

civilianized to the point that it has been very difficult during this large sustained 

conflict to adequately serve the needs of Active and Reserve, deployed and at-home, 

members and their families. While substantial funds have been allocated, my imVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00166 Fmt 6633 Sfmt 6621 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
163

pression is that most of these funds are non-recurring, and not permitted to be used 

to increase the infrastructure of positions to support PH. Without recurring funds, 

we are at risk of coming out of this war with an infrastructure no better prepared 

for the next war than it was prior to September 11. Thus, I suggest that the following recommendation may deserve further legislative attention.

5.3.1.1 .......... Congress should provide, and the military Services should allocate, sufficient and continuing funding to fully implement and properly staff an effective system supporting the 

PH of servicemembers and their families. 

I know that Members of Congress are deeply concerned about the PH of 

servicemembers and their families, and deeply committed to making long-lasting 

change. For that reason, I suggest that the following recommendation be considered 

for legislative action.

5.4.1.5 .......... Each Service Surgeon General’s annual report to Congress should include data about the 

PH of servicemembers and their families, and on the efforts to improve PH. 

UNIFORMED BEHAVIORAL HEALTH PROVIDERS

2. Senator LIEBERMAN. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, I hope that we all agree that Post Traumatic 

Stress Disorder (PTSD), Traumatic Brain Injury (TBI), and other mental health 

issues are significant health challenges facing the Department and our 

servicemembers in this conflict. I believe that now we must move beyond simply recognizing that PTSD, TBI, and other mental health issues are a problem and find 

long-term solutions. In order for the immediate mental health needs of servicemembers to be met, and to build the continuum of care for PH called for by the 

Department of Defense (DOD) Mental Health Task Force, we must have significantly more uniformed behavioral health providers. Growing our uniformed behavioral health workforce is critical to a long-term solution to our mental health crisis 

and also to inoculate our forces against such injuries in the future. What plans do 

each of the Services have to increase the number of uniformed behavioral health 

providers? 

Lieutenant General SCHOOMAKER. The Army offers several programs to increase 

and train mental health professionals in uniform. The Clinical Psychology Internship Program is a postdoctoral program which trains up to 30 interns per year. Participants are on Active Duty during this program and incur an additional Active 

Duty service obligation. The Health Professions Scholarship Program is available for 

students pursuing a doctorate in Clinical Psychology in exchange for an Active Duty 

service obligation. The newly-established Masters in Social Work program at the 

U.S. Army Medical Department Center and School will send up to 25 students per 

year to Fayetteville State University starting in Academic Year 2008. The Uniformed Services University of the Health Sciences offers a Clinical Psychology 

Training Program, and has introduced a new Adult Psychiatric Mental Health 

Nurse Practitioner (PMH–NP) program. The PMH–NP program is a 24-month, fulltime program, that will begin in Academic Year 2008. 

Vice Admiral ROBINSON. The Navy will increase authorized endstrength by 14 

Psychiatrists, 4 Clinical Psychologists, and 3 Mental Health Nurse Practitioners. In 

addition there will be increased uniformed mental health assets bought by the Marine Corps to support the Combat Stress Control and Readiness Program (OSCAR). 

The numbers have not been finalized by the Marine Corps but the Navy has already 

taken steps to increase the accession and retention of our mental health practitioners. 

The Psychiatry multi-year special pay has increased $8,000 each of the past 2 fiscal years and will be evaluated again for fiscal year 2009 by OSD/HA. NDAA for 

Fiscal Year 2007 authorized a Critical Wartime Skills Accession Bonus (CWSAB). 

As a result, the DOD initiated a $175,000 CWSAB for Psychiatrists for a 4-year 

commitment in fiscal year 2008. This rate will be revaluated for fiscal year 2009 

by OSD/HA. The CWSAB has been fully funded for 50 physician direct accessions 

in fiscal year 2009. 

Clinical Psychologists with 3 to 8 years of service are now eligible for $60,000 

Critical Skills Retention Bonus (CSRB) for a 4-year commitment. Navy and OSD are 

also reviewing an accession bonus for Clinical Psychologists and the OSD/HA and 

the three Services are evaluating the NDAA for Fiscal Year 2008 Special Pay authority to pay Clinical Psychologists a multi-year retention bonus. 

The Navy has also established six new Mental Health Nurse Practitioner billets 

in fiscal year 2008 with plans to grow this community in the near future. 

164

Lieutenant General ROUDEBUSH. We agree that meeting the mental health needs 

of our airmen is a priority that requires a comprehensive integrated mental health 

structure. The Air Force has taken a two-pronged approach to growing mental 

health providers. In the short-term, we have hired 32 mental health professionals 

at the locations with the highest operational tempo and are hiring 75 contract personnel to provide direct patient care and support the establishment of Active Duty 

Directors of Psychological Health at every Air Force installation worldwide. We have 

also assigned an Air Force Active Duty mental health clinician to my staff as a consultant on PH. 

In the long-term, Active Duty authorizations for mental health providers require 

an AFMS-wide evaluation of our medical services and potential offsets to live within 

our budgetary constraints. The Air Force plans to recruit an additional 71 psychologists (68 AD/3 GS), 44 social workers (25 AD/19 GS), 6 psychiatrists (6 AD), and 

6 mental health nurses (6 GS) in fiscal year 2008. 

Our goal is to improve the continuity of mental health care by collaborating with 

the Department of Veterans Affairs (VA) and Public Health Service, and by shoring 

up our access to the civilian network of medical providers. The directors of PH will 

help facilitate these relationships.

3. Senator LIEBERMAN. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, would additional authorizations for bonus and 

special pays assist in recruiting and retaining uniformed behavioral health providers? 

Lieutenant General SCHOOMAKER. Yes, the Army competes within a market that 

suffers from shortages of qualified mental health professionals. Additional incentives specific to mental health are needed to recruit and retain these professionals 

in the Army. Current bonuses and special pays include the following:

1. Psychiatrists who execute a multi-year special pay contract that extends 

their Active Duty service obligation are paid $17,000 per year for a 2-year 

contract, $25,000 per year for a 3-year contract, and $33,000 per year for 

a 4-year contract. 

2. Licensed Clinical Psychologists are offered the Critical Skills Retention 

Bonus (CSRB) at a rate of $13,000 per year for 2 years or $25,000 per year 

for 3 years. In addition, the Health Professions Loan Repayment Program 

(HPLRP) is available for the accession of 5 Clinical Psychologists and the 

retention of 20 Clinical Psychologists per year at the rate of $38,000 per 

year. Finally, the Health Professions Scholarship Program is available to 

students pursuing a doctorate in Clinical Psychology in exchange for an Active Duty service obligation. 

3. Social Workers in the grade of Captain are offered the CSRB at the rate 

of $25,000 for a 3-year Active Duty service obligation. The HPLRP is also 

available for the accession of 5 Social Workers and the retention of 20 Clinical Psychologists per year at the rate of $38,437 per year. Finally, a Masters of Social Work program has been established at the U.S. Army Medical 

Department Center and School to send up to 25 students per year to Fayetteville State University starting in Academic Year 2008. 

4. Psychiatric Nurses and Psychiatric Nurse Practitioners are authorized 

to receive Registered Nurse Incentive Special Pay at a rate of $5,000 per 

year for 1 year, $10,000 per year for 2 years, $15,000 per year for 3 years, 

and $20,000 per year for 4 years. The Uniformed Services University of the 

Health Sciences has also introduced a new Adult Psychiatric Mental Health 

Nurse Practitioner (PMH–NP) program. The PMH–NP program is a 24-

month, full-time program beginning in Academic Year 2008, with Army allocations to be determined.

Vice Admiral ROBINSON. The recruiting and retention tools provided by the 

NDAAs for Fiscal Year 2007 and Fiscal Year 2008 have been very helpful. These, 

coupled with proposals for fiscal year 2009, should go a long way to help us meet 

our goals. However, we constantly review the efficiency of our tools and if it is 

deemed that these tools are insufficient, then more will be requested. 

The military-civilian pay differential and current OPTEMPO to support the global 

war on terrorism has affected the retention of many of our health care providers, 

especially our mental health providers. 

Navy continues to work with the Tri-service Health Professions Incentive Working 

Group (HPIWG) to address Special and Incentive pays based on inventory needs by 

specialty including behavioral health providers. In the proposed NDAA for Fiscal 

Year 2009, there is an accession bonus for fully trained clinical psychologists to address recruiting challenges. 

165

The following describes the current incentives to attract and retain behavioral 

health specialists. Some have been recently enacted from the 2007 and 2008 NDAAs 

and we are monitoring the effects on recruiting and retention.

1. Psychiatry (Medical Corps)

a. Eligible for the following entitlements: Variable Special Pay, Additional 

Special Pay, and Board Certified Pay.

b. Eligible for the following discretionary special pays: Incentive Special 

Pay (ISP) $15,000/year and Multiyear Special Pay (MSP) 2 year-$17,000/

year, 3 year-$25,000/year, and 4 year-$33,000/year. The 4 year MSP for 

Psychiatrist has increased from $17,000/year in fiscal year 2006 to $25,000/

year in fiscal year 2007 to $33,000 in fiscal year 2008.

The NDAA 2008 allows up to $400,000 CWSAB for board certified direct acces- sions. DOD/HA has authorized $175,000 accession bonus for psychiatrists who accept a 4-year commitment. During the discharge of this Active Duty Service Obligation, individuals are not be eligible for the Multi-year Incentive Special Pay or 

Multi-year Special Pay. The number of psychiatrists Navy medicine can directly access is limited by our accession goal in fiscal year 2008. The proposed fiscal year 

2009 goal has been increased to support this bonus and an increase in accessing 

psychiatrists.

c. Psychiatrists are eligible for the Health Profession Loan Repayment 

Program (HPLRP) if they meet eligibility requirements. HPLRP can be 

used as an accession incentive and as a retention incentive. This program 

provides up to $38,300 per year to repay qualified school loans. HPLRP obligation runs consecutively with other obligations.

2. Clinical Psychologists (Medical Service Corps)

a. The Navy recently implimemented a Critical Skills Retention Bonus for 

Clinical Psychologists. The incentive pays $60,000 ($15,000/year) for 4-year 

contract at MSR. Clinical Psychology Officers with 3–8 years of commissioned service are eligible. 

b. Psychologists are eligible for the HPLRP if they meet eligibility requirements. HPLRP can be used as an accession incentive and as a retention incentive. This program provides up to $38,300 per year to repay qualified 

school loans. HPLRP obligation runs consecutively with other obligations. 

c. Clinical Psychologists are eligible for Board Certified Pay. 

d. A fiscal year 2009 ULB for a $70,000 Clinical Psychology Accession 

Bonus of was submitted and forwarded by DOD. This is in the proposed 

2009 NDAA.

3. Social Workers

a. Social Workers are also eligible for HPLRP as an accession and retention tool. 

b. Social Workers are eligible for Board Certified Pay.

4. Mental Health Nurse Practitioners

a. Nurse Corps recently recognized Registered Nurse Mental Health Nurse 

Practitioners with subspecialty code. 

b. Once approved by Assistant Secretary of Health Affairs Mental Health 

Nurse Practitioners will be eligible for board certified pay.

Lieutenant General ROUDEBUSH. Increases to current authorizations and implementation of new bonuses and special pays among uniformed behavioral health providers may have an impact on some aspects of recruiting. Larger bonuses and special pays might encourage more psychiatry residents and newly graduated providers 

to consider the military as a viable place to start their careers. However, it may be 

difficult to offer a large enough accession bonus to entice an established behavioral 

health professional in civilian practice to leave and enter the military. Fully trained 

and qualified providers who come onto Active Duty service usually do so for reasons 

other than monetary gain. 

Increases to current authorizations and implementation of new bonuses and special pays would likely benefit retention. Uniformed behavioral health providers who 

are ambivalent about staying in the military because of increased demands and 

stresses might be persuaded to remain if their pay was closer to or slightly above 

the pay of their civilian counterparts.

4. Senator LIEBERMAN. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, what has the impact of military to civilian conversions over the last several years been on the ability to provide behavioral health 

services in a time of war? 

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Lieutenant General SCHOOMAKER. Within the Army, we programmed 107 military 

behavioral health specialties for civilian conversion in fiscal year 2006 and fiscal 

year 2007 combined. We found, however, that in some local markets we were unable 

to replace military providers with civilians in a timely manner and so only executed 

51 conversions and restored the military requirement to 56 of those billets. The conversion of those 51 billets decreased the depth of the pool we can draw from to support deployment needs. 

Our increasing understanding of the scope of this challenge has led us to significantly increase the number of uniformed providers as we reshape our behavioral 

health structure. MEDCOM has the full support of Army leadership in this restructuring. We have been allowed complete flexibility to change the grade and skill of 

military positions as we see fit to best meet our growing behavioral health needs. 

Among the increases in fiscal year 2008 and fiscal year 2009 are 100 enlisted mental health specialists, 18 psychiatrists, 6 child psychiatrists, 8 psychiatric nurses, 19 

social workers, and 12 clinical psychologists. 

Vice Admiral ROBINSON. Military-to-civilian conversions have not impacted Navy’s 

ability to provide behavioral health services. Although some billets were targeted for 

conversion in the early years, those were quickly restored. There has been no reduction in mental health capability associated with military to civilian conversions. 

Lieutenant General ROUDEBUSH. The impact of military to civilian conversions 

has been minimal for the Air Force Medical Service. A total of 3 psychologist positions and 19 social worker positions have been converted in the past 3 years. Two 

of the psychologist positions have been filled, and 10 social workers have been hired. 

The social worker positions converted are Family Advocacy Officers (FAO), who 

work outside of the medical treatment facilities, rather than in clinical behavioral 

health care.

5. Senator LIEBERMAN. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, what models are the Services using in determining current and future uniformed provider staffing requirements, especially in 

light of new initiatives such as the Navy/Marine Corps Combat Stress Control and 

Readiness Program (OSCAR)? 

Lieutenant General SCHOOMAKER. The Army uses MEDCOM’s Automated Staffing Assessment Model (ASAM) to determine current and projected uniformed provider and ancillary support staffing requirements within Army fixed medical treatment facilities. Additionally, MEDCOM recently concluded an in-depth study of behavioral health staffing that will be used in concert with the ASAM to increase requirements for psychiatrists, social workers, clinical psychologists, mental health 

nurse practitioners, and behavioral health specialists. Finally, the Army Medical 

Department has adjusted its basis for allocating mental health support to the 

warfighter. In 2006, we assigned 1 behavioral health professional to support every 

1,000 warfighters. Currently, our target is 1 behavioral health provider for every 

700 soldiers. 

Vice Admiral ROBINSON. Operational medical requirements for the Marine Corps, 

to include the OSCAR teams, are set by Headquarters Marine Corps. As a new requirement, additional ‘‘Blue in Support of Green’’ (BISOG) billets for the OSCAR 

program are to be established in a phased manner starting in fiscal year 2010. Beginning with the Active divisions and Marine Forces Reserve, the Marine Corps will 

eventually staff enough OSCAR teams to support all of the Marine Corps operational forces, to include air and logistics units, down to the regimental level or 

equivalent. 

Navy Medicine will support the BISOG requirements through accession and retention initiatives and increased BSO 18 staffing to support the rotation base of the 

OSCAR billets. Navy Medicine determines the mental health staffing at their Medical Treatment Facilities using workload models and the rotation requirements 

needed to support operational staffing requirements. 

Lieutenant General ROUDEBUSH. The Air Force has historically used a patient 

population-based product line medical manpower standard to formulate requirements for specific health care product lines, to include mental health. This population-based product line medical manpower standard methodology is what is used 

to formulate future requirements during programmatic/execution processes. 

In addition to the established mental health standards, the Air Force added a Director, PH, at each of its Air Force Bases and has enhanced the Behavioral Health 

Outpatient Program (BHOP) at 20–25 bases that did not have a dedicated BHOP 

provider. The BHOP integrates behavioral health consultants (BHCs) into the primary care setting to help provide early recognition and intervention for those patients with psychosocial issues or behavioral health issues that may require more 

intensive specialty mental health care.

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SUICIDE PREVENTION

6. Senator LIEBERMAN. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, our greatest resources in the Armed Forces are 

our personnel and we must implement measures that prevent suicides and assure 

those in uniform and their families that even one life lost is one too many. Too much 

of our current debate on suicide has focused on whether or not there are statistically 

significant differences in suicides rates from 1 year to the next or when in comparison to those in the general population. Instead, I urge the DOD and the committee 

to focus efforts on establishing protocols to investigate all suicides to determine 

causes and contributing factors, procedures to take immediate corrective action 

when necessary, and track the implementation of all Service-wide and force-wide 

recommendations emerging from such investigations. I believe that suicide prevention is critical to the health and future of our forces. What measures have the Services taken to date to prevent any increases in suicide rates given the physical and 

mental strain many servicemembers and their families are experiencing? 

Lieutenant General SCHOOMAKER. On March 20, 2008, the Deputy Chief of Staff, 

G–1 and the Surgeon General hosted a Suicide Prevention General Officer Steering 

Committee (GOSC). The GOSC’s efforts will be ongoing, with a focus on targeting 

the root causes of suicide, while engaging all levels of the chain-of-command. The 

GOSC approved the following: (1) conducting suicide prevention chain teaching for 

the entire force between June 1, 2008, and August 31, 2008; (2) establishing a suicide prevention analysis and reporting cell that has epidemiological consultation-like 

capabilities; and (3) developing the GOSC charter and expanding its membership. 

The GOSC also reaffirmed the Army Suicide Prevention overarching strategies and 

expanded them. They include: (1) raising soldier and leader awareness of the signs 

and symptoms of suicide and improving intervention skills; (2) providing actionable 

intelligence to leaders regarding suicides and attempted suicides; (3) improving soldiers’ access to comprehensive care; (4) reducing the stigma associated with seeking 

mental health care; and (5) improving soldiers’ and their families’ life skills. 

Vice Admiral ROBINSON. Navy’s suicide prevention program goes beyond statistical baselines to focus on root causes that may lead to suicidal thinking. Navy programs and leadership training are designed to facilitate early recognition of sailors 

and marines who may be experiencing stress reactions for any reason, and to intervene with an appropriate level of support. Navy maintains an active suicide prevention program at each command, which include:

• Mandatory annual training on suicide awareness, including risk factors, 

protective factors, warning signs and how to obtain assistance for self and 

shipmate. 

• Life-skills/health promotions training (on such topics as alcohol abuse 

avoidance, skills for managing finances, stress, conflict, and relationships) 

to enhance coping skills and reduce incidence of problems that increase suicide risk. 

• Crisis intervention plans that outline the process for identification, referral, access to treatment, and follow-up for personnel who indicate a heightened risk of suicide. 

• Support for those who seek help with personal problems including access 

to prevention, counseling, and treatment programs and services supporting 

the early resolution of mental health, family and personal problems that 

underlie suicidal behavior. 

• Reporting of suicides and collection of data to inform prevention efforts 

and policy decisions. 

• Providing supportive response to sailors and family members affected by 

suicide loss. 

• All sailors have a duty to take care of each other and seek help for another sailor in distress.

The Manual of the Judge Advocate General (JAG Instruction 5800.7E) requires 

a command investigation to be conducted with deaths of military personnel apparently caused by suicide or under other unusual circumstances. Also, the Article 

1770–030 of the Naval Military Personnel Manual (NAVPERS 15560D), directs completion of a Personnel Casualty Report (PCR), which provides visibility throughout 

Navy senior leadership, including the Bureau of Medicine and Surgery. Beginning 

in January 2008, PCR submission initiates the DOD Suicide Event Report 

(DODSER) reporting process by which gathering of standardized information occurs 

across DOD. The DODSER collects information on the decedent’s demographics, circumstances of death, medical and performance history, recent stressors and behaviors, deployment history, combat experiences, substance use/abuse, and other information, to enable informed assessment of the causes of suicide to better develop 

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mitigation and prevention strategies. Navy reports are individually reviewed by a 

licensed mental health provider and collective data are analyzed for trends. While 

Navy suicide rates have remained relatively steady given increasing demands and 

stress on our sailors, even the loss of just one sailor or family member to suicide 

is one too many. We are continuously working to improve mental health initiatives 

and intervention focused on reducing the number of suicides in the Navy, as well 

as initiatives to enhance leadership’s ability to recognize and understand depression 

and stress injuries, and the impact they have on sailor and family resilience. 

Lieutenant General ROUDEBUSH. The loss of any airman to suicide is a tragedy 

of great concern to Air Force senior leaders. The Air Force has taken a multi-faceted, commander-driven and community wide approach to suicide prevention. Prevention of such events requires a culture of mutual responsibility, devotion and commitment. Our suicide data tracking systems are in place to monitor the effectiveness 

of these concerted prevention efforts. 

I would like to ensure the committee those discussions related to the reduction 

of suicides from year to year, and the metrics to demonstrate change, are not reflective of our attempt to dehumanize the tragedy, but represent our pursuit of programs and initiatives that are successful at guiding our efforts to reach those in 

need of help and support. 

Every Air Force suicide is investigated by the Air Force Office of Special Investigations and reviewed in detail by installation and Major Command leadership to 

identify lessons learned that might inform our efforts to identify and intervene with 

those at risk. Additionally, when there has been recent involvement of medical or 

mental health services, a Medical Incident Investigation (MII) is commissioned to 

review the chain of events leading up the death in terms of the standard of care 

provided and potential missed opportunities or systems failures that were contributory. This MII is briefed to the major command commander and up to the Office 

of the Air Force Surgeon General. The lessons learned from these various investigations are briefed to our most senior Air Force leaders and aggregated into an annual 

report which is disseminated to commanders throughout the Air Force. 

Background: 

The Air Force has achieved a 28 percent decrease in Air Force suicide rates since 

the program’s inception in 1996. The Air Force Suicide Prevention Program was 

added to the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (NREPP) in 2007, and is 

currently 1 of 10 suicide prevention programs listed on the registry. This listing is 

not about chest thumping, it is about a successful program that makes a difference. 

Air Force prevention efforts are centered on effective detection and treatment. A 

central component of this risk recognition and referral process is the recurring suicide prevention training for all airmen. To better standardize Air Force suicide prevention training, a revamped computer-based training was released on 15 Oct 07 

as part of the Chief of Staff, U.S. Air Force’s (CSAF) new Total Force Awareness 

Training initiative. This effort incorporates suicide prevention education into the 

CSAF’s core training priorities, ensuring suicide prevention will continue to receive 

prioritized focus and attention. 

Air Force Suicide Prevention Program (AFSPP) introduced the Frontline Supervisors Training in 2008. This interactive training provides a powerful vehicle for 

educating those with the most contact and greatest opportunity to intervene with 

airmen under stress. Lastly, suicide risk assessment training for mental health providers was conducted at 45 installations throughout 2007 to ensure Air Force mental health providers are highly proficient in evaluating and managing suicide risk. 

Throughout the next year, the Air Force Suicide Prevention Program will monitor 

the Frontline Supervisors Training and the new computer-based suicide prevention 

training to ensure these initiatives are effectively meeting the training needs of airmen.

7. Senator LIEBERMAN. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, would the Services support measures to initiate 

investigations on all suicides and establish Department-wide standards and protocols for taking necessary corrective actions? 

Lieutenant General SCHOOMAKER. The Army supports measures to initiate investigations on all suicides and to establish Department-wide standards and protocols. 

The Army currently investigates all suicides through the Criminal Investigation 

Command. Additionally, units are required to conduct a Commander’s Inquiry 

(known as a 15–6 investigation) on all suspected suicides. The Army currently uses 

a standardized instrument for reporting suicides and attempted suicides, the Army 

Suicide Event Report. Army behavioral health providers compile this report. This 

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instrument has been adopted recently by the other Services and is now known as 

the DODSER. Finally, the Army is planning to develop a multi-disciplinary suicide 

prevention analysis and reporting cell that has epidemiological consultation-like capabilities. This cell will integrate all of the above data. 

Vice Admiral ROBINSON. The Navy fully supports the standardization for data collection/investigation into every suicide, which commenced at the beginning of CY 

2008 with the implementation of the DODSER. The DODSER provides detailed insight into the circumstances, both personal and professional, surrounding the decedent at the time of the suicide. As the data is compiled we now have the ability 

to perform trend analysis and use the results to revise suicide prevention policy as 

needed. However, standardizing protocols for taking necessary corrective actions 

would likely be counterproductive. Every suicide presents unique circumstances and 

a standard protocol may not address the prevention efforts that would be the best 

course of action in that specific incident. Commanders in the field should be able 

to draw on multiple resources to take the most appropriate course of action when 

a suicide occurs. Standardizing protocols would tie leader’s hands in making the 

right decisions for their command. 

Lieutenant General ROUDEBUSH. The Air Force would support such proposals. In 

fact, the Air Force and DOD have already taken steps to implement similar activities. The Air Force tracks and analyzes suicide and suicide attempt data using the 

Air Force Suicide Event Surveillance System. In early 2008, the DOD Suicide Prevention and Risk Reduction Committee (composed of the Suicide Prevention Program Managers from each Service) launched the DOD Suicide Event Reporting System to track data on suicides and suicide attempts across all the Services. 

Every Air Force suicide is investigated by the Air Force Office of Special Investigations and reviewed in detail by installation and Major Command leadership to 

identify lessons learned that might inform our efforts to identify and intervene with 

those at risk. Additionally, when there has been recent involvement of medical or 

mental health services, a Medical Incident Investigation (MII) is commissioned to 

review the chain of events leading up the death in terms of the standard of care 

provided and potential missed opportunities or systems failures that were contributory. This MII is briefed to the major command commander and up to the Office 

of the Air Force Surgeon General. Suicides related to domestic or child abuse are 

examined in the DOD-mandated Annual Fatality Review. The lessons learned from 

these various investigations are briefed to our most senior Air Force leaders and aggregated into an annual report which is disseminated to commanders throughout 

the Air Force.

DEFENSE CENTER OF EXCELLENCE

8. Senator LIEBERMAN. Colonel Sutton, last year, Senator Boxer and I introduced 

S.1196, the Mental Health Care for Our Wounded Warriors Act, which was incorporated, into the NDAA for Fiscal Year 2008. In addition to the mandates laid out 

in those provisions, the Defense Center of Excellence (DCoE) has also been charged 

with implementing many of the recommendations of the Mental Health Task Force 

Report. I believe that adequate resourcing of the Center is critical for its early and 

long-term utility and success. What resources do you need at this time to carry out 

the directives for the DCoE outlined in the NDAA for Fiscal Year 2008 and to implement the numerous recommendations of the Mental Health Task Force Report? 

Colonel SUTTON. Congress has generously provided funding for the Department 

and the Center for fiscal year 2008 and fiscal year 2009. Our greatest challenge at 

present is the ability to use that funding effectively and efficiently to immediately 

staff the Center and to begin the programs necessary to fulfill the recommendations 

of the MHTF. Within the military health system, our clinical staffs are busy on the 

front lines both at home and in deployed status. The Department has initiated several actions to increase the numbers of mental health professionals to support our 

wounded warriors and their family members.

STRAINS OF MILITARY FAMILIES

9. Senator LIEBERMAN. Lieutenant General Schoomaker, we have been reading an 

increasing number of reports on the strain that military families are experiencing. 

Last summer, an article published in the Journal of the American Medical Association cited rising rates of child maltreatment in military families, primarily attributed to spouses alone during deployments. My staff has also been visiting a number 

of military bases across the country and they have heard reports at bases of increasing reports of domestic violence, substance abuse in families, and mental health 

170

issues in spouses and children. What initiatives is the Army undertaking to assess 

the needs of military families and to direct resources to meet those needs? 

Lieutenant General SCHOOMAKER. In July 2007, the Army Surgeon General’s Office informed all Army Medical Department providers of the observed increases in 

child neglect rates during deployments and directed them to increase the screening 

of the spouses of deployed soldiers for depression and any signs of poor coping capacity. Additionally, 16 hours of free child care at child development centers has 

been made available for each child of deployed soldiers and wounded warriors. In 

November 2007, the Secretary of the Army teamed with the Gallup organization to 

initiate quarterly surveys of Army families as a part of the Army Family Covenant. 

The intent is to assess Army family health through satisfaction surveys of all Army 

families, including those who live away from Army installations. The survey includes questions that will help us evaluate services provided to families during deployments. 

The article published last August in the Journal of the American Medical Association, ‘‘Child Maltreatment in Enlisted Soldiers’ Families During Combat-Related Deployments,’’ did not cite rising rates of child abuse overall. However, it did demonstrate that children were at 4 times greater risk of neglect by the civilian spouse 

during deployments. The rate of physical abuse was actually less during deployments. Similarly, the observed rates of domestic violence have not increased overall 

since the deployments began—rates have gone down. We have found that rates decrease during deployments and rise again after reunion, but rates do not rise above 

pre-deployment levels.

10. Senator LIEBERMAN. Lieutenant General Schoomaker, what additional resources or authorities does the DOD require to accomplish these objectives? 

Lieutenant General SCHOOMAKER. The Army plans to more than double the number of marriage and family therapists that will be available to our soldiers and families this summer. We are using funding appropriated in the fiscal year 2007 Supplemental Appropriations Act to hire an additional 35 marriage and family therapists, 

bringing our total across the Army to 60. Based on our experience from the past 

few years, we determined that the ratio of one therapist for each brigade size element would best support our families. We have had 25 marriage and family therapists at select locations since 2003 and have observed more positive outcomes of 

family maltreatment cases when such services have been available. After the staffing increases this summer, we will continue to monitor outcomes to see if further 

adjustments are necessary.

REALLOCATION OF FUNDS

11. Senator LIEBERMAN. Lieutenant General Schoomaker, the Base Realignment 

and Closure process will lead to a greater concentration of military families at a 

smaller number of bases across the United States. How will funding be reallocated 

to ensure that resources will be available for families as they relocate? 

Lieutenant General SCHOOMAKER. We are performing detailed planning to align 

health care capability with demand for services across time. Resources will be realigned to support both soldiers and their families using a resourcing model based 

on population timelines to ensure adequate health care continues at all of our medical treatment facilities. In areas where there is a potential for a lapse in care due 

to the difficulty in hiring providers or the timing of new construction or the expansion of existing health care facilities, we are developing mitigation strategies, such 

as the increased use of the TRICARE network.

SUBSTANCE ABUSE

12. Senator LIEBERMAN. Colonel Castro, substance abuse appears to be on the rise 

on military bases. Many of these individuals abusing substances also have PTSD, 

TBI, depression, or another mental health condition. I am growing increasingly concerned that we must not only focus on the psychological and brain injuries, but also 

on understanding how better to assess and treat substance abuse. Is substance 

abuse on the rise on our military bases and among those that have deployed to Iraq 

and Afghanistan? 

Colonel CASTRO. The most recent data from the fifth Mental Health Advisory 

Team (MHAT V) conducted in 2007 found that 8 percent of soldiers deployed to Iraq 

reported using alcohol in theater and 1.4 percent reported using illegal drugs/substances. These reports of alcohol and substance abuse do not differ statistically from 

rates in 2006 (6.8 percent and 1.6 percent). The Army maintains a formal drug testVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00174 Fmt 6633 Sfmt 6621 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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ing program in theater, and the drug positive results have remained significantly 

lower than 1 percent for the last 3 years. Our drug positive rates across the Army 

have also remained relatively stable since the beginning of global war on terrorism. 

We have seen an increase in positive tests for pain killers, but the vast majority 

of those positives are found to be legitimate use. We have seen an increase in selfreports of alcohol abuse from 28 percent pre-global war on terrorism to 32 percent 

for those soldiers returning from deployment. We have also seen an increase in the 

numbers of soldiers being diagnosed with alcohol abuse or dependence. We have initiated use of more early intervention programs that are used with soldiers at the 

first sign of trouble. We are in the process of developing mediated versions of our 

best prevention/intervention programs to expand our reach and we have accelerated 

the hiring of substance abuse treatment professionals. We understand the importance of meeting soldiers’ needs regarding substance abuse and we are responding 

accordingly.

13. Senator LIEBERMAN. Colonel Castro, how integrated are substance abuse programs with behavioral health services in military treatment facilities? Is the level 

of integration sufficient? If not, what integrated models of care is DOD examining 

and are there plans to export those models to military treatment facilities? 

Colonel CASTRO. The level of integration is sufficient, because we are able to 

maintain the necessary communication and coordination to take care of soldiers 

while adhering to Federal law concerning privacy. We are looking at the feasibility 

of integrating records. The Army Substance Abuse Program (ASAP) is a command 

program in which the commanders and providers collaborate in our prevention efforts and assist soldiers who abuse alcohol or drugs. If soldiers have a substance 

abuse problem, they are referred to ASAP substance abuse counselors who are part 

of the behavioral health network, but are located in separate clinics. The regulation 

requires the soldier be mandated into treatment and that the commander be a part 

of the treatment planning; commanders are required to attend rehabilitation meetings with the servicemember and provider. The program also outlines commander’s 

requirements if soldiers test positive for drugs or fail at attempts for rehabilitation. 

Specific laws (42 U.S.C., Sec 290dd–2) govern the privacy of soldiers who are in substance abuse treatment. This law is more stringent than those applied to other behavioral health programs or records. That being said, there is continuous cooperation and collaboration between the substance abuse clinics and other behavioral 

health providers. An example is dealing with or treating PTSD. Behavioral health 

and substance abuse clinics cross-check with each other to ensure that soldiers presenting with PTSD symptoms or substance abuse are also evaluated for the other 

since many patients suffering from PTSD self-medicate with alcohol.

MENTAL HEALTH NEEDS OF FEMALE SERVICEMEMBERS

14. Senator LIEBERMAN. Colonel Sutton, last year, Senator Boxer and I had included a provision in the NDAA for Fiscal Year 2008 for DOD to conduct a study 

on the potentially unique mental health needs of female servicemembers. Determining whether or not psychological injuries and brain injuries manifest differently 

in men and women will be important, especially when developing long-term research 

and treatment infrastructures across DOD. Will the DCoE be involved in this study? 

Colonel SUTTON. The DCoE recognizes and supports the unique needs of women 

servicemembers and veterans. One of the eight directorates of the DCoE, Research, 

Program Evaluation, Quality and Surveillance, has identified women’s health issues 

as a priority research area. To emphasize the importance of this focus, the Research 

Directorate now actively includes statements encouraging examination of genderspecific issues in its request for proposals and broad agency announcements. 

The DCoE encourages meritorious research on the mental health needs of female 

servicemembers. Basic, translational, behavioral and clinical research in women 

servicemembers’ health, especially applied to sex/gender differences, are of particular interest. Studies considering the health disparities/differences and diversity 

are also important.

15. Senator LIEBERMAN. Colonel Sutton, what other initiatives will the Center be 

undertaking to examine the possibility that female servicemembers may process 

stress, trauma, and TBI differently than male counterparts? 

Colonel SUTTON. The DCoE is collaborating with the scientific, health professionals and advocacy communities to fully address the unique gender-specific needs 

of recovering servicemembers and veterans with PH and TBI concerns/needs. In 

early March, the DCoE will hold an interagency initial planning meeting on womVerDate 0ct 09 2002 11:01 Dec 09, 2008 Jkt 000000 PO 00000 Frm 00175 Fmt 6633 Sfmt 6621 C:\DOCS\45652.TXT SARMSER2 PsN: JUNEB
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en’s issues related to PH and TBI by inviting its prospective collaborative partners 

from the VA, the Defense Health Board, and the National Institute of Health Office 

of Research on Women’s Health. Ongoing research is examining the short- and longterm effects and outcomes of PH issues and TBI in women. These findings will be 

used to inform best practices. The DCoE will take the lead in creating best practices 

workshops in addressing the PH and TBI needs and concerns of servicemembers. 

QUESTIONS SUBMITTED BY SENATOR CLAIRE MCCASKILL

PERSONALITY DISORDER DISCHARGES

16. Senator MCCASKILL. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, I am concerned with the continuing use of administrative personality disorder discharges in the Services, especially in instances 

involving combat veterans. A personality disorder discharge results in a 

servicemember being dismissed from service without medical or personnel benefits 

because his or her behavioral issues are determined to be pre-existing. I am concerned with the frequency that these highly prejudicial discharges are occurring—

particularly in cases involving combat veterans. I am also especially concerned because these discharges are processed by unit commanders in concert with the personnel commands, not by medical professionals and the medical command, although 

I understand that it is a diagnosis from a medical professional that enables the discharge. Are you concerned that administrative personality disorder discharges are 

being misused in the DOD/your Service? 

Lieutenant General SCHOOMAKER. No, we do not believe personality disorder discharges are being or have been misused. We recently completed a project to gather 

available data regarding the personality disorder separations of Army soldiers who 

have been deployed and were separated between 2001 and 2006. The data is currently being reviewed by Army leadership; however, initial assessments did not reveal evidence of systematic misuse in the Army. While gathering the data, however, 

issues were identified with the manner in which diagnoses are documented. Therefore, we took immediate steps to improve the level of medical review for personality 

disorder discharges to address this issue. The Army Medical Department implemented a new policy in August 2007, requiring all recommendations for personality 

disorder separations be reviewed by the installation’s Chief of Behavioral Health. 

This will add an additional layer of experienced medical review to the separation 

process. 

Vice Admiral ROBINSON. I believe that administrative personality disorder discharges are being properly used by the Navy. We have a valid process for determining if a personality disorder discharge is warranted with significant safeguards. 

A convenience of the Government separation as detailed in the Navy’s Military Personnel Manual (MPM) 1910–122, clearly states the requirements for personality disorder separation as:

• Clinical diagnosis required, i.e., psychiatrist or clinical psychologist 

(Ph.D.-level) 

• Disorder must be so severe that the member’s ability to function in the 

Navy environment is significantly impaired 

• Impairment interferes with the member’s performance of duty, or poses 

a threat to the safety or well-being of the member or others

Furthermore, MPM 1910–122 requires various safeguards to protect an individual 

being separated by reason of convenience of the government. It specifically requires 

written notification to an individual requesting a mental health evaluation and 

clearly states the right of an individual to a second, independent mental health professional opinion. Additionally, an individual is reminded of their right to an Inspector General investigation if they feel their referral is a reprisal from the command. 

Lieutenant General ROUDEBUSH. Air Force policy is clear that airmen will not be 

discharged for personality disorders when other psychiatric disorders that warrant 

medical disability processing are present. Units and personnel offices cannot discharge airmen for personality disorders without the recommendation of an Air Force 

mental health provider. Air Force mental health providers are trained in the careful 

assessment and diagnosis of airmen with mental health problems, and render a diagnosis of a personality disorder only when a lifelong pattern of maladaptive behavior is clearly present. If other psychiatric disorders are present, including combatrelated conditions, Air Force mental health providers refer those individuals for a 

Medical Evaluation Board. 

I have full confidence that our medical and mental health providers maintain high 

standards of competence and adhere to their ethical obligation to provide the best 

173

possible care to every patient, and have not seen anything that has suggested that 

administrative personality disorder discharges are being misused in the Air Force.

17. Senator MCCASKILL. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, do you believe these discharges should continue 

to be handled as administrative discharges or should there be a more extensive 

medical process, like a Medical Evaluation Board? 

Lieutenant General SCHOOMAKER. I do not believe personality disorder discharges 

should require a Medical Evaluation Board. In the Army, the diagnosis of a personality disorder is made by a psychiatrist or a doctoral-level clinical psychologist with 

necessary and appropriate professional credentials who is privileged to conduct mental health evaluations for the DOD. In addition, all recommended separations for 

personality disorder are now reviewed by the installation’s Chief of Behavioral 

Health. Finally, all soldiers recommended for a personality disorder separation receive a mental status evaluation. Based on the findings of the evaluation, a soldier 

may be referred for a Medical Evaluation Board. With these procedures in place, 

a more extensive medical process is not required. 

Vice Admiral ROBINSON. I believe that these discharges should continue to be 

handled as administrative discharges. The process for identifying and evaluating a 

personality disorder is fair to the individual and a reasonable method to separate 

someone, honorably and without undo delay or expense to the government. It is important to note that personality disorder is not a mental illness but, rather, a disorder and in this case simply a disorder which makes one incompatible for military 

service. The Navy uses the Diagnostic and Statistical Manual of Mental Disorders, 

4th Ed., (DSM IV), which requires that all other mental illnesses and disorders 

must be eliminated before a valid diagnosis of personality disorder can be made. 

DSM IV is the basic reference followed by Navy Medical professionals in examining 

for mental illness and disorders. If during the evaluation the mental health professional (psychiatrist or Ph.D. clinical psychologist) recommends a Medical Evaluation 

Board, that process is initiated. 

Lieutenant General ROUDEBUSH. Currently, both the administrative separation of 

airmen for conditions unsuited to service and the medical discharge of personnel 

unfit for service require thorough medical evaluations. 

It is appropriate for psychological conditions as outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual for Psychiatric Conditions, 

4th Edition, and defined by regulations as unsuitable for service to be processed for 

administrative separation after the thorough evaluation by an Air Force mental 

health provider. This group of conditions includes personality disorders, a diagnosis 

that reflects a lifelong pattern of maladaptive behavior. Other examples include 

sleepwalking, dyslexia, airsickness, flying phobia, claustrophobia, and adjustment 

disorders. 

All psychiatric disorders not explicitly defined as unsuited to service are processed 

through the medical evaluation board system. Medical evaluation boards are initiated when an Air Force mental health provider identifies concerns about an airman’s fitness for continued service. Disorders warranting a medical evaluation 

board are explicitly excluded from the administrative separation process.

18. Senator MCCASKILL. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, would you support a moratorium on the personality disorder discharges? 

Lieutenant General SCHOOMAKER. I do not support a moratorium on all personality disorder discharges. Based on the review of data that is underway, we anticipate a need to tighten the criteria under which this separation may be applied, and 

improve enforcement of procedures already in place. 

Vice Admiral ROBINSON. I believe that a moratorium on personality disorder discharges would put an undue burden on our already stressed forces and potentially 

add to the number of considerable hazards associated with military service. A 

servicemember is only separated for a personality disorder if a mental health professional determines the disorder is so severe that the member’s ability to function effectively in the Navy environment is significantly impaired to the point where it 

interferes with the performance of their duties or poses a threat to the safety or well 

being of the member or others. 

Lieutenant General ROUDEBUSH. Air Force mental health personnel exhibit high 

standards of professional and ethical conduct, and when an airmen displays a lifelong pattern of maladaptive behavior the diagnosis of a personality disorder is appropriate. In these cases, the successful adaptation to the military environment is 

unlikely. When an airman is failing to adapt because of a personality disorder, administrative separation is in the best interests of the airman and the Air Force. A 

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moratorium on personality discharges will force commanders to address these airmen through other measures, such as punitive discharges. This would be unfair to 

airmen with personality disorders, because the failure to adapt is secondary to the 

disorder and not misconduct. 

We must also appreciate that further restriction on a Commander’s ability to separate personnel who are not a good fit to our force, is a drain on leaders, stresses 

our health care system, and may well impact spill over to other areas of culture (i.e. 

like suicide rates, AWOL).

19. Senator MCCASKILL. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, do you believe the 1982 DOD directive on personality disorder discharges needs to be updated? 

Lieutenant General SCHOOMAKER. I believe all of our policies and directives 

should be routinely reviewed and updated to reflect the realities of a Nation at war 

in a persistent conflict. 

Vice Admiral ROBINSON. DOD Directive 1332.14, Enlisted Administrative Separations, outlines policy for personality disorder discharges. This directive was originally issued in January, 1982 and updated in December, 1993 and March, 1994 and 

presently meets our needs. Navy policies regarding enlisted separations are in accordance with this directive and I do not believe it needs updating at this time. 

Lieutenant General ROUDEBUSH. It is reasonable that a document last published 

in 1982 be reviewed for currency and updated as appropriate.

20. Senator MCCASKILL. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, do you believe new safeguards should be applied to personality disorder discharges, especially in light of the heavy combat activity of most of today’s servicemembers? 

Lieutenant General SCHOOMAKER. Yes, some additional safeguards should be applied to personality disorder discharges. For example, the Army implemented a new 

policy in August 2007, where all recommendations for separation for a personality 

disorder require review by the installation’s Chief of Behavioral Health. The Army 

Staff is currently reviewing additional safeguards for soldiers based on length of 

service and combat experience. 

Vice Admiral ROBINSON. I believe that the current DOD and Navy policies regarding personality disorder discharges are sufficient to meet the needs of our 

servicemembers. I certainly recognize that the global war on terrorism has placed 

our sailors in harm’s way and some may suffer from anxiety disorders like PTSD 

or other problems like TBI. In order for an individual to be discharged for a personality disorder they must receive a mental health evaluation by a psychiatrist or 

Navy clinical psychologist (Ph.D.). Our mental health professionals are sensitized to 

the special needs of our sailors returning from a combat zone and are able to distinguish between PTSD and a personality disorder. Additionally, the Navy will add a 

requirement to the Military Personnel Manual 1910–122 to include the statement 

in all personality disorder diagnoses that the examination included survey for symptoms of PTSD and TBI, and that none were found. 

Lieutenant General ROUDEBUSH. I agree that existing safeguards must be strictly 

adhered to, and by and large, we do. These safeguards include the following: 1) involvement of Air Force mental health providers; 2) the use of diagnostic criteria for 

personality disorders as published in the American Psychiatric Association’s Diagnostic and Statistical Manual for Psychiatric Conditions, 4th Edition; and 3) the requirement in DOD Directive 6490.1 that a member with a personality disorder must 

have an impairment ‘‘so severe so as to preclude satisfactory performance of duty’’ 

before administrative separation can be considered. A key feature of personality disorders involves persistent and pervasive patterns of behavior which are distinguishable by professionals from transient or emergent psychological issues, such as posttraumatic stress, insomnia, and adjustment disorders. 

If the implication is that we are missing diagnoses and there is evidence to support that, it would make sense to ensure our mental health experts have current 

training on developing conditions and the literature related to it. 

We must also appreciate that further restriction on a commander’s ability to separate personnel who are not a good fit to our force may have other impacts, such as 

negatively affecting unit morale and stressing health care resources, and may well 

spill over to other areas (e.g. suicide rates, AWOL). 

The table below shows Air Force data for personality disorder discharges; the 

number of airmen administratively separated for this reason has not gone up during 

Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). 

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21. Senator MCCASKILL. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, do you believe a review board should be established to review past personality disorder discharges of combat veterans, as I have 

joined Senator Bond and others in calling for? 

Lieutenant General SCHOOMAKER. Soldiers and veterans currently have the right 

to appeal their discharges to the Army Board for Correction of Military Records, as 

created by Congress. I do not believe a separate review board is needed. 

Vice Admiral ROBINSON. To date, there is no evidence there is a problem in the 

Navy with personality disorder discharges and combat veterans. However, the 

NDAA for Fiscal Year 2008 requires DOD to report to Congress by 1 Apr 08 on all 

cases of administrative separation of any servicemember who had served in Iraq or 

Afghanistan since October 2001 for personality disorder. Before the establishment 

of a review board, I believe it would be prudent to await the results of this report. 

Lieutenant General ROUDEBUSH. I do not believe an across-the-board review is 

necessary. I am confident in the professional and ethical conduct of Air Force mental health providers in these cases, and this contention is supported by recent data 

from the Air Force Personnel Center. Trends indicate no increase in personality disorder discharges since the start of the war. Of those separated for a personality disorder, more than 60 percent are discharged during their first 6 months on Active 

Duty and less than 5 percent have deployed. These data suggest that the Air Force 

uses administrative discharges to appropriately discharge airmen with longstanding 

personality issues that render them unsuitable for military service.

FEMALE WOUNDED WARRIORS

22. Senator MCCASKILL. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, I am interested in the physical and mental 

health needs of our female wounded warriors. Many studies have shown that 

women have particularly unique needs when it comes to mental health and that 

PTSD and TBI can sometimes be more difficult to diagnose in women. I was pleased 

that the NDAA for Fiscal Year 2008 included language that addressed potential 

unique needs of female wounded warriors. Are you confident that we are doing 

enough to recognize where there are differing needs for treatment of female wounded warriors? 

Lieutenant General SCHOOMAKER. No, but we are using a variety of treatment 

interventions to address the unique needs of our female soldiers. When clinically appropriate, we will have female-only groups. We are attempting to hire 330 more civilian contract mental health providers (266 in the United States and 64 at our 

overseas locations), who will treat all soldiers. Our educational products, such as the 

Battlemind training programs and suicide prevention products, consider women as 

part of their target audience. More research is needed to assess the gender difference in the military population, specifically as related to global war on terrorism 

operations. 

Vice Admiral ROBINSON. Navy has long recognized the importance of women’s 

health issues and established a women’s health program office in the Bureau of 

Medicine and Surgery many years before the onset of the global war on terrorism. 

I am confident that Navy health care providers are intimately familiar with the 


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varying needs of our heterogeneous beneficiary population, including those of our female wounded warriors. Through supplemental appropriations recently enacted to 

address PH and TBI diagnosis and treatment requirements among servicemembers, 

we have expanded access to care for all wounded warriors, which, in turn, allows 

us to more effectively address the unique needs of uniformed servicemembers, 

whether female or male. 

Lieutenant General ROUDEBUSH. Since OEF/OIF are the first U.S. engagements 

where women have been exposed to combat stress in large numbers, we clearly have 

lessons to learn. 

Trauma theory and treatment models fortunately have been developed through 

the study of responses to combat, disasters, motor vehicle accidents, sexual assault, 

and abuse trauma. Our current evidence-based trauma treatments have been used 

effectively with both men and women across the spectrum of exposures and trauma 

types. We are confident that our models of trauma adequately account for female 

trauma in terms of both assessment and treatment. 

Nonetheless, the study of combat-related trauma and mild TBI in women remains 

in its infancy, and our Air Force and joint Service subject matter experts, in conjunction with experts from the Centers of Excellence and from academia, are now 

beginning to establish a body of literature that will help to improve our understanding in these areas.

23. Senator MCCASKILL. Lieutenant General Schoomaker, Vice Admiral Robinson, 

and Lieutenant General Roudebush, are we doing enough to train our mental health 

and medical professionals to recognize differing symptom patterns? For example, do 

you have separate group counseling session for women when treating PTSD? 

Lieutenant General SCHOOMAKER. We consider the uniqueness of every patient 

and provide the best possible treatment available, based on the individual patient’s 

symptoms. In some of our facilities, however, we do offer separate counseling groups 

for women diagnosed with PTSD, when clinically appropriate. There is no centralized data base that allows us to track which facilities offer female only groups. We 

examine the specific needs of our female soldiers and strive to use treatment approaches that best meet their needs. We also partner with the VA and make use 

of their specialized programs for women experiencing PTSD. We will further review 

our training curriculum to ensure that we are offering adequate training to recognize differing symptom patterns in our women patients. 

Vice Admiral ROBINSON. Using the congressional TBI and PH supplemental funds 

the Navy is implementing enhanced training to facilitate early recognition of stress 

injuries and appropriate initiation of clinical intervention at initial point of service. 

To achieve this goal we are using a two-tiered training approach. First, we are 

teaching the early recognition of stress injuries to a broad range of Navy caregivers; 

for example, physicians, nurses, corpsmen, chaplains, fleet and family service personnel. The stress injury continuum training that was started in September 2007 

teaches awareness and intervention skills for stress reactions and those with stress 

injuries. Sailors and marines who show potential stress illness behaviors are referred to mental health for assessment. The second tier consists of enhanced training for the assessment and treatment of PTSD and mild TBI to primary care physicians and nurse practitioners. The goal is to initiate appropriate therapy for mildPTSD and mild-TBI where sailors and marines receive their routine health care. 

The goals of this training are to enhance early recognition of problems that interfere 

with daily life, begin appropriate treatment in a non-stigmatizing care environment, 

and facilitate better use of limited mental health clinician services for more complex 

patients. 

The treatment of PTSD uses a combination of cognitive behavioral therapy strategies, medications, individual, and group therapies based on a comprehensive assessment of individual symptoms and treatment goals. Specific decisions about what 

type of PTSD group therapy is most appropriate are dependent more on trauma exposure rather than gender. Decisions about participation in group therapy are made 

by the patient and their primary care provider. The trauma experiences of both 

women and men who have been sexually assaulted tend to have common issues 

around violation, powerlessness, and vulnerability and both genders can relate to 

those issues. Similarly, those exposed to violent crime and motor vehicle accidents 

have different trauma themes than those with combat stress injuries. It is also important to note that mixed trauma group therapy can be very effective for all participants regardless of gender or trauma if the individual is ready for group therapy 

and the clinicians address the diversity of trauma, commonality of post-trauma 

symptoms, and the effectiveness of recovery strategies. 

Lieutenant General ROUDEBUSH. We know from the scientific literature on PTSD 

that women are at higher risk to develop PTSD than men and that they report twice 

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the lifetime prevalence of the disorder in the U.S. population. In the Air Force, female deployers are offered a comprehensive range of medical and mental health 

services to meet their needs as identified through our screening procedures. The 

Post-Deployment Health Assessment (PDHA) and Post-Deployment Health Reassessment (PDHRA) employ the Primary Care PTSD Screen (PC–PTSD). The 

PDHRA also employs the PTSD Checklist-Military Version (PCL–M) for assessment 

of both male and female respondents who screen positive on the PC–PTSD. The 

choice of therapeutic modalities including individual, marital, or group therapy are 

generally determined collaboratively by the mental health provider and the patient 

to accommodate the needs of the patient. We are taking the mental health of our 

female deployers extremely seriously and are eager to incorporate the lessons 

learned from the Air Force, other Services, and the growing body of research in this 

area.

TRICARE AND MENTAL HEALTH ISSUES

24. Senator MCCASKILL. Vice Admiral Arthur, Dr. MacDermid, Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant General Roudebush, 

should we expand TRICARE coverage to nonclinical mental health counseling? Isn’t 

routine counseling a great way to prevent mental health issues from elevating and 

becoming more urgent and clinical in nature? 

Vice Admiral ARTHUR and Dr. MACDERMID. The task force strongly supported access to routine counseling for servicemembers and their families. In recommendation 

5.3.4.10, we recommended that TRICARE services be expanded to include treatment 

for ‘V-codes,’ such as partner relational problems, physical/sexual abuse, bereavement, parent-child relational problems, and other appropriate services. This was the 

single task force recommendation not endorsed by the Secretary of Defense. I believe the reason is that Military OneSource provides access to short-term non-medical counseling at no charge for all military members and their families. 

Lieutenant General SCHOOMAKER. The Senior Army Leadership has identified a 

vital need to address nonclinical mental health counseling for soldiers and their 

families challenged by frequent and long overseas deployments. Ensuring the availability of comprehensive and sufficient nonclinical counseling services is a top Army 

priority. In partnership with the TRICARE Management Activity, we are seeking 

ways to deliver better and more comprehensive nonclinical mental health counseling 

for soldiers and their families. Army leadership is addressing this priority with the 

Assistant Secretary of Defense for Health Affairs. 

Vice Admiral ROBINSON. Implementing guidelines of 32 CFR § 199.6, reflected in 

the TRICARE Policy Manual, already provide the necessary flexibility and support 

to leverage non-clinical mental health counseling and support to beneficiaries while 

supporting access to a higher level of care if symptoms worsen. 

The issue of promoting mental health versus waiting to treat mental illness is 

crucial. The Navy and Marine Corps Operational Stress Control program teaches a 

form of stress first-aid that increases shipmate awareness of stress reactions, appropriate responses and helping those experience such stress reactions to seek further 

help. Providing, peers, family members, and unit leaders with the tools to help others deal with the stresses associated with daily life and crisis stressors will 

strengthen the most important factors for ensuring good mental health-social support and group cohesion. The next level of resources are the life-skills counseling 

services to help build enhanced coping options. If good social support and enhanced 

coping skills do not help to improve a servicemember’s quality of life, clinical counseling and augmented social supports should be used. 

Lieutenant General ROUDEBUSH. Non-clinical mental health counseling is widely 

available to Air Force members and their families, through Military OneSource and 

Military Family Life Consultants in our Airmen and Family Readiness Centers. 

However, I do not support expanding TRICARE coverage to include non-clinical 

services. Maintaining a high degree of confidence in the Air Force Medical Service 

and TRICARE is best accomplished by covering the delivery of evidence-based mental health services by licensed mental health professionals. To maintain the highest 

standards of professional medical care, we must resist the temptation to consider 

the full range of needs and services that might benefit military members and families to be clinical in nature. We cannot maintain appropriate standards of care and 

practice fiscal responsibility if we expand our medical services in this manner. I submit that there are appropriate mechanisms to meet these needs as previously discussed and I support their continued availability as services distinct from medical 

care.

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25. Senator MCCASKILL. Vice Admiral Arthur, Dr. MacDermid, Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant General Roudebush, have 

you looked at the mental health professions and determined if we have professionals 

out there who could be providing care to our servicemembers that are currently 

being left out of the TRICARE system? Please discuss both clinical and non-clinical 

mental health professionals. 

Vice Admiral ARTHUR and Dr. MACDERMID. In recommendation 5.3.3.3, the task 

force recommended that a full spectrum of mental health professions be used to support the PH of servicemembers and their families. A companion recommendation is 

5.2.3.3., which recommends that mental health professionals apply evidence-based 

clinical practice guidelines. 

The task force received testimony from several practitioner organizations seeking 

greater inclusion in the TRICARE system. We believe that TRICARE should constantly be monitoring the development of mental health professions, and when a 

profession has matured to the point that its training and certification procedures 

are such that there can be adequate confidence in the quality of care the members 

of that profession are likely to provide, then that profession should be included in 

TRICARE spectrum. 

Lieutenant General SCHOOMAKER. Currently, we are making extensive use of clinical and non-clinical mental health providers. Clinical personnel include psychiatrists, psychologists, social workers and psychiatric social workers. Our clinical personnel need to be licensed and credentialed, so that we can be assured we have the 

best quality providers. We also provide nonclinical mental health support through 

the Military and Family Life Consultant (MFLC) Program which provides shortterm, nonmedical counseling services to military families. MFLCs can help people 

who are having trouble coping with concerns and issues of daily life. Counselors and 

other nonclinical mental health professionals often provide support and counseling 

at our schools. In addition, Military OneSource (MOS) is staffed by both clinical and 

nonclinical mental health professionals. Military OneSource supplements existing 

family programs by providing a website and a worldwide, 24-hour, 7-day-a-week information and referral telephone service to all Active, Guard, and Reserve soldiers, 

deployed civilians and their families. Military OneSource services are provided at 

no-cost to the soldier. 

There are many clinicians who have not signed up to be TRICARE providers. 

Anecdotally, providers claim difficulties with paperwork, reimbursement, and interference in medical decisions. The TRICARE Management Activity (TMA) is working 

to resolve these issues and urging more providers to sign up. Since May 2007, an 

additional 2,800 behavioral health providers have joined the TRICARE network. In 

addition, TMA recently required the Managed Care Support Contractor (MCSC) to 

establish toll-free Behavioral Health Provider Locators and Appointment Assistance 

Services. This service allows soldiers and their families to call the MCSC to receive 

assistance with locating a network mental health provider. 

Vice Admiral ROBINSON. The MCSCs have developed and continue to refine comprehensive provider networks supporting the MHS including nonclinical mental 

health professionals (Counselors, Pastoral Counselors, and Licensed Clinical Social 

Workers). Although there is variability with the reporting format from three contractors, it appears that the majority of the networks include nonclinical mental 

health professionals. Although the capacity exists in the majority of the networks, 

the overall use of nonclinical mental health care support may be impacted due to 

referral patterns and the level of knowledge required of the health plan by network 

providers (primary care managers (PCMs)). The PCMs may not be leveraging the 

support from nonclinical mental health professionals in their efforts to provide care. 

This presents an education and marketing opportunity for TMA to ensure that existing capabilities within the health care plan are clearly articulated to network PCMs. 

Lieutenant General ROUDEBUSH. There will always be a certain percentage of providers who make a choice not to participate in the TRICARE program, just as they 

make that same choice for other health plans. The real issue is not whether all providers accept TRICARE but if there are adequate numbers of providers accepting 

it in the areas where our servicemembers and families live. The provider’s choice 

to participate in TRICARE is contingent upon a whole list of variables. There are 

undoubtedly methods by which TRICARE could increase its attractiveness to potential providers, including simplicity of claims filing, increased responsiveness to questions, and reimbursement rates. As the TRICARE program is not a Service program 

but in fact a DOD program, none of these changes are within the Services’ ability 

to implement. We work closely with the TMA to identify locations that appear to 

have issues with access to medical care. They in turn work through the Managed 

Care Support contractor to contact providers in that area to encourage them to participate in the TRICARE program.

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26. Senator MCCASKILL. Vice Admiral Arthur, Dr. MacDermid, Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant General Roudebush, how 

are reimbursement rates in TRICARE affecting access to mental health care for our 

servicemembers? 

Vice Admiral ARTHUR and Dr. MACDERMID. The task force was repeatedly told 

during its site visits that low TRICARE reimbursement rates are a disincentive to 

participation in the system. Of course, many practitioners would say the same about 

reimbursement rates for other government programs, so TRICARE is not unique. 

Military families are unique, however, in their service to the country in times of war 

and thus may merit special treatment. According to what we were told, slow reimbursement and cumbersome application processes are additional barriers. 

Lieutenant General SCHOOMAKER. The Supplemental Health Care Program 

(SHCP) is the process for providing soldiers health care services from civilian providers. TRICARE reimbursement under SHCP uses the same reimbursement rate 

system as the rest of the TRICARE program. There is also a reimbursement waiver 

system in place to pay higher reimbursement amounts to ensure appropriate access 

to care for soldiers. This system allows the Managed Care Support Contractors 

(MCSCs) to increase rates up to 115 percent of the maximum allowable charge. If 

this increase does not improve access, the MCSC will determine the lowest rate the 

provider will accept. The MCSC will request approval of this higher reimbursement 

amount from the TMA. 

Additionally, TMA continues to assess civilian provider acceptance of TRICARE 

patients. The results of TMA’s 2007 survey of civilian providers show that only 55 

percent of psychiatrists accepting new patients will accept TRICARE new patients. 

Approximately 25 percent of providers noted reimbursement rates as the main reason they will not accept TRICARE patients. Fortunately, title 10 provides the DOD 

the flexibility to approve higher reimbursement amounts in order to obtain adequate 

access to health care services. TMA is currently performing a nationwide analysis 

of access to mental health services. This analysis will evaluate the impact of reimbursement rates on mental health access. Where appropriate, TMA will have the 

ability to increase rates to improve access. 

Vice Admiral ROBINSON. The Managed Care Support Contractors (MCSCs) monitor network adequacy and provide monthly Network Status/Inadequacy Reports—

Network Management Activities. Reports are forwarded to the Regional TMA with 

copies provided by the Regions for Service review and comment. 

Recent reports provide the following information related specifically to mental 

health:

• Shortage of Psychiatrists in Brunswick, ME—Naval Air Station [Require four 

Psychiatrists and we have two] 

• Shortage of Psychiatrists and Psychologists in the area around Naval Hospital Cherry Point 

• Shortage of Psychiatrist in the area around Naval Air Station Springfield, 

Missouri [require one more Psychiatrist] 

• The contractors have not indicated that the above shortages are attributed to 

low reimbursement rates 

• Shortage of Psychologists in the area around Yuma USMC/El Centro area 

[four Psychologist refusing to contract because they do not need additional business]

• Two factors may attribute to the above shortage:

• Anecdotally, this may be attributed to low reimbursement rates: the 

reimbursement rate may not be enough for the local psychologists to 

increase their availability 

• Or, it may be attributed to the fact that there are limited qualified 

behavioral health providers within this area and the demand is beyond 

the local capacity.

We have and continue to experience shortages of ENT, Anesthesiology, and Plastic 

Surgery in the area around Twentynine Palms. The MCSC (TriWest) continues to 

pursue these specialties despite the reluctance of providers to contract due to low 

reimbursement rates. 

Although we have seen other surgical and medical specialties refuse to join the 

TRICARE network due to low reimbursement rates, we are not attributing shortages with mental health providers to reimbursement rates; other than the anecdotal 

information on the providers in Yuma USMC/El Centro. Standard reimbursement 

rates in areas that have high demand and low mental health resources may not be 

sufficient to entice or reward providers to offer preferred access to TRICARE beneficiaries. 

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Lieutenant General ROUDEBUSH. According to the DOD/HA survey, Civilian Physician Acceptance of New Patients Under TRICARE Standard, conducted from fiscal 

years 2004–2007, of those physicians not accepting new patients, the number one 

reason was reimbursement. This ranged, as the number one reason, from 23.6 percent to 28 percent for the 4 years of the survey. The second highest reason for not 

taking new TRICARE Standard patients was the physician was not available or was 

too busy. 

The specialty least likely to accept any new patients, regardless of whether they 

were TRICARE, was psychiatry with only 89.4 percent accepting any new patients. 

Psychiatry is also the least likely specialty to accept new TRICARE Standard patients, with only 48.8 percent stating they would take new TRICARE Standard patients. 

Taking those two survey results into consideration, it could be deduced that reimbursement rates are in fact affecting the decision of providers to accept new 

TRICARE patients.

27. Senator MCCASKILL. Vice Admiral Arthur, Dr. MacDermid, Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant General Roudebush, do 

we have a problem getting mental health professions to enroll in and participate in 

the TRICARE network? 

Vice Admiral ARTHUR and Dr. MACDERMID. During site visits, the task force was 

not told of difficulties getting professions to accept TRICARE, but was told that professionals are sometimes reluctant, for the reasons outlined above. Or professionals 

might accept TRICARE but severely limit the number of TRICARE patients that 

will be seen, in order to minimize negative financial impact on their practice. 

Lieutenant General SCHOOMAKER. Participation in the TRICARE network by mental health providers varies from market to market. The 2007 TMA nationwide survey shows that psychiatrists have the lowest acceptance of TRICARE patients when 

compared to all other provider types. The Managed Care Support Contractors are 

aware of the increased demand for mental health services and are actively engaged 

in the recruitment of mental health providers. 

Vice Admiral ROBINSON. The TRICARE Program is managed by OSD(HA). While 

some Navy Medicine beneficiaries utilize TRICARE, we do not have any direct oversight over the mental health manning issues that TRICARE may have. We do however, monitor network adequacy reports provided by the Managed Care Support 

Contractors. 

Lieutenant General ROUDEBUSH. Getting mental health professionals to enroll in 

and participate in the TRICARE network is challenging. Currently there is a nationwide shortage of mental health professionals. Several task forces, including the recent Mental Health Task Force, identified several critical shortfalls within this specialty area. As we generate additional requirements in an environment where there 

is no unused capacity, Alaska for example, we will find these shortages increasing.

28. Senator MCCASKILL. Vice Admiral Arthur, Dr. MacDermid, Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant General Roudebush, what 

do you think we need to do to get more mental health professionals accepting 

TRICARE? 

Vice Admiral ARTHUR and Dr. MACDERMID. According to what we were told on 

site visits, raise reimbursement rates, speed processing of claims, and reduce administrative burden. 

Lieutenant General SCHOOMAKER. The DOD has the authority to adjust TRICARE 

reimbursement rates in specific markets for specific specialties. The TMA is currently performing a nationwide analysis of access to mental health services. The nationwide review by TMA will indicate which areas are having problems with mental 

health access and which area may be candidates for an increase in reimbursement 

rates. 

Vice Admiral ROBINSON. The TRICARE Program is managed by OSD(HA). While 

some Navy Medicine beneficiaries utilize TRICARE, we do not control general contract terms and other conditions that are set by OSD(HA). 

Lieutenant General ROUDEBUSH. The DOD/HA survey, Civilian Physician Acceptance of New Patients Under TRICARE Standard, conducted from fiscal years 2004–

2007, indicated that the number one reason physicians were not accepting new patients was reimbursement. This answer ranged from 23.6 percent to 28 percent for 

the 4 years of the survey. The second highest reason for not taking new TRICARE 

Standard patients was their practices were full. This answer ranged from 3 percent 

to 18 percent for the 4 years of the survey. A few other reasons were listed but were 

significantly less likely to result in a physician not taking new TRICARE patients. 

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Based on this data, it appears the area that would most likely result in increased 

provider acceptance of TRICARE would be in the reimbursement arena.

29. Senator MCCASKILL. Vice Admiral Arthur, Dr. MacDermid, Lieutenant General Schoomaker, Vice Admiral Robinson, and Lieutenant General Roudebush, what 

are we doing or should we be doing, in particular, to ensure mental health care access to servicemembers living in rural and remote areas, such as Guard members 

who demobilize in rural parts of Missouri? 

Vice Admiral ARTHUR and Dr. MACDERMID. Like their civilian counterparts, military families living in rural areas face several problems in accessing care for PH. 

There is a well-known shortage of providers, such as psychologists and psychiatrists, 

in such areas. There are now fewer military installations than in the past. Another 

problem is that the civilian providers who are present in these areas may be whom 

they come in contact. 

Many advocacy, professional and government organizations are working on the 

problem of reaching rural families, and it seems clear that a multi-pronged strategy 

is required. Elements of such a strategy likely include: a) increasing the number of 

military professionals who can be assigned to military installations as needed; b) 

creating incentives for civilian professionals to locate in underserved areas; c) increasing the number of DOD family assistance centers and VA vet centers; and d) 

increasing use of technology, such as web-based self-assessment and education, telephone-based counseling, telemedicine, and other emerging strategies. 

Lieutenant General SCHOOMAKER. Military OneSource now offers six telephonic 

mental health counseling sessions which U.S. Army Reserve and National Guard 

soldiers can use in remote areas. Additionally, in December 2007, the TMA required 

the Managed Care Support Contractors (MCSC) to establish toll-free Behavioral 

Health Provider Locators and Appointment Assistance Services. This service allows 

soldiers and their families to call the MCSC and receive assistance locating a network mental health provider. The provider locator and assistance staff have assisted 

more than 1,500 beneficiaries successfully locate and make mental health appointments. This often requires the locator staff to conference call with the beneficiary 

and provider to ensure a satisfactory appointment. 

Since October 2006, the Army Wounded Warrior Program has placed approximately 35 staff at VA Medical Centers around the country to assist wounded warriors, veterans, and their families access needed health care and social support services. Additionally, Warrior Transition Unit Forward Teams, formerly called AMEDD 

VA Liaisons, are assigned to VA Polytrauma Rehabilitation Centers. These uniformed personnel are strengthening the links between Army Medical Treatment Facilities, Warrior Transition Units, VA medical facilities, and civilian facilities. Some 

of their outreach efforts are directed at Army National Guard and U.S. Army Reserve soldiers. 

Family support is also part of the Army Family Covenant Initiative and the Army 

Campaign Plan. The Army Family Covenant Initiative is an approach to standardize and fully fund family programs and services to support an expeditionary 

Army. The Army Integrated Family Support Network (AIFSN) is a service delivery 

system that is part of this initiative and will integrate all the programs and services 

currently operational in a State or region, like the Beyond the Yellow Ribbon Program, which is a program built specifically for National Guard soldiers and their 

families. The purpose of the Beyond the Yellow Ribbon Program is to provide concise, coordinated, and unified support to our citizen-soldier and their families to ensure a safe, healthy, and successful reintegration following deployments. Connecting 

programs, like Beyond the Yellow Ribbon, to AIFSN will provide a conduit for the 

Army to better prepare and care for all of its soldiers. 

Vice Admiral ROBINSON. We have implemented several programs and initiatives 

to ensure that sailors and marines are provided mental health support during and 

after demobilization. Each of the Uniformed Services promote and participate in 

‘‘Military OneSource’’—a DOD web-based program providing comprehensive information and assistance (including guidance for obtaining counseling) for 

servicemembers. It also offers 24-hour/7-day-per-week toll free telephone access for 

assistance and support. During demobilization, sailors and marines receive briefings 

on post-deployment medical and dental benefits including those available through 

the Transitional Assistance Management Program (TAMP), TRICARE Reserve Select (TRS), as well as information and resources available at Navy and Marine 

Corps Reserve Centers. 

TAMP offers transitional TRICARE coverage for up to 180 days following separation for eligible members and their families. National Guard and Reserve members 

separated from Active Duty after having been ordered to Active Duty for more than 

182

30 days in support of a contingency operation are eligible for this coverage. Eligible 

members and family members include those who are:

• Involuntarily separated from Active Duty 

• Separated from Active Duty after being involuntarily retained in support 

of a contingency operation. 

• Separated from Active Duty following a voluntary agreement to stay on 

Active Duty for less than 1 year in support of a contingency mission.

To retain coverage, members must reenroll in TRICARE Prime during their transition period. This enables servicemembers and their families to access support 

through the Behavioral Health Provider Locater and Appointment Assistance Program, provided by all three Management Care Support Contractors. This program 

offers 24-hour/7-day-per-week assistance in locating and obtaining behavioral health 

care. 

In addition to service described above, Navy Medicine ensures that Post-Deployment Health Centers actively support completion of PDHAs, for Active and Reserve 

component members, to monitor the needs of servicemembers. 

Navy medicine has used a portion of the TBI and PH Supplemental to fund additional support for Naval Reserve personnel. The Navy Reserve has received $2.64 

million worth of support to establish the Navy Reserve Psychological Health Outreach Program. The goals for this pilot program are to:

• Create a PH ‘‘safety net’’ for Navy reservists and their families, who are 

at risk for not having their stress injuries identified and treated in an expeditious manner; 

• Improve the overall PH of Navy reservists and their families; and 

• Identify long-term strategies to improve PH support services for reservists and their families.

Outreach Coordinators will also be responsible for:

• Coordinating ‘‘Returning Warrior Workshop’’ presentations in conjunction 

with Navy Reserve Component Command Family Readiness Coordinators 

and members of the Chaplain Corps; 

• Working with the Navy Reserve PDHRA program manager to ensure reservists follow through with recommended or requested referrals to mental 

health care providers; and 

• Facilitating access to PH support resources for Navy Reserve family 

members.

With respect to specific concerns you expressed regarding rural Missouri, I would 

offer that, while there have been some difficulties in maintaining a robust network 

at Naval Air Station Springfield, and the surrounding area, the Managed Care Support Contractor (TriWest) is proactively addressing the shortage (one provider) with 

psychiatrists. TriWest has contracted 11 Mental Health Counselors to improve mental health access within this area. We are also exploring partnering with the University of Missouri in using their curriculum for the Training Enhancement in Rural 

Mental Health program to expand the capabilities of our primary care providers, 

both Active and Reserve component, to care for patients with higher level behavioral 

health problems. 

Lieutenant General ROUDEBUSH. The Military Medical Support Office (MMSO) 

serves as the centralized Tri-Service point of contact to coordinate health care outside the cognizance of a Military Treatment Facility for TRICARE Prime Remoteeligible Active Duty military and Reserve component servicemembers within the 50 

United States and District of Columbia. The MMSO assists the member in finding 

providers and ensuring smooth claims processing. The Air Force has three full-time 

military members at the MMSO ensuring these members receive timely assistance.

[Whereupon, at 4:46 p.m., the subcommittee adjourned.]

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