[House Hearing, 110 Congress]
[From the U.S. Government Printing 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 
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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 
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                            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

                              ----------                              


                         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.

Blair, S.N., and Connelly, J.C. (1996). How much physical activity 
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Christianson, C.H. and Baum, C.M. (Eds.) Occupational Therapy: 
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    Characteristics of leisure time physical activity associated with 
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    (2004). Environmental influences on cognitive and brain plasticity 
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    940-957.
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    mental and physical health benefits associated with physical 
    activity. Current Opinion in Psychiatry. 18: 189-193.
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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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.''
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \5\ Substance Abuse and Mental Health Services Administration. 
National Consensus Conference on Mental Health Recovery and Systems 
Transformation.
---------------------------------------------------------------------------
    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.