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Hearing of the Defense Subcommittee of the House Appropriations Committee - Psychological Health and Traumatic Brain Injury Programs

Location: Washington, DC

Hearing of the Defense Subcommittee of the House Appropriations Committee - Psychological Health and Traumatic Brain Injury Programs


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REP. MURTHA: We'll come to order. Let me welcome Dr. Embrey and -- and General Sutton to the committee and let me acknowledge Nick Bonaconnie (ph). Used to play for one of those teams in a -- you know, other than the Steelers. You know, I got my Steeler tie on. You notice that, Nick? But he's been very involved in research with spinal cord injury. Done a marvelous job there and we appreciate the work that he's done.

But we appreciate the work you two have done. A couple years ago this committee realized because we visit the hospitals so often that we had real problems with PTSD and brain injuries, and we put $900 million in and we want you to talk about how you spent that money, talk about how important it was, and then we put a billion dollars, I think, for PTSD last year. I was just out to Fort Carson and every place I go suicide rates are up, homicides up, divorce rates up.

So we got a lot of problems and much of it come from PTSD. In a book that a doctor friend of mine gave me, "War and Medicine", they talk about it's going to cost -- they quote the trillion dollar war and said it's going to cost $660 billion to treat PTSD after the Iraq war. I don't know if that's accurate but certainly we're going in that direction with the amount of money that we're spending and the sooner we get to it the better off we are, everybody that I've talked to.

But to give you an example, I was at one of the bases not long ago and the commander certainly recognized the problem, but in talking to some of the enlisted men in a private conversation one was telling me that he -- he was in Iraq and this fellow said he was going to commit suicide and he said, "Well, here's a rifle. Go out and shoot yourself." You know, that's not the way we want to handle it and yet it's -- it'll take a long time for that to get down to the -- to the NCO level.

The other thing that I noticed is the quality accorded to them is much less than it was. We have a tendency, those that's been there, to say the ones coming in now aren't as good as the old corps but still we -- we find that this is a real -- a real problem according to them. They call them sugar babies and so forth. But what I worry about if the quality has decreased, if we are facing people with a lot more psychological problems that come in the military just for the money or to get away to get a job, we're going to have more PTSD. And so it's something we have to really focus on and I know you folks are in the forefront and we appreciate it.

This committee has been in the forefront of taking care of military medicine for a long time and we've -- we've increased the money substantially year after year. Dr. Embrey mentioned to me that she was pleased to see that her request for increase in research for research has gone up substantially -- advanced research -- and I'm glad to hear that and we'll look at it and maybe even put more money in if we see that -- if you can persuade us that it's necessary and you're -- you two are very persuasive so we -- we appreciate your appearing before the committee, and I ask Mr. Frelinghuysen if he has a -- any comments.

REP. FRELINGHUYSEN: Thank you, Mr. Chairman. This is an important hearing and I'm substituting for Congressman Bill Young, who I may say would very much associate his, as would I, his remarks to those of the chairman. I think your work (here ?) is important. Let me first of all -- I think we all pay tribute to those obviously who fight in our behalf in Iraq and Afghanistan but to the remarkable work that physicians and medics do before you in fact deal with the more substantial parts of working to make their lives sufficient and better. Really what happens on the battlefield compared to Vietnam, remarkable transformation of healthcare and support.

But to you, General, I read of your distinguished career. You're in fact were at the (present ?) -- the creation of this new entity and have seen it through and we're particularly proud of your work, your distinguished -- (inaudible) -- history of work in the military and Ms. Embrey, as well for your work in this important area. I'm very pleased that both of you are here. We look forward to a productive hearing.

REP. MURTHA: As Mr. Frelinghuysen said, Bill Young has been in the forefront of military medicine when he was chairman and this is a bipartisan committee. We -- when we send a bill to the full committee it's not changed and when it goes to the floor it's not changed, and it goes to conference and we have some concessions and adjustments that we make. But as a whole the bill that comes out of here pretty well is the bill that you'll see at the end of the day. But we appreciate your coming before the committee and your dedicated work in the field of medicine. Dr. Embrey, if you'll lead off.

MS. EMBREY: Thank you, Mr. Chairman, Mr. Frelinghuysen. I thank you for the opportunity to bring you up to date on what the Department of Defense is doing to improve the quality of care for our warriors with psychological health needs and traumatic brain injury. We are very pleased to be here and we thank the committee, you especially, for the support that you've given us since the war began and we very much appreciate it.

REP. MURTHA: (Off mike.)

MS. EMBREY: Sorry. Is this better? Okay. We're committed to ensuring that every warrior, especially those with psychological health or traumatic brain injuries, receives consistently excellent care across the entire continuum of care from prevention, protection, diagnosis, treatment, recovery, and transition from the Department of Defense to the Department of Veterans Affairs or to the private sector. In 2007, the Department of Defense embarked on a comprehensive plan to transform our system of care for psychological stress and traumatic brain injuries.

The plan was based on seven strategic goals. First, to build a very strong culture of health leadership and advocacy for these two topics. The second was to improve the quality and consistency of care around the country as well as in locations where we have personnel across the globe; third, to increase the timeliness and frequency and quality of care regardless of where the patient is located.

Fourth, to strengthen individual and family health, wellness, and resilience; fifth, to ensure early identification and intervention for individuals who have conditions as well as concerns, which are not the same thing; sixth, to eliminate gaps particularly in the handoffs between physicians as they move from location to location; and lastly, to establish a very strong foundation of research to address gaps and to build new technologies and therapies for these two topics.

Throughout 2008, as you will see in our statement for the record, we made significant progress towards achieving those strategic objectives.

We established the Defense Centers of Excellence for psychological health and traumatic brain injury, which General Sutton is the director of. She is leading the effort to develop excellence in practice standards, training, outreach, research, and direct care for those with mental health and TBI concerns.

We established clinical standards which incorporated lessons learned and best practices to improve the quality of care and introduced evidence-based care as the enterprise standard for acute stress disorder and PTSD and depression as well as substance abuse disorders. To assess the likelihood of traumatic brain injury mild, we introduced a military acute concussion evaluation tool and published clinical guidelines for its management in field settings. We implemented a standardized training -- training curriculum for medical providers and we initiated a certification process for TBI programs at military treatment facilities.

To improve access to care regardless of location we funded additional mental health providers in contracts as well as civilians. We are also seeking ways to embed military uniformed providers in our units in operational settings. We also implemented a policy that requires first appointment access within seven days for psychological health issues. To strengthen resilience to psychological stress and traumatic events, we are implementing solid prevention and health protection policies, mitigating organizational risk factors, and strengthening family wellness programs.

To ensure early identification and intervention, we enhanced post-deployment health assessments and reassessments, modifying them to include information that helps us understand and early intervene problems as they occur. We are working to eliminate gaps in care as patients transition throughout the various systems or to different locations. Lastly, we are establishing a strong foundation of research that will improve prevention, detection, diagnosis, particularly for traumatic brain injury, and treatment.

Mr. Chairman, I'd like to thank you again for your contribution. My comments -- our joint statement is provided for the record. We stand by to answer questions.

REP. MURTHA: (Off mike.)

GEN. SUTTON: Mr. Chairman, Mr. Frelinghuysen, good morning and thank you so much for your supportive comments. I would just say that, sir, I join Ms. Embrey in -- in thanking you for the privilege of being here this morning and to review what -- what we've done this last year. We have come a long way since a little over a year ago when we started out with a title on a paper with passion in our hearts for this effort.

Since then, today, Mr. Chairman, I'm proud to report we've got five component centers, we've got a sixth center -- the National Intrepid Center of Excellence, which will be the hub of our network. We've got Dr. James Kelly, who has just joined us from the University of Colorado. He will serve as the director. We have a network of 20 and growing sites. These are a mixture of the VA poly-trauma centers as well as military treatment facilities as well as civilian facilities. Last month, we opened up the pilot assisted living program in Johnstown where we have three families and soldiers who are there recovering. We have a number of training programs going on.

We've trained over 2,700 providers. We have launched together with the department and the services over 90 research studies and we're continuing in that process with the FY '08 supplemental and the CSI. We're also, sir, in the process of working with the vice chiefs to launch a public national educational campaign because we can do all of these other things, Mr. Chairman. We can become that open front door for the Department of Defense, working with the VA for all issues related to these concerns, and we have done that.

We can continue our unceasing efforts to grab next generation solutions and bring them here and now today. But fundamentally, our challenge becomes that of transforming the culture -- transforming the culture to one of transparency, resilience, accountability, candor, strength -- one which supports individuals and their family members and recognizes that seeking support, seeking treatment, is an act of courage and strength. And so, Mr. Chairman, we will continue our efforts. We look forward to addressing your questions and, of course, we are committed to bringing excellence in all things on behalf of those who are so deserving.

I would just close my opening comments, sir, with some wisdom from a great -- great preacher who started out his life as a slave, and when looking back over the state of America at the end of his life he said this. He said, "We ain't where we want to be. We ain't where we ought to be. We ain't where we gonna be. But thank God we ain't where we was." I look forward to your questions, Mr. Chairman.

REP. MURTHA: Well, you gave me a couple articles which we want to put in the record and let me just -- just read the titles of the article. It was very poignant. One was by Gabriel Luera, L-U-E-R-A, and the other is -- is by a survivor of the war and to me having been there -- and one a Doonesbury cartoon which I don't know if we can put the cartoons in there but it's -- it's very poignant products of people who know what it's all about in -- in being at the war.

But you mentioned the Intrepid and Bill Young and I have talked about this and we're committed to putting the additional money in because we know the private sector they have done so much so many places all over the world and particularly in Fisher Houses and so forth that we're going to -- we'll put the $20 million in the -- in the supplemental. We'll recommend it to the subcommittee and we feel confident the subcommittee will -- will agree to fund the -- the equipment and so forth. The Guard and Reserve -- I know with the -- with the unit you have in Johnstown you're addressing problems that the Guard and Reserve have. That's one of the things that's worried us for a long time.

I've had a number of people -- and I've talked about it before, one had a foot amputated and he was blinded and he's struggling -- and in the early part of the war we didn't do near as good a job as we're doing now. One young fellow lost both his hands and was blinded. So we have a lot of them that get lost once -- once they -- they leave and the sooner we get to PTSD in particular the better off we are. And the work that's been done with prosthesis has just been absolutely amazing. In his "War and Medicine" when you look back at the Crimean War and World War I you see examples of how difficult it was for them to be rehabilitated versus the way we -- we do it today.

So it's like that former slave said. We aren't where we want to be but we're going to get there and we've got a ways to go. So I'm -- I'm impressed. Now, one -- one of the things I mentioned, General Mattis came to see me. He says at -- at Pendleton they have a new process of teaching the young people when they go to war about what it's all about before they get there with all the sights, sounds, and smells and so forth, and I don't know if any medical people have looked at it but I'd be very interested if you'd have somebody go out there and evaluate it from a medical standpoint to see if there's anything in addition we should do.

I was supposed to go out there and I just couldn't get out there to look at it. But he claims it -- and having been in Iraq himself for a long period of time he claims that could be the best type of thing to harden the mental aspect of this thing before they go to war. One -- two other points -- one, transplants. I had some people in that -- that said they could transplant hands, and I know that Dr. Embrey looked into it and -- and she feels that the cost is really expensive and the rejection process is so onerous.

But we're going to put some money in for that because we think we ought to do more research on rejection. I know sometimes their rejection medicine is so onerous that they feel like well, I wish I hadn't gone through it. Now, I know a lot of members have -- have -- finally say well, take that leg off because it's causing such a problem or take that arm off because it just is not getting any better. So but we -- we still think we ought to do research.

So we'll put extra money in and if somebody wants to be -- have a hand transplant or an arm transplant you'll certainly have that available. I know it's expensive but I think we -- that's the kind of stuff we need to do, especially if they lost both hands and I've seen a number of them that lost both hands and they -- (their ?) good morale when they're in the hospital but I know it has to affect them when they -- when they go home. But I appreciate the work you two do because there's no -- no better people to be in charge of this field than -- than you two are so we appreciate it. Mr. Frelinghuysen?

REP. FRELINGHUYSEN: Either one of you, will you talk -- give us a few of the -- give the committee a few of the statistics (relate to ?) traumatic brain injury.

GEN. SUTTON: Yes, sir. What we are finding is we're finding that of the continuum of traumatic brain injuries which, of course, encompasses mild traumatic brain injury or concussion, moderate and severe, of the over 8,000 troops that we currently have in our registry between 80 and 85 percent of them fortunately are mild concussion, but that doesn't mean that we're not concerned about them. Clearly, much of our research is aimed at better understanding what the impact of blast injury is, for example, and the differences between the concussion that may be experienced on a football field versus that which occurs on a battlefield where you have such a mix of factors -- the life-threatening stressors, the very real physical risks, the psychological risks, the moral and the spiritual risks.

When we bring troops back home and do the screening, we find that the incidence of traumatic brain injury -- and again, most of these are concussion because if they were moderate or severe they would have come through our medical evacuation system where we keep our arms around them and then had a care coordination process for ensuring that we keep our arms around their needs as well as their families. But for those who come back with their units it ranges between 10 to 20 percent of those who screen positive for concussion or mild traumatic brain injury. This is very similar to what the Rand study, which used a different methodology, earlier last year reported. When those individuals then get clinical evaluation whether it be in the VA system or within our own military treatment --

REP. FRELINGHUYSEN: Can you -- can you make the distinction here? You know, I -- I know that the -- according to the figures I have of the 61,000 veterans that the VA has screened for TBI to date 11,000 -- approximately 11 (thousand) to 12,000 or as you said between 19 -- about 19 or 20 percent screened positive for TBI. What's the handoff between the active DOD and the VA? You know, we like the notion on this committee that the DOD and the VA are joined at the hip, but in reality how are they co-joined?

GEN. SUTTON: Well, sir, let me give you an example. During this conflict, DOD has already transferred over a million records -- those post-deployment health assessment records and the post-deployment reassessment health records -- so that the VA providers will have those records when they see troops. This is a work in progress but I will tell you that the handoff, the -- the linkage between DOD and VA is -- is at the level that I have not seen in my 28 years in service. As an example of that would be the fact that when Secretary Peake first got into office last year one of the first things he did was he -- he sent one of his best and brightest psychologists, Dr. Sonja Batten, to become our deputy at the Defense Centers of Excellence.

So this is an ongoing partnership that continues to grow and develop, broaden and deepen. Ma'am, I don't know if you'd like to add to that.

MS. EMBREY: I'd like to talk a little bit about how we engage with the Department of Veterans Affairs. Back in 2007, the deputy secretaries of both departments determined that we needed to get together and to develop common approaches for how we solve some of the challenges associated with psychological health and traumatic brain injuries specifically. Together, with the oversight of and leadership of the top leaders in both departments we embarked on a series of initiatives to include coming up with common protocols for how we screen and assess for traumatic -- mild traumatic brain injuries.

We have had a decade's worth of partnership with -- on traumatic brain injury with the DVBIC, the defense brain injury center -- Defense Veterans Brain Injury Center, sorry. We -- we've had a whole series of updated clinical practice guidelines and post-deployment health guidelines that we've developed in partnership with the VA and we apply those to both of our health communities. So I would say that we have unprecedented levels of collaboration and sharing across the continuum of care.

REP. FRELINGHUYSEN: Obviously, those with -- that are severely -- have severe traumatic brain injury are wholly embraced by both the DOD and VA system. But obviously there -- there are obviously other soldiers besides the regular military, Guard and Reserve, who -- who are under -- have suffered concussions from IEDs. What happens to, should we say, the citizen soldier who it is -- is not hospitalized but let's say months down the road and we've had plenty of discussion in here -- what happens to that man or woman who might suffer psychological and certainly some symptoms of traumatic brain injury?

GEN. SUTTON: I would note that the -- the VA has completed a Herculean effort in contacting over 500,000 troops. These were troops who had gotten out of uniform or perhaps gone back to their communities as Guardsmen and Reservists before the screening had been implemented for TBI -- contacted every one of those troops directly, gave them the information on how to enroll, checked in with them to see how they were doing, and made that personal contact that is so important. Every individual who gets treated at the VA gets screened just as our individuals in -- in the DOD get screened.

REP. FRELINGHUYSEN: There is a desire obviously of many men and women in the service to get far away from the trauma they experienced, and I'm not talking about necessarily TBI but obviously the war environment, and I -- I assume that what you're saying you're giving them fairly high marks for the follow-up.

MS. EMBREY: Sir, we -- we use the same screening tool and in addition to that the department implemented a post-deployment reassessment six to nine months following deployment, and we engage the VA in that screening process for all service members whether they're Guard, Reserve, or active duty, and that -- that is the time in which we evaluate how they're doing. It's the point in time where research tells us it is the optimum time to early intervene, especially for mental health issues. So we have partnered with the VA and we conduct those screening processes with the VA for the Guard and Reserve specifically.

GEN. SUTTON: Sir, I know you'll also be glad to know that during this transition period there has been no momentum lost with the actions of the Senior Oversight Council that Ms. Embrey addressed. Just last week we had our first Senior Oversight Council meeting. It was chaired by Secretary Gates and Secretary Shinseki. I was asked to give a briefing on what the collaborative efforts are that are going on with the VA and DOD, joined by Dr. Ira Katz (ph) specifically aimed at suicide prevention. I will say that the national lifeline, that 1- 800-273-TALK, the VA has gotten over 100,000 calls on that --


GEN. SUTTON: -- many of them from our service members who are either still active, Guard, or Reserve, and we're working closely with our outreach center and all of the call centers to make sure that when an individual calls in we have the right processes in place to make sure that we take care of their needs, get them back plugged into the system, and there have been over 2,000 clear saves already -- (cross talk) -- two months.

REP. FRELINGHUYSEN: Excellent progress. Thank you both. Thank you, Mr. Chairman.

REP. MURTHA: Yet suicide rates are up.

GEN. SUTTON: Yes, sir. This is -- this is an area that clearly is demanding our greatest efforts and focused urgency. We are focused working on the -- on the far end of that continuum to make sure that our service members are aware of the danger signs who know how to -- and know how to intervene. Each service has a program that is geared towards that end.

But we also know how important it is to get what we say to the left -- to get -- to get to this side of writing the note or buying the weapon or giving one's prized possessions away, and to address all of those psychological health principles both at the individual, family, and community level that will build resilience, that will foster post-traumatic growth, and yes, will good Lord willing reduce our suicide numbers which, as you know, sir, in recent years have -- have gone up within the Army, at any rate.

REP. MURTHA: Well, you folks have done a magnificent job. In this book that I quoted, the American Revolution 41 percent of the people died from injuries and it goes -- stays about the same. Civil War went up to 56 percent, 37 percent in World War II, 26 percent in the Korean War, but it's down to 11 percent in -- in Iraqi Freedom. Now, Afghanistan -- and this is something that we need some advice on -- we keep playing around with these helicopters which we need to get these folks out. It's taken longer to get out in Afghanistan.

So I would assume that's one of the reasons that the casualty or the percentage of people who die from injuries or wounds is higher. So you folks need to -- you know, the military keep playing around with -- with coming up with a helicopter that'll work. We put $100 million in to fix the one up because they couldn't make a decision. We need a recommendation (that ?) you folks ought to get on them a little bit because you can see the difference there between the people in Afghanistan and Iraq where they get them out in a hurry in Iraq, and Afghanistan, for one reason or another and I would assume is because they don't have the ability to evacuate them so -- as quickly as they'd like.

MS. EMBREY: Sir, if I can address that a little bit. I know that Secretary of Defense, Secretary Gates, and General Petraeus both have identified this concern and have specifically asked for a plan that distributes medical assets in such a way that we can respond more effectively as we expand operations in Afghanistan.

REP. MURTHA: But Doctor, we don't get a decision. We keep getting studies. That's the problem with the Defense Department. They study it to death. In the meantime, people are not making it because they don't have the equipment they need out in the field. That's the frustrating thing to me. You know, it's like any decision over there. It takes them forever to make a decision. In this particular case, we've been in front of them in TBI. We've been in front of them in -- in post-traumatic stress, all these areas. So you need to urge them a little bit to get -- get better medical evacuation.

REP. OSKY: Thank you, Mr. Chairman.

Two lines of questioning. One is for individuals who do have a problem, who have been injured. Do you have a concern? Is there a problem about identifying them before they leave service? We've had this discussion in previous hearings about "I just want to sign my papers, I'm fine, I want to get out."

Are we losing people? Do you have programs in place to do a better job to say "Listen, there's no shame here. We want to help. We're not trying to force you out, to deny you got a problem."

How are you dealing with that?

MS. EMBREY: The Department of Defense recognizes that we need -- its part of our Force Health Protection policy.

We are focused on maintaining and sustaining a healthy and fit force and we set up several metrics to evaluate how healthy the force is and how medically ready they are to deploy. We instituted a series of assessments, some of which are required by law, some of which are appropriate to ensure that we are constantly evaluating the health and the fitness of a person to serve.

We do that throughout their career. We do it on accession, we do it every year at a periodic health assessment and then prior to deployment, during deployment and following deployment, twice we evaluate the status of the health of the individuals so that we can appropriately intervene and sustain a healthy force.

When individuals do not come forward, we figure these forced assessment processes allow us to maintain visibility and as an individual separates, there's also a very elaborate separation physical process, which involves now the VA, as we evaluate injuries that have occurred over a lifetime. We have been evaluating a pilot to do just that and that would evaluate not only what an individual has suffered as a result of their service to us, but how compensable it might be from the VA perspective.

We're doing that with VA providers, so we believe we've improved the process significantly.

REP. OSKY: Okay.

What about children? Could you describe programs and how do you identify which children may be having a program? Is it through school programs?

MS. EMBREY: Yes sir.

Children certainly bare a good share of the toll and the wear and tear of deployment stress. We have a number of programs in place; the Military Family and Life Consultants working with the school systems, we partner with Military Child Education Coalition, for example, with their Living in the New Normal Program.

We've also invested in the National Child Traumatic Stress Network. The Uniform Services University is the military site for this national network that is working together to coordinate efforts to develop the research strategy, to collaborate and to identify; particularly building on the work of Dr. Steve Cozza, who during his time as the Chief of Psychiatry at Walter Reed, really pioneered a lot of the research that has helped us better understand how to support children who are part of wounded warrior families, as well as now in a broader community paced effort -- how can we reach out and give the support that is developmentally appropriate for children of military families.

We know now, eight years into this conflict, that for the children who were six, seven, eight years old when 9/11 happened, they're now in their teenage years and there are different issues that affect them that we absolutely must continue to support them and their parents in addressing; so, a number of programs, for example, the Mr. Poe Program. If you go to, they've got a number of videos using real military families and children to illustrate some of the challenges as well as the strengths.

We've partnered with Sesame Workshop, who has now issued the second of what will be a three DVD series -- the first one, "Talk, Listen and Connect", focusing on the general deployment stress issues for families and giving them a way to talk about it and to make it approachable.

The second one, which was launched last spring, focused in on the changes caused by deployments; both psychological/physical changes and how families adapt to those changes. This spring, we will be launching the third in the series, which will address the issues of grief, trauma and loss due to losing a parent.

So, we're continuing to focus our efforts on communities, families and we know that children are not only our armed forces of the future, they're our precious, precious treasure here and now. We will continue our efforts in that regard as well as continue to invest in the research, which will help us to better understand their evolving needs.

REP. OSKY: Any particular unmet needs you have that we can be helpful with, whether it's monetary or directive, to do a better job?

MS. EMBREY: This committee, particularly, has been extraordinarily helpful to us with the $900 million provided to us and then subsequent supplemental funds and honoring and increasing our budget requests over the last year.

We are challenged to make sure that we responsibly expend those dollars and we are learning from the infusion of those dollars right now. I would say that you've helped us significantly and we would like to report back to you in future hearings or briefings to let you know how we are doing with the money you've already provided, which is significant.

REP. OSKY: Thank you very much for your work. Thank you, Mr. Chairman.

REP. MORAN: (Off mike.)-- children who have lost their parents in the war. I coached football and taught class at Fort Devens after college for a while; boy, you could immediately recognize kids behavior based upon the status of their parents; either overseas or those who had lost parents. We do need to extend that but the first priority is what the Chairman put in the 2007 Supplemental for mental health care and that's the purpose of this hearing. It was $900 million, more than a billion has been provided now.

We were concerned last year, that of that billion dollars, only about $53 million was actually obligated. I know that that has now been corrected, that there is a substantial amount of money that is going into the purposes for which it was intended and particularly, looking at alternative means of providing mental health care; breaking from the tradition.

One of the problems I think that we've encountered is the military culture, as the Chairman and Mr. Frelinghuysen mentioned, its contrary to the culture to acknowledge that you might have some kind of mental health concern, particularly PTSD; you tough it out. That's counterproductive in terms of what we're seeing, and one of the contributing factors to the fact that suicide rates are twice what they are among the general population.

One of the things we found is that almost half of the military families are using what's called complementary medicine, integrative medicine -- I guess that's the term that you now use. Again, contrary to the culture, but they find that even meditation, yoga, all kinds of things that you never would have imagined in the last generation, is actually helpful in coping with the stress, the psychological problems that PTSD generates. Are you encouraging that or are you running into any resistance?

GEN. SUTTON: Thank you so much for that question, sir.

We are absolutely encouraging that. In fact, last spring, we published a request for proposal and were able to fund 10 projects specifically focused on complementary and alternative forms of therapy, such as yoga, acupuncture, tai-chi, facilitated pet therapy. We're continuing that work.

We know that in places like Fort Bliss, places like Fort Campbell, place like Camp Lejeune as well as Camp Pendleton -- and sir, I did have a chance two weeks ago to meet with General Leonard there at Camp Pendleton and to review that program, which was actually initiated through a partnership through our top psychological health advisor, Russ Schilling, and --

We are looking broadly. We recognize that this is a moment in history that may not pass our way again; certainly not in this lifetime. So, we see ourselves in a position where, through our efforts to transform military culture, we can perhaps even serve as a model for the nation at large. To that end, we are working very closely with the Samueli Institute; Dr. Wayne Jonas, as you know, has been a real pioneer in this area; as well as with the RAND Corporation.

This next year -- this year now, that we're in -- within the next month, we are launching the initial phases of what we're calling the Win-Win Network, the Warrior Wellness Innovation Network. This will be a series of pilot studies that we can put program outcome metrics against some of these promising practices. Whether it be the ones that we've already mentioned or non-invasive neuro-modulation; there a number of different bio feedback products and social networking tools and web 2.0 and 3.0 tools that really, we're so excited about.

For example, last fall, we launched our website, which now is getting 4,000 a month providing tools, providing interactivity, we've invested in Second Life and Island and now we're working with the VA so that we can make this truly a seamless transition.

So, yes sir, we will continue our efforts to both better understand the potential advocacy and use of these kinds of therapies as well as to promote them as part of our culture of resilience, performance and wellness.

REP. MORAN: Well said.

I want to get in a couple of questions so, maybe you can address that as well. I want your colleague to be able to speak as well, General. I'm also -- there are two other things that I'm concerned about; you can choose which ones to emphasize in your response.

When soldiers call the hotline that VA has set up, some people have suggested that it they are much more likely to talk, to listen, if the person on the other end has gone through their experience, is a veteran themselves. While the hotline that military one source is a terrific program, I wonder if we shouldn't compliment it with volunteers -- veterans, who would be more than happy to do that, many of them -- but it might encourage other veterans to be more likely to call, even though you've already gotten a lot of calls; I know that and I understand you've saved maybe a couple thousand lives.

I'd like for you to respond to that and then, in terms of personnel, you had said that -- actually we put into the language in the bill that you needed to hire more mental health providers, that for all the good intentions, unless you've got the mental health providers out there, you're very limited. You can do stuff on the web and so on, but you've really need professionals dealing with PTSD victims -- clients, I guess I should say.

Have you found them? Are you hiring them? I don't know how you're doing it because public health service has a great need as well and the public health service was supposed to provide the personnel that you needed to implement this program. Those are three things.

If you would like to, Ms. Embrey, maybe respond to the alternative medicine as well, because its very important for us, if we're going to fund it, we've got to be able to show objectively that it does work.

Thank you.

MS. EMBREY: Alternative medicine or alternative therapies are often not considered by the medical community as medically reimbursable (in ?) insurance companies.

So, it's very important that we -- that's why the Center of Excellence was stood up is to non-medicalize some of these approaches and to address these issues in ways that non-physicians and social workers and other folks that aren't certified, per say, can engage. Studying them and studying the metrics of their effectiveness is very important.

We believe very strongly that our leaders and our commanders own this issue, that we should not medicalize this; we should make it a part of their normal day-to-day living, that an individual should view themselves as a person who is striving to stay fit and healthy to perform their mission. Fitness includes mind and body and spirit and that just as we send people the gym to be physically fit, we need to create an environment where people can go to the psychological gym and that we develop through research the tools that will work to strengthen vulnerabilities in our mental health.

So, that's in answer to your first question.

REP. MORAN: Well put, thank you.

MS. EMBREY: Secondly, I think the idea that the Department of Veterans' Affairs -- I'm sorry, I'm an old timer; I keep thinking of VA as Veterans' Administration, but it is the Department of VA.

REP. MORAN: We do too, so it's okay.


MS. EMBREY: I think the idea of having a veteran who understands is the whole concept behind the Veterans' Centers that they stood up.

I think that we are trying to embed and engage our line leaders and outreach and education for the very same reason -- for our active duty service members -- that they are creating mechanisms within their units, within their command and within their line structures that don't medicalize it, but help people understand the signs and symptoms and to recognize when medical intervention is appropriate and to refer them at that time, without penalty.

Then to answer your question, "Are we hiring folks?" Yes, we are. Are we hiring enough? I don't think we could hire enough at this point, but I think we should give a lot of credit to the Tri-Care Community, out Purchase Care Network.

They have expanded their outreach to hire mental health providers to deal with our family members and beneficiaries and including retirees who, surprisingly, are affected and stressed by this environment as well. They've hired more than 3,000 health providers in our network since last year.

The services have a target of hiring 1,000 providers by this point in time. They have actually been able to hire 800 so far, approximately; so they're not as successful as they would like. We have several initiatives that are actually combining the energy of all of the services to have a single way, so that they are not competing with each other and elevating the salaries. So, that's one initiative that we're taking to try to improve that national recruiting initiative.

Lastly, the Public Health Service is assisting us. They were required by law to recruit a cadre(?), a fairly large cadre of mental health professionals to deal with Katrina-like events to be prepared to deal with that. We realize that if they had them on a string and they weren't being used, that that would be a problem. So, what we asked in a memorandum of agreement with them was to share those assets when they hired them to help us in our time of need.

We had a landmark agreement to support that and they are recruiting as best they can to meet our specific needs as they recruit to meet their objectives under the law.

REP. MORAN: Thank you very much, Ms. Embrey, General Sutton. You're both very articulate and I'm glad you're doing what you're doing.

Thank you, Mr. Chairman.

REP. FRELINGUYSEN: You put a little meat on the bones when Senator Dole and Secretary Donna Shalala did their work with the Wounded Warrior Program at Walter-Reed.

The Army was down 20 percent from its full compliment of psychologists at that point in time; the Air Force was missing 17 percent of its 235 authorized psychologists. It only filled, I think, 11 of the 23 internship slots last year. The Navy, which also provides -- correct me if I'm wrong -- psychological services for the Marine Corps, that was down 29 percent with only 87 of it 122 psychologists in non-training positions on board.

I know the figures are a little bit outdated; where do we stand now?

GEN. SUTTON: Sir, when the services came together as part of the Red Cell that Ms. Embrey led last summer, they identified what they projected their provided needs were going to be; that was roughly 1,000 additional providers that were identified of whom, approximately 80 percent have been hired at this point, thankfully, a year/year and a half later.

I think the other question though, that your question raises, is the need for us to look at our uniformed provider population, the authorized slots, because we know that with the needs on the home front, as well as the needs on the battle front, that there's been a tremendous load in operational and deployment load on our uniformed providers.

That's why, as we get the results back from this Center for Navel Analysis Staffing Study, which we're currently working to complete at this point, we'll be able to take a look from a risk adjusted population health stand point to look at the total complement of our team; both our uniformed providers as well as our government service/civilian providers as well as our contract providers.

It's a team effort, but your question raises a number of important dimensions that we are continuing to pay attention to.

MS. EMBREY: I'd like to also add that even if -- one of the other initiatives that Loree specifically has undertaken -- excuse me,

General Sutton -- is we recognize that our military treatment facilities are not where all of our assets are that need care.

General Sutton has in her Center of Excellence established a specific center that is focused on tele-medicine that will provide a fairly extensive network to use expertise that is resident in our system to provide consultative care in remote areas; this is particularly to address the issues of our guardsman and reservists who live in small towns, who do not have access to the kind of expertise that is needed.

She has a staff that's working those issues extensively and leveraging the already excellent(?) networks that were established with the VA.

REP. MURTHA: Mr. Bishop.

REP. BISHOP: Thank you very much, Mr. Chairman, and thank you so much, for what you ladies do for our defense health.

PTSD and TBI are real challenges that we are facing with this committee and our force and you have indicated in your testimony that -- well, let me just say that because of the challenges that we face, recruitment and retention of trained military personnel who are affected by TBI and PTSD is difficult. The replacement costs, which this committee has to be very concerned about, are very, very high. If you've got a pilot or a special ops person who suffers from PTSD or TBI, you're talking about hundreds of thousands of dollars per soldier to replace that particular personnel.

In your testimony, you talk about the fact that in FY 2007 and 2008 you executed research development and testing in the areas of psychological health and TBI, including complimentary and alternative medicine approaches to treating PTSD and TBI; yoga, even acupuncture.

My question to you, based on some information that I have recently seen, is what has the Department of Defense done in relation to hypobaric oxygen therapy treatment that has been used and which has been found to be extremely effective and economical in treating TBI as well as PTSD? There have been particular concerns where it has been tried and utilized and results were given, but Tri-Care would reimburse the cost of the treatment.

It is my understanding that you can get 80 of those treatments for about $16,000, compared to hundreds of thousand of dollars to retain or to train and recruit new military personnel. So, tell me about the hypobaric oxygen therapy support that the department has given and whether or not you are going to pursue that, whether or not you think its something that we ought to pursue and if it would give results, would you please? And explain, for those who may not know what that is, what that treatment consists of.

GEN. SUTTON: Yes sir.

Hyperbaric oxygen is a treatment that has been around for years; it's been used, for example, very effectively with would healing as well as divers in terms of folks who have the "bends". There are a number of different uses for which there is clearly sound evidence upon which to base that practice.

When it comes to traumatic brain injury, at this point, although there are some very promising case studies, we have not yet got the science in front of us that will allow us to move forward and establish this as a standard of care. Having said that, we are as hopeful as anyone that this may actually become a proven standard of care that we can use on behalf of our troops who are experiencing Post-Traumatic Stress and TBI.

We were looking forward to funding, research, quality research in the FY 2007 and FY 2008 broad agency announcement. There was one study proposal that met scientific muster with our peer reviewed process; we funded it, a pre-clinical animal study. We've also worked with Dr. Bill Duncan, who's here today, and his group, Dr. Harsh at Louisiana State University, as well as Dr. Syfu (ph) who is at Richmond, and Dr. Lynn Weaver at Utah, just to name a few of the experts in this area.

We brought together understanding that the research hadn't been done and we didn't get the proposals that would have allowed us to move forward. We said, "Well, let's bring together the leading experts across the services, across the government and across the nation.


So, early last December, we brought together approximately 60 individuals and spent two days immersed in this. The individuals who had done off label work with hyperbaric oxygen brought their pilot study data, we were able to lay that out on the table and the consensus was among that group, that in fact there was enough information, there was enough data, enough evidence that would allow us to go forward to conduct a multi-site, randomized clinical controlled trial.

So that is the course that we are on right now. We are working across those various studies that I mentioned in terms of the individuals that who are using it for off label uses at this point and we're very eager to bring that data into the randomized controlled trial data. We are, at this point, compressing what is ordinarily a 12 to 18 or 24 month cycle of study, preparation and development so that we can launch with subject enrollment as early as this April and launch a multi-site, randomized controlled clinical trial so that within a year, we will have some definitive evidence that will point us towards what the same and efficacious use for this modality may be.

REP. BISHOP: You think it's very promising.

GEN. SUTTON: It's very promising, sir.

REP. BISHOP: You have the resources now that you need to move forward with it?


REP. BISHOP: Okay, there's nothing else that this committee needs to do to --

GEN. SUTTON: Sir, we are -- at this point, we have a meeting scheduled with the FDA at the end of this month; they have been very helpful with this in helping us understand what the requirements will be. In this case, it will for an investigational new drug registration.

We are moving full speed ahead on this without squandering any of the scientific rigor and safety and standards that are, of course, so important in the integrity of any scientific research process. But, nothing more needed from this committee; we have everything that we need to move forward and we're very much looking forward to the outcome of this study.

REP. BISHOP: Thank you very much.

I understand that one of the people who participated in the pilot was a General who had brain injuries and had miraculous recovery as a result of this HPOT therapy and that it holds great promise for treating and it would save our government a lot of money in having to retrain people who are discharged who are well trained, as a result of TBI and PTSD.

GEN. SUTTON: Yes sir. We are all united in that hope that we can do whatever it takes to bring relief, health and wellbeing to our troops who are suffering.

Thank you.

REP. KILPATRICK: Outstanding.

As a new member of the subcommittee -- outstanding. First, that there are women in charge. I'm most impressed by that. General; General Sutton, your passion and your understanding and the rigor that you use in presenting yourself in the material is outstanding; to the both of you.

How long -- how old is this Defense Center of Excellence?

GEN. SUTTON: Ma'am, thank you for your kind comments and your words of support. The Defense Center of Excellence opened its doors on the 30th of November in 2007. At that time we had a receptionist, a phone number, a bank of empty offices, a part-time chief of staff, and two contractors, thanks to Ms. Embrey's generosity. From that point forward, ma'am, we have evolved the concept, we've grown the five component centers that I mentioned, we developed the design and concept of operations for the National Intrepid Center of Excellence which will be the hub of our national and global network.

We have also recognized the importance of broadening our focus. You know, you'll recall perhaps in the spring and summer of 2007 following the Walter Reed tragedy, there was a lot of focus on PTSD and TBI.

REP. KILPATRICK: And long has that been defined as such? I mean, how old does it go back? I have a --

GEN. SUTTON: Post traumatic stress disorder was actually codified in the diagnostic and statistical manual for the American Psychiatric Association in 1980.


GEN. SUTTON: And in fact --

REP. KILPATRICK: It's been evolving ever since?

GEN. SUTTON: But I will tell you, ma'am, and this is where it's so important for us to learn from history, is that we know from the beginning of time that these issues related to the adversity of war and post traumatic stress, everyone is affected by combat. In fact, I would worry about an individual who going down range and experience what our warriors are experiencing today, who would come back and say, you know, it didn't affect me a bit. Of course it does.

In our own Civil War, we talked about it then as soldier's heart, which remains to this day my favorite phrase for these --


GEN. SUTTON: -- these struggles but of course World War I shell shock, World War II battle fatigue, more recently combat stress and post traumatic stress.

REP. KILPATRICK: That's where I was kind of going. I have an uncle, World War II veteran, mental illness, came home looking fine but for the next 60 years was in and out of mental health hospitals and lived there for a couple of years, just died last year 80-some years old. Did not find it at first, came home looking normal but he obviously had battle-something and lost his mind literally. I'm happy to see the innovations and how we've moved forward on that.

I have one of my staffers here who's Riley Grimes who won an award from the Purple Heart Association just recently for his work in this area. So he's been kind of updating me, he's a Marine himself so he has a certain passion for that. So I wanted to appreciate you for that.

Tour of duty, and we keep hearing, they keep going back again and again, some two, three, four time deployment. I just last week was with a weekend with Chairman Dicks in Washington State on a Naval submarine, two of them, and one aircraft carrier talking to young sailors I'm told, sailors not soldiers sailors. And many of them had been out two or three times. Just depose that with suicide and what you discussed earlier with both TBI and PDSD. How does it all relate? How can we help with that? What needs to happen?

It comes back to me that we're short in military. Contractors we're talked about a little bit in this Committee and we're going to talk about it more. I know we have more now than ever before. Do we need, and this may not be your part because I know you're health, with the shortages that we're seeing in the enlisted and the repeated tours of duty, and TBI and PDSD, how does it all intertwine and relate?

GEN. SUTTON: Thank you for that question, ma'am. It is a serious concern.

I think once again looking back to our history, never in the history of our Republic has so much been placed on the shoulders of so few on behalf of so many for so long. And so there's an enormous challenge for us to both do some of the things that are already underway in terms of expanding and increasing the force strength, as well as tailing back on the tour lengths, those are certainly factors, risk factors that we're well aware of.

I think also there are the struggles and you mentioned the Navy, the Navy and the Air Force, those troops who have been included as individual augmentees for units to go down range and to do things perhaps for which they had not been trained initially and then they received training and go down as part of a unit but not their home unit. That also carries significant stressors related to it.

We know that in the history of warfare, actually suicides themselves, the suicide rate typically during high intensity warfare, is not adversely affected. And that makes some sense because when you're in high intensity warfare, you're focused on a goal, operations are very fast, very intense, very deadly at times certainly but suicide doesn't seem to be affected adversely in those conditions. We know that when it becomes a lower intensity and more protracted situation --

REP. KILPATRICK: Like multiple tours of duty?

GEN. SUTTON: -- like multiple tours, like the kinds of stressors on families, like the physical, spiritual, psychological and moral wear and tear over a protracted period of time, certainly that has its impact but I would like to also point out that while everyone is effected by combat, the majority of individuals do not go on to develop a disorder. The majority of folks who experience concussion or mild TBI completely recover from that injury and do well.

Now it's important for us to document it as we would any other injury, and it's important for us to monitor and evaluate to see does this troop need to take a knee, do they need to take a few days before they get back into the battle? And of course we have some of the same challenges as a civilian world does with high school football age and college age players who want to stay in the battle.

But those are all things that are important for us to continue to monitor, to act, to develop those programs while at the same time we ensure that we put the truth out in terms of the fact that most folks will actually do very well, and in fact many, despite the adversity of war, will go on to claim what has been termed now post traumatic growth. That is to say that even for example the double lower extremity amputee that I spoke with last week at the Canadian embassy who told me, ma'am, if someone offered to give me back my legs today, I wouldn't take them. I've grown so much in this experience, I know so much more about myself, my family, life, what my purpose is. Individuals despite the most adverse and ugliest of situations can develop a greater sense of purpose, of faith, of meaning, of connection to others.

And so it's important as we go forward that we communicate accurately and balance not only the tough reality of war, but also ensure that individuals understand that this is an experience like other traumatic experience from which individuals can not only bounce back but also grow stronger as a result.

REP. KILPATRICK: Thank you. Mr. Chairman one more based on what you just said. So will we find in five, ten years ran studies that show it's not the combat itself, but maybe the tour of duties or duty that would cause the rates to increase?

GEN. SUTTON: You know those are all questions that as we focus our longitudinal prospect studies, now over the next 10 to 15 years we will absolutely be able to understand more about those factors. Right now what we know is that each of those factors has an additive affect but we don't understand completely the relationship between them, as well as the various factors that combine to make this such a tough experience for both troops as well as family members and I must also recognize and I appreciate so much the Committee commenting on the service and sacrifice of our health care professionals. It's just phenomenal.


GEN. SUTTON: Thank you. And they deserve our care and concern as well. Thank you.

REP. MURTHA: Mr. Dicks.

REP. DICKS: I apologize for not being here for your testimony. I have another subcommittee that I chair that we're reviewing what the conduct of the Department of the Interior this morning so.

But there's questions I wanted to ask. One, I had some people come into my office and I know you've discussed this but I want to discuss it a little bit further, on hyperbaric oxygen therapy treatments. And what they basically told me is that they're having great difficulty because the Surgeon General I think of the Navy is somehow doesn't like this treatment or thinks this treatment, you know, has to be studied further, FDA, whatever, but that there have been 16 instances where they use, what I guess an off-label prescription, and in all 16 of these the people have been dramatically improved. In cases that were very severe and this is with traumatic brain injury.

So if you've had 16 successes and I think this is 16 for 16, why would we then go have a study? I mean, what I am concerned about, now General Corelli(PH) keeps telling me that we're moving out, that we're going to get something in the field, but I don't see that yet. Except I understand we're doing yoga and massage and things like this. To me it seems as if the higher priority might be the hyperbaric oxygen treatment if it's really helping these people beyond or you know, beyond these other things. I mean, I can't understand why it is, you know, that it's taking us so long to come to grips with this and to take action.

MS. : Sir, thank you for your comments and your question. First of all, let me just clarify the Navy Surgeon General has been enormously supportive of this endeavor, in fact hosted a conference at his office last August --

REP. DICKS: About a year ago.

MS. : All of the Surgeon Generals and in fact the vice chief, the service vice chiefs and you mentioned General Corelli, but all of the service vice chiefs have come forward and in fact are now serving as a --

REP. DICKS: But when are we going to study it? Why can't we just implement it and let people get this treatment?

MS. : Sir, we brought together the 60 leading experts in the country to advise us on this issue because --

REP. DICKS: (Inaudible).

GEN. SUTTON: Oh, yes, sir.

REP. DICKS: Sixteen people were treated and 16 people were successfully -- (inaudible) -- is that accurate?

REP. : Who said yes sir in the back? Are you a witness or are you a public --

MR. : No, sir -- (inaudible) --.

REP. : Okay. Well that's good. So you know about this too.

MR. : -- (inaudible).

MS. : I have seen some case reports --

REP. : -- (inaudible) -- people know whether it's accurate or not?

MS. : I have not seen 16 case study reports, but I have seen the five that Dr. Duncan had recently distributed --

REP. : Dr. Duncan work for you?

MS. : He does not, sir. But we are, we certainly are colleagues.

REP. : Who does he work with?

MS. : He works with, well I'll let Dr. Duncan speak for himself, he works with --

MR. DUNCAN: I'm a pro bono lobbyist for the hyperbaric community to get these men and women treated as quickly as possible.

REP. : -- (inaudible) -- actually we know of 16 have been treated and -- (inaudible)?

MS. : We do not know, sir, I have not seen that data. I will tell you that Dr. Jim Kelly who was a member of the consensus group study, the group of experts that met in December as was Dr. Duncan, when they looked at these promising case studies, and that's what they are --

REP. : When was this?

MS. : -- they are very promising.

REP. : When was this?

MS. : Early December of 208, sir.

REP. : That's three months ago.

MS. : Yes, sir. And when we came out of that conference, the consensus of those national experts was that given these promising case study results, given the promising off label uses for this modality, that the time is now ripe for us to proceed to what becomes the gold standard for scientific evidence. And this is an opinion that is supported by the leading experts across the nation. We are being responsible scientists and leaders in this area, we are --

REP. : How does these doctors, these 16 doctors decide that they didn't need any further studies or analysis that they could go forward and prescribe this and then have it work and yet we're still not --

MS. : -- (inaudible).

REP. : -- we're still not moving out on this? This is what is very frustrating to me.

MS. : Sir, off label use if the Department of Defense were to establish a policy to direct doctors to a standard of care that was off label, not FDA demonstrated in science and evidence --

REP. : I think the FDA's approved this by the way.

MS. : Not for this. And the issue is we and the Department of Defense have a long standing policy that we do not direct off label practices without the evidence behind it. So any doctor can talk to their colleagues and make a judgment based on the particulars of that individual to use a therapy in an off label way.

For instance, aspirin for heart, you know, for heart, cardiac issues. That's an off label use of aspirin, although aspirin isn't a prescribed drug, but it's a simple way to understand it. So for me, for the Department of Defense, we can't just make a policy to go do this since it is an off label application. We have to --

REP. : -- (inaudible) -- work?

MS. : Doctors can choose to do it on a case by case basis, but as a Department policy, we cannot direct our, as a standard of care, without the evidence.

REP. DICKS: My, my time is running. I have another question. The other issue I -- excuse me -- (inaudible) --.

REP. MURTHA: Tell us what this is, tell us what this encompasses, this process.

MS. : Well FDA and --

REP. MURTHA: I mean what is -- (inaudible) --

(Cross talk)

REP. MURTHA: What is hyperbaric therapy?

GEN. SUTTON: Yes, hyperbaric oxygen therapy involves a series of usually 40 to 60 treatments where an individual's exposed to increased atmospheric pressure of oxygen and it is certainly closely supervised medically. It has proven to be effective for conditions such as wound healing as well --

REP. : -- (inaudible) --.

MS. : -- infection as well as certainly when divers for example get the bends, the research though just simply has not yet been done to establish its use for TBI.

REP. : -- (inaudible) --

MS. : A chamber, yes.

REP. : -- chamber.

REP. : -- (inaudible) -- atmospheric pressure -- (inaudible) -- and it's closely monitored?

MS. : Yes, sir.

REP. : And they add increased oxygen also.

REP. DICKS: And these off label prescriptions were people with traumatic brain injury who were, who because of the treatment were vastly improved and able to go back to their jobs. I mean, so I think it's worth at least, I mean I'm glad you're at least looking at it, it just takes so long, and this is what's frustrating.

REP. BISHOP: They also generated new nerves, nerves that had been killed were regenerated in the brain.

REP. MURTHA: Well I have to take the side of the Defense Department. I mean, I argue with you folks all the time about these things but we want to make sure it's safe because there's always effects that we don't recognize. We were talking earlier Norm about transplants and when you transplant a hand, there's something that's, they haven't done a lot of, but the rejection figure really causes a lot of problems. So you know we've got to be careful here but from what I'm hearing is we certainly ought to move as quickly as we can studying this thing so that we know what we're doing.

GEN. SUTTON: Absolutely.

REP. DICKS: If I can just finish up here, the other one I wanted to ask you about, our Committee last year in a report said to DoD to establish and use a web based clinical mental health service program as a way to deliver critical, clinical mental health services to service members and their families, particularly in rural areas. Now I know that, and I've talked to General Corelli, I've talked to everybody about this, I know you sent out a request for information and now you're going to have an RFP on this and I've been told that this is going to be, a decision is going to be made on this by April. Is that correct?

GEN. SUTTON: Actually, sir --

REP. DICKS: I happen to think that for a lot of people who don't like to, who are fearful that there's going to be recriminations, to have a web based system, I think you could even do this in country, where they would be able to go back, talk to a psychiatrist, and have it done privately and get the help that they need. I think this has, and especially for our Guard and Reserve people who aren't at a, like Fort Lewis or at a base, this is another way of trying to reach out and help these people. And we see these suicide numbers going up, up, up and yet again, we put this in months ago and we're supposed to get a report back on March 16th, it's frustrating that we can't move this forward a little more expeditiously. Because I think it's an idea that's at least worth studying and we should do it as soon as possible.

GEN. SUTTON: Sir, I completely agree with you and I would like to inform you of some of the efforts that are already underway.

For example, Military One Source, an individual can get counseling online, by phone or in person.

The Military Mental Health Tool, which was launched last year, develops the ability for an individual in the safety, the privacy of their own home to be able to assess their mental health and to get linked up with those who can help them.

Last fall, we launched the After Deployment.Org. It's a web 2.0, 3.0 socially interactive tool which likewise again is a web based stigma free opportunity for troops to get help.

De-stress which is a program that was developed in partnership with Duke University and Dartmouth and has now been --

REP. DICKS: Is this where the yoga comes in?

GEN. SUTTON: No, sir, distress is a web based treatment program involving coaching and treatment for post traumatic stress as well as depression. We also have a training module that is available for providers, primary care providers, and we are embedding behavioral health providers in our clinics across the services in concert with the VA.

All of this, sir, in addition to the request for proposal that is feeding off of the 23 submissions for information, there's a lot of interest in this area and we share, we're excited about it. All of these efforts, sir, will serve as a down payment if you will for what I would say is possibly the most revolutionary project that we are endeavored in right now and that has to do with the simcoach (ph).

We are working with the Institute for Creative Technology in Southern California as well as with Carney Mellon and DARPA, we are bringing the best of artificial intelligence, the best of neuroscience knowledge, the best of simulated conversation and expert technology and voice recognition to provide a coach, an avatar coach with this generation, virtual is as real as real is to us, that will provide that opportunity to have a coach that they can talk with who can bring in the most promising tools and practices and yes providers no matter where one is stationed. And we've launched the SBIR on that, we've got four submissions, we're moving forwards towards the simcoach (ph), we will have as a down payment yes, in the very near future we will have providers who troops and their family members can access online as well.

Every avenue that we can possibly use to connect with our troops and their family members to provide them that help, that support, that compassion that they need, we're committed to providing.

MS. EMBREY: Sir, I'd also like to just clarify too, out of the over billion dollars that this Committee has provided to us for, to study these topics, only five million was provided for the study of alternative medicine such as yoga.

REP. DICKS: -- ask for reprogramming?

MS. : Well that was also Congressional direction to engage in study of alternative medicine for these topics. It was a Congressionally directed act --

REP. DICKS: So this is where the yoga and what do you do with the pin pricks?

MS. : Acupuncture.

REP. DICKS: Acupuncture, all that.

MS. : Yes.

REP. DICKS : What are the results of that? How's that working?

MS. : It works.

GEN. SUTTON: Actually sir, there are some very promising results. A couple of months ago Dr. Kelly and I had a chance to visit the Rehab Institute of Chicago where we've funded some research, in this case, looking at the efficacy of using acupuncture for sleep conditions. We know that sleep problems, it's the number one factor that effects our troops coming back, and of course when your sleep's not going well, nothing goes well over the long term. And pain management as well.

So in talking with that particular research group, one of the things that they're very hopeful about at this point, the preliminary findings are looking good, but the possibility exists that we could just as we provided our front line Corps men and medics a tourniquet to be able to perform life saving practices that will save lives for severely injured extremities, we're looking at the possibility of having a very basic acupuncture kit which could be used for sleep, for pain, if the research continues to support it.

Our own deployment health clinical center has done some of the pioneering work looking at virtual cognitive behavioral therapy and its use for post traumatic stress. Also the use of yoga and acupuncture. We've got a program just up the road at the Deployment Health Clinical Center that has a three week regimen, they bring in referrals from all over the Department of Defense, folks who just aren't getting better where they are locally and it's not clear why. We bring together the best of Eastern medicine, the best of Western medicine, and as one officer last spring testified here on the Hill, he said I owe my life to this program, my family, we've had continued testimonials as well as rigorous science that have demonstrated the efficacy of some of these promising practices.

So it's on that basis that whether it be hyperbaric oxygen or yoga or acupuncture or tai chi, we will continue to follow these promising practices and learn everything we can on behalf of our troops and their loved ones.

REP. : (Inaudible.)

MS. : That is --

REP. : (Inaudible) -- but we said study it and come up with a result -- (inaudible).

REP. FRELINGHUYSEN: Just so I understand it, you service a clearing house, you should know that members of Congress are visited by a variety of different constituents, university based R&D, hospital based R&D which may not be university connected, the private sector with a variety of therapeutic proposals to deal with TBI. Just assure the Committee that you are the general clearing house for such proposals here. I mean, the ingenuity that it out there is incredible what people are coming up with. But you are the gate keeper?

GEN. SUTTON: It is absolutely phenomenal sir, and as we've gone across the country and visited with the leading programs across the country, whether it be places like Mayo Clinic, Cleveland Clinic, UCLA, Stanford, Cornell, Kessler Institute. I mean just, these programs across the country who are doing just incredible work much of the time in partnership with our own scientists, our own clinicians, we are working right now for example with the NIH, their center for information technology.

We are signing a memorandum of agreement that will establish the same data analytic and storage infrastructure as was developed for autism. This will allow researchers around the country and around the world to have visibility of the knowledge as we reap it, as we harvest it from this research that will then advance and catalyze the development of effective treatments and approaches for our troops.

So we're absolutely joined at the hip with for example our consortium, our research as well as our clinical consortium, the leading minds not only in this country, but around the world.

So we are absolutely committed to continuing to develop those relationships, that network of networks not just in this country but in places like Canada, like Great Britain, like Australia, Spain, any number of countries that we've already been partnering with.

I would also mention, sir, is that as important as the medical --

REP. MURTHA: You're going to give your stamp of approval here?

GEN. SUTTON: Oh yes, sir.

REP. MURTHA: This is obviously based on you know, sound science medicine. I mean, there are a lot of interesting people that come into our lives, but we want to make sure that it's substantiated in a way that it has veracity.

MS. : We adhere to excellence --

REP. MURTHA: But is it truly effective?

GEN. SUTTON: Yes, sir, in all things, and that means that we cannot squander, we cannot violate scientific rigor and integrity. So we will not do that. But we certainly will relentlessly pursue leading and advanced ways of treating, of diagnosing, of screening, of building resilience, of supporting our troops and their loved ones with this sense of focused urgency because we know time is not our friend.

Thank you.

REP. MURTHA: One of the things we're still concerned about is there a number of wounded warrior programs. We don't think that you have proved to this Committee who funds these programs that they're working. We need you to give us some proof if there are gaps in the program, overlapping programs, are we spending money in areas where we shouldn't be spending it? I'm not convinced that, you know, it sounds good, you know, you can get up here and tell me apocryphal stories but we want to see the proof, we want to see that these are working because there's someplace else we could spend the money, we want to spend the money there.

The Congress is anxious to spend money in the places where it works. But you know many times when you get a name like wounded warrior, that sounds good, but you know, there's a lot of programs in that category that we're not sure of merit funding. So you need to show us about that.

The other thing, simulation out there, you said you looked at the simulation out there at Camp Pendleton. Do you think that hardens the mind that helps with their mental attitude when they go into combat?

GEN. SUTTON: Sir, the evidence points to the fact that any time that we can build resilience through the use of tough realistic and yes, dangerous training that as closely as possible approximates what a troop will encounter in battle, that will much better prepare them --

REP. MURTHA: No, I want you --

GEN. SUTTON: -- for that experience.

REP. MURTHA: -- to answer specifically, does this help because General Madison wants me to fund that, he wants me to recommend to the subcommittee we fund that and one at Lejeune. Does that help, that's what I'm asking you. Does this particular program help toughen mentally the people going into combat?

GEN. SUTTON: Sir, we have research that is undergoing right now, looking at those specific programs, the preliminary results are promising, I will let you know in six months what my opinion is on --

REP. MURTHA: You want to let us know --

GEN. SUTTON: -- proliferating.

REP. MURTHA: -- if you can by May or June because that's when we'll be funding the programs.

GEN. SUTTON: Okay sir.

REP. MURTHA: Any other questions? Mr. Bingaman?

REP. BINGAMAN: Yes, sir. Ms. Embrey, one of DoD's psychological health strategic goals is to ensure early identification and prevention for individual conditions but apparently this does not always occur. I've got two soldiers from my district who were not properly diagnosed on redeployment for PTSD and they suffered relationally, that is ended up in divorce, and they suffered professionally, ended up with some problems that ended up getting busted. The issue seems to be improper screening at the local unit level. DoD has designed the National Intrepid Center of Excellence to deal with PTSD nationally, but what is being done to rectify the issue of poor PSD screening at the local unit level? And how can our troops who are suffering from PTSD and related mental health problems be properly screened so that they don't suffer disciplinary actions which are really a function of the PTSD?

MS. EMBREY: I think that we have struggled very hard to develop sensitive and specific screening tools that allow us to understand through a dialogue of questions whether or not an individual is at risk for referral and intervention for PTSD and other traumatic stress.

The challenges is that some individuals may chose, either they're in denial or they chose not to answer the questions honestly. And as a result they make it through the screening without referral. And so what we're trying to do is as a double pronged process, which is to address the issue through outreach with the line leadership.

We learned that individuals respond well to traumatic stress with very strong leaders --

REP. BINGAMAN: Can I interrupt you for a second? I've got an example right here where an individual says that on the 20th of January he approached his first land supervisor with an issue that he needed to see the chaplain, he was having mental issues and needed to be dealt with. All the way through he was set up for an appointment, it was cancelled. He tried to make it through, it was rescheduled, it was set up, it was cancelled, all the way and his next appointment is now set for March the 9th. He has not gotten the support that he needed on the unit level, and that's to make my question short. But I've got a narrative here on what this particular soldier had to go through and still has not gotten his therapy, not gotten to talk to a therapist.

MS. EMBREY: I misunderstood your question. I thought you were talking about our assessment process. Actually when an individual seeks care, I mean, there is emphasis from the very top of the Department when a person approaches a commander for a referral, it may well be that the culture has not changed and we need to further emphasize it further down the line and make sure that people understand that when people have identified a need, that they are taken care of as quickly as possible.

REP. MURTHA: Let me just stress a last question here the CSAR(PH) thing. I just saw a classified report, staff went down and got me a classified report, you folks have to weigh in on this. We can't let the budget drive the number of medical helicopters we have. They don't want to announce the number they have because it's inadequate in my estimation. The amount of time it takes to get these people out of the field is absolutely unacceptable. So I wish you folks would look at it and then make a recommendation to us in particular.

I went out to Nellis and I was unhappy about, and so we put $100 million into refurbishing the ones, the RFP fell by the wayside. Now Secretary Gates is himself involved, but sometimes they get sidetracked by numbers. You folks are the ones that use it, and you folks are the ones that should make the recommendations so I need to hear from you about the numbers you need and see if there's anything we can do. It's a complicated problem and with the altitudes they have, with the outposts that are so isolated, it's a much different situation and the Afghans are a much more difficult enemy than the Iraqis.

So we've got some real problems here. But we appreciate you're coming before the Committee, your dedication to the health of our soldiers. And the Committee will now adjourn until 10:00 Thursday, March 5th.


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