[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
POST TRAUMATIC STRESS DISORDER
TREATMENT AND RESEARCH:
MOVING AHEAD TOWARD RECOVERY
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
APRIL 1, 2008
__________
Serial No. 110-78
__________
Printed for the use of the Committee on Veterans' Affairs
----------
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana VERN BUCHANAN, Florida
JERRY McNERNEY, California VACANT
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania HENRY E. BROWN, Jr., South
SHELLEY BERKLEY, Nevada Carolina
JOHN T. SALAZAR, Colorado VACANT
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
April 1, 2008
Page
Post Traumatic Stress Disorder Treatment and Research: Moving
Ahead Toward Recovery.......................................... 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 42
Hon. Jeff Miller, Ranking Republican Member, prepared statement
of............................................................. 42
Hon. Henry E. Brown, Jr.......................................... 2
Hon. John T. Salazar............................................. 3
Prepared statement of Congressman Salazar.................... 43
Hon. Phil Hare................................................... 3
Hon. Shelley Berkley............................................. 4
WITNESSES
U.S. Department of Defense, Colonel Charles W. Hoge, M.D., USA,
Director, Division of Psychiatry and Neuroscience, Walter Reed
Army Institute of Research, Department of the Army............. 5
Prepared statement of Colonel Hoge........................... 43
U.S. Department of Veterans Affairs, Ira Katz, M.D., Ph.D.,
Deputy Chief Patient Care Services Officer for Mental Health,
Veterans Health Administration................................. 37
Prepared statement of Dr. Katz............................... 58
______
American Occupational Therapy Association, Carolyn M. Baum, Ph.D,
OTR/L, FAOTA, Immediate Past President, and Professor,
Occupational Therapy and Neurology, Elias Michael Director of
the Program in Occupational Therapy, Washington University
School of Medicine, St. Louis, MO.............................. 21
Prepared statement of Dr. Baum............................... 45
Iraq and Afghanistan Veterans of America, Todd Bowers, Director
of Government Affairs.......................................... 31
Prepared statement of Mr. Bowers............................. 56
Matchar, David, M.D., Member, Committee on Treatment of
Posttraumatic Stress Disorder, Board on Population Health and
Public Health Practice, Institute of Medicine, The National
Academies, and Director and Professor of Medicine, Center for
Clinical Health Policy Research, Duke University Medical
Center, Durham, NC............................................. 23
Prepared statement of Dr. Matchar............................ 50
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Chair,
National PTSD and Substance Abuse Committee.................... 29
Prepared statement of Dr. Berger............................. 54
Virtual Reality Medical Center, San Diego, CA, Mark D.
Wiederhold, M.D., Ph.D., FACP, President....................... 25
Prepared statement of Dr. Wiederhold......................... 53
SUBMISSIONS FOR THE RECORD
American Legion, Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission, statement............... 62
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director, statement................................ 64
Veterans of Foreign Wars of the United States, Christopher
Needham, Senior Legislative Associate, National Legislative
Service........................................................ 68
POST TRAUMATIC STRESS DISORDER TREATMENT AND RESEARCH:
MOVING AHEAD TOWARD RECOVERY
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TUESDAY, APRIL 1, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:01 a.m., in
Room 334, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Snyder, Hare, Doyle,
Berkley, Salazar, Miller, and Brown of South Carolina.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I would like to call the hearing to order. I
would like to welcome everyone here to the Subcommittee on
Health's hearing. We are here today to talk about Post
Traumatic Stress Disorder (PTSD) treatment and research in the
U.S. Department of Veterans Affairs (VA).
Post traumatic stress disorder is among the most common
diagnoses made by the Veterans Health Administration (VHA). Of
the approximately 300,000 veterans from Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF) who have access
to VA healthcare, nearly 20 percent, 60,000 veterans have
received a preliminary diagnosis of PTSD.
The VA also continues to treat veterans from Vietnam and
other conflicts who have PTSD.
With the release of the 2007 Institute of Medicine (IOM)
report, we learned that we still have much work to do in our
understanding of how to best treat PTSD. I hope that my
colleagues will continue to work with me in supporting VA's
PTSD research programs.
I look forward to hearing testimony today from several
organizations that are working to provide comprehensive and
cutting-edge treatment for PTSD.
The Subcommittee recognizes that this is an important issue
and one that we will be working with for a long time to come.
We are committed to ensuring that all veterans receive the best
possible treatment when they go to the VA.
That is one of the reasons why we are having this hearing
today. We will have several more hearings dealing with PTSD
because this is an important issue, an issue that there are
still a lot of unanswered questions. So I look forward to the
testimony here today.
I would like to recognize Mr. Brown for any opening
statement he might have.
[The prepared statement of Chairman Michaud appears on p.
42.]
OPENING STATEMENT OF HON. HENRY E. BROWN, JR.
Mr. Brown of South Carolina. Thank you, Mr. Chairman, for
holding this meeting today. And this is a continuing of several
meetings we have had dealing with this issue. It is certainly
an important problem, important issue that we need to face.
Thank you for your leadership on this.
Following every war in history, what we now call post
traumatic stress disorder or PTSD has sadly affected the lives
of many brave men and women who have worn the uniform.
This Committee, over the years, has held numerous hearings
to bring to the forefront the emotional toll the trauma of
combat can lay on our veterans and the need for us as a nation
to effectively care for those who suffer with military-related
PTSD and experience difficultly reintegrating into civilian
life.
In response to the Congressional mandate, VA established a
national Center for PTSD in 1989. This center was created to
advance the well-being of veterans through research, education
and training, and the diagnosis and treatment of PTSD.
VA has since moved to expand its program and currently
employs over 200 specialized PTSD programs in every healthcare
network. Available care includes omission behavior therapy,
which has shown to be the most effective type of treatment for
PTSD.
Many servicemembers who develop PTSD can recover with
effective treatment. Yet, PTSD is still the most common mental
disorder affecting OIF and OEF veterans seeking VA healthcare.
About 20 percent of all separated OIF and OEF veterans who have
sought VA healthcare received a PTSD diagnosis.
Even more alarming, a recent study conducted by VA shows
that young servicemembers between the ages of 18 and 24 are at
the highest risk of mental health problems and PTSD to be 3
times as likely as those over 40 to be diagnosed with PTSD and/
or other mental health problems. Clearly PTSD remains a very
prominent injury that our veterans endure. That is precisely
why today's hearing is so critical.
We must continue to focus on how best to strengthen
research and rapidly disseminate effective clinical care in all
settings so that we can finally understand this illness, break
through it, and move forward with complete recovery, bringing
relief to the many heroic veterans who still fight daily
battles no less harrowing than the ones they fought in combat.
On that end, I want to thank our witnesses for being here
today and to present their expert views on what may cause and,
more importantly, preclude PTSD from emerging among our
veterans.
Again, thank you and I yield back, Mr. Chairman.
Mr. Michaud. Thank you very much, Mr. Brown.
Mr. Salazar, do you have an opening statement?
OPENING STATEMENT OF HON. JOHN T. SALAZAR
Mr. Salazar. Thank you, Mr. Chairman. First of all, let me
thank you and Ranking Member Brown for having this important
hearing. I appreciate your dedication to our veterans and your
hard work.
We are fortunate to have this opportunity today to discuss
the impact of PTSD and what effect it is having on our
returning troops, veterans and their families. And I look
forward to hearing the testimony of the experts that are
joining us.
I want to thank you, Colonel, for your dedication to our
service men and women and thank you for your service to our
country.
I think an important part of our discussion today will be
to hear about the research on PTSD cases regarding Vietnam, OEF
and OIF soldiers. I think it is important to look at them both
individually and in comparison to one another.
I also look forward to hearing about the research that is
done on exposure therapy. Innovative and new treatments are
essential to the health of our veterans and our current forces.
Our veterans deserve to know that once they leave the
battlefield and return home that we have programs in place to
take care of them.
Mr. Chairman, I want to thank you and the Members of this
Subcommittee for being so dedicated and giving us the
opportunity to discuss construction authorizations.
Thank you, Mr. Chairman, and I yield back.
[The prepared statement of Congressman Salazar appears on
p. 43.]
Mr. Michaud. Thank you.
Mr. Hare.
OPENING STATEMENT OF HON. PHIL HARE
Mr. Hare. Thank you, Mr. Chairman, and thank you very much
for holding this hearing today. And I thank the Ranking Member
also for being here with us this morning.
Today is the third hearing that this Subcommittee has had
examining mental health for our veterans. And I find today's
hearing on PTSD particularly poignant. We can all agree that
PTSD is the signature wound of the current conflict and that
the need to provide treatment is key.
Unfortunately, we have over 22,000 brave men and women who
will not have access to VA treatment because they were
discharged from the military because of a so-called preexisting
personality disorder, not PTSD, from their service.
The Secretary of Defense is today required to submit a
report to the Armed Services Committee evaluating the
efficiency and fairness of this practice. And as we talk about
the different treatment and research being done, I would ask
that all the Members of this Subcommittee, all the people here
today, all the panel members keep those soldiers in mind who
are fighting their battle against PTSD alone without access to
the benefit of VA healthcare that they have earned.
I spoke to a young man named Louie in Chillicothe,
Illinois, who had severe problems when he came back. And he was
asked and ordered, I should say, to have his reenlistment bonus
with interest paid back. This is a young man who gave
everything he had to this Nation and is now, because of the
conditions that he has, working 2 days a week at a Subway
sandwich place because he cannot hold full-time employment.
We can do much better than that, Mr. Chairman, for our
veterans. We owe it to them. And as I told Louie, I have asked
him every month when he receives that bill to send it to my
office and I will forward it with an appropriate response
because Louie is not going to pay that bill.
He was screened four times prior to deployment and he does
not have, I do not believe, personality disorder preexisting
conditions. It was a terrible way to treat somebody.
And to think that there are an additional 22,000 people
like Louie out there, I think, is a disgrace and something we
have to address and fix. And clearly this is something that I
think we owe to the best and the brightest that we put in
harm's way.
So I thank you, Mr. Chairman, for having this hearing today
and look forward to listening to the panel and asking
questions. Thank you.
Mr. Michaud. Thank you very much.
Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman. I understand that Mr.
Brown was so kind as to already read my prepared statement and
I will enter further the statement into the record. Thank you.
[The prepared statement of Congressman Miller appears on
p. 43.]
Mr. Michaud. Thank you.
Ms. Berkley.
OPENING STATEMENT OF HON. SHELLEY BERKLEY
Ms. Berkley. Thank you very much, Mr. Chairman, and
welcome. We are very appreciative that you are here for our
third hearing on this particular issue.
Mr. Chairman, I want to thank you for holding this hearing
on a very important issue that this Committee recognizes
finally that it is important. And I think that our Nation has
truly ignored this issue for many, many years and for many,
many wars.
There are 3,070 veterans enrolled in the VA's southern
Nevada healthcare system with a diagnosis of PTSD. As we know,
nationally 1 in 5 veterans returning from Iraq and Afghanistan
suffers from PTSD. Twenty-three percent of members of the Armed
Forces on active duty acknowledge significant problems with
substance abuse.
I do not think it is lost on anybody that our veterans need
to receive the help that they need to deal with these issues.
A constituent of mine, and I have mentioned this before,
but it bears mentioning again, Lance Corporal Justin Bailey
returned from Iraq with PTSD. He developed a substance abuse
disorder. His family, his loving parents insisted out of
desperation that he check himself into a VA facility in west
LA. After being given five medications on a self-medication
policy, he overdosed and died. That is just horrific having
survived his time in service to our country and then coming
home and dying under the care of the VA.
I have introduced the ``Mental Health Improvements Act,''
which aims to improve the treatment and services provided by
the Department of Veterans Affairs for veterans with PTSD and
substance abuse disorders. In the interest of time, I will not
read the different sections of this bill, but I would like to
urge all of my colleagues on this Committee to co-sponsor the
legislation. It is imperative that we not only provide
healthcare for our veterans, but mental healthcare as well. I
believe this bill and others that have been introduced will
help in my opinion.
I had dinner last night with an old friend of mine from
northern Nevada who is a Vietnam vet. I have known him since we
were in high school in different parts of the State. He talks
to this day of having flashbacks and problems. We know it
exists.
And I told him I thought that it should be mandatory when
people leave the Armed Forces that they are interviewed and
then followed up with periodically and make it mandatory that
they do so. He thought that would be a very good idea and
would, in fact, prevent a lot of mental health issues that
veterans in years gone by have suffered, but nobody recognized
as PTSD.
And I thank you very much.
Mr. Michaud. Thank you very much, Ms. Berkley.
Once again, Colonel, I would like to thank you for coming
today. On our first panel is Colonel Charles Hoge, who is the
Director of the Division of Psychiatric and Neuroscience at
Walter Reed Army Institute of Research.
We look forward to hearing your testimony and appreciate
all the service that you have given this great Nation of ours.
And without further ado, you may begin, Colonel.
STATEMENT OF COLONEL CHARLES W. HOGE, M.D., USA, DIRECTOR,
DIVISION OF PSYCHIATRY AND NEUROSCIENCE, WALTER REED ARMY
INSTITUTE OF RESEARCH, DEPARTMENT OF THE ARMY, U.S. DEPARTMENT
OF DEFENSE
Colonel Hoge. Thank you, Mr. Chairman, Ranking Member,
Members of the Committee, thank you so much for the honor of
being here. I think this is my third testimony before this
Committee.
And I was thinking about, you know, what is new since the
last time that I testified and wanted to share a little bit
about 3 different efforts that we have recently published just
in the last 6 months that answer some fundamental questions
about the importance of PTSD in our servicemembers coming home.
I am going to focus my comments on the wonderful work of my
very dedicated team at Walter Reed Army Institute of Research,
but I want to acknowledge up front and thank you and other
Members of Congress for the appropriation, fiscal year 2007
appropriation of $300 million for PTSD and TBI research which
is now in the process of being distributed through grant
mechanisms managed by Medical Research and Material Command at
Fort Detrick to a variety of VA, civilian, and U.S. Department
of Defense (DoD) researchers.
So I think that in the next few years, the hope is that we
will see significant advancements in our understanding and
ability to treat soldiers and veterans with PTSD.
The first thing I would like to mention is we have been
doing some continuous assessments of the lessons learned from
our post-deployment health assessment programs within the Army.
And the PDHA, the post-deployment health assessment, is
completed when servicemembers initially return and then the
post-deployment health reassessment (PDHRA) 3 to 6 months
later.
And we have looked at now longitudinally at the
relationship of answers that they gave on the first assessment
with the answers they gave on the second assessment. And I
think that, you know, we have clearly confirmed the importance
of that second assessment, particularly for our Reserve
component servicemembers.
Twenty percent of our active component servicemembers were
referred for mental health treatment or evaluation from the
PDHA and PDHRA process and about 40 percent of our Reserve
component members. And that difference that develops between
active component and Reserve, it is not apparent when they
first return. They look exactly the same. But about 6 months
later, you see this difference emerge and there is a variety of
possible reasons for that.
The second thing I would like to comment on has to do with
the multiple deployments and the dwell time. We have just
recently released our MHAT5 report, the Mental Health Advisory
Team 5. This is an unprecedented effort to survey and assess
the well-being of troops while the war is going on.
We have done assessments every year in Iraq since the
beginning of the war and two assessments in Afghanistan. And
the two things that we learned this year are that multiple
deployments, that there is a direct relationship between the
number of deployments and the psychological well-being of
servicemembers.
So those non-commissioned officers (NCOs) who are on their
third deployment in Iraq, had a nearly 30 percent rate of
significant combat stress or depression symptoms compared to
about 20 percent of those NCOs on their second deployment to
Iraq compared to 12 percent of those on their first deployment
to Iraq.
So there is a clear linear relationship. It is a little bit
more difficult to show that relationship after they return from
deployment because there is an attrition, there is an
association of mental health problems with attrition from
service. And so the linear relationship between multiple
deployments was very clearly evident in the MHAT5 data that we
collected this past year.
The second thing we learned from the MHAT5 was that those
soldiers serving in Afghanistan in brigade combat teams are
experiencing rates of combat and mental health rates very
comparable to those soldiers serving in brigade combat teams in
Iraq. So that is a fairly new development in the last year.
The third study that I would like to comment on briefly is
the publication we just published January 31st in the New
England Journal of Medicine having to do with the relationship
of mild traumatic brain injury (TBI) to PTSD. And there has, I
think, been a bit of confusion and I want to clarify
terminology. Mild traumatic brain injury is exactly the same
thing as concussion.
What is often reported in news media, for instance, is up
to 20 percent of servicemembers coming back from Iraq have
traumatic injury and often they show a seriously injured,
seriously brain injured individual. And it is often not made
clear that the vast majority of those soldiers and
servicemembers being labeled as having traumatic brain injury,
in fact, have had concussions, what soldiers refer to as
getting their bell rung or athletes refer to as getting their
bell rung.
A concussion is an injury where there is a blow to the head
or a jolt to the head that results in brief loss of
consciousness or a brief alteration or change in consciousness.
There may be a memory gap that lasts for a few hours.
But there is expectation of full recovery after concussion
and that is very different than moderate and severe traumatic
brain injuries which almost always result in evacuation from
theater and sometimes long-term care needed to rehabilitate
servicemembers with moderate and severe TBI.
There has obviously been a lot of concern lately about mild
traumatic brain injury and about potential long-term effects of
mild traumatic brain injury possibly in association with blast
exposures. And some of the types of symptoms that
servicemembers have coming back are things like headaches,
irritability, concentration problems, memory problems.
And so our study looked to see what the relationship of
those types of symptoms when servicemembers came home to having
a concussion in theater. And what we learned was that, it was a
somewhat surprising finding to us, was that PTSD and depression
was actually what we could attribute the symptoms to. It is
very difficult to attribute the symptoms in soldiers with
concussions directly to the concussion.
What we found was that the vast majority of these physical
health symptoms and post-concussive symptoms occurred in
soldiers with PTSD and there was a very strong relationship
between having a concussion in Iraq and developing PTSD. Almost
half of soldiers who had a concussion developed PTSD, met the
criteria for PTSD when they came home.
What the implications are of this is, the unfortunate truth
is that we really do not have a definitive diagnostic test that
can tell us definitively who had a concussion or whether
symptoms that soldiers are having in the post-deployment period
are, in fact, due to that concussion. And that makes it very
difficult to do screening and know with accuracy what the cause
of the symptoms are.
The major implication or finding is the soldiers coming
back and getting post-deployment screening that there is a risk
that they may get misdiagnosed as having brain injury when, in
fact, the real problem is post traumatic stress or depression.
PTSD and depression, I think a lot of people do not realize
are biological, physiological disorders that cause a variety of
physical health symptoms and consequences. And I think what is
happening in Iraq is when a soldier suffers a concussion, that
is a very life-threatening experience in that context of
concussion on the battlefield, that very life-threatening
traumatic experience then sets up the potential for PTSD and
depression and then PTSD and depression can lead to the
physical health consequences through a variety of mechanisms.
I guess I am a little bit over time, but I just wanted to
mention that one of the issues with multiple deployments and
the dwell time when soldiers come back, we have learned from
the research that we have done that 12 months is not sufficient
for soldiers to ``reset'' and be ready to go back for another
deployment. In fact, we see rates of PTSD rise as soldiers come
home.
And there is sort of a paradox. We are asking soldiers to,
when they come home, to reset and transition home and those
very things that we label symptoms when they come home and can
get them in trouble and can interfere with their functioning
when they come home and their relationships when they come
home, those symptoms of PTSD are, in fact, often necessary
adaptive mechanisms that they need in combat, you know, the
deprivation, the ability to the hyper-alert state that they
have to maintain for long periods of time.
So we are asking a lot of our servicemembers when we ask
them to transition and sort of turn on and turn off these
skills and it is, I think, a little bit unrealistic and, in
fact, our data have shown that rates of PTSD increase over the
first year. They do not decrease. They do decrease for a
certain percentage of individuals, but then there are other
individuals who manifest the symptoms as the year goes on.
So I think that the key lessons that we have learned have
to do with this relationship of PTSD and mild TBI and some
things about multiple deployments and dwell time and some
lessons learned from post-deployment health assessment.
Thank you very much for the opportunity to discuss this
with you.
[The prepared statement of Colonel Hoge appears on p. 43.]
Mr. Michaud. Thank you very much, Colonel, for your
testimony this morning and your rundown of current DoD PTSD
research programs.
Do you see any gaps in the current research programs and,
if so, where are those gaps and what future research regarding
PTSD does the Department of Defense have planned, if any?
Colonel Hoge. Yes, sir. I think the biggest gap in research
has to do with clinical trials of the efficacy of psychotherapy
and medication trials and understanding exactly what the
elements of psychotherapy are that are effective and what
works, what does not work, establishing group therapy practices
that are effective. We have not been able to show necessarily
the effectiveness of group therapy the way we have for
individual therapy.
So there is a lot of questions within the psychotherapy and
medication treatment arena. There are huge gaps in that area.
And I think that to some extent, the funding that has been
allocated, you know, hopefully will fill some of those gaps,
but I think the gaps remain.
Mr. Michaud. What about the future research? Does DoD have
any future research planned on PTSD?
Colonel Hoge. Within my own institute, I think one of the
key studies that we are planning, we have done a lot of work
with helping soldiers to transition through an educational
program called Battle Mind. And we show that to be moderately
effective, particularly for those soldiers with the highest
levels of combat experiences.
But, you know, it did not have the effectiveness that we
would like to see. And so we are working, my team is working on
developing an advanced version of that that we hope to be able
to test in a field trial in the coming time period.
I actually do not know to what extent how many clinical
trials are going to be funded out of the appropriation, the
fiscal year 2007 appropriation that is being managed by Medical
Research and Materiel Command (MRMC), but I know there are
clinical trials included in that as well.
Mr. Michaud. Thank you.
You had mentioned TBI screening sometimes being mislabeled.
Can you tell us some of the recommendations that your research
group made to leaders of the Army in this regard.
Colonel Hoge. There were 3 areas of recommendations that we
made. One pertained to modifications to our post-deployment
screening to assure that all health problems are addressed and
symptoms that are identified that need to be addressed, while
at the same time minimizing the risks involved. There are, I
believe, enormous risks and mislabeling individuals as being
brain injured. And so we have provided some specific
recommendations about how we might structure the post-
deployment screening in a way to minimize those risks.
The second set of recommendations pertain to risk
communication and/or education. It is how we communicate about
the disorder. And I think even just the term mild traumatic
brain injury, which is a synonym of concussion, for some
reason, mild traumatic brain injury has sort of caught on as
the term, you know, that is being most widely used.
I think that is unfortunate. I think that soldiers and
family members understand the word concussion much better and
concussion is a lot less stigmatizing than the term brain
injury. So I have been advocating for communication strategies
that promote the expectation of recovery and even to include
just simply using the term concussion.
And so risk communication, the screening, and then I think
the key focus of caring for soldiers with traumatic brain
injury is getting the word out there. The education strategy
that is most important is that soldiers learn that they need to
come in and get seen when they have a concussion on the
battlefield and not blow it off as soldiers sometimes tend to
do and athletes tend to do as well, you know, get them in, get
them seen right there on the battlefield because that is really
the time to be evaluated. Once they come home, it becomes a lot
murkier and difficult to sort out what the etiology of
particular symptoms are.
Mr. Michaud. Thank you. I appreciate that.
I have no problem with trying to call it what it is. My
only concern is if you look at, for instance, disability
ratings, the VA tends to be higher than the Department of
Defense because they look at the individual holistically.
I just hope that changing the name does not necessarily
prevent the Army from taking care of our men and women who
served in uniform because that, I know, is a concern with a lot
of veterans out there is trying to shift the burden back on to
the veterans themselves versus taking care of it. So I just
hope the research that you are doing is not trying to not take
care of our veterans.
I think it is very important that we do take care of our
veterans regardless of whether we call it a concussion or TBI
and that is the bottom line for myself in that critical area.
Colonel Hoge. Absolutely, sir. Agree completely.
Mr. Michaud. Thank you.
Mr. Miller.
Mr. Miller. Thank you very much, Mr. Chairman, and I
associate myself with many of the questions that you asked the
witness because I think that we are all concerned and focusing
from the same angle.
You mentioned $300 million that was appropriated in 2007. I
am interested in knowing a couple of things. How are we doing
with spending the money, can you elaborate a little bit on the
programs? This is a question that is loaded when I ask it, but
was it enough and what else do we need to do?
Colonel Hoge. Sir, I am not really the person in a position
to comment on the expenditure of those funds because I run the
research program at Walter Reed Army Institute of Research and
I am not in charge of the program. That is at a higher level.
So I will have to take that for the record, but that has
certainly been information readily available. And my
understanding, you know, the processes have been put in place
and the grants are now in the process of being awarded. So I do
not think there will be any issues with spending the full
amount of that for the research.
[The following was subsequently received from DoD:]
Fiscal Year 2007 (FY07) Psychological Health and Traumatic Brain Injury
Research Program Investment Strategy
The Department of Defense's (DoD's) investment strategy for
the FY07 $150 million (M) post traumatic stress disorder (PTSD)
and $150M traumatic brain injury (TBI) appropriations included
multiple highly competitive Intramural (DoD and Veterans
Affairs [VA]) and Extramural award mechanisms. Intramural
funding mechanisms were dedicated to supporting only research
aimed at accelerating ongoing PTSD- or TBI-oriented DoD and VA
research projects or programs. Intramural proposals were
solicited under two PTSD- and two TBI-focused funding
mechanisms, the Investigator-Initiated Research Award, which
supports basic and clinically oriented research, and the
Advanced Technology--Therapeutic Development Award, which
supports demonstration studies of pharmaceuticals (drugs,
biologics, and vaccines) and medical devices in preclinical
systems and/or the testing of therapeutics and devices in
clinical studies. Approximately $35M each of the PTSD and TBI
appropriations has been approved for funding ongoing DoD and VA
research projects or programs.
The opportunities for funding research in PTSD and TBI
through the Extramural award mechanisms were open to all
investigators worldwide, including military, academic,
pharmaceutical, biotechnology, and other industry partners. The
competition was open but rigorous, and the process ensured that
the best and brightest are funded to provide solutions to the
problems of those impacted by PTSD and TBI. Applicants were
encouraged to collaborate with military investigators to ensure
that solutions will be military-relevant. The Extramural award
mechanisms solicited included the Investigator-Initiated
Research Award and the Advanced Technology--Therapeutic
Development Award, along with the Concept Award, which supports
the exploration of a new idea or innovative concept that could
give rise to a testable hypothesis; the New Investigator Award,
which supports bringing new researchers into the fields of PTSD
and TBI; the Multidisciplinary Research Consortium Award, which
is intended to optimize research and accelerate solutions to
major overarching problems in PTSD and TBI; and the PTSD/TBI
Clinical Consortium Award, which combines the efforts of the
Nation's leading investigators to bring to market novel
treatments or interventions that will ultimately decrease the
impact of military-relevant PTSD and TBI within the DoD and the
VA. The Clinical Consortium is required to integrate with the
DoD Psychological Health and Traumatic Brain Injury Center of
Excellence (DCoE). Further, outcomes from all Intramural and
Extramural awards focused on treatment and interventions will
be leveraged to support the DCoE's efforts to expedite fielding
of PTSD and TBI treatments and interventions.
Congress mandated that the Program be administered according
to the highly effective U.S. Army Medical Research and Materiel
Command two-tier review process, which includes both external
scientific (peer) review, conducted by an external panel of
expert scientists and programmatic review. After scientific
peer review has been completed for each proposal, a
programmatic review is conducted by a Joint Program Integration
Panel (JPIP), which consists of representatives from the
Departments of Defense, Veterans Affairs, and Health and Human
Services. The members of the JPIP represent the major funding
organizations for PTSD and TBI and as such are able to
recommend funding research that is complementary to ongoing
efforts. Four rounds of peer and programmatic review have been
completed, occurring between June 2007 and April 2008. The
final round of peer and programmatic review are slated for May
and June 2008, respectively.
Mr. Miller. Do you think that the current timing of the
post-deployment health re-assessment study, the 6 months, is
the appropriate timeframe within to do that study?
Colonel Hoge. Yes. Yes, sir. Clearly when they first come
home, when servicemembers first come home, the screening only
identifies a small percentage of individuals who will then go
on to develop problems. So we need that second assessment.
And there is about a two- to threefold increase in rates of
reporting mental health problems at that second assessment time
point. Three to 6 months seems to be about right. We could go
as early as 2 months or, you know, as late as 6 months, but
somewhere in that range is certainly reasonable.
Mr. Miller. I think in the beginning of some of your
testimony, you were talking about a 12-month timeframe, not
having enough time to reset when they are redeployed. I am
wondering if 6 months is too soon or does there need to be, you
know, a second risk assessment?
Colonel Hoge. Some units are actually conducting the second
assessment or conducting the second assessment 3 to 6 months
and then they are doing it again shortly before redeployment to
theater. But I am not advocating that that be done, but I know
that some units are in the process of----
Mr. Miller. Do we have any numbers that quantify that
second risk assessment at all? Is there a spike between the 6
and the 10 months or----
Colonel Hoge. Not really. The 6 month and 12 month figures
are very, very comparable to one another from the data that we
have seen in a different context. We have studied soldiers with
surveys that use similar instruments on them at 3, 6, and 12
months and we found that 6 and 12 months are very similar in
prevalence rates.
Mr. Miller. Thank you. That is all, Mr. Chairman.
Mr. Michaud. Thank you.
Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman.
Colonel, just a couple of questions here. Do you believe
that there is a stigma that surrounds PTSD and other mental
health conditions that stops soldiers from actually seeking
help?
Colonel Hoge. Absolutely. Our surveys have indicated that
over half of soldiers who have significant mental health
symptoms do not receive treatment. They do not come in and get
any help at all. And we know that based on some of our survey
data that concerns about perceptions within their unit,
perceptions by their leaders, et cetera, are some of their
concerns.
Now, we have been working ardently since the start of the
war to destigmatize through education programs and the Battle
Mind training, for instance, and other types of education
programs. And I think the word is getting out there. We have a
slight decrease in perceptions of stigma during this last visit
to Iraq that my team took. The perceptions of stigma seemed to
improve slightly compared to previous years.
But we are not seeing, you know, huge changes in
perceptions of stigma. Small changes in perceptions of stigma
from the work that we have been doing.
Mr. Hare. It would seem to me one of the ways we could
really handle this would be to--in my State of Illinois, I know
particularly with the Guard, every returning person coming back
is screened and, I would hope we could get to the point at some
point where every person who serves is screened so that they do
not have to say, I think there might be something wrong here or
this may not manifest itself for some period of time.
The other part is, I have a Vet Center right by my district
office and a lot of times the family members will come over.
They will say we do not know what happened to him. Why is he
hitting the child or why are things going wrong. And so it is
that being able to not have to cross the line and say, I think
I have a problem here.
And I just would like to know from your perspective what
happens to these people, who do not identify and you do not get
the chance or people do not get a chance to help them?
They are out there and, I am wondering, from your
perspective, what happens without that treatment and how long a
person goes. They need this treatment, as you said, while they
are over there. If they cannot get it, we try to get it for
them when they are here. What happens to these men and women?
Colonel Hoge. There is universal screening, you know, in
the PDHA and PDHRA. So everyone does go through a systematic
routine screening process. But the screening processes
themselves are somewhat inaccurate.
In fact, one of the publications that we published in
November when we looked at the relationship of referral or
treatment for PTSD symptoms from the first screen when they
initially come and the subsequent screen 6 months later, we
found no direct relationship in improvement in symptoms, which
was somewhat of a counterintuitive finding. We were not
expecting that.
And there a lot of potential reasons. Part of that may have
to do with the inaccuracy of the screening. These are not 100
percent, you know. There is no way to 100 percent identify
individuals. And we have a lot better screening, I can
guarantee you, for PTSD than we have for mild TBI. But that is
kind of another topic.
So that is one inherent problem. And then when we identify
problems, it is still voluntary. We cannot force a soldier to
receive mental health treatment. We can encourage them to. We
have a limited ability to get a soldier help if there is overt
threats to self or others. But aside from that, you know, it is
a voluntary process. We can encourage individuals to go in and
get help and they can choose not to. And that is an individual
thing.
And then there is the stigma, which is not just in the
military. It is a stigma in society in general of receiving
mental health treatment. So there is stigma and there are
barriers, depending on where a person lives, how close the
clinic is, how accessible the doctor is.
You know, in units, for instance, doctors rotate frequently
and so sometimes there is a lack of stability. You know, a
person might develop a relationship with a physician and then 3
months later, the physician has been deployed. And so that can
affect the person's desire to continue with treatment.
So there are a lot of factors and it is a tough question
that you ask in terms of what is going to happen to these
individuals because, you know, this is part of, you know, sort
of what we have recognized since the beginning of the war.
There is going to be a significant psychological cost.
Mr. Hare. Mr. Chairman, my time is up.
But, Colonel, first of all, thank you for your service to
the country. But, I was struck by the multiple deployments, the
30 percent, 20 percent, 12 percent, and, those figures. I hope
a lot more people are listening to those figures than the
people sitting in this room.
And also when you said the 12 months is just not enough for
a person to be able to reset. We have been talking about
getting people when they come back the opportunity to have some
time to be able to, but then, some of these deployments and
redeployments are happening so quickly that we are just
asking--this is a recipe for disaster.
So I really appreciate your sharing those figures with us.
And, again, thank you very much.
And thank you, Mr. Chairman.
Mr. Michaud. Thank you very much, Mr. Hare.
Mr. Brown.
Mr. Brown of South Carolina. Thank you, Colonel. I
appreciate your testimony and appreciate your service.
I noticed in your testimony that you alluded to the $300
million that is going to be, I guess, spread around between
Department of Defense and the VA and also some private
providers.
Could you share with me how that effort is actually taking
place and if, in fact, the private sector is also contributing
dollars to this effort?
Colonel Hoge. Sir, I work at the Walter Reed Army Institute
of Research and that program is managed by the command above
me, the Medical Research and Materiel Command. There is a very
systematic process that involves putting out grant invitations
to have grant proposals submitted and then those are all peer
reviewed and there is a peer review process that establishes
which ones get funded based on the science and also based on
the needs of the military and the VA.
So there is a very systematic process in place to determine
which proposals should get funded and which do not get funded
and how the money is distributed. And I will be happy to take
the question for the record in terms of the details and
specifics on how that is being done.
[The response was provided in the followup information
provided by DoD, in response to Mr. Miller's earlier question.]
Mr. Brown of South Carolina. Okay. I would appreciate that,
sir. How about the National Institutes of Health (NIH)? Are
they contributing to this research too?
Colonel Hoge. They have also had their own grant funding
mechanisms, so they are also actively involved, participated in
the planning, the meetings that were held to prioritize how the
money should be allocated, and have also had the opportunity to
apply for the funding in a collaborative manner with other
investigators within DoD and VA. So----
Mr. Brown of South Carolina. And at the conclusion of this
study, what do you hope to be able to accomplish?
Colonel Hoge. The grants, again, this is a little bit
outside my area because I am not responsible for this, but I
know that the grant process spans the domain of basic science
and applied research and clinical trials research. My hope is
that there will be sufficient lessons learned at sort of the
upper end of that in terms of clinical trials and that is what
I hope, you know, sort of would be my priority. I think the
biggest gap is in the area of clinical trials, new therapeutic
modalities for the treatment of PTSD.
Mr. Brown of South Carolina. I guess one of my greatest
passions is the homeless veteran and how he sort of, you know,
fell out of the system. And I think most of those homeless
veterans are suffering from some sort of mental disorder, PTSD
or similar form.
And I am hoping that we could find, at the end of the
research, that we could find a way to diagnose those people
that maybe have the problem or the potential of developing that
problem later because by the time they come with the problem,
they do not have the wherewithal to be able to find help.
And so, I would hope as part of research that we would
address, you know, the homelessness problem, we find ourselves
with a lot of our veterans.
Colonel Hoge. Yes, sir.
Mr. Brown of South Carolina. Thank you, Mr. Chairman. I
yield back.
Mr. Michaud. Thank you, Mr. Brown. The homeless veterans'
issue actually will be a full Committee hearing on April 9th on
homeless veterans.
Ms. Berkley.
Ms. Berkley. I will be very anxious to participate in that
hearing as well, but let me remind my colleagues it takes a
little bit of money to be able to care for these people.
Let me ask you a couple of questions, if I may. Something
that you said struck a cord with me when you said that there
have been studies that demonstrate that if people are called
back up to service before a year or even after a year, that it
is just not enough time in between tours of duty.
Did I hear you correctly?
Colonel Hoge. Yeah. Well, what we have found is that, yeah.
That is what I said. What I said is that the 12 months is
insufficient, appears to be insufficient based on the data that
we have, ma'am.
Ms. Berkley. Now, it is my understanding, and correct me if
I am wrong, that our Armed Forces are so stretched right now
that people are being called back to duty in a far shorter time
than 12 months. Twelve months is recommended. But in many
instances, they have a 90-day stay at home and they are back in
the theater of war.
Is that your understanding as well?
Colonel Hoge. I do not know actually, you know, how many
units have rotated back before 12 months. So I would have to
find that out for you.
[The information from DoD follows:]
In general, the Army does not require soldiers to violate
individual dwell and has systems in place to honor the
soldiers' dwell time. Army policy is in place to honor dwell or
adjust for the instances where soldiers are at risk for
violating dwell. There are instances where soldiers may
volunteer to break dwell and some instances where they may be
required to break dwell due to their having a critical skill.
HRC understands how this affects the soldiers life and requires
General Officer level approval any time this course of action
is taken.
When assessing how many soldiers have deployed prior to
receiving their earned dwell we find that the cause is often
more patriotic and selfless. As an example we had a unit this
week that had greater than 100 personnel non-deployable due to
their dwell time being too short. When queried by their
leaders, forty of the soldiers volunteered to break dwell. This
demonstrates selflessness of our heroic Army.
Additionally, our dwell numbers have increased in some
instances due to soldiers voluntarily reenlisting specifically
for a unit that is deploying. Once the soldier arrives at their
chosen unit they of course deploy with the same.
For example, in units that are deploying in the near future
there are a total of 33,862 soldiers. Of these soldiers 33,246
(98.2 percent) have no dwell issues. Of the remaining 616
soldiers, nearly half of them have volunteered to deploy short
of their authorized dwell periods.
The system is not perfect and there are soldiers, in the end,
that are placed in situations where they must deploy
repetitively and violate their dwell. It is up to the
individual Commanders and Leaders to ensure that soldiers are
afforded their earned dwell time. Army Human Resources Command
knows that this issue is important to the soldier and has made
strong efforts to prevent this sort of issue from occurring.
Ms. Berkley. I would appreciate it because it is my
understanding that it is a much shorter period of time in many
instances.
And I am going to share with you another Nevada story. A
young man from Pahrump, Nevada, had done his tour of duty. He
was back home in Pahrump. He had been raised by his
grandmother, so he went back to his grandmother's home. He was
called back. He did not want to go back. He told his
grandmother he would rather kill himself than go back.
He was interviewed by a psychologist or a psychiatrist.
They said that he was depressed and gave him Prozac. He was
sent back. He was on suicide watch and the day after he was
taken off of suicide watch, he killed himself.
Now, it seems to me that we ought to be doing a better job
of screening people and fully appreciating when they are not
capable mentally of handling the strain of war.
Do you agree with that?
Colonel Hoge. I agree completely in the sense that, you
know, if we had the ability to accurately identify who will do
well in combat and who will not--I mean, the fact of the matter
is that----
Ms. Berkley. Forgive me for interrupting.
Colonel Hoge. Yes, ma'am.
Ms. Berkley. But don't you think if the military put this
young man on suicide watch that they had a pretty good inkling
that he was not doing well mentally?
Colonel Hoge. Yeah. I cannot comment on the specifics of
the case. Presumably, you know, when they took him off suicide
watch, you know, I am sure they, you know, had good reasons to
do that, you know, based on what he told them.
But unfortunately there are tragic situations that happen
and, you know, there has been an increase of suicide rates in
theater because everyone has access to firearms. And so
impulsivity that normally, you know, might not lead to suicide,
in that circumstance where they have easy access to firearms
can be a catastrophic event and a very unfortunate one.
Ms. Berkley. Let me ask you another question on a different
issue. If you have a serviceman who gets a gunshot wound and he
is bleeding profusely, do you have to ask his permission to
treat him or do you just treat him? And if we just treat him,
why is it if somebody has a mental wound that we have to tread
carefully?
It would seem to me that somebody's mental problem is just
as serious as somebody's physical wound and we ought not to
have to get permission from that person in order to treat them.
Why is it that we make this distinction?
Colonel Hoge. There are lots of answers to that and the
first one that comes to mind is simply that the only way to get
better is in part to have the desire to do so and to make that
commitment. And we cannot force people to get better with
psychiatric problems. The reason why therapy works is because
of the alliance that we form between the doctor and the
patient, between the counselor and the patient.
Ms. Berkley. Well, what if it was mandatory? What if we
determined that it was part of getting out of the service that
you are interviewed by a mental health expert and then 6 months
later and a year later and maybe 5 years later, but have it
mandatory that they must, in fact, get this counseling, just to
be able to keep track of the problems because I agree with you,
unless you recognize you have a problem, it is very difficult
to overcome it, but I surmise that a lot of these young men and
women do not even recognize that they have the problem?
Colonel Hoge. I agree with you, ma'am, that many of them do
not recognize that they have a problem. And sometimes when they
do, they are not necessarily willing or interested in
treatment. There are options available to them to get treatment
through other means.
For instance, Military OneSource, which is a separate track
that is not part of the medical system. They can get care in
the VA system or Vet Centers. They can get help from chaplains.
There is a huge amount of counseling that is provided by
chaplains. And a lot of individuals actually do get better on
their own, you know, with or without treatment.
But I think that in terms of requiring mandatory
counseling, I think that I could see it might seem valuable on
the surface, but I think the second order of consequences, you
know, would be enormous, draining much needed resources, which
are already overstretched and overtaxed away from those who
most need it would be one, for instance.
And also I just do not think that by and large if we
force--we cannot. We cannot ethically do that, force
individuals to get better. And they are not going to get better
if we do. They will find every way to rebel against that.
Ms. Berkley. Okay. Could I ask one more question? Thank
you.
There is something else. I am getting a lot of calls from
medical doctors in Las Vegas saying that the VA is not paying
them on a timely manner, in a timely manner. And they are
becoming very reticent to renew their contracts with the VA,
which could create a pretty big crisis in the VA healthcare
system if the doctors that we are contracting with do not get
paid.
I am wondering if you have heard anything from mental
health experts, doctors, psychologists, psychiatrists. I would
assume that it is a challenge to find enough doctors,
psychologists, psychiatrists that are trained to deal with
mental health issues as it is and if we are not paying them in
a timely manner, I would believe it would become even more
challenging to get them to contract with the VA.
Are you hearing anything like that?
Colonel Hoge. I cannot comment on the VA situation. But
within DoD, there was, as you know, I am sure, the Mental
Health Task Force was a comprehensive self-assessment, very,
you know, critical, you know, self-assessment by DoD to look
exactly at that question of whether the resources were
sufficient and available and accessible within particularly our
remote operational, you know, locations, where the deployment
platform locations, and it showed that there are some very
significant challenges. That report came out in June, last
June, challenges in terms of having sufficient resources and
personnel trained, you know, mental health professionals at our
remote locations.
Ms. Berkley. Thank you very much.
And, Mr. Chairman, I would hope that this Subcommittee or
perhaps the Committee would look into this issue of
compensating these doctors or lack thereof because we are going
to end up with a real problem if they do not renew their
contracts because they have not been paid by the VA.
Thank you.
Mr. Michaud. Very good point.
Mr. Doyle.
Mr. Doyle. Thank you, Mr. Chairman, and I apologize to you
and the Colonel that I missed your testimony. I have a
simultaneous Telecommunications Subcommittee hearing going on.
Colonel, I was reading through your testimony as the
questions were being asked, and the one thing that really just
sticks out here is you see for the first time you have had a
sizeable number of soldiers studied that were on their third
rotation to Iraq.
And it is really striking to see how the increased risk
goes up with each deployment. And I hope that is something that
the Department of Defense is taking a close look at, at what we
are doing to these young men and women as we put them through
third rotations and that it should only be done when absolutely
necessary.
I had a couple representatives from the American Legion in
my office earlier, and I heard you talk about the stigma of
being identified as someone with post traumatic stress disorder
or just having mental health issues. And they brought up
another interesting point, not just from the medical side, but
how it seems to be affecting our veterans on the employment
side, too, that a lot of employers are a little bit nervous
about maybe hiring people that are just coming back from this
war because they are hearing so much in the media about, you
know, traumatic brain injury and post traumatic stress disorder
and that it is also affecting our veterans on the economic
front.
So, as you embark amongst this campaign to educate people
about PTSD so that they get treatment and help, I think it
might also be, you know, a good idea if DoD in some way can
help educate employers as to the treatments that are available
and that these vets once they are treated, you know, should not
be stigmatized when they go look for a job just because they
have received this treatment, that employers have a
responsibility to take a look at our young men and women that
served the country and not use this as a reason not to hire
them. I know they would not do that overtly, but it seems like
it is causing some problems.
But the only question I have and maybe you could just
educate me on this, the representatives I had from American
Legion were talking about, you know, the distinction between
regular military and National Guard and Reserves with regards
to treatment.
And they were under the impression, I do not know if it is
correct or not, maybe you can tell us, that when you have
somebody that is in the National Guard and Reserve and they
have a mental health issue coming back from combat, PTSD or the
like, they can get treatment obviously. They have the benefit
to get treatment, that their family members are not able to
receive counseling.
A lot of time, as you know, these issues are issues within
the family with marriages breaking up. We see the high divorce
rate taking place in the National Guard and Reserve that seems
to get worse as these young men and women are deployed and have
multiple deployments.
What assistance is there that is available to families of
National Guard and Reservists that are also going through tough
times, trying to understand how they should be helping the
veteran or responding to some of the things they are seeing at
home when this happens and is it available to them?
Colonel Hoge. Yeah. I can comment, you know, from my
perspective within DoD. There are a variety of different
services for family members and counseling both within the
medical system and outside of the medical system through the
support, family support programs on----
Mr. Doyle. Vet Centers and----
Colonel Hoge. Yeah. And through Military OneSource, for
instance, which is an employee assistance model program that
has a strong focus on marital and family therapy. So there is
different----
Mr. Doyle. And this is available to families of National
Guard and Reserves?
Colonel Hoge. Yes, sir. I believe so. I am a little
hesitant there, but, yes, I think that is the case.
Mr. Doyle. Very good.
Colonel Hoge. Yeah. And I can find out for sure, but I
believe that is the case.
Mr. Doyle. Well, thank you very much, Colonel.
Mr. Chairman, I yield back.
Mr. Michaud. Thank you very much.
Mr. Snyder.
Mr. Snyder. Thank you, Mr. Chairman.
I appreciate your written testimony here today,
specifically referring to research projects. Most of the time,
our discussion at this Committee is about how to fund more
research and we do not actually get a full presentation about
some of the results.
We have been told, Colonel, that there are an abundance of
good research projects that could still be done out there if
there was funding available for that.
Do you agree with that statement?
Colonel Hoge. Yes, sir. And, again, in the clinical trials
arena, I think that is a true statement for sure.
Mr. Snyder. Clinical trials, meaning the kind of studies
where you need to have 5,000 or 10,000 or 30,000 people
participating which takes a lot of staff time and labor and
recordkeeping. Is that the kind of trials you are talking
about?
Colonel Hoge. No. What we need actually are smaller
randomized controlled studies----
Mr. Snyder. Of therapies?
Colonel Hoge. Of therapy, yeah, to break down what specific
elements of therapy work, you know, how can we improve therapy,
can we create group therapy processes that work as effectively
as individual therapy, which would have implications in terms
of resources, and medications. There is a variety of new
medication opportunities that need to be tested in randomized
trials as well.
Mr. Snyder. I would like to give you a softball question,
if I could, and just let you take whatever time I have
remaining on it. In your written statement on page six, you say
both PTSD and depression are biological disorders that are
associated with a host of chemical changes in the body's
hormonal system, immune system, and nervous system.
I would just like you to amplify on that with the remaining
time I have because we have a lot of discussions here about
somehow the division between mental health and physical health
and it comes up in a lot of context as mental health parity
bills and that kind of thing.
But would you just take the remaining 3 or 4 minutes I have
and just discuss in a little more detail those kinds of changes
that you are talking about?
Colonel Hoge. Yeah. I mean, this is an important, a hugely
important topic because we, you know, still within society, we
think of PTSD as a mental disorder and, you know, other
problems, TBI, for instance, mild TBI as a physical disorder.
And that is just a very artificial distinction.
The fact of the matter is that there are a host of changes
that happen within the nervous system, endocrine system, even
in the immune system as a result of stress, traumatic stress,
persistent stress in the combat environment, and these types of
changes can lead to a host of physical health problems.
So we know, for instance, that individuals who have PTSD
and depression are much more likely to use medical services, to
miss work due to illness, to have more pain, to have more
headaches, even to have more post-concussive symptoms. In fact,
it is one of the strongest risk factors for the persistence of
symptoms after a concussion is the presence, the coexistence of
some sort of mental health problem like depression or anxiety
or PTSD.
So the degree to which we can, you know, help people
understand that this is--and the other thing is that these are
normal biological processes that are adaptive and necessary in
combat. Being hyper-alert is a survival mechanism that soldiers
need in combat and they are not going to let go of that when
they come home because that is, in fact, their body, you know,
their Lindex System, the part of their brain that has to do
with response to threat has been altered as a result of their
training and, you know, what they have done as part of the
professional duties in combat.
So they are not going to necessarily let go of that. And
the reactions that they have, while other people may perceive
them as being abnormal are, in fact, things that are adaptive,
that as soon as they go back into combat for their next
rotation, they have to turn it all back on again.
So we can look at some of these biological changes both in
the context of what is normal reactions to stress and then also
in the context of at what point do those reactions become
abnormal and really interfere with the person's life. And those
are, you know, questions which are active focus of research
now.
Mr. Snyder. I will take my last 15 seconds. I think there
is also a lot of research going on now in young children who
are raised as babies, who are born into very stressful
environments, whether it is a home with abuse or a home with
poverty, and that chronic stress month after month, year after
year leads to some kind of permanent changes in the brain
because of the development of a baby's brain. But this aspect
of stress as somehow just being a mental thing is an incorrect,
I think, application of the term.
Thank you.
Colonel Hoge. Yes, sir. Just a quick comment. The vast
majority of individuals who are exposed to very significant
traumatic events either in combat or in other settings do not
develop PTSD. The vast majority do not develop PTSD. And that
is a real active, you know, very important area of interest is
what is it that, you know, causes some individuals to develop
PTSD and others to not develop PTSD.
Mr. Michaud. Thank you very much. Once again, Colonel,
thank you very much for appearing today, but also thank you for
your service to this country. We appreciate it. Thank you.
Colonel Hoge. Thank you, sir. Thank all of you. Thank you.
Mr. Michaud. I would ask the second panel to come forward.
And while they are coming forward, we have Carolyn Baum, who is
the immediate past President of American Occupational Therapy
Association (AOTA); Dr. David Matchar, who is the Director and
Professor of Medicine at the Center for Clinical Health Policy
Research at Duke University Medical Center; and Dr. Mark
Wiederhold, who is President of Virtual Reality Medical Center.
I want to thank all 3 of you for coming here today. We
appreciate it and look forward to your testimony. And we will
start with Dr. Baum.
STATEMENTS OF CAROLYN M. BAUM, PH.D., OTR/L, FAOTA, IMMEDIATE
PAST PRESIDENT, AMERICAN OCCUPATIONAL THERAPY ASSOCIATION, AND
PROFESSOR, OCCUPATIONAL THERAPY AND NEUROLOGY, ELIAS MICHAEL
DIRECTOR OF THE PROGRAM IN OCCUPATIONAL THERAPY, WASHINGTON
UNIVERSITY SCHOOL OF MEDICINE, ST. LOUIS, MO; DAVID MATCHAR,
M.D., MEMBER, COMMITTEE ON TREATMENT OF POSTTRAUMATIC STRESS
DISORDER, BOARD ON POPULATION HEALTH AND PUBLIC HEALTH
PRACTICE, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES, AND
DIRECTOR AND PROFESSOR OF MEDICINE, CENTER FOR CLINICAL HEALTH
POLICY RESEARCH, DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NC;
AND MARK D. WIEDERHOLD, M.D., PH.D., FACP, PRESIDENT, VIRTUAL
REALITY MEDICAL CENTER, SAN DIEGO, CA; ACCOMPANIED BY GERALD M.
HAASE, M.D., FOUNDER AND CHIEF MEDICAL OFFICER, PREMIER
MICRONUTRIENT CORPORATION, NASHVILLE, TN
STATEMENT OF CAROLYN M. BAUM, PH.D., OTR/L, FAOTA
Dr. Baum. Thank you, Mr. Chairman, Members of the
Subcommittee, for giving me the opportunity on behalf of the
American Occupational Therapy Association to discuss issues
regarding post traumatic stress disorders.
You introduced me, so I will bypass that. I also am the
Professor of both Occupational Therapy and Neurology at
Washington University School of Medicine.
Occupational Therapy (OT) has had a rich history providing
services to veterans dating back to World War I. Occupational
therapists help wounded warriors return to their military
responsibilities or transition into civilian life. We do this
by helping them set goals, develop strategies to accomplish
their goals, and gain the skills that allow them to achieve the
maximum level of participation and independence.
Occupational therapy perhaps is best known for its work in
rehabilitation services after stroke, loss of vision, physical
injury, including amputations, and traumatic brain injury, but
occupational therapists also treat individuals with stress-
related disorders that result in mental and cognitive
impairments as well.
OT plays a unique role in helping veterans recover from
PTSD as they serve as key members of the team, that along with
physicians and psychologists who use medication and counseling,
the occupational therapist employs performance strategies that
support the veterans in achieving success in their performance
in daily activities.
Actually, it is in these daily activities that it is
possible to observe the problems veterans are having with
multi-tasking, with sequencing of tasks, with their safety,
with their judgment, and actually identifying the cognitive
fatigue which has a very important need for consideration.
These are all problems that require strategies for individuals
to overcome.
The effective treatment of PTSD and the return of veterans
back into their work, their family, and community lives really
requires an integrated system of care that includes assessment,
goal setting, treatment, and learning to self-manage life with
PTSD.
Rehabilitation does not stop when veterans are discharged
from hospitals or medical care. It must be provided along a
continuum addressing community reintegration, social
reconnections, and work accommodations. All these are areas in
which occupational therapists play an important role.
Veterans with PTSD often have difficulty in their daily
lives and avoid activities because they result in anxiety or
fear or even anger. Consider, for example, a soldier who is
driving on routine patrol when a road-side bomb explodes. Upon
returning home, the veteran might experience flashbacks of that
event triggered simply by driving.
The therapist might use simulated or virtual reality
driving experiences or even actual driving experience in a
controlled environment to help the veteran extinguish or
reframe the negative stress reactions.
Therapists also work with veterans to help them manage
issues related to PTSD such as depression, mild head injury, or
concussion, and substance abuse by helping them develop
strategies to reengage in daily life that are meaningful for
them and their families. Having the families involved is
particularly important because we know the importance of social
support to individuals recovering from PTSD.
The unique contribution of occupational therapy is highly
valued by the Army for their combat stress control. The Army
model deserves additional attention from the Veterans
Administration and the Subcommittee because it fully recognizes
occupational therapy's contribution as a member of the team by
adding the performance component to the medication and
counseling provided by other team members. We recommend the VA
consider and adopt the Army model.
The Veterans Administration has made significant strides in
preparing to meet the needs of veterans, but work remains to be
done. There are only 750 occupational therapists in the entire
VA system. While both the Veterans Administration and the
Department of Defense guidelines for PTSD exist and include
occupational therapy, it is the experience of our members that
the inclusion of occupational therapist varies from site to
site. This variation does not ensure full access to effective
treatment.
The American Occupational Therapy Association encourages
the Committee to look at this issue. From the consultation with
AOTA's members within the VA, we have heard that they are
struggling to maintain the quality of care for which they are
known because of increased demand for rehabilitation services
and gaps in staffing.
The most important issue is to ensure that veterans receive
the services they need to recover and reenter community life,
able to care for themselves and others, able to work and make
contributions to their families and communities. If the VA has
staffing problems, they should look for, and contract with,
community programs to provide the services that the veterans
need.
Just as you discussed earlier with Colonel Hoge, there is
also a need to study the effectiveness of complex
interventions, medications, counseling, and I would ask for
consideration to add the third leg to the stool, the importance
of daily life performance.
Research should seek to understand the relationship of
quality of life to PTSD symptom severity, disability, treatment
outcomes and cost. The problem begs for an interdisciplinary
translational clinical study.
Mr. Chairman, I have made additional recommendations in my
written testimony, but I want to highlight a couple of issues
for your Subcommittee's consideration.
To increase the numbers of occupational therapists within
the Veterans Administration, we would urge that the
Subcommittee consider expanding the Student Loan Repayment
Program to ensure that the VA remains an attractive employment
option because there is a real supply and demand issue for OTs
right now and that would draw people to the VA services.
Salaries in the VA appear to be lower than other healthcare
settings. The Bureau of Labor Statistics estimated in 2006 that
the average salary in California for occupational therapists
was $73,000. Right now the Palo Alto Polytrauma Rehab Center is
offering $50,000 for two new positions that have been vacant
since last July.
New positions continue to be added across the country, but
salary will continue to be an issue, and AOTA urges the
Subcommittee and the VA to attend to salary, recruitment, and
retention issues.
Mr. Chairman, in conclusion, I want to reiterate that
occupational therapy has expertise in the treatment of
functional impairments resulting from a broad range of
conditions faced by veterans, including PTSD. Occupational
therapy should be explicitly included on treatment teams to
address the every-day life issues of veterans and their
families through the phases of recovery and community
reintegration.
Thank you very much for the opportunity to provide
testimony to the Subcommittee. AOTA looks forward to working
with Congress and the VA to meet the needs of our veterans. And
I would be happy to answer any questions. Thank you.
[The prepared statement of Dr. Baum appears on p. 45.]
Mr. Michaud. Thank you very much, Dr. Baum.
Dr. Matchar.
STATEMENT OF DAVID MATCHAR, M.D.
Dr. Matchar. Good morning, Mr. Chairman and Members of the
Committee. My name is David Matchar. I am Director and
Professor of Medicine at the Center for Clinical Health Policy
Research at Duke University Medical Center and served as a
member of the Institute of Medicine Committee, which produced
the report ``Treatment of Post Traumatic Stress Disorder and
Assessment of the Evidence.'' This study was sponsored by the
Department of Veterans Affairs.
The VA charged the Institute of Medicine Committee with
several specific tasks. To respond to its main task, which is
making conclusions regarding efficacy, the Committee developed
methods using generally accepted international standards for
conducting a systematic qualitative review.
The Committee's conclusions were ultimately based on its
judgments of the sufficiency of the body of evidence for each
category or class of treatment. The Committee was not asked to
recommend what therapies clinicians should use or not use.
The Committee's assessment winnowed down the nearly 2,800
articles identified in our search to 89 randomized control
trials, 37 studies of treatment with medications, such as
Selective Serotonin Reuptake Inhibitors or SSRIs and
anticonvulsants, and 52 studies of treatments with
psychotherapy. I would be happy to provide details about the
criteria the Committee used and about how we evaluated the
methodological quality of the studies we reviewed.
The evidence on pharmacotherapy in general was limited with
relatively few studies meeting inclusion criteria and free of
significant methodological limitations. Even among the SSRIs
with the most substantial evidence base, the Committee was
struck by inconsistencies in the results and serious
methodological limitations.
The Committee found the evidence for SSRIs and all other
drug classes for which randomized trials were identified
inadequate to conclude efficacy.
The Committee reviewed studies on several types of
psychotherapy. The Committee judged the evidence for exposure
therapy sufficient to conclude efficacy. Exposure therapies are
a family of therapies that include confronting trauma-related
memories or stimuli and may be used in combination with other
therapeutic approaches. The evidence for all but one of the
remaining psychotherapy categories was inadequate to conclude
efficacy.
The Committee's conclusions of inadequacy regarding
evidence for most treatment modalities should not be considered
clinical practice guidelines. Finding that the evidence is
inadequate is not a determination that the treatment does not
work.
The Committee recognizes that clinical treatment decisions
must be made every day based on many other factors and
considerations such as patient preference, availability,
ethical issues, and clinical experience that we were not asked
to addressed and we did not.
The Committee was struck by the lack of evidence on
treatment efficacy in one population compared to another. The
Diagnostic and Statistical Manual criteria recognizes only one
type of PTSD. Yet, reasonable people might question whether all
PTSD is the same and whether one can expect a treatment shown
effective in one group, for example, earthquake survivors, to
also work for U.S. combat veterans.
However, we found no evidence either that PTSD is the same
or that it is different in veteran or VA populations compared
with civilian populations.
A minority opinion on the report was based on the belief
that there are subgroups and the evidence should be examined
separately for them, but the Committee majority concluded
otherwise.
The Committee found that PTSD needs more attention from
high-quality research, including in veterans. The Committee
highlighted several research-related issues in the report,
including methodological quality, investigator independence,
and special populations.
We recommended that funders of PTSD research take steps to
ensure that investigators use methods to improve the internal
validity of research, for example, the use of blinding and
adequate patient followup.
The Committee also noted that the majority of drug studies
have been funded by the pharmaceutical manufacturers and the
majority of psychotherapy studies have been conducted by the
individuals who developed the techniques or their close
collaborators.
The Committee recommends that a broad range of
investigators be supported to conduct replication and
confirmation studies.
The research literature is not informative on the issue of
patients who have PTSD and other health problems, such as
substance abuse, other anxiety disorders, or traumatic brain
injury, or about special veteran populations, such as ethnic
and cultural minorities, women, and people with physical
impairments.
We recommend that the most important subpopulations be
defined to design research around interventions tailored to
their special needs.
Finally, the Committee made two general recommendations
about research and veterans. First, recommend that Congress
require and ensure that resources are available to fund quality
research on the treatment of veterans with PTSD with
involvement of all relevant stakeholders.
Second, we recommend that the VA take an active leadership
role in identifying the high impact studies that will most
efficiently provide clinically useful information.
The Committee is grateful to have the opportunity to be of
assistance to the VA and hopes that the Department and Congress
find the report useful in moving ahead to strengthen PTSD
research.
Thank you for the opportunity to testify, and I would be
happy to address any questions the Committee might have.
[The prepared statement of Dr. Matchar appears on p. 50.]
Mr. Michaud. Thank you very much, Doctor.
Dr. Wiederhold.
STATEMENT OF MARK WIEDERHOLD, M.D., PH.D., FACP
Dr. Wiederhold. Mr. Chairman, Members of the Subcommittee,
I am pleased to be here today to discuss a new innovative
technology currently undergoing testing in the Veterans
Administration and Navy facilities that has promised to speed
and improve effectiveness of PTSD treatment.
We thank the Committee and you, Chairman Michaud, for your
active interest in PTSD research.
My company, the Virtual Reality Medical Center, is
currently testing virtual reality (VR) therapy to treat PTSD in
five VA hospitals with requests from six additional facilities
for the technology.
We have been treating patients with VR therapy for the past
12 years and have an overall success rate of 92 percent. This
is defined as a reduction in symptoms, improved work
performance, or the successful completion of a task which was
previously impossible.
Our centers and clinics have broad experience in treating
patients with VR therapy. The technology that my company and
others have been studying is virtual reality or virtual reality
exposure therapy for PTSD. The research protocol works by
allowing the therapist to gradually expose the combat veteran
to distressing stimuli in the virtual scenarios while teaching
the study participant to regulate breathing and physiological
arousal. After a number of sessions, the fighter flight
response to distressing stimuli is extinguished.
Use of virtual reality technology helps veterans of the
current engagement to overcome the reluctance they have in
coming forward for help.
Virtual Baghdad, which is shown in Exhibit A, is a
realistic environment consisting of a single map that allows
the user to navigate seamlessly through a suite of different
but thematically connected virtual scenarios. I can see myself
in the village or the marketplace said one of the Navy Corpsman
who participated in our study.
Virtual reality exposure therapy is an investigative
treatment modality for PTSD that has been in existence for
about 10 years. It has been used successfully with Vietnam era
veterans and with survivors of traumatic events such as motor
vehicle accidents, earthquakes, bus bombings in Israel, and 9/
11 survivors.
A panel of academic and government experts have published a
consensus opinion that exposure therapy is the most appropriate
therapy for PTSD. While exposure might sound counterintuitive,
it is necessary for treatment success.
In virtual reality, PTSD patients who normally avoid
reminders of the trauma are systematically exposed to combat-
related stimuli. This allow for individually paced emotional
processing and desensitization to occur.
Current research funded by the Office of Naval Research is
focused on determining the optimal treatment protocol for Iraqi
war veterans with different co-morbidities. For example, those
with mild traumatic brain injury and PTSD may require more
treatment sessions than those with mild depression and PTSD.
Results to date show that the virtual reality protocol is
successful in decreasing symptoms of PTSD, depression, and
anxiety.
Study investigators are currently conducting 3-month
followup visits to ensure that the treatment is lasting.
Investigators are also performing physiological assessments to
help design a study that would construct a profile of veterans
who might do especially well with VR technology.
One of our systems is in Iraq right now and could be used
in such research. In fact, we have just received strong
interest from the Navy in advancing research in just this
context.
However, we are here to speak about our experience and
success with the VA and leave you with 3 additional advanced
technologies which could significantly help improve the lives
of veterans with PTSD.
First, it is important to correlate the progress of VR
therapy not only with psychophysiology but also with brain
imaging. In collaboration with other researchers, we have
postulated that there may exist a functional Magnetic Resonance
Imaging (fMRI) or functional brain imaging signature for PTSD,
the discovery of which could lead to more targeted treatment.
Second, VR can be used both alone or in combination with
neuro-protective agents such as antioxidants to conduct stress
inoculation training pre-deployment. It is important to track
how well both technologies work to avert PTSD.
Third, VR may be an important piece of the puzzle as tools
are developed that can assess and treat the many co-morbid
conditions that accompany PTSD. For example, virtual reality
can be useful both in cognitive rehabilitation for TBI as well
as physical rehabilitation for veterans with amputations.
Mr. Chairman, I thank you for the opportunity to present
this important technology today. I would be pleased at this
time to answer any questions you may have.
[The prepared statement of Dr. Wiederhold appears on p.
53.]
Mr. Hare [presiding]. Thank you all very much.
Dr. Baum, you talked about your concern that the VA does
not effectively integrate occupational therapists into multi-
disciplinary post traumatic stress disorder and treatment
teams.
I was wondering if you might share with us what you think
the reason is for the fragmented way the VA integrates
occupational therapists into the treatment teams, and also, how
can the VA do a better job to integrate occupational therapists
into these teams?
Dr. Baum. Thank you.
It may be a volume problem. I think the VA is having such
an increased number of patients with many, many needs, with
traumatic brain injuries and the polytrauma and the amputations
that they may not have enough manpower assigned to that. And
they have, as I mentioned, vacancies in the VA system that need
to be filled.
So I think that by making the critical need to have the VA
respond with training teams of professionals to address this
issue, that bringing the occupational therapist into that does
bring that performance piece into the management of the
patients' lives.
Mr. Hare. Thank you.
Dr. Matchar, you talked about the IOM's findings regarding
the current state of research on post traumatic stress disorder
in combat veterans.
So as we move forward, what specific areas do you think the
VA should invest research resources to close some of the gaps
in research on treatment for PTSD?
Dr. Matchar. Well, first of all, the research that should
be funded should be focused on methodologically high-quality
studies so that at the end of the day, whatever therapies are
being evaluated, that we can make reasonable inferences that
these are going to work and who they are going to work for and
that we also have understandings of the context in which they
work, how long they should work.
So it is those kinds of issues that are really key. The
specific therapies, personally I have no opinion about. I mean,
there are certainly some promising therapies out there, but it
is really more a question of how it is studied as opposed to
what is being studied from my perspective, but that is only
because I am more of a methodologist than a scholar in this
field.
Mr. Hare. How do you think the VA can work with other
Federal research organizations such as the NIH to advance
different areas of research?
Dr. Matchar. I think that the most important thing that
could be done, again in my opinion, is that they establish a
coordinated effort, that there are a lot of questions that need
to be asked and answered and asking them in a coherent way, a
systematic way, allocating research so that you are maximizing
your bang for the buck, so to speak, in the research endeavor,
making sure that the outcome measures and the methodological
approaches are uniform across groups, so NIH, Department of
Defense, and VA. I think one of the Committee's recommendations
was that the VA take a leadership role in establishing that
kind of coordinated agenda.
Mr. Hare. Just to be fair and pick on all 3 of you, Dr.
Wiederhold, in your testimony, you talked about how neuro-
protection might further enhance the utilization of virtual
reality exposure therapy and provide a benefit for combat
veterans.
What exactly do you mean by neuro-protective?
Dr. Wiederhold. Can I refer that question to somebody in
the audience or----
Mr. Hare. Sure.
Dr. Wiederhold. Dr. Haase.
Dr. Haase. I am Gerry Haase from Premier Micronutrient
Corporation.
As we heard this morning from Colonel Hoge, there are some
key biochemical issues that are involved in PTSD. It is not
just a mental issue. And, in fact, excess free radicals and
chronic inflammation have been implicated in most of the
serious psychological illnesses as well as dementias.
In fact, very high levels of free radicals such as
peroxynitrite and products of inflammation such as interleukin
6 and tuminicrosis factor alpha have been measured in PTSD
patients. So if you can abrogate those processes, you can
probably block those effects that would cause symptomatology
and PTSD.
We also know that these pro-inflammatory cytokines, when
they are mixed with oxidative stress, actually turn on the
glutamate pathway which is exactly one of the biochemical
pathways that Colonel Hoge was talking about. And this pathway
can, in fact, be blocked by the use of proper neuro-protective
agents such as formulations with antioxidants.
We also know that in virtual reality therapy, which is a
very effective exposure therapy as Dr. Wiederhold talked about,
the fear response mechanism is actually turned on. This arousal
response is turned on to get the effect of the VR. That also
turns on the glutamate pathway which is toxic to neurons and
that can be blocked by the proper neuro-protective agents.
Now, what is the evidence that these neuro-protective
agents might work? We actually have 3 pieces of evidence that
we have been working on. One was in human civilians where we
could
prove that the proper antioxidants would, in fact, block this
oxidative damage.
The second was in a rodent model of Parkinson's disease
where we actually could show that the proper antioxidants could
block the Parkinsonian symptoms in this rodent model that were
turned on by not only something called MPTP, which not only
works in a rodent model for PTSD, but, in fact, is a
contaminant of some drugs that are recreational drugs and
causes Parkinson's in humans. So we can block that.
And, most importantly, since Colonel Hoge told us about the
overlap between TBI and PTSD, we did a randomized prospected
blinded study in returning Marines from Iraq that had mild TBI
and they had neuro-cognitive damage and they had focus problems
and balance problems.
And in this blinded trial using the methodology is so
important, as was pointed out by Dr. Matchar, we found that the
antioxidant treated group did much better in all the domains
measured at 12 weeks compared to a standard therapy.
So it appears to us that if you use neuro-protection on a
chemical basis in addition to the other therapies, we will
probably have a good effect in PTSD and this should be tested.
Thank you.
Mr. Hare. Thank you.
Let me thank this panel very much for taking the time to
come before us today. I appreciate your testimony very much.
Thank you again for coming.
Our next panel is Dr. Thomas Berger, who is the Chair of
the National Post Traumatic Stress Disorder and Substance Abuse
Committee for Vietnam Veterans of America (VVA) and Todd
Bowers, who is the Director of Government Affairs of the Iraq
and Afghanistan Veterans of America (IAVA).
Let me welcome both of you. Thank you so much for taking
the time to come by.
Dr. Berger, we will start with you, if you do not mind.
STATEMENTS OF THOMAS J. BERGER, PH.D., CHAIR, NATIONAL PTSD AND
SUBSTANCE ABUSE COMMITTEE, VIETNAM VETERANS OF AMERICA; AND
TODD BOWERS, DIRECTOR OF GOVERNMENT AFFAIRS, IRAQ AND
AFGHANISTAN VETERANS OF AMERICA
STATEMENT OF THOMAS J. BERGER, PH.D.
Dr. Berger. Mr. Chairman, other distinguished Members of
the Subcommittee, Vietnam Veterans of America thanks you for
the opportunity again to present our views on PTSD treatment
and research, moving ahead toward recovery.
VVA also thanks the Subcommittee for its concern about the
mental healthcare of our troops and veterans and your
particular leadership in holding this hearing today.
However, as we are gathered here today after 5 years of
combat in Iraq and Afghanistan, VVA is again sadly compelled to
repeat its message that no one really knows how many of our OEF
and OIF troops have been or will be affected by their wartime
experiences.
To be sure, there have been some attempts by the military
services to address combat stress at pre-deployment through
cognitive awareness programs as Colonel Hoge mentioned such as
Battle Mind and the use of innovative combat stress teams. Yet,
no one can really say how serious any individual soldier's
mental and emotional problems will become after actual combat
exposure or the resulting impact that these wounds will have on
their physiological health and their general psychosocial
readjustment to life away from the battle zone.
VVA would like to ask DoD if the Armed Services have
developed any combat stress resiliency models that were
referenced earlier and if they have, what is their efficacy and
by what measures do they judge the efficacy?
Furthermore, despite the increased availability of
behavioral health services to deployed military personnel, the
true incidence of PTSD among active-duty troops may still be
unreported as was hinted at earlier today.
As Colonel Hoge mentioned, a recent retrospective report
documented what most in the military already know, specifically
that of those whose evaluations were positive for a mental
disorder, only 23 to 40 percent complained of or sought help
for their mental health problems while still on active duty,
primarily because of stigma and discrimination.
Thus, no one really knows whether those with PTSD who
remain undiagnosed and so untreated will fail at reintegration
upon their return to civilian life, but is beyond speculation,
and we have heard mentioned several times today is that the
more combat exposure a soldier sees, the greater the odds that
our soldiers will suffer mental and emotional stress that can
become debilitating. And our troops are seeing both more and
longer deployments.
Without proper diagnosis and treatment, the psychological
stresses of war will never really end.
Upon separation from active military service, our male, and
increasingly so our female, veterans face yet other obstacles
in the search for mental health treatment and recovery
programs, particularly within the VA healthcare system.
In spite of the infusion of unprecedented amounts of money,
the addition of new Vet Centers, community-based facilities
that we call CBOCs, and the VA's efforts to hire additional
clinical staff, the access to and availability of VA mental
health treatment and recovery programs remains problematic and
highly variable across the country, especially for women
veterans and veterans in western and rural States such as
Montana.
Moreover, the demands to meet the mental health needs of
OEF and OIF vets in many localities around the country is
squeezing the VA's ability to treat the veterans of World War
II, Korea, and Vietnam.
But despite the shortcomings that I have mentioned, one
piece of good news is that since PTSD was added to the third
edition of the Diagnostic and Statistical Manual of Mental
Disorders, the DSM-III at the time, a great deal of attention
has been paid by the VA to the development of instruments for
assessing PTSD as well as to the therapeutic treatment
modalities used to manage them or even overcome the most
troubling of symptoms. And we have heard some of those
mentioned today.
We have also heard, however, that the National Academy's
Institute of Medicine's Committee on Post Traumatic Stress
Disorders about their report which found that ``most PTSD
treatments have not proven effective'' with the one exception
for exposure therapy.
Therefore, VVA strongly supports the IOM Committee's
recommendation that ``the VA and other government agencies that
fund clinical research should make sure that studies of PTSD
therapies take necessary steps and employ methods that would
handle effectively problems that affect the quality of the
results of these studies'' and that, again, ``Congress should
ensure that resources are available for VA and other Federal
agencies to fund quality research on treatment of PTSD and that
all stakeholders including veterans are represented in the
research planning.''
For mental illness, the standard medical model is seriously
flawed because it provides treatment in the hope of reducing
symptoms and, thus, approximating some notion of normality,
when in reality, normal is only a setting on your clothes
dryer.
Recovery exists or can exist within the context of the
illness. Reduce the stigma and discrimination against the
folks, increase their social roles and participation which
provide them a reason to get better in the first place. And
then you provide the treatment and support services along with
that.
Therefore, the issue is not so much making them normal, but
helping them get their lives back together. In other words,
recovery means living with the illness, managing it, and
getting better, recognizing there might be limitations.
Most major psychiatric illnesses are episodic, but chronic.
So recovery involves both coming to terms with the symptoms and
finding a meaningful life in the midst of these.
Finally, the need for timely, effective, evidence-based
psychiatric, psychological, pharmacological, if necessary,
interventions along with effective evidence-based psychosocial
treatment programs as here.
With the conflicts in Afghanistan and Iraq continuing and
no immediate end in sight, VVA believes it is time to address
the issues now rather than later.
That concludes my testimony. Thank you very much, and I
will be glad to answer any questions you might have.
[The prepared statement of Dr. Berger appears on p. 54.]
Mr. Hare. Thank you, Dr. Berger, and thank you for that
very compelling testimony.
Mr. Bowers.
STATEMENT OF TODD BOWERS
Mr. Bowers. Mr. Chairman, on behalf of the Iraq and
Afghanistan Veterans of American and our tens of thousands of
members nationwide, I thank you for the opportunity to testify
today regarding this important subject.
I would also like to point out today that my testimony is
as Director of Government Affairs for the Iraq and Afghanistan
Veterans of America and does not reflect the views or opinions
of the Marine Corps Reserves which I am currently a member of.
During the Iraq and Afghanistan wars, American troop mental
health injuries have been documented and analyzed as they occur
and the rates are already comparable to Vietnam. But thanks to
today's understanding of mental health screening and treatment,
the battle for mental healthcare fought by Vietnam veterans
need not be repeated.
We have an unprecedented opportunity to respond immediately
and effectively to the veterans' mental health crisis. Mental
health problems among Iraq and Afghanistan veterans are already
widespread. The VA has given preliminary mental health
diagnoses to over 100,000 Iraq and Afghanistan veterans, but
this is just the tip of the iceberg.
The VA's Special Committee on PTSD concluded that 15 to 20
percent of OIF/OEF veterans will suffer from a diagnosable
mental health disorder. Another 15 to 20 percent may be at risk
for significant symptoms short of a full diagnosis, but severe
enough to cause significant functional impairment.
These veterans are seeking mental health treatment in
historic numbers. According to the VA, OEF/OIF enrollees have
significantly different VA healthcare utilization patterns than
non-OEF/OIF enrollees.
For example, OEF/OIF enrollees are expected to need more
than eight times the number of PTSD residential rehab services
than non-OEF/OIF enrollees. With this massive influx of
veterans seeking mental health treatment, it is paramount that
we ensure the treatment they are receiving is the most
effective and will pave a path to recovery.
But before I speak about the specifics of PTSD treatment
and research, I would like to talk about two of the barriers
that keep veterans from getting the proper treatment in the
first place.
The first step to treating PTSD is combating the stigma
that keeps troops from admitting they are facing a mental
health problem. As Colonel Hoge mentioned, approximately 50
percent of soldiers and Marines in Iraq who test positive for a
psychological problem are concerned that they will be seen as
weak by their fellow servicemembers and almost 1 in 3 of these
troops worry about the effect of mental health diagnosis on
their career. Because of these fears, those most in need of
counseling will rarely seek it out.
Recently my Reserve unit took part in completing our post-
deployment health reassessment, which includes a series of
mental health questions. While we underwent the training, one
of my Marines asked me about post traumatic stress disorder. He
said, and I quote, ``If there is nothing wrong with it, then
why is it called a disorder?'' I could not have agreed with him
more.
To destigmatize the psychological injuries of war, IAVA has
recently partnered with the Ad Council to conduct a 3-year
public service announcement campaign and to try and combat this
stigma and ensure that troops who need mental healthcare get
it. Our goal is to inform servicemembers and veterans that
there is treatment available and that it does work.
As the Colonel mentioned, there is also a problem with
stigma in regards to society. That is what we hope this
campaign will also address. It will let people know that
Marines like myself who have served are not damaged goods. We
merely have an injury and we can be treated and step back into
service.
Once a servicemember is willing to seek treatment, the next
step is ensuring that they have a convenient access to care. On
this front, there is much more that must be done, particularly
for rural veterans. More than one-quarter of veterans live at
least an hour from a VA hospital. IAVA is a big supporter of
the Vet Center system and we believe it should be expanded to
give more veterans local access to the Vet Centers' walk-in
counseling services.
The problems related to getting troops adequate mental
health treatment cannot be resolved unless these two issues,
stigma and access, are addressed. However, once a servicemember
suffering from PTSD has access to care, we also need to ensure
they receive the best possible treatment.
Currently a variety of treatments are available.
Psychotherapy in which a therapist helps the patient learn to
think about the trauma without experiencing stress is an
effective form of treatment. This version of therapy sometimes
includes exposure to the trauma in a safe way, either by
speaking or writing about the trauma, or in some new studies
through virtual reality.
Some mental healthcare providers have reported positive
results from a similar kind of therapy called eye movement
desensitization and reprocessing.
In addition, there are medications commonly used to treat
depression or anxiety that may limit the symptoms of PTSD, but
these drugs do not address the root cause of the trauma itself.
IAVA is very concerned that in some instances, prescription
medications are being seen as a cure-all that will somehow fix
PTSD or replace the face-to-face counseling from mental health
professionals that will actually help the servicemembers cope
effectively with their memories of war.
And I will address this briefly too. When I returned from
my second tour, I faced the same reintegration issues that most
servicemembers face. I had a hard time sitting in class, was
scatter brained, had a very difficult time sleeping. When I
sought some assistance from my school health center, I was
given a whole slew of drugs. That lasted about 4 days when I
realized I was needing to take two pills for sleep, two pills
which I call super Ritalin, if you will, for adults during the
day.
It did not effectively help me until I was able to sit down
and actually talk with someone and they told me the steps I
could take to help get myself settled down. It worked
incredibly well, the face-to-face treatment, but there are, we
are finding from our membership, a lot of issues with dealing
with medication to try and treat PTSD.
A recent Institute of Medicine study entitled, ``Treatment
of Post Traumatic Stress Disorder and Assessment of the
Evidence,'' that we have heard a lot about today outlined the
many gaps in current research. Among the problems they
identified, many studies lack the characteristics of internal
validity. That means too many people were dropping out of these
studies, the samples were too small, or followup was too short.
The Institute of Medicine Committee also identified serious
issues with the independence of the researchers. The majority
of drug studies were funded by pharmaceutical manufacturers and
many of the psychotherapy studies were conducted by individuals
who developed the techniques.
Finally, the Committee concluded that there were serious
gaps in the subpopulations assessed in the studies. Veterans
may react differently to treatment than civilians, but few of
the studies were conducted in the veterans populations.
There is also not enough research into care for suffering
from co-morbid disorders such as TBI or depression.
The solution is more and better research. To respond to the
IOM findings, IAVA wholeheartedly supports more funding for VA
research into PTSD and other medical conditions affecting Iraq
and Afghanistan veterans.
Thank you for your attention and your work on behalf of
Iraq and Afghanistan veterans. If the Committee has any
questions for me, I will gladly answer them at this time.
[The prepared statement of Mr. Bowers appears on p. 56.]
Mr. Hare. Thank you both very much.
Let me just say, before I ask a couple questions of you
both here, I represent 23 counties in west central Illinois,
much of that rural. You would swear that the only people that
ever have a problem, if somebody gets sick or needs help, that
they live in Chicago or Rockford or Peoria. If you come from
Carthage, Illinois, and Hancock, Illinois, right on the river,
you have veterans that serve and it is a very difficult process
to get those vets to the places where they can get the help.
So I could not agree with you more that we need to do more
in terms of rural healthcare for veterans because these are
people who have served this country and do not have the
resources, whether it is CBOCs or whatever for them to go. It
makes it pretty hard to treat somebody when they have no place
to go.
Dr. Berger, much of what we are hearing during this hearing
about PTSD is focused on OEF and OIF veterans and obviously,
that is part of the reason we are here.
But with that said, there is also, I am sure, a significant
number of Vietnam vets who are suffering from post traumatic
stress. I would like, if you would not mind, just maybe sharing
some of the unique needs that the Vietnam vets with PTSD have,
and specifically how these needs differ from OEF and OIF
veterans? The second part of this question would be what
specific steps do you think the VA can and should take to
ensure that the needs of Vietnam veterans are being adequately
addressed?
Dr. Berger. Well, first, Mr. Chairman, thank you for asking
the question.
There are significant differences in the types of warfare
given even the four decades between them. The troops nowadays
are serving longer deployments and more frequently, whereas in
Vietnam you served a 12-month tour if you were in any Armed
Services unit with the exception of the Marine Corps in which
you served 13 months.
There are other significant differences in the makeup of
the Armed Forces themselves. Today's Armed Forces, of course,
are a volunteer service, whereas a great number of the women
and men who served in Vietnam were not only volunteers, but a
large majority of them were draftees.
Lots of major differences, but the fact of the matter is
that when we came back, and now I speak on behalf of Vietnam
veterans, we did not have a lot of the resources available. In
fact, there was a lot of stigma and discrimination directed
against us.
I mean, PTSD did not exist as we know it now. At the time,
it became known, of course, as post-Vietnam stress syndrome and
it has been known for thousands of years. But, I mean, given
the nomenclature of post--there are lots of differences.
Our principal concern is that with the lack of or reduced
organizational capacity, and I mean that across the board in
terms of resources, personnel, that sort of thing within the
VA, and the priority being given to treating the OIF/OEF
veterans, that our vets and vets from Korea and World War II
are being squeezed out.
We have lots of anecdotal information to indicate that is
happening around the country. I just took a call last week from
a fellow out in southern California that said his Vietnam
veterans support group, which was meeting in the VA and there
was a licensed clinical social worker that has been working
with this group for over 10 years, they were told they could no
longer meet there, okay, and the social worker was taken off
there because they do not have the resources to handle
everybody at this time.
That is just outrageous. And I am sure as you indicated in
your rural districts or parts of your district that are rural,
the troops are not getting the help that they need and that
includes the Vietnam vets.
Mr. Hare. You are right, Mr. Berger. It is outrageous and
we have to do something quickly to fix that. To walk out on
people like that makes absolutely no sense.
Mr. Bowers, you talked about several barriers to treatment
faced by OEF and OIF vets with PTSD. And just two quick
questions.
What specific actions do you think the VA can take to help
eliminate the barriers to treatment and also do you feel that
most of these vets know that they are even eligible for
treatment for PTSD for 5 years at VA medical facilities? I
mean, is that option given to them? Are they aware that they
even have that?
Mr. Bowers. I can answer both of those in one response. My
drill before last when I went in for my weekend duty, we
underwent, as I mentioned, our PDHR assessment where we filled
out the PDHR. I then had a one-on-one meeting with a counselor
who then could give us a referral slip whether we needed to go
see someone or find out what other resources were available.
At that point, we then took all the Marines, lined them up,
and they registered with the VA right there on the spot. They
were given information to know what VA programs were available,
what resources were available.
Then they took the Marines and they lined them up at the
Vet Centers. They had approximately six representatives there
from local Washington, DC, area Vet Centers who let them know
what resources were available. It was textbook. I do not think
we could do it any better. The problem is that was my unit
taking initiative. It is not mandated that way. And this was
the first time that I have seen out of our 3 deployments that
we have had servicemembers come back and had it organized in
this fashion.
So until it is required that for Reservists and National
Guardsmen to when they return as they are conducting these
assessments to have the VA there as a resource, we are going to
continue to see people fall through the cracks.
And I am very proud of my unit for what they did. But,
again, it is not something that is done DoD or VA-wide.
Mr. Hare. Thank you.
Mr. Miller.
Mr. Miller. Thank you very much.
Doctor, we all know we cannot force people to seek medical
attention.
Dr. Berger. Yes.
Mr. Miller. And probably rightfully so, but how can VA
better reach out and find the people who need the most help?
Dr. Berger. Well, I am not a marketing strategist by any
means, sir. But I think that there has to be more marketing
efforts directed at outreach efforts, particularly in our rural
areas. I think that would help a great deal.
I know that there are efforts being made around the country
as part of the TAP Program, the Transition Assistance Program,
because I do participate in one myself where administrators
from the VA occasionally show up to talk to the Guard members
and inform them of the services, but it is not, at least in the
Midwest it is not as widespread as I think it should be.
So I think it is more a marketing kind of thing in the
sense of getting the word out. Plus, I think also that there
needs to be encouragement by their colleagues such as Sergeant
Bowers here.
And if I may, sir, I know this is highly unusual, but I
would like to recognize Sergeant Bowers for not only his two
tours in Iraq, but I learned today that he has been called up
for a third time.
Mr. Bowers. He is correct. But I am not going to the desert
this time. I am going some place relatively tropical, but I do
not think there will be any umbrellas in our drinks or anything
else. So it will be a change of scenery, but I will be leaving
next month.
And it is with that, that I thank this Committee for the
opportunities you have provided me with testifying before you
and I look forward to seeing you next winter.
Mr. Miller. Thank you very much, Sergeant, for your
service. If we can find out where you are, maybe I will bring
an umbrella personally.
Mr. Bowers. I will bring the coconut, sir.
Mr. Miller. Doctor, thank you for your testimony today as
well.
Mr. Hare. Well, let me thank this panel. Just before you
go, Sergeant Bowers, we wish you God's speed on your third
deployment.
I want to thank both of you for your service to this
Nation. I know you have been here before and testified before
this Subcommittee and others and you are wonderful examples of
what we can do and what we can expect from our veterans. I
thank you so very much for that. So thank you for stopping by.
Mr. Bowers. Thank you, sir.
Mr. Hare. You are welcome.
Our last panel is Dr. Ira Katz, who is the Deputy Chief
Patient Care Service Officer for Mental Health for the Veterans
Health Administration. He is accompanied by Dr. Matthew
Friedman.
I welcome you, Dr. Katz. Thank you for coming.
STATEMENT OF IRA KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT CARE
SERVICES OFFICER FOR MENTAL HEALTH, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY MATTHEW FRIEDMAN, M.D., PH.D., EXECUTIVE
DIRECTOR, NATIONAL CENTER FOR PTSD, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Katz. Mr. Chairman, Ranking Member, I am pleased to be
here today to discuss VA's treatment and research programs in
PTSD.
I am proud to be accompanied by Dr. Matthew Friedman,
Director of VA's National Center for PTSD, and one of the
Nation's foremost clinician and citizen scientists.
In his introductory remarks, Mr. Michaud focused on the
120,000 returning veterans who have come to VA medical centers
and clinics and been diagnosed with a mental health condition
and the nearly 60,000 who have been diagnosed with PTSD.
The 60,000 figure makes PTSD the most common of the mental
health problems, but it is by no means the only one, with
depression a close second.
However, these numbers, as substantial as they are,
underestimate the scope of VA's mental health services for
returning veterans.
Our Vet Centers provide care to a substantial number of
OEF/OIF veterans. To date, they have provided care to an
additional 7,000 returning veterans with PTSD and a far greater
number with readjustment problems without specific diagnoses.
As has been mentioned, it has been since the Vietnam War
that we learned about PTSD as a distinct mental health
condition that we have developed criteria and strategies for
diagnosis and have done research and established effective
treatment.
It is important to recognize that most of the 400,000
veterans seen for PTSD in VA last year were Vietnam era
veterans. Returning veterans represent an opportunity to apply
lessons that we have learned since Vietnam to prevent the
chronic course for PTSD that was all too common among Vietnam
veterans.
At the same time, we cannot lose sight of the ongoing need
to develop better treatments for all veterans with PTSD, OIF/
OEF veterans and those from Vietnam as well as other eras.
VA has responded to the challenge of returning veterans and
to the opportunities created by scientific advances with
dramatic enhancements to our mental health programs. The
budgets increased from $2 billion in 2001 to over $3\1/2\
billion this year. The number of mental health professionals
has also grown. Over the past 2\1/2\ years, we have hired 3,800
new mental health staff for a total of nearly 17,000.
This has allowed VA to establish PTSD specialty care
programs in each of our medical centers and in many of our
larger community-based outpatient departments. There are also
major expanses in Vet Center programs with ongoing increases in
the number of centers from 209 to 232.
VA's approach to PTSD is to promote early recognition and
treatment. There is community outreach including collaborations
in virtually all of the post-deployment health reassessments as
well as screening for all veterans seen in our system. When
there are positive screens, veterans are further evaluated and
referred to mental health providers as needed.
Evidence from research suggests that the most effective
forms of treatment for PTSD are certain forms of psychotherapy,
specifically prolonged exposure and cognitive processing
therapy.
It has been somewhat over a year since publication of
findings from a landmark VA cooperative study demonstrating the
effectiveness of prolonged exposure, the work of Dr. Friedman
and his colleagues. Completion of this research was a major
event.
However, of comparable importance even before the findings
were published, VA began large-scale training programs for
mental health staff so they could deliver these treatments in
real-life clinical care.
Other research is ongoing. Two specific projects are large-
scale clinical trials as has been mentioned earlier. One
follows up on early small-scale studies by VA investigators,
suggesting that prazosin, an inexpensive generic drug already
used by millions of Americans for high blood pressure, could
improve sleep and reduce nightmares in PTSD. Currently a large-
scale multi-site trial is being implemented to evaluate its
effectiveness.
Another trial is based on both clinical exposure and
smaller clinical trials suggesting that newer antipsychotic
medications may be effective in reducing symptoms in service-
related chronic PTSD.
VA is currently conducting a large randomized clinical
trial to determine if this drug risperidone is effective in
veterans with chronic PTSD who continue to have symptoms
despite receiving standard medications.
Other VA research is focusing on mechanisms underlying
stress responses and resilience, longitudinal studies on
deployment and its consequences, genetic risk and protective
factors, novel therapeutics, effective strategies for
rehabilitation of those with persistent symptoms and new
strategies for the delivery of care including another study of
Dr. Friedman looking at primary care management of PTSD.
Mental health is an important part of overall health. VA is
committed to providing the highest quality of care possible to
our Nation's veterans. Because VA researchers are also
clinicians caring for veterans, VA is uniquely positioned to
move scientific discoveries from investigators' clinical trials
into patient care. This, in fact, is the primary goal of our
research program.
Thank you again, Mr. Chairman. Dr. Friedman and I will be
pleased to answer questions.
[The prepared statement of Dr. Katz appears on p. 58.]
Mr. Hare. Thank you, Doctor.
Just a couple of questions. In your testimony, you
mentioned that if a veteran is reluctant to seek care for post
traumatic stress disorder or other mental conditions that you
watch over them for a period of time.
What does that exactly mean? Are there follow up
appointments to assess the progression of the symptoms? Do you
do it by phone calls or how do you watch over these folks?
Dr. Katz. Yeah. I will respond and also ask Matt for his
sense of this.
For those who come to VA, those who are screened and
evaluated, some very obviously have PTSD, some very obviously
don't. Many people are somewhere in between. If they prefer to
be treated, they should be treated. If they are reluctant, we
should keep an eye on them. If they get better on their own,
terrific. If not, if they remain symptomatic or if their
symptoms worsen, we should reapproach them and teach more about
the benefits of treatment.
This sort of watchful waiting is a very important part of
care, especially for people in the mid range where the doctor
does not necessarily know whether or not treatment is necessary
the first or second or even the third time we see the patients.
Matt.
Dr. Friedman. Thank you, Ira.
I think that one of the more important things that is
happening with the current war and our attempts to provide
treatment for veterans is that we know a lot more what to
expect than we did following Vietnam. And, I think as a result
of the experience that we have had for the past several decades
is we have been able to educate the public. This is really a
kind of a preventive public health approach trying to get
information out to the veterans, to their families, to the
communities, to their employers so that should there be
difficulties readjusting and reintegrating, people will know
what to look for, what to expect.
As Dr. Hoge emphasized, the expectation is that most people
are going to have a few speed bumps along the road to
reintegration, but they are going to get past it. I think that
is why the watchful waiting that Dr. Katz mentioned is such a
reasonable and important approach.
But for those people who do run into trouble, and we know
that there is going to be a sizeable minority that either they
will know themselves, their families will know, their employers
will know, their loved ones will know, and then we can get the
information out, where do you go for help. So this is a new
development, a very important one.
Mr. Hare. Since there is no particular timetable with a
person who has been diagnosed with post traumatic stress
disorder, how long do we watch them? I mean, how long should we
be, making sure that, we are communicating with them and their
families to see that if there is some way we can do
intervention because this, as I understand, is something that
can manifest itself down the road?
Currently how long are we monitoring them and how long
should we monitor them? Should this be an ongoing thing for
years or from your perspective, what is the best way, because,
as I said, I do not think there is any particular timetable
where we can say, well, in 6 months if it is not there, it is
just not going to happen?
Dr. Katz. You are absolutely right. We screen annually for
the first 5 years after people are discharged and then every 5
years afterward.
If they are suffering, if there is impairment, we urge
treatment sooner. If it is very mild and marginal, deferring to
the veteran's preference makes sense as long as the symptoms do
not worsen.
Dr. Friedman. One of the problems or major characteristics
of PTSD is that there can be a delayed onset. I mean, Colonel
Hoge testified that just in terms of the newly returned
veterans, many of people's expression of PTSD symptoms was not
apparent at the point of demobilization and did not become
apparent until 6 months later.
Well, our experience with Vietnam veterans and some of the
research coming out of Israel indicates that the onset may be
delayed for many, many years. And so as Dr. Katz said, we need
to keep the word out there. We need to keep our partnerships
with the veterans services organizations like VVA so that if
something happens down the road, they will know what it might
be and they will know where to go for help.
Dr. Katz. At the risk of double teaming you on this and----
Mr. Hare. I am the only one here. That is fine.
Dr. Katz. One of the findings that has gotten me thinking
from Dr. Hoge's work is that half of the people with symptoms
apparent on the PDHA assessments were no longer symptomatic by
the time the PDHRA came around. So there can be delays in the
onset of symptoms, but also there can be offset for symptoms
during this time without doubt, many veterans are vulnerable to
the delayed onset of PTSD, but in addition, a good deal of
resilience is apparent after people return home.
Mr. Hare. My time is up, but I wanted to ask Dr. Friedman
one last question before I let you go.
In your experience with PTSD, do you think at some point in
the future, the VA will be able, to a certain extent, provide
clinical guidelines to help mental health professionals with
the VA tailor plans to treat soldiers with PTSD and, if so,
what in your opinion are the strongest treatment solutions that
have been discovered so far?
Dr. Friedman. That is a complicated question. Let me chip
away at it. You know, first of all, there are VA/DoD practice
guidelines based on the best evidence. And as the research
continues, and you have heard from many people about this today
who have emphasized the importance of the need for new
research, and as the new results come in, obviously the
practice guidelines will need to be tailored accordingly.
Again, repeating some of the answers that some of the other
people have said, I think that there is a tremendous need for
new research. We do have, as Dr. Katz and others have
emphasized, we have very, very effective cognitive behavioral
treatments such as prolonged exposure and cognitive processing
therapy.
And Dr. Katz has been very, very visionary in supporting
efforts to disseminate these treatments. One of the problems
that we have, not just in VA because VA is kind of a microcosm
of the Nation in general, there is something wrong with the
picture in that the most effective treatments are utilized by a
minority of the therapists. So that thanks to Dr. Katz's
support, we are now out there training hundreds of VA
practitioners in these new treatments so that when people come
knocking, we will be able to provide the best treatment that is
available. These are going to be self-sustaining programs and
so we will be able to increase the reservoir of qualified
people out there.
There is the possibility that there are other
psychotherapeutic approaches. There is one approach for
treating dually diagnosed people that have both substance abuse
and PTSD. One of our national Center for PTSD investigators,
Dr. Lisa Nagivitz, has been pushing that and we are doing that
both in VA and in the DoD.
As for medications, I think that the results of the IOM
report reflect the fact that to date, the medications that are
out there have not been designed with PTSD in mind. They are
antidepressants that have been retested in PTSD patients and
they have had moderate success.
But what is more exciting as I look to the future, as we
understand more about the pathophysiology about PTSD, about how
brain function is altered as a result of exposure to traumatic
stress, that we can look down the road for new and much, much
more effective pharmacological agents that will really attack
the problem at its core.
Mr. Hare. Let me thank Dr. Katz and Dr. Friedman for coming
by this afternoon and to all of our witnesses, let me thank
you. This has been a very informative hearing.
At the end of the day, I know that all of us want to do the
very best we can to make sure that not just the service person
but their families can get some treatment and some relief in
this. They have given us everything and that is the bare
minimum we can do. I appreciate all of you for being here
today. Again, thank you very much.
With that, this hearing is adjourned.
[Whereupon, at 12:15 p.m., the Subcommittee adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud
Chairman, Subcommittee on Health
I would like to welcome everyone to our Subcommittee hearing. We
are here today to talk about PTSD Treatment and Research in the
Department of Veterans Affairs.
Post-traumatic stress disorder is among the most common diagnoses
made by the Veterans Health Administration. Of the approximately
300,000 veterans from Operations Enduring and Iraqi Freedom who have
accessed VA health care, nearly 20 percent--60,000 veterans--have
received a preliminary diagnosis of PTSD. The VA also continues to
treat veterans from Vietnam and other conflicts who have PTSD.
With the release of the 2007 IOM report ``Treatment of Post
Traumatic Stress Disorder: An Assessment of the Evidence'', we learned
that we still have much work to do in our understanding of how to best
treat PTSD. I hope that my colleagues will continue to work with me in
supporting VA's PTSD research programs.
I look forward to hearing testimony today from several
organizations that are working to provide comprehensive and cutting
edge treatment to those with PTSD. The committee recognizes that this
is an important issue and one that will be with us for a long time to
come. We are committed to ensuring that all veterans receive the best
treatment possible.
Prepared Statement of Hon. Jeff Miller
Ranking Republican Member, Subcommittee on Health
Thank you, Mr. Chairman.
Following every war in history, what we now call Post Traumatic
Stress Disorder or PTSD has sadly affected the lives of many brave men
and women who have worn the uniform.
And, this Committee over the years has held numerous hearings to
bring to the forefront the emotional toll the trauma of combat can lay
on our veterans and the need for us as a Nation to effectively care for
those who suffer with military-related PTSD and experience difficulty
reintegrating into civilian life.
In response to a Congressional mandate, VA established the National
Center for PTSD in 1989. This Center was created to advance the well-
being of veterans through research, education and training in the
diagnosis and treatment of PTSD. VA has since moved to expand its
programs and currently employs over 200 specialized PTSD programs in
every health care network. Available care includes cognitive
behavioral therapy, which is shown to be a most effective type of treatm
ent for PTSD.
Many service members who develop PTSD can recover with effective
treatment. Yet, PTSD it is still the most common mental disorder
affecting OIF/OEF veterans seeking VA health care. About 20% of all
separated OIF/OEF veterans who have sought VA health care received a
PTSD diagnosis. Even more alarming, a recent study conducted by VA
shows that young service members between the ages of 18 and 24 are at
the highest risk for mental health problems and PTSD, being three times
as likely as those over 40 to be diagnosed with PTSD and/or another
mental health problem.
Clearly PTSD remains a very prominent injury that our veterans
endure and that is precisely why today's hearing is so crucial. We must
continue to focus on how best to strengthen research and rapidly
disseminate effective clinical care in all settings so that we can
finally understand this illness, break through it and move forward with
complete recovery--bringing relief to the many heroic veterans who
still fight daily battles no less harrowing than the ones they fought
in combat.
On that end, I want to thank our witnesses for being here today to
present their expert views on what may cause, and more importantly,
preclude PTSD from emerging among our veterans.
Again, thank you, and I yield back.
Prepared Statement of Hon. John T. Salazar
Good morning Chairman Michaud, Ranking Member Miller and
distinguished members of this subcommittee.
We are fortunate to have the opportunity to discuss the impact that
PTSD is having on our returning troops, veterans and their families.
I look forward to hearing the testimony of the experts that join us
today.
I thank them for their dedication to our servicemen and women.
An important part of our discussion today will be to hear about the
research on PTSD cases in Vietnam and OEF/OIF soldiers.
It is important to look at these two individually and in comparison
to one another.
I also look forward to hearing about the research done on exposure
therapy.
Innovative and new treatments are essential to the health of our
veterans and our current force.
Our Veterans deserve to know that once they leave the battlefield
and return home, we have programs in place to care for them.
Mr. Chairman, I thank you and the members of this committee for
giving us the opportunity to discuss construction authorizations.
Prepared Statement of Colonel Charles W. Hoge, M.D., USA Director
Division of Psychiatry and Neuroscience,
Walter Reed Army Institute of Research,
Department of the Army, U.S. Department of Defense
Mr. Chairman and Members of the Committee, thank you for this
opportunity to discuss the Army's research on Post-Traumatic Stress
Disorder (PTSD) at Walter Reed Army Institute of Research (WRAIR). I
will focus on research initiatives at WRAIR but want to first
acknowledge and thank Congress for the tremendous increase in funding
for PTSD and Traumatic Brain Injury (TBI) research. The $300 million
dollars allocated to PTSD and TBI research in the FY07 appropriation is
in the process of being awarded to numerous Department of Defense
(DoD), Department of Veterans Affairs (VA), and civilian research
organizations under the management of the U.S. Army Medical Research
and Materiel Command's Office of Congressionally Directed Medical
Research Programs (CDMRP).
I would like to briefly discuss the findings of three studies
published since my last testimony to this Committee in September 2006,
which highlight both the successes and challenges in addressing the
mental health needs of our service members.
The first is a study reported this past November in the Journal of
the American Medical Association (JAMA) involving nearly 90,000
Soldiers who completed both the post-deployment health assessment
(PDHA) and the post-deployment health reassessment (PDHRA) after return
from deployment to Iraq. Soldiers completed the PDHA immediately upon
their return and they completed the PDHRA six months later. The study
confirmed that many mental health concerns do not emerge until several
months after return from deployment, highlighting the importance of the
timing of the PDHRA, particularly for Reserve Component Soldiers.
Twenty percent of Active Component and 42% of Reserve Component
Soldiers were identified as needing mental health referral or
treatment, most often for PTSD symptoms, depression, or interpersonal
conflict. About half of Soldiers with PTSD symptoms identified on the
PDHA showed improvement by the time of the PDHRA, often without
treatment. However, more than twice as many Soldiers who did not have
PTSD symptoms initially became symptomatic during this same period. One
counterintuitive finding was that we could not demonstrate any direct
relationship between referral or treatment for PTSD as identified on
the PDHA and symptom improvement six months later on the PDHRA. The
difficulty in demonstrating the effectiveness of the PDHA assessment
may reflect, in part, the inherent limitations in screening or the fact
that mental health services remain overburdened with the current
operational tempo, despite the extensive efforts to bolster services
and training. An encouraging finding was that many Soldiers sought care
within 30 days of the PDHA and PDHRA even if they were not referred,
which suggests these assessments may be encouraging individuals to seek
help on their own following discussion of mental health issues with a
health professional or participation in concurrent Battlemind
education.
The second study I'll discuss is the recently released Mental
Health Advisory Team 5 (MHAT-V) report. We have conducted MHAT
evaluations every year in Iraq since the start of the war, and twice in
Afghanistan. The MHATs have shown that longer deployments, multiple
deployments, greater time away from base camps, and combat intensity
all contribute to higher rates of PTSD, depression, and marital
problems. The MHAT-V included for the first time a sizable number of
Soldiers on their 3rd rotation to Iraq. The study showed that with each
deployment there is an increased risk; 27% of Soldiers on their third
deployment reported serious combat stress or depression symptoms,
compared with 19% on their second, and 12% on their first deployment.
The MHAT-V also showed that Soldiers in brigade combat teams deployed
to Afghanistan are now experiencing levels of combat exposure and
mental health rates equivalent to those experienced by Soldiers
deployed to Iraq.
Soldiers encounter a variety of traumatic experiences and stresses
as part of their professional duties. The majority cope extraordinarily
well and transition home successfully. However, surveys in the post-
deployment period have shown that rates of mental health problems,
particularly PTSD, remain elevated and even increase during the first
12 months after return home, indicating that 12 months is insufficient
time to reset the mental health of Soldiers after a year-plus combat
tour. Many of the reactions that we label as ``symptoms'' of PTSD when
Soldiers come home are, in fact, adaptive skills necessary in combat
that Soldiers must turn on again when they return for their next
deployment.
The 3rd study I'll discuss is one that we just published in the New
England Journal of Medicine pertaining to the relationship of PTSD to
mild traumatic brain injury (or ``mild TBI''). It is important to
clarify terminology. Reports have indicated that as many as 20% of
troops returning from Iraq and Afghanistan have had traumatic brain
injuries, but what is not always made explicit is that the vast
majority of these are concussions. ``Mild TBI'' means exactly the same
thing as ``concussion,'' which athletes or Soldiers also refer to as
getting their ``bell rung'' or being ``knocked out.'' I advocate using
the term ``concussion'' because it is less stigmatizing than the term
``brain injury,'' is better understood by Soldiers and Families, and is
less likely to be confused with moderate or severe TBI. A concussion is
a blow or jolt to the head that causes a brief loss of consciousness or
change in consciousness, such as disorientation or confusion. Full
recovery is expected, usually within a few hours or days. This is very
different from moderate or severe TBI, where there is an obvious injury
to the brain that almost always requires evacuation from theater.
Although most Soldiers are able to go back to duty quickly after
concussions, there has been concern that concussions in combat,
particularly from blasts, may have lasting effects that are not
immediately visible. Some Soldiers report persistent symptoms (termed
``post-concussive symptoms''), such as headaches, irritability,
fatigue, dizziness, problems concentrating, sleep disturbance, balance
problems, and cognitive or memory difficulties. Our study involving
2,500 infantry Soldiers was one of the first to look at the
relationship between concussions Soldiers sustained while deployed to
Iraq and these types of physical and mental health outcomes three
months after their return.
There were three key conclusions from this study:
First, the study highlighted a problem that we face with not having
an accurate diagnostic tool in the post-deployment period. We are not
aware of any questionnaire or test that can accurately tell us who had
a concussion while deployed, or which symptoms were caused by a
concussion that occurred months earlier, as we are attempting to do
with post-deployment screening. In our study sample, 15% of Soldiers
reported a concussion while deployed based on the questions currently
being used on the post-deployment assessment forms. However, only one-
third of these, or 5% of the Soldiers, reported an injury in which they
were knocked unconscious, usually for just a few seconds or minutes.
The rest had injuries that only involved being briefly ``dazed or
confused'' without loss of consciousness, and it was not clear how many
of these were true concussions. We found that this type of injury did
not confer much excess risk of adverse health effects after
redeployment.
The second important finding was that having a concussion was
strongly associated with PTSD. Forty-four percent of Soldiers who lost
consciousness met the criteria for PTSD, compared with 16% of those who
had other types of injuries and 9% who had no injury.
Third, and the most important finding, was that the symptoms that
we thought were due to the concussions were actually attributed to PTSD
or depression. If a concussion was the cause of the post-concussive
symptoms we should have been able to confirm an association of these
symptoms with a concussion, both in those Soldiers who had PTSD and in
the larger group of Soldiers who did not. We did not see this in either
group. Instead, all the physical health outcomes and symptoms were
associated with PTSD or depression. Both PTSD and depression are
biological disorders that are associated with a host of chemical
changes in the body's hormonal system, immune system, and autonomic
nervous system. Many studies have shown that PTSD and depression are
linked to physical health symptoms, including all of the symptoms in
the ``post-concussion'' category, to include cognitive and memory
problems.
This study allowed us to refine our knowledge about what
distinguishes concussions in combat from concussions in other settings.
Concussions on the football field, for example, are not known to be
associated with PTSD. It is possible that there is an additive effect
in the brain when a soldier who is already seriously stressed in combat
sustains a blow to the head, or there may be something unique about
blast exposure, as many people are speculating. However, a hypothesis
that is better supported by our data as well as other medical
literature is the life threatening context in which the concussion
occurs. Being knocked unconscious from a blast during combat is about
as close a call as one can get to losing one's life. There are
frequently other traumatic events that occur at the same time, such as
a team member being seriously injured or killed, all of which can
precipitate PTSD or depression.
The most important implication of this study is that current post-
deployment TBI screening efforts may lead to a large number of service
members being mislabeled as ``brain injured'' when there are other
reasons for their symptoms that require different treatment. The
optimal time to evaluate and treat concussion is at the time of injury,
and it is my opinion that post-deployment screening efforts months
after injury may actually lead to unintended harmful effects. As a
result, my research group has provided recommendations to medical
leaders at Army and DoD to refine the post-deployment screening efforts
to assure that all health concerns are addressed in a way that
minimizes potential risks. These recommendations are now under
consideration. In addition to screening and treatment, our study has
important implications for educating Soldiers and Families about mild
TBI (i.e. concussion).
Thank you so much for your attention and I look forward to your
questions.
Prepared Statement of Carolyn M. Baum, Ph.D., OTR/L, FAOTA
Immediate Past President, American Occupational Therapy Association, and
Professor, Occupational Therapy and Neurology,
Elias Michael Director of the Program in Occupational Therapy,
Washington University School of Medicine, St. Louis, MO
Mr. Chairman and Members of the Subcommittee, thank you for giving
the American Occupational Therapy Association (AOTA) the opportunity to
testify before the Subcommittee to address the challenges of providing
optimal identification and treatment of Post Traumatic Stress Disorder
(PTSD). My name is Dr. Carolyn Baum. I am the immediate past President
of AOTA. I am also a professor of occupational therapy and neurology
and the Elias Michael Director of the Program of Occupational Therapy
at the Washington University School of Medicine in St. Louis, Missouri.
AOTA and the Profession of Occupational Therapy
AOTA and I are grateful to the Chairman and Members of the
Subcommittee for your leadership in addressing the healthcare needs of
the approximately 8 million veterans enrolled in the U.S. Department of
Veterans Affairs (VA) health care delivery system. As the professional
association representing occupational therapy, AOTA has more than
38,000 members dedicated to providing the health care and
rehabilitative services that help people recover and gain the skills
needed to return to family, work and community life.
The goal of occupational therapy is to enable individuals with
functional impairments, regardless of the cause, to attain their
maximum level of participation and independence. With injured veterans,
this can mean helping the veteran learn how to manage activities
necessary for maintaining a household--everything from cooking and
washing laundry to handling financial affairs; it can mean learning to
manage medications; it can mean coping with triggers to prevent anxiety
or anger and learning strategies to manage the health conditions
associated with their injuries. Occupational therapists help wounded
warriors return to their military roles and responsibilities or
transition into civilian life; we do this by helping them to develop or
regain the skills and strategies that allow them to be successful in
all areas of their lives.
Our purpose in this statement is to share the unique role that
occupational therapy plays in helping veterans recover from Post
Traumatic Stress Disorder (PTSD). We also want to provide
recommendations for improving the system of care for this all-too-
common disorder among our veterans. This is particularly true in
today's environment as many of the returning veterans from Iraq and
Afghanistan have sustained serious injuries and been exposed to
operational conditions that make PTSD a natural reaction to these
extraordinary stresses. While immediate focus is necessary on veterans
of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF),
it must also be noted that the effects of PTSD, if unidentified and
untreated, can be delayed and can impact people many years after the
trauma took place. Experience with WWII veterans reaching the age of
retirement and their increasing identification and struggle with PTSD
raises a flag of caution for Korean war and Vietnam veterans. The
importance of followup screenings to identify individuals who are
living with delayed-onset PTSD can't be overemphasized. This need alone
provides a strong argument for the full use of occupational therapists
for the ongoing assessment of PTSD signs and symptoms for all those who
may be affected.
Mr. Chairman, we at the American Occupational Therapy Association
are aware that the conflicts in Iraq and Afghanistan continue to
increase the Veteran Administration's patient workload. From
consultation with our members within the VA, we have heard that they
are struggling to maintain the quality care for which they are known as
a result of the increased demand for rehabilitation services. Of
concern to AOTA and our members is the need for an increased focus on
rehabilitation that will meet the needs of the veteran as he or she
faces serious problems that require comprehensive rehabilitation
services. There must be a continuum of rehabilitation in hospitals,
outpatient clinics, and community rehabilitation centers. Because of
the severity of their injuries and conditions, many injured veterans
need rehabilitation in their home environment, in order to assess the
modifications needed for them to be functional in their homes. Many who
are in wheelchairs need an occupational therapist's help to work with
building contractors to design and build an accessible route into and
out of their homes. Rehabilitation does not stop when veterans are
discharged from hospital or medical care; the process continues with
post-rehabilitation fitness, community reintegration, social
reconnection and work accommodations. All of these are areas in which
occupational therapists play an important role.
Occupational therapy rehabilitation can be viewed developmentally
and includes four phases: biomedical, client-centered, community-based
and independent living. All four phases of rehabilitation may be
necessary, as recovery occurs across time. The focus moves from medical
treatment to assistance with recovery, to helping people achieve their
goals and finally to helping them return to their roles in service, in
families and communities, and learn to live with a disabling condition.
To determine the specific rehabilitative needs of each veteran, it is
necessary to conduct a multidimensional assessment of the person, of
the environment and the occupational needs of the individual, to choose
the most effective approach (Christiansen, Baum, 2005).
The effective treatment of PTSD and the return of veterans back
into their family and community life requires an integrated system of
care that includes assessment, goal setting, treatment, and learning to
``self-manage'' life after injury.
The Role of Occupational Therapy in PTSD Treatment
Occupational therapy is probably best known for the rehabilitation
of individuals after illness or injury, for example, stroke, loss of
vision, traumatic brain injuries (TBI), and physical burns, wounds, and
amputations. However, occupational therapists treat individuals with
functional impairment regardless of the specific cause and go beyond
the range of physical injury or illness to include the mental and
cognitive impairments that can cause disabling conditions. (Gerardi,
Newton, 2004).
Occupational therapy's approach to addressing health needs stems
from a body of knowledge that is translated from neuroscience,
occupational science and environmental science and from evidence-based
interventions that recognize the importance of engagement in life and
activities in maintaining and restoring health. Occupational therapists
and occupational therapy assistants use a body of knowledge and
evidence-based interventions that identify the causes of difficulties
that are limiting participation. In the case of veterans, these are
obstacles that limit their ability to reintegrate into military or
civilian life.
In brief, occupational therapy is based on the following evidence-
based constructs: (1) Health is linked to engagement in occupation
(Haapanen et al, 1996; 1997; Blair & Connelly, 1996; Samitz, 1998, Dorn
et al, 1999 and Pennedo & Dahm, 2005.
(2) A healthful, balanced lifestyle is maintained by habits developed
and sustained from engagement in daily occupations (Wilcock, 1998). (3)
Lack of occupation leads to physiological deterioration and the loss of
ability to perform competently in daily life (Kielhofner, 1992). (4)
People need to make use of their capacities through engagement in
individually motivating and ongoing occupations, and if they pursue
this need, they will, enhance their health (Wilcock, 1993).
Occupational therapy uses a client-centered approach to
rehabilitation that differs from traditional biomedical therapies. The
approach and expertise of occupational therapy practitioners enables
them to consider the client's needs, the environmental factors and the
family concerns to help the veteran develop and implement effective
strategies to overcome disability and maximize quality of life. In
client-centered rehabilitation, the strengths and desires of the
patient are significant tools for recovery and the therapist is engaged
by the veteran to assist them with the achievement of personal goals
that will help them return to family, work and community life
(Christiansen, Baum, 2005).
The unique perspective of occupational therapy is highly prized by
the Army for combat and operational stress control and that model
should inform the use of occupational therapy within the VA. AOTA
understands the variations in the nature of combat stress and the
deeper aspects of PTSD, but the Army model deserves additional
attention from the VA and the Subcommittee because occupational therapy
brings a third dimension to the system of care commonly employed for
PTSD treatment within the VA. Pharmaceutical intervention and
counseling are essential aspects of PTSD treatment but they do not use
therapeutic activity nor focus as specifically as occupational therapy
does on the reduction of functional impairment and the maximization of
function and performance. Medication, counseling, and engagement and
participation in social and therapeutic activities are all critical
tools in helping veterans to recover from PTSD.
Veterans with PTSD have difficulty performing their daily life
roles and activities because they reexperience events, and avoid
certain activities because they are numbing and/or result in a state of
hyperarousal, anxiety or even anger. Consider for example, a soldier
who is driving on routine patrol and when a roadside bomb explodes
under the vehicle. The soldier might experience a life-threatening
injury, or witness the death of a unit member in the vehicle. Upon
returning stateside, the individual with PTSD might experience
disturbing flashbacks of the event triggered simply by getting behind
the wheel of a car, or by driving in general. The individual might then
avoid driving altogether, creating a negative spiral that affects his
or her ability to engage in important activities involving everything
from employment to community and social participation. But occupational
therapy can help.
A study by Erica Stern, at the University of Minnesota, compared
the driving behaviors and driving related anxiety of 150 soldiers who
had returned from OIF to 49 soldiers who had not been deployed.
Returned soldiers' reporting on their past 30 days of American driving,
reported significantly worse driving behaviors (with a large percentage
of OIF soldiers reporting that they sometimes or always fell into
combat driving behaviors, e.g., drove through stop signs (25%), drove
in the middle of the road or into oncoming traffic (23%), drove
erratically in a tunnel (11%), made turns or lane changes without
signaling (35%). Nearly a third of the group had been told that they
drove dangerously. These soldiers were a general sample, without known
PTSD, yet in addition to their slips into combat driving behaviors,
they also reported significantly more frequent anxiety than their non-
deployed comrades. Twenty percent were anxious when driving at any
time, with larger numbers being anxious in specific civilian driving
situations that mimic combat threats associated with driving, e.g.,
when driving near roadside debris (31%), near parked cars (25%),
through tunnels/underpasses (19%), in slow or stopped traffic (41%), at
night (28%), and when passed by other cars (31%), or another car
approached quickly or boxed them in (49%). These soldiers were a
convenience sample without known PTSD or head injury. When we hear how
their driving is effected, we can easily understand the ways that
driving and other daily activities are likely to be changed in soldiers
with PTSD.
An occupational therapist would work with the veteran to address
the functional impairment caused by the PTSD symptoms. The therapist
might use simulated or virtual reality driving experiences in a safe
and controlled environment in order to help the veteran extinguish or
reframe negative mental or physical reactions.
Overall, an occupational therapist would help the veteran with PTSD
through a graduated series of desensitization experiences within the
context of daily activities. This is done by grading the individual's
reactions to traumatic associations at baseline, and a variety of
techniques (i.e., relaxation exercises, guided imagery and
visualization) to counteract and reduce the reaction to disturbing
thoughts and images. Strengthening a person's general coping skills can
be addressed by identifying the activities and behavior associated with
positive outcomes. Therapists also work with veterans with PTSD to
engage in activities that will help them manage or ameliorate
depressive symptoms and/or excessive anxiety, and address issues of
substance abuse.
For a person with PTSD, occupational therapists might address
issues of cognitive executive function, such as memory, planning or
organizational skills, that are limiting the individual's performance.
They address this by using cognitive behavioral strategies and assist
the individual with learning and developing compensatory strategies to
improve performance and maximize independence. Another approach used by
occupational therapists in task analysis; breaking down complex tasks
into manageable parts. This strategy can be effective with activities
as basic as bathing and dressing to something as complex as balancing a
checkbook or even returning to a particular job.
Such an approach is important for the treatment of PTSD as the
person must not only address the issues they experience during acute
episodes, but they must also learn strategies to use at a later time
when they have recurrent episodes. It is also important to include the
families in this process as they can be instrumental in the recognition
of problems that require professional attention. They also need to
understand what their loved one is experiencing. Occupational therapy's
unique approach is to work with the person in regard to the interaction
of all aspects of their life and environment.
Occupational Therapy in the Veterans Administration
The VA has made significant strides in preparing to meet the needs
of returning OIF/OEF veterans but work remains to be done. AOTA urges
Congress to continue to monitor how the VA uses occupational therapists
and other professionals to assure that quality care is provided and
that the full scopes of practice of all professions are brought to bear
to meet veterans' needs. Veterans deserve every service and
intervention that professionals have been trained to provide. But they
should receive services only from qualified professionals.
Throughout the VA system, but particularly within the Polytrauma
Rehabilitation Centers, there should be a special focus on appropriate
training and on evidence-based practice. Monitoring how each profession
is integrated into the team should be done to provide for continuous
quality improvement in these facilities.
Additionally, AOTA is concerned about the fragmented way the VA
integrates or more problematically, does not integrate occupational
therapists and other professionals into multidisciplinary teams for
assessment and treatment of PTSD. While VA and Department of Defense
(DoD) treatment guidelines for PTSD exist and include occupational
therapy, it is the experience of our members that the inclusion of
occupational therapists varies from site to site. This variation does
not ensure full access to effective treatments and AOTA encourages the
Committee to look at this issue in detail. It is also our concern that
because of the primary role occupational therapy plays in the
assessment and treatment of other conditions like TBI, low-vision and
traumatic amputations, veterans with PTSD are not getting the access to
occupational therapy they need. Occupational therapists are simply not
as readily available as they need to be to address PTSD because their
workload is so high in other areas. Additional therapists are needed to
address PTSD because the unique, activity-based focus of occupational
therapy is so critical to recovery from PTSD, particularly during the
community reintegration phase of recovery.
It is possible for the private sector to supplement the Veterans
Administration. Occupational therapists at Washington University School
of Medicine in St. Louis are currently contracted to provide services
with three of our community based programs. Veterans referred to us are
evaluated by the Community Practice Program in their home to determine
the issues that may be limiting their ability to care for themselves or
others, get in and out of their homes if they are using mobility
devices; and to determine if their home arrangements support them in
daily tasks like toileting, bathing, preparing meals and maintaining
the household. Their needs and goals are determined based on real life
needs. If they have unmet mobility or work needs they are referred to
either the Washington University Enabling Mobility Center (EMC) where
they are evaluated and receive mobility and other equipment that will
maximize their independence. If needed, they begin a program of post
rehabilitation fitness (similar to what is provided at the Intrepid
Center at Fort Sam Houston). It is in the fitness program where the
veteran can re-build their strength and endurance while socializing
with other persons with mobility limitations on equipment designed for
people in wheelchairs. If the veteran has a cognitive impairment and
needs additional rehabilitation to be able to work or return to school
they are referred to our Occupational Performance Center (OPC) where
they learn strategies to perform work tasks and are assisted in
maximizing their work potential using both simulated and then actual
work tasks. The OPC team works with employers to create the right
environmental fit to use the capacities of the worker. In this program
people have gone back to complex jobs like nursing, teaching and the
law in addition to trade jobs.
Considerations for the Committee's Attention
1. In order to increase the numbers of occupational therapists
within the VA, AOTA urges the Subcommittee to consider expanding loan
repayment programs to ensure that the VA remains an attractive
employment option. This is particularly important because salaries in
the VA do not tend to be as high as salaries in other healthcare
settings. The Bureau of Labor Statistics (BLS) estimated that in 2006,
the last year for which data is available, the average salary for an
occupational therapist was $62,510. This month, there are two positions
at the Palo Alto Polytrauma Rehabilitation Center that are offering
$50,599 and have been open since last July 2007. This variation in
salary and subsequent inability to fill the positions is troubling. It
is even more alarming when placed in the context of California salaries
for occupational therapists for 2006, which averaged $73,120. That
represents a more than $20,000 salary gap between what is being offered
by the VA for a highly complex position treating veterans with
polytrauma compared to the statewide average salary. To add to our
concern Mr. Chairman, there are additional occupational therapy and
rehabilitation positions that were recently posted at that facility as
well. The need is not being met by these salary differentials.
2. The BLS data indicates that occupational therapists and
occupational therapy assistants are two of the fastest growing
professions, with a projected 33% increase in overall positions by
2017. AOTA urges the Subcommittee and the VA to vigilantly attend to
recruitment and retention issues as the market for therapists becomes
increasingly competitive.
3. AOTA encourages the VA to conduct a thorough, system-wide
salary survey to ensure that the VA remains competitive and able to
attract the quality, experienced staff necessary to ensure the best
care for our veterans. Sites like the four Polytrauma Rehabilitation
Centers and the 17 Polytrauma Network sites require the highest quality
staff with significant training and experience in treating veterans
with multiple injuries and illnesses, often including PTSD. In hearing
from our members from the Polytrauma Network and from others across the
country, continuing education is an area that requires additional
attention. This is particularly true in relation to the most severely
injured veterans where expertise in multiple areas of practice is
necessary. Veterans deserve best practices based on current research
and evidence.
4. In discussions with the VA National Office, AOTA has offered to
work with the VA to develop and implement training modules related to
some of the areas of greatest need. This training would be developed
with civilian and VA participants to benefit from their collective
knowledge, experience and expertise. AOTA is ready to collaborate again
with the VA, as we have in the past and we urge the VA to partner with
AOTA to help meet the continuing education needs of occupational
therapists and occupational therapy assistants within the VA.
5. AOTA encourages the Committee to hold a hearing on
rehabilitation and reintegration of veterans and invite participation
of the national associations, like AOTA, that represent the professions
most involved in these phases of recovery in the VA. Such a panel would
address best practices, multidisciplinary communication and service
coordination to ensure veterans receive the highest quality and most
efficient care. The hearing would inform the Subcommittee on the way
various professionals are being used by the VA to meet veterans' needs
and provide suggestions for improvement and enhancement of current
systems of care.
6. Finally, I would like to address the importance of coordination
between the VA and the Department of Defense (DoD) in regard to the
transition from active duty to veteran status. It is essential that the
VA and DoD ensure continuity of care for all veterans, but especially
for those with PTSD and TBI. While the roles and responsibilities of
each organization are different, the service member does not process
the immediate transformation of their change in status as quickly as
the paperwork is done. For service members becoming veterans because of
injuries sustained on active duty, the transition can be overwhelming.
The Army and other services have established Warrior Transition or
similar units to allow recovering soldiers to engage in treatment in
familiar circumstances and surroundings. During this stage, VA
rehabilitation counselors can meet with soldiers to help create a
continuous transition. These counselors often collaborate with the
occupational therapists caring for the soldiers in the Warrior
Transition units. This is particularly relevant to PTSD because of the
prominent role occupational therapists play in Army Combat Stress
Control units.
Mr. Chairman, in conclusion I want to reiterate that occupational
therapy has expertise in the treatment of functional impairment
resulting from a broad range of conditions faced by veterans and should
be explicitly included in systems of care or treatment teams
established to treat veterans and their families during the acute
stages of recovery through the rehabilitation and community
reintegration phases. It is the unique treatment focus contributed by
occupational therapy--not the replacement of other services--that can
help veterans regain control of their anxiety and their future so that
they can return to relationships and activities of meaning and purpose
in their lives.
Roughly 750 occupational therapists are currently employed by the
VA, but many more will be necessary to meet the needs of the new
generation of veterans. Occupational therapy allows veterans with PTSD
to return to activities of meaning that deliver a sense of normalcy and
belonging to veterans and their families.
Thank you for the opportunity to provide testimony to the
Subcommittee. AOTA looks forward to working with Congress and the VA to
ensure that the profession of occupational therapy is doing everything
in its power to meet the needs of our veterans. Mr. Chairman, I would
be happy to answer any questions you or the Subcommittee might have.
Thank you.
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Haapanen, N., Miilunpalo, S., Vuori, I., Oja, P., Pasanen, M. (1996).
Characteristics of leisure time physical activity associated with
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Association of leisure time physical activity with the risk of
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(2004). Environmental influences on cognitive and brain plasticity
during aging. Journal of Gerontology: Medical Sciences, 59A(9),
940-957.
Peneddo, F.J. & Dahn, R. (2005). Exercise and well-being: a review of
mental and physical health benefits associated with physical
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cause mortality. A public health perspective. Weiner Klinische
Wochenschrtft, 110 (17), 589-596.
Wilcock, A. (1998). Reflections on doing, being and becoming. Canadian
Journal of Occupational Therapy, 65(5), 248-256.
Wilcock, A. (1993). A theory of the human need for occupation.
Occupational Science: Australia, 1(1), 17-24.
World Health Organisation (2001). Introduction to the ICIDH-2: The
International Classification of Functioning and Disability. http://
www.who.int/icidh/.
Zimmer, Z. Hickey, T., and Searle, M.S. (1995). Activity participation
and well-being among older people with arthritis. The
Gerontologist, 35, 463-471.
Prepared Statement of David Matchar, M.D.
Member, Committee on Treatment of Posttraumatic Stress Disorder,
Board on Population Health and Public Health Practice,
Institute of Medicine, The National Academies, and
Director and Professor of Medicine, Center for Clinical Health
Policy Research, Duke University Medical Center, Durham, NC
Good morning, Mr. Chairman and members of the Committee. My name is
David Matchar. I am Director and Professor of Medicine at the Center
for Clinical Health Policy Research at Duke University Medical Center
and served as a member of the Institute of Medicine committee which
produced the report Treatment of Posttraumatic Stress Disorder: An
Assessment of the Evidence.\1\ The Institute of Medicine was chartered
in 1970 as a component of the National Academy of Sciences. This study
was sponsored by the Department of Veterans Affairs as part of an
ongoing series of reports on the health of veterans.
---------------------------------------------------------------------------
\1\ The report may be viewed on the Web site of the National
Academies Press: http://www.nap.edu/catalog.php?record_id=11955.
---------------------------------------------------------------------------
The Department of Veterans Affairs charged the Institute of
Medicine committee with several specific tasks. We were asked to: (1)
review the evidence and make conclusions regarding the efficacy of
available treatment modalities; (2) note restrictions of the
conclusions to certain populations; (3) answer questions related to
treatment goals, timing and length; (4) note areas where evidence is
limited by insufficient research attention or poorly conducted studies;
and (5) comment on gaps and future research.
To respond to its first task, making conclusions regarding
efficacy, the committee developed methods using generally accepted
international standards for conducting a systematic qualitative review.
This included developing key questions, specifying the literature
search strategy, inclusion and exclusion criteria, key quality criteria
(such as assessor blinding or independence, and treatment of missing
data), and judging the weight of the body of evidence. The committee's
conclusions were ultimately based on its judgments of the sufficiency
of the body of evidence for each category or class of treatment. Here,
I should make an important distinction between what the committee did,
which was to evaluate the evidence, and clinical practice guidelines.
The committee was not asked to recommend what therapies clinicians
should use or not use. Making such recommendations is the work of
professional associations (such as the American Psychiatric
Association) and guidelines are also developed by government agencies
such as the VA. Clinical practice guidelines have different purposes
and frequently include a very broad range of considerations.
The committee focused its review on randomized controlled trials
(RCTs) because their design is most bias resistant to answer questions
of efficacy, and because the statement of task asked that we review the
highest level of evidence available, which was RCTs in most cases.
Application of the committee's inclusion criteria (such as, studies
that were published in English, were based on Diagnostic and
Statistical Manual criteria, and included a PTSD outcome measure)
narrowed the list of nearly 2,800 articles down to 89 RCTs, 37 studies
of treatment with medications, and 52 studies of treatment with
psychotherapy. Among the medication studies, the committee found
studies of drugs such as selective serotonin reuptake inhibitors
(SSRIs) and anticonvulsants.
The evidence on pharmacotherapy in general was limited, with
relatively few studies meeting inclusion criteria and free of
significant methodological limitations. Even among the SSRIs, with the
most substantial evidence base, the committee was struck by
inconsistencies in the results of studies, and serious methodologic
limitations. The committee found the evidence for SSRIs (and all other
drug classes for which RCTs were identified) inadequate to conclude
efficacy. The report provides comments on several of the drug classes
indicating areas where evidence might be suggestive in important
subgroups.
The committee grouped the psychotherapy studies empirically into
categories as actually examined in the literature, and did not attempt
to enter the debates in the field about how the various therapies may
be related at the level of theory. Among the psychotherapies, the
committee identified studies where the therapy being investigated was
exposure therapies alone or in combination with another component,
cognitive restructuring, one or more types of coping skills training,
Eye Movement Desensitization and Reprocessing (EMDR), other
psychotherapy, and group format therapy. (The term exposure therapies
refers to a family of therapies that include confronting the trauma-
related memories or stimuli.)
The committee judged the evidence for exposure therapy sufficient
to conclude efficacy. The evidence for all but one of the remaining
psychotherapy categories (including the broad ``group therapy''
category) was inadequate to conclude efficacy. The evidence on other
psychotherapies, such as hypnosis and brief eclectic psychotherapy was
so limited that the committee did not form conclusions at all.
The committee's conclusions of inadequacy regarding evidence for
most treatment modalities should not be misinterpreted as if they are
clinical practice guidelines. Finding that the evidence is inadequate
is not a determination that the treatment does not work. It is an
honorable conclusion of scientific neutrality. The committee recognizes
that clinical treatment decisions must be made every day based on many
other factors and considerations, such as patient preference,
availability, ethical issues, and clinical experience, that we were not
asked to address, and we did not.
Next, the committee considered the issue of whether conclusions may
be drawn about treatment efficacy in regard to population, provider, or
setting. The committee was struck by the lack of evidence on this
important issue. The Diagnostic and Statistical Manual criteria do not
recognize more than one type of PTSD (such PTSD distinguished by trauma
type), yet reasonable people might question whether all PTSD is the
same and whether one can expect a treatment shown effective in one
group, for example earthquake survivors, to also work for U.S. combat
veterans. Rigorously speaking, a study only applies to the population
actually studied unless there are data showing the data applies to
other groups. We found no evidence either that PTSD is the same or that
it's different in veteran or VA populations compared with civilian
populations. A minority opinion in the report was based on the belief
that there are subgroups and the evidence should be examined separately
for them, but the committee majority concluded otherwise.
VA asked the committee to comment on what the literature tells us
about the meaning of recovery, the effect of early intervention, and
the impact of treatment length (e.g., brief vs. prolonged therapy). The
committee found no generally accepted and used definition of recovery
in PTSD. We recommend that clinicians and researchers work toward
common outcome measure that are valid in research, allow comparability
between studies, and are useful to clinicians.
We interpreted early intervention to mean keeping cases of PTSD
from becoming chronic. Intervention before the diagnosis of PTSD or
before the possibility of meeting the definition of PTSD (generally,
early intervention in the literature occurs immediately post-trauma,
referring to a condition that's a precursor to PTSD, such as Acute
Stress Disorder) was not part of our scope, because it refers to people
who do not yet have or may never develop PTSD. We could not reach a
conclusion on the value of early intervention, and recommended that
further research specify time since trauma and duration of PTSD
diagnosis. Interventions should be tested for efficacy at clinically
meaningful intervals.
On length of treatment the committee found that the research varied
widely in length of treatment even for a single modality, and was not
able to reach a general conclusion. We recommend that trials focus on
optimal length of given treatments, and that trials of comparative
effectiveness between treatments should follow. There is also a need
for longer term followup studies after treatment concludes.
Our last two tasks were to address areas inadequately studied and
recommendations for further research. Our overall message here is that
PTSD needs more attention from high-quality research, including in
veterans. The committee highlighted several research-related issues in
the report, including internal validity (for example, was there
blinding in the study, was there adequate followup of patients, were
missing data handled with appropriate analyses?), investigator
independence, and special populations.
As outlined in our methods and in a technical appendix, the
committee found much of the research on PTSD to have major limitations
when judged against contemporary standards in conducting randomized
controlled trials. While recognizing that PTSD research perhaps
presents special challenges, we know that high quality studies are
possible because we found them in our search, and there are authorities
in the field of PTSD research who have called for more attention to
methodologic quality. We recommend that funders of PTSD research take
steps to insure that investigators use methods to improve the internal
validity of research.
The committee also noted that the majority of drug studies have
been funded by the pharmaceutical manufacturers, and the majority of
psychotherapy studies have been conducted by the individuals who
developed the techniques or their close collaborators. The committee
recommends that a broad range of investigators be supported to conduct
replication and confirmation studies.
The committee recognized that PTSD is usually associated with other
problems such as comorbid substance abuse, depression, and other
anxiety disorders. More recently, there's been growing concern about
people with PTSD and traumatic brain injury. The research literature is
not informative on this issue of patients who have PTSD and other
disorders. It also does not address PTSD in special veteran populations
such as ethnic and cultural minorities, women, and people with physical
impairments. We recommend that the most important such subpopulations
be defined to design research around interventions tailored to their
special needs.
Finally, the committee made two general recommendations about
research in veterans. First, the committee found that research on
veterans with PTSD is inadequate to answer questions about
interventions, settings, and length of treatment. We recommend that
Congress require and ensure that resources are available to fund
quality research on the treatment of veterans with PTSD, with
involvement of all relevant stakeholders. Second, the committee found
that the available research is not focused on actual practice. We
recommend that the VA take an active leadership role in identifying the
high impact studies that will most efficiently provide clinically
useful information.
In closing, I would like to highlight the three key messages of
this report.
1. Many of the studies that have looked into the effectiveness of
PTSD therapies have methodological flaws and therefore do not provide a
clear picture of what works and what does not work.
2. Various pharmaceuticals and psychotherapies may or may not be
effective in helping patients with PTSD; we simply do not know in the
absence of good data in most cases. To strengthen study quality, we
need: larger studies, longer and more complete followup of all
participants (including those who discontinue treatment before the
study is over), and better selection of which treatments to study and
which to compare to each other, with priority given to the most widely
used therapies. Also, greater focus on veteran populations and special
subpopulations (e.g. those with traumatic brain injury, substance
abuse).
3. Given the growing number of veterans with PTSD and the
seriousness of this disorder, the VA, Congress, and the research
community urgently need to take steps to ensure that the right studies
are undertaken to yield scientifically valid and generally applicable
data that would help clinicians most effectively treat PTSD sufferers.
The committee is grateful to have had the opportunity to be of
assistance to VA, and hopes that the department and Congress find the
report useful in moving ahead to strengthen PTSD research.
Thank you for the opportunity to testify. I would be happy to
address any questions the Committee might have.
Prepared Statement of Mark D. Wiederhold, M.D., Ph.D.,
FACP President, Virtual Reality Medical Center, San Diego, CA
Mr. Chairman and members of the Subcommittee, I am pleased to be
here today to discuss a new and innovative technology, currently
undergoing testing in Veterans Administration and Navy facilities, that
has promise to speed and improve effectiveness of PTSD treatment. We
thank the Committee and you, Chairman Michaud, for your active interest
in PTSD research.
My company the Virtual Reality Medical Center is currently testing
virtual reality therapy to treat PTSD in 5 VA hospitals with requests
from 6 additional facilities for the technology. We have been treating
patients with VR therapy for the past 12 years, and have an overall
success rate of 92%. This is defined as a reduction in symptoms,
improved work performance or the successful completion of a task which
was previously impossible. Our centers and clinics have treated more
patients with VR therapy than any other center in the world.
The technology that my company and others have been studying is
virtual reality, or VR, exposure therapy for PTSD. The research
protocol works by allowing the therapist to gradually expose the combat
veteran to distressing stimuli in the virtual scenarios, while teaching
the study participant to regulate breathing and physiological arousal.
After a number of sessions, the ``fight or flight'' response to
distressing stimuli is extinguished. Use of the virtual reality
technology, helps veterans of the current engagement to overcome the
reluctance they have in coming forward for help. Virtual Baghdad (which
is shown in exhibit A) is a realistic environment, consisting of a
single ``map'' that allows the user to navigate seamlessly through a
suite of different but thematically connected virtual scenarios. ``I
can see myself in the village or the marketplace,'' said one of the
Navy corpsman who participated in our study.
Virtual reality exposure therapy as an investigative treatment
modality for PTSD has been in existence for about 10 years. It has been
used successfully with Vietnam era veterans and with survivors of
traumatic events such as motor vehicle accidents, Earthquakes, bus
bombings, and 9/11.
A panel of academic and government experts has published a
consensus opinion that exposure therapy is the most appropriate therapy
for PTSD. But traditional exposure therapy requires that veterans
relive the experience in imagination, which is what they are trying to
avoid. When our clinician informed a study participant that he wouldn't
have to relive his experiences every session, he said, ``I sure hope
not.'' One advantage of virtual reality is that it helps make it safe
for the veteran to engage emotionally, thus allowing the fear structure
to be accessed and the abnormal response to be extinguished.
Current research funded by the Office of Naval Research is focused
on determining the optimal treatment protocol for Iraqi war veterans
with different co-morbidities. For example, those with mild traumatic
brain injury and PTSD may require more treatment sessions than those
with mild depression and PTSD. Results to date show that the virtual
reality protocol is sucessful in decreasing symptoms of PTSD,
depression, and anxiety. Study investigators are currently conducting
3-month followup visits to ensure that the treatment is lasting.
Investigators are also performing periodic physiological assessments to
help design a study that would construct a profile of veterans who
might do especially well with VR technology. One of my company's
systems is in Iraq right now and could be used in such research. In
fact we have received strong interest from the Navy in advancing
research in just this context.
However we are here to speak about our experience and success with
the VA and to leave you with three additional uses of advanced
technology which could significantly help improve the lives of veterans
with PTSD.
First, it is important to correlate the progress of VR therapy not
only with psychophysiology, but also with brain imaging. In
collaboration with other researchers, we have postulated that there may
exist an ``fMRI signature'' or functional brain imaging signature for
PTSD, the discovery of which could lead to more targeted treatment.
Second, VR can be used, both alone and in combination with
neuroprotective agents such as antioxidants, to conduct stress
inoculation training pre-deployment. It is important to track how well
both technologies work to avert PTSD.
Third, VR may be an important piece of the puzzle as tools are
developed that can assess and treat the many comorbid conditions that
accompany PTSD. For example, VR can be useful both in cognitive
rehabilitation for TBI and in physical rehabilitation for veterans with
amputations.
Mr. Chairman, I thank you for the opportunity to present this
important technology today. I would be pleased at this time to answer
any questions you may have.
Prepared Statement of Thomas J. Berger, Ph.D.,
Chair, National PTSD and Substance Abuse Committee,
Vietnam Veterans of America
Mr. Chairman, Ranking Member Miller, Distinguished Members of this
Subcommittee, and guests, Vietnam Veterans of America (VVA) thanks you
for the opportunity to present our views on ``PTSD Treatment and
Research: Moving Ahead Toward Recovery.'' VVA also thanks this
Subcommittee for its concern about the mental healthcare of our troops
and veterans, and your leadership in holding this hearing today.
However, as we are gathered here today after five years of combat
in Iraq and Afghanistan, VVA is again sadly compelled to repeat its
message that no one really knows how many of our OEF and OIF troops
have been or will be affected by their wartime experiences. To be sure,
there have been some attempts by the military services to address
combat stress at pre-deployment through such cognitive awareness
programs as ``Battle Mind'' and the use of innovative ``combat stress
teams''. Yet no one can really say how serious an individual soldier's
emotional and mental problems will become after actual combat exposure,
or how chronic both the neuro-psychiatric wounds (e.g., PTSD and TBI)
may become, or the resulting impact that these wounds will have on
their physiological health and their general psycho-social readjustment
to life away from the battle zone. VVA would like to ask if the armed
services have developed any combat stress resiliency models and if so,
what is their efficacy and by what measures?
Furthermore, despite the increased availability of behavioral
health services to deployed military personnel, the true incidence of
PTSD among active duty troops may still be underreported. A recent
retrospective report on PTSD documented what most in the military
already know: specifically, that of those whose evaluations were
positive for a mental disorder, only 23 to 40 percent complained of, or
sought help for, their mental health problems while still on active
duty, primarily because of stigma. Thus no one knows whether those with
PTSD who remain undiagnosed and so untreated will fail at reintegration
upon their return to civilian life.
What is beyond speculation is that the more combat exposure a
soldier sees, the greater the odds that our soldiers will suffer mental
and emotional stress that can become debilitating, and our troops are
seeing both more and longer deployments. Without proper diagnosis and
treatment, the psychological stresses of war never really end,
increasing the odds that our soldiers will suffer mental and emotional
stress that can become debilitating if left untreated. This places them
at higher risk for self-medication and abuse with alcohol and drugs,
domestic violence, unemployment & underemployment, homelessness,
incarceration, medical co-morbidities such as cardiovascular diseases,
and suicide.
Upon separation from active military service, our male (and
increasingly) female veterans face yet other obstacles in the search
for mental health treatment and recovery programs, particularly within
the VA healthcare system. In spite of the infusion of unprecedented
funding, the addition of new Vet Centers and community-based facilities
(i.e., CBOCs), and the VA's efforts to hire additional clinical staff,
access to, and the availability of, VA mental health treatment and
recovery programs remains problematic and highly variable across the
country, especially for women veterans and veterans in western and
rural states such as Montana. Moreover, the demands to meet the mental
health needs of OEF and OIF veterans in many localities around the
country is squeezing the VA's ability to treat the veterans of WWII,
Korea and Vietnam.
Despite the shortcomings and gaps noted above, the one piece of
good news is that since 1980, when the American Psychiatric Association
(APA) added PTSD to the third edition of its ``Diagnostic and
Statistical Manual of Mental Disorders (DSM-III)'' classification
scheme, a great deal of attention has been devoted by the VA to the
development of instruments for assessing PTSD [see Keane et al.\1\], as
well as to therapeutic PTSD treatment modalities [see Foa et al.\2\ and
the National Center for PTSD's Fact Sheets \3\] to assist veterans with
managing or even overcoming the most troubling of the symptoms
associated with PTSD. The range of treatment modalities utilized in VA
services and programs includes cognitive-behavioral therapies (i.e.,
CBTs) such as exposure therapy, pharmacotherapies such as selective
serotonin reuptake inhibitors (i.e., SSRI antidepressants) and mood
stabilizers (e.g., Depakote), and other treatment modalities such as
cognitive restructuring, group therapy, and coping skills.
---------------------------------------------------------------------------
\1\ Keane, T.M., Wolfe, J., & Taylor, K.I. (1987). Post Traumatic
Stress Disorder: Evidence for diagnostic validity and methods of
psychological assessment. Journal of Clinical Psychology, 43, 32-43.
\2\ Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective
treatments for PTSD: Practice guidelines from the International Society
for Traumatic Stress Studies. New York: Guilford Publications.
\3\ National Center for PTSD Fact Sheets. U.S. Department of
Veterans Affairs. National Center for PTSD (Matthew J. Friedman, M.D.,
Ph.D., Executive Director). On-line access at www.ncptsd.va.gov).
---------------------------------------------------------------------------
However, as you may recall, back in October 2007 the National
Academies' Institute of Medicine's Committee on Post Traumatic Stress
Disorder issued a report \4\ which found that ``most PTSD treatments
have not proven effective,'' with one exception for ``exposure
therapy''.
---------------------------------------------------------------------------
\4\ ``Treatment of Post Traumatic Stress Disorder: An Assessment of
the Evidence'' (2007). Committee on Treatment of Post Traumatic Stress
Disorder Board on Population Health and Public Health Practice.
Institute of Medicine of the National Academies.
---------------------------------------------------------------------------
The IOM Committee reviewed 2,771 published studies conducted since
1980 (when PTSD was added to the DSM-III), and identified only 90
studies (53 psychotherapeutic and 37 pharmacological treatments) that
met its criteria for trials from which it could anticipate reliable and
informative data on of PTSD therapies. Several problems and limitations
characterized much of the research on these PTSD treatments, making the
data less informative than expected. Many of the studies had problems
in their design, how they were conducted, a low number of veteran
participants, and high dropout rates--ranging from 20 percent to 50
percent of participants--reducing the certainty of several studies'
results. Moreover, the majority of the drug studies were funded by
pharmaceutical firms, and many of the psychotherapy studies were
conducted by individuals or their close collaborators who had developed
the techniques.
According to IOM Committee Chair Alfred O. Berg, Professor of
Family Medicine at the University of Washington, School of Medicine,
``At this time we can make no judgment about the effectiveness of most
psychotherapies or about any medications in helping patients with
PTSD.'' These therapies may or may not be effective--we just don't know
in the absence of good data. Our findings underscore the urgent need
for high-quality studies that can assist clinicians in providing the
best possible care to veterans and others who suffer from this serious
disorder.''
Therefore VVA strongly supports the IOM Committee's recommendations
that the ``VA and other government agencies that fund clinical research
should make sure that studies of PTSD therapies take necessary steps
and employ methods that would handle effectively problems that affect
the quality of the results'' and that ``Congress should ensure that
resources are available for VA and other federal agencies to fund
quality research on treatment of PTSD and that all stakeholders--
including veterans--are represented in the research planning.''
In addition to whatever scientifically rigorous treatment modality
used, VVA also believes that it must be integrated into an effective,
evidence-based treatment program that incorporates psychosocial
elements and services (e.g., symptom management, recovery strategies,
housing, finances, employment, family and social support, etc.) in the
manner developed by the Substance Abuse and Mental Health Services
Administration (i.e., SAMHSA) and is tailored to the individual's needs
for achieving the goal of successful PTSD treatment and recovery. And
of course, for individuals suffering from co-occurring disorders, an
integrated evidence-based dual diagnosis treatment model must be
utilized.
But such integrated treatment programs take time and cost money and
with the large number of veterans involved, lots of money, along with
accountability for its expenditure--an area where the VA has had
problems in the past. For example, according to a GAO report issued in
November 2006, the Department of Veterans Affairs did not spend all of
the extra $300 million it budgeted to increase mental health services
and failed to keep track of how some of the money was used, even though
the VA launched a plan in 2004 to improve its mental health services
for veterans with post traumatic stress disorders and substance-abuse
problems.
To fill gaps in services, the department added $100 million for
mental health initiatives in 2005 and another $200 million in 2006.
That money was to be distributed to its regional networks of hospitals,
medical centers and clinics for new services. But the VA fell short of
the spending by $12 million in 2005 and about $42 million in fiscal
2006, said the GAO report. It distributed $35 million in 2005 to its 21
healthcare networks, but didn't inform the networks the money was
supposed to be used for mental health initiatives. VA medical centers
returned $46 million to headquarters because they couldn't spend the
money in fiscal 2006. In addition, the VA cannot determine to what
extent about $112 million was spent on mental health services
improvements or new services in 2006.
In September 2006 the VA said that it had increased funding for
mental health services, hired 100 more counselors for the Vet Center
program and was not overwhelmed by the rising demand. That money is
only a portion of what VA spends on mental health. The VA planned to
spend about $2 billion on mental health services in FY 2006. But the
additional spending from existing funds on what VA dubbed its Mental
Healthcare Strategic Plan was trumpeted by VA as a way to eliminate
gaps in mental health services now and services that would be needed in
the future.
With the infusion of so many new dollars to strengthen the
organizational capacity of VA in mental health programs and services
(particularly PTSD), VVA wants to make certain that America's veterans
get the ``bang for the buck'' in the expenditures of these taxpayer
dollars. VVA encourages this Committee to get an accounting of all of
the funds allocated out to the Veterans integrated Service Networks
(VISNs) to determine who received these funds, what did they do with
the funds (e.g., how many clinicians hired, who did what with how many
veterans served for what period of time), and what is the overall
analysis of how effectively the VISNs used the funds for both short
term (1-2 Years), and what appears to be the medium term or possibly
permanent effect (e.g., more than two years).
Finally, the need for timely, effective evidence-based psychiatric/
psychological and pharmacological (if necessary) interventions along
with integrated psychosocial treatment programs is here. And with the
conflicts in Afghanistan and Iraq continuing with no end in sight, VVA
believes that the time to address these issues is now, rather than
later.
I thank you again for the opportunity to offer VVA's views on this
important issue and I'll be glad to answer any questions you might
have.
Prepared Statement of Todd Bowers,
Director of Government Affairs, Iraq and Afghanistan Veterans of
America
Mr. Chairman, ranking member and distinguished members of the
committee, on behalf of Iraq and Afghanistan Veterans of America, and
our tens of thousands of members nationwide, I thank you for the
opportunity to testify today regarding this important subject. I would
also like to point out that my testimony today is as the Director of
Government Affairs for the Iraq and Afghanistan Veterans of America and
does not reflect the views and opinions of the United States Marine
Corps.
During the Iraq and Afghanistan Wars, American troops' mental
health injuries have been documented and analyzed as they occur, and
rates are already comparable to Vietnam. But thanks to today's
understanding of mental health screening and treatment, the battle for
mental healthcare fought by the Vietnam veterans need not be repeated.
We have an unprecedented opportunity to respond immediately and
effectively to the veterans' mental health crisis.
Mental health problems among Iraq and Afghanistan veterans are
already widespread. The VA has given preliminary mental health
diagnoses to over 100,000 Iraq and Afghanistan veterans. But this is
just the tip of the iceberg. The VA's Special Committee on PTSD
concluded that:
``Fifteen to 20 percent of OIF/OEF veterans will suffer from
a diagnosable mental health disorder. . . . Another 15 to 20
percent may be at risk for significant symptoms short of full
diagnosis but severe enough to cause significant functional
impairment.''
These veterans are seeking mental health treatment in historic
numbers. According to the VA, ``OEF/OIF enrollees have significantly
different VA healthcare utilization patterns than non-OEF/OIF
enrollees. For example OEF/OIF enrollees are expected to need more than
eight times the number of PTSD Residential Rehab services than non-OEF/
OIF enrollees.'' With this massive influx of veterans seeking mental
health treatment, it is paramount that we ensure the treatment they are
receiving is the most effective and will pave a path to recovery.
But before I speak about the specifics of PTSD treatment and
research, I'd like to talk about two of the barriers that keep veterans
from getting the proper treatment in the first place.
The first step to treating PTSD is combating the stigma that keeps
troops from admitting they are facing a mental health problem.
Approximately 50 percent of soldiers and Marines in Iraq who test
positive for a psychological problem are concerned that they will be
seen as weak by their fellow service members, and almost one in three
of these troops worry about the effect of a mental health diagnosis on
their career. Because of these fears, those most in need of counseling
will rarely seek it out. Recently, my reserve unit took part in
completing our Post-Deployment Health Reassessment, which includes a
series of mental health questions. While we underwent the training, one
of my Marines asked me about Post Traumatic Stress Disorder. He said:
``If there is nothing wrong with it, then why is it called a
Disorder?'' I could not have agreed with him more. To de-stigmatize the
psychological injuries of war, IAVA has recently partnered with the Ad
Council to conduct a three-year Public Service Announcement campaign to
try and combat this stigma, and ensure that troops who need mental
health care get it. Our goal is to inform service members and veterans
that there is treatment available and it does work.
Once a service member is willing to seek treatment, the next step
is assuring that they have convenient access to care. On this front,
there is much more that must be done, particularly for rural veterans.
More than one-quarter of veterans live at least an hour from a VA
hospital. IAVA is a big supporter of the Vet Center system, and we
believe it should be expanded to give more veterans local access to the
Vet Centers' walk-in counseling services.
The problems related to getting troops adequate mental health
treatment cannot be resolved unless these two issues--stigma and
access--are addressed. However, once a service member suffering from
PTSD has access to care, we also need to ensure they receive the best
possible treatment.
Currently, a variety of treatments are available. Psychotherapy, in
which a therapist helps the patient learn to think about the trauma
without experiencing stress, is an effective form of treatment. This
version of therapy sometimes includes ``exposure'' to the trauma in a
safe way--either by speaking or writing about the trauma, or in some
new studies, through virtual reality. Some mental healthcare providers
have reported positive results from a similar kind of therapy called
Eye Movement Desensitization and Reprocessing (EMDR).
In addition, there are medications commonly used to treat
depression or anxiety that may limit the symptoms of PTSD. But these
drugs do not address the root cause, the trauma itself. IAVA is very
concerned that, in some instances, prescription medications are being
seen as a ``cure-all'' that can somehow ``fix'' PTSD or replace the
face-to-face counseling from a mental health professional that will
actually help service members cope effectively with their memories of
war.
Everyone knows that counseling and medication can be effective in
helping psychologically wounded veterans get back on their feet, and
IAVA encourages any veteran who thinks they may be facing a mental
health problem to seek treatment immediately. But we are also aware of
the limitations of current research into the treatments of PTSD.
A recent Institute of Medicine study, entitled ``Treatment of Post
Traumatic Stress Disorder: An Assessment of the Evidence,'' outlined
the many gaps in current research. Among the problems they identified:
``Many studies lack basic characteristics of internal
validity.'' That means too many people were dropping out of these
studies, the samples were too small, or followup was too short.
The IOM Committee also identified serious issues with the
independence of the researchers. ``The majority of drug studies were
funded by pharmaceutical manufacturers,'' and ``many of the
psychotherapy studies were conducted by individuals who developed the
techniques.''
Finally, the Committee concluded that there were serious
gaps in the subpopulations assessed in these studies. Veterans may
react differently to treatment than civilians, but few of the studies
were conducted in veteran populations. There's also not enough research
into care for people suffering from co-morbid disorders, such as TBI or
depression.
The solution is more and better research. To respond to the IOM
findings, IAVA wholeheartedly supports more funding for VA research
into PTSD and other medical conditions affecting Iraq and Afghanistan
veterans.
Thank you for your attention and your work on behalf of Iraq and
Afghanistan veterans. If the Committee has any questions for me, I'll
gladly answer them at this time.
Respectfully submitted,
TODD BOWERS
Director of Governmental Affairs,
Iraq and Afghanistan Veterans of America
Prepared Statement of Ira Katz, M.D., Ph.D.,
Deputy Chief Patient Care Services Officer for Mental Health,
Veterans Health Administration, U.S. Department of Veterans Affairs
Mr. Chairman and members of the Subcommittee, I am pleased to be
here today to discuss the Department of Veterans Affairs (VA) treatment
and research for post traumatic stress disorder (PTSD). I am
accompanied by Dr. Matthew Friedman, Director of VA's National Center
for PTSD.
From the beginning of Operation Enduring Freedom in Afghanistan
until the end of Fiscal Year (FY) 2007, nearly 800,000 service men and
women separated from the armed forces after service in Iraq or
Afghanistan. Almost 300,000 of them have sought care in a VA medical
center or clinic. Of these, about 120,000 received at least a
preliminary mental health diagnosis, with PTSD being the most common
seen diagnosis--nearly 60,000. Although PTSD is the most frequently
identified of the mental health conditions that can result from
deployment to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/
OIF), it is by no means the only one. Depression, for example, is a
close second.
Care for OEF/OIF veterans is among the highest priorities of VA's
mental health care system. For these veterans, VA has the opportunity
to apply what has been learned through research and clinical experience
about the diagnosis and treatment of mental health conditions to
intervene early and to work to prevent the chronic or persistent
courses of illnesses, especially PTSD that have occurred in too many
veterans of prior eras. Since the Vietnam war, PTSD has been recognized
as a medically distinct mental disorder; strategies for diagnosing the
illness have been validated, and effective treatments have been
developed. Although rates are high among OEF/OIF veterans, most of the
400,000 veterans seen in VA last year for PTSD are Vietnam era
veterans.
VA has a number of intensive programs to ensure mental health
problems are recognized, diagnosed, and treated. We do outreach to
bring veterans into our system, and once they arrive, we screen for
mental health conditions. For those who screen positive for mental
health conditions, we conduct evaluations to recognize urgent needs,
followed by comprehensive diagnostic and treatment planning
evaluations.
If a veteran comes to VA concerned they may have PTSD, or if a
veteran screens positive for PTSD symptoms, we are very much interested
in whether PTSD is the correct diagnosis, since the veteran may have
another condition, such as depression. Alternatively, a veteran may not
have any mental health condition at all and may be experiencing a
normal reaction to traumatic events related to deployment and combat.
Our responsibility is to respect the strength and resilience of our
service men and women, and follow their preferences in helping them to
readjust to civilian life. When veterans are having difficulties, we
must intervene early and effectively. At VA, care is available and
treatments work.
Overview of Mental Health Care in Medical Facilities
VA provides mental health services to veterans in all our medical
facilities, and mental health services are provided in specialty mental
health settings in all medical centers. VA also provides services for
homeless veterans, including transitional housing paired with services
which address the social, vocational, and mental health problems that
contributed to becoming homeless. VA works very closely with the
Department of Labor (DoL) on combating homelessness among our homeless
veteran population. We are also increasing the scope and scale of
programs conducted jointly with the Department of Housing and Urban
Development. In addition, mental health care is integrated into primary
care clinics, rehabilitation programs, and nursing homes.
Specific care for PTSD is provided in multiple settings. Last year,
approximately 35 percent of veterans with PTSD were treated by PTSD
Clinical Teams or Specialists; 55 percent were treated in general
mental health settings; and 10 percent in primary care. Treatment
settings depend on the symptoms and severity of the illness; response
to prior treatment; and the presence of coexisting mental health or
medical conditions.
PTSD Clinical Teams or Specialists are in each of our medical
centers and in many of our larger Community Based Outpatient Clinics
(CBOCs). VA offers inpatient and residential rehabilitation options
across the country. Veterans with serious mental illnesses are seen in
specialized programs, such as mental health intensive case management;
psychosocial rehabilitation; and recovery day programs and work
programs.
VA employs full- and part-time psychiatrists and full- and part-
time psychologists who work in collaboration with social workers,
mental health nurses, counselors, rehabilitation specialists, and other
clinicians to provide a full continuum of mental health services for
veterans. The numbers of these mental health professionals have grown
steadily in the last two and a half years, as a result of focused
efforts to build mental health staff and programs. We have hired over
3,800 new mental health staff in that time period, for a total mental
health staff of nearly 17,000.
OEF/OIF has brought many new patients into our system with
illnesses that are more acute than those of veterans from prior eras,
and VA has responded with major increases in staffing. Addressing
increases in acuity and ensuring that new staff are aware of military
and VA culture, as well as the latest advances in clinical science,
requires education. I am pleased to report that as we speak, in San
Antonio, VA's National Center for PTSD has gathered the leaders of each
of our specialty care programs in PTSD for a mentoring program. The
goal is to ensure that all programs in all our facilities are
delivering safe, effective, efficient, and compassionate care in
similar ways.
VA is committed to enhancing the mental health services it provides
to address the needs of returning veterans and veterans from prior
eras. This commitment is reflected in increases in funding from $2
billion in 2001 to a projected amount of over $3.5 billion this year.
VA views this level of funding as an investment, recognizing that
appropriate attention to the mental and physical health needs of
veterans will have a positive impact on their successful re-integration
into their families, their jobs, their communities, the economy, and
our society as a whole.
Access to Mental Health Services Through Vet Centers
In addition to the care provided in medical facilities and CBOCs,
VA's Vet Centers provide counseling and readjustment services to
returning war veterans. It is now well-established that rehabilitation
for war-related PTSD and other military-related readjustment problems,
along with the treatment of physical wounds of war, is a central aspect
of VA's continuum of health care programs for war veterans. Vet
Center's mission goes beyond medical care to providing a holistic mix
of services designed to treat the veteran as a whole person in his or
her community setting. Vet Centers provide an alternative to
traditional access for mental health care because some veterans may be
reluctant to access medical centers and clinics. Vet Centers are
staffed by interdisciplinary teams which include psychologists, nurses
and social workers, many of whom are veterans themselves.
VA is currently expanding the number of its Vet Centers. In
February 2007, VA announced plans to establish 23 new Vet Centers,
increasing the number nationally from 209 to 232. This expansion began
in 2007, and is planned for completion in 2008. Some Vet Centers have
established telehealth links to VA medical centers that extend VA
mental health service delivery to remote areas to underserved veteran
populations, including Native Americans on reservations. Vet Centers
address the psychological and social readjustment and rehabilitation
process for veterans and support ongoing enhancements under the VA
Mental Health Strategic Plan.
From early in FY 2003 through the end of FY 2007, Vet Centers have
provided readjustment services to 268,987 veteran returnees from OEF
and OIF. Of this total, 205,481 veterans were provided outreach
services, and 63,506 were provided substantive clinical readjustment
services in Vet Centers.
Interventions for Post Traumatic Stress Disorder
VA's approach to treating PTSD is to promote early recognition of
this condition for those who meet formal criteria for diagnosis, as
well as those who may be experiencing symptoms. Our goal is to make
evidence-based treatments available early to prevent chronicity and
lasting impairment.
Screening veterans for PTSD is a vital first step toward helping
veterans recover from the psychological wounds of war. Veterans are
screened on a routine basis through contact in Primary Care Clinics.
When there is a positive screen, our patients are further evaluated and
referred to mental health providers for further follow-up, as
necessary.
If a veteran first enters the system through a clinical program
other than primary care, screening for PTSD will be done in that
setting. Screening also occurs for traumatic brain injury, depression,
substance use disorder, and military sexual trauma. VA evaluates all
positive screens and conduct timely follow-up. When the follow-up
reveal either a likely diagnosis or early signs a veteran is having
increasing mental health problems, VA begins timely treatment for those
problems.
Medications can be effective treatments for PTSD. Specifically,
several antidepressants that act on the neurotransmitter serotonin have
been found to be effective and safe for the treatment of PTSD. A number
of other medications are currently being studied.
The available evidence, however, suggests that the most effective
forms of treatment for PTSD are certain types of psychotherapy.
Specifically, there is compelling evidence, much resulting from VA
supported research, that two types of cognitive-behavioral therapy for
treating PTSD are effective: prolonged exposure therapy and cognitive
processing therapy. In prolonged exposure therapy, patients are asked
to re-experience traumatic events repeatedly in a safe, therapeutic
environment. While a therapist provides reassurance, they may be asked
to tell the story of their trauma during each session or even have it
taped. They would then be asked to listen to the tapes between sessions
as homework. By providing repeated but safe exposures to the trauma,
the treatment is able to extinguish fear responses and to decrease
symptoms. Cognitive processing therapy also includes elements of
exposure, but it emphasizes the importance of describing the trauma
verbally, and understanding it. The goal is to develop a mastery of
trauma-related stimuli and memories.
Last year, VA investigators reported that findings from a
randomized clinical trial of psychotherapy demonstrating that prolonged
exposure therapy was effective. Even before these results were
published, we were developing plans to implement the treatment
throughout our system. To make both cognitive processing therapy and
prolonged exposure treatments broadly available, VA has implemented
extensive training programs for providers in our system. We are
partnering with the Department of Defense (DoD) to make these training
opportunities available to DoD mental health staff.
Other forms of psychotherapy treatments are also highly promising.
One treatment, ``Seeking Safety'' appears to be effective for treating
PTSD complicated by alcohol use disorders or other forms of substance
abuse. VA is currently implementing this treatment, while at the same
time conducting further research on its effectiveness.
In addition, there is increasing evidence of the effectiveness of
psychosocial rehabilitation. Treatment is available to veterans for
whom there may be residual symptoms after several evidence-based
treatments to help them function in the family, in the community, or on
the job.
Sometimes mild to moderate PTSD symptoms without a full diagnosis
represent normal reactions to highly abnormal situations. Many
returning veterans will recover without treatment, supported by their
families, communities, and employers. In fact, what is most striking
about our service members and veterans is not their vulnerability, but
their resilience. When people prefer treatment, we encourage it. When
they are reluctant, we watch them over time, and urge treatment if
symptoms persist or worsen.
Mental Health Research
VA continues to support a strong behavioral and psychiatric
disorders research portfolio focused on further understanding and
treating mental health problems in veterans. Investigations are
directed toward substance abuse, PTSD, adjustment and anxiety
disorders, psychotic disorders, dementia and memory disorders, and
related brain damage. Many laboratory studies are being conducted to
better understand the changes that take place when someone is suffering
from adjustment problems or mental illness. Clinical trials are
underway to test new drug and therapy treatments specifically targeted
to help veterans. VA also has a strong program for developing and
implementing better mental health care, including enhancing
collaborative care models, improving access to mental health care
through innovations such as telemedicine and the Internet, and reducing
barriers to veterans seeking mental health care. Several ongoing
projects are investigating how veterans with mental illness might
benefit from rehabilitation approaches, including vocational
rehabilitation, skills training, and cognitive therapy to improve
everyday functioning and work performance. Future research will enable
VA to determine how to care for veterans with mental illness so that
they can return to their highest level of functioning.
In a landmark ongoing study, VA researchers, collaborating with
DoD, are collecting risk factors and health information from military
personnel prior to their deployments to Iraq. These soldiers will be
reassessed upon their return, and several times afterward, to identify
possible changes in their emotions or thinking following combat duty in
Iraq and to identify predisposing factors to PTSD and other health
conditions. To date, researchers have reported that troops who served
in Iraq showed mild deficits in some tasks involving learning, memory,
and attention compared with non-deployed troops, but scored better on a
test of reaction time. The researchers have proposed longitudinal
followup studies to determine if these neuropsychological effects might
fade over time, or be a precursor to PTSD (Journal of the American
Medical Association. 2006; 296(5):519-529). An additional goal for this
research is to examine the neuropsychological associations of traumatic
brain injury (TBI) with the development of PTSD at long-term follow-up.
Veterans with PTSD commonly experience nightmares and sleep
disturbances, which can seriously impair their mood, daytime
functioning, relationships, and overall quality of life. In an exciting
new treatment development, VA investigators have found that prazosin,
an inexpensive generic drug already used by millions of Americans for
high blood pressure and prostate problems, improves sleep and reduces
trauma nightmares in a small number of veterans with PTSD (Biological
Psychiatry. 2007; 61(8):928-934). Plans are underway for a large,
multi-site trial to confirm the drug's effectiveness.
In addition, VA investigators are currently conducting the first
ever clinical trial of a medication to treat military service-related
chronic PTSD. It will also be the largest placebo controlled double-
blind study (the most rigorous type of clinical trial) of its kind ever
conducted. It will involve 400 veterans diagnosed with military-related
chronic PTSD at 20 VA medical centers across the nation. The main
objective of the study is to determine if risperidone is effective in
veterans with chronic PTSD who continue to have symptoms despite
receiving standard medications used for this disorder. Risperidone is
being studied since it has been shown to be safe and has received a
good deal of preliminary study in the treatment of PTSD patients.
In 2006, VA launched the Genomic Medicine Program as part of its
Personalized Medicine Initiative. A PTSD Genetics Working Group was
established to explore and define a research program to identify the
genes which are important in determining how an individual responds to
the experience of deployment, especially their response following
combat exposure. By carefully characterizing those affected by combat-
related PTSD and conducting genetic analyses, VA will be in a position
to identify genetic variants contributing to PTSD and other post-
deployment adjustment disorders, such as major depression. Once this
program is established, this resource will be available for continued
research including studying the genetic relationship to treatment
response.
Other research on PTSD, related disorders, and coexisting
conditions is being conducted by the National Center for PTSD, the
Mental Illness Research Education and Clinical Centers, and the new
Centers of Excellence in Mental Health and PTSD. These studies include
investigations on stress and resilience; deployment and its
consequences; novel therapeutics; and new strategies for the delivery
of care, including primary care management.
Conclusion
Mental Health is an important part of overall health. VA is
committed to providing the highest quality of care possible to our
nation's veterans. Because VA researchers are also clinicians caring
for veterans, VA is uniquely positioned to move scientific discoveries
from investigators' laboratories into patient care. One of the major
medical advances resulting from World War II was the translation of
penicillin from a laboratory curiosity to a medicine that could be
produced in sufficient quantity to be delivered to soldiers with
battlefield injuries. Although the basic research had been done
earlier, the translation of laboratory findings to the bedside and
clinic came from the war. In a similar way, the spotlight on PTSD and
its treatment has stimulated VA to translate evidence-based therapies
from interventions delivered primarily in research clinics to real
treatments for real patients. We believe this work will have a profound
impact on mental health care, not only in VA, but throughout the
country.
VA takes great pride in the research that keeps it at the forefront
of modern medicine and health care. We expect to see further remarkable
discoveries, and the translation of these discoveries into care in the
coming decades.
Thank you again, Mr. Chairman, for having me here today. I will
answer any questions you or the other members may have.
Prepared Statement of Joseph L. Wilson, Deputy Director,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to submit The American Legion's
views on Post Traumatic Stress Disorder (PTSD) Treatment and Research.
While the Department of Veterans Affairs (VA) continuously treats those
who suffer from PTSD, more resources are required to ensure that the
growing numbers of veterans and patients are evaluated and accommodated
respectively.
VA Research
According to research from the National Center for PTSD, Operation
Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans are
at higher risk for PTSD. The VA has reported that approximately 25
percent of the 300,000 separated veterans have received a diagnosis of
a probable mental health disorder.
VA states that due to the enhancement of body armor and exceptional
medical care on the battlefield, many soldiers are surviving major
blast-related injuries and will require long-term, specialized care;
For those new veterans readjusting to civilian life, mental health
challenges, such as PTSD, may be their most critical issue.
Currently, VA researchers are working to improve mental health care
by developing screening methods for mental problems; it has been proven
that early recognition and treatment results in better patient
outcomes. VA is also leading the way in conducting studies on both drug
and psychosocial/behavioral therapies; and studying treatment for women
veterans, who may experience trauma differently than male veterans.
VA also reports that many soldiers diagnosed with PTSD respond well
to standard treatments, while others do not; it is based on individual
needs. The American Legion applauds VA on making strides through
current research and for establishing new programs; however, the
aforementioned suggests that every veteran isn't receiving adequate
care to accommodate his or her needs. While effective treatment is
being utilized, the overall results also warrant more research, to
include the funding to support PTSD research.
Usually, there are questions that prompt studies and research.
Currently, one question includes, ``Can VA identify biological markers
that might help guide psychological evaluation, treatment selection,
and outcomes?'' To assist with answering this type question, VA
researchers are testing whether a computer-simulated ``virtual
reality'' can be used to deliver a controlled type of exposure (to
combat) therapy.
VA is also developing various ways to provide care to veterans
residing in rural areas, to include videoconferencing, delivery of
health information and services by telephone, and Internet. Lastly VA
is attempting to ensure evidence-based, state-of-the-art care is
available to all veterans with PTSD by rapidly transferring scientific
breakthroughs from the laboratory into patient care.
The rapid integration of scientific breakthroughs into patient care
is extremely critical because it may interrupt the deterioration of the
patient's mental health, as well as halt other issues that arise within
the veterans' community, such as family problems.
Specialized PTSD Services
VA recently extended health care services to OEF/OIF veterans
through its health care system from two years to five years following
the veteran's discharge or release from active duty. According to VA,
there are veterans whose condition cannot be maintained in a primary
care or in a general mental health setting and therefore are managed
within a specialized environment by clinicians who have concentrated
their clinical work in the area of PTSD treatment.
These specialized programs are outpatient treatment programs, to
include a PTSD clinical team, substance use and PTSD team, Women's
Stress Disorder Treatment Team/Military Sexual Trauma Team, and PTSD
Day Hospital. There are also inpatient treatment programs, to include
an Evaluation and Brief Treatment Unit, Specialized Inpatient PTSD
Unit, PTSD Residential Rehabilitation Program, Women's Trauma Recovery
Program, and PTSD Domiciliary.
Although these programs are located throughout the nation at
various VA medical facilities, The American Legion suggests that
adequate funding must be provided to ensure these programs are
consistently in place throughout the entire VA system. This will ensure
a more proactive approach as more veterans seek treatment upon their
return from combat.
National Institute of Mental Health
The National Institute of Mental Health (NIMH), over the years, has
gradually strengthened its connection to VA and Department of Defense
(DoD) to obtain more knowledge regarding the extent and nature of
mental health needs related to war related trauma, and to accelerate
the discovery of fundamental knowledge needed to improve treatment, and
to ensure that all veterans who may benefit from treatment such as PTSD
actually receive it. The American Legion supports the collaboration
between these organizations and urges Congress to provide adequate
funding to ensure such research efforts continue.
According to NIMH, their investment in overall PTSD research went
from $15 million in Fiscal Year (FY) 1997 to approximately $45 million
in FY 2006. During FY 2006, NIMH and VA awarded approximately $1.2
million to support new projects targeting mental health needs of Active
Duty, Guard and Reserve personnel returning from Iraq or Afghanistan.
New initiatives proposed by NIMH for FY 2008 include projects to
advance the prevention of post-deployment mental health problems among
members of high-risk occupations who regularly encounter traumatic
situations, to include those who suffer from combat related trauma and
military sexual trauma (MST).
The American Legion supports these proactive initiatives proposed
by the NIMH. We also believe such proposals may enable veterans to
recover more effectively from conditions that trigger PTSD. We
therefore urge Congress to ensure such initiatives remain a priority in
researching for the advancement of PTSD treatment.
These new initiatives include exploration of new treatments, to
include new medications that appear to selectively affect the encoding
of traumatic memories. In partnership with VA and DoD, NIMH is actively
attempting to create effective psychosocial treatments, such as
cognitive behavioral therapy; making them more widely available along
with Internet-based self-help therapy and telephone assisted therapy.
Other research by NIMH is attempting to enhance cognitive, personality,
and social protective factors, as well as minimize factors that ward
off full-blown PTSD after trauma.
The American Legion applauds all efforts made on behalf of
organizations and their researchers to administer treatment to prevent
PTSD and maintain research into this vital issue among America's
veterans. However, we also must remain mindful to ensure veterans from
every era are not subject to undue stress such as unreasonable frequent
evaluations that call for veterans to report to facilities periodically
within the month.
Institute Of Medicine (IOM)
The IOM's Committee on Treatment of PTSD, in its charge from the
VA, recently undertook a systematic review of PTSD literature and
subsequently recommended that Congress require and ensure that
resources are available for VA and other relevant Federal agencies to
fund quality research on the treatment of PTSD in veteran populations
and to ensure that all stakeholders are included in research plans. The
American Legion supports the call for funding of quality research on
treatment of PTSD in veteran populations. We also ask that an equal
emphasis be placed on veterans residing in rural communities throughout
the nation.
Upon reviewing the issue of PTSD interventions, which as previously
stated, has not systematically and comprehensively addressed the needs
of veterans with respect to effectiveness of treatment and the
comparative efficacy of treatments in clinical use, the Committee
recommended that VA take an active leadership role in identifying
research priorities for addressing the most important gaps in evidence
in clinical efficiency and comparative effectiveness.
The Committee also pointed out possible areas for future research,
to include, comparisons of the use of psychotherapy and medication,
evaluation of individual and group formats for psychotherapy
modalities, and evaluations of the effectiveness of combined use of
psychotherapy and medication; the effectiveness of the aforementioned
were tested within individual and group environments.
According to the VA, available research continues to leave
significant gaps in assessing the effectiveness of interventions within
subpopulations of veterans who suffer from PTSD, as well as ethnic and
cultural minorities, women, and older individuals. In response to this
issue, the Committee recommended that VA assist clinicians and
researchers in identifying the most important subpopulations of
veterans with PTSD and designing specific research studies of
interventions tailored to these subpopulations.
Conclusion
Mr. Chairman, The American Legion agrees that gaps continue to
remain in PTSD treatment of the veteran population. During The American
Legion's System Worth Saving Task Force site visits to Vet Centers in
2007, management stated that the uppermost form of outreach was a mere
conversation among veterans (word-of-mouth). The American Legion
believes relying on veteran to veteran word-of-mouth outreach is
inadequate. VA must promote its readjustment and mental health programs
more effectively in order to help the veteran move ahead toward their
recovery.
While there are various effective outreach tools in place, to
include Global War on Terrorism Counselors or GWOTs, the concern also
remains that research findings are not being expedited to clinical
mediums within the VA. We support the continuous efforts of VA research
to treat and/or accommodate this nation's veteran. Therefore, we urge
that every measure be taken to ensure these advances are communicated
and implemented within the most rural corners of this nation to ensure
all veterans receive timely, adequate, and up to date mental health
care.
Mr. Chairman and members of the Subcommittee, The American Legion
sincerely appreciates the opportunity to submit testimony and looks
forward to working with you and your colleagues to continue to ensure
all veterans are informed, evaluated, and/or receives the best quality
treatment for PTSD. Thank you.
Prepared Statement of Adrian M. Atizado,
Assistant National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV), an
organization of more than 1.3 million service-disabled veterans, to
submit this testimony for the record of this hearing on posttraumatic
stress disorder (PTSD) treatment and research. We appreciate the
opportunity to offer our views on the Department of Veterans Affairs
(VA) specialized programs for this condition.
Current research indicates combat veterans of Operations Enduring
Freedom and Iraqi Freedom (OEF/OIF) veterans are at higher risk for the
anxiety disorder PTSD and other mental health problems, including
substance use disorder, as a result of, or consequent to, their
military experiences. VA reports that veterans of these current wars
have sought care for a wide range of possible medical and psychological
conditions, including mental health conditions, such as adjustment
disorder, anxiety, depression, PTSD, and the effects of substance
abuse. Through January 2008, VA reported that of the 299,585 separated
OEF/OIF veterans who have sought VA health care since fiscal year 2002,
40 percent, or a total of 120,049 unique patients, had been diagnosed
with a possible mental health disorder. Nearly 60,000 of these enrolled
OEF/OIF veterans had a probable diagnosis of PTSD, and 40,000 have been
diagnosed with depression.
The increasing rate of OEF/OIF veterans seeking VA health care, and
the emerging trends in health care utilization of this group drive the
need to ensure access to, and make available, robust services for:
depression; stress and anxiety reactions, including PTSD; individual or
group counseling; specialized intensive outpatient treatment for severe
PTSD--including cognitive behavioral best practices; services for
relationship problems (including marital and family counseling);
psychopharmacology services; and, substance-use disorder interventions
and treatment, including initial assessment and referral, brief
intervention and/or motivational counseling, traditional outpatient
counseling and intensive outpatient substance-use disorder care.
In its 2001 report, ``Crossing the Quality Chasm: A New Health Care
System for the 21st Century,'' the Institute of Medicine (IOM) put
forward six aims that now underpin the standard of care for U.S.
medical care providers. The IOM aims that health care will be safe
(avoiding errors and injury), effective (based on the best scientific
knowledge), patient-centered (respectful of, and responsive to patient
preferences, needs and values), timely (reduced waiting time and
harmful delay), efficient (avoiding waste), and equitable (unvarying,
based on race, ethnicity, gender, geography, or socioeconomic status).
VA has embraced these aims and consistent with them, VA's offices
of Health Services Research and Development and Rehabilitation Research
and Development are focusing on a number of important areas including
PTSD. The complex and unique injuries sustained by troops serving in
Iraq and Afghanistan have created the need for new research and
treatment strategies focused on addressing the unique needs of the
newest generation of combat disabled veterans. Furthermore, because of
VA's long history in providing effective readjustment counseling
services that are culturally sensitive to veterans and their unique
military combat experiences, unquestionably VA is the optimum source
for readjustment services for our newest veterans. VA provides the
range of post-deployment mental health services veterans from current
and previous wars may require, and provides services that are evidence-
based which integrates the best research evidence, clinical expertise
and patient needs.
Though clinical practice guidelines initially evolved in response
to studies demonstrating significant variations in risk-adjusted
practice patterns and costs, VHA has embraced the use of evidence-based
clinical practice guidelines as one strategy to improve care by
reducing variation in practice and systematizing ``best practices.''
Like any other tool in medical care, these guidelines set out to
improve the processes of care for patient cohorts, to reduce errors,
and provide more consistent quality of care and utilization of
resources throughout the system. Researchers had correctly hypothesized
that establishing criteria for the appropriate use of procedures and
services might decrease inappropriate utilization and improve care
outcomes. Since guidelines also are cornerstones for accountability,
and facilitate learning and the conduct of further research, they are
subject to continual review and necessary revisions.
While clinical practice guidelines have been developed since the
early 1990's, the VA took the important step to promote the use of
evidence-based approaches by initiating development of a joint VA-
Department of Defense (DoD) Practice Guideline for Management of PTSD.
The guideline advocates application of a variety of evidence-based
practices for treatment of veterans with PTSD. In addition, the
National Center for PTSD (NCPTSD) in collaboration with Walter Reed
Army Medical Center (WRAMC), developed an Iraq War Clinician Guide (now
in its second edition), to guide treatment of returning personnel with
PTSD, and generally better prepare VA mental health providers to
receive and effectively treat returning veterans.
Despite the clear articulation of best practices in the PTSD
clinical practice guideline and the Iraq War Clinician Guide, many of
the recommended practices are not widely implemented in the VA health
care system. Staff awareness about PTSD and efficacious treatments,
knowledge and skill deficits, clinician attitudes, and institutional
barriers all prevent widespread dissemination of recommended practices.
DAV has, and will continue to call for improvements to better
disseminate the information in the field to increase awareness, ability
and knowledge, in addition to decreasing both clinical and
institutional barriers, to implementing these guidelines.
Research
The aforementioned limitations notwithstanding, DoD and VA share a
unique obligation to meet the mental health care and rehabilitation
needs of veterans who are suffering from readjustment difficulties as a
result of combat service. Both agencies need to ensure that appropriate
research is conducted and that federal mental health programs are
adapted to meet the unique needs of the newest generation of combat
service personnel and veterans, while continuing to address the needs
of older veterans with substance abuse problems, PTSD, other combat-
related readjustment issues, and other mental health challenges.
Congress must remain vigilant to ensure that research and treatment
programs are authorized and sufficiently funded to ensure these needs
are met.
In our October 2007 testimony before this Subcommittee, the DAV
urged VA to continue research that is veteran-centered and specifically
focused on rehabilitation of veterans with physical and cognitive
impairments related to military service, and to establish studies to
identify and promote effective and efficient strategies to improve the
delivery of health-care to veterans. We believe these research
priorities should include:
A study to objectively and systematically measure the
expectations of OEF/OIF veterans to help VA better serve this
population. These veterans are younger, have family and community
support systems in place, and are frequently dealing with complicated
post-service readjustment, employment, education and other issues. VA
should conduct health services and other research to identify services
to meet their mental health needs.
Studies to address access issues for this new population
including tracking of OEF/OIF veterans to learn what services they
utilize. VA should also examine barriers to care, especially those that
relate to attitudes of veterans and their families toward being treated
in the VA, and any breakdown in access this may cause.
VA should quickly disseminate and deploy resources to
make evidence-based PTSD treatment easily accessible. In particular,
for women veterans across the country, and explore options for
providing child care for those needing it to enable them to achieve
access to treatment.
VA should conduct research to fully understand the dual
burden of military sexual trauma and combat-related PTSD, and develop
the best treatment practices and programs for this population.
DoD should fund a prospective, population and gender-
based health study of veterans who served in OEF/OIF. An epidemiologic
study with at least a ten-year follow-up period is needed. This study
should be carried out by DoD, VA and academic researchers in a
collaborative manner.
Treatment of Posttraumatic Stress Disorder: An Assessment of the
Evidence
As this Subcommittee is aware, VA contracted with IOM to study the
ramifications of PTSD in the veteran population. IOM established three
Committees to address the various aspects of PTSD: a Committee on PTSD
Diagnosis and Assessment which submitted its report in June 2006; a
Committee on Compensation for PTSD which submitted its report on May
08, 2007; and a Committee on PTSD Diagnosis and Treatment which
submitted its report on October 17, 2007.
Based on a review of literature on best treatment practices, types
and timing of specific interventions, and comment on the prognosis of
individuals diagnosed with PTSD (including co-morbidities), the most
recent IOM report indicates few studies have been conducted on the
efficacy of treatments for veterans suffering from PTSD. In addition,
no conclusion could be made about most treatment modalities, save
exposure therapy.
The report reveals most of the evidence supporting the use of
medications and psychological therapies for PTSD is supported by
evidence compiled by researchers with conflicts of interest in the
outcome of the studies or funded by pharmaceutical companies that make
the drugs used in the therapies. In addition, the report could not
highlight evidence showing any medication such as Selective Serotonin
Reuptake Inhibitors (SSRIs) were effective in treating PTSD. There was
insufficient evidence to determine the value of early intervention and
an optimal length or treatment. Moreover, there was insufficient
evidence to support the use of a range of psychotherapies known as
cognitive restructuring, coping skills training, eye-movement
desensitization and reprocessing therapy, and group therapy.
With formidable challenges in conducting high quality research, the
report suggests many studies had design or methodological flaws,
inadequate control for confounders, high dropout rates of 20 to 50
percent, and possible conflicts of interest among researchers.
Additionally, discussion during the committee meeting noted that the
diagnosis of PTSD itself has a high degree of overlap with other
conditions, and therefore efforts to determine efficacy of therapies
may suffer from a lack of specificity. We note however, that despite
using a high threshold for inclusion and evaluation of PTSD treatment
studies into this IOM report, it underscores the need for rigorous
studies of all treatment modalities that will address major limitations
of available research in finding optimal PTSD treatment when judged
against contemporary standards. Moreover, the fact that the committee
found literature that met the reliability requirement to determine
efficacy,\1\ means it is wholly within the realm of possibility for VA
or others to conduct research that will allow a more definitive
assessment of the effectiveness of PTSD treatment modalities.
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\1\ 2,771 indentified but narrowed down to 90 studies that were
either randomized controlled trials, placebo-controlled pharmacotherapy
trials, or controlled psychotherapy trials. Chosen studies met the
criteria for Level-1 evidence in accordance with evidence-based
medicine standards.
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While clinical trials take years to plan, conduct, and complete,
and well-designed randomized clinical trials are costly in both time
and resources, treatment still must be provided, and the DAV is
concerned if the effectiveness of available treatment is questionable,
some veteran patients may become frustrated and discontinue seeking VA
mental health services. For example, the IOM committee report noted
that while there were more clinical trials of SSRIs than of other
drugs, outcomes were split in the seven most useful studies. The
largest study fossil showed no improvement in primary PTSD outcomes and
saw many patients drop out. The American Psychiatric Association's
Clinical Practice Guideline for the Assessment and Treatment of
Patients with Acute Stress Disorder and PTSD and VA's National Center
for Posttraumatic Stress Disorder recommends SSRIs. SSRIs are a class
of antidepressants used in the treatment of anxiety disorders and
depression as first-line medications for PTSD pharmacotherapy in
veterans suffering from PTSD.
The DAV believes that this report should be used as a guide to
facilitate high quality research and not decrease access or treatment
options. Particularly since this IOM report is the third in a series
requested by VA asking for guidance in diagnosing, treating, and
assessing disability in veterans with PTSD, and that the report
indicates research gaps in regard to special veteran populations.
In light of the October 2007 IOM report, we applaud VA's actions
regarding the efficacy of exposure therapy by initiating training of VA
mental health providers in the use of exposure-based therapies,
starting with cognitive and most recently including prolonged exposure
therapy. In addition, VA had announced plans for a ``consensus
conference'' with DoD and National Institutes of Health to exchange
knowledge and work toward shared state-of-the art approaches for
research in PTSD. In the interim, VA staff has been directed to work
with DoD to evaluate early interventions such as the Army's
``BATTLEMIND'' training and the ``Marine Operational Stress
Surveillance and Training Program,'' designed to help combat troops
transition back to non-deployed civilian status.
The DAV is a strong advocate and believer of research as it
provides the evidence base for effective treatment for veterans. We
urge this Subcommittee to continue to conduct regular oversight on the
entities charged with conducting research to ensure a comprehensive
high quality evidence base for the veteran population suffering from
PTSD and its effect on the improvement of PTSD treatment.
The Recovery Model
As part of a larger social movement of self-determination and
empowerment, the recovery movement calls for a fundamental
transformation of the mental health care delivery system to one that is
evidence based, recovery focused, and consumer and family driven, and
where recovery from mental illnesses and emotional disturbances should
be the common and recognized outcome of mental health
services.2,3,4 These changes were prompted in the
President's New Freedom Commission on Mental Health, in its report
entitled ``Achieving the Promise: Transforming Mental Health Care in
America.''
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\2\ Nat'l Recovery Consensus Statement: http://
mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/
\3\ SAMHSA's Nat'l Transformation Agenda: http://www.samhsa.gov/
Federalactionagenda/NFC_TOC.aspx
\4\ Surgeon General's M.H. Report: http://www.surgeongeneral.gov/
library/mentalhealth/home.html#preface
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The resulting December 1, 2003, VA Action Agenda, ``Achieving the
Promise: Transforming Mental Health Care in the VA,'' involves 82
system-wide changes and includes a number of recommendations to
successfully adopt the recovery model in VA mental health programs
nationwide. Some of those recommendations include educating VA staff on
recovery, developing a strategic plan for mental health research that
supports VA recovery-based mental health care, initiating a national
Recovery and Rehabilitation Task Force, developing a manual on
establishing a peer-support program, providing supported employment
programs to promote recovery and the ability of veterans to live
productively in the community, and promoting the integration of mental
health into primary care services.
The VA Mental Health Strategic Plan Workgroup developed a five-year
strategic plan to eliminate deficiencies and gaps in the availability
and adequacy of mental health services that VA provides across the
nation. The plan includes a number of action items that build on the
recommendations of the President's Commission and the VA Secretary's
Mental Health Taskforce recommendations.
As with other public health systems that are implementing pilot
projects in several states to transform their mental health systems to
emphasize the recovery model, concerns have been raised with respect to
the VA mental health delivery system. There is a general concern over
the use of the evidence-based medical model, which involves the
elimination or reduction of symptoms and return to pre-morbid levels of
function, and the recovery model, which, ``enables a person with a
mental health problem to live a meaningful life in a community of his
or her choice while striving to achieve his or her full potential.''
\5\ Although both the medical and recovery models can influence what
treatments are provided, the recovery model emphasizes how the
treatment is provided. Having a greater emphasis placed on peer support
and personal experience has the potential to be a source of conflict
particularly in a paternalistic health care model. Moreover, the
inclusion of caregivers and family members as partners in treatment
planning for the veteran is a necessity in the recovery model and
current VA authority may prove to be insufficient for successful
implementation throughout the continuum of VA mental health services.
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\5\ Substance Abuse and Mental Health Services Administration.
National Consensus Conference on Mental Health Recovery and Systems
Transformation.
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We are aware of, and applaud VA for actively promoting the
recruitment of peers as mental health service providers, and hiring
over 3,700 of the 4,347 authorized new mental health professionals
since the beginning of implementation in 2005, for providing program
funding to integrate mental health and primary care in over 100 sites,
and for large-scale training for VA providers on the delivery of
evidence-based psychotherapies. However, this new emphasis of recovery
and the requirements needed to reach its goals require additional
resources, equipment, and space. For example, in fiscal year 2007, $347
million was transferred from Medical Services to Medical Facilities to
increase infrastructure capacity through three initiatives: $58 million
for appropriate clinic space; $130 million for additional leased space
and equipment for VA medical centers, Community Based Outpatient
Clinics (CBOCs) and nursing homes; $159 million for non-recurring
maintenance projects to provide a safer environment.
Additionally, VA recovery programs have had difficulty becoming
established and program managers have not made consistent efforts to
involve veterans and family members locally. In order for VA to fully
adopt the recovery model, it is imperative that its mental health care
system be patient- and family-driven in addition to being focused on
recovery. Despite some progress as reported earlier in this testimony,
the current level of effort and provision of PTSD treatment remain
challenging.
In closing, the DAV urges Congress to ensure that veterans' needs
for quality mental health care are met, so that the promise of recovery
can be achieved. Moreover, we encourage this Subcommittee to continue
conducting regular oversight on the progress of VA's Mental Health
Strategic Plan and the 2003 VA Action Agenda to ensure that your
expectations about effective treatment and recovery are met.
Mr. Chairman, this concludes our statement and we appreciate the
opportunity to express our views on this important topic.
Prepared Statement of Christopher Needham,
Senior Legislative Associate, National Legislative Service,
Veterans of Foreign Wars of the United States
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
On behalf of the 2.3 million men and women of the Veterans of
Foreign Wars of the U.S. and our Auxiliaries, I thank you for the
opportunity to present our views on this most important topic. It is
clear that the mental health care of our returning servicemen and women
is of utmost importance.
The battles may end when the last bullet is fired, but for the
hundreds of thousands of men and women who have separated from the
military after having served in Iraq and Afghanistan, the impact of the
war continues. It is an impact that is felt not just by the veteran,
but also his or her loved ones, and it is an impact that affects each
individual differently. Some are able to pick up their lives and move
on. Others have great difficulty dealing with the emotions and
reactions they have. This grateful nation must see to it that every one
of these brave men and women has the services they need--the helping
hand--to overcome these difficulties, easing the transition into
civilian life and becoming as whole as possible. No veteran should
suffer untreated for what happened to him or her while serving this
nation.
The mental health issue that has received the greatest attention--
and the subject of today's hearing--is posttraumatic stress disorder,
PTSD. PTSD is an anxiety disorder that sometimes develops following
stressful and traumatic events. For veterans serving in a war zone,
surrounded by death and destruction, traumatic events are difficult to
avoid.
Nobody goes into a war zone and returns the same. Everyone is
affected to some degree. Some service men and women return to normal
after a short time. Others have problems that linger. Still others have
problems that get worse. This is important because a one-size approach
to mental healt hcare is likely not going to work. We need an emphasis
on approaches to treatment that are tailored for an individual's needs
and what will work best for him or her.
Therein lays one of the bigger problems with PTSD. There is still
much we do not know about its causes and optimal treatments for its
conditions. The VFW urges more research into these important issues so
that past and present generations of veterans can have the care they
need to become whole, but also so that future generations will not have
to suffer from its effects.
We know that exposure to stresses and traumas can lead to PTSD, but
we do not know why some suffer from it more than others. Are there
groups of veterans that are more susceptible? Are certain ages or sexes
more likely to suffer? What background factors, if any, contribute to
the illness? The more information we have about its causes, the better
treatment options should be. Better information about those veterans
more inclined to have PTSD could lead to earlier treatment and better
screening, vastly improving the military's and VA's outreach efforts.
We need to study the conditions such as depression and substance
abuse that are often co-morbid with PTSD. How are they related? Will
treating the one condition improve the others? What else must health-
care practitioners be aware of?
The questions yet to be answered also include treatment options.
There is still no consensus on what treatment options provide the best
chance for improvement. An October 2007 Institute of Medicine report,
``Treatment of PTSD: An Assessment of the Evidence,'' showed that there
is inadequate evidence to assess the efficacy of most PTSD treatments,
including many antidepressant pharmaceuticals, group therapies or
coping skills training. The report did find that exposure therapy--one
of the courses of treatment that VA uses--is effective.
The report laid out eight key recommendations for future study on
which it believes VA and other research organizations must concentrate.
These include the need for research into interventions, settings, and
lengths of treatment; studies of the effects of treatment in
subpopulations of veterans with PTSD, especially those with traumatic
brain injury, major depression, other anxiety disorders, or substance
abuse, as well as ethnic and cultural minorities, women, and older
individuals; and, research into the optimal length and duration of
treatment, especially over the long-term.
The key with this report is that it did not find that these other
forms of treatments are ineffective, just that the current research is
not sufficient to determine this one way or another. Accordingly, we
strongly urge VA to continue using all treatment methods, as well as
attempting to innovate by finding new solutions that may work just as,
if not more, effectively.
We also strongly believe that more needs to be done to remove the
stigma of mental illness. PTSD can affect anyone, and it is not a sign
of weakness to seek treatment. Too many service men and women have
reported fears of losing standing among their peers or potential for
career advancement as barriers to care.
We also must have improvements to the mental-health screening
programs. In some cases, especially among returning National Guard
members, there is a strong disincentive to seek treatment in that self-
identifying would delay their separation as they are treated for their
condition.
To combat this, we believe that mental health screenings should be
included as part of a routine health care examination, especially among
those groups--such as separating service members--more at risk of PTSD
and other mental health issues. By screening everyone, no individual is
isolated or made to feel weak, and all can then have further access to
treatment for any problems identified.
There are a few other areas of concern we all need to be mindful
of.
First, we need to ensure that the growing number of women veterans
is being served by VA. Female veterans of OEF/OIF are experiencing
conflict and situations that no other previous generations of women
veterans have faced. They are involved in a conflict with no true
frontline and in a high-stress situation with almost no relent. Since
these situations are so new, VA must actively monitor and assess the
level and types of treatment women veterans need and VA must conduct
proper outreach so that they understand the benefits and services VA
provides.
Second, we need to see continued improvement in mental health care
options for families. We need new models of support that help OEF/OIF
veterans overcome these mental health challenges. Families are an
essential component of recovery, providing a support network, but also
serving as eyes and ears for veterans who are truly in crisis and need
more help.
The difficulties many veterans have dealing with these issues are
putting an extreme strain on families, eroding this crucial base of
support. Divorce rates are growing and the number of veterans reporting
difficulties or strains with their families has increased too.
DoD needs to do a better job educating families on what to expect
from a returning service member, and also give them tools to care for
their loved ones when dealing with the difficult transition out of a
combat zone. We need both DoD and VA to provide meaningful family and
marital counseling, too. Ensuring the stability of the family and
support structure can only help the service member improve.
As part of those efforts, we have been pleased to see VA expand the
number of Vet Centers throughout the system. We are strongly supportive
of Vet Centers, feeling that the relaxed, less formal, drop-in approach
is conducive to encouraging veterans to seek the care they need. As
part of their mandate, Vet Centers provide family counseling, which can
be of great aid to our veterans. We have heard many compliments about
the types and quality of service Vet Centers provide, but our concern
remains with the staffing levels. Most Vet Centers have handled the
increased demand for care relatively well, but with the number of OEF/
OIF veterans returning and reporting some degree of mental health
issue, the demand is sure to dramatically increase. Accordingly, we
need VA to ensure that the centers are fully staffed, and we need
Congress to use its oversight power to ensure that VA is meeting the
demand for care and services.
Mr. Chairman, this concludes my testimony. I thank you for the
opportunity to present the VFW's views, and I would be happy to answer
any questions that you or the committee may have.