U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

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

http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,

U.S. Government Printing Office. Phone 202–512–1800, or 866–512–1800 (toll-free). E-mail, gpo@custhelp.com.

i 

80–753 2013

[H.A.S.C. No. 113–24] 

MENTAL HEALTH RESEARCH 

HEARING 

BEFORE THE

SUBCOMMITTEE ON MILITARY PERSONNEL 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

HEARING HELD 

APRIL 10, 2013 
(II) 

SUBCOMMITTEE ON MILITARY PERSONNEL 

JOE WILSON, South Carolina, Chairman 

WALTER B. JONES, North Carolina 

JOSEPH J. HECK, Nevada 

AUSTIN SCOTT, Georgia 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

CHRISTOPHER P. GIBSON, New York 

KRISTI L. NOEM, South Dakota 

SUSAN A. DAVIS, California 

ROBERT A. BRADY, Pennsylvania 

MADELEINE Z. BORDALLO, Guam 

DAVID LOEBSACK, Iowa 

NIKI TSONGAS, Massachusetts 

CAROL SHEA-PORTER, New Hampshire 

JEANETTE JAMES, Professional Staff Member 

DEBRA WADA, Professional Staff Member 

COLIN BOSSE, Staff Assistant 
(III) 

C O N T E N T S 

CHRONOLOGICAL LIST OF HEARINGS 

2013 

Page 

HEARING: 

Wednesday, April 10, 2013, Mental Health Research .......................................... 1 

APPENDIX: 

Wednesday, April 10, 2013 ..................................................................................... 25 

WEDNESDAY, APRIL 10, 2013 

MENTAL HEALTH RESEARCH 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Ranking Member, 

Subcommittee on Military Personnel ................................................................. 2 

Wilson, Hon. Joe, a Representative from South Carolina, Chairman, Subcommittee on Military Personnel ........................................................................ 1 

WITNESSES 

Carr, CDR Russell B., M.D., USN, Service Chief, Adult Behavioral Health 

Clinic, U.S. Navy, Walter Reed National Military Medical Center at Bethesda .................................................................................................................... 10 

Horoho, LTG Patricia D., USA, Surgeon General, U.S. Army ............................. 6 

Nathan, VADM Matthew L., USN, Surgeon General, U.S. Navy ....................... 7 

Travis, Lt Gen Thomas W., USAF, Surgeon General, U.S. Air Force ................. 9 

Woodson, Dr. Jonathan, Assistant Secretary of Defense for Health Affairs, 

U.S. Department of Defense ................................................................................ 4 

APPENDIX 

PREPARED STATEMENTS: 

Horoho, LTG Patricia D. .................................................................................. 45 

Nathan, VADM Matthew L., joint with CDR Russell B. Carr ..................... 61 

Travis, Lt Gen Thomas W. .............................................................................. 71 

Wilson, Hon. Joe ............................................................................................... 31 

Woodson, Dr. Jonathan .................................................................................... 32 

DOCUMENTS SUBMITTED FOR THE RECORD: 

[There were no Documents submitted.] 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Mrs. Noem ......................................................................................................... 85 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

Ms. Shea-Porter ................................................................................................ 89 

(1) 

MENTAL HEALTH RESEARCH 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, SUBCOMMITTEE ON MILITARY PERSONNEL, Washington, DC, Wednesday, April 10, 2013. 

The subcommittee met, pursuant to call, at 3:47 p.m., in room 

2118, Rayburn House Office Building, Hon. Joe Wilson (chairman 

of the subcommittee) presiding. 

OPENING STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH CAROLINA, CHAIRMAN, SUBCOMMITTEE 

ON MILITARY PERSONNEL 

Mr. WILSON. Good afternoon. And, ladies and gentlemen, thank 

you for attending a meeting of the Military Personnel Subcommittee Hearing on Mental Health Research—very important to 

the military and the young people who make possible for us to have 

the freedoms to be here today. 

Today the subcommittee will hear testimony on the research conducted by the Department of Defense and the military services to 

address deployment-related psychological health needs of service 

members particularly traumatic brain injury, TBI, and post-traumatic stress disorder, PTSD. 

Before I begin I would like to thank Ranking Member Susan 

Davis from California for suggesting that we hold this hearing. I 

would also like to recognize her leadership in this role while both— 

when she was chairwoman of the committee and now as ranking 

member. 

Today, we continue to address the signature wounds of the wars 

in Iraq and Afghanistan, PTSD and TBI. Our unwavering commitment is to our service members who are experiencing the challenge 

of multiple deployments. 

Collectively, the Department of Defense and in particular the 

leaders of the military health system who appear before us today 

have done tremendous work responding to the mental health needs 

of our service members and families. This has not been an easy 

task. I want to thank you for your efforts. Since 2007, Congress has appropriated close to $1.5 billion for 

scientific and clinical research for the Department to improve the 

prevention, screening, diagnosis, and treatment of PTSD and TBI. 

This investment has funded nearly 1,000 studies in collaboration 

with Federal, academic, and public/private partnerships. How have 

these studies increased the understanding of these conditions and 

how has this new knowledge translated into more effective methods 

of preventing and treating TBI and PTSD? 
2 

I am also anxious to hear about the future of these research efforts. How has sequestration and the Continuing Resolution affected both ongoing studies and those that are yet to be begun? We 

must not lose the momentum we have gained through this research. 

We must continue to build on the hard work that has already 

been done to fill in any remaining gaps in scientific knowledge. I 

am committed to supporting the Department of Defense’s goal to 

prevent and treat these devastating conditions. Our service members deserve no less. 

With that, I want to welcome our witnesses and I look forward 

to their testimony. 

Before I would introduce our panel, let me offer Congresswoman 

Susan Davis of San Diego an opportunity to make her opening remarks. 

[The prepared statement of Mr. Wilson can be found in the Appendix on page 31.] 

STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE 

FROM CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Mrs. DAVIS. Thank you. Thank you, Mr. Chairman. Let me join 

you in welcoming our witnesses. 

Dr. Woodson, General Horoho and Admiral Nathan, we want to 

welcome you back. 

General Travis, I understand that this will be your first testimony, and we certainly welcome you as well. 

Commander Carr, thank you for coming to testify and to share 

your expertise as a clinician with the subcommittee. 

We appreciate your service to the Nation, all of you, to our Nation, and appreciate your being here. 

Mr. Chairman, I want to thank you as well for your interest and 

for holding this hearing on mental health research. 

Over the past decade, the press has continued to characterize 

post-traumatic stress disorder and traumatic brain injuries as the 

signature wounds of the current conflicts. And I prefer to mention 

PTSD as PTS, post-traumatic stress, because I think what we know 

about that is not necessarily a disorder—obviously, some normal 

activity in many, many ways, a normal response to the situation 

that people find themselves in, but one of course that we must 

work with and we must work with it as it reflects the way in which 

it is amplified in the people who suffer from it. 

As a result of over the last several years Congress has responded 

by increasing the resources and the requirements for mental health 

prevention, treatment, and research. 

And what is important is that members of this subcommittee I 

believe understand where the mental health research is today and 

how we should move forward in the area of mental health especially given the fact that increasing fiscal constraints of the Department will be felt over time. 

As PTS and TBI begin to emerge as prominent injuries from the 

conflicts in Afghanistan and Iraq and stories of service members 

facing difficulty to obtain appropriate care begin to increase, Con-
3 

gress began its efforts to push the Services and the Department of 

Defense to be more proactive in this area. 

And efforts by Congress to address the issues that were being 

raised began back in 2004 actually when the Secretary of Defense 

was directed to conduct a study of the mental health services available to service members at that time. 

Since then, Congress has imposed a number of requirements, a 

number of policies and programs in an effort to improve the prevention, the treatment, and the research of PTS and TBI. 

Congressional action also included providing nearly $2 billion in 

funding for PTS- and TBI-related research. To date, the DOD [Department of Defense] has invested over $710 million in over 500 research projects related to the prevention, screening, diagnose, and 

treatment of TBI. 

More than $717 million has been provided for over 400 research 

project relations to the research of psychological health of service 

members including PTS, suicide prevention, military substance 

abuse resilience, prevention of violence within the military, and 

family related research. 

I certainly understand that science and research, particularly 

treatment research and pharmaceutical development, takes a significant amount of time before we can see concrete results. I think 

we all understand that. But it has been nearly 6 years since we 

began to significantly increase the funding that has been provided 

specifically for mental health research. 

It would help members to better understand how that money has 

been used. What, if any, are the results that have come from the 

research? Where are the potential breakthroughs? What areas in 

fact may not be as productive, what gaps may exist that should be 

addressed, and how should we begin to prioritize the demands that 

continue to grow in this area? 

I look forward to your testimony to hear from all of you especially on where we need to focus our attention to complement the 

ongoing activities of mental health research, prevention, and treatment. 

As the budget continues to shrink, of course greater pressure to 

reduce research and development funding will grow, and we need 

to ensure that our limited resources are being used in the most efficient manner. 

Thank you, Mr. Chairman, for the hearing today. 

Mr. WILSON. Thank you, Mrs. Davis. 

Even before we begin I would like to also welcome, additional 

members of Congress here because what you are doing and what 

you are saying is so important. And we have Congressman Bill 

Young who has been chairman of the House Appropriations Committee and as a veteran himself, a champion on behalf of service 

members and he is backed up by an extraordinary lady, his wife, 

Beverly, who is here today. And if you ever wonder where she is 

coming from, it says ‘‘Support the Troops,’’ and she means it, and 

she does. So both of you, thank you for being here. 

Additionally, we have Congressman Tim Murphy. Tim is actually 

a member of the Navy Reserve and he, with his medical background, has just been such a resource for all of us in Congress. So 
4 

Congressman Murphy of Pennsylvania, thank you for being here 

today, too. 

We are joined today by an outstanding panel. Given the size of 

our panel, the desire to give each witness the opportunity to 

present his or her testimony, each member an opportunity to question the witnesses, I would respectfully remind the witnesses to 

summarize, to the greatest extent possible, the high points of your 

written testimony in 3 minutes. 

I assure you your written comments and statements will be made 

part of the record. Let me welcome the panel. 

A longtime person who we can count on to be at virtually every 

hearing, Dr. Jonathan Woodson, the Assistant Secretary of Defense 

for Health Affairs, Department of Defense. 

I would like to welcome Lieutenant General Patricia D. Horoho, 

U.S. Army, the Surgeon General of the U.S. Army, United States 

Army. 

And we have Vice Admiral Matthew L. Nathan, who I am just 

so grateful, the Medical Corps, United States Navy, the Surgeon 

General, United States Navy. 

Additionally, we have Lieutenant General Thomas W. Travis, 

U.S. Air Force, the Surgeon General and of the U.S. Air Force. This 

is his first appearance. I want to welcome you. 

I also appreciate that we have a shared Virginia heritage and 

also as a graduate of Uniformed Services University of Health 

Sciences, I have a son who is a fellow graduate and I know what 

a great institution that is. 

Commander Russell B. Carr, M.D., United States Navy Service 

Chief, the Adult Behavioral Health Clinic of Walter Reed National 

Military Medical Center, U.S. Navy. 

So thank all of you for being here today. We will begin with Dr. 

Woodson and proceed, and again, thank all of you for being here. 

STATEMENT OF DR. JONATHAN WOODSON, ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE 

Dr. WOODSON. Chairman Wilson, Ranking Member Davis, distinguished members of the committee, thank you for the opportunity 

to be here today. 

Our Armed Forces have been engaged in combat operations for 

over 11 years. Our service members have performed selflessly and 

courageously. Their experiences have been unique in the history of 

warfare. 

They have survived injuries that 15 to 20 years ago would not 

be survivable and while this survivability rate is a reflection of our 

investments in medical research, it also brings with it new challenges in recovery and reintegration. They have returned to the 

war zones on multiple deployments placing exceptional stressors on 

their lives and on those of their families. 

While our investments in medical research are focused on both 

the visible and invisible wounds of war, today I will focus mainly 

on our research efforts surrounding the invisible wounds, TBI, 

PTSD, depression, and other mental illnesses and suicidal thoughts 

and behaviors. 
5 

Our research extends through a broad spectrum of activities. 

Foundational science, epidemiology, and ideology, how we can better prevent these illnesses and injuries, when someone is injured 

or ill how we can more rapidly and accurately diagnose their condition, when we have identified their condition how we can most effectively treat the individuals, how we can improve the opportunities for in the timeliness of recovery and recuperation including follow-up care and services research, and what the long-term needs 

of our wounded, ill, and injured will be in the decades ahead. 

In many cases over the past decade, we have been able to rapidly 

transfer our research findings to practical applications on the field, 

yet it is always—as is always, in the case of science, there are gaps 

that remain particularly in the neural and behavioral sciences. 

I will not cite each study we have under way today, but I will 

make several points about the nature of our research. First, the 

Department is not doing this work alone. We are working closely 

with our colleagues in the Department of Veterans Affairs, the Department of Health and Human Services to include the National 

Institutes of Health, the Center for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, and we have engaged the Department of Education. In addition, we have extensive collaborative efforts with private and public 

universities in industry. 

Second, we also are effectively leveraging the impressive scientific capabilities of our partner organizations by sharing clinical 

data that will benefit not just our service members but all Americans. 

For instance, the DOD, NIH [National Institutes of Health] Federal TBI Research Informatics System links TBI clinical research 

from the Department of Defense, VA [Department of Veterans Affairs], and NIH. In addition to the tremendous value it provides, 

shared data repositories decrease costs of research of standardized 

collection of research data and allow access for researchers outside 

of the original study creating opportunities for faster advancement 

in science through collaboration. 

Finally, we are intently focused on continuing to move from our 

research from the laboratory to the bench, from the bench to the 

bedside, of those who are ill and injured by more aggressively managing the portfolio of research, reducing the duplication and closing 

gaps by rigorous joint program and interagency scientific reviews. 

Scientific understanding and progress does not occur overnight 

as has been noted, yet we all recognize the urgency surrounding 

the work that we do. I want to express my great appreciation to 

this committee for the longstanding support and advocacy for our 

medical research agenda. It has made a difference in lives saved, 

in the prevention of illness and injury, and in the acceleration of 

recovery for so many of our service members. 

With your continued support and engagement, I am confident 

that we will continue to make progress in this important work and 

meet both our medical and moral obligation to those who have 

served and sacrificed. Thank you for the opportunity to speak to 

you today on these important matters, and I look forward to your 

questions. 
6 

[The prepared statement of Dr. Woodson can be found in the Appendix on page 32.] 

Mr. WILSON. Thank you very much, Mr. Secretary. 

General Horoho. 

STATEMENT OF LTG PATRICIA D. HOROHO, USA, SURGEON 

GENERAL, U.S. ARMY 

General HOROHO. Thank you, sir. 

Chairman Wilson, Ranking Member Davis, and distinguished 

members of the subcommittee, thank you for the opportunity to appear to you today to discuss the Army’s mental health research initiatives and to highlight the incredible work of dedicated men and 

women with which I have the honor to serve with. 

I would like to begin today with a story which illustrates the 

miracles which are possible from the investment in research and 

medical innovation. 

On June 2, 2009, during Staff Sergeant Paul Roberts’ deployment 

to Afghanistan his unit was performing a combat patrol when his 

vehicle was hit with an improvised explosive device. The impact of 

the IED [improvised explosive device] destroyed the vehicle, killed 

the driver, the gunner, and the interpreter. 

Staff Sergeant Roberts was the only survivor. He sustained severe injuries from the explosion including third-degree burns to his 

wrists and legs, second-degree burns to his arms and face, and 

traumatic brain injury. 

Due to the tremendous research investments made in combat 

trauma, psychological health, and TBI, Staff Sergeant Roberts recovered from both his visible and invisible wounds. He was medically retired and has successfully transitioned from military to civilian life. 

His survival and recovery from these horrific injuries and successful transition to the civilian life is a direct result of the fruit 

borne by years of medical research. 

Traumatic brain injury and post-traumatic stress and post-traumatic stress disorder have been characterized in the public as the 

signature wounds of Operation Enduring Freedom and Operation 

Iraqi Freedom. 

From 2001 to 2006, funding for research and psychological 

health, traumatic brain injury, and suicides totaled $83 million. As 

the impact of the invisible wounds of the war became increasingly 

evident, Congress significantly increased funding for critical research, and as was stated earlier, a total of $1.4 billion of research 

and over 900 research projects have been supported over the last 

several years. 

And I would like to highlight a few of the policies and programs 

which were guided by the past decade’s medical research efforts. 

TBI research findings have directly affected policy and changed the 

way the military acute concussion evaluation is used and administered in the deployment environment which has resulted in a 98- 

percent return-to-duty rate. 

The immediate goal in TBI diagnostics have been able to identify 

the unique biological effects of TBI. We are working on a capability 

for medics in austere combat environments to administer a simple 

test to detect TBI. 
7 

Similar to our approach to concussive injuries, Army medicine 

has harvested research findings to inform the identification in the 

treatment of combat stress and PTSD. The mental health advisory 

team examinations of in-theater behavioral health issues have impacted policy, improved distribution of mental health resources and 

services throughout theater, and modified the doctrine of our combat operational stress teams. 

Research has informed the development of new clinical practice 

guidelines. Army medicine has developed the embedded behavior 

health program to put care where the soldiers are. Embedded behavior health moves behavior health personnel out of our large hospitals, forms them into teams, and places them in smaller clinics 

much closer to where the soldiers live. 

This creates working relationships between behavior health providers and unit leaders to better understand the specific challenges 

soldiers face and then tailors their clinical services to serve them. 

This care model has demonstrated significant reductions in key behavior health measures while knocking down access barriers and 

stigma. 

Military medicine is at an important crossroads. We owe it to 

this generation of our soldiers and our families to help them deal 

with the consequences of war long after the last soldier departs Afghanistan. 

Our commitment to support wounded warriors and their families 

must never waver, and our programs of support must be built and 

sustained for the long road. 

In closing, a strong decisive Army will be, as it has always been, 

the strength of our Nation. In partnership with the Department of 

Defense, my colleagues on the panel today, the Department of Veterans Affairs, and civilian partners in Congress, we will be prepared for tomorrow’s challenges. 

Thank you again for the opportunity to testify in front of this 

committee today, and more importantly, thank you for the support 

you have given over the last 12 years. Thank you. 

[The prepared statement of General Horoho can be found in the 

Appendix on page 45.] 

Mr. WILSON. Thank you, General, for your very positive message. 

Admiral Nathan. 

STATEMENT OF VADM MATTHEW L. NATHAN, USN, SURGEON 

GENERAL, U.S. NAVY 

Admiral NATHAN. Chairman Wilson, Ranking Member Davis, distinguished members of the subcommittee, thank you for this opportunity to discuss mental health research including our progress, opportunities, and our challenges. We are sincerely grateful for your 

leadership and for the support you have shown in this area over 

the years. 

All of us in military medicine are dedicated to ensuring that the 

resources you’ve provided translate into effective treatment modalities and advances in caring for our service members. 

Navy Medicine Research, Development, Testing, and Evaluation 

is foundational to our mission of force health protection. Cuttingedge RDT&E [Research, Development, Test, and Evaluation] pro-
8 

grams bolster both our current and future capabilities and help 

sustain a culture of excellence. 

Our 2013 Navy Medicine Chartered Course reflects the strategic 

goals of readiness, value, and jointness, and these key priorities are 

fully synchronized with our translational research efforts, particularly those focused on post-traumatic stress, traumatic brain injury, and suicide prevention. 

Our clinical investigation programs are the core of the Navy 

Medicine PH–TBI [Psychological Health and Traumatic Brain Injury] translational research efforts. 

CIPs [Clinical Investigations Programs] result in actionable intelligence for our providers on resilience building, stress reduction, 

prevention efforts, and psychological treatment interventions. 

Our priority remains translating our investments, your investments, into advancements in caring for our sailors, our marines, 

and their families. Collectively, military medicine has done this exceptionally well in the combat casualty arena as evidenced by the 

unprecedented battlefield survival rates in our recent conflicts. 

We have leveraged research, advances, and point-of-injury treatment, evacuation and clinical practices as well as a registry of trauma throughout the continuum of care to save lives. Our commitment remains to realize the same level of progress and success in 

caring for our personnel with post-traumatic stress, traumatic 

brain injury, and other related mental health injuries. 

Our work continues to demonstrate progress and we see progress 

in several key areas including: identifying new therapies and 

strengthening the evidence for existing prevention and treatment 

interventions; utilizing surveillance practices to enhance communication, coordination, and detection; integrating innovative technologies and alternative therapies with treatment and prevention 

efforts; developing and validating risk and resilient screening tools 

to guide interventions and mitigate negative behavioral health outcomes following traumatic exposures; providing clinical and operational leaders, information, and strategies to facilitate early detection and improve outcomes; and capitalizing on data signals and 

surveillance outcomes to optimize effective decisionmaking and 

guide future mental health operations. 

Careful monitoring and assessment is inherent in our ongoing 

evaluation process. We are applying critical reviews through each 

phase and milestone to help ensure that our funded projects meet 

the intended objectives and provide the potential for long-term 

value to both our clinicians, our patients, and their families. 

Sound partnerships and collaborations have been critical to our 

research efforts. We are working in close collaboration with the 

Army, the Air Force, DOD, The Centers of Excellence, as well as 

the VA, other Federal agencies, and leading academic and private 

institutions. 

I believe military medicine can lead the way forward in this area; 

however, as I have said previously we will not solve this alone. The 

issues associated with mental health are presenting a national 

challenge and requires the expertise and commitment of our civilian colleagues from medical and nursing schools to leading research centers to private practice providers. 
9 

We must continue to undertake these efforts with a renewed 

sense of urgency. It is our obligation to those entrusted to our care. 

In summary, deriving best value from our research investments 

requires careful planning, sharp execution, and good stewardship of 

our resources. We are committed to finding solutions and providing 

innovations to enhance clinical diagnostics and therapies to improve the outcomes of our injured service members. 

On behalf of the men and women of Navy Medicine, I thank you 

for your support, your confidence, your leadership, and I look forward to your questions. Thank you. 

[The joint prepared statement of Admiral Nathan and Commander Carr can be found in the Appendix on page 61.] 

Mr. WILSON. Thank you very much, Admiral. 

General Travis. 

STATEMENT OF LT GEN THOMAS W. TRAVIS, USAF, SURGEON 

GENERAL, U.S. AIR FORCE 

General TRAVIS. Mr. Chairman, thank you for your kind welcome, my first experience here and I am looking forward to it. 

Ranking Member Davis, distinguished members of the committee, thank you for providing this forum to address something 

that is important not only to the military but also to this Nation 

and that is mental health and mental health research. 

The Air Force Medical Services made meaningful progress towards translating mental health research into clinical, and I would 

add, operational practice to improve behavioral health prevention, 

treatment outcomes, ensuring better health, operational performance, and of course quality of life for our airmen wherever they 

serve and after they serve. 

Fortunately, the rates for PTSD, PTS, and traumatic brain injury 

in airmen have remained relatively low, but we have joined with 

DOD in participating in research in these areas and of course benefit from the results as we treat our airmen and their families. 

While the Medical Research Materiel Command Structure and 

the Defense Centers of Excellence in Psychological Health and TBI, 

DCoE [Defense Centers of Excellence], have primary responsibility 

for the oversight of these areas of research for the DOD, our Air 

Force research teams focus their efforts on specific operational Air 

Force issues where needed while also participating in many joint 

and interagency research activities. 

Much of our mental health research is conducted at the 59th 

Medical Wing at Lackland Air Force Base in Texas and the 711th 

Human Performance Wing at Wright-Patterson Air Force Base in 

Ohio. We are very excited and encouraged by these research successes that have already translated into the clinical operational 

practice. 

As an example of the latter, as a result of our study on the 

stressors experienced by remotely piloted aircraft mission unit 

members, we are now embedding psychologists with the right clearances in remote warfare units to provide early intervention and 

care and have convinced commanders to improve staffing and 

change work shift cycles to align with the recommendations of the 

study. They have paid attention and the changes have been made 
10 

and we are seeing some promising results in these new remote 

warfare career fields. 

We are of course closely following our deployed airmen to understand the impact of war on psychological health to mitigate future 

battlefield mental health stressors. We have studies in place to examine secondary mental health effects when moving brain-injured 

patients in our air-vac system, best practices for psychiatric evacuees, and two studies particularly examining the stresses in pararescue, combat rescue, and special ops forces that may result in improved clinical practice guidelines and prevention. 

And while the Air Force suicide rate remains below the DOD average and age-adjusted civilian rates, we strive to make continuous 

improvements in that very important program as well. 

The Air Force is partnered with various universities but specifically the University of Rochester in 2004 to 2010 to evaluate the 

effectiveness of the suicide prevention program and we found out 

that in years when that program is more fully implemented Air 

Force suicide rates have been lower and we continue now to partner with various universities to learn more and then of course we 

share that information through the DOD suicide prevention office. 

In summary, these mental health research programs will help us 

prepare for tomorrow’s challenges while addressing long-term 

issues experienced by returning warriors. 

Thank you for your support of Air Force medicine, military medicine, and I hope today’s discussion is useful for all of us and I do 

look forward to your questions. 

[The prepared statement of General Travis can be found in the 

Appendix on page 71.] 

Mr. WILSON. Thank you very much, General. 

And we proceed with Commander Carr. 

STATEMENT OF CDR RUSSELL B. CARR, M.D., USN, SERVICE 

CHIEF, ADULT BEHAVIORAL HEALTH CLINIC, U.S. NAVY, 

WALTER REED NATIONAL MILITARY MEDICAL CENTER AT 

BETHESDA 

Commander CARR. Chairman Wilson, Ranking Member Davis, 

distinguished members of the subcommittee, I am honored to be 

with you today as a mental health clinician representing my colleagues throughout the Department of Defense. 

I am a board-certified psychiatrist and a psychoanalyst. I have 

also deployed to Iraq with the Army where I experienced firsthand 

both the blast of IEDs and the deaths of fellow Americans. 

Over the past decade, I have also heard the horrors of combat 

from my patients. From these experiences, I understand why some 

combat veterans feel they deserve to die while others feel more at 

ease sleeping under a bridge than rejoining the communities they 

fought to defend. I also understand why we must fight for them 

every day to help all of them. 

Currently, I run the Adult Outpatient Mental Health Clinic at 

Walter Reed. The wars continue in our offices just like in every 

mental health clinic in the DOD. Almost everyone we see is suicidal. We use all of the approaches at our disposal both evidencebased and innovative ones to keep them alive and to help them reconnect with the rest of America. 
11 

Since the wars in Iraq and Afghanistan began, our knowledge 

about comment related PTSD or PTS has grown exponentially. Research must continue. It is not quick and it is not easy but we 

must continue it. 

Here are a few examples of recent research that has directly impacted military mental health care. The PTSD checklist, also called 

the PCL, is a rating scale developed through research to help clinicians identify service members with PTSD and to track their symptoms over time. 

Recent research has also found that the benzodiazepine class of 

medications typically used for anxiety actually worsen many PTSD 

symptoms. They are no longer a standard treatment for PTSD. 

The last example is the blood pressure medication named 

Prazosin or Minipress. It has been found in an off-label use to reduce the nightmares and excessive alertness that many people with 

PTSD experience. 

In closing, we have made tremendous strides in understanding 

PTSD but there is still much to do. We are leveraging the best 

available technologies including talk therapies and treating it, but 

even the best treatments do not work for 30 to 40 percent of patients. In my opinion as a clinical expert, we need talk therapies 

created specifically for combat-related PTSD. 

As reflected in Admiral Nathan’s written testimony, military clinicians will continue to collaborate with their civilian counterparts 

to create life-changing treatments for those who continue to suffer. 

What I hope you take from my comments is that we cannot settle 

for success with only some of our service members and leave the 

rest behind allowing them to return to their hometowns as broken, 

tormented souls. The battle for our veterans’ lives is one we cannot 

lose. We fight it through continued research. 

It is my pleasure to testify before you today and I look forward 

to your questions. 

[The joint prepared statement of Commander Carr and Admiral 

Nathan can be found in the Appendix on page 61.] 

Mr. WILSON. Thank you very much, Commander Carr. 

Each of you has, have come across as so sincere and caring about 

our personnel and their families, military families. I want to thank 

each of you. 

We want to proceed to have a 5-minute questions with each person of the subcommittee and I am very grateful that Jeanette 

James who has served as an Army nurse, we are very fortunate, 

she will be maintaining the time. She is above reproach and I am 

just really proud of her resource on the professional staff and you 

know and we want the American people to know what extraordinary staff people we have who are available on issues such as we 

have today. 

As we begin, and the 5 minutes applies particularly to me, I 

want to ask our first four witnesses, and I have a keen interest in 

this. I was the past president of Mid-Carolina Mental Health Association and so as you were presenting different points, I—this is an 

issue that I have worked on for many years with a very personal 

interest and knowing what can be done. It is my understanding 

though that DOD will stop funding medical research for the rest 
12 

of fiscal year 2013 and use the funds to pay TRICARE providers 

instead. 

Please explain what impact resource constraints such as of the 

continuing resolution and sequestration have had on PTSD and 

TBI research. How will your constrained budgets affect your ability 

to continue studies beyond the fiscal year 2013 and beginning with 

Mr. Secretary on and then I have got another question, Commander Carr, for you. 

Dr. WOODSON. Thank you so much for that question. And no 

doubt 2013 is a difficult year from a budget point of view. Not only 

because of the actual cuts that are imposed by sequestration but 

cuts late in the year, the CR [Continuing Resolution], we have had 

to manage almost month by month in terms of our strategy. 

But to answer your question specifically, our intent is not to stop 

funding for research. In fact, most of the research for 2013 has already been funded. So those projects are ongoing, but really to drill 

down into your question, we are not going to wholesale shift money 

out of research on these important areas to solve other budgetary 

problems. We are going to have to find creative ways of solving the 

budgetary problems but that is not going to be what happens. 

Mr. WILSON. That is great news. Thank you. 

General HOROHO. —excuse me—tremendous challenges across 

Army medicine with sequestration and then medical research materiel command is one of my subordinate commands that oversee 

many of these research projects. 

And so as I look at the overall funding for Army medicine, I have 

made decisions that will protect behavioral health, warrior care as 

well as primary care and made the decision in primary care because part of what we have learned out of research is the positive 

impact of embedding behavioral health in our primary care clinics 

as a touch point. So that is why we have looked at that area. 

The impact that it is having on Medical Research Materiel Command is that we will be focusing on ensuring that we keep our top 

researchers in some of the projects that we can’t fund this year 

that they won’t stop but we want to maintain the talent because 

you can’t raise that up quickly and so that is a concern of mine is 

how do we make sure we maintain the capabilities for future research that needs to be done. 

So were still—I can’t give you a direct answer because we are literally monitoring the budget monthly as things change and looking 

at how we move money from the direct care over to the research. 

Mr. WILSON. But it does not—— 

General HOROHO. But we are committed. 

Mr. WILSON. But it does not appear to be a precipitous cutoff? 

General HOROHO. No, sir. There is nothing that we have cut off 

at all across the board. 

Mr. WILSON. Okay. Excellent. Thank you. 

Admiral NATHAN. Mr. Chairman, there are two prongs to it. One 

is the dollars for funding the programs themselves and then the 

other would be the personnel piece that might be sensitive to furlough. 

We have received no indication that we have to remove monies 

from research and/or development to pay for the operating and 

maintenance funding of our medical centers. So we are proceeding 
13 

until apprehended with all research in behavioral health and in 

wounded warrior programs. 

There are research programs and there are research grants that 

are heavily laden with civilian personnel, Federal employees, and 

the Department of the Navy has been so far fairly flexible in allowing exemptions to furlough where possible to protect any programs 

that are prioritized as wounded warrior and or recovering warrior 

programs. 

So at this point in time, I am fairly comfortable and confident 

that we are going to be able to continue the inertia that we have 

in these research programs for mental health, behavioral health, 

post-traumatic stress, suicide prevention. 

Mr. WILSON. Thank you so much. That is very positive. 

General Travis. 

General TRAVIS. Yes sir, I would echo what everyone else at the 

table has said. The Air Force DHP [Defense Health Program] funded R&D [Research and Development] and O&M [Operations and 

Maintenance] fund mental health research represent about 10 percent of the research portfolio and we have not impacted those 

whatsoever. 

We don’t know yet what the impact of sequestration on what we 

are going to be able to do this year but at this point, my intent is 

to keep R&D going and we will see as the years go by and budgets 

come down the impact of that. 

Very worrisome, because we are just now I think learning so 

much and I think to cut off the funding at this part, at this time 

as this war comes down would be really a shame. 

Mr. WILSON. And thank you all and following the 5-minute rule, 

I proceed to Congresswoman Susan Davis. 

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

And I wanted to come back with a few other questions, but Commander Carr, I just wonder from something you had said about the 

importance of talk therapies and the fact that we still don’t know 

a lot about which have the desired effect perhaps. I am not sure 

if I am saying that correctly. 

What I actually wondered from your statements, we are here because we want to talk about research and we want to maintain 

that, but at the same time sometimes when we are spending a lot 

of money I know that we hear out in the field essentially that some 

of that money might be better spent with making certain that we 

have the clinicians that we need that are well trained and perhaps 

have even had some experience in theater themselves. 

Is that something that you feel as well that sometimes we perhaps don’t do as good a job in making sure that we have all the 

available help necessary especially in communities that have a 

more difficult time accessing that kind of help? 

Commander CARR. Ma’am, trying to understand your question in 

terms of do we need more staffing, is that—— 

Mrs. DAVIS. Well I think we always need more staffing, but I 

think that there is also sometimes a feeling that we are spending 

money and time on research which I happen to believe is a good 

thing, but on the other hand that sometimes maybe that has a 

higher priority than having the clinicians in the field that we need. 
14 

I am just wondering from your experience if you wanted to comment on that. We always can’t do it 100-percent correct. I am just 

wondering if you sense some of that feeling and you get it from the 

clinicians that are in the field. 

Commander CARR. Yes ma’am, I—you know, I think we have 

spent much of the last several years to really standardizing a lot 

of the therapies that we use for particularly PTSD was what I was 

referring and I think we have a lot of—I would say all of our providers involved at this point had a lot of skills and a lot of experience but we are always trying to treat everyone that we can. I 

think that was part of what I am trying to say that not all of our 

patients responded to the same standardized treatments. And so 

we are always needing more—you know when I mention talk therapies in particular, I really believe the PTS, PTSD, the major treatment for this therapy, different forms of psychotherapy and medications can help with controlling symptoms, but we really need 

therapies specifically for combat trauma and of course, as you are 

saying, people who have been there, as some of my patients say to 

me. And they see the ribbons on my uniform and they say you will 

get it—you will understand because you have been there. You 

know, it is really—I don’t see it as necessarily exclusionary when 

they say that, but one of hope. They are wanting to be understood 

and wanting to feel understood by the person with them. And they 

think that someone who has been there can maybe do that. 

Mrs. DAVIS. I think it is interesting that we haven’t talked too 

much about stigma and we have spoken of that so many times in 

the past and it may be that we are overcoming that issue and 

working to look at the kinds of research, the kinds of therapies that 

are really the most helpful. 

Dr. Woodson, in your written testimony you mention the need to 

establish a coordinated military veterans and civilian brain donor 

registry and tissue banking system. And I am wondering, does that 

require any legislative authority to do that and is DOD now working to establish a system like that? 

Dr. WOODSON. Thank you very much for that question. Actually, 

we have established one. What we are learning is that we need to 

assist with some administrative changes so that service men and 

women and others who would choose at the time of their death to 

donate their brain can do so more easily and we can identify them. 

This is actually very important going forward in our collaborative 

efforts with the NIH and many of the civilian academic partners 

and will add I think a great deal to our understanding of the 

pathobiology of these diseases. 

So at this time I don’t think we need legislation, but we do need 

is some changes in administrative process. 

Mrs. DAVIS. And do you see that—in collaboration with the initiative that the president has mentioned as well—— 

Dr. WOODSON. Absolutely, yes. 

Mrs. DAVIS [continuing]. And the money would be—I understand about, what, $50 million or so will be going to DARPA [Defense Advanced Research Projects Agency]. 

Dr. WOODSON. Yes. 

Mrs. DAVIS. Okay, great. Thank you very much. 

My time is up, but I hope we have another round, thank you. 
15 

Mr. WILSON. Thank you Mrs. Davis, and we now proceed to Dr. 

Wenstrup, of Ohio. 

Dr. WENSTRUP. Thank you, and I am not sure who to address 

this to specifically so whoever feels they have the answer, if there 

is an answer, let me know. But I was wondering if there has been 

any look at risk factors before deployment such as—we all know 

the risk factor of going to war. I understand that part, but are 

there other risk factors that pertain to some of the troops before 

they deploy? 

General HOROHO. Thank you, sir. 

A couple things that we have looked at in the predeployment is 

looking at the stress factors of stress on the family, prior deployments, the number of deployments, any behavioral health history, 

and so we now have a behavior health data portal which is a Webenabled that asks consistent questions across the board and kind 

of tease out those risk factors that then is shared when we are 

looking at our treatment protocol and then it also can be shared 

with the provider that is in theater so that as we work on that care 

coordination and treatment plan. 

And we are also working with fusion cell of information. So there 

are many risk factors that are out there and sometimes commanders see one piece of that, behavior health sees another piece 

of it, primary care, so we have been working with developing a 

database, a commander’s dashboard, that will fuse all of that information together as we look at the health of the force. 

Dr. WENSTRUP. Are there ever any struggles between commanders who certainly don’t want to lose a troop but someone may 

be having too many risk factors to deploy? 

General HOROHO. I don’t think it is so much that, as we have 

seen with embedding behavior health, what it has done, it has actually I think brought our leaders closer with our soldiers and the 

behavior health community. 

We have seen a 58-percent reduction in risky behaviors just by 

having embedded behavior health in the units and so commanders 

are actually embracing this. And I think it is more and why we 

haven’t talked about stigma is because we have got five touch 

points now. And I think people are being much more comfortable, 

but this is part of our battle rhythm and the way that we need to 

take care of our soldiers and their family members. So I think that 

communication is helping. 

Dr. WENSTRUP. I thank you very much, ma’am. 

Dr. Woodson, did you want to add something to that? 

Dr. WOODSON. Just a couple of quick points. Clearly, if someone 

has a prior history of PTSD and particularly if it is undiagnosed 

or untreated, that is going to be a problem. 

Now as it relates to a previous history of PTSD, I think as we 

are dissecting through the data, one of the things that we are finding is that there are service men and women who come into the 

service with undiagnosed and unreported prior psychological trauma that is made worse perhaps by their military deployment experience. 

We are just getting through that data, but being able to dissect 

into the lives of the young people who come into the service and 
16 

understanding what kinds of trauma they might have been exposed 

to is really going to be important for the future. 

Dr. WENSTRUP. Thank you. 

I have a question for you, General Travis. You mentioned something about the reduction of the suicide rate within the Air Force. 

Is that within the Air Force or is that military wide? 

General TRAVIS. Well, we are all struggling with this and of 

course we now coordinate many of our strategies together to the 

DOD suicide prevention program, but the Air Force has had some 

success with an 11 element program that focuses mainly on leadership community, education, and of course special protection for 

folks under investigation. 

We have also targeted suicide prevention efforts at our most at 

risk career fields such as security police and maintenance, believe 

it or not because they have had some special problems. So our outreach to their supervisors and to those members were very specific 

in educating those folks and we have seen great results so far. 

I mean, everybody’s rates are slowly going up, but our program 

seems to be working and as with anything, it does take a while 

year-to-year to show the response. 

And one other just a comment to add to your last question, we 

have several studies going on our frequent deployers such as special ops and security forces as well and we look at family resilience, 

we look at relationships, we look at their social context, their psychosocial context on these frequent deployers, and because we do 

embed or dedicate, EOD [Explosive Ordnance Disposal] is another 

community that we are very tightly connected with, we actually 

know the families, they know us. 

That builds a trust that I think as Congresswoman Davis mentioned, the stigma issue is starting to become a little bit less of a 

problem. So we are learning a lot, and I think we will learn a lot 

more as we continue. 

Dr. WENSTRUP. Thank you all very much. 

I yield back my time. 

Mr. WILSON. Thank you very much and we have Congresswoman 

Noem, of South Dakota. 

Mrs. NOEM. Well, thank you, Mr. Chairman. I appreciate it and 

I want to thank everyone on the panel for being here today as well. 

It has been a great conversation and great discussion for me to 

hear. 

I have a couple of questions and I believe that it was Lieutenant 

General Horoho who has discussed the 900 different research 

projects that are going on throughout the DOD when it comes to 

acceleration of improvement, when it comes to not only our active 

military. And I might ask you to speculate a little bit into veterans 

as well after they come back from deployment and maybe aren’t in 

engagement anymore, but I am curious about environment. 

If some of these research programs have looked at surroundings 

and environment during the treatment process of PTSD or TBI if 

being in a calm or more peaceful situation accelerates that type of 

improvement. If you would speak to that. 

I would also like Commander Carr to speak to that as well if he 

notices because I think when you have specialized programs for 

treatment that they can engage in we may see that acceleration 
17 

much quicker and I would like to know if different programs, 

where they are located, how the facilities are arranged if that can 

make a big difference for military men and women. 

General HOROHO. Yes, ma’am. Thank you very much for that 

question and I can talk about it from firsthand experience in Afghanistan. 

We have 11 concussive care centers in Afghanistan and what we 

did at those centers we actually took our concussive care coordinators as well as our behavioral health and married those together 

in a very healing environment, so darkened rooms, small little 

lights, calm music, sleep tapes, and really looking at alternative 

medicine, how do you use that when someone is exposed to concussions, IED blasts, or other behavior health issues. 

Very, very positive feedback and that has actually led to our 98- 

percent return-to-duty rate in theater. We have also taken that 

same concept when—which has really driven the pain management 

task force is looking at how do you take alternative medicine therapies, or yoga, which also talks about the healing environment, relaxation, mindfulness, virtual reality, all of those are being incorporated into the communities in which we provide behavior 

healthcare. 

Mrs. NOEM. Okay, great. 

Commander Carr, if you could speak to that as well and then 

even talk about specific facilities or programs that may be available 

throughout the country that our men and women can participate 

in. 

Commander CARR. Well, I can talk about, ma’am, what I see as 

the importance of when you say peaceful environment, I actually 

think of the relationship between the—their therapist and the soldier or marine person coming in for treatment that—by peace I 

mean feeling gotten—feeling understood and being able to feel they 

have a safe place to—to process to talk about what they have experienced. 

You know, how I understand that, how I understand trauma is 

that it comes from feeling—people feeling—that no one else gets 

what they have experienced. They can’t tell it to anyone. They cannot process it with anyone and they are left alone. 

So it may mean that their battle buddies, their unit that they are 

with may help them—may feel in that sense peaceful to them, you 

know versus a place they may go home and no one else gets it and 

understands or someone who comes to see me, it is the relationship 

that I try and build with them. 

So I don’t think in terms of facilities, I you know, I think, unfortunately I—you know, my knowledge is much more local. I would 

have to take for the record any information on specific treatment 

facilities. 

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

page 85.] 

Mrs. NOEM. Okay. 

Dr. Woodson, could you refer to that? Another portion may be a 

way to describe this question is, is it often that our men and 

women have the opportunity to withdraw to a facility for a treatment program that helps them go back to Active Duty or service 
18 

quicker, and what about that would possibly make that acceleration of improvement happen? 

Dr. WOODSON. It is an excellent question and let me try to answer it two ways. I think we are learning out of the National Intrepid Center of Excellence that number one, you need to give special environments to some service members suffering from PTSD 

and TBI. And you need to give them a multidisciplinary evaluation 

because it may be a number of factors that are contributing to persistence of symptoms. You need to dissect them out and treat them 

appropriately. 

But the other part of the question is that as it were, looking 

through the research and learning more about this, one size is not 

going to fit all. And that what promotes a positive response and improvement in one individual of PTSD is not what is going to be in 

the other. 

And so if you look at the literature there is everything from service dogs that are helpful and it might be this issue of a service dog 

allowing a service member to reconnect with feelings and emotion 

and the world to equestrian therapy to golf lessons. And what I am 

saying to you is that one of the individualized approaches in the 

future probably is to figure out how to get that service member to 

reconnect. 

Mrs. NOEM. So with these research programs, are those of some 

of the things that we are researching and doing studies on so that 

we have different types of programs available throughout the country? 

Dr. WOODSON. So in our portfolio, we are looking at these alternative therapies and within the portfolio of PTSD we are really trying to get a better understanding of who is at risk, what are the 

triggers, and then what are the therapeutic options. 

Now I say that with the understanding and hope that you have 

the understanding that there is so much that is not known yet 

about this specific—— 

Mrs. NOEM. Well I have had some tell me that even it can make 

a difference for many to be in a rural area compared to an urban 

area, a larger facility versus a smaller facility, that even those 

types of changes can be beneficial for some over others. 

Dr. WOODSON. Now, I would agree with that. The issue is again 

I think it is going to—we are going to have to figure out how to 

predict an individual response to different therapies. 

I would say that as a last note that much of what we are doing 

is resonating in the civilian community. We are understanding that 

many more people suffer from this problem in the civilian community and some of the very same things that we are trying to deal 

with need to be discussed, dissected out, and we need to gain 

knowledge on the better. Combat-related PTSD may be a subclass. 

Mrs. NOEM. Thank you. 

I apologize. I am over my time, Mr. Chairman. 

Mr. WILSON. Thank you, Mrs. Noem. 

We will proceed to Congressman Austin Scott, of Georgia. 

Mr. SCOTT. Ma’am, gentlemen, thank you so much for being here. 

And Dr. Woodson, you spoke to an issue, very briefly about an 

issue that I want to talk about a little bit. We are all obviously all 

concerned about the mental health issues of our soldiers when they 
19 

come back and our citizens as a whole. And I think we are—we 

have got beyond I think the stigma of it, which I think was maybe 

the first issue at least for moving beyond that. And I think that, 

you know, the progress that is being made is pretty encouraging. 

I guess I get back to the challenge and commander you mentioned this and several of you have about the fact that what works 

for one doesn’t necessarily work for one person doesn’t necessarily 

work for the next person. 

But General Horoho, I am from Georgia, Fort Benning’s right 

down the road, not in my district but obviously a lot of our soldiers 

that are in combat are based there and many of our other bases. 

As far as equestrian therapy goes, we have a facility close to 

Benning called Hopes and Dreams. It is in Quitman. They have got 

some innovative ways that they have worked with members who 

have come back with problems. 

They have had a lot of successes and I guess my question is 

when we talk about the equestrian facilities and other things, what 

ongoing research is there with these alternative treatments and 

what are the opportunities for organizations like Hopes and 

Dreams to expand their reach, if you will, and their support of our 

soldiers when they come back? 

General HOROHO. Thank you, sir. We have with looking at 

equine therapy were actually doing more of that in the Western region and looking to see whether or not that is beneficial. So Fort 

Riley is one of the areas where we have been using that therapy 

to look at and evaluate. So that is kind of where we have focused 

it. 

The opportunity is there with collaborative partnerships so if 

those—if there is an area near Fort Benning and that organization 

would like to partner, that is something that can be done with the 

local commanders and the commander of the facility there. 

Mr. SCOTT. Okay. I will get you some information on that and 

I appreciate that. 

One of the other areas that I have questions about is the 

hyperbaric chambers and the studies that were done with the use 

of hyperbaric chambers. What would—and it doesn’t matter to me 

whichever one—Dr. Woodson, maybe start with you since you are— 

what—the research that came from those tests, what opportunities 

are there, what challenges are there? What are the beliefs of the 

DOD right now with the use of hyperbaric treatments? 

Dr. WOODSON. That is a great question. As you know, we took 

on a rigorous evaluation of hyperbaric oxygen therapy a few years 

back. The literature had a lot of anecdotal reports, uncontrolled reports of benefit in TBI and other diseases to tell you the truth. 

We have four trials. The first—and the Surgeon Generals can 

speak to specific trials—was reported out I think in the September 

timeframe and that showed that while it wasn’t detrimental to the 

individual, it did not show any clear benefit. We have another trial 

that is due out either this month or next month and another I believe due out in the fall. 

What we hope to do is after these trials are completed and some 

are placebo-controlled trials is then convene a consensus panel to 

make final recommendations around this particular therapy. 
20 

Mr. SCOTT. I have talked to soldiers that have been involved in 

it and some of them of feel like it helps and some of them don’t. 

Again, it might be one of those issues where it works for one and 

doesn’t necessarily work for the other. And I hope that that when 

the decision is made that we are doing whatever we can to make 

sure that we are opening that opportunity for people who do want 

to try it. 

With that said, Mr. Chairman, I will turn the remainder of my 

time back in, and thank you for being here. 

Mr. WILSON. Thank you, Congressman Scott, and in consultation 

with the ranking member, we will proceed with a second round of 

questions. 

Commander Carr, I am interested in how PTSD and TBI research has improved medical care for service members. Please give 

us examples of improvements from your own practice. 

Commander CARR. Thank you, sir. I can think of a couple of applications of what I—of examples that I described in my opening 

remarks. Prazosin, it is a medication that was found—it is actually 

a high blood pressure medication and it was discovered several 

years ago that it would decrease nightmares, decrease arousal 

symptoms; treating right now a Army physician who has had severe PTSD from being in Fallujah for about a year, the battalion 

aid station. 

She saw horrific casualties, she has attempted suicide three 

times. She has made it clear, there will not be a fourth that is not 

successful. I inherited her as a patient when I got more—she was 

struggling with other therapies and I tried her on this medication, 

and it has worked. It has reduced a lot of her ‘‘on edge’’ all the 

time, feeling like—as she puts it—being ‘‘over there’’ all the time. 

She can start to reengage a little bit more and feel connected 

again and we still have to process a lot in therapy. Again, talk 

therapy is really where the work is done with improving PTSD, but 

it has really been a gamechanger for her. 

You know, I can think of other in terms of specific examples of 

other treatments. You know we have a—I think of a patient right 

now that you know had struggled with some of the standard treatments that have been tried before. 

As I mentioned before, they are not all the—not everyone, as you 

have heard from other panel members, not everyone responds to 

standard treatments and part of that is some of the main therapies 

that we use were actually originally developed for one-time sexual 

assault trauma and transferred over into combat trauma which is 

much more—much more extensive going over several years, many 

incidents, and it is a different—as I argued before, combat trauma 

is a different experience. As Dr. Woodson said it is a subset in 

many ways of forms of PTSD and the standard treatments may 

work very well, but others it doesn’t work for and the—they need 

something that focuses more on the state that they are in, that 

they are left versus specific incidents that they are trying to overcome or process in their mind. 

And you know I have been working with at least several in you 

know, much more of what are called psychodynamic approaches or 

other more innovative approaches that have started—you know 

that are basically trying to help reach them where they are. And 
21 

you know, there is ongoing research in those fields as well that I 

am learning from, I take in information from. I am continuing to 

try to seek the latest research and learn more about them. 

Mr. WILSON. Thank you very much. And I can tell you you are 

really putting your heart into what you are doing too, so thank you. 

And General Horoho, I have a—it is a hypothetical and it would 

be advice to a commander and that is if a soldier is in theater and 

has killed the enemy while deployed and feels that he can’t do it 

anymore but tells his command this, what does the command—how 

do they react? What do they do? 

General HOROHO. Okay. Sir, thank you. As we look at that, that 

commander looking at that has several options. 

Right now we have 90 sites for telebehavior health in Afghanistan. So some of the most remote combat outposts for exactly what 

you are talking about. So we have our combat stress control teams 

that are far forward on the battlefield so they would be able to turn 

to someone that has a habitual relationship with the unit and say, 

‘‘I need you to please talk to the soldier.’’ A lot of times it is done 

after-hours, so that soldier is—you know, if they want their privacy 

they will do it after-hours because they don’t want their peers to 

sometimes to know that they are going. 

They can have telebehavior health so that we are trying to get 

in front of something so that you are not waiting until you read a 

playback or having to go to either Bagram or Kandahar. We can 

get that capability far forward in being able to deal with it and 

then we have our chaplains that are there as well. 

And we also have the resiliency centers and if I could just really 

focus on that because we talked so much about treatment, diagnosis and treatment but really a tremendous amount of work is 

being done on resiliency and trying to get far forward of the left 

of the boom. 

And the comprehensive soldier family fitness of looking at what 

are the strengths that an individual has, what are the stressors in 

their lives, and what are the right coping skills so that we can 

equip those individuals with that. 

That is now a standard across the entire army and we are trying 

to put as much capabilities either through telehealth which we 

have had about a 780-percent increase, which is tremendous and 

so we have had over 7,700 behavior health appointments a day. 

So we have seen a huge increase and I think that is helping. And 

part of that is used from this telehealth that we have in theater. 

So he has many resources to be able to reach out to and then 

if they feel like they need to be taken back to the Resiliency Center 

and have several days of rest, they are doing that. From 7 to sometimes 14 days of rest. 

Mr. WILSON. That is extraordinarily encouraging, and I have 

seen domestically the success of telemedicine. So this is as a parent 

of four members of the—serving in the military today, what you 

said is just incredibly encouraging. Thank you very much. 

And I proceed now to Mrs. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. I think it is really obvious listening to you that we have deployed many different modalities, really tried to respond as quickly as possible. What we know 

about scientific research and I think you mentioned this, General, 
22 

that it takes about 16 years sometimes to be able to translate that 

into real practice and policies and yet it feels as if we have tried 

to shorten that. 

What is helping that process along? Can we do it even faster in 

some cases? And is it a financial problem that we face in terms of 

trying to do that or is it more the nature of what you are working 

with? 

Dr. Woodson. 

Dr. WOODSON. Maybe perhaps I can take that question on. You 

have asked two very good questions. One had to do with what have 

you done that has translated into making a practice better for the 

physician at the front line? What is the value of the research? 

Well, what we have done actually is we have in some sense reengineered the way we call what is the best evidence in medical 

science and then get it out to the field. 

And if I could, we have published a series of guidelines that we 

get out to the field that are readily available to clinicians so that 

they don’t have to plow through all of the literature and the like. 

We, DCoE’s, one of DCoE’s main benefit has been to get the experts together, decide what is the best evidence about what works 

and get it out to the field. This strategy has reduced our death 

rates from trauma and it is reducing I think the impact of these 

nonvisible wounds of war and allowing us to treat them more effectively. 

Now having said that, there is a sort of a ying and a yang circle. 

We can look at the outcomes of the best evidence and say it is not 

good enough and feed that back into research design to improve 

protocol. 

The other thing is with this design, we can—and the collaborations we have set up—we can move through the science and the 

process of investigation a lot more quickly to generate new knowledge and then to get it back into practice. 

So we are trying to reengineer the way we do research as much 

as we are trying to make sure that the clinicians have the latest 

and greatest and best-evidence treatments available to them. 

Admiral NATHAN. If I could just give you a tactical example of 

what is happening at Camp Pendleton in San Diego—— 

Mrs. DAVIS. Right. I was going to ask you about that, but I am 

running out of time. 

Admiral NATHAN. So the question is, you go into a large clinic 

where lots of people are being seen by lots of providers and perhaps 

one provider has stumbled onto something that works pretty well 

and how do we distribute that, how do we disseminate that quickly 

and rapidly? 

So that program, every patient—there are over 3,000 that have 

been enrolled so far—are given iPads when they come in and go 

through a series of standardized questions about how they are 

doing. 

This is before they see the provider and they go through a standard where they can enter in the kind of treatments they have been 

receiving. That is all correlated in real-time as to how this large 

cohort of patient populations seen at these mental health clinics 

are doing in San Diego and Camp Pendleton. 
23 

That then immediately feeds back to the clinicians through the 

electronic medical record telling them what the general number of 

people are who are experiencing the symptom, what treatment they 

have been on so far, and has it worked or not. And all of a sudden, 

in real-time, you can change your therapy based on how the herd 

is sort of running. And we have seen great results with that. Already that has changed the paradigm out there of how we are 

treating sleep disturbances because what the doctors and the providers thought was the right answer turned out to be wrong. 

And these patients are also salvoed through email at home and 

their families are salvoed through emails at home. And so all this 

is collected and this is real-time information now that you have at 

your fingertips that tells you the providers in my clinic are trying 

this. It is not working. Why would I try it? Let me try something 

else. And then it catches on much more quickly. 

Mrs. DAVIS. That is a very good to know. It—so—because I think 

the other thing that is happening at Pendleton is people are getting 

a lot of attention and—in an organized way that doesn’t enhance 

stigma—that really—— 

One other quick question, Dr. Woodson, was just about the—you 

know, the Defense Centers of Excellence and coming under the 

Army now as the executive agent essentially. Is there anything 

about that that members of Congress should be concerned about 

because obviously we wanted to be certain that the centers were 

able to help all of us with that kind of information that you mention. 

Dr. WOODSON. So rather than concern I would greet it as good 

news and here is the reason why. The generals and admirals to my 

left I couldn’t be more proud of in terms of working together in a 

collaborative way to make improvements. 

MRMC [Medical Research and Materiel Command] is becoming 

more of a joint research asset. As we move to the defense health 

agency standup you are going to see part of that process formalize. 

So in moving DCoE under MRMC it gives it sort of administrative 

support that it couldn’t have out on its own and because it needed 

to generate protocols, distribute funds, take care of personnel, it 

frees it up from those activities in some sense and gives it appropriate support and oversight. 

It becomes a much more efficient process. return on investment 

is greater. So this is good news, and I will let the distinguished 

panel here talk to the benefits of joint research programs but 

again, I think we get answers faster, at lower cost, when we approach it collaboratively. 

Mrs. DAVIS. Thank you. 

Mr. WILSON. Thank you, Mrs. Davis. 

Dr. Wenstrup. 

Dr. WENSTRUP. Thank you, Mr. Chairman. 

You know, often, PTS is recognized sometimes long after the deployment and that is why we do the follow-up surveys and questions and find out how people are doing. Certainly often it is a recognized after that honeymoon period when someone comes home 

and just thrilled to be home. 

You know, what we have had other wars in our history and there 

have been various levels of combat stress or whatever it was 
24 

deemed at those times and you know we have had some wars 

where people came home to parades to meet headquarters where 

people came home and were spit upon. 

And I wonder if there is any effect from our society. In other 

words, is the way that society is approaching our troops, does that 

have any effect in your opinions on the high rise of PTS. 

In other words, coming home to an ambivalent nation. It is not 

really recognizing the sacrifices that are being made or in many 

people’s minds don’t feel it is important or many say we shouldn’t 

be there and you come home to that and you have given another 

year of your life and people are saying, what a waste. 

I am just wondering if that has any effect on some of the troops 

and maybe Commander Carr, you can address that first or whoever 

would like to. 

Dr. WOODSON. Let me just make an opening comment that I 

can’t answer your question specifically because I don’t know if we 

have dissected out all of those factors, but I would perhaps challenge one premise that PTSD is more prevalent now then it was 

in other wars. 

We just ignored it in other wars. Remember, PTSD wasn’t coded 

as a diagnosis until 1981 after—well after Vietnam. So I can remember just to give your personal story of hearing stories about 

my uncles when they came back from the wars and how the family 

talked about them being different. And so the point being is that 

it occurred in the other wars, we just ignored it at that point. We 

didn’t have a diagnosis for it. 

Commander CARR. Yes, sir. I agree with Dr. Woodson. I mean, 

there is World War II and the medical evacuations from the Pacific 

were—about a third of them were psychiatric and that is not really 

discussed very much from that war. 

Partly it is generational and there is a lot of silence, but there 

is definitely—there is definitely—it was called ‘‘combat fatigue’’ 

back then, but there was definitely what we would call PTSD now 

and you can hear it described of children whose say father fought 

in World War II and it may just not have been called that, but they 

were—they were seen as different. 

You know their spouse may say, ‘‘Well, they were never the same 

after the war.’’ And you know, ‘‘They have been abusive at times,’’ 

or ‘‘They may have drank a lot more,’’ and it is present with all 

wars, sir. 

Dr. WENSTRUP. My question though is do we as a society have 

any effect on the patients as they return or is this all due to their 

experience in theater or how we welcome them home. 

There may not be an answer but I am just curious and I recognize what you are saying that a lot of times we just didn’t talk 

about it in the other wars as we are now. 

Commander CARR. Sir, the only thing I would add is I think the 

expression of it is probably different. As an example, you know, 

someone that I treated described his father. He had three purple 

hearts from the African Campaign in World War II; campaign in 

North Africa rather and you know he came back—you know he 

came back a hero, but he still had PTSD but he was described as 

being different from the war. 
25 

You know whereas patients now may—maybe—they may react 

differently. People who have PTSD may talk in a much more negative way about their situation, about the wars, was it worth it. I 

have had patients who will say well, there is going to be no unconditional surrender on a battleship at the end of this and it does impact how they perceive themselves. 

Now both sets of those have PTSD but they just—it is just expressed differently I would say, sir. 

Dr. WENSTRUP. Thank you very much. I appreciate it. 

I yield back my time. 

Mr. WILSON. Thank you, Dr. Wenstrup. 

And we will be concluding with Congressman Austin Scott, of 

Georgia. 

Mr. SCOTT. Thank you. Thank you, Mr. Chairman. 

I have one quick question, Dr. Woodson, or any of you can address this. What about the spouses? When our soldiers come home 

obviously if the soldier is going through these things then obviously 

the spouse is sharing—in those areas—are we making therapy 

available for them? 

Dr. WOODSON. Yes. Absolutely. We have certainly increased our 

focus on families understanding that families are enablers. They 

are an important contributor and they suffer from the deployment 

both while the service member is away and when they come back 

the reintegration process and then if they come back having been 

harmed by their wartime experience, it becomes even more of a 

stress. 

We are looking for ways actually to do even good research on 

families. We are a little bit encumbered because not being in the 

military of course we can’t require them to participate in certain 

surveys and the like, but we are engaging more and more partners 

to look at what the effects of this stress is on the family and then 

what specifically we need to do about it. 

I am particularly concerned about children of service members 

who have been overseas and the fact that we don’t know enough 

about how to manage deployments, reintegration, and issues within 

families as a result of service to this Nation. 

Mr. SCOTT. Thank you. 

Mr. Chairman, I yield the remainder of my time. 

Mr. WILSON. Thank you very much. 

And as we conclude, again, on behalf of the entire subcommittee, 

I would like to thank all of you for being here. We appreciate your 

genuine concern for service members, military families. 

Secretary Woodson, thank you for concluding on that. 

Again, it is really reassuring as a veteran, as a part of a military 

family today, to know what you are providing and what this means 

to our country. 

With there being no further, we shall be adjourned. 

[Whereupon, at 5:12 p.m., the subcommittee was adjourned.] 

A P P E N D I X 

APRIL 10, 2013 

PREPARED STATEMENTS SUBMITTED FOR THE RECORD 

APRIL 10, 2013 

(31) 

Statement of Hon. Joe Wilson 

Chairman, House Subcommittee on Military Personnel 

Hearing on 

Mental Health Research 

April 10, 2013 

Today the Subcommittee will hear testimony on the research conducted by the Department of Defense and the military services to 

address deployment-related psychological health needs of service 

members, particularly Traumatic Brain Injury (TBI) and Post-traumatic Stress Disorder (PTSD). Before I begin, I’d like to thank 

Ranking Member Susan Davis from California for suggesting that 

we hold this hearing. I’d also like to recognize her leadership in 

this area both while she was the Chairwoman of the committee and 

now as the Ranking Member. 

Today, we continue to address the signature wounds of the wars 

in Iraq and Afghanistan, PTSD and TBI. Our unwavering commitment is to our service members who are experiencing the challenge 

of multiple deployments. Collectively the Department of Defense 

and, in particular, the leaders of the military health system who 

appear before us today, have done tremendous work responding to 

the mental health needs of our service members and their families. 

This has not been an easy task. I want to thank you for your 

efforts. 

Since 2007, Congress has appropriated close to $1.5 billion for 

scientific and clinical research for the Department to improve the 

prevention, screening, diagnosis and treatment of PTSD and TBI. 

This investment has funded nearly one thousand studies in collaboration with Federal, academic, and public-private partnerships. 

How have these studies increased the understanding of these conditions and how has this new knowledge translated into more effective methods of preventing and treating TBI and PTSD? 

I am also anxious to hear about the future of these research efforts. How has sequestration and the Continuing Resolution affected both ongoing studies and those that are yet to begin? We 

must not lose the momentum we have gained through this research. We must continue to build on the hard work that’s already 

been done to fill any remaining gaps in scientific knowledge. I am 

committed to support DOD’s goal to prevent and treat these devastating conditions. Our service members deserve no less. 
32 
33 
34 
35 
36 
37 
38 
39 
40 
41 
42 
43 
44 
45 
46 
47 
48 
49 
50 
51 
52 
53 
54 
55 
56 
57 
58 
59 
60 
61 
62 
63 
64 
65 
66 
67 
68 
69 
70 
71 
72 
73 
74 
75 
76 
77 
78 
79 
80 
81 

WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

APRIL 10, 2013 

(85) 

RESPONSE TO QUESTION SUBMITTED BY MRS. NOEM 

Commander CARR. While the relationship between provider and patient is probably the most important factor in the treatment of psychological health issues, it 

is also true that a tranquil, non-threatening environment is a vital aspect of psychotherapy, perhaps particularly for PTSD. There are two outstanding programs that 

serve as examples of the type of calm, peaceful environment that is important for 

PTSD care. One is the NICoE, or the National Intrepid Center of Excellence, located 

in Bethesda on the same campus as Walter Reed National Military Medical Center. 

NICoE has been developed as a place for innovative assessment and treatment for 

service members who have not responded to standard treatments for TBI and psychological health concerns. It has a beautiful architecture and a soothing environment that creates a unique experience for wounded warriors who are treated there. 

The second program is called OASIS, or Overcoming Adversity and Stress Injury 

Support, which is located at Naval Medical Center San Diego. OASIS offers a comprehensive program of evidence-based treatments for the mind and body. It also has 

beautiful oceanfront views that are integral to its peaceful treatment environment. 

[See page 17.] 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING 

APRIL 10, 2013 

(89) 

QUESTIONS SUBMITTED BY MS. SHEA-PORTER 

Ms. SHEA-PORTER. 1) In your testimony you’ve noted new drugs that can help 

with PTSD. I’m interested in what progress you’ve made using canine therapy for 

PTSD or TBI. Please tell me about your research and results using canine therapy 

for treatment or mitigation of PTSD or TBI symptoms. 

Dr. WOODSON. At this time, the DOD has no results to provide from canine studies of therapy for treatment or mitigation of PTSD or TBI symptoms. We included 

a request for studies to evaluate the role of service animals in PTSD recovery in 

a recent Program Announcement and received some research submissions in response. However, review of those submissions is not complete. 

Ms. SHEA-PORTER. 2) In your testimony you’ve noted new drugs that can help 

with PTSD. I’m interested in what progress you’ve made using canine therapy for 

PTSD or TBI. Please tell me about your research and results using canine therapy 

for treatment or mitigation of PTSD or TBI symptoms. 

General HOROHO. The Army supports complementary integrative medicine in appropriate circumstances and is open to alternative therapies. Canine assisted therapy for PTSD is an emerging area of alternative therapy. While some Service Members who received dogs from sources outside the Army have reported that the dogs 

have helped mitigate their symptoms, the medical benefit of canine assisted therapy 

for PTSD or TBI symptoms has not been validated by any formal studies. 

Neither USAMEDCOM nor USAMRMC has any currently funded studies involving canine therapy for treatment or mitigation of PTSD or TBI symptoms; however, 

the Army has an interest in pursuing such a study. USAMRMC included a request 

for studies to evaluate the role of service animals in PTSD recovery in a recent Program Announcement. Some research proposals have been received, they are currently in the review process. 

Ms. SHEA-PORTER. 3) In your testimony you’ve noted new drugs that can help 

with PTSD. I’m interested in what progress you’ve made using canine therapy for 

PTSD or TBI. Please tell me about your research and results using canine therapy 

for treatment or mitigation of PTSD or TBI symptoms. 

Admiral NATHAN. Therapy dogs are used in a variety of Navy Medicine settings 

to help reduce anxiety, lower emotional reactivity, and provide a sense of security 

to our patients. 

While Animal Assisted Therapy (AAT) remains experimental (i.e., more research 

is required), it has been shown to be effective in helping to treat a number of psychological disorders exhibited by many types of patients. These include hospitalized 

psychiatric patients, children with developmental disorders, patients with substance 

abuse problems, and victims of trauma. Therapy dogs have frequently been used 

overseas to help service members cope with the stressors of living in a deployed environment. They are also used in several of our facilities to help patients cope with 

the challenges associated with their medical condition. There is substantial anecdotal data suggesting that therapy dogs can be beneficial to service members with 

PTSD. 

At the National Intrepid Center of Excellence (NICoE), therapy dogs have proven 

to be an extremely useful part of the therapy regimen. One reason for this is therapy dogs help facilitate positive social interactions between service member-trainers 

and the public. With the dogs at their side, service members can begin to rebuild 

their sense of trust in others and their sense of self-worth. NICoE utilizes a contracted service, Warrior Canine Connection (WCC), to teach service members with 

PTSD and TBI how these dogs can be used to help manage their symptoms. Additionally, in collaboration with both the Uniformed Services University of the Health 

Sciences (USUHS) and NICoE’s Research Directorate, WCC is striving to gain scientifically-based evidence to demonstrate the benefits of the warrior-canine bond in 

reducing the symptoms of TBI and PTSD. They are also exploring the bio-mechanisms triggered during this human-animal interaction, which may correlate with 

the observed reduction in symptoms. 
90 

1 Barker, S. B., & Dawson, K. S. (1998). The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatric Services, 49(6), 797–802. 2Lefkowitz, C., Prout, M., Bleiberg, J., Paharia, I., & Debiak, D. (2005). Animal-assisted prolonged exposure: A treatment for survivors of sexual assault suffering posttraumatic stress disorder. Society and Animals, 13(4), 275–296. 

Ms. SHEA-PORTER. 4) In your testimony you’ve noted new drugs that can help 

with PTSD. I’m interested in what progress you’ve made using canine therapy for 

PTSD or TBI. Please tell me about your research and results using canine therapy 

for treatment or mitigation of PTSD or TBI symptoms. 

General TRAVIS. Research has demonstrated that the use of canine therapy is beneficial in the support of people with either physical or mental health diagnoses. Canine-assisted therapies can reduce anxiety [Barker and Dawson (1998)] 1 and complement other therapies for Post-Traumatic Stress Disorder (PTSD) like Prolonged 

Exposure treatment [Lefkowitz, et al, 2005]. 2 While there is a research project in 

canine therapy approved through Walter Reed National Medical Center, the Air 

Force does not have any mental health research specifically addressing canine therapy. However, with the support of Womack Army Medical Center, Pope Air Force 

Base (AFB) has implemented a service dog training program. Pope AFB’s program 

began June 2012 as a complementary treatment intervention for complex PTSD/ 

Traumatic Brain Injury cases and expects to expand to include a total of 8 service 

animals within the next several months. Although Pope AFB’s canine program is 

not research, reports are that those service members in the program typically show 

a decrease in suicidal thoughts, an increased sense of safety, independence, motivation and self-efficacy. 

Ms. SHEA-PORTER. 5) In your testimony you’ve noted new drugs that can help 

with PTSD. I’m interested in what progress you’ve made using canine therapy for 

PTSD or TBI. Please tell me about your research and results using canine therapy 

for treatment or mitigation of PTSD or TBI symptoms. 

Commander CARR. [The information was not available at the time of printing.] 

Æ