[House Hearing, 111 Congress]
[From the U.S. Government Printing Office]




 
                  THE NEXUS BETWEEN ENGAGED IN COMBAT
                   WITH THE ENEMY AND POST-TRAUMATIC
                      STRESS DISORDER IN AN ERA OF
                        CHANGING WARFARE TACTICS

=======================================================================

                                HEARING

                               before the

                 SUBCOMMITTEE ON DISABILITY ASSISTANCE
                          AND MEMORIAL AFFAIRS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 24, 2009

                               __________

                            Serial No. 111-9

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                  U.S. GOVERNMENT PRINTING OFFICE
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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
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                    JOHN J. HALL, New York, Chairman

DEBORAH L. HALVORSON, Illinois       DOUG LAMBORN, Colorado, Ranking
JOE DONNELLY, Indiana                JEFF MILLER, Florida
CIRO D. RODRIGUEZ, Texas             BRIAN P. BILBRAY, California
ANN KIRKPATRICK, Arizona

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             March 24, 2009

                                                                   Page
The Nexus Between Engaged in Combat with the Enemy and Post-
  Traumatic Stress Disorder in an Era of Changing Warfare Tactics     1

                           OPENING STATEMENTS

Chairman John J. Hall............................................     1
    Prepared statement of Chairman Hall..........................    36
Hon. Doug Lamborn, Ranking Republican Member.....................     3
    Prepared statement of Congressman Lamborn....................    37

                               WITNESSES

U.S. Department of Defense:
    Rear Admiral David J. Smith, M.D., SHCE, USN, Joint Staff 
      Surgeon, Office of the Chairman of the Joint Chiefs of 
      Staff, Wounded and Survivor Care Task Force................    19
        Prepared statement of Admiral Smith......................    53
    Colonel Robert Ireland, Program Director, Mental Health 
      Policy, Office of the Assistant Secretary of Defense for 
      Health Affairs.............................................    21
        Prepared statement of Colonel Ireland....................    53
U.S. Department of Veterans Affairs:
    Bradley G. Mayes, Director, Compensation and Pension Service, 
      Veterans Benefits Administration...........................    23
        Prepared statement of Mr. Mayes..........................    54
    Antonette Zeiss, Ph.D., Deputy Chief Consultant, Office of 
      Mental Health Services, Office of Patient Care Services, 
      Veterans Health Administration.............................    24
        Prepared statement of Dr. Zeiss..........................    56

                                 ______

American Legion, Ian C. De Planque, Assistant Director, Veterans 
  Affairs and Rehabilitation Commission..........................     5
    Prepared statement of Mr. De Planque.........................    38
Iraq and Afghanistan Veterans of America, Carolyn Schapper, Repres
  entative.......................................................     8
    Prepared statement of Ms. Schapper...........................    43
Kilpatrick, Dean G., Ph.D., Distinguished University Professor, 
  and Director, National Crime Victims Research and Treatment 
  Center, Medical University of South Carolina, Charleston, SC, 
  and Member, Committee on Veterans' Compensation for 
  Posttraumatic Stress Disorder, Institute of Medicine and 
  National Research Council, The National Academies..............    13
    Prepared statement of Dr. Kilpatrick.........................    44
Murdoch, Maureen, M.D., MPH, Core Investigator, Center for 
  Chronic Disease Outcomes Research, Minneapolis Veterans Affairs 
  Medical Center, Veterans Health Administration, U.S. Department 
  of Veterans Affairs............................................    26
    Prepared statement of Dr. Murdoch............................    58
Tanielian, Terri, MA, Study Co-Director, ``Invisible Wounds of 
  War'' Study Team, RAND Corporation.............................    15
    Prepared statement of Ms. Tanielian..........................    47
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior 
  Analyst for Veterans' Benefits and Mental Health Issues........     7
    Prepared statement of Dr. Berger.............................    41

                       SUBMISSIONS FOR THE RECORD

National Council on Disability, John R. Vaughn, Chairperson, 
  letter and attachments.........................................    59
Veterans for Common Sense, Paul Sullivan, Executive Director, 
  statement......................................................    63

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Ian De Planque, Assistant Director, Veterans 
      Affairs and Rehabilitation Commission, American Legion, 
      letter dated April 7, 2009, and response letter dated May 
      4, 2009....................................................    68
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Thomas Berger, Ph.D., Senior Analyst for 
      Veterans' Benefits and Mental Health Issues, Vietnam 
      Veterans of America, letter dated April 7, 2009, and VVA 
      responses..................................................    72
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Carolyn Schapper, Representative, Iraq and 
      Afghanistan Veterans of America, letter dated April 7, 
      2009, and IAVA responses...................................    74
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Dean G. Kilpatrick, Ph.D., Member, Committee on 
      Veterans' Compensation for Posttraumatic Stress Disorder, 
      Institute of Medicine, and Dr. Kilpatrick's responses......    75
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Terri Tanielian, Study Co-Director, ``Invisible 
      Wounds of War,'' RAND Corporation, letter dated April 7, 
      2009, and Ms. Tanielian and Ms. Eibner's responses.........    78
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Rear Admiral David Smith, M.D., SHCE, USN, 
      Joint Staff Surgeon, Office of the Chairman of the Joint 
      Chiefs of Staff, Wounded and Survivor Care Task Force, U.S. 
      Department of Defense, letter dated April 7, 2009, and DoD 
      responses..................................................    81
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Colonel Robert Ireland, Program Director, 
      Mental Health Policy, Office of the Assistant Secretary of 
      Defense for Health Affairs, U.S. Department of Defense, and 
      DoD responses..............................................    84
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Bradley Mayes, Director, Compensation and 
      Pension Service, Veterans Benefits Administration, U.S. 
      Department of Veterans Affairs, letter dated April 7, 2009, 
      and VA responses...........................................    88
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Antonette Zeiss, Ph.D., Deputy Chief 
      Consultant, Office of Mental Health Services, Office of 
      Patient Care Services, Veterans Health Administration, U.S. 
      Department of Veterans Affairs, letter dated April 7, 2009, 
      and VA responses...........................................    92
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Maureen Murdoch, M.D., MPH, Core Investigator, 
      Center for Chronic Disease Outcomes Research, Minneapolis 
      Veterans Affairs Medical Center, Veterans Health 
      Administration, U.S. Department of Veterans Affairs, letter 
      dated April 7, 2009, and VA responses......................   100


                  THE NEXUS BETWEEN ENGAGED IN COMBAT
                   WITH THE ENEMY AND POST-TRAUMATIC
                      STRESS DISORDER IN AN ERA OF
                        CHANGING WARFARE TACTICS

                              ----------                              


                        TUESDAY, MARCH 24, 2009

         U.S. House of Representatives,    
            Committee on Veterans' Affairs,
              Subcommittee on Disability Assistance
                                      and Memorial Affairs,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 2:13 p.m., in 
Room 334, Cannon House Office Building, Hon. John J. Hall 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Hall, Donnelly, and Lamborn.

               OPENING STATEMENT OF CHAIRMAN HALL

    Mr. Hall. Good afternoon, ladies and gentlemen. The 
Veterans' Affairs Disability Assistance and Memorial Affairs 
Subcommittee hearing on the topic of ``The Nexus Between 
Engaged in Combat with the Enemy and Post-Traumatic Stress 
Disorder (PTSD) in an Era of Changing Warfare Tactics'' will 
now come to order.
    I would ask everyone to rise for the Pledge of Allegiance. 
Flags are located at both ends of the room.
    [Pledge of Allegiance.]
    The task of today's hearing will prove to be both 
retrospective and prospective in order to understand Title 38, 
section 1154. We must look both backward to the original intent 
of Congress and forward to defining it in an era of modern 
warfare tactics and counterinsurgency.
    I ask that the full text of title 38 U.S. Code, section 
1154, be entered into the record.
    [The information follows:]

                     Title 38 U.S.C., Section 1154
 Consideration to be accorded time, place, and circumstances of service
          (a) The Secretary shall include in the regulations pertaining 
        to service-connection of disabilities (1) additional provisions 
        in effect requiring that in each case where a veteran is 
        seeking service-connection for any disability due consideration 
        shall be given to the places, types, and circumstances of such 
        veteran's service as shown by such veteran's service record, 
        the official history of each organization in which such veteran 
        served, such veteran's medical records, and all pertinent 
        medical and lay evidence, and (2) the provisions required by 
        section 5 of the Veterans' Dioxin and Radiation Exposure 
        Compensation Standards Act (Public Law 98-542; 98 Stat. 2727).
          (b) In the case of any veteran who engaged in combat with the 
        enemy in active service with a military, naval, or air 
        organization of the United States during a period of war, 
        campaign, or expedition, the Secretary shall accept as 
        sufficient proof of service-connection of any disease or injury 
        alleged to have been incurred in or aggravated by such service 
        satisfactory lay or other evidence of service incurrence or 
        aggravation of such injury or disease, if consistent with the 
        circumstances, conditions, or hardships of such service, 
        notwithstanding the fact that there is no official record of 
        such incurrence or aggravation in such service, and, to that 
        end, shall resolve every reasonable doubt in favor of the 
        veteran. Service-connection of such injury or disease may be 
        rebutted by clear and convincing evidence to the contrary. The 
        reasons for granting or denying service-connection in each case 
        shall be recorded in full.

    Mr. Hall. So what does it mean to have been ``engaged in 
combat with the enemy'' to a sufficient enough degree to prove 
a stressor that in turn, warrants service connection for post-
traumatic stress disorder, or PTSD, by the Department of 
Veterans Affairs (VA)? And what has been the intent of 
Congress?
    Congress' commitment originated with the Military Pension 
Law of 1776. By the end of the Civil War, Congress recognized, 
``every soldier who was disabled while in service of the 
Republic, either by wounds, broken limbs, accidental injuries, 
or was broken down in the service by the exposure and hardships 
incident to camp life and field duty is entitled to an invalid 
pension.''
    It was believed that those exposures and hardships led to a 
malaise at the time known as, ``Soldier's Heart,'' which we now 
know as PTSD. I find Soldier's Heart to be more poetic myself.
    Shortly after the 65th Congress declared war on Germany, it 
passed the War Risk Insurance Act of 1917, which outlined 
benefits to World War I veterans. In 2 years, it was amended 22 
times. These amendments included the first VA Schedule for 
Rating Disabilities and established wartime versus peacetime 
rates for pension. The 1933 rating schedule included 
instructions to notate the phrase, ``incurred in service and 
combat with an enemy of the United States,'' and to list the 
period of wartime service. This practice indicated that the 
enemy was a foreign government or a hostile force of a nation 
and not an individual combatant.
    On December 12, 1941, days after the attack on Pearl 
Harbor, Congress expressed its desire to, ``overcome the 
adverse effect of a lack of an official record,'' and ``the 
difficulties encountered in assembling records of combat 
veterans.''
    Congress further instituted, ``more liberal service pension 
laws by extending full cooperation to the veteran.'' The 1945 
rating schedule required that wartime service be noted by 
including the phrase, ``disability resulted from injury 
received in actual combat in an expedition or occupation.'' 
Importantly, this prerequisite refined the broader 1933 
required statement.
    Additionally, the 1945 schedule described the onset of 
``War Psychosis'' as the result of ``incident in battle or 
enemy action or following bombing, shipwreck, imprisonment, 
exhaustion or prolonged operational fatigue.'' This diagnosis 
was removed when the rating schedule for mental disorders was 
revised in 1976, 1988 and 1996.
    Some would say that our service men and women are 
experiencing prolonged operational fatigue today. But at any 
rate, the current rating schedule for PTSD has been described 
as vague and subjective. Furthermore, the adjudication process 
does not solely accept, as the law prescribes, lay evidence as 
sufficient proof as long as it is consistent with the 
circumstances, conditions, or hardships of such service, 
notwithstanding that there is no official record.
    This law should seem self-evident as to the intent of 
Congress. So why isn't it? The controversy seems to exist 
because of numerous interpretations of Congressional intent. 
Leading decisionmakers at VA General Counsel have issued 
opinions and court decisions that concluded that if it were the 
intent of Congress to specify a combat zone or theater of 
combat operations, Congress would have done so as it has in 
other provisions of the law under Title 38, but omitted in 
section 1154.
    So our intention today is to reopen this dialog. The nature 
of wartime services changed, as many can agree. Warfare 
encompasses acts of terrorism, insurgency, and guerilla 
tactics. No place is safe and the enemy may not be readily 
identifiable.
    Psychiatry has changed also. PTSD is a relatively new 
diagnosis, first having appeared in the Diagnostic and 
Statistical Manual in 1980, 5 years after the end of the 
Vietnam War. Since then, an array of mental health research has 
been conducted and assessment techniques have been developed.
    Since the world is not the same place it was in 1941, I 
have introduced H.R. 952, the ``COMBAT PTSD Act,'' to redefine 
section 1154 to include a theater of combat operations during a 
period of war or in combat against a hostile force. There 
should be a better way for VA, to assist veterans suffering 
from PTSD, to adjudicate those claims without it being 
burdensome, stressful and adversarial. Veterans still face 
issues with stigma, gender and racial disparities in rating 
decisions, poorly conducted disability exams, and inadequate 
military histories. So, I am eager to hear from the witnesses 
today about their experiences with denials, inequities and 
variances.
    In the last few years, the Institute of Medicine (IOM) 
comprehensively reviewed the research on PTSD diagnosis, 
assessment and compensation. In 2008, the RAND report on the 
``Invisible Wounds of War'' gave us a new perspective on the 
costs of war when soldiers are left without treatment or 
support. I look forward to hearing more of its witnesses' 
analyses.
    Finally, the U.S. Department of Defense (DoD) and VA will 
share their insights into how they determine combat versus 
noncombat and how they have chosen to evaluate PTSD disability.
    So I welcome you all. I look forward to all of the 
witnesses' testimony and now will yield to Ranking Member 
Lamborn for his opening statement.
    [The prepared statement of Chairman Hall appears on p. 36.]

             OPENING STATEMENT OF HON. DOUG LAMBORN

    Mr. Lamborn. Thank you, Mr. Chairman, for yielding. I am 
pleased to have the opportunity to discuss the important issue 
before us today. I hope that through the collective efforts and 
knowledge of the individuals gathered here this afternoon, we 
can help ensure that every veteran who has service-related PTSD 
is able to access the benefits to which they are entitled.
    Chairman Hall, I would also like to commend you for your 
compassion toward our veterans. I know it has been a 
longstanding issue for you to ensure that no one falls through 
the cracks due to unintended consequences of the laws and 
regulations pertaining to compensation for PTSD.
    You have reintroduced in the 111th Congress a bill to 
clarify the meaning of ``combat with the enemy'' for purposes 
of service connection. As you and our witnesses are aware, 
section 1154(b) of Title 38 already provides special 
consideration for veterans attempting to establish service 
connection for PTSD or other medical conditions incurred or 
aggravated in combat. In short, this means that the VA must 
accept a combat veteran's lay testimony as sufficient proof of 
service connection for any disease or injury incurred in 
combat, even if there is no official record of such incident.
    Congress established this broad threshold in recognition of 
the chaotic nature of battle and the appropriateness of 
resolving every reasonable doubt in favor of the veteran. 
Unfortunately, circumstances can conceivably arise in which an 
individual who is not a combat veteran under the existing 
definition is exposed to an overwhelming stressor but he or she 
is unable to prove evidence of the occurrence. This is 
especially true for veterans of Vietnam and earlier wars. And 
this is the problem we are trying to resolve.
    Chairman Hall's proposed solution is the bill which would 
essentially redefine ``combat with the enemy'' to include 
service on active duty in a theater of combat operations.
    As I have stated previously, I am concerned that too broad 
of a presumptive threshold would damage the integrity of the 
system. I also believe that too loose a definition of 
``combat'' would diminish the immeasurable sacrifice and 
service of those who actually did engage in battle with the 
enemy.
    While I understand and appreciate the effort to address 
problems regarding the VA claims backlog, I believe that they 
generally result from procedural issues and we can and should 
address those problems accordingly. In addition to the policy 
concerns I have stated, I would also point out that the 
mandatory offsets that would be necessary to pass this bill 
under existing PAYGO rules would be difficult to find.
    Mr. Chairman, as you know it is always a challenge to 
identify offsets within our jurisdiction, and the Congressional 
Budget Office estimated cost of this measure last year exceeded 
$4 billion. I certainly would not be in favor of reducing 
existing veterans benefits elsewhere in the VA budget in order 
to establish an overly broad definition of ``combat with the 
enemy.''
    Mr. Chairman, I extend my thanks to you for holding this 
hearing and I look forward to hearing the testimony of our 
colleagues and witnesses on our panel today. And I yield back.
    [The prepared statement of Congressman Lamborn appears on 
p. 37.]
    Mr. Hall. Thank you, Congressman Lamborn. I would like to 
welcome all of our panelists today and other Members of the 
Subcommittee as they arrive. Congressman Donnelly.
    I will remind all panelists that your complete written 
statements have been made a part of the hearing record, so you 
can limit your remarks so that we can have sufficient time to 
follow up with questions once everyone has had the opportunity 
to testify.
    On our first panel is Mr. Ian De Planque, Assistant 
Director of Veterans Affairs and Rehabilitation Commission at 
the American Legion; Dr. Thomas J. Berger, Senior Analyst for 
Veterans' Benefits and Mental Health Issues at Vietnam Veterans 
of America (VVA); and Ms. Carolyn Schapper, a member of the 
Iraq and Afghanistan Veterans of America (IAVA).
    Welcome to our first panelists. You may come join us at the 
witness table, please.
    Mr. De Planque, your statement is entered into the record. 
You are now recognized for 5 minutes.

 STATEMENTS OF IAN C. DE PLANQUE, ASSISTANT DIRECTOR, VETERANS 
AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION; THOMAS 
  J. BERGER, PH.D., SENIOR ANALYST FOR VETERANS' BENEFITS AND 
MENTAL HEALTH ISSUES, VIETNAM VETERANS OF AMERICA; AND CAROLYN 
  SCHAPPER, REPRESENTATIVE, IRAQ AND AFGHANISTAN VETERANS OF 
                            AMERICA

                 STATEMENT OF IAN C. DE PLANQUE

    Mr. De Planque. Thank you. Good afternoon Mr. Chairman, 
Members of the Subcommittee. On behalf of the American Legion, 
I would like to thank you for allowing me the opportunity to 
present this testimony today.
    We are basically here to clarify the concept of engaged in 
combat with the enemy in a manner that is consistent with the 
realities of warfare in today's world. I think it is important 
to note that this is not creating any sort of new benefit. What 
is really at issue today is an attempt to clarify the meaning 
and intent of the existing statute in section 1154(b). What we 
are looking at is something that hopefully fulfills the 
original intent of the statute, while at the same time 
streamlining some of the red tape involved with one small part 
of the claims process.
    These provisions were created in recognition of the 
recordkeeping abnormalities and difficulties experienced in the 
thick of war fighting. They were created to recognize that in 
war we don't always have the time to write meticulously 
detailed reports. However, these statutes were originally 
created in 1941 and the distinctions between being in a combat 
zone and being on the frontline were perhaps more cut and dry 
than what we are seeing in the age of modern warfare.
    As with all things in life, the world changes and we must 
evaluate these changes and make sure we adapt to them. In 
today's nonlinear battlefield, the frontline is not so clear. 
Simply drawing a line on a map and stating that this unit was 
present here does not always adequately reflect the extent of 
combat situations where servicemembers are in harm's way.
    I would like to present an example of two soldiers. Both 
soldiers witnessed the exact same event, an event clearly 
consistent with the hardships and circumstances of combat as 
presented in 1154(b). However, because of the differences in 
military occupational speciality (MOS) of the two soldiers, one 
faces much more difficult battle when he returns home. Imagine 
a convoy traveling through southeastern Afghanistan. An 
improvised explosive device (IED) detonates ahead of them on 
the road. Fortunately, no American soldiers are injured. No 
vehicles are damaged in the blast. However, by the side of the 
road, a family of Afghans are struck by the blast and killed 
instantly. In the convoy, the soldiers traveling by witness the 
aftermath of the explosion.
    Subsequent to this event, two soldiers in the convoy 
develop post-traumatic stress disorder as a result of what they 
have seen. The first veteran is an infantryman, a veteran of 
several combat operations prior to this convoy and a recipient 
of the Combat Infantryman Badge (CIB). The second veteran is a 
mechanic pulled along on the convoy as part of a temporary 
assignment and has no decorations of combat.
    When they file a claim with the VA, both veterans must 
prove and do prove that they have the present condition of PTSD 
and that a doctor links the PTSD to the event described above.
    Now they must prove the third element of the claim. They 
must prove that the alleged incident occurred. Here is where 
the two soldiers are then treated differently. The first 
veteran, the infantryman, has a combat infantry badge. As long 
as his story is consistent with the hardships and circumstances 
of combat, which we can all agree that it is, the VA cedes the 
existence of the event and a claim is granted.
    The second veteran has no combat decoration. In his job he 
was fortunate enough to not have been injured or merited a 
Purple Heart. His story is the same story, exactly consistent 
with the circumstances of war, but he lacks a decoration to say 
that he was in combat. This veteran must now prove several 
things happened. He must prove that he was on the convoy. This 
can be difficult, if not impossible. Temporary details are 
assigned in the military all the time, other duties as 
assigned. You piece together troops because you have one 
overriding goal: Get the job done.
    If the veteran is fortunate, morning reports or patrol 
reports not only exist for the routine convoy, but they 
actually are detailed enough to list all the personnel who went 
on it. This is not always the case. Assuming that the veteran 
can prove that he was on this particular convoy on this 
particular day, he must now prove that this convoy experienced 
the incident described above. This is not as easy as it sounds. 
Does every incident get recorded? What if no Americans were 
hurt? What if no equipment was damaged?
    The provisions of 1154(b) were intended to reflect the 
often thin recordkeeping in combat. Detailed notes aren't 
always there. Now, keep in mind, all of this sifting through 
the records has to be done by VA and the veteran. This is a 
colossal amount of effort. Requests must be sent back and forth 
to various repositories of records. This problem is compounded 
by the fact that Guard and Reserve units often keep their own 
records separate from those of active duty, and that the 
records don't always mesh up the way that they should. If a 
veteran can't find all of these separate pieces in writing, 
then the VA must deny the claim because they can't verify the 
alleged incident.
    Ultimately we have to ask ourselves why we are holding two 
soldiers serving in the same military to different standards 
when the hardships and circumstances faced by them are so 
vastly similar. 1154(b) was never intended nor should it be 
used as a means of handing out benefits carte blanche. It only 
exists as a means to help sort through the fog of war and 
establish the existence of events that might not otherwise be 
meticulously documented. It is a means to fill in the last 
piece of the puzzle for veterans who have already proved that 
they are deserving of a benefit otherwise.
    A great deal of things have changed in our understanding of 
the realities of modern warfare. This does not mean, however, 
that our Nation's duties to aid and assist the brave men and 
women who go forth to defend it on the fields of battle should 
change. In the modern combat zone the battlefield is 
everywhere, and we need to treat all the veterans who serve 
with the same hand. Thank you very much.
    [The prepared statement of Mr. De Planque appears on p. 
38.]
    Mr. Hall. Thank you, Mr. De Planque. Mr. Berger, you are 
now recognized for 5 minutes.

              STATEMENT OF THOMAS J. BERGER, PH.D.

    Dr. Berger. Mr. Chairman, Ranking Member Lamborn, and other 
distinguished Members of the House Veterans' Affairs Committee, 
Subcommittee on Disability Assistance and Memorial Affairs, 
Vietnam Veterans of America thanks you for the opportunity to 
present our views on the record surrounding the Department of 
Veterans Affairs' application of the provisions found in Title 
38 U.S.C. 1154, the definition of ``engaged in combat with the 
enemy'' and its effect on processing claims for veterans 
suffering from post-traumatic stress disorder.
    Despite the promises of change from this Administration, 
for those most in need of renewed attention are veterans of our 
military who have come home from war seeking disability 
benefits for post-traumatic stress disorder. While the 
dysfunctional state of the VA claims adjudication system has 
become a matter of growing public concern, the rhetoric 
surrounding our obligation to returning troops still falls 
short of actual legislative priorities. Meanwhile, recent 
efforts to reform the VA benefits system through litigation 
have only affirmed the need for legislative action with courts 
repeatedly dismissing the issue as a Congressional matter.
    The resulting inertia makes the passage of Congressman 
Hall's proposed change to 38 U.S.C. especially vital, 
particularly when viewed in conjunction with his proposed 
COMBAT PTSD Act. Under current VA policy, disability claims are 
effectively presumed fraudulent until proven otherwise. Beyond 
establishing their medical condition, claimants must prove, 
through elaborate documentation, that their disability stems 
from the military service while a veteran was ``engaged in 
combat.'' While the disability claims process imposes a toll on 
all veterans seeking benefits, this burden falls with 
particular weight on those with PTSD who must identify the 
specific stressor that triggered their condition, even if they 
have already been diagnosed and referred to treatment.
    A personal story: A very good friend of mine who served as 
a combat medic with the 25th Light Infantry Division in Vietnam 
just passed away recently. He suffered hepatitis, had a liver 
transplant. All of that he had to fight for, for years with the 
VA, because as a combat medic, he did not receive the Combat 
Infantryman's Badge. This man died without ever receiving all 
the benefits and compensation that was due him.
    Under the existing system the VA Clinicians Guide warns 
examiners that PTSD symptoms are ``relatively easy to 
fabricate'' directing them to supplement treatment records with 
elaborate documentation from claimants' family and friends 
concerning changes from pre- to post-service status. Despite 
the fact that one of the diagnostic criteria for PTSD is an 
inability to recall important aspects of a trauma, reviewers 
routinely deny or remand claims due to incomplete information.
    At the same time, the VA continues to measure employee 
productivity by number of cases processed, offering reviewers 
an incentive to take any shortcut necessary to clear their 
desks of pending claims. The resulting combination of too much 
work and too little time ultimately gives rise to premature and 
inaccurate determinations, setting in motion years of appeals.
    Claimants seeking compensation for military sexual trauma, 
for example, are inevitably obstructed by the military's policy 
of retaining harassment complaint files for only 2 years, 
eliminating critical evidence of the stressor that gave rise to 
their condition. Even in the best of circumstances, the 
retrieval of military records is a bureaucratic nightmare 
requiring protracted negotiation with a central archive in 
Missouri, other National Archives facilities, and/or DoD 
agencies.
    In spite of these inequities, the VA defends its current 
system as a precaution against claimant fraud. And even 
according to VA spokesperson Kerri Childress, eliminating the 
proof requirement, quote, would be a travesty for veterans, an 
assault to the pride of honest soldiers when other vets are 
scammed by the system.
    Establishing service in combat as the presumptive stressor 
for the incurrence of PTSD would be a long overdue first step 
toward fixing a notoriously broken system. VVA can support the 
proposed legislative change because we believe the proposed 
change to be well intended and most considerate for those of 
our veterans suffering from PTSD and who face interminable 
delays and denials in their compensation claims from the VA 
under the current claims processes and procedures.
    VVA thanks this Committee for the opportunity to submit its 
views and testimony on this important veterans issue. Thank 
you, sir.
    [The prepared statement of Dr. Berger appears on p. 41.]
    Mr. Hall. Thank you, Dr. Berger. Ms. Schapper, you are now 
recognized for 5 minutes.

                 STATEMENT OF CAROLYN SCHAPPER

    Ms. Schapper. Mr. Chairman and Members of the Subcommittee, 
thank you for inviting me to testify today on behalf of Iraq 
and Afghanistan Veterans of America, the Nation's first and 
largest nonpartisan organization for veterans of the current 
conflicts. I would like to thank you all for your unwavering 
commitment to our Nation's veterans.
    My name is Carolyn Schapper and I am a combat veteran. 
While serving as a member of the military intelligence unit in 
Iraq from October 2005 to September 2006 with the Georgia 
National Guard, I participated in approximately 200 combat 
patrols. While many of these patrols included positive 
interactions with the local population, I did encounter direct 
fire, improvised explosive devices and other threats during 
some of my missions. Overall, I valued the opportunity to learn 
about the Iraqi people, my country and myself.
    However, when I came home from Iraq, I dealt with a wide 
range of adjustment issues and symptoms including rage, anger, 
withdrawal and depression, high anxiety, agitation, nightmares 
and hypervigilance. When you are in this state of mind, it is 
difficult to traverse the VA's maze. I might still be lost if I 
had not had the good luck of running into another veteran who 
had already gotten help and who had pointed out that a Vet 
Center could help me start navigating the VA system.
    While I was able to receive the appropriate help and rating 
from the VA due to the existence of proper paperwork for my 
adjustment issues, many of my sisters-in-arms have not been so 
lucky. Part of the problem is that because females are excluded 
from official combat roles in the military, women veterans have 
a greater burden of proof when it comes to establishing combat-
related PTSD. But the reality on the ground in Iraq and 
Afghanistan is that there is no clear frontline, and female 
servicemembers are seeing combat. Modern warfare makes it 
impossible to delineate between combat, combat support, and 
combat service support roles. You do not even need to leave the 
forward operating base to be exposed to the continual threat of 
mortars and rockets. Military personnel are often required to 
walk around in, or sleep in, body armor. As one female veteran 
told me, life in Iraq and Afghanistan is combat.
    Moreover, many female troops in Iraq and Afghanistan have 
been exposed to direct fire while serving in support roles such 
as military police, helicopter pilots and truck drivers. All of 
our troops, whether or not they serve in the combat arms, must 
exhibit constant vigilance. And this can take an extreme 
psychological toll on all servicemembers.
    The traditional understanding of female servicemembers' 
military duties has been the biggest hurdle to getting them 
adequate compensation for their injury. The nature of PTSD and 
other psychological injuries makes it difficult to identify the 
exact stressor, and therefore, disability may be determined 
based on the claims processor's perception of exposure to 
combat.
    While service connection for PTSD would seem obvious for a 
male infantryman, it can easily come under more scrutiny for a 
female intelligence soldier despite how much actual combat 
either of them have seen.
    Another obstacle that female servicemembers face when 
trying to establish presumption of service-connected PTSD 
involves collecting the proper paperwork, especially in 
instances of military sexual trauma. Some women forgo 
documenting their injury, whether combat or sexual trauma, 
rather than get official military documentation from a male 
commander or doctor. If you are suffering from a mental health 
injury, the possibility of having someone question, deride or 
expose such a personal and painful experience is often 
overwhelming and can lead many female servicemembers to avoid 
the process altogether.
    H.R. 952, introduced by the Chairman, solves this problem. 
It changes Title 38 to presume service connection for PTSD 
based solely on a servicemember's presence in the combat zone. 
IAVA wholeheartedly endorses this legislation and looks forward 
to working with the Subcommittee to see this bill become law.
    While this legislation will aid veterans once they have 
become diagnosed with a psychological injury and are seeking 
disability compensation, we know not every servicemember or 
veteran is getting the care they need. To better identify 
troops suffering from psychological injuries and help them 
receive the appropriate treatment, IAVA recommends mandatory 
face-to-face and confidential screenings by a licensed medical 
professional for all servicemembers both before and after 
combat tour. This is one of the organization's top legislative 
priorities for 2009.
    To help ensure that veterans seeking access to care and 
benefits, particularly those in need of treatment for their 
psychological injuries, get the support they need, IAVA has 
partnered with the Ad Council to conduct a multiyear public 
service announcement (PSA) campaign. The IAVA-Ad Council 
Veteran Support PSAs are currently running on television, 
radio, print, outdoors and online. The companion campaign, 
engaging the family and friends of new veterans will, be 
launching later this year.
    I will leave you with this final thought. More and more 
women are being called upon to serve a more active role in the 
combat zone and all too often find themselves in harm's way. 
There is no better way to honor the service and sacrifices of 
these brave women than to ensure that when they are injured, 
they receive the care and compensation they deserve.
    Thank you again for the opportunity to testify on this 
critical issue. And I think we would all be pleased to take 
your questions at this time.
    [The prepared statement of Ms. Schapper appears on p. 43.]
    Mr. Hall. Thank you Ms. Schapper.
    First, Mr. De Planque, in your statement you noted that if 
Congress were to change section 1154 it would not be creating a 
new benefit, but providing a clarification to the original law 
since the veterans' entitlement already existed. Can you expand 
upon this contention and how entitlement is already 
established?
    Mr. De Planque. Yes. Essentially what I am trying to 
address with this is that it is not in any sense trying to give 
out a golden ticket to PTSD or anything. The problem, what 1154 
was created to address, is the problem of establishing 
incidents that happen in combat, in the combat area.
    I will give a very quick example from my personal 
experience. In Afghanistan, my platoon came under fire and 
engaged in combat with the enemy. We were an infantry platoon 
so we all got CIBs out of the deal and we all--what we said 
happened happened. But I compiled all of the reports because 
every soldier had to file a contact report and everything. And 
I compiled all of those for our platoon and pushed them on. We 
had over 20 people involved in that. There were over 20 
different stories of what happened. Everybody experiences 
things a little bit differently. And when you look at all of 
those things, you realize just how hard it is to get an 
accurate record of exactly what happened.
    I think that that is what 1154(b) was about, is that it is 
very, very hard to document and to really capture everything 
that is happening in combat, which is a zone-wide exposure when 
you look at it in modern warfare. So what 1154(b) is about is 
establishing that those things happened.
    With the VA claim, it is not just that you establish that 
something happened, you still have to have a present diagnosis. 
You still have to have a linkage opinion between the two of 
those. These aspects of the claims process are not changing at 
all, and they haven't changed and they are not affected by 
1154(b); 1154(b) is establishing the incident in service. And 
that is the difficult part and that is the thing that--when I 
talk about what this is doing and clarifying it, it is trying 
to create a sense of equity between infantry soldiers, for 
example, who have that ticket, that CIB that says, you know, 
what you said happened happened, and other soldiers who are 
going through exactly the same things and exactly the same 
conditions are having their word--they are having a much more 
difficult time proving their word because it is not being taken 
for granted unless they can say, this combat occurred.
    And so in terms of not establishing the benefit, it is more 
attempting to deal with the existing facet of benefits, the 
sort of nebulous area of confirming something that happened in 
combat or in a combat zone.
    Mr. Hall. Thank you.
    Dr. Berger, at what point would you support VA accepting a 
veteran's lay statement as proof of a stressor, instead of 
requiring VA to continue to develop a claim by searching for 
records and documents that may or may not exist at any of the 
centers you mentioned in your statement?
    Dr. Berger. Certainly what we call buddy records would seem 
very appropriate. As I mentioned, my colleague was a combat 
medic with the 25th, had to rely heavily on people that he 
served with in order to document his service. And that 
particular unit that he served with, the time period took place 
in the Michelin rubber plantation area in the Republic of South 
Vietnam at the time. A lot of enemy action down there. But as I 
said, he did not receive a CIB, so it was very difficult for 
him to prove that he had actually been in combat. So certainly 
the supporting statements of colleagues who are with you at the 
time would help.
    I know that in my own personal case, I was in a field 
hospital up north, and there weren't many of us Navy corpsmen 
there present. In fact, there is only one alive today who could 
document my presence there. I would have to go through the 
Marines that I served with in order to prove that I was even 
there.
    Mr. Hall. How accurate would you say veterans are when they 
self-report their stressors? In your observations, have you 
seen many cases where stressors are exaggerated?
    Dr. Berger. I think Bruce Dohrenwend, a Professor at 
Columbia University who reevaluated the National Vietnam 
Veterans' Readjustment Study (NVVRS) a couple of years ago, 
stated it clearly when they looked at the NVVRS data, the PTSD 
data from Vietnam veterans, and found very few, very few 
instances of fraud, lying in the process that they used to 
document their combat service.
    Mr. Hall. Thank you, sir.
    And, Ms. Schapper, are there situations that the IAVA is 
aware of where veterans who served in Iraq or Afghanistan were 
not considered to be combat veterans and therefore had their 
PTSD claims denied?
    Ms. Schapper. I don't have specific instances from IAVA. 
But I do have instances of fellow female servicewomen who have 
had difficulty. I did not have difficulty supplying the 
``burden of proof'' because I was lucky enough that I was 
either a convoy commander or a team sergeant and I wrote up all 
the reports for the incidents that occurred. But as Mr. 
DePlanque was saying earlier, that if you don't happen to have 
your name on that report, that you were in that instance, that 
combat, that IED, you will be denied. And I do know several 
female servicemembers who have been denied because their name 
was not on the proper paperwork.
    Mr. Hall. I am over my time. But before I turn it over to 
the Ranking Member, I wanted to ask one more question, if I 
could. What would you suggest the VA do to improve its 
assistance to female veterans in order to help develop their 
claims?
    Ms. Schapper. Personally I would like to see stronger 
women's centers in the VA and women's PTSD groups for combat 
and/or military sexual trauma. Right now a lot of the PTSD 
groups are mixed groups. And although some women do feel open 
to speaking in those groups, I do believe most of them hold 
back a lot of experiences just because men are in there as 
well.
    Mr. Hall. Okay. Thank you very much.
    Mr. Lamborn.
    Mr. Lamborn. Thank you. And Ms. Schapper, I have a question 
for you also. If I heard you correctly during your testimony, 
you talked about how this bill, if passed, would help in the 
case of a woman who has suffered sexual assault or rape. Did I 
hear you correctly? And if so, what would the connection be?
    Ms. Schapper. This bill wouldn't specifically address 
military sexual trauma. I was using that as an instance of how 
women often feel more exposed and that people generally 
question them more. Whether it is sexual trauma or combat, that 
is often more difficult for them to prove they have any sort of 
PTSD symptoms at all.
    Mr. Lamborn. Okay. Thank you for that clarification. Mr. 
Chairman, I would yield back.
    Mr. Hall. Thank you. Well first of all, thank you all for 
your service to our country. And thank you for your service to 
our veterans and for being here to testify today.
    We will now excuse you and move on to our second panel, 
which consists of Dean G. Kilpatrick, Ph.D., member of the 
Committee on Veterans Compensation for Post-Traumatic Stress 
Disorder, Institute of Medicine of the National Academies; 
Terry Tanielian, Co-Study Director of the ``Invisible Wounds of 
War Study'' by the RAND Center for Military Health Policy 
Research, accompanied by Christine Eibner, also a Ph.D. and 
Economist with the RAND Corporation.
    As usual, your full written statement is entered into the 
record, so feel free to abridge it if you wish. Mr. Kilpatrick, 
you are recognized for 5 minutes.

    STATEMENTS OF DEAN G. KILPATRICK, PH.D., DISTINGUISHED 
  UNIVERSITY PROFESSOR, AND DIRECTOR, NATIONAL CRIME VICTIMS 
  RESEARCH AND TREATMENT CENTER, MEDICAL UNIVERSITY OF SOUTH 
 CAROLINA, CHARLESTON, SC, AND MEMBER, COMMITTEE ON VETERANS' 
 COMPENSATION FOR POSTTRAUMATIC STRESS DISORDER, INSTITUTE OF 
MEDICINE AND NATIONAL RESEARCH COUNCIL, THE NATIONAL ACADEMIES; 
AND TERRI TANIELIAN, MA, STUDY CO-DIRECTOR, ``INVISIBLE WOUNDS 
OF WAR'' STUDY TEAM, RAND CORPORATION, ACCOMPANIED BY CHRISTINE 
           EIBNER, PH.D., ECONOMIST, RAND CORPORATION

             STATEMENT OF DEAN G. KILPATRICK, PH.D.

    Dr. Kilpatrick. Thank you very much, Mr. Chairman, Mr. 
Ranking Member, and Members of the Committee. I appreciate the 
opportunity of being able to testify on behalf of the National 
Academy of Sciences' Committee on Veterans Compensation For 
Post-Traumatic Stress Disorder.
    In June 2007, our Committee completed its report entitled, 
``PTSD Compensation and Military Service.'' I am here today to 
share with you some of the contents of that report and will 
briefly address four issues: the evaluation of traumatic 
exposures for VA compensation and pension purposes; the 
reliability and completeness of military records for evaluation 
of exposure to stressors; what studies say about malingering in 
the veteran population; and the means that mental health 
professionals use to detect malingering.
    In terms of the first issue, VA Compensation and Pension 
(C&P) examinations for PTSD consist of a review of medical 
history, evaluations of mental status and of social and 
occupational functioning, a diagnostic examination and an 
assessment of exposure to traumatic events occurred during 
military service. To help focus the examination, the VA 
Veterans Benefits Administration (VBA) provides examiners with 
worksheets that set forth what an assessment should cover. The 
PTSD worksheet indicates the elements of a claimant's military 
history that should be documented, or it indicates that that 
should include military occupational specialty, combat wounds 
sustained, citations or medals received, and a clear 
description of ``the specific stressor event the veteran 
considered to be particularly traumatic, particularly if the 
stressor is the type of personal assault including sexual 
assault, providing information with examples, if possible.''
    It notes that a diagnoses of PTSD cannot be made or 
adequately documented or ruled out without obtaining detailed 
military history and reviewing the claims folder. This means 
that the initial review of the folder conducted prior to 
examination, the history and the examination itself, and the 
dictation for an examination initially establishing PTSD will 
often require more time than for examinations of other 
disorders. They recommend that 90 minutes to 2 hours on an 
initial exam is normal.
    There was also a Best Practices Manual developed by VA that 
stated that the initial PTSD compensation basically requires up 
to 3 hours. Not withstanding this guidance, our Committee, and 
testimony reported to our Committee, indicated that some people 
are so pressured that they spend as little as 20 minutes on 
these exams. And we concluded that that was an unacceptably 
short period of time.
    Military records, with respect to the second issue, are 
prized because they are thought to be a description or an 
unbiased source of evidence to support or refute claims. 
However, specifically the conclusion that this is so was really 
not supported by our Committee. And in fact, the National 
Archives and Research Administration warns that, ``Detailed 
information about the veteran's participation in military 
battles and engagements is not contained in military service 
records and personnel files.'' Studies indicate, instead, that 
broad-based research into other indicators of the likelihood of 
having experienced traumatic stressors has value. And in fact, 
someone just mentioned Dr. Dohrenwend's NVVRS reexamination 
study in which they looked at news accounts and a variety of 
other things to augment the official records.
    Our Committee concluded that the most effective strategy 
for dealing with problems with self-reports of traumatic 
exposure is to ensure that a comprehensive, consistent and 
rigorous process is used throughout the VA to verify veteran-
reported evidence.
    What studies say about malingering in veterans populations: 
The Committee noted that assessment of malingering--and, I 
would add, accusing someone of malingering--is a high-stakes 
issue, because it is as devastating to falsely accuse a veteran 
of malingering as it is unfair to other veterans to miss 
malingered cases.
    Our Committee concluded that while misrepresentation of 
combat involvement and traumatic exposure undoubtedly does 
occur, the evidence is insufficient to establish how prevalent 
this is. And in fact, there is not a lot of evidence that it is 
prevalent, or how much effect malingering has on the ultimate 
outcome of disability claims. The preponderance of evidence 
does not support the notion that receiving compensation for 
PTSD makes veterans less likely to 
make treatment gains or acknowledge improvement from treatment.
    Finally, the means that mental health professionals use to 
detect malingering, although there is a need for a reliable 
valid way to detect malingering, experts agree that there is no 
magic bullet or gold standard for doing so. It would be really 
nice if we had a means for determining whether someone is 
telling the truth or not or if they are malingering or not. 
But, unfortunately, no way exists to do that in a simple 
manner.
    While some investigators use psychological tests to 
indirectly infer the possibility of malingering, these measures 
have clear limitations and should not be used as the sole basis 
for determining whether a veteran is malingering.
    The Committee concluded that in the absence of a definitive 
measure, the most effective way to detect inappropriate PTSD 
claims is to require a consistent and comprehensive state-of-
the-art examination and assessment that allows the time to 
conduct appropriate testing and assessment in these specific 
circumstances where it would inform the assessment.
    Thank you very much. And I will be happy to take questions.
    [The prepared statement of Dr. Kilpatrick appears on p. 
44.]
    Mr. Hall. Thank you, Mr. Kilpatrick.
    Ms. Tanielian, you are now recognized for 5 minutes.

                STATEMENT OF TERRI TANIELIAN, MA

    Ms. Tanielian. Chairman Hall, Representative Lamborn, and 
distinguished Members of the Subcommittee, thank you for 
inviting me to testify today. It is an honor and a pleasure to 
be here.
    Last April, my colleagues and I released findings from a 1-
year project entitled ``Invisible Wounds of War.'' This 
independent study focused on three major conditions: post-
traumatic stress disorder, major depression and traumatic brain 
injury among Iraq and Afghanistan veterans.
    My comments today will focus on our findings about 
servicemembers' exposure to trauma during deployment, 
prevalence of mental health conditions post deployment and 
their associated costs to society as they bear directly on the 
issue you are considering today.
    First, how is exposure to combat trauma assessed? In 
research studies, combat experience has been assessed in a 
variety of ways. These include documenting deployment to a 
combat zone based on receipt of hostile-fire pay, or assessing 
specific experiences during deployment based on self-report.
    In our study, combat trauma exposure was assessed using 
questions from recent Army studies and included both direct and 
vicarious trauma exposure. Rates of reported exposure to 
specific types of combat trauma range from 5 to 50 percent in 
our study, with close to one-third reporting exposure to two or 
more traumatic events. Vicariously experienced traumas, such as 
having a friend who was seriously wounded or killed, were the 
most frequently reported.
    Despite these exposures, most military servicemembers who 
have deployed to date will return home from war without 
problems and readjust successfully. But many have already 
returned or will return with significant mental health 
problems.
    Among Iraq and Afghanistan veterans, our study found rates 
of PTSD and major depression to be relatively high, 
particularly when compared with the general population. In late 
2007, we conducted a telephone study of about 2,000 previously 
deployed individuals. Using well-accepted screening tools, we 
estimated substantial rates of mental health problems in the 
past 30 days, with 14 percent reporting current symptoms 
consistent with a diagnoses of PTSD and 14 percent reporting 
current symptoms consistent with a diagnoses of depression; 9 
percent of veterans reported symptoms consistent with a 
diagnoses of both.
    We found that some specific groups previously 
underrepresented in studies, including the Reserves and those 
who had left military service, may be at higher risk of 
suffering from these conditions. We also found that the single 
best predictor of reporting current mental health problems was 
the number of reported combat traumas while deployed.
    From the literature, we know that socioeconomic status, 
access to post-deployment social support and transition 
services, as well as treatment can mitigate the immediate 
consequences of these post-combat mental health problems.
    In our study, however, only about half of those with 
current PTSD or major depression have sought help from a 
physician or other provider in the past year. And of those, 
just over half received minimally adequate treatment.
    The number who received proven effective care would be 
expected to be even smaller. Survey respondents identified many 
barriers to getting treatment for their mental health problem. 
In particular, they were concerned that treatment would not be 
kept confidential and would constrain future job assignments.
    The costs of these invisible wounds go beyond the immediate 
costs of mental health treatment. Adverse consequences that may 
arise from post-deployment mental problems include suicide, 
engagement in unhealthy behaviors, substance abuse, 
unemployment, homelessness, marital strain and domestic 
violence. The costs stemming from these problems are 
substantial and include costs related to lost productivity, 
reduced quality of life, treatment and premature mortality.
    To quantify these costs, RAND used a microsimulation model 
to estimate 2-year post-deployment costs associated with PTSD 
and depression for military servicemembers returning from Iraq 
and Afghanistan. Our analyses used a societal cost perspective 
which considers costs that accrue to all members of U.S. 
society, including the Government, servicemembers, their 
families, employers, private health insurers, taxpayers and 
others.
    We found that, unless treated, PTSD and depression exact a 
high economic toll to society. Our model predicted that the 2-
year post-deployment cost to society for 1.6 million deployed 
servicemembers ranged from $4 to $6.2 billion. The majority of 
these costs were due to lost productivity; and for a variety of 
reasons, the model underestimates the total future costs to 
society.
    While these costs are high, we also found that providing 
evidence-based treatment for PTSD and depression can reduce 
societal costs. We estimate that evidence-based treatment for 
PTSD and major depression would pay for itself within 2 years, 
even without including the many known costs.
    Investing in evidence-based care for all those in need can 
reduce costs to society by $1.7 billion in just 2 years. 
However, ensuring that all veterans with these conditions get 
quality care will require addressing the significant gaps that 
exist in access to and quality of care for our Nation's 
veterans.
    Thank you again for the opportunity to testify today and to 
share the results of our research. I am joined by my colleague 
Christine Eibner, the Health Economist who led these cost 
analyses. And together we are happy to answer your questions. 
Thank you.
    [The prepared statement of Ms. Tanielian appears on p. 47.]
    Mr. Hall. Thank you.
    So, Ms. Eibner, you have no statement of your own. You are 
in a support role?
    Ms. Eibner. Right. Exactly.
    Mr. Hall. Thank you, Ms. Tanielian. Thank you for your 
study. It is an impressive piece of work.
    Dr. Kilpatrick, generally speaking, how well can a mental 
health provider validate a veteran's self-reported history of 
trauma? Do you rule out other diagnoses during the evaluation 
period, including malingering?
    Dr. Kilpatrick. Well, I think if a mental health 
professional is well trained, understands about post-traumatic 
stress disorder, understands specifically about not just combat 
but war zone exposure, including military sexual trauma, and 
looks at the entire picture including the self-report of the 
veteran, what we do is we really see how well everything hangs 
together.
    And, frankly, in terms of post-traumatic stress disorder, 
there are things that people write books about it 
theoretically, in terms of how to malinger it. And I am not 
suggesting that you cannot fool a clinician, because you 
probably can fool anybody a little bit. But I do think that for 
the most part, by looking at how well the symptoms hang 
together and the types of experiences, including things that 
many people don't know about and wouldn't know to think of in 
order to make something up, that we can tell pretty much 
whether people are telling the truth.
    The other thing that I would say--and I think our Committee 
felt this way, too--is that it is really the stance of people 
doing these examinations is important. And if the stance is 
that we are going to assume that everybody is lying until they 
prove to me that they are not, that we felt was really unfair 
and unsupported by the data on how much malingering there 
really is.
    On the other hand, you can be somewhat skeptical but at the 
same time saying, I am going to assume that this person is 
telling me the truth until my antenna goes up and I find some 
reason to believe that they are not.
    Mr. Hall. Along that line of thinking, there has been a 
great deal of concern regarding false positives for PTSD. What 
about false negatives? Are veterans being denied post-traumatic 
stress disorder compensation, in your opinion, who maybe should 
not have been?
    Dr. Kilpatrick. Well, I think if you look at the whole 
picture and you say, all right, how many people--and I think 
your study is--the study that we just heard about is very good. 
Like how many veterans would we estimate have had, had PTSD, 
and then we look at how many of those come forward to the VA, 
there is going to be a lot of attrition there for various 
reasons.
    And then you look at--there is a C&P examination, and how 
many of those are denied? I think the group that--one could 
make the case that there are a lot of unserved veterans with 
PTSD who are unserved and uncompensated. And that would be a 
much larger number than a very small number of veterans who 
maybe have malingered or exaggerated something and have gotten 
a treatment or compensation.
    Mr. Hall. Thank you.
    Ms. Tanielian, in the model of consequences for post-combat 
mental health and cognitive conditions, figure 5.1 in the RAND 
report, one of the categories listed as a resource or 
vulnerability is social, which includes support, transition, 
socioeconomic status and treatment availability. Would you 
agree that VA service connection can impact each of those and 
transform vulnerabilities into resources?
    Ms. Tanielian. Based on the literature, we understand that 
an individual has certain resources or vulnerabilities to 
whether or not they will actually develop a disorder and then 
how they cope and whether or not those consequences can be 
mitigated. Access to social support, socioeconomic status and 
transition services are associated with being able to mitigate 
those consequences. And so to the extent that the eligibility 
requirements in place to gain those services make it so that 
those services are more available, then they have the 
opportunity to promote better outcomes for individuals.
    Mr. Hall. Right. You didn't address this directly because 
your report was done for the DoD, but as I understand, they are 
not in the compensation business.
    Ms. Tanielian. Actually, our report was independent of both 
the DoD and the VA. We looked specifically at trying to 
identify the size and scope of the problem associated with 
PTSD, depression and traumatic brain injury among returning 
troops.
    Mr. Hall. Okay. But it is nonetheless your opinion, as I 
understand, that you just stated that compensation would 
mitigate some of the negative outcomes from detrimental impact 
on social support, life or identity transitions and 
socioeconomic status.
    Ms. Tanielian. Our study identified several barriers to 
getting help for mental concerns reasons and problems. To the 
extent that eligibility requirements and structural barriers 
are diminished, more veterans would have access to appropriate 
care, and thus lower the cost to society associated with PTSD.
    Mr. Hall. Thank you. Last I wanted to ask you, RAND 
suggested the societal cost of untreated PTSD could run from $4 
to $6 billion over a 2-year period just for Iraq and 
Afghanistan veterans. I understand that these figures only 
somewhat include the cost to VA. If you adjusted for the cost 
of disability compensation, do you think the cost to society 
would be more or less? And why?
    Ms. Tanielian. Sure. I am going to actually ask Dr. Eibner 
to address that question.
    Ms. Eibner. Sir, we believe this does incorporate the cost 
to the VA in terms of disability compensation. And the reason 
is, we account for lost productivity in our estimates. So the 
lost productivity cost is really what the VA payments are 
designed to replace. So it is included in that category.
    Mr. Hall. Okay. Thank you very much. Mr. Lamborn.
    Mr. Lamborn. Thank you, Mr. Chairman.
    Ms. Tanielian, how did you diagnose PTSD among the people 
you interviewed? Was there a physician with you? Or what were 
the mechanics of that?
    Ms. Tanielian. As I mentioned, we conducted a telephone 
survey of 2,000 individuals who had been previously deployed. 
We used well-accepted screening measures that are used in 
conducting epidemiological studies for detecting need for 
various different health reasons. Using these screening tools, 
we identified current symptoms of PTSD and depression that were 
consistent with a diagnoses using DSM-IV scoring criteria for 
these screening tools. And so we report the number who were at 
the level of consistent symptoms of a diagnosis with PTSD and 
depression using these validated screening measures.
    Mr. Lamborn. Thank you. And Mr. Chairman, they have done a 
good job of explaining themselves. I don't have any further 
questions.
    Mr. Hall. They sure have. Thank you very much.
    We still have--well, this diagram of the immediate 
consequences and emergent outcomes and the experience of the 
post-combat disorder and what resources and vulnerabilities 
there are, that is enough to keep me working for a while. And 
it comes in a book. If you haven't seen it, all of you here in 
the audience, it is definitely worth reading. It is a serious 
contribution and an important contribution to our country's 
attempt to help our veterans through this difficult problem. So 
I thank you all on this panel for your testimony. You are now 
excused.
    Moving at breakneck speed, thanks to the fact that there 
are no votes being called, and the fact that most of our 
Members are not here using their 5 minutes--we will call our 
third panel. Rear Admiral David J. Smith, a Joint Staff Surgeon 
for the United States Department of Defense; Colonel Robert 
Ireland, Program Director of Mental Health Policy for the 
Office of the Assistant Secretary of Defense for Health 
Affairs, U.S. Department of Defense; Bradley G. Mayes, Director 
of the Compensation and Pension Service for the Veterans 
Benefits Administration, U.S. Department of Veterans Affairs, 
accompanied by Richard Hipolit, General Counsel for the 
Department of Veterans Affairs; Antonette Zeiss, Ph.D., Deputy 
Chief Consultant, Office of Mental Health Services for the 
Veterans Health Administration (VHA); and Maureen Murdoch, 
M.D., Core Investigator, Center for Chronic Disease Outcomes 
Research of the Minneapolis Veterans Affairs Medical Center, 
Veterans Health Administration, U.S. Department of Veterans 
Affairs.
    As always, your statement is entered into the record as 
written. You can feel free to deviate from it.
    Mr. Hall. Starting with Rear Admiral Smith, you are 
recognized for 5 minutes.

  STATEMENTS OF REAR ADMIRAL DAVID J. SMITH, M.D., SHCE, USN, 
JOINT STAFF SURGEON, OFFICE OF THE CHAIRMAN OF THE JOINT CHIEFS 
OF STAFF, WOUNDED AND SURVIVOR CARE TASK FORCE, U.S. DEPARTMENT 
 OF DEFENSE; COLONEL ROBERT IRELAND, PROGRAM DIRECTOR, MENTAL 
HEALTH POLICY, OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE FOR 
 HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE; BRADLEY G. MAYES, 
 DIRECTOR, COMPENSATION AND PENSION SERVICE, VETERANS BENEFITS 
  ADMINISTRATION, U.S. DEPARTMENT OF VETERANS; ACCOMPANIED BY 
 RICHARD HIPOLIT, GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL, 
 U.S. DEPARTMENT OF VETERANS AFFAIRS; ANTONETTE ZEISS, PH.D., 
  DEPUTY CHIEF CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES, 
       OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH 
   ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 
   MAUREEN MURDOCH, M.D., MPH, CORE INVESTIGATOR, CENTER FOR 
CHRONIC DISEASE OUTCOMES RESEARCH, MINNEAPOLIS VETERANS AFFAIRS 
                MEDICAL CENTER, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                         STATEMENT OF 
          REAR ADMIRAL DAVID J. SMITH, M.D., SHCE, USN

    Admiral Smith. Mr. Chairman, distinguished Members of the 
Subcommittee, I am privileged to appear before you today and 
report on wounded-warrior issues and specifically those 
associated with post-traumatic stress disorder.
    In my capacity as the Joint Staff Surgeon, I serve as the 
Chief Medical Advisor to the Chairman of the Joint Chiefs of 
Staff and as a Senior Member of the Chairman's Warrior and 
Survivor Care Task Force.
    On behalf of the Chairman, let me emphasize to you that 
wounded warrior issues, particularly including post-traumatic 
stress, continue to be a top priority for the Chairman and the 
Department of Defense as a whole.
    Working in concert with the respective services, we 
continue to focus on revitalizing and reconstituting the force, 
actively identifying the needs of and giving support to our 
servicemembers' families and removing the stigma associated 
with post-traumatic stress within the DoD.
    I make the statement of revitalizing and reconstituting the 
force, because those are the terms the Chairman uses when 
speaking of the top issues and, specifically, his imperative 
concern.
    I, along with the task force, continuously focus on 
improving current programs, while inviting the creation of new 
ones. And we are strongly focused on teaming with the Veterans 
Affairs and nongovernmental organizations to ensure our 
veterans and their families receive care that they so aptly 
deserve after they leave active duty.
    In regards to doctrine definitions and terminology 
associated with post-traumatic stress, let me say that the 
Department evaluates definitions for their use in doctrine, but 
we do not evaluate definitions for the potential implications 
on benefit determination.
    DoD's definitions and terminologies may be used, but are 
not replacements for policy and law in determination matters.
    The doctrine and definitions are tools we use to provide a 
common starting point across the Department, but compensation 
will continue to be dictated by policy and law rather than 
terms of reference for post-traumatic stress.
    The DoD and the VA use the Diagnostic and Statistical 
Manual for Mental Disorders, 4th edition, frequently referred 
to as the DSM-IV, for the diagnosis of post-traumatic stress 
disorder, and CFR 38 outlines the necessary prerequisites for 
eligibility.
    With these rule sets, the medical community then applies 
professional judgment to interpret and diagnose individual 
cases, and the DoD continuously monitors changes within the 
medical community of terms of reference, research findings, and 
new treatment modalities and improvements to ensure we stay in 
touch with changes that do occur.
    Now, let me take a moment of your time to identify one area 
of concern related to the treatment of post-traumatic stress 
and other issues related to the care of our servicemembers and 
veterans. The disability evaluation and compensation system, in 
its current state, is clearly too complex and burdensome for 
even the most tolerant of our servicemembers and veterans.
    The time associated with working through the system has 
been identified as a significant additional stressor to our 
servicemembers and their families that we want to fix. And in 
contrast to the stop-gap efforts, which have been employed in 
the past, I believe that the disability evaluation and 
compensation system requires revolutionary, systemic overhaul.
    DoD is working closely with our representatives from the 
Veterans Affairs counterparts to begin this process. Both 
Secretary Gates and Admiral Mullen have identified this issue 
as an important focus area for DoD and VA.
    I identified this issue to the Committee and its Members to 
let you know we are keenly aware of the problem, and at some 
time in the future DoD and VA may ask for assistance from the 
Legislative Branch to help streamline and correct deficiencies 
that may require adjustments to current law.
    DoD will continue to keep your Committee and the Congress 
at whole apprised of the situation as we work through the 
nuances to help fix the disability evaluation system.
    Now, I would like to reemphasize the point to you: Congress 
and the DoD have committed hundreds of millions of dollars to 
improve our understanding of combat and operational stress, 
psychological health, the resilience of our personnel, as well 
as to diagnose and treat post-traumatic stress and related 
conditions, including mild traumatic brain injury.
    We continue to face many challenges and are working closely 
with the Veterans Affairs, the National Institute of Mental 
Health, and academic centers across the country to better 
improve our services for veterans and their families. We will 
continue to focus on post-traumatic stress until we feel every 
servicemember is optimally prepared to cope with combat stress 
and, when needed, is receiving the treatment he or she has 
earned through their service.
    Mr. Chairman, thank you again for the invitation to appear 
here this afternoon, and I am pleased to respond to any 
questions you or the Subcommittee Members may have.
    [The prepared statement of Admiral Smith appears on p. 53.]
    Mr. Hall. Thank you, Admiral. I am pleased to hear you 
talk, as does Secretary Shinseki, about his ongoing and 
evolving work with Secretary Gates and the two Departments 
working together, because there is so much of this that is a 
continuum that starts with entry into active duty and continues 
on into one's later years as a veteran. Many of these problems 
can best be solved if the two Departments work together.
    And when you talk about, I think you said, revolutionary 
and systematic overhaul of the disability evaluation system, 
you may be aware that last year we passed a bill that was 
passed by the Senate also and signed into law to do just that. 
So it will take a while to do it, but we have started the ball 
rolling and hopefully that revolutionary and systematic 
overhaul will happen. Colonel Ireland, you now have the floor 
for 5 minutes.

              STATEMENT OF COLONEL ROBERT IRELAND

    Colonel Ireland. Chairman Hall, Ranking Member Lamborn, and 
distinguished Members of the Subcommittee, thank you for this 
opportunity to discuss the Department of Defense approach to 
diagnosing PTSD and defining related stressors and the use of 
the servicemember's record.
    In many ways, due to the complexities we have heard earlier 
today, it may seem quite simple on the DoD clinical side. When 
servicemembers' medical conditions do require further medical 
evaluation in order to assess whether they are retainable in 
their service to perform their duties, military treatment 
facility clinicians perform an evaluation, write a summary and 
submit it for review by a medical evaluation board, or MEB.
    This consists simply of two or three clinicians in the 
treatment--medical treatment facility. And when it is a mental 
health issue it should include--must include--a psychiatrist. 
So if there is an MEB review of the psychiatric condition, 
there should be a sign-off by a psychiatrist on that report.
    The report is to confirm the diagnosis and document 
thoroughly the medical condition of the member and to review 
each case based on relevant facts. The local MEB simply 
determines whether the servicemember meets the retention 
standards and can be returned to duty, or whether the member 
fails to meet those standards and would require either a waiver 
to continue in service or has to go to a Physical Evaluation 
Board (PEB) for further consideration to look at whether they 
should be retained with that waiver, separated with or without 
severance pay, or retired.
    All of these fall outside of the clinical processes at the 
local level and are a service matter with the Personnel 
Physical Evaluation Board system.
    With respect to PTSD, military providers do use the same 
criteria as their civilian counterparts to diagnose PTSD, using 
the American Psychiatric Association's (APA's) DSM-IV criteria. 
And I will skip going through those criteria to avoid 
duplication and save some time.
    With regard to comments on stressors, there is a long 
history of how that word is used and the development of theory 
related to it. But to simply to refer to well, that was an 
appropriate stressor, is probably an oversimplification in 
assessing what someone has experienced, what they have 
witnessed. And then we also need to consider how that caused a 
physiologic reaction within them and an emotional reaction--and 
then for human beings, usually there is some form of self-
assessment of that experience or that event and one's own 
perception of one's own reaction to it, and one's sense of 
whether they can meet the demand. And when they can't, that is 
usually when they show up to mental health. So a stressor is a 
complex thing to speak about, and simply checking off the 
stressors of what would cause PTSD may be an 
oversimplification.
    To conclude, the importance of such records of these 
evaluations and PEB recommendations and conclusions to 
transitioning servicemembers cannot be overemphasized. We do 
encourage servicemembers to request copies of their medical and 
mental health records upon separation from the military to 
assure continuity of care, irrespective of where they receive 
their care in the future.
    Those utilizing the VA have the added advantage of VA 
provider visibility of their medical and their mental health 
records through the use of the Bidirectional Health Information 
Exchange, which is functional and is receiving military medical 
records.
    Thank you, again, for allowing the opportunity to appear 
before you and to discuss these issues.
    [The prepared statement of Colonel Ireland appears on p. 
53.]
    Mr. Hall. Thank you, Colonel.
    Mr. Mayes, welcome back. It is always good to see you. You 
are now recognized for 5 minutes.

                 STATEMENT OF BRADLEY G. MAYES

    Mr. Mayes. Thank you.
    Mr. Chairman, Ranking Member Lamborn, I would like to thank 
you for the opportunity to testify on this important topic of 
post-traumatic stress disorder. Mr. Dick Hipolit, from the 
Department of Veterans Affairs, Office of General Counsel, 
accompanies me today.
    The number of veterans receiving service-connected 
compensation for PTSD from VA has grown dramatically. From 
fiscal year 1999 through fiscal year 2008, the number increased 
from 120,000 to more than 345,000.
    We all share the goals of preventing this disability, 
minimizing its impact on our veterans, and providing those who 
suffer from it with just compensation for their service to our 
country. Consequently, VA has expanded its efforts to assist 
veterans with the claims process and keep pace with the 
increased number of claims.
    Today, I will briefly describe the PTSD claims process and 
explain how VA applies the statutory requirements of 38 U.S.C., 
section 1154, to the processing of these claims. Section 1154, 
which, as we heard earlier, was enacted by Congress in 1941, 
requires that VA consider the time, place and circumstances of 
a veteran's service in deciding a claim for service connection.
    Section 1154(b) provides for reliance on certain evidence 
as a basis for service connection of disabilities that result 
from a veteran's engagement in combat with the enemy. As a 
result, veterans who engaged in combat with the enemy and filed 
claims for service-connected disability related to that combat 
are not subject to the same evidentiary requirements as 
noncombat veterans. Their lay statements alone may provide the 
basis for a service-connected disability without additional 
factual or credible supporting evidence.
    In PTSD claims, a combat veteran's personal stressor 
statement can serve to establish the occurrence of the 
stressor.
    The processing of PTSD claims is governed by our 
regulations at 3.304(f). Specifically this regulation states 
that in order for service connection for PTSD to be granted, 
there must be, first of all, medical evidence diagnosing the 
condition.
    Second of all, medical evidence establishing a link between 
current symptoms and an in-service stressor.
    And then, third, credible supporting evidence that the 
claimed in-service stressor occurred.
    As I said, the first two requirements involve medical 
assessments, while the third requirement may be satisfied by 
nonmedical evidence.
    PTSD is defined as a mental disorder that results from a 
stressor. That third requirement of the regulation emphasizes 
the importance of the stressor and the obligation of the 
Department of Veterans Affairs to seek credible evidence 
supporting the occurrence of that stressor.
    In PTSD claims where the stressor is not combat related, 
VBA personnel conduct research and develop for credible 
evidence to support the claimed stressor.
    However, we have incorporated into our regulations the 
1154(b) provisions, so that when there is evidence of combat 
participation and the stressors related to that combat, no 
stressor corroboration is required. The veteran's lay statement 
alone, as stated, is sufficient to establish the occurrence of 
the stressor.
    Through the years, VA has made changes to our regulations 
at 3.304(f) based on the requirement at section 1154 of the 
statute that mandates us to consider the time, place and 
circumstance of a veteran's service. The definition and 
diagnostic criteria for PTSD evolved to a great extent from the 
psychiatric community's attempt during the seventies to explain 
the psychological problems of some Vietnam War veterans. Once 
the medical community recognized this mental disorder, VA added 
it as a disability to the schedule. VA then moved to 
incorporate PTSD diagnostic criteria from the APA's DSM-IV into 
the PTSD claim evaluation process.
    Given the delay that may occur between the occurrence of 
that stressor and the onset of PTSD, and the subjective nature 
of a person's response to an event, VA concluded when it first 
promulgated the regs in 1993, that it was reasonable to require 
corroboration of the in-service stressor.
    However, as the military incorporated more female members 
into its ranks, VA recognized that PTSD could result from 
personal assault and sexual trauma.
    To meet this evolving situation, VA added a section at 
3.304(f), which provides for acceptance of evidence for 
stressor corroboration in such cases from multiple sources 
other than the veteran's service records. The evidence may 
include local law enforcement records, hospital or rape crisis 
center records, or testimony from family, friends or clergy 
members.
    Although the combat participation provisions of section 
1154 have been in effect for many years, the VA has recently 
provided a regulatory change that further extends the intent of 
that statute and recognizes the changing conditions of modern 
warfare.
    A new section, 3.304(f)(1), now provides for service 
connection of PTSD when there is an in-service diagnosis of the 
disability. In such cases, the veteran's lay stressor statement 
and the medical examiner's association of PTSD with a stressor 
is sufficient to establish service connection where PTSD is 
diagnosed.
    This liberalization of regulatory requirements is due to 
the recognition by VA of the heightened awareness of PTSD among 
military medical personnel, resulting in the increasing numbers 
and reliability of PTSD diagnoses for personnel that are still 
on active duty.
    These descriptions of PTSD-related initiatives make it 
clear that VA is committed to following the mandate of the 
provisions of section 1154, and adjusting the PTSD claims 
process as necessary to serve our veterans.
    This concludes my testimony, and I would be happy to answer 
any questions that the Members may have.
    [The prepared statement of Mr. Mayes appears on p. 54.]
    Mr. Hall. Thank you, Mr. Mayes.
    Dr. Zeiss.

              STATEMENT OF ANTONETTE ZEISS, PH.D.

    Dr. Zeiss. Good afternoon, Chairman Hall and Members of the 
Subcommittee.
    Thank you for the opportunity to discuss the diagnosis of 
PTSD by Veterans Health Administration health clinicians, 
particularly in the context of a compensation and pension 
claim.
    The Department of Veterans Affairs is recognized for its 
outstanding PTSD treatment and research programs, the quality 
of VA health care in this area is outstanding, and we improve 
as we learn more. All VA clinicians, including those 
responsible for completing compensation and pension 
evaluations, adhere to the Diagnostic and Statistical Manual of 
Mental Disorders, 4th edition, Text Revision, DSM-IV-TR of the 
American Psychiatric Association.
    According to these clinical criteria, PTSD can follow 
exposure to a severely traumatic stressor that involves 
personal experience of an event involving actual or threatened 
death or serious injury. It also can be triggered by witnessing 
an event that involves death, injury or a threat to the 
physical integrity of another. This would meet criterion A in 
the DSM-IV criteria for PTSD.
    The person's response to the event, also to meet criterion 
A, must involve intense fear, helplessness or horror. If 
criterion A is met, then symptoms characteristic of PTSD to 
fully establish the diagnosis would be explored, including 
persistent reexperiencing of the traumatic event, persistent 
avoidance of stimuli associated with the trauma, along with 
numbing of general responsiveness and persistent symptoms of 
increased arousal.
    No single individual would display all these symptoms, and 
a diagnosis requires a combination of a sufficient number of 
symptoms, while recognizing that individual patterns will vary.
    PTSD also can be experienced in many ways. Symptoms must 
last for more than 1 month to receive the diagnosis, and the 
disturbance must cause clinically different distress or 
impairment in social, occupational or other important areas of 
functioning.
    Military combat certainly creates situations that fit the 
DSM-IV-TR description of a severe stressor event that could 
result in PTSD. The likelihood of developing PTSD is known to 
increase as the proximity to, intensity of, and number of 
exposures to such stressors increase.
    PTSD is associated with increased rates of other mental 
health conditions and can directly or indirectly contribute to 
other medical conditions. Symptoms may be brief or persistent. 
The course of PTSD may ebb and return over time, and PTSD can 
have delayed onset. Clinicians use these criteria in 
discussions with patients to identify cases of PTSD.
    VA seeks to ensure that we offer the right diagnosis in all 
clinical settings, whether for C&P examinations or part of the 
standard mental health assessment. In the C&P context, only 
psychiatrists and psychologists may conduct an initial C&P 
examination in which a diagnosis of PTSD is being considered in 
response to a claim by a veteran.
    In addition, any psychiatrist or psychologist who will 
conduct a PTSD C&P exam must complete specific training on that 
process and receive certification in conducting C&P 
examinations in relation to diagnostic criteria of PTSD.
    We recognize that many individuals with symptoms of combat 
stress or PTSD may find it difficult to discuss the details of 
those experiences. Without the patient disclosing the source of 
the stress, it is impossible for a clinician to diagnose PTSD 
according to the clinical criteria of DSM-IV-TR. This is part 
of why only doctoral-level providers are allowed to conduct 
initial exams and to have the sensitivity and expertise to 
enable a full description of the concerns being presented.
    VHA clinicians who conduct the clinical interview for the 
diagnosis of PTSD in the context of a claim do not ask for 
external corroborating evidence for the described stressful 
event. That would be really determined by the clinician's 
experience of the description of the veteran of their stressful 
experience, and how that led to the symptoms that they also 
would describe.
    Apart from issues of determining diagnosis in the C&P 
context, identifying and treating patients with PTSD and other 
mental health conditions is, of course, of paramount concern 
for Veterans Health Administration, and we provide mental 
health care in many different environments, including Vet 
Centers.
    And I might add that while the RAND study showed about 14 
percent returning with possible PTSD, in VA we are serving over 
20 percent of those veterans who have returned and sought care 
from VA, and have been diagnosed with possible PTSD. So we are 
very much trying to identify cases and ensure delivery of care 
as well as, in the appropriate context, support for claims.
    So I have submitted my written statement, and just convey 
that any veteran with a mental health condition we hope will 
seek care from VA, will receive treatment and counseling for 
mental health conditions, and we are ready to help.
    Thank you for the opportunity to speak, and I am prepared 
to answer questions.
    [The prepared statement of Dr. Zeiss appears on p. 56.]
    Mr. Hall. Thank you, Dr. Zeiss.
    Dr. Murdoch, you are now recognized for 5 minutes.

            STATEMENT OF MAUREEN MURDOCH. M.D., MPH

    Dr. Murdoch. Thank you. Mr. Chair and Members of the 
Subcommittee, thank you for the opportunity to appear before 
you today to present findings from my team's research on post-
traumatic stress disorder disability awards.
    I must note that the views presented here are mine and 
don't necessarily represent the view of the Department of 
Veterans Affairs; and they reflect the results of my studies, 
not necessarily other studies that have been done. And I must 
emphasize that this research was done more than 10 years ago 
and may not reflect experiences of new cohorts of veterans.
    So I am sure you know that PTSD is the most common 
psychiatric condition for which veterans seek VA disability 
benefits. Between 1998 and 2000, my colleagues and I conducted 
three studies looking at differences in PTSD disability awards.
    The first study was a historical administrative database 
evaluation of all 180,039 veterans who applied for disability 
benefits between 1980 and 1998. The second was a mailed survey 
of about 5,000 veterans who applied for disability benefits 
between 1994 and 1998. And then, finally, we did a claims audit 
of about 345 veterans who also responded to the survey.
    These studies had several objectives, but the most relevant 
to today's proceedings included identifying the role of combat 
experience on receiving disability benefits for PTSD and 
understanding how claiming combat versus military sexual trauma 
influenced gender differences in receiving PTSD service 
connection.
    From the historical database study, we learned that rates 
of service connection increased over time between 1980 and 
1998. And across all time periods, men and women who were 
documented as being combat-injured in the database had a rate 
of service connection of greater than 90 percent.
    By 1998, the observed rate of service connection for men 
without combat injuries was 64 percent, and the rate for women 
without combat injuries was 57 percent. From the survey's study 
which, again, covered the time period between 1994 and 1998, we 
again saw that more than 90 percent of men and women who had 
documented combat injury in the database received service 
connection for PTSD.
    Of those who did not, who were not identified as being 
combat injured, 52 percent of women and 64 percent of men 
received PTSD service connection. However, this gender 
difference was almost completely explained by the men and 
women's different rate of combat experience. Regardless of 
gender, veterans with more combat experiences were more likely 
to receive service connection than veterans with fewer or no 
combat experiences.
    Since men were more likely to report combat experiences, 
they were also more likely to be service connected for PTSD. I 
would also like to point out that in this study, 30 percent of 
the women reported some kind of combat experience.
    In our claims audit of 345 veterans who participated in the 
mailed survey, we found that 85 percent of men received a 
diagnosis of PTSD from a qualified clinician, compared to 76 
percent of women.
    Veterans who were selected for chart audits did not get 
service connection for PTSD unless his or her examining 
clinician made a diagnosis of PTSD. About a third of veterans 
with PTSD diagnosis did not receive service connection.
    Veterans diagnosed with PTSD at the time of their clinical 
examination reported an average of two more combat experiences 
at the time of survey, compared to men who were not diagnosed 
with PTSD.
    Women who were diagnosed with PTSD were as likely to report 
a military sexual assault on the survey as were those not 
diagnosed. So, put another way, reporting more combat 
experiences was associated with greater odds of PTSD diagnosis, 
but reporting sexual assault was not.
    The factor most strongly associated with veterans receiving 
a diagnosis of PTSD was having a stressor documented in their 
claims file.
    Mr. Chairman, Subcommittee Members, this concludes my 
statement, and I am pleased to respond to any questions you may 
have. Thank you.
    [The prepared statement of Dr. Murdoch appears on p. 58.]
    Mr. Hall. Thank you, Doctor.
    I will begin my questioning with Admiral Smith. In its 
testimony in an earlier panel, the IAVA referred to ``combat 
support'' and ``combat service support.'' Can you describe 
these terms and how they function in a combat zone or combat 
theater of operations?
    Admiral Smith. I am not sure that I am the expert that can 
answer that but--and I said in my testimony--the doctrine that 
we set up is primarily based on needs of what we need within 
the military.
    For example, in doctrine we don't have a definition for 
``combat,'' because it is clear from Webster's Dictionary what 
that is. There is a DoD Instruction that talks about benefits, 
that actually does define, based on CFR, various aspects of 
combat, and that is DoD-I 1332.38 that I have with me.
    Mr. Hall. Okay, and this question would be to you and 
Colonel Ireland both. Given the circumstances in Iraq and 
Afghanistan, would you say that it is distinguishable in terms 
of who is engaged in combat with the enemy and who is not?
    Let me elaborate? As one Member of Congress who went and 
slept in the Green Zone for one night and was told, if you hear 
a siren in the middle of the night, jump out of bed and run 
over to that bunker because last week we lost two soldiers to 
incoming mortar rounds; now if that was my one-night experience 
in the Green Zone, the safest place in the country, then 
presumably supply sergeants, nurses, cooks, servicemembers who 
are there on a break from being out in the countryside working 
at their regular duties, are all subject to a nightly 
possibility of incoming rounds impacting close to them and 
injuring or killing members of our forces.
    Obviously, there are different degrees of combat. You can't 
compare that to being attacked or ambushed on the road and hit 
with an IED and so on or so forth. But nonetheless, it is the 
kind of thing that repeated experience might cause--in some 
people--might cause symptoms.
    Admiral Smith. Yes, sir. As far as combat, clearly that is 
where the history becomes so important; because as you aptly 
pointed out, it varies dramatically by the location you are in, 
the particular jobs that you are assigned and what your 
experiences are there.
    Over the course of the last 10 years, a number of combat 
badges have actually been developed and the definitions of 
those are defined by each one of the services. And then it is 
dependent on the particular commander of the units as to who 
gets allocated that designation.
    Mr. Hall. Colonel Ireland, do you care to add to that?
    Colonel Ireland. From the clinical perspective, it doesn't 
matter much whether we were involved in offensive or defensive 
or no operations whatsoever at the time of attack. So that is 
not part of my expertise to comment, sir.
    Mr. Hall. Does the Post-Deployment Health Reassessment 
(PDHRA) program screen for PTSD, Colonel Ireland, and what 
happens with those PDHRA results?
    Colonel Ireland. The results of the assessment are made 
available to the VA, and then clinicians can pull them up off 
their screen and look at them when they see a patient.
    From our standpoint, the servicemember is evaluated by a 
designated health care member to review their physical and 
mental health concerns on the health assessment, and discuss 
with them the nature of them--to determine how badly they are 
bothered by them--to make a brief functional assessment, but 
not a formal one, and make a determination as to whether 
further evaluation or treatment may be necessary, and then 
discuss with the member various options they may have, both 
clinical and preclinical, and help them influence the 
direction, dependent on the number of endorsements, the 
severity of what they are perceiving and the member's 
willingness to engage in care.
    So the member may go to a chaplain but not necessarily go--
but refuses to go to a clinic for evaluation, we start there 
with preclinical care.
    If they don't want to see anyone, we might refer them to 
http://afterdeployment.org--our Web site, so we will try to 
work with a member based on the severity of their condition and 
what they are willing to do.
    Mr. Hall. Can you tell us more about the DoD BATTLEMIND 
program and how it identifies potentially traumatic events. And 
is BATTLEMIND mandatory for all servicemembers before and after 
deployments?
    Colonel Ireland. BATTLEMIND is a unique Army program, sir, 
and it is using mostly Army contexts to display its messages. 
Those types of messages are included in other types of 
programs.
    For example, the Air Force is utilizing LANDING GEAR, a 
similar-type program, but using more of the experiences 
familiar to Air Force members. It is my understanding, though, 
that other services are using BATTLEMIND for certain situations 
and are certainly free to do so. As in suicide prevention, we 
encourage the sharing and stealing of good ideas wherever they 
are found.
    Mr. Hall. Thank you.
    Mr. Mayes, as you have acknowledged, the language in 
section 1154 that was enacted by Congress in 1941--and VA, of 
course, has to base its rulemaking on it--if Congress broadened 
the definition, would VA change its requirements?
    Mr. Mayes. Well, certainly, if Congress passed legislation 
that changed the language, for example, that is in section 1154 
right now, then we would engage in rulemaking to comport with 
the law.
    Mr. Hall. Thank you. I am going to turn it over to Ranking 
Member Lamborn.
    Mr. Lamborn. I thank the Chairman.
    Admiral Smith, what type of recourse does a non-combat 
veteran have if the traumatic event he or she experienced is 
not expressly written down in their service record?
    Admiral Smith. I am not sure that I can answer from a DoD 
perspective. Within the DoD, it would be reliant on their 
history and in trying to document it by talking to members of 
their unit, et cetera. But we primarily are relying on the 
medical information that we received during the encounter.
    I think I am going to have to defer to the VA relative to 
how one would document that or how they would deal with that 
from a benefits point of view.
    Mr. Lamborn. Okay, let's turn that over--if someone wants 
to address that.
    Mr. Mayes. Ranking Member, could you repeat the question? I 
am sorry; you caught me there.
    Mr. Lamborn. What type of recourse would a noncombat 
veteran have if the traumatic event they experienced is not 
expressly written down in their service record?
    Mr. Mayes. Well, as I said in my testimony, we will go 
ahead and develop for that stressor, that would then 
substantiate or could be used to support a diagnosis of post-
traumatic stress disorder. So we are required by statute, as 
stipulated in section 5107, to go out and secure any evidence 
that the veteran might have available or presented to us or 
indicated that they have in their possession.
    We would go out and look at service records. Potentially we 
would ask for buddy statements. And so we would begin to 
assemble a picture that would begin to try and corroborate the 
stressor that is asserted by the claimant. And with that 
evidence that we had collected--if it was sufficient, if there 
was sufficient corroboration and there was an indication that 
the veteran was suffering from symptoms related to PTSD--then 
we would send that documentation along with a request to our 
colleagues in VHA for a C&P exam so that they could then 
provide the other two elements--and that is the diagnosis and 
the medical link between that diagnosis and the stressor that 
is asserted by the claimant.
    Mr. Lamborn. Okay. Thank you.
    Admiral Smith, back to you. How would a servicemember's 
record reflect their temporary assignments while in theater? 
For example, would a record show that a helicopter mechanic was 
temporarily assigned to a convoy, and would their records show 
that they saw potentially traumatic events while part of the 
convoy?
    Admiral Smith. I think I am going to have to take that for 
record, sir. Sorry.
    Mr. Lamborn. Okay. Well, we could maybe get a written 
response at another time.
    Admiral Smith. Sure.
    [The DoD subsequently provided the following information:]

          Currently there is no uniform recording of the exposure to 
        traumatic events within a service member's records when they 
        are assigned to temporary duties described by Congressman 
        Lamborn such as convoy duty or patrol.
          This is a problem identified recently by a task force formed 
        by the Chief of the Army National Guard Bureau as well as by a 
        team of investigators sent by the Chairman of the Joint Chiefs 
        of Staff to Iraq and Afghanistan in February. Currently, these 
        combat events are recorded in CIDNE (Combined Information Data 
        Network Exchange) and SIGACT (Significant Activity) Reports. 
        CIDNE and SIGACT reporting are used for battlefield 
        intelligence. There are no direct linkages, however, of 
        personnel data to these reports. In some cases, these exposures 
        to traumatic events are recorded in the service member's 
        medical record if they report for medical evaluation or 
        treatment. In other cases, the service member may report the 
        exposure in their Post Deployment Health Assessment or Post 
        Deployment Re-assessment (PDHA and PDHRA) long after the event. 
        The Office of the Surgeon General of the Army is working in 
        conjunction with the Chief of the National Guard Bureau in the 
        development of a joint application for associating service 
        member identification numbers with CIDNE and SIGACT reporting. 
        The Chairman of the Joint Chiefs of Staff has formally listed 
        this tracking program as one of his top wounded warrior 
        priorities.

    Mr. Lamborn. Mr. Mayes, can the definition of combat under 
section 1154 be improved on, short of making everyone in the 
combat theater fall under the definition?
    Mr. Mayes. My sense is--let me back up and say, first of 
all, any veteran can be service-connected for PTSD. They don't 
have to be a combat veteran. So let's start from that premise.
    I believe, and we have looked to the legislative history on 
section 1154, regarding section 1154, that the intent of 
Congress was to reduce the evidentiary burden on those veterans 
who engaged in combat with the enemy. And they were very 
specific. Congress was very specific in selecting that language 
when you look at the bills that were being contemplated at the 
time.
    If the intent is to address the evidentiary burden to prove 
the stressor for a noncombat veteran, I believe you can get at 
that by looking at section 1154, but you can also get there 
possibly by looking at the regulations that we have codified at 
3.304(f), 38 CFR, 3.304(f).
    And we have done that over the years. That is what I was 
saying. We have reduced the evidentiary burden for female 
veterans suffering from post-traumatic stress disorder due to 
personal assault.
    We have reduced the evidentiary burden for American ex-
POWs. We have reduced the evidentiary burden for veterans 
diagnosed with post-traumatic stress disorder when they are 
diagnosed while still on active duty.
    And we would certainly be willing to work with the 
Committee to explore avenues for achieving what I think it is 
that is being attempted here, as I understand it. However, it 
is not a legislative hearing. We didn't come over to talk about 
the proposed bill, but I extend my offer to work with the 
Committee.
    Mr. Lamborn. May I have one followup question, Mr. 
Chairman?
    Mr. Hall. Yes.
    Mr. Lamborn. My time has expired, but as a followup to this 
important line of reasoning that we are all discussing here, 
you maybe were able to hear the example earlier from the 
American Legion representative about two people in the same 
convoy but they had differing burdens of proof afterward.
    Do you have any reflections on that particular scenario 
based on what you just said?
    Mr. Mayes. Well, I do, Mr. Lamborn. As a matter of fact, I 
made a note of it. Mr. De Planque, I thought, did an 
outstanding job of laying out the issue.
    And the truth is that if we could place the servicemember--
or the veteran who was not in the combat MOS--if we could place 
them in that area at the time that those events were occurring, 
then our procedures, where we are today, would allow us to 
grant service connection in that case as long as the evidence 
that corroborated the stressor was used by the clinician as the 
stressor that supported the diagnosis of post-traumatic stress.
    So that was my point. There is a way to reach the noncombat 
veteran right now in our existing procedures, and I would say 
that on its face, we have seen a dramatic increase in the 
number of veterans that are on the rolls for PTSD. It is a 188 
percent increase in the last 10 years, as opposed to a 10-
percent increase on the rolls for all disabilities.
    So the things that we have done along the line to reduce 
that evidentiary burden, I believe, are part of the reason, not 
all of the reason, but part of the reason that we are seeing 
that dramatic increase in veterans receiving compensation for 
PTSD.
    Mr. Lamborn. Okay. Thank you all for your answers and for 
being here today.
    Mr. Hall. Thank you, Mr. Lamborn.
    I would like to follow up, if I may, by noting, Mr. Mayes, 
that you testified there are 345,520 veterans who are service-
connected for PTSD. Dr. Zeiss testified that she is treating 
442,862 veterans, which is an almost 100,000 different number. 
What do you attribute that difference to? Or I could ask Dr. 
Zeiss the same thing.
    Mr. Mayes. Well, I can't definitively say why every 
veteran--I mean, there is no way for me to know why a veteran 
might be treated for PTSD, yet not file a claim for post-
traumatic stress disorder. I mean, I can only offer you 
conjecture.
    But, certainly, it is possible that some veterans are 
seeking counseling and treatment to get healthy, and aren't 
interested in proceeding to VBA to file a claim for disability 
compensation.
    Mr. Hall. Dr. Zeiss?
    Dr. Zeiss. I would say the same, and say that we are very 
grateful to Congress that you have offered the 5-year window 
where all veterans returning from the current conflicts can 
come to VA and have eligibility to receive care. So it is not 
necessary to establish a service-connected diagnosis of PTSD 
for these returning veterans in order to be diagnosed and 
receive care on the VHA side of the house.
    Clearly there are many veterans who are receiving care with 
the diagnosis of PTSD. And what their individual reasons for 
perhaps not submitting a claim, or what the data is about how 
many of them have submitted a claim that has not been accepted, 
we don't have that data on the VHA side of the house.
    Mr. Hall. Or maybe the treatment is so successful that they 
don't feel that they are in need of assistance.
    In your testimony, Dr. Zeiss, you noted that safety and 
trust are important issues when discussing these traumatic 
events. Patients need to be comfortable, examiners need to be 
sensitive.
    The IOM recommends exams take at least 90 minutes and 
perhaps up to 3 hours, but noted that VA exams frequently can 
take as little as 20 minutes. How can you achieve safety, trust 
and comfort in that short a time to elicit a complete military 
history and develop an understanding of the patient stressors?
    Dr. Zeiss. Our guidelines and part of the training for 
those who are going to conduct C&P exams would support what has 
been said by IOM. And the recommendation is that the exams 
should take at least 2 hours, I believe, was the final 
decision.
    It is certainly the case that for some repeat exams, where 
the only question is what the current level of disability is, 
and there is not a diagnosis being established, a much shorter 
interview might be very appropriate.
    But for a diagnostic exam, we have been at pains to stress 
and to try to set up a system in which full interviews would be 
done in a timeframe that supports the recommendation of IOM and 
our own VHA recommendations, and we continue to follow up to 
try to ensure that that is the standard.
    Mr. Hall. How good are you, do you think, at detecting 
veterans who might claim to have PTSD who don't actually have 
it?
    Dr. Zeiss. Well, I thought that Dr. Kilpatrick covered that 
beautifully, and so I will simply echo some of the things that 
he said. Everyone would love it if we had a simple test that 
could establish malingering or a simple blood test that 
established PTSD, and many of these issues would be moot. We 
don't. This is a much more complex and experiential kind of 
decision and clinical process.
    And so clinicians need to be sensitive, as Dr. Kilpatrick 
said. We should start with the assumption that people are 
telling us the truth. But if there are red flags in what they 
are saying, if there are different stories at different points, 
or contradictory things being said, the clinician may want to 
slow down and take additional time.
    We actually have in the established practices for doing a 
C&P exam for PTSD, and in the training, the idea that if there 
is such a concern, the clinician has the option of setting up a 
second interview or an opportunity for psychological testing. 
No psychological testing, as Dr. Kilpatrick said, could give a 
definitive answer, but it might inform whether or not there is 
some malingering.
    It also might inform whether the appropriate diagnosis is 
not PTSD but some other mental health problem.
    So we have tried to build into the process clinically 
sensitive ways to ensure that the clinician is really attending 
to all the information they are getting and making staged 
decisions about how much additional evaluation should occur 
prior to making the diagnosis.
    Mr. Hall. And you are using the Best Practices Manual for 
PTSD and C&P exams?
    Dr. Zeiss. That is part of the training evaluation, and 
there is also a study going on looking at the CAPS process, the 
Best Practices Manual, to see whether or not in fact it does 
lead to superior quality of diagnosis.
    Mr. Hall. Are worksheets for the PTSD C&P exams mandated?
    Dr. Zeiss. Yes. We have developed those in collaboration 
with the VBA. All clinicians who are doing the C&P interview 
would complete that information to provide to VBA. And if they 
don't, it comes back from VBA, and they will not make a 
decision until they have that complete information.
    Mr. Hall. A couple more quick ones. When the Compensation 
Pension Examine Program (CPEP) has reviewed VHA records for 
PTSD, how accurate have those records have been?
    Dr. Zeiss. I am sorry, I couldn't hear.
    Mr. Hall. When the CPEP has reviewed VHA records for PTSD, 
how accurate have those exams been?
    Dr. Zeiss. I would defer the answer to that to Mr. Mayes. 
CPEP is a part of VBA, and that data would be evaluated 
internally within the VBA side.
    Mr. Mayes. I don't have that data with me today, but we can 
certainly take that back and provide it for the record. Just so 
I am clear, you are looking for the accuracy of only PTSD 
exams; is that correct, Mr. Chairman?
    Mr. Hall. Yes, please.
    Mr. Mayes. Okay.
    [The VA provided the information in response to Question #5 
of the post-hearing questions and responses for the record, 
which appears on p. 91.]
    Mr. Hall. I understand that primary care providers have 
been instructed to screen Iraq and Afghanistan veterans for 
traumatic brain injury and PTSD. I guess this could go to Mr. 
Mayes and Dr. Zeiss.
    Why not screen all combat veterans for both?
    Dr. Zeiss. We are mandated to screen all veterans, not just 
the currently returning veterans. And in addition, there is 
mandatory screening for depression, military sexual trauma and 
problem drinking.
    Mr. Hall. Let me just close by posing a--we heard a couple 
of hypotheticals before when one of the earlier panels was 
here.
    This is an actual case that we are aware of that a veterans 
service organization (VSO) representative is working on for a 
Vietnam veteran who was trained as a cook and--deployed to a 
forward base in Vietnam.
    When he arrived there, according to the veteran, the 
commander looked at his papers and said, ``I don't know what 
you were sent here for. We don't have a mess hall. Here is a 
rifle, you are doing perimeter duty.''
    And so he spent his tour in Vietnam doing perimeter guard 
duty, taking incoming fire at night, and finished his tour and 
came back to the United States and was discharged and has, I 
understand, the classic symptoms of PTSD. Let's assume for the 
sake of argument that is true. Now, obviously, none of you have 
seen him. This is not a case where we have examined the person 
in question. But the VSO rep who is working with him is himself 
a veteran, obviously, a Vietnam veteran. Because of the fact, 
so far, that this veteran's record says he was a cook, he is so 
far being denied PTSD classification, which would accord him a 
disability compensation.
    Does a change such as that, which we are considering to 
provide a presumed stressor, once there is a diagnosis--you 
have to have the diagnosis from a doctoral-level person--but 
once you have that service in uniform in a combat zone, would 
provide this stressor to allow disability assistance?
    Does that sound like that would solve that kind of problem, 
Admiral, starting with you? Or would it be necessary? Is it 
necessary to solve that problem?
    Admiral Smith. Well, from the testimony that I have heard 
and looking over what the CFR actually says, it would appear 
that it could be documented that he was not doing mess work. If 
there is no documentation for that, that is where the conundrum 
comes in.
    Mr. Hall. Colonel?
    Colonel Ireland. It sounds like what you are proposing may 
apply and be helpful to that person.
    Mr. Hall. Mr. Mayes?
    Mr. Mayes. Two comments. The first comment is, I believe, 
that if we could gather sufficient corroborating evidence that 
we could service-connect that veteran--for example, evidence 
that he participated in hostile activities, the types of 
activities that would support a diagnosis of PTSD. And then we 
would need, as I said, the diagnosis and the medical evidence 
establishing the link between that stressor and that diagnosis. 
That is my first comment.
    So I think we are reaching veterans with similar fact 
patterns.
    My second comment is if, hypothetically, you relaxed the 
evidentiary burden for that veteran, then their lay testimony 
alone would serve as sufficient evidence for the stressor. It 
would also, if they claimed a low-back condition, their lay 
testimony alone would establish the injury to the lower back or 
any disability, because changing their evidentiary threshold at 
1154 is going to apply across the board, not just to 
neuropsychiatric disabilities.
    Those are the two comments that I would offer.
    Mr. Hall. Dr. Zeiss?
    Dr. Zeiss. I don't think that from the VHA examiner's 
perspective, a change in the law would change our approach, 
because we are not looking at the evidentiary burden.
    Mr. Hall. Right.
    Dr. Zeiss. The person would have the same kind of 
evaluation and that information would be evaluated by VBA.
    Mr. Hall. Dr. Murdoch?
    Dr. Murdoch. I don't think I have anything to add.
    Mr. Hall. Okay. Well, there are many more variations on 
that theme.
    I commend you all for the work that you are doing and your 
service to our veterans.
    And just the fact that the numbers, as Mr. Mayes among 
others have noted, numbers are going up of the veterans who are 
being treated for PTSD is a sign that at the very least the 
outreach is working better, and that hopefully some of the 
stigma is being removed. Veterans are realizing that help is 
available, and that asking for it doesn't place them in some 
kind of dubious category that will make it harder for them as 
they continue. On the contrary, it should make the rest of 
their lives more successful and easier.
    So we are looking at some success already that I think is 
good, and our aim here is to try to make that--to maximize that 
success, if we can, if it is helpful to provide this presumed 
stressor.
    I thank you all for your testimony. If we have any further 
questions, we will send them to you in writing. Admiral Smith, 
Colonel Ireland, Mr. Mayes, Mr. Hipolit--sorry I didn't ask you 
a question directly, I am sure you will get over it.
    Mr. Hipolit. Maybe next time.
    Mr. Hall. Right. We will think of one. Dr. Zeiss and Dr. 
Murdoch, thank you all. This hearing is now adjourned.
    [Whereupon, at 4:08 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

           Prepared Statement of Hon. John J. Hall, Chairman,
       Subcommittee on Disability Assistance and Memorial Affairs

    Good Morning Ladies and Gentleman:
    The task of today's hearing will prove to be both retrospective and 
prospective; for in order to understand title 38 section 1154, we must 
look both backward to the original intent of Congress, and forward to 
defining it in an era of modern warfare tactics and counterinsurgency. 
I ask that the full text of title 38 United States Code section 1154 be 
entered into the record.
    So, what does it mean to have been ``Engaged in Combat with the 
Enemy'' to a sufficient enough degree to prove a stressor that in turn 
warrants service connection for Post-Traumatic Stress Disorder--or 
PTSD--by the Department of Veterans Affairs and what has been the 
intent of Congress?
    Congress' commitment originated with the Military Pension Law of 
1776 and by the end of the Civil War, Congress recognized that ``every 
soldier who was disabled while in service of the Republic, either by 
wounds, broken limbs, accidental injuries, . . . or was broken down in 
the service by the exposure and hardships incident to camp life and 
field duty . . . is entitled to an invalid pension.'' It was believed 
that those exposures and hardships led to a malaise known as 
``Soldier's Heart''--what we now know as PTSD.
    Shortly after the 65th Congress declared war on Germany, it passed 
the War Risk Insurance Act of 1917, which outlined benefits to WWI 
veterans. In 2 years, it was amended 22 times. These amendments 
included the first VA Schedule for Rating Disabilities and established 
wartime versus peacetime rates for pension.
    The 1933 Rating Schedule included instructions to notate the phrase 
``incurred in service in combat with an enemy of the United States'' 
and to list the period of wartime service. This practice indicated that 
the enemy was a foreign government or a hostile force of a nation, and 
not an individual combatant.
    On December 12, 1941, days after the attack on Pearl Harbor, 
Congress expressed its desire to ``overcome the adverse effect of a 
lack of an official record . . .'' and ``the difficulties encountered 
in assembling records of combat veterans.'' Congress further instituted 
``more liberal service pension laws . . . by extending full cooperation 
to the veteran.''
    The 1945 Rating Schedule required that wartime service be noted by 
including the phrase ``disability resulted from injury received in 
actual combat in an expedition or occupation.'' Importantly, this 
prerequisite refined the broader 1933 required statement. Additionally, 
the 1945 schedule described the onset of ``War Psychosis'' as the 
result of an ``incident in battle or enemy action, or following 
bombing, shipwreck, imprisonment, exhaustion, or prolonged operational 
fatigue.'' This diagnosis was removed when the Rating Schedule for 
mental disorders was revised in 1976, 1988, and 1996.
    The current Rating Schedule for PTSD has been described as vague 
and subjective. Furthermore, the adjudication process does not solely 
accept, as the law prescribes, lay evidence as sufficient proof as long 
as it is consistent with the circumstances, conditions, or hardships of 
such service, notwithstanding that there is no official record. This 
law should seem self-evident as to the intent of Congress! So why isn't 
it? The controversy seems to exist because of numerous interpretations 
of Congressional intent. Leading decisionmakers at VA General Counsel 
have issued opinions and Court decisions concluded that if it were the 
intent of Congress to specify a combat zone or a theater of combat 
operations, Congress would have done so as it has in other provisions 
of the law under title 38, but omitted in section 1154.
    My intention today is to re-open this dialog. The nature of wartime 
service has changed as many can agree. Warfare encompasses acts of 
terrorism, insurgency, and guerilla tactics. No place is safe and the 
enemy may not be readily identifiable.
    Psychiatry has changed too. PTSD is a relatively new diagnosis; 
first having appeared in the Diagnostic and Statistical Manual in 
1980--5 years after the end of the Vietnam War. An array of mental 
health research has been conducted and assessment techniques have been 
developed. Since the world is not the same place it was in 1941, I have 
introduced H.R. 952, the Combat PTSD Act to redefine section 1154 to 
include a theater of combat operations during a period of war or in 
combat against a hostile force.
    There should be a better way for VA to assist veterans suffering 
from PTSD adjudicate those claims without it being burdensome, 
stressful and adversarial. Veterans still face issues with stigma, 
gender and racial disparities in rating decisions, poorly conducted 
disability exams, and inadequate military histories. So, I am eager to 
hear from the witnesses today about their experiences with denials, 
inequities, and variances. In the last few years, the IOM 
comprehensively reviewed the research on PTSD diagnosis, assessment, 
and compensation. In 2008, the RAND Report on the Invisible Wounds of 
War gave us a new perspective on the costs of war when soldiers are 
left without treatment or support and I look forward to hearing more of 
its witness' analysis. Finally, DoD and VA will share their insights 
into how they determine combat vs. noncombat and how they have chosen 
to evaluate PTSD disability.

                                 
  Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member,
       Subcommittee on Disability Assistance and Memorial Affairs

    Thank you, Chairman Hall for yielding.
    I am pleased to have the opportunity to discuss the important issue 
before us today.
    I hope that through the collective efforts and knowledge of the 
individuals gathered here this afternoon, we can help ensure that every 
veteran who has service-related PTSD is able to access the benefits to 
which they are entitled.
    Chairman Hall, I would also like to commend you for your compassion 
toward our veterans.
    I know it has been a longstanding issue for you to ensure no one 
falls through the cracks due to unintended consequences of the laws and 
regulations pertaining to compensation for PTSD.
    You've reintroduced in the 111th Congress, a bill to clarify the 
meaning of ``combat with the enemy'' for purposes of service-
connection.
    As you and our witnesses are aware, section 1154(b) of title 38, 
United States Code, already provides special consideration for veterans 
attempting to establish service-connection for PTSD or other medical 
conditions incurred or aggravated in combat.
    In short, this means that the VA must accept a combat veteran's lay 
testimony as sufficient proof of service-connection for any disease or 
injury incurred in combat, even if there is no official record of such 
incident.
    Congress established this broad threshold in recognition of the 
chaotic nature of battle, and the appropriateness of resolving every 
reasonable doubt in favor of the veteran.
    Unfortunately, circumstances could conceivably arise in which an 
individual, who is not a combat veteran under the existing definition, 
is exposed to an overwhelming stressor, but he or she is unable to 
provide evidence of the occurrence.
    This is especially true for veterans of Vietnam and earlier wars.
    This is the problem we are trying to resolve.
    Chairman Hall's proposed solution is his bill, which would 
essentially redefine ``combat with the enemy'' to include service on 
active duty in a theater of combat operations.
    As I've stated previously, I am concerned that too broad of a 
presumptive threshold would damage the integrity of the system.
    I also believe that too loose of a definition of combat would 
diminish the immeasurable sacrifice and service of those who actually 
did engage in battle with the enemy.
    While I understand and appreciate the effort to address problems 
regarding the VA claims backlog, I believe that they generally result 
from procedural issues and we should address those problems 
accordingly.
    In addition to the policy concerns I have stated, I would also 
point out that the mandatory offsets that would be necessary to pass 
this bill under existing PAYGO rules, would be difficult to find.
    Mr. Chairman as you know, it is always a challenge to identify 
offsets within our jurisdiction, and the CBO estimated cost of this 
measure last year exceeded $4 billion.
    I would not be in favor of reducing existing veterans' benefits in 
order to establish an overly broad definition of combat with the enemy.
    Mr. Chairman I extend my thanks to you for holding this hearing and 
I look forward to hearing the testimony of our colleagues and the 
witnesses on our panel today. I yield back.

                                 
      Prepared Statement of Ian C. De Planque Assistant Director,
    Veterans Affairs and Rehabilitation Commission, American Legion

    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to present the American Legion's 
views on ``The Nexus between Engaged in Combat with the Enemy and Post-
Traumatic Stress Disorder (PTSD) in an Era of Changing Warfare 
Tactics.'' The progression of modern warfare through the end of the 
20th century and the beginning of the 21st century has seen fundamental 
changes in how we must view the battlefield. We must give recognition 
to the unique exigencies of the modern battlefield. As we examine the 
modern day state of war fighting, it becomes clear that old models of 
clear cut boundaries have given way to nonlinear battlefields, where 
simply defined lines of battle are no longer present. In recognition of 
this state of asymmetrical warfare, we must look at assumptions of how 
combat operations are defined and recorded by the Nation's military. 
The American Legion commends the Subcommittee for holding a hearing to 
discuss this extremely important and topical issue.
    Combat veterans have a huge advantage when attempting to establish 
service-connection for PTSD or other medical conditions incurred or 
aggravated in combat. Claims for service-connection of a combat-related 
condition receive special treatment under law and regulation 
administered by Department of Veterans Affairs (VA). They receive 
favorable treatment because war is, and has always been, a chaotic 
endeavor. It can be difficult to record every detail of operations in 
the heat of battle. There are so many unrecorded nuances to the 
activity of military forces that Congress has specifically directed 
that the special circumstance of combat merit special circumstances in 
the establishment of incidents during military service in the 
conditions of war. Therefore, if a combat veteran states that he or she 
suffered a disease, injury, or stressor event during combat, VA must 
generally accept that statement as fact. This is true even if there are 
no service records that support the statement.
    Specifically, section 1154(b) of title 38, United States Code 
(USC), provides:

          In the case of any veteran who engaged in combat with the 
        enemy in active service with a military, naval, or air 
        organization of the United States during a period of war, 
        campaign, or expedition, the Secretary shall accept as 
        sufficient proof of service-connection of any disease or injury 
        alleged to have been incurred in or aggravated by such service 
        satisfactory lay or other evidence of service incurrence or 
        aggravation of such injury or disease, if consistent with the 
        circumstances, conditions, or hardships of such service, 
        notwithstanding the fact that there is no official record of 
        such incurrence or aggravation in such service, and, to that 
        end, shall resolve every reasonable doubt in favor of the 
        veteran. Service-connection of such injury or disease may be 
        rebutted by clear and convincing evidence to the contrary. The 
        reasons for granting or denying service-connection in each case 
        shall be recorded in full.

    As a point of clarification, the special provisions in section 
1154(b) lower the burden on the veteran to show that the injury, 
disease or event during service, which the veteran claims led to the 
current medical condition, in fact happened. Section 1154(b) does not, 
however, remove the need to prove the other two requirements for 
service-connection: medical evidence of current disability and medical 
evidence of a relationship between the current medical condition and 
the in-service precipitating injury, disease or event. Medical 
evidence, not lay evidence, is nearly always needed to satisfy those 
two requirements for a grant of service-connection. For example, if a 
combat veteran seeking service-connection for a shoulder disability 
states that ``he landed with great force on the shoulder after being 
knocked to the ground by a shell blast,'' then under section 1154(b), 
his statement is likely to be sufficient proof that the incident 
happened. For service-connection to be granted, however, the veteran 
will also need to present medical evidence of a current shoulder 
disability and medical evidence of an etiological link between the 
current shoulder problem and the combat injury. Section 1154(b) does 
not help the veteran meet those two requirements. It should also be 
noted that the relaxed evidentiary standards in section 1154(b) only 
apply to incidents that are combat-related. They do not apply to 
veterans who did not engage in combat and they do not apply when combat 
veterans are trying to prove the occurrence of noncombat incidents.
    Unfortunately for many veterans, the most difficult burden is 
establishing themselves as a combat veteran in order to benefit from 
the advantages afforded by statute. In order to determine whether VA is 
required to accept a particular veteran's ``satisfactory lay or other 
evidence'' as sufficient proof of service incurrence under section 
1154(b), an initial determination must be made as to whether the 
veteran ``engaged in combat with the enemy.'' The United States Court 
of Appeals for Veterans Claims (CAVC) has held that this determination 
is not governed by the specific evidentiary standards and procedures in 
section 1154(b), which only apply once combat service has been 
established. See Cohen v. Brown, 10 Vet. App. 128, 146 (1997).
    The Veterans Benefits Administration's (VBA) Adjudication 
Procedures Manual M21-1MR PART III, SUBPART 4, CHAPTER 4, section H, 
Par., 29b states that ``Engaging in combat with the enemy means 
personal participation in events constituting an actual fight or 
encounter with a military foe or hostile unit or instrumentality. It 
includes presence during such events either as a combatant, or 
servicemember performing duty in support of combatants, such as 
providing medical care to the wounded'' (emphasis added). In Sizemore 
v. Principi, 18 Vet. App. 264, 272 (2004), the CAVC concluded that a 
determination whether a veteran was in combat must be made on a case-
by-case basis, and the definition of ``engaged in combat with the 
enemy,'' as used in section 1154(b) of title 38, USC, requires that the 
veteran has ``personally participated in events constituting an actual 
fight or encounter with a military foe or hostile unit or 
instrumentality.''
    Unless a veteran was wounded or received a specific combat 
decoration or badge (such as the Combat Infantryman Badge or Combat 
Action Ribbon) or award for valor, it is often very difficult to 
establish that a veteran engaged in combat with the enemy in order to 
trigger the combat presumptions under section 1154(b). Despite the 
various narrow, and in our opinion outdated, interpretations of combat 
as discussed above, we must recognize, however, that the very meaning 
of the term ``engaged in combat with the enemy'' has taken on a whole 
new meaning as the nature of warfare in today's world has changed. This 
is especially true of service in the combat zones of Iraq and 
Afghanistan.
    Due to the fluidity of the modern battlefield and the nature of the 
enemy's tactics, there is no defined frontline or rear (safe) area. It 
is simply a reality of today's warfare that servicemembers in 
traditional non-combat occupations and support roles are subjected to 
enemy attacks such as mortar fire, sniper fire, and improvised 
explosive devices (IED) just as their counterparts in combat arms-
related occupational fields. Unfortunately, such incidents are rarely 
documented making it extremely difficult, if not impossible in some 
instances, for many veterans to verify in order to prove that they 
``engaged in combat with the enemy,'' to the satisfaction of VA, to 
trigger the combat presumptions of section 1154(b).
    Servicemembers, who received a combat-related badge or award for 
valor, trigger the combat-related presumptions of section 1154(b), but 
a clerk riding in a Humvee, who witnessed the carnage of an IED attack 
on a convoy, and later develops PTSD, does not automatically trigger 
such a presumption. Proving that the incident happened or that clerk 
was involved in the incident, in order to benefit from the presumption 
afforded under section 1154(b), can be extremely time consuming and 
difficult. In some instances, it may even be impossible to submit 
official documentation or records of the incident because such records 
do not exist. A good example of this is a soldier stationed in the 
Green Zone in Iraq who falls and injures his or her knee while running 
for cover during a mortar attack and later develops a chronic knee 
condition, but never received treatment after the initial injury. Since 
the soldier didn't think he or she was hurt that bad and never sought 
treatment for the knee, the only proof the soldier has to offer that he 
or she injured his or her knee during an enemy attack on his or her 
base is his or her word. Since the soldier was stationed in a ``safe'' 
area and did not receive a combat decoration or award or participate in 
any combat operations, establishing that he or she ``engaged in combat 
with the enemy'' in order to satisfy the current narrow interpretation 
of the phrase just to trigger the provisions of section 1154(b) will be 
extremely difficult, if not impossible. Adding to this already 
difficult burden is the VA General Counsel decision ruling that ``the 
absence from a veteran's service records of any ordinary indicators of 
combat service may, in appropriate cases, support a reasonable 
inference that the veteran did not engage in combat.'' This means that, 
according to the General Counsel, records supporting such an inference 
may be considered as negative evidence even though they do not 
affirmatively show that the veteran did not engage in combat. See 
VAOPGCPREC 12-99, dated October 18, 1999.
    In addressing the definition of ``engaged in combat with the 
enemy,'' the VA General Counsel noted that the phrase is not defined by 
any applicable statute or regulation. In offering its interpretation, 
the General Counsel examined the legislative history surrounding the 
1941 enactment of the provisions now provided in section 1154(b). The 
General Counsel noted that there had been several bills considered in 
the House of Representatives that contained varying criteria for 
invoking the special evidentiary requirements now contained in section 
1154(b). These bills used phrases such as ``in a combat area'' (H.R. 
4737, 77th Cong., 1st Sess. 1941; H.R.2652, 77th Cong., 1st Sess. 1941) 
and ``within the zone of advance'' (H.R. 1587, 77th Cong., 1st Sess. 
1941; H.R. 9953, 76th Cong., 3d Sess. 1940). Language addressing 
veterans who were subjected to ``arduous conditions of military or 
naval service'' in a war, campaign, or expedition was also used (H.R. 
6450, 76th Cong., 3d Sess. 1940). The General Counsel surmised that, in 
light of these various proposed standards, Congress' choice of the 
language ``engaged in combat with the enemy'' must be ``viewed as 
purposeful.'' The General Counsel concluded that, ``[c]onsistent with 
the ordinary meaning of that phrase, therefore, section 1154(b) 
requires that the veteran have actually participated in combat with the 
enemy and would not apply to veterans who served in a general ``combat 
area'' or ``combat zone'' but did not themselves engage in combat with 
the enemy.'' See VAOPGCPREC 12-99, dated October 18, 1999. It is 
important to point out that even if VA's view of Congress' intent in 
1941 is correct, today's battles, as has been emphasized throughout 
this statement, no longer take place on a linear battlefield. Defined 
lines of battle are no longer present and ``general'' combat areas or 
combat zones no longer exist. Therefore, it is essential that a statute 
based in a forties reality of combat adapt to the realities of combat 
in the 21st century.
    Given the evolving nature of modern warfare, as reflected in the 
enemy's unconventional tactics on today's battlefields, and the 
outdated and overly restrictive interpretations of combat by both the 
courts and VA, it not only makes sense to clarify the definition of 
``engaged in combat with the enemy'' under section 1154(b) in a manner 
consistent with the new realities of modern warfare, it is essential 
that we do so, not just for those serving now, but for those who have 
served in the past and those who will serve in the future. Such a 
clarification would also benefit the VA by negating extensive 
development, and in some cases overdevelopment, of the combat-related 
stressor verification portion of a PTSD claim or the incident in 
service requirement of claims for other combat-related conditions and, 
in doing so, reduce the length of time it takes to adjudicate such 
claims. To this end, Congress must examine the manner in which combat 
is defined for the purposes of the statute. It is not a matter of 
drastically changing the existing law or creating a new benefit, but 
simply clarifying how it must be construed. Under the provisions of 
section 1154(b) soldiers, sailors and airmen are still required to 
detail alleged incidents. The only question that arises is when do the 
provisions of this subsection apply and how is combat to be judged on 
this modern, nonlinear battlefield?
    The American Legion is well aware that these alleged incidents must 
still be consistent with the conditions and actions of a combat 
situation, indeed that combat or combat conditions must be alleged. 
Furthermore, we are aware that simply accepting the occurrence of these 
occurrences in combat is not a magic wand to grant service-connection 
for any condition, as a veteran must still show evidence of a present 
condition and of a medical linkage between the incident and present 
condition.
    Mr. Chairman, the American Legion reinforces the belief that we as 
a Nation must reexamine how we view many aspects of war and war 
fighting. While many things have changed, there are and will always be 
some consistencies. This Nation has a long tradition of extending its 
hand to those who have sacrificed to protect and serve. We have never, 
nor should we ever, veered from the promises to ``. . . care for him 
who shall have borne the battle and for his widow and his orphan . . 
.'' as was ably stated by President Abraham Lincoln.
    It is our hope that the information we have presented on what is at 
issue here will provide some insight into this challenging topic. The 
American Legion stands ready to assist this Subcommittee and VA in the 
examination of the criteria which must be met to trigger the provisions 
of section 1154(b) of title 38, USC. Thank you again for this 
opportunity to provide testimony on behalf of the members of the 
American Legion.

                                 
   Prepared Statement of Thomas J. Berger, Ph.D., Senior Analyst for
   Veterans' Benefits and Mental Health Issues, Vietnam Veterans of 
                                America

    Mr. Chairman, Ranking Member Lamborn, Distinguished Members of the 
House Veterans' Affairs Committee's Subcommittee on Disability 
Assistance & Memorial Affairs, and honored guests, Vietnam Veterans of 
America (VVA) thanks you for the opportunity to present our statement 
for the record surrounding the Department of Veterans Affairs (VA) 
application of the provisions found in Title 38 United States Code 
1154, the definition of ``engaged in combat with the enemy'' and its 
effect on processing claims for veterans suffering from Post-
Traumatic Stress Disorder (PTSD).
    Background: VVA reminds the Chairman and the distinguished Members 
of this Subcommittee that the Veterans Claims Assistance Act (VCAA) 
became effective in November 2000. Designed to codify VA's longstanding 
practice of assisting veterans (at least in theory) in developing their 
claims for benefits, Congress promulgated this statute ``to reaffirm 
and clarify the duty of the Secretary of Veterans Affairs to assist 
claimants for benefits under laws administered by the Secretary . . .'' 
In other words, the enactment of the VCAA in November 2000, in 
conjunction with its implementing regulations, was supposed to render 
mandatory assistance to all veteran-claimants upon submission of a 
claim, and in this way, it ``defined VA's obligation to fully develop 
the record. . . .'' And while the VCAA imposes a substantial duty on 
the VA to assist the veteran-claimant in obtaining evidence in support 
of a claim, it also obliges the claimant to aid in this process by 
providing ``enough information to identify and locate the existing 
records including the custodian or agency holding the records; and the 
approximate timeframe covered by the records. . . . ''
    VA fought proper implementation of the VCAA for several years, and 
only after losing in court did they move to at least in theory 
implement the VCAA according to the Congressional intent and eliminate 
the usually misapplied requirement to present a ``well-grounded'' claim 
before the VA would assist a veteran with his or her claim. Prior to 
passage of the VCAA, 38 U.S.C.S. 5107(a) stated:

          Except when otherwise provided by the Secretary in accordance 
        with the provisions of this title, a person who submits a claim 
        for benefits under a law administered by the Secretary shall 
        have the burden of submitting evidence sufficient to justify a 
        belief by a fair and impartial individual that the claim is 
        well grounded. The Secretary shall assist such a claimant in 
        developing the facts pertinent to the claim. Section 5107 as 
        revised by the VCAA eliminates the words well-grounded and 
        simply states: CLAIMANT RESPONSIBILITY Except as otherwise 
        provided by law, a claimant has the responsibility to present 
        and support a claim for benefits under laws administered by the 
        Secretary.

    Enactment of the VCAA ended the confusion, unnecessary expenses, 
premature denials and improper adjudications caused by the 
interpretation of the words ``well-grounded claim.'' Essentially, 10 
years of CAVC and U.S. Court of Appeals for the Federal Circuit case 
law dealing with the well-grounded claim requirement no longer has 
relevance because that requirement has been eliminated by the 2000 VCAA 
law.
    It is clear now that the intent of the Congress is for the VA to 
assist almost every claimant with the development of their claim, 
except for those who have no reasonable possibility of obtaining 
benefits. (In effect, the well-grounded claim requirement has been 
replaced with the no reasonable possibility standard.) It is also clear 
that the VA is obligated to explain to all claimants just what evidence 
is necessary to substantiate their claims before a final adjudication 
can be promulgated.
    The VCAA does not however change any of the rules governing what a 
claimant needs to prove to be granted a VA benefit. Nor does the VCAA 
change the burden of proof or the standard of proof that the VA must 
apply to a claim. The burden of proof is generally on the claimant and 
the rule in existence both before and after the VCAA requires the VA to 
grant a claim if either (1) a preponderance of the evidence supports 
the claim or (2) the weight of the evidence in support of the claim is 
approximately equal to the weight of the evidence against the claim.
    In filing a PTSD claim the veteran is required to have proof that 
he or she experienced a ``stressor'' event in service; that is, a 
traumatic event that involves experiencing, witnessing, or confronting 
an event or events that involve actual or threatened death and/or 
serious injury, or encountering a threat to the physical integrity of 
others, and responding with intense fear, helplessness or horror. 
Subsequently, the medical evidence must reflect a diagnosis of PTSD at 
any time during or after service and a link between the current 
diagnosis and the in-service stressor event, which may involve combat 
or non-combat-related events.
    While the veteran need not prove that s/he incurred an in-service 
disease or physical injury, the record must nevertheless contain 
``credible supporting evidence'' to establish the existence of the 
claimed stressor event, with the only exceptions being if the veteran 
engaged in combat or was a prisoner of war and the claimed stressor was 
related to that combat or captivity. Combat exposure verification is 
based on the receipt of certain military decorations verified within 
service personnel records, and the VA has recognized that a ``number of 
citations appear to be awarded primarily or exclusively for 
circumstances related to combat,'' including for example, the Medal of 
Honor, Navy Cross, and Combat Infantryman's Badge. In addition, the 
United States Court of Appeals for Veterans Claims (CAVC) has also 
eased the burden on veterans by finding that personal participation in 
combat need not be established.
    Therefore, although the veteran with verified combat service has no 
burden to verify his or her claimed stressor (having instead only the 
burden to verify that s/he participated in combat), the veteran for 
whom combat participation is not established in the record is not so 
fortunate. His or her claim must have ``credible supporting evidence'' 
or face denial. Non-combat stressors typically include, but are not 
limited to, exposure to or involvement in aircraft crashes, vehicle 
crashes, ship wrecks, explosions, rape or assault, witnessing a death, 
duty on a burn ward, and/or service with a graves registration unit. 
The non-combat stressor may be experienced alone or with a group of 
people and is not necessarily limited to just one single episode. In 
addition, in personal trauma cases such as in-service sexual assault, 
alternative sources may be used to verify the stressful event and can 
include documents from rape crisis centers, counselors, clergy, health 
clinics, civilian police reports, medical records immediately following 
the incident, and/or diaries or journals, or other credible evidence. 
Herein lies a major problem in our view, because the VA does not 
necessarily accept or apply these criteria uniformly and consistently.
    In addition, if the veteran provides sufficient detail, the VA can 
submit a referral to the U.S. Army and Joint Services Records Research 
Center (JSRRC) to conduct a records search to verify the in-service 
stressor. These requests are supposed to be sent through the VA's 
Personnel Information Exchange System (PIES) using codes. Once the 
request is submitted through PIES, there is an interface process from 
the Defense Personnel Records Information Retrieval System to the 
appropriate military service records information management system 
(which may utilize a completely different coding system) whereupon it 
is then sent to the JSRRC electronically.
    The JSRRC does not search through records in an attempt to identify 
an in-service stressor, but rather to verify the stressor. Some of the 
difficulties with the JSRRC include the fact that not every event that 
occurred during the course of the veteran's service is recorded, and 
service records do not typically chronicle the specific experiences of 
individual servicemembers. In addition, most of the records searched by 
the JSRRC are not stored electronically and must be searched manually. 
Typically, the staff will bring out one to a dozen boxes of written 
material, and the JSRRC staff member has 30 minutes to go through this 
mass of material. Obviously, more often than not, the majority of the 
data available is not combed, even in a cursory manner, because there 
is not time to so. The Committee should be aware that reportedly there 
are only 13 staff members to do this work, and they are more than 4,000 
requests in arrears. Moreover, there is no master index of subjects or 
names, and military records are often incomplete. The JSRRC is under 
the control of DoD, as are all the unit and individual records. 
Therefore the VA cannot control this essential step in the current 
process.
    If the Congress is looking for very useful ways to stimulate the 
economy, and to accomplish much needed work at the same time, then 
working with your colleagues on the Armed Services Committee to start 
the long needed process of computerizing and indexing these key 
military records would be a most useful thing to do. The DoD can 
utilize the Temporary (up to 1 year) Schedule A hiring authority issued 
by the President earlier this month to hire disabled young veterans to 
start this work immediately. We would note that the latest Bureau of 
Labor Statistics (BLS) reported that the unemployment figure for our 
youngest veterans is 11.2%, which in and of itself cries out for 
immediate meaningful action by the Congress.
    In summary, an appropriate process already exists for VA PTSD 
claims processing as mandated by the Congress back in 2000. However, it 
doesn't work, because the VA has again failed to provide for the 
consistency, uniformity and efficiency that are necessary to ensure 
that this process works in a timely fashion for all veteran-claimants. 
Further, DoD has been dilatory in doing its part to supply needed 
information in a complete, thorough, and timely manner.
    Obviously, something needs to be done to render what has become an 
intolerable chronic problem for veterans who are legitimately seeking 
service connection compensation and access to quality medical services 
for their very real neuro-psychiatric wounds.
VVA Position on H.R. 952
    VVA can support the proposed legislative change as outlined in H.R. 
952 if the intent is that it be applied to veterans with a valid 
diagnosis (i.e., in the manner called for as noted in the 2006 I.O.M. 
report at http://iom.edu/CMS/3793/32410.aspx) of PTSD, and if the 
intent is that any veteran who served in a combat zone be taken at 
their word that the event or incident which occurred in service gave 
rise to their disability. The criteria recommended by the Institute of 
Medicine or the National Academies of Sciences should be taken as the 
definitive methodology. Incidentally, that methodology, which includes 
testing and intense analysis largely mirrors that contained in the 
``Best Practices'' PTSD manual. The problem, of course, is that VA does 
not do it, despite the 3,800 new clinicians they have hired ostensibly 
to better treat PTSD. VVA has come to learn that a similar legislative 
change has been proposed on the Senate side by Senator Charles Schumer 
of New York.
    It would of course be useful if VA used their own ``Best 
Practices'' manual in the adjudication of PTSD claims . . . but they do 
not. In fact, the only place that one can get a copy of that 2002 
manual, produced at great expense, is from VVA. So the VA does not 
properly train their physicians nor do they properly train the folks 
who are adjudicators.
    If need be, VVA offers its assistance in developing clearer 
language in the proposed legislative change because we believe the 
proposed H.R. 952 to be well-intended and most considerate for those of 
our veterans suffering from PTSD and who face interminable delays and 
denials in their VA compensation claims under the current claims 
process and procedures. VVA thanks this Committee for the opportunity 
to submit its views and testimony on this important veterans' issue.

                                 
         Prepared Statement of Carolyn Schapper, Representative
                Iraq and Afghanistan Veterans of America

    Mr. Chairman and Members of the Subcommittee, thank you for 
inviting me to testify today. On behalf of Iraq and Afghanistan 
Veterans of America, the Nation's first and largest non-partisan 
organization for veterans of the current conflicts, I would like to 
thank you all for your unwavering commitment to our Nation's veterans.
    My name is Carolyn Schapper, and I am a combat veteran. While 
serving as a member of a Military Intelligence unit in Iraq from 
October 2005 to September 2006 with the Georgia National Guard, I 
participated in approximately 200 combat patrols. Whether it was 
interacting with the local population or extracting injured personnel, 
I encountered direct fire, Improvised Explosive Devices (IEDs), and the 
constant threat from insurgents.
    When I came home from Iraq, I dealt with a wide range of adjustment 
issues/Post-Traumatic Stress Disorder (PTSD) symptoms; rage, anger, 
revenge-seeking, increased alcohol use, withdrawal from friends and 
family, depression, high anxiety, agitation, nightmares and hyper-
vigilance. I could barely stay focused at work, let alone traverse the 
VA maze. I might still be lost if I had not had the dumb luck of 
running into another veteran who already had gotten help, and who 
pointed out that a Vet Center could help me start navigating the VA 
system. While I was able to find help and receive the appropriate 
disability compensation for my psychological injury, many of my 
sisters-in-arms have not been so lucky.
    Part of the problem is that, because females are excluded from 
official ``combat roles'' in the military, women veterans have a 
greater burden of proof when it comes to establishing combat-related 
PTSD. But the reality on the ground in Iraq and Afghanistan is that 
there is no clear front line, and female servicemembers are seeing 
combat.
    Modern warfare makes it impossible to delineate between combat, 
combat-support, and combat service support roles. You do not even need 
to leave the Forward Operating Base to be exposed to the continual 
threat of mortars and rockets. Military personnel are often required to 
walk around in or sleep in body armor. As one female veteran told me, 
``Life in Iraq and Afghanistan is combat.'' Moreover, many female 
troops in Iraq and Afghanistan have been exposed to direct fire while 
serving in support roles, such as military police, helicopter pilots, 
and truckdrivers. All of our troops, whether or not they serve in the 
combat arms, must exhibit constant vigilance, and this can take an 
extreme psychological toll on our servicemembers.
    The traditional understanding of female servicemembers' military 
duties has been the biggest hurdle to getting them adequate 
compensation for their injury. The nature of PTSD and other 
psychological injuries makes it difficult to identify the exact 
stressor, and therefore, disability may be determined based on the 
claims processor's perception of exposure to combat. While a service-
connection for PTSD would seem obvious for a male infantryman, it could 
easily come under more scrutiny for a female intelligence soldier 
despite how much actual contact either of us had with enemy forces.
    Another issue that female servicemembers face when trying to 
establish presumption of service-connected PTSD involves collecting the 
proper paperwork. Especially in instances of Military Sexual Trauma, 
some women would rather forgo documenting their injury, rather than get 
official military documentation from a male commander or doctor. If you 
are suffering from a mental health injury, the possibility of having 
someone question, deride or expose such a personal and painful 
experience is often overwhelming, and can lead many female 
servicemembers to avoid the process altogether.
    H.R. 952, introduced by the Chairman, solves this problem by 
changing Title 38 to presume service-connection for PTSD based solely 
on a servicemember's presence in a combat zone. IAVA wholeheartedly 
endorses this bill, and looks forward to working with the Subcommittee 
to see this legislation become law.
    While this legislation will aid veterans once they have been 
diagnosed with a psychological injury and are seeking disability 
compensation, we know that not every servicemember or veteran is 
getting the care they need. This is why IAVA has partnered with the Ad 
Council to conduct a multiyear Public Service Announcement campaign to 
help ease the transition and readjustment challenges facing Iraq and 
Afghanistan veterans when they return home. The campaign also helps 
ensure that veterans seeking access to care and benefits, and 
particularly those who need treatment for their psychological injuries, 
get the support they need. Ad Council is responsible for many of the 
Nation's most iconic and successful PSA campaigns in history, including 
``Only You Can Prevent Forest Fires,'' ``A Mind is a Terrible Thing to 
Waste,'' and ``Friends Don't Let Friends Drive Drunk.'' The IAVA-Ad 
Council Veteran Support PSAs are currently running on television, 
radio, in print, outdoors and online. A companion campaign engaging the 
family and friends of new veterans will be launching later this year.
    I will leave you with this final thought. More and more, women are 
being called upon to serve a more active role in the combat zone, and 
all too often find themselves in harm's way. There is no better way to 
honor their service and sacrifices than to ensure that when they are 
injured, they receive the care and compensation they deserve. Thank you 
again for the opportunity to testify on this critical issue, and I 
would be pleased to take your questions at this time.

            Respectfully,
                                                   Carolyn Schapper

                                 
            Prepared Statement of Dean G. Kilpatrick, Ph.D.,
           Distinguished University Professor, and Director,
         National Crime Victims Research and Treatment Center,
       Medical University of South Carolina, Charleston, SC, and
     Member, Committee on Veterans' Compensation for Posttraumatic
 Stress Disorder, Institute of Medicine and National Research Council,
                         The National Academies
     The Institute of Medicine and National Research Council Report
   ``PTSD Compensation and Military Service'' Findings Regarding the
          Evaluation of Traumatic Exposures and Malingering in
                   Veterans Seeking PTSD Compensation

    Good afternoon, Mr. Chairman, Mr. Ranking Member, and Members of 
the Committee. My name is Dean Kilpatrick and I am Distinguished 
University Professor in the Department of Psychiatry and Behavioral 
Sciences and Director of the National Crime Victims Research and 
Treatment Center at the Medical University of South Carolina. Thank you 
for the opportunity to testify on behalf of the Members of the 
Committee on Veterans' Compensation for Post-Traumatic Stress Disorder. 
This Committee was convened under the auspices of the National Research 
Council and the Institute of Medicine of the National Academy of 
Sciences. Our Committee's work--which was conducted between March 2006 
and July 2007--was requested by the Department of Veterans Affairs, 
which provided funding for the effort.
    In June 2007, our Committee completed its report, entitled PTSD 
Compensation and Military Service. I am pleased to be here today to 
share with you some of the content of that report, the knowledge I've 
gained as a clinical psychologist and researcher on traumatic stress, 
and my experience as someone who previously served as a clinician at 
the VA.
    I will briefly address four issues in this testimony:

      The evaluation of traumatic exposures for VA compensation 
and pension purposes,
      The reliability and completeness of military records for 
evaluation of exposure to stressors,
      What studies say about malingering in the veterans 
population, and
      The means that mental health professionals use to detect 
malingering.

Evaluation of traumatic exposures for VA compensation and pension 
        purposes
    VA compensation and pension (C&P) examinations for PTSD consist of 
a review of medical history; evaluations of mental status and of social 
and occupational function; a diagnostic examination, which may include 
psychological testing; and an assessment of the exposure to traumatic 
events that occurred during military service.
    To help focus the examination, the Veterans Benefits Administration 
(VBA) provides examiners with worksheets that set forth what an 
assessment should cover. These worksheets are designed to ensure that a 
rating specialist receives all the information necessary to rate a 
claim.
    The PTSD worksheet provides guidance on the elements of a 
claimant's military history that should be documented. These include 
Military Occupational Specialty (MOS), combat wounds sustained, 
citations or medals received, and a clear description of the ``specific 
stressor event(s) the veteran considered to be particularly traumatic, 
particularly if the stressor is a type of personal assault, including 
sexual assault, [providing] information, with examples, if possible.'' 
The worksheet notes:

          . . . Service connection for post-traumatic stress disorder 
        (PTSD) requires medical evidence establishing a diagnosis of 
        the condition that conforms to the diagnostic criteria of DSM-
        IV, credible supporting evidence that the claimed in-service 
        stressor actually occurred, and a link, established by medical 
        evidence, between current symptomatology and the claimed in-
        service stressor. It is the responsibility of the examiner to 
        indicate the traumatic stressor leading to PTSD, if he or she 
        makes the diagnosis of PTSD.
          A diagnosis of PTSD cannot be adequately documented or ruled 
        out without obtaining a detailed military history and reviewing 
        the claims folder. This means that initial review of the folder 
        prior to examination, the history and examination itself, and 
        the dictation for an examination initially establishing PTSD 
        will often require more time than for examinations of other 
        disorders. Ninety minutes to 2 hours on an initial exam is 
        normal. (emphasis added)

    A Best Practice Manual developed by VA practitioners also offers 
guidance on assessing trauma exposure, and recommends tests that can be 
administered to help elicit information. The Manual states that 
``[i]nitial PTSD compensation and pension evaluations typically require 
up to 3 hours to complete, but complex cases may demand additional 
time.'' It estimates that 30 minutes of that time would be used for 
records review and an additional 20 minutes for orientation to the 
interview, review of the military history, and conduct of the trauma 
assessment.
    Notwithstanding this guidance, testimony presented to the Committee 
indicated that clinicians often feel pressured to severely constrain 
the time that they devote to conducting a PTSD C&P examination--
sometimes to as little as 20 minutes.
The reliability and completeness of military records for evaluation of 
        exposure to stressors
    VA's statutory ``duty to assist'' includes helping veterans gather 
evidence to support their claims, including the provision of VA records 
and facilitation of requests for information from the Department of 
Defense (DoD) and other sources. Military personnel records--which 
document duty stations and assignments, MOS, citations, medals, and 
related administrative information--are valued in this regard because 
they are perceived as unbiased evidence that can corroborate or refute 
claimants' accounts. One study reviewed by the Committee found that 
less than half of treatment-seeking Vietnam veterans reporting combat 
involvement had objective evidence of combat exposure documented in 
their publicly available military personnel records. It concluded that 
a ``meaningful'' number of treatment-seekers ``may be exaggerating or 
misrepresenting their involvement [and combat exposure] in Vietnam and, 
by inference, they attributed this to ``the disability benefit 
incentive'' and compensation-seeking.
    However, this conclusion is not supported by other research that 
the Committee examined, calling into question whether the information 
available in the military personnel files is always adequate to 
evaluate trauma exposure. The National Archives and Research 
Administration, the Nation's conservator of the military personnel 
records, offers the following caveat for users of these data: 
``Detailed information about the veteran's participation in military 
battles and engagements is NOT contained in the record''. Studies 
indicate, instead, that broad-based research into other indicators of 
the likelihood of having experienced traumatic stressors has value. 
This may be especially important in cases of PTSD related to sexual 
assault. Available information suggests that female veterans are less 
likely to receive service connection for PTSD and that this is a 
consequence of the relative difficulty of substantiating exposure to 
noncombat traumatic stressors like military sexual assault.
    The Committee concluded that the most effective strategy for 
dealing with problems with self-reports of traumatic exposure is to 
ensure that a comprehensive, consistent, and rigorous process is used 
throughout the VA to verify veteran-reported evidence.
What studies say about malingering in the veterans population
    The Committee noted that assessment of malingering is a high stakes 
issue because it is as devastating to falsely accuse a veteran of 
malingering as it is unfair to other veterans to miss malingered cases. 
The most recent edition of the Diagnostic and Statistical Manual of 
Mental Disorders (DSM-IV) defines malingering as ``the intentional 
production of false or grossly exaggerated physical or psychological 
symptoms motivated by external incentives . . . such as obtaining 
financial compensation''.
    Combat veterans who are evaluated for PTSD frequently exhibit 
elevations across various assessment measures, including elevations on 
tests used to detect symptom overreporting. Concerns have thus been 
raised regarding the accuracy of veterans' accounts of their 
psychological functioning, which in turn poses significant challenges 
for diagnostic assessment and treatment. While some research and 
commentary suggests that this pattern may reflect, at least in part, 
symptom over reporting by a subset of veterans who are motivated by 
possible receipt of financial compensation, access to treatment, and 
other incentives, the Committee found that literature examining the 
relationship between compensation seeking and reported levels of 
psychopathology has in fact yielded mixed results.
    The Committee's review of the literature concluded that, while 
misrepresentation of combat involvement and trauma exposure undoubtedly 
does happen among veterans seeking treatment and compensation for PTSD, 
the evidence currently available is insufficient to establish how 
prevalent such misrepresentations are and how much effect they have on 
the ultimate outcome of disability claims. Further, while some veterans 
do drop out of mental-health treatment once they obtain service-
connected disability compensation for PTSD, the currently available 
data suggest that this concern may not apply to the majority of 
veterans who seek and obtain such awards. Although more research is 
needed, the Committee concluded that the preponderance of evidence does 
not support the notion that receiving compensation for PTSD makes 
veterans less likely to make treatment gains or acknowledge improvement 
from treatment.
The means that mental health professionals use to detect malingering
    Although there is a need for a reliable, valid way to detect 
malingering, experts agree that there is no magic bullet or gold 
standard for doing so. Several investigators have used scales from such 
tests as the Minnesota Multiphasic Personality Inventory (MMPI) and 
MMPI-2 to indirectly infer the possibility of malingering, and the Best 
Practice Manual notes that they are useful in identifying the test-
taking style of veterans and in assessing service-connected PTSD 
status. However, these measures have clear limitations and should not 
be used as the sole basis for assessing whether a veteran is 
malingering with respect to PTSD status. The Committee concluded that, 
in the absence of a definitive measure, the most effective way to 
detect inappropriate PTSD claims is to require a consistent and 
comprehensive state-of-the-art examination and assessment that allows 
the time to conduct appropriate testing in those specific circumstances 
where the examining clinician believes it would inform the assessment.
    Our Committee also reached a series of other findings and 
recommendations regarding the conduct of VA's compensation and pension 
system for PTSD that are detailed in the body of our report. The 
National Academies previously provided the Subcommittee with copies of 
this report and would happy to fulfill any additional requests for it.
    Thank you for your attention. I'm happy to answer your questions.
Publications referenced in this testimony
    American Psychiatric Association. 2000. Diagnostic and Statistical 
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). 
Washington DC: APA.
    Frueh BC, Elhai JD, Grubaugh AL, Monnier J, Kashdan TB, Sauvageot 
JA, Hamner MB, Burkett BG, Arana GW. 2005. Documented combat exposure 
of U.S. veterans seeking treatment for combat-related post-traumatic 
stress disorder. British Journal of Psychiatry 186(6):467-472.
    Institute of Medicine. 2007. PTSD Compensation and Military 
Service. Washington, DC: National Academies Press. [Online]. Available: 
http://www.nap.edu/
catalog.php?record_id=11870 [accessed 20 March 2009].
    U.S. National Archives and Records Administration. 2009. Military 
Service Records and Official Military Personnel Files. [Online]. 
Available: http://www.archives.gov/veterans/military-service-records/ 
[accessed 20 March 2009].
    Watson P, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane T, 
Hamblen JL. 2002. Best Practice Manual for Post-Traumatic Stress 
Disorder (PTSD) Compensation and Pension Examinations. [Online]. 
Available: http://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf 
[accessed 20 March 2009].

                                 
     Prepared Statement of Terri Tanielian,* MA, Study Co-Director,
          Invisible Wounds of War Study Team, RAND Corporation
 Assessing Combat Exposure and Post-Traumatic Stress Disorder in Troops
       and Estimating the Costs to Society Implications from the
                 RAND Invisible Wounds of War Study \1\

    Chairman Hall, Representative Lamborn, and distinguished Members of 
the Subcommittee, thank you for inviting me to testify today. It is an 
honor and pleasure to be here. I will discuss the findings from our 
study ``Invisible Wounds of War'' as they relate to the topic of your 
hearing today. More specifically, my testimony will briefly review the 
findings from our study related to assessing exposure to combat and 
prevalence of post-traumatic stress disorder and depression among 
servicemembers returning from Operations Enduring Freedom and Iraqi 
Freedom; as well as the societal costs associated with these 
conditions. The full findings and recommendations from our study were 
also presented in the testimony to the full House Committee on Veterans 
Affairs on June 11, 2009.
---------------------------------------------------------------------------
    * The opinions and conclusions expressed in this testimony are the 
author's alone and should not be interpreted as representing those of 
RAND or any of the sponsors of its research. This product is part of 
the RAND Corporation testimony series. RAND testimonies record 
testimony presented by RAND associates to Federal, State, or local 
legislative Committees; Government-appointed commissions and panels; 
and private review and oversight bodies. The RAND Corporation is a 
nonprofit research organization providing objective analysis and 
effective solutions that address the challenges facing the public and 
private sectors around the world. RAND's publications do not 
necessarily reflect the opinions of its research clients and sponsors.
    \1\ This testimony is available for free download at http://
www.rand.org/pubs/testimonies/CT321/.
---------------------------------------------------------------------------
Background
    Since October 2001, approximately 1.7 million U.S. troops have 
deployed as part of Operation Enduring Freedom (OEF; Afghanistan) and 
Operation Iraqi Freedom (OIF; Iraq). The pace of the deployments in 
these current conflicts is unprecedented in the history of the all-
volunteer force (Belasco, 2007; Bruner, 2006). Not only are a higher 
proportion of the armed forces being deployed, but deployments have 
been longer, redeployment to combat has been common, and breaks between 
deployments have been infrequent (Hosek, Kavanagh, and Miller, 2006). 
At the same time, episodes of intense combat notwithstanding, these 
operations have employed smaller forces and have produced casualty 
rates of killed or wounded that are historically lower than in earlier 
prolonged wars, such as Vietnam and Korea. Advances in both medical 
technology and body armor mean that more servicemembers are surviving 
experiences that would have led to death in prior wars (Regan, 2004; 
Warden, 2006). However, casualties of a different kind have emerged in 
large numbers--invisible wounds, such as post traumatic stress 
disorder.
    As with safeguarding physical health, safeguarding mental health is 
an integral component of the United States' national responsibilities 
to recruit, prepare, and sustain a military force and to address 
service-connected injuries and disabilities. But safeguarding mental 
health is also critical for compensating and honoring those who have 
served our Nation.
    In April 2008, my colleagues and I released the findings from a 1-
year project entitled ``Invisible Wounds of War. This independent study 
focused on three major conditions--post-traumatic stress disorder 
(PTSD), major depressive disorder, and traumatic brain injury (TBI). 
Unlike the physical wounds of war that maim or disfigure, these 
conditions remain invisible to other servicemembers, to family members, 
and to society in general. All three conditions affect mood, thoughts, 
and behavior; yet these wounds often go unrecognized and 
unacknowledged. Our study was guided by a series of overarching 
questions about the prevalence of mental health conditions, costs 
associated with these conditions, and the care system available to meet 
the needs of servicemembers afflicted with these conditions. In my 
comments today, I will focus on our findings about servicemembers' 
exposure to trauma during deployment, prevalence of mental health 
conditions post deployment among OEF/OIF veterans, and the costs to 
society associated with these conditions among veterans, as they bear 
directly on the issue you are considering today. Specifically, I will 
address several related questions:
    Deployment Related Experiences and Exposure to Trauma: How is 
exposure to combat trauma assessed among OEF/OIF troops in research 
studies?
    Prevalence of PTSD and Depression: What is the scope of mental 
health conditions that troops experience when returning from deployment 
to Afghanistan and Iraq?
    Societal Costs of PTSD and Depression Among Veterans: What are the 
costs of these conditions, including treatment costs and costs stemming 
from lost productivity and other consequences? What are the costs and 
potential savings associated with different levels of medical care--
including proven, evidence-based care; usual care; and no care?
How is exposure to combat trauma assessed among OEF/OIF troops in 
        research studies?
    In research studies, combat experience has been assessed using a 
variety of different means, including documenting deployment to a 
combat zone based on receipt of hostile-fire pay or assessing specific 
experiences during deployment based on self-report. Most of the prior 
research has evaluated the relationship between these exposures and the 
development of post-combat adjustment difficulties such as post-
traumatic stress disorder. Scholarly interest in exposure to combat-
related traumas emerged following the official designation of PTSD as a 
psychiatric disorder by the American Psychiatric Association in 1980 
(APA, 1980). The PTSD diagnosis replaced earlier terms such as ``battle 
fatigue'' and ``war neurosis.'' Among other changes, the PTSD diagnosis 
required a ``catastrophic stressor that was outside the range of usual 
human experience'', and this requirement spurred the need to assess 
such experiences. The definition of what constitutes a trauma has 
changed over time, but the requirement that PTSD be linked to specific 
experiences remains. Researchers studying veteran populations since 
that time have used different scales to assess (using mainly self-
report) specific details about a variety of exposures that military 
personnel may experience when deployed to a war zone.
    In our study, combat trauma exposure was assessed using 24 
questions that were adapted from Hoge et al. (2004) and includes both 
direct and vicarious trauma exposure (e.g., witnessing a traumatic 
event that occurred to others). However, we found that many questions 
were empirically redundant with one another, and thus used only a 
subset of exposures (11 questions) to form a combat exposure measure 
that formed two indices: (1) a one-question measure that assessed 
whether the servicemember had ever experienced an injury or wound that 
required hospitalization while deployed (this may or may not have 
required medical evacuation from theater), and (2) a scale derived by 
counting the number of ten specific trauma exposures that occurred 
during any of the servicemember's OEF/OIF deployments.
    Rates of reported trauma exposures on these 11 items are presented 
in Table 1. As shown, rates of exposure to specific types of combat 
trauma ranged from 5 to 50 percent, with high reporting levels for many 
traumatic events. Vicariously experienced traumas (e.g., having a 
friend who was seriously wounded or killed) were the most frequently 
reported. About 10-15 percent of OEF/OIF veterans reported NO trauma 
exposures, and about 15-20 percent reported exposure to just ONE event 
(largely death or injury of a friend), so most (close to 75 percent) 
reported multiple exposures.


         Table 1.  Rates of Trauma Exposure in OEF/OIF (N=1965)
------------------------------------------------------------------------
                                         Weighted      95% CI    95% CI
                                        Percentage       LL        UL
------------------------------------------------------------------------
Having a friend who was seriously              49.6      45.7      53.6
 wounded or killed
------------------------------------------------------------------------
Seeing dead or seriously injured non-          45.2      41.3      49.1
 combatants
------------------------------------------------------------------------
Witnessing an accident resulting in            45.0      41.1      48.9
 serious injury or death
------------------------------------------------------------------------
Smelling decomposing bodies                    37.0      33.3      40.7
------------------------------------------------------------------------
Being physically moved or knocked              22.9      19.6      26.1
 over by an explosion
------------------------------------------------------------------------
Being injured, not requiring                   22.8      19.2      26.3
 hospitalization
------------------------------------------------------------------------
Having a blow to the head from any             18.1      15.1      21.1
 accident or injury
------------------------------------------------------------------------
Being injured, requiring                       10.7       8.2      13.1
 hospitalization
------------------------------------------------------------------------
Engaging in hand-to-hand combat                 9.5       7.3      11.6
------------------------------------------------------------------------
Witnessing brutality toward                     5.3       3.3       7.3
 detainees/prisoners
------------------------------------------------------------------------
Being responsible for the death of a            5.2       3.0       7.4
 civilian
------------------------------------------------------------------------
Source: Schell and Marshall, 2008, in Tanielian and Jaycox (eds).
  Invisible Wounds of War: Psychological and Cognitive Injuries, Their
  Consequences, and Services to Assist Recovery. RAND Corporation, MG-
  720CCF.
Note: CI = Confidence Interval; LL = Lower Limit; UL = Upper Limit.
  Percentages are weighted to reflect the full population of 1.64
  million servicemembers who had deployed to OEF/OIF as of October 31,
  2007.

What is the scope of mental health issues faced by OEF/OIF troops 
        returning from deployment?
    Most of the military servicemembers who have deployed to date in 
support of OIF or OEF will return home from war without problems and 
readjust successfully, but many have already returned or will return 
with significant mental health conditions. Among OEF/OIF veterans, our 
study found rates of PTSD and major depression to be relatively high, 
particularly when compared with the general U.S. civilian population. 
In late fall 2007, we conducted a telephone study of 1,965 previously 
deployed individuals sampled from 24 geographic areas. Using well-
accepted screening tools for conducting epidemiological studies, we 
estimated substantial rates of mental health problems in the past 30 
days among OEF/OIF veterans, with 14 percent reporting current symptoms 
consistent with a diagnosis of PTSD and 14 percent reporting symptoms 
consistent with a diagnosis of major depression (9 percent of veterans 
reported symptoms consistent with a diagnosis of both PTSD and major 
depression). Major depression is often not considered a combat-related 
injury; however, our analyses suggest that it is highly associated with 
combat exposure and should be considered in the spectrum of post-
deployment mental health consequences.
    Assuming that the prevalence found in this study is representative 
of the 1.64 million servicemembers who had been deployed for OEF/OIF as 
of October 2007, we estimate that as of April 2008 approximately 
303,000 OEF/OIF veterans were suffering from PTSD or major depression. 
We also found that some specific groups, previously underrepresented in 
studies--including the Reserve Components and those who have left 
military service--may be at higher risk of suffering from these 
conditions. But the single best predictor of reporting current mental 
health problems consistent with a diagnosis of PTSD or depression was 
the number of combat traumas reported while deployed. It is important 
to note that these data were cross-sectional in nature, that is, they 
provide a snapshot of the scope of mental health need among OEF/OIF 
veterans. These estimates may change as more individuals return from 
deployments or more individuals begin to suffer post-combat related 
difficulties that rise to a level of meeting diagnostic criteria.
    Seeking and Receiving Treatment. Military servicemembers with 
probable PTSD or major depression seek care at about the same rate as 
the civilian population, and, just as in the civilian population, many 
of the afflicted individuals were not receiving treatment. About half 
(53 percent) of those who met the criteria for current PTSD or major 
depression had sought help from a physician or mental health provider 
for a mental health problem in the past year. Even when individuals 
receive care for their mental health condition, too few receive quality 
care. Of those who have a mental disorder and also sought medical care 
for that problem, just over half received a minimally adequate 
treatment. The number who received quality care (i.e., a treatment that 
has been demonstrated to be effective) would be expected to be even 
smaller. Focused efforts are needed to significantly improve both 
accessibility to care and quality of care for these groups. The 
prevalence of PTSD and major depression will likely remain high unless 
greater efforts are made to enhance systems of care for these 
individuals. Survey respondents identified many barriers to getting 
treatment for their mental health problems. In general, respondents 
were concerned that treatment would not be kept confidential and would 
constrain future job assignments and military-career advancement. About 
45 percent were concerned that drug therapies for mental health 
problems may have unpleasant side effects, and about one-quarter 
thought that even good mental health care was not very effective. These 
barriers suggest the need for increased access to confidential, 
evidence-based psychotherapy, to maintain high levels of readiness and 
functioning among previously deployed servicemembers and veterans.
What are the costs of these mental health and cognitive conditions to 
        the individual and to society?
    The costs of these invisible wounds go beyond the immediate costs 
of mental health treatment. Adverse consequences that may arise from 
post-deployment mental and cognitive impairments include suicide, 
reduced physical health, increased engagement in unhealthy behaviors, 
substance abuse, unemployment, poor performance while at work, 
homelessness, marital strain, domestic violence, and poor parent-child 
relationships. The costs stemming from these consequences are 
substantial, and may include costs related to lost productivity, 
reduced quality of life, substance abuse treatment, and premature 
mortality.
    To quantify these costs, RAND undertook an extensive review of the 
literature on the costs and consequences of post-traumatic stress 
disorder (PTSD) and depression. Our analysis included the development 
and use of a micro-simulation model to estimate 2-year post-deployment 
costs associated with PTSD and depression for military servicemembers 
returning from OEF and OIF. Our analyses use a societal cost 
perspective, which considers costs that accrue to all members of U.S. 
society including Government agencies (e.g., DoD and VA), 
servicemembers, their families, employers, private health insurers, 
taxpayers, and others. In conducting the micro-simulation analysis for 
PTSD and depression, we also estimated the costs and potential savings 
associated with different levels of medical care, including proven, 
evidence-based care, usual care, and no care.
    We found that unless treated, PTSD and depression have wide-ranging 
and negative implications for those afflicted and exact a high economic 
toll to society. The presence of any one of these conditions can impair 
future health, work productivity, and family and social relationships. 
Individuals afflicted with any of these conditions are more likely to 
have other psychiatric diagnoses (e.g., substance use) and are at 
increased risk for attempting suicide. They have higher rates of 
unhealthy behaviors (e.g., smoking, overeating, unsafe sex) and higher 
rates of physical health problems and mortality. Individuals with any 
of these conditions also tend to miss more days of work or report being 
less productive. There is also a possible connection between having one 
of these conditions and being homeless. Suffering from these conditions 
can also impair relationships, disrupt marriages, aggravate the 
difficulties of parenting, and cause problems in children that may 
extend the consequences of combat experiences across generations. 
Below, we summarize some of the key negative outcomes that have been 
linked to PTSD and depression in prior studies. For a more thorough 
discussion of these issues, please see Tanielian and Jaycox [Eds.], 
2008, Chapter Five.
    Suicide: Depression and PTSD both increase the risk for suicide, as 
shown by evidence from studies of both military and civilian 
populations. Psychological autopsy studies of civilian suicides have 
consistently shown that a large number of civilians who committed 
suicide had a probable depressive disorder. One study showed that 
approximately 30 percent of veterans committing suicide within 1-year 
had a mental health disorder such as depression, as did approximately 
40 percent of veterans attempting suicide. Although not as strongly 
associated with suicide as depression, PTSD is more strongly associated 
with suicidal thoughts and attempts than any other anxiety disorder and 
has also been linked to elevated rates of suicide among Vietnam 
veterans.
    Physical Health: Depression and PTSD have been linked to increased 
morbidity. With respect to physical health, cardiovascular diseases are 
the most frequently studied morbidity outcome among persons with 
psychiatric disorders. Both PTSD and depression have been linked to 
higher rates of heart disease in military and civilian populations. 
Depression also affects conditions associated with aging, including 
osteoporosis, arthritis, Type 2 diabetes, certain cancers, periodontal 
disease, and frailty.
    Health-compromising Behaviors: The link between depression and PTSD 
and negative physical health outcomes may be partly explained by 
increases in health-risk behaviors that influence health outcomes. For 
example, research on civilian populations has shown a clear link 
between PTSD and depression and smoking, as well as a link between 
symptoms of depression and PTSD and sexual risk taking.
    Substance Abuse: Rates of co-occurring substance use disorders with 
PTSD and depression, are common and are often associated with more-
severe diagnostic symptoms and poorer treatment outcomes. Several 
studies have examined the relationship between mental disorders and 
alcohol and drug abuse. The results have varied, depending on the 
specific condition studied. Studies of Vietnam veterans showed that 
PTSD increases the risk of alcohol and substance abuse, while other 
studies of civilian populations have found that depression tends to be 
a consequence of substance abuse rather than a cause.
    Labor Market Outcomes: PTSD and depression influence labor-market 
outcomes as well. Specifically, there is compelling evidence indicating 
that these conditions will affect servicemembers' return to employment, 
their productivity at work, and their future job prospects. Studies of 
Vietnam veterans have also found that those with a diagnosis of 
depression or PTSD had lower hourly wages than Vietnam veterans without 
a diagnosis.
    Homelessness: Few studies have examined the rates of homelessness 
among individuals with PTSD or depression; rather, most studies have 
studied the prevalence of mental disorders among homeless individuals. 
Compared with non-homeless persons in the general population, homeless 
people have higher rates of mental disorder and are more likely to 
experience a severe mental disorder. One study found that 75 percent of 
homeless individuals with PTSD had developed the condition prior to 
becoming homeless. However, evidence in this area is not strong, and 
the prevalence of mental disorders among homeless people may be 
overstated, possibly the consequence of studies relying on poor 
sampling methods or flawed assumptions.
    Marriage and Intimate Relationships: The effects of post-combat 
mental and cognitive conditions inevitably extend beyond the afflicted 
servicemember. As servicemembers go through life, their impairments 
cannot fail to wear on those with whom they interact, and those closest 
to the servicemember are likely to be the most severely affected. 
Studies of Vietnam veterans, whose results parallel those among 
civilian populations, have linked PTSD and depression to difficulties 
maintaining intimate relationships, and these deficits account for a 
greatly increased risk of distressed relationships, intimate-partner 
violence, and divorce among those afflicted.
    Child Outcomes: In addition, the interpersonal deficits that 
interfere with emotional intimacy in the romantic relationships of 
servicemembers with these PTSD and depression may interfere with their 
interactions with their children. In particular, interviews with 
spouses of veterans from several conflicts (World War II, Korea, and 
Vietnam) have all revealed a higher rate of problems among children of 
veterans with symptoms of PTSD. Rates of academic problems, as well as 
rates of psychiatric treatment, were also higher in children of 
veterans with PTSD compared to children of veterans without PTSD. The 
implications of a parent's depression on children's outcomes has not 
been studied directly in military populations, but numerous studies of 
civilian populations have shown that the children of depressed parents 
are at far greater risk of behavioral problems and psychiatric 
diagnoses than children of non-depressed parents.
    A limitation of the research summarized above is that virtually 
none of the studies we reviewed were randomized controlled trials, and 
thus may not be able to detect causal relationships between these 
disorders and subsequent adverse consequences such as homelessness, 
substance abuse, or relationship problems. Further, the majority of 
studies reviewed drew from data on Vietnam-era veterans or from data on 
civilians. Nevertheless, these studies are important for understanding 
the range of co-morbidities and behavioral outcomes likely to be 
associated with PTSD and depression, and this information is relevant 
for determining the required resources for treating veterans with these 
conditions. Effective treatments for PTSD and depression exist 
(Tanielian and Jaycox [Eds.), 2008, Chapter 7), and can greatly improve 
functioning. With adequate treatment and support, some veterans may 
avoid negative outcomes altogether.
What are the associated economic costs to society?
    To understand the consequences of these conditions in economic 
terms, we developed a microsimulation model. Using data from the 
literature (which had limited information on specific populations and 
costs), we estimated the costs associated with mental health conditions 
(PTSD and major depression) for a hypothetical cohort of military 
personnel deployed to Afghanistan and Iraq.
    We defined costs in terms of lost productivity, treatment, and 
suicide attempts and completions, and we estimated costs over a 2-year 
period (see Tanielian and Jaycox [Eds.], 2008, Chapter Six). For this 
analysis, we focus specifically on the costs of PTSD and depression, 
and we considered the costs associated with different types of 
treatment and different patterns of comorbidity, allowing for remission 
and relapse rates to be influenced by treatment type. The data 
available to conduct this type of detailed analysis for specific mental 
health conditions, however, did not support projecting costs beyond a 2 
year time horizon.
    For each condition, we generated two estimates--one that included 
the medical costs and the value of lives lost due to suicide, and one 
that excluded such costs. We were unable to estimate the costs 
associated with homelessness, domestic violence, family strain, and 
substance abuse because reliable data are not available to create 
credible dollar figures for these outcomes. If figures for these 
consequences were available, the costs of having these conditions would 
be higher. Our estimates represent costs incurred within the first 2 
years after returning home from deployment, so they accrue at different 
times for different personnel. For servicemembers who returned more 
than 2 years ago and have not redeployed, these costs have already been 
incurred. However, these calculations omit costs for servicemembers who 
may deploy in the future, and they do not include costs associated with 
chronic or recurring cases that linger beyond 2 years. (Details of our 
model assumptions and parameters can be found in Tanielian and Jaycox 
[Eds.], 2008, Chapter Six).
    Our microsimulation model predicts that 2-year post-deployment 
costs to society resulting from PTSD and major depression for 1.64 
million deployed servicemembers (as of October 2007) could range from 
$4.0 to $6.2 billion (in 2007 dollars), depending on how we account for 
the costs of lives lost to suicide. For PTSD, average costs per case 
over 2 years range from $5,904 to $10,298; for depression, costs range 
from $15,461 to $25,757; and for PTSD and major depression together, 
costs range from $12,427 to $16,884. The majority of the costs were due 
to lost productivity. Because these numbers do not account for future 
costs that may be incurred if additional personnel deploy and because 
they are limited to 2 years following deployment, they underestimate 
total future costs to society.
    Providing Evidence-Based Treatment for PTSD and Depression Can 
Reduce Societal Costs. Certain treatments have been shown to be 
effective for both PTSD and major depression, but these evidence-based 
treatments are not yet available in all treatment settings. We estimate 
that evidence-based treatment for PTSD and major depression would pay 
for itself within 2 years, even without considering costs related to 
substance abuse, homelessness, family strain, and other indirect 
consequences of mental health conditions. Evidence-based care for PTSD 
and major depression could save as much as $1.7 billion, or $1,063 per 
returning veteran; the savings come from increases in productivity, as 
well as from reductions in the expected number of suicides. Given these 
numbers, investments in evidence-based treatment would make sense, not 
only because of higher remission and recovery rates but also because 
such treatment would increase the productivity of servicemembers. The 
benefits to increased productivity would outweigh the higher costs of 
providing evidence-based care. These benefits would likely be even 
higher had we been able to capture the full spectrum of costs 
associated with mental health conditions. However, a caveat is that we 
did not consider additional implementation and outreach costs (over and 
above the day-to-day costs of care) that might be incurred if DoD and 
the VA attempted to expand evidence-based treatment beyond current 
capacity.
Summary
    Our study found high rates of exposures to combat trauma during 
deployment and revealed serious prevalence (18.5 percent) of current 
PTSD and depression among servicemembers who had returned from OEF or 
OIF. In our analyses (not presented in this testimony), we also found 
significant gaps in access to and the quality of care provided to this 
population. Too few of those with PTSD and depression were getting 
help, and among those that were getting help too few were getting even 
minimally adequate care. If left untreated or under-treated, these 
conditions can have negative cascading consequences and result in a 
high economic toll. Investing in evidence based care for all of those 
in need can reduce the costs to society in just 2 years. Ensuring all 
veterans afflicted with these conditions will require addressing the 
significant gaps that exist in access to and quality of care for our 
Nation's veterans.
    Thank you again for the opportunity to testify today and to share 
the results of our research. Additional information about our study 
findings and recommendations can be found at: http://veterans.rand.org.
References
    American Psychiatric Association, Diagnostic and Statistical Manual 
For Mental Disorders, Third Edition. Washington, DC. American 
Psychiatric Association, 1980.
    Belasco, A. The Cost of Iraq, Afghanistan, and Other Global War on 
Terror Operations Since 9/11. Washington, D.C.: Congressional Research 
Service, 2007.
    Bruner, E.F. Military Forces: What Is the Appropriate Size for the 
United States? Washington, D.C.: Congressional Research Service, 2006.
    Hoge, C.W., C.A. Castro, S.C. Messer, D. McGurk, D.I. Cotting, and 
R.L. Koffman. Combat duty in Iraq and Afghanistan, mental health 
problems, and barriers to care. New England Journal of Medicine, Vol. 
351, No. 1, July 2004, pp. 13-22.
    Hosek, J., J. Kavanagh, and L. Miller. How Deployments Affect 
Service Members. Santa Monica, Calif.: RAND Corporation, MG-432-RC, 
2006. As of March 13, 2008: http://www.rand.org/pubs/monographs/MG432/.
    Institute of Medicine, Committee on Treatment of Post-traumatic 
Stress Disorder, Board on Population Health and Public Health Practice. 
Treatment of Post-traumatic Stress Disorder: An Assessment of the 
Evidence. Washington, D.C.: National Academies Press, 2007.
    Regan, T. Report: High survival rate for U.S. troops wounded in 
Iraq. Christian Science Monitor, November 29, 2004.
    Tanielian, T. and L.H. Jaycox (Eds). Invisible Wounds of War: 
Psychological and Cognitive Injuries, Their Consequences and Services 
to Assist Recovery. Santa Monica, California. RAND Corporation MG 720-
CCF, 2008.
    Warden, D. Military TBI during the Iraq and Afghanistan wars. 
Journal of Head Trauma Rehabilitation, Vol. 21, No. 5, 2006, pp. 398-
402.

                                 
  Prepared Statement of Rear Admiral David J. Smith, M.D., SHCE, USN,
  Joint Staff Surgeon, Office of the Chairman of the Joint Chiefs of 
                                 Staff,
    Wounded and Survivor Care Task Force, U.S. Department of Defense

    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to appear before you today. In my capacity as the Joint 
Staff Surgeon, I serve as the medical advisor to the Chairman of the 
Joint Chiefs of Staff, the Joint Staff and Combatant Commanders and 
coordinate operational medicine, force health protection and readiness 
issues among the Combatant Commands, the Office of the Secretary of 
Defense and the services. I am a board-certified Occupational Medicine 
physician with 27 years of service and additional background in medical 
management and undersea medicine.
    I serve as the senior ranking member of the Chairman's Wounded and 
Survivor Care Task Force. Under the direction of the Chairman, the Task 
Force has been actively engaged in focused efforts to implement 
necessary change and reinforce successful efforts to improve the health 
of the force and to ensure the appropriate care and support is provided 
for our wounded servicemembers, their families, and the families of 
those killed in action so they can effectively manage the physical and 
mental challenges incurred during military service.
    Mr. Chairman, thank you again for the invitation to appear here 
this afternoon. I am pleased to respond to any questions you or the 
Subcommittee Members may have.

                                 
    Prepared Statement of Colonel Robert Ireland, Program Director,
 Mental Health Policy, Office of the Assistant Secretary of Defense for
               Health Affairs, U.S. Department of Defense

    Chairman Hall, Ranking Member Lamborn, and distinguished Members of 
the Subcommittee, thank you for the opportunity to discuss the 
Department of Veterans Affairs (VA), Title 38, United States Code, 
section 1154, and how these provisions align with the Department of 
Defense's (DoD) approach to diagnosing Post-Traumatic Stress Disorder 
(PTSD), defining related stressors, and the use of the servicemember's 
medical record.
PTSD, Stressors, and Military Mental Health
    When servicemembers' medical condition(s) requires further medical 
evaluation to ensure they meet Service-specific medical retention 
standards, military clinicians

will write a summary and submit it for review by a military Medical 
Evaluation Board (MEB). The MEB typically consists of two to three 
providers at a local installation medical treatment facility. Any MEB 
review of a psychiatric diagnosis must contain a thorough psychiatric 
evaluation and include the signature of at least one psychiatrist. The 
MEB is required to:

    1.  Confirm the medical diagnosis(es).
    2.  Document the servicemember's current medical condition to 
include treatment status and potential for medical recovery.
    3.  Review each case based on relevant facts.

    The MEB determines whether the servicemember meets Service-specific 
medical retention standards and is medically qualified to return to 
duty, or whether the servicemember fails to meet Service-specific 
medical retention standards, in which case the MEB recommends the case 
be forwarded to a Physical Evaluation Board (PEB) that has the 
authority to determine retention, separation with or without severance 
pay, or retirement. Decisions related to continued military service, 
separation, or retirement due to a disability are part of the DoD 
personnel process.
    With respect to PTSD, military providers use the same criteria as 
their civilian counterparts to diagnose PTSD (a common disorder in both 
settings), as defined by the American Psychiatric Association's 
Diagnostic and Statistical Manual for Mental Disorders, 4th Edition-TR 
(DSM-IV TR). The first criterion, ``A'', requires:
    The person has been exposed to a traumatic event in which both of 
the following have been present:

    1.  The person experienced, witnessed, or was confronted with an 
event or events that involved actual or threatened death or serious 
injury, or a threat to the physical integrity of self or others.
    2.  The person's response involved intense fear, helplessness, or 
horror.

    In a medical record, at least one such event should be documented 
by a provider in order to show how it met both components of Criterion 
A: a traumatic event and specific intense responses to it. It is not 
enough to simply list ``stressors,'' which, in reality, involve 
perception of a threat, one's emotional and physical responses to it, 
and a perception about whether or not one can manage one's reactions.
    Documentation of re-experiencing, avoidance, and hyper-arousal 
symptoms should connect to corresponding traumatic events. Veterans 
should be encouraged to provide copies of their military medical and 
mental health records to ensure continuity of care and assist in 
confirmation of their entitlements.
    Thank you again for allowing me the opportunity to appear before 
you to discuss Military Mental Health and for your continued support. I 
look forward to working together to improve mental health care for our 
beneficiaries.

                                 
           Prepared Statement of Bradley G. Mayes, Director,
  Compensation and Pension Service, Veterans Benefits Administration,
                  U.S. Department of Veterans Affairs

The evolving PTSD claims process and the application of 38 U.S.C. 
        Sec. 1154
    Mr. Chairman and Members of the Committee:
    I would like to thank the Chairman for this opportunity to testify 
on the important topic of post-traumatic stress disorder (PTSD). Mr. 
Richard Hipolit of the Department of Veterans Affairs (VA) Office of 
General Counsel accompanies me today. The number of veterans receiving 
service-connected compensation for PTSD from VA has grown dramatically. 
From fiscal year 1999 through fiscal year 2008, the number increased 
from 120,000 to 345,520. We all share the goals of preventing this 
disability, minimizing its impact on our veterans, and providing those 
who suffer from it with just compensation for their service to our 
country. Consequently, VA has expanded its efforts to assist veterans 
with the claims process and keep pace with the increased number of 
claims. Today I will describe the PTSD claims process and explain how 
VA applies the statutory requirements of 38 U.S.C. Sec. 1154 to the 
processing of these claims. I will also describe the challenges met by 
VA through the years as PTSD claims and warfare tactics have evolved.
38 U.S.C. Sec. 1154
    Section 1154, which was enacted by Congress in 1941, requires that 
VA consider the time, place, and circumstances of a veteran's service 
in deciding a claim for service connection. Section 1154(b) provides 
for a reliance on certain evidence as a basis for service connection of 
disabilities that result from a veteran's engagement in combat with the 
enemy. As a result, veterans who ``engaged in combat with the enemy'' 
and file claims for service-connected disability related to that combat 
are not subject to the same evidentiary requirements as non-combat 
veterans. Their lay statements alone may provide the basis for service 
connecting a disability, without additional factual or credible 
supporting evidence. In PTSD claims, a combat veteran's personal 
stressor statement can serve to establish the occurrence of the 
stressor.
The PTSD Claims Process
    The processing of PTSD claims is governed by 38 C.F.R. 
Sec. 3.304(f). This regulation states that, in order for service 
connection for PTSD to be granted, there must be: (a) medical evidence 
diagnosing the condition, (b) medical evidence establishing a link 
between current symptoms and an in-service stressor, and (c) credible 
supporting evidence that the claimed in-service stressor occurred. The 
first two requirements involve medical assessments, while the third 
requirement may be satisfied by non-medical evidence. PTSD is defined 
as a mental disorder that results from a stressor. The third 
requirement of the regulation emphasizes the importance of the stressor 
and the obligation of the Veterans Benefits Administration (VBA) to 
seek credible evidence supporting the occurrence of that stressor.
    In PTSD claims where the stressor is not combat-related, VBA 
personnel will conduct research and develop credible evidence to 
support the claimed stressor. However, the statutory directives of 
Sec. 1154(b) have been incorporated into PTSD regulations at 
Sec. 3.304(f)(2), so that when there is evidence of combat 
participation, and the stressor is related to that combat, no stressor 
corroboration is required. The veteran's lay statement alone is 
sufficient to establish the occurrence of the stressor. In Moran v. 
Peake, 525 F.3d 1157, 1159 (Fed. Cir. 2008), the United States Court of 
Appeals for the Federal Circuit held ``the term `engaged in combat with 
the enemy' in Sec. 1154(b) requires that the veteran have personally 
participated in events constituting an actual fight or encounter with a 
military foe or hostile unit or instrumentality, as determined on a 
case-by-case basis.'' The Court said that ``[a] showing of no more than 
service in a general ``combat area'' or ``combat zone'' is not 
sufficient to trigger the evidentiary benefit of Sec. 1154(b).'' When 
no combat award has been received, VBA relies on the circumstances of 
the individual case, as determined from the veteran's service records 
and other sources, to evaluate whether the veteran engaged in combat.
VBA responses to the changing circumstances of PTSD and warfare tactics
    Through the years VA has made changes to Sec. 3.304(f) based on the 
Sec. 1154 mandate to consider the time, place, and circumstances of a 
veteran's service.
    The definition and diagnostic criteria for PTSD evolved to a great 
extent from the psychiatric community's attempt during the seventies to 
explain the psychological problems of some Vietnam War Veterans. Once 
the medical community recognized this mental disorder, VA added it as a 
disability to the VA rating schedule. VA then moved to incorporate PTSD 
diagnostic criteria from the American Psychiatric Association's 
Diagnostic and Statistical Manual of Mental Disorders (DSM) into the 
PTSD claims evaluation process. According to DSM-IV, the symptoms of 
PTSD ``usually begin within the first 3 months after the trauma, 
although there may be a delay of months, or even years, before symptoms 
appear.'' Given the delay that may occur between the occurrence of a 
stressor and the onset of PTSD and the subjective nature of a person's 
response to an event, VA concluded, when it first promulgated 
Sec. 3.304(f) in 1993, that it is reasonable to require corroboration 
of the in-service stressor, a conclusion with which the Federal Circuit 
agreed in Nat'l Org. of Veterans' Advocates, Inc. v. Sec'y of Veterans 
Affairs, 330 F.3d 1345, 1351-52 (Fed. Cir. 2003). Work is currently 
underway to update the disability rating schedule to compensate more 
effectively for disability due to PTSD.
    As the military incorporated more female members into its ranks, 
VBA recognized that PTSD could result from personal assault and sexual 
trauma. These types of claims were increasing in numbers and are 
difficult to document. To meet this evolving situation, VA added 
Sec. 3.304(f)(4), which provides for acceptance of evidence for 
stressor corroboration in such cases from multiple sources other than 
the veteran's service records. This evidence may include local law 
enforcement records, hospital or rape crisis center records, or 
testimony from family, friends, or clergy members. In addition, this 
evidence may be submitted to an appropriate medical or mental health 
professional for an opinion regarding the occurrence of the stressor. 
This expanded concept of potential evidence to corroborate the stressor 
in personal assault PTSD claims shows a positive and sensitive 
responsiveness on the part of VA to the changing demographics of the 
veteran population.
    For the evaluation of PTSD claims where the stressor is not combat-
related or the claimed stressor is related to combat but there is no 
initial evidence of combat participation, VBA has provided claims 
processing personnel with special tools to research veterans' stressor 
statements. A website was developed that contains a database of 
thousands of declassified military unit histories and combat action 
reports from all periods of military conflict. In many cases, evidence 
is found in these documents to support the veteran's stressor statement 
or confirm combat participation. Nationwide training was conducted to 
explain the use of this database and other official Web sites that can 
aid with stressor corroboration. This initiative illustrates the VBA 
commitment to assisting veterans with PTSD claims.
    Although the combat participation provisions of Sec. 1154 have been 
in effect for many years, VA has recently provided a PTSD regulatory 
change that further carries out the intent of that statute and 
recognizes the changing conditions of modern warfare. Section 
3.304(f)(1) now provides for service connection of PTSD when there is 
an in-service diagnosis of the disability. In such cases, the veteran's 
lay stressor statement and the medical examiner's association of PTSD 
with that stressor is sufficient to establish service connection when 
PTSD is diagnosed. This liberalization of regulatory requirements is 
due to the recognition by VA of the heightened awareness of PTSD among 
military medical personnel, resulting in increasing numbers and 
reliability of PTSD diagnoses for personnel still on active duty. This 
regulation also facilitates the timely resolution of PTSD claims and 
provides expedited payment of needed benefits to veterans.
    These descriptions of PTSD-related initiatives make it clear that 
VA is committed to following the mandate of Sec. 1154 and adjusting the 
PTSD claims process as necessary to better serve veterans. This 
concludes my testimony and I would be happy to answer any questions the 
Committee Members may have.

                                 
 Prepared Statement of Antonette Zeiss, Ph.D., Deputy Chief Consultant,
   Office of Mental Health Services, Office of Patient Care Services,
  Veterans Health Administration, U.S. Department of Veterans Affairs

    Good afternoon, Mr. Chairman and Members of the Subcommittee. Thank 
you for the opportunity to discuss ``The Nexus between `Engaged in 
Combat with the Enemy' and PTSD in an Era of Changing Warfare 
Tactics.'' I am here to discuss the diagnosis of post-traumatic stress 
disorder (PTSD) by Veterans Health Administration (VHA) clinicians.
    VA is nationally recognized for its outstanding PTSD treatment and 
research programs, and the quality of VA health care in this area is 
outstanding, with continual enhancements as more is learned. For 
example, VA's National Center for PTSD advances the clinical care and 
social welfare of Veterans through research, education and training on 
PTSD and stress-related disorders. Those advances are used to guide 
clinical program development in collaboration with the Office of Mental 
Health Services.
    All VA clinicians, including those responsible for completing 
Compensation and Pension (C&P) evaluations, adhere to the Diagnostic 
and Statistical Manual of Mental Disorders, 4th edition, Text Revision 
(DSM-IV-TR), recognized as the authoritative source for mental health 
conditions. According to the DSM-IV-TR clinical criteria, PTSD can 
follow exposure to a severely traumatic stressor that involves personal 
experience of an event involving actual or threatened death or serious 
injury. It can also be triggered by witnessing an event that involves 
death, injury, or a threat to the physical integrity of another. The 
person's response to the event must involve intense fear, helplessness 
or horror. The symptoms characteristic of PTSD include persistent re-
experiencing of the traumatic event, persistent avoidance of stimuli 
associated with the trauma, numbing of general responsiveness, and 
persistent symptoms of increased arousal. No single individual displays 
all these symptoms, and a diagnosis requires a combination of a 
sufficient number of symptoms, while recognizing that individual 
patterns will vary. PTSD can be experienced in many ways. Symptoms must 
last for more than 1 month and the disturbance must cause clinically 
significant distress or impairment in social, occupational or other 
important areas of functioning. Military combat certainly creates 
situations that fit the DSM-IV TR description of a severe stressor 
event that can result in PTSD. The likelihood of developing PTSD is 
known to increase as the proximity to, intensity of, and number of 
exposures to such stressors increase.
    PTSD is associated with increased rates of other mental health 
conditions, including Major Depressive Disorder, Substance-Related 
Disorders, Generalized Anxiety Disorder, and others. PTSD can directly 
or indirectly contribute to other medical conditions. Duration and 
intensity of symptoms can vary across individuals and within 
individuals over time. Symptoms may be brief or persistent; the course 
of PTSD may ebb and return over time, and PTSD can have delayed onset. 
Clinicians use these criteria and discussions with patients to identify 
cases of PTSD, sometimes in combination with additional psychological 
testing. VA adheres to the guidance of the DSM-IV-TR when it states, 
``Specific assessments of the traumatic experience and concomitant 
symptoms are needed for such individuals.'' VA seeks to ensure we offer 
the right diagnosis in all clinical settings, whether for C&P 
examinations or as part of a standard mental health assessment.
    Because personal experience in combat can be such a significant 
source of trauma, our mental health professionals have been trained to 
solicit this information from patients. Only Psychiatrists and 
Psychologists may conduct initial C&P examinations in which a diagnosis 
of PTSD is being considered in response to a claim by a Veteran. In 
addition, any Psychiatrist or Psychologist who will conduct a PTSD C&P 
examination must complete training and receive certification in the 
process of conducting C&P examinations in relation to the diagnostic 
criteria of PTSD. We recognize that many individuals with symptoms of 
combat stress or PTSD find it difficult to discuss the details of their 
experiences, although they can more easily describe their symptoms and 
level of distress. However, without the patient disclosing the source 
of the stress, it is impossible for a clinician to diagnose PTSD 
according to the clinical criteria of the DSM-IV-TR. Clinicians must 
develop a sense of safety and trust with some patients in order to make 
them feel comfortable enough to share their trauma in the clinical 
interview. The expertise and sensitivity required for such clinical 
evaluation are two reasons why only doctoral level Psychiatry and 
Psychology providers are allowed to conduct initial exams. VHA 
clinicians conducting the clinical interview for the diagnosis of PTSD 
in the context of a Veteran's claim do not ask for external 
corroborating evidence for the described stressful event. VBA requires 
this evidence to make a determination of service-connection for C&P.
    Apart from issues of determining diagnoses in the C&P context, 
identifying and treating patients with PTSD and other mental health 
conditions are paramount for VHA. VA's efforts to facilitate treatment 
while removing the stigma associated with seeking mental health care 
are yielding valuable results. VA screens any patient seen in our 
facilities for depression, post-traumatic stress disorder (PTSD), 
problem drinking, and military sexual trauma. We have incorporated this 
screening and treatment into primary care settings. We also offer a 
full continuum of care, including inpatient, residential 
rehabilitation, and outpatient services for Veterans with one or more 
of the following conditions (this list is illustrative, not 
exhaustive): PTSD, alcohol and substance abuse disorders, depression, 
anxiety, and other serious mental illnesses. We further offer programs 
for Veterans at risk of suicide, Veterans who are homeless, and 
Veterans who have experienced military sexual trauma with resulting 
development or exacerbation of mental health problems.
    In Fiscal Year 2008, VA treated 442,862 unique Veterans for PTSD in 
VA medical centers, clinics, inpatient settings, and residential 
rehabilitation programs. Given the increasing numbers of Veterans 
seeking VA care for PTSD, VA is monitoring the promptness and 
efficiency of services provided them, such as ``time to first 
appointment'' for Veterans of all service eras who present with new 
mental health problems. Nationally, we are meeting our new standard of 
care, which is to see all new patients seeking a mental health care 
appointment within 14 days of their requested date, 95 percent of the 
time. Almost all VISNs meet this standard, and focused efforts continue 
to bring all VISNs and facilities up to this standard. We conduct an 
initial evaluation of all patients with potential mental health issues 
within 24 hours of contact and we provide urgent care immediately. VA 
has extended hours of operation, expanded points of access, and 
increased our core staff to date by 5,000 positions. We plan again this 
year to continue increasing the number of mental health professionals 
and support staff in the field to ensure sustained operations of this 
vital service line.
    We also believe it is essential that our mental health 
professionals across the system be able to provide the most effective 
treatment for PTSD once it has been identified. In addition to use of 
effective psychoactive medications, VA is conducting national training 
initiatives to educate therapists in two particular evidence-based 
psychotherapies (EBPs) for PTSD. A number of studies have supported the 
use of these exposure-based treatments for PTSD. The first of these 
therapies is Cognitive Processing Therapy (CPT); training for CPT began 
in 2006, and to date, VA has trained over 1,100 VA clinicians in the 
use of CPT. The second national initiative is an education and training 
module on Prolonged Exposure (PE) for treatment of PTSD; this training 
began in 2008, and to date, OMHS has trained over 350 clinicians in the 
use of PE. For both of these psychotherapies, following didactic 
training, clinicians participate in clinical consultations to attain 
full competency in the therapy. VA is also using new CPT and PE 
treatment manuals, developed for VA with inclusion of material on the 
treatment of issues arising from combat trauma during military service.
    VA provides mental health care in several different environments, 
including Vet Centers. There are strong, mutual interactions between 
Vet Centers and our clinical programs. Vet Centers provide a wide range 
of services that help Veterans cope with and transcend readjustment 
issues related to their military experiences in war. Services include 
counseling for Veterans, marital & family counseling for military 
related issues, bereavement counseling, military sexual trauma 
counseling and referral, demobilization outreach/services, substance 
abuse assessment and referral, employment assistance, referral to VA 
medical centers, VBA referral and Veterans community outreach and 
education. Vet Centers provide a non-traditional therapeutic 
environment where Veterans and their families can receive counseling 
for readjustment needs and learn more about VA's services and benefits. 
By the end of FY 2009, 271 Vet Centers with 1,526 employees will be 
operational to address the needs of Veterans. Additionally, VA is 
deploying a fleet of 50 new Mobile Vet Centers this year that will 
provide outreach to returning Veterans at demobilization activities 
across the country and in remote areas. Vet Centers facilitate 
referrals to either Veterans Benefits Administration offices or VHA 
facilities to ensure Veterans have multiple avenues available for 
receiving the care and benefits they have earned through service to the 
country.
    Thank you again for this opportunity to speak about VA's diagnosis 
and treatment of PTSD in Veterans and its relevance to the 
determination of whether a diagnosis of PTSD is warranted when Veterans 
submit claims to VBA. I am prepared to answer any questions you may 
have.

                                 
  Prepared Statement of Maureen Murdoch, M.D., MPH, Core Investigator,
             Center for Chronic Disease Outcomes Research,
              Minneapolis Veterans Affairs Medical Center,
  Veterans Health Administration, U.S. Department of Veterans Affairs

    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to appear before you today to present findings from my 
team's research on post-traumatic stress disorder (PTSD) disability 
awards. I must note the views presented today are mine and do not 
necessarily represent the views of the Department of Veterans Affairs 
(VA) and reflect the results of my studies and not necessarily the 
findings of other research. It is also important to note that these 
data were collected almost 10 years ago and may not reflect experiences 
of a new cohort of Veterans from Operation Enduring Freedom or 
Operation Iraqi Freedom.
Background
    PTSD is the most common psychiatric condition for which Veterans 
seek VA disability benefits. Between 1998 and 2000, my colleagues and I 
conducted three studies looking at differences in PTSD disability 
awards.
    The first study was a historical, administrative database 
evaluation of all 180,039 Veterans who applied for PTSD disability 
benefits between 1980 and 1998. The second was a mailed survey of 
almost 5,000 men and women Veterans who applied for PTSD disability 
benefits between 1994 and 1998. Surveys were collected from 1998 to 
2000, and responses were supplemented with VA administrative data. The 
third study involved conducting a claims audit of 345 Veterans who also 
participated in the survey.
    Although these studies had several objectives, those most relevant 
to today's proceedings include: (1) Identifying the role of combat 
experience on receiving PTSD service-connection; and (2) Understanding 
how claiming combat versus military sexual trauma influenced gender 
differences in receiving PTSD service connection.
Results of the Studies
    From the historical database study, we learned that rates of 
service-connection increased over time. Across all time periods, men 
and women who had been identified as being ``combat injured'' in the 
database were twice as likely to receive service-connection for PTSD 
compared to men and women who were not combat injured.
    By 1998, the observed rate of service-connection for PTSD was 94 
percent among combat-injured men and 92 percent among combat-injured 
women.
    For men without combat injuries, the rate of PTSD service-
connection in 1998 was 64 percent, and the rate for women without 
combat injuries was 57 percent.
    From the survey study, which covered the time period from 1994 to 
1998, we learned that 94 percent of men and 29 percent of women 
reported some type of combat experience. Twenty-four percent of men and 
2 percent of women were identified as being ``combat-injured'' in VA 
databases. ``Combat injury'' probably anchors the extreme end of a 
broad range of combat-associated experiences for these Veterans. Four 
percent of men and 71 percent of women reported sexual assault. As with 
the historical study, we again saw that more than 90 percent of men and 
women identified as ``combat-injured'' received PTSD service-
connection. Among those who were not identified as combat-injured, 52 
percent of women and 64 percent of men received PTSD service-
connection. However, this gender difference was almost entirely 
explained by men and women's different rates of combat experience. 
Regardless of gender, Veterans with more combat experiences were more 
likely to receive a service-connection for PTSD than Veterans with 
fewer or no combat experience. Since men were more likely to report 
combat experiences, they were also more likely to receive service-
connection for PTSD.
    In our claims audits of 345 Veterans who participated in the mail 
survey, we found that 85 percent of men received a diagnosis of PTSD 
from a qualified clinician compared to 76 percent of women. No Veteran 
selected for chart audit received a service-connection for PTSD unless 
his or her examining clinician made a diagnosis of PTSD. About a third 
of Veterans diagnosed with PTSD did not receive service-connection. 
Veterans diagnosed with PTSD at the time of their clinical examination 
reported an average of two more combat experiences at the time of the 
survey compared to men who were not diagnosed with PTSD. Women who were 
diagnosed with PTSD were as likely to report a military sexual assault 
on the survey as were women not diagnosed with PTSD. The factor most 
strongly associated with Veterans receiving a diagnosis of PTSD was 
having a stressor documented in their claims file.
    Mr. Chairman, this concludes my statement. I am pleased to respond 
to any questions you or the Subcommittee Members may have. Thank you.

                                 
     Statement of John R. Vaughn, Chairperson, National Council on 
                               Disability

                                     National Council on Disability
                                                    Washington, DC.
                                                      April 2, 2009

The Honorable John Hall
The Honorable Doug Lamborn
House Committee on Veterans' Affairs
337 Cannon House Office Building
Washington, DC 20515

Dear Chairman Hall and Ranking Member Lamborn:

    I am pleased to write to you on behalf of the National Council on 
Disability (NCD), an independent Federal agency, to submit for the 
record the executive summary of our most recent report entitled 
``Invisible Wounds: Serving Servicemembers and Veterans with PTSD and 
TBI.'' We are making this submission in order for it to be considered 
part of the record for the March 24, 2009 hearing of the House 
Veterans' Affairs Subcommittee on Disability Assistance and Memorial 
Affairs entitled ``The Nexus between Engaged in Combat with the Enemy 
and PTSD in an Era of Changing Warfare Tactics.''
    In light of last Tuesday's hearing on Post-Traumatic Stress 
Disorder (PTSD), we have chosen to submit a summary of our most recent 
report, which addresses the military health care systems which are 
serving servicemembers and veterans with PTSD and Traumatic Brain 
Injury (TBI). The Council addressed both PTSD and TBI together, as they 
are often experienced together and because the symptoms of each are 
often difficult to distinguish.
    In its full report, NCD outlines a reality that many studies and 
commissions have presented in greater detail--that while many evidence-
based practices exist to address PTSD and TBI, servicemembers and 
veterans face numerous barriers in accessing these vital interventions 
and services. The summary that follows offers ten policy 
recommendations for the Committee's consideration.
    NCD is composed of 15 members, appointed by the President with the 
consent of the U.S. Senate. The purpose of NCD is to promote policies, 
programs, practices, and procedures that guarantee equal opportunity 
for all individuals with disabilities, and that empower individuals 
with disabilities to achieve economic self-sufficiency, independent 
living, and integration into all aspects of society. To accomplish 
this, we gather stakeholder input, review Federal programs and 
legislation, and provide advice to the President, Congress and 
governmental agencies. Much of this advice comes in the form of timely 
reports and papers NCD releases throughout each year.
    If you have any questions about this submission or any matter 
related to disability policy, please contact NCD Executive Director 
Michael Collins by phone at (202) 272-2004, or email at 
mcollins@ncd.gov. On behalf of NCD, thank you for your leadership in 
focusing attention on this important topic. I also thank you for the 
opportunity to submit this statement for the record.

            Sincerely,
                                                     John R. Vaughn
                                                        Chairperson
                               __________
Invisible Wounds: Serving Service Members and Veterans With PTSD and TBI

                     National Council on Disability
                             March 4, 2009
National Council on Disability
1331 F Street, NW, Suite 850
Washington, DC 20004

Read the full report at: http://www.ncd.gov/newsroom/publications/2009/
veterans.doc
Executive Summary
    More than 1.6 million American servicemembers have deployed to Iraq 
and Afghanistan in Operation Iraqi Freedom (OIF) and Operation Enduring 
Freedom (OEF). As of December 2008, more than 4,000 troops have been 
killed and over 30,000 have returned from a combat zone with visible 
wounds and a range of permanent disabilities. In addition, an estimated 
25-40 percent have less visible wounds--psychological and neurological 
injuries associated with post traumatic stress disorder (PTSD) or 
traumatic brain injury (TBI), which have been dubbed ``signature 
injuries'' of the Iraq War.
    Although the Department of Defense (DoD) and the Veterans 
Administration (VA) have dedicated unprecedented attention and 
resources to address PTSD and TBI in recent years, and evidence 
suggests that these policies and strategies have had a positive impact, 
work still needs to be done. In 2007, the Department of Defense Task 
Force on Mental Health concluded that

          Despite the progressive recognition of the burden of mental 
        illnesses and substance abuse and the development of many new 
        and promising programs for their prevention and treatment, 
        current efforts are inadequate to ensure the psychological 
        health of our fighting forces. Repeated deployments of mental 
        health providers to support operations have revealed and 
        exacerbated pre-existing staffing inadequacies for providing 
        services to military members and their families. New strategies 
        to effectively provide services to members of the Reserve 
        Components are required. Insufficient attention has been paid 
        to the vital task of prevention.

    PTSD and TBI can be quite debilitating, but the effects can be 
mitigated by early intervention and prompt effective treatment. 
Although medical and scientific research on how to prevent, screen for, 
and treat these injuries is incomplete, evidence-based practices have 
been identified. A number of panels and commissions have identified 
gaps between evidence-based practices and the current care provided by 
DoD and VA and have recommended strategies to address these gaps. The 
window of opportunity to assist the servicemembers and veterans who 
have sacrificed for the country is quickly closing. It is incumbent 
upon the country to promptly implement the recommendations of previous 
panels and commissions and fill the remaining gaps in the mental health 
service systems.
    In terms of prevention, emphasis must be placed on minimizing 
combat stress reactions, and preventing normal stress reactions from 
developing into PTSD when they do occur. When PTSD or TBI does occur, 
the goal of treatment must be to help the servicemember regain the 
capacity to lead a complete life, to work, to partake in leisure and 
civic activities, and to form and maintain healthy relationships.
    PTSD and TBI are often addressed together because they often occur 
together and because the symptoms are at times difficult to 
distinguish.
    PTSD is an anxiety disorder arising from ``exposure to a traumatic 
event that involved actual or threatened death or serious injury.'' It 
is associated with a host of chemical changes in the body's hormonal 
system, and autonomic nervous system. Symptoms vary considerably but 
the essential features of PTSD include:

      Re-experiencing: Such as flashbacks, nightmares and 
intrusive memories;
      Avoidance/Numbing: Including a feeling of estrangement 
from others; and,
      Hyperarousal/Hypervigilance: Including feelings of being 
constantly in danger.

    The challenge for both professionals and veterans is to recognize 
the difference between ``a normal response to abnormal circumstances'' 
and PTSD. Some will develop symptoms of PTSD while they are deployed, 
but for others it will emerge later, after several years in many cases.
    According to current estimates, between 10 and 30 percent of 
servicemembers will develop PTSD within a year of leaving combat. When 
we consider a range of mental health issues including depression, 
generalized anxiety disorder, and substance abuse, the number increases 
to between 16 and 49 percent.
    Traumatic brain injury (TBI), also called acquired brain injury or 
simply head injury, occurs when a sudden trauma causes damage to the 
brain. TBI can result when the head suddenly and violently hits an 
object, or when an object pierces the skull and enters brain tissue. 
Victims may have a wide range of symptoms such as difficulty thinking, 
memory problems, attention deficits, mood swings, frustrations, 
headaches, or fatigue. Between 11 and 20 percent of servicemembers may 
have acquired a traumatic injury in Iraq and Afghanistan.
    Evidence-based practices to prevent PTSD include teaching skills to 
enhance cognitive fitness and psychological resilience that can reduce 
the detrimental impact of trauma. In terms of screening, evidence 
suggests that identifying PTSD and TBI early and quickly referring 
people to treatment can shorten their suffering and lessen the severity 
of their functional impairment. Several types of rehabilitative and 
cognitive therapies, counseling, and medications have shown promise in 
treating both injuries.
    Servicemembers and veterans may access care through the Department 
of Defense, the Veterans Health Administration, or the private sector. 
Each health care system has a number of strengths and weaknesses in 
delivering evidence-based care. For example:
    Department of Defense: DoD has developed a number of evidence-based 
programs designed to (1) maintain the psychological readiness of the 
forces in order to reduce the incidence of stress reactions; (2) embed 
psychological services in deployed settings to ensure early 
intervention when stress reactions occur; and (3) deliver evidence 
based rehabilitative therapies on base and through TRICARE, a managed 
care system that uses a network of civilian providers. However, the 
military, not unlike the civilian health care setting, has a shortage 
of mental health providers who must be spread about military bases and 
deployed settings.
    Servicemembers who rely on the TRICARE network may have limited 
access to services. Because of the low reimbursement rates, many of 
TRICARE's providers are not accepting new TRICARE patients and because 
of the shortage of available mental health providers in some areas, 
enrollees may wait weeks or months for an available appointment.
    Veterans Health Administration: VA has undergone significant 
changes in the past 10-15 years that has transformed it into an 
integrated system that generally provides high quality care. In 
response to the increased demand for services to treat OEF/OIF veterans 
with PTSD, the system has invested resources in expanding outreach 
activities enhancing the availability and timeliness of specialized 
PTSD services. Nevertheless, access to care is still unacceptably 
variable across the VA system.
    Some servicemembers continue to face barriers to seeking care. 
These barriers include stigma and limited access.
    Stigma: Servicemembers are affected by three types of stigma:

      Public stigma: The notion that a veteran would be 
perceived as weak, treated differently, or blamed for their problem if 
he or she sought help.
      Self Stigma: The individual may feel weak, ashamed and 
embarrassed.
      Structural Stigma: Many servicemembers believe their 
military careers will suffer if they seek psychological services. 
Although the level of fear may be out of proportion to the risk, the 
military has institutional policies and practices that restrict 
opportunities for servicemembers who reveal that they have a 
psychological health issue by seeking mental health services.

    Limited Access: Even when servicemembers or veterans decide to seek 
care, they need to find the ``right'' provider at the ``right'' time. 
Long waiting lists, lack of information about where to find treatment, 
long distances to providers, and limited clinic hours create barriers 
to getting care. When care is not readily available, the ``window of 
opportunity'' may be lost.
    Culturally diverse populations and women face additional barriers. 
Despite high rates of PTSD, African American, Latino, Asian, and Native 
American veterans are less likely to use mental health services. This 
is due, in part, to increased stigma, absence of culturally competent 
mental health providers, and lack of linguistically accessible 
information for family members with limited English proficiency who are 
providing support for the veteran. Women have an increased risk of PTSD 
because of the prevalence of Military Sexual Trauma.
    Family and Peer Support: Family support is a key component to the 
veteran's recovery. However, because of the stress of providing care, 
the veteran's PTSD puts the family at increased risk of developing 
mental health issues as well. The current system provides inadequate 
support for the family in its caregiving role and inadequate access to 
mental health services that directly address the psychological well-
being of the spouse, children, or parents.
    Support from peers who have shared a similar experience is also 
important. Peers can provide information, offer support and 
encouragement, provide assistance with skill building, and provide a 
social network to lessen isolation. Peer support may come in the form 
of naturally occurring mutual support groups; consumer-run services; 
formal peer counseling services. In addition, consumers need to be 
involved in the development and deployment of services for patients 
with PTSD and TBI.
Recommendations and Conclusion
    The wars in Iraq and Afghanistan are resulting in injuries that are 
currently disabling for many, and potentially disabling for still more. 
They are also putting unprecedented strain on families and 
relationships, which can contribute to the severity of the 
servicemember's disability over the course of time. NCD concurs with 
the recommendations of previous Commissions, Task Forces and national 
organizations that:

 1.  A comprehensive continuum of care for mental disorders, including 
PTSD, and for TBI should be readily accessible by all servicemembers 
and veterans. This 
requires adequate staffing and adequate funding of VA and DoD health sys
tems.
 2.  Mechanisms for screening servicemembers for PTSD and TBI should be 
continuously improved to include baseline testing for all 
servicemembers pre-deployment and followup testing for individuals that 
are placed in situations where head trauma may occur.
 3.  The current array of mental health and substance abuse services 
covered by TRICARE should be expanded and brought in line with other 
similar health plans.

    It is particularly critical that prevention and early intervention 
services be robust. Effective early intervention can limit the degree 
of long term disability and is to the benefit of the servicemember or 
veteran, his or her family and society. Therefore, NCD recommends that:

 4.  Early intervention services such as marital relationship 
counseling and short term interventions for early hazardous use of 
alcohol and other substances should be strengthened and universally 
accessible in VA and TRICARE.

    Consumers play a critical role in improving the rehabilitation 
process. There are many opportunities for consumers to enhance the 
services offered to servicemembers and veterans and their families. NCD 
recommends that:

 5.  DoD and VA should maximize the use of OIF/OEF veterans in 
rehabilitative roles for which they are qualified including as outreach 
workers, peer counselors and as members of the professional staff.
 6.  Consumers should be integrally involved in the development and 
dissemination of training materials for professionals working with OIF/
OEF veterans and servicemembers.
 7.  Current and potential users of VA, TRICARE and other DoD mental 
health and TBI services should be periodically surveyed by a competent 
independent body to assess their perceptions of: a) the barriers to 
receiving care, including distance, cost, stigma, and availability of 
information about services offered; and b) the quality, appropriateness 
to their presenting problems and user-friendliness of the services 
offered.
 8.  VA should mandate that an active mental health consumer council be 
established at every VA medical center, rather than have this be a 
local option as is currently the case.
 9.  Congress should mandate a Secretarial level VA Mental Health 
Advisory Committee and a Secretarial level TBI Advisory Committee with 
strong representation from consumers and veterans organizations, with a 
mandate to evaluate and critique VA's efforts to upgrade mental health 
and TBI services and report their findings to both the Secretary of 
Veterans Affairs and Congress.

    DoD and VA have initiated a number of improvements, but as noted by 
earlier Commissions and Task Forces, gaps continue to exist.
    It is imperative that these gaps be filled in a timely manner. 
Early intervention and treatment is critical to the long-term 
adjustment and recovery of servicemembers and veterans with PTSD and 
TBI. NCD recommends that:

10.  Congress and the agencies responsible for the care of OEF/OIF 
veterans must redouble the sense of urgency to develop and deploy a 
complete array of prevention, early intervention and rehabilitation 
services to meet their needs now.

    As this report indicates, the medical and scientific knowledge 
needed to comprehensively address PTSD and TBI is incomplete. However, 
many evidence-based practices do exist. Unfortunately, servicemembers 
and veterans face a number of barriers in accessing these practices 
including stigma; inadequate information; insufficient services to 
support families; limited access to available services, and a shortage 
of services in some areas. Many studies and commissions have presented 
detailed recommendations to address these needs. There is an urgent 
need to implement these recommendations.

                                 
Statement of Paul Sullivan, Executive Director, Veterans for Common Sense

    Veterans for Common Sense (VCS) thanks Subcommittee Chairman John 
Hall, Ranking Member Doug Lamborn, and Members of the Subcommittee for 
allowing us to submit a written statement for the record about today's 
hearing on ``The Nexus Between Engaged in Combat with the Enemy and 
Post-Traumatic Stress Disorder in an Era of Changing Warfare Tactics.''
    VCS applauds your attention to the issue of post traumatic stress 
disorder (PTSD) among deployed veterans. Left untreated, PTSD is a 
significant factor that increases the risk of broken homes, 
unemployment, drug and alcohol abuse, crime, homelessness, and suicide. 
According to the Institute of Medicine (IOM), deployment is associated 
with increased risk of PTSD, suicide, and other significant health 
problems.
    In order to mitigate the long-term adverse consequences of PTSD, 
VCS advocates improving the quality and timeliness of how the 
Department of Veterans Affairs (VA) processes PTSD disability 
compensation benefit claims.
    The situation is most acute for the 1.83 million U.S. 
servicemembers deployed to the Iraq and Afghanistan wars, especially 
since nearly 40 percent have deployed to combat twice or more.\1\
---------------------------------------------------------------------------
    \1\ Department of Defense, ``Contingency Tracking System,'' through 
Oct. 31, 2008.
---------------------------------------------------------------------------
    We are disappointed VA failed to take advantage of five 
opportunities to address this issue since 2007. Less than 2 years ago, 
VA ignored an important PTSD disability claim ruling, Castle v. 
Mansfield. In 2008, VA ignored the IOM report linking PTSD to 
deployment to a war zone. The same year, VA ignored the growing 
disability backlog and the escalating surge of PTSD claims filed by 
Iraq and Afghanistan war veterans. In 2009, VA ignored a request by VCS 
to issue new regulations to streamline the adjudication of PTSD claims.
    In light of VA's intentional inaction on this issue, VCS strongly 
urges Congress to quickly pass H.R. 952, the ``COMBAT PTSD Act,'' 
introduced by Chairman Hall last month.
VA Ignored Three Important Cases: Daye, Suozzi, and Pentecost
    VA missed an important opportunity to streamline PTSD claims after 
the United States Court of Appeals for Veterans Claims (``the Court'') 
issued its recent decision in the case of Daye v. Nicholson 20 Vet. 
App. 512 (2006) concerning the amount of evidence needed for a veteran 
to corroborate a stressor occurred. The Court held that:

          When a claim for PTSD is based on a noncombat stressor, `the 
        noncombat veteran's testimony alone is insufficient proof of a 
        stressor.' Corroboration does not require, however, `that there 
        be corroboration of every detail including the appellant's 
        personal participation in the [activity].'

    The Daye decision relied upon two prior decisions by the Court: 
Souzzi v. Brown 10 Vet. App. 307 (1997), and Pentecost v. Principi 16 
Vet. App. 124 (2002). Clearly, a veteran does not need to ``verify'' 
personal involvement in a stressful event. The veteran need only 
provide corroborating evidence they were deployed in the war zone along 
with credible evidence of an event.
    Yet, even though the Court has provided clear guidance as to how VA 
should assess in-service stressor-related evidence submitted in support 
of PTSD claims, VA consistently fails to develop and adjudicate these 
claims correctly.\2\
---------------------------------------------------------------------------
    \2\ VA, ``No Across-the-Board Review of PTSD Cases--Secretary 
Nicholson,'' press release quoting then Secretary James Nicholson, Nov. 
11, 2005. http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1042.
---------------------------------------------------------------------------
    These three Court decisions are equally important because the 
military does not document every combat incident, especially the deaths 
of civilians.
    In 2004, a landmark Army study confirmed nearly universal 
involvement in combat among U.S. servicemembers deployed to Iraq and 
Afghanistan. In one critical finding, the study found that nearly all 
Marines and soldiers deployed to Iraq reported they were ``attacked or 
ambushed.'' \3\
---------------------------------------------------------------------------
    \3\ Hoge, Charles, et. al., ``Combat Duty in Iraq and Afghanistan, 
Mental Health Problems, and Barriers to Care,'' New England Journal of 
Medicine, 2004. http://content.nejm.org/cgi/content/full/351/1/13.
---------------------------------------------------------------------------
    This table prepared by Army Colonel Charles Hoge demonstrates the 
need for the VA to make a whole-sale change in its mindset; that is, 
simply because a veteran's service records do not include notations of 
combat, it does not mean they were not exposed to combat-related events 
or incidents, and the stresses to those incidents.
    Too often, the VA is quick to assume that when a veteran's service 
record is void of combat notations, their PTSD-related claim for VA 
benefits is fraudulent or not valid.


 Table 1.  Combat Experiences Reported by Members of the U.S. Army and Marine Corps after Deployment to Iraq or
                                                  Afghanistan *
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
                                                                                                  Marine Groups
                                                                                    Army Groups
                                                                 -----------------------------------------------




----------------------------------------------------------------------------------------------------------------



                                                                    Afghanistan
                                                                       (N=1062)    Iraq (N=894)    Iraq (N=815)
                                                               -------------------------------------------------
Experience                                                                number/total number (percent)
----------------------------------------------------------------------------------------------------------------
Being attacked or ambushed                                       1139/1961 (58)    798/883 (89)    764/805 (95)
----------------------------------------------------------------------------------------------------------------
Receiving incoming artillery, rocket, or
  mortar fire                                                    1648/1960 (84)    753/872 (86)    740/802 (92)
----------------------------------------------------------------------------------------------------------------
Being shot at or receiving small-arms fire                       1302/1962 (66)    826/886 (93)    779/802 (97)
----------------------------------------------------------------------------------------------------------------
Shooting or directing fire at the enemy                           534/1961 (27)    672/879 (77)    692/800 (87)
----------------------------------------------------------------------------------------------------------------
Being responsible for the death of an enemy
  combatant                                                       229/1961 (12)    414/871 (48)    511/789 (65)
----------------------------------------------------------------------------------------------------------------
Being responsible for the death of a
  noncombatant                                                     17/1961 (1)     116/861 (14)    219/794 (28)
----------------------------------------------------------------------------------------------------------------
Seeing dead bodies or human remains                               771/1958 (39)    832/879 (95)    759/805 (94)
----------------------------------------------------------------------------------------------------------------
Handling or uncovering human remains                              229/1961 (12)    443/881 (50)    445/800 (57)
----------------------------------------------------------------------------------------------------------------
Seeing dead or seriously injured or killed                        591/1961 (30)    572/882 (65)    604/803 (83)
----------------------------------------------------------------------------------------------------------------
Knowing someone seriously injured or killed                       850/1962 (43)    751/878 (86)    693/797 (87)
----------------------------------------------------------------------------------------------------------------
Participating in demining operations                              314/1962 (16)    329/867 (38)    270/787 (34)
----------------------------------------------------------------------------------------------------------------
Seeing ill or injured women or children
  whom you were unable to help                                    907/1961 (5)     604/878 (69)    665/805 (83)
----------------------------------------------------------------------------------------------------------------
Being wounded or injured                                           90/1961 (5)     119/870 (14)     75/803 (9)
----------------------------------------------------------------------------------------------------------------
Had a close call, was shot or hit, but
  protective gear saved you                                         --      67/870 (8)      77/805 (10)
----------------------------------------------------------------------------------------------------------------
Had a buddy shot or hit who was near you                            --     192/880 (22)    208/797 (26)
----------------------------------------------------------------------------------------------------------------
Clearing or searching homes or building                          1108/1961 (57)    705/884 (80)    695/805 (86)
----------------------------------------------------------------------------------------------------------------
Engaging in hand-to-hand combat                                    51/1961 (3)     189/876 (22)     75/800 (9)
----------------------------------------------------------------------------------------------------------------
Saved the life of a soldier or civilian                           125/1961 (6)     183/859 (21)    150/789 (19)
----------------------------------------------------------------------------------------------------------------
* Data exclude missing values, because not all respondents answered every question. Combat experiences are
  worded as in the survey.
 The question was not included in the survey.

VA Ignored 2008 IOM Study Linking Deployment to PTSD and Suicide
    VA missed their second opportunity to issue new regulations 
streamlining PTSD claims when an IOM review of peer-reviewed scientific 
research concluded that PTSD and suicide are associated with deployment 
to a war zone:

          The epidemiologic literature on deployed vs. nondeployed 
        veterans yielded sufficient evidence of an association between 
        deployment to a war zone and psychiatric disorders, including 
        post traumatic stress disorder (PTSD), other anxiety disorders, 
        and depression; alcohol abuse; accidental death and suicide in 
        the first few years after return from deployment; and marital 
        and family conflict, including interpersonal violence (emphasis 
        added).\4\
---------------------------------------------------------------------------
    \4\ IOM, Gulf War and Health: Volume 6. Physiologic, Psychologic, 
and Psychosocial Effects of Deployment-Related Stress, 2008, page 319, 
http://www.nap.edu/catalog.php?record_id=11922.

    Similarly, VA ignored two prior IOM reports on PTSD. In 2006, IOM 
validated the diagnosis of PTSD and listed war zone exposures not 
---------------------------------------------------------------------------
directly associated with combat:

          A war environment is rife with opportunities for exposure to 
        traumatic events of many types. Types of traumatic stressors 
        related to war include serving in dangerous military roles, 
        such as driving a truck at risk for encountering roadside 
        bombs, patrolling the streets, and searching homes for enemy 
        combatants, suicide attacks, sexual assaults or severe sexual 
        harassment, physical assault, duties involving graves 
        registration, accidents causing serious injuries or death, 
        friendly fire, serving in medical units, killing or injuring 
        someone, seeing someone being killed, injured, or tortured, and 
        being taken hostage.\5\
---------------------------------------------------------------------------
    \5\ IOM, Subcommittee on Post-Traumatic Stress Disorder of the 
Committee on Gulf War and Health: Physiologic, Psychologic, and 
Psychosocial Effects of Deployment-Related Stress, ``Post-Traumatic 
Stress Disorder: Diagnosis and Assessment'' 2006, http://www.nap.edu/
catalog/11674.html.

    In 2007, a third IOM report addressed VA's concerns regarding the 
steep increase in disability payments made to veterans service-
connected for PTSD. During the period from 1999 to 2004, the amount of 
money VA paid rose from $1.72 billion to $4.28 billion.\6\ To explain 
the rise in PTSD benefit payments, the IOM concluded that:
---------------------------------------------------------------------------
    \6\ IOM, ``PTSD Compensation and Military Service'' 2007, http://
www.nap.edu/catalog.php? record_id=11870.

          PTSD can develop at any time after exposure to a traumatic 
        stressor. The scientific literature does not identify any 
        differences material to the consideration of compensation 
        between delayed-onset or delayed-identification cases and those 
        chronic PTSD cases where there is a shorter time interval 
        between the stressor and the recognition of symptoms.\7\
---------------------------------------------------------------------------
    \7\ Ibid.

    VA leaders could and should have promptly issued regulations to 
streamline PTSD claims based on the best available current scientific 
literature, including three separate IOM reports.
VA Ignored Growing Disability Claims Backlog, Now Nearly 900,000
    VA missed their third opportunity to issue improved PTSD 
regulations when the claim backlog ballooned over the past few years. 
The disability claims backlog has soared, from just over 600,000 in 
January 2004 to nearly 900,000 in March 2009.\8\
---------------------------------------------------------------------------
    \8\ VA, ``Monday Morning Workload Report,'' Mar. 14, 2009, 
indicates 697,000 claims of all types pending at VA regional offices 
plus another 190,000 claims pending at VA's Board of Veterans Appeals.
---------------------------------------------------------------------------
    VA's current claims backlog nightmare includes more than 60,000 
pending claims from Iraq and Afghanistan war veterans for any type of 
medical condition. To date, more than 370,000 Iraq and Afghanistan war 
veterans have filed a disability claim against VA for any type of 
condition, overwhelming evidence that the two current wars are creating 
a sustained and significant hardship on VA's already broken claims 
system.\9\
---------------------------------------------------------------------------
    \9\ VA, ``VA Benefits Activity: Veterans Deployed to the Global War 
on Terror,'' Mar. 2009.
---------------------------------------------------------------------------
    VA could and should have issued new regulations to expedite PTSD 
claims in order to break the bottleneck of 900,000 claims awaiting 
adjudication.
VA Ignored PTSD Claims Filed by Iraq and Afghanistan War Veterans
    VA missed their fourth opportunity for new regulations when the 
Department learned that only half of the Iraq and Afghanistan war 
veterans diagnosed with PTSD received PTSD disability compensation 
benefits from VA.
    According to the most recent VA reports obtained exclusively by VCS 
using the Freedom of Information Act (FOIA), more than 105,000 Iraq and 
Afghanistan war veterans were diagnosed by VA with PTSD.\10\ However, 
only 51,000 Iraq and Afghanistan war veterans were granted disability 
benefits by VA for PTSD.\11\
---------------------------------------------------------------------------
    \10\ VA Facility Specific OIF/OEF Veterans Coded with Potential 
PTSD, 4th Qt FY 2008, Dec. 23, 2008.
    \11\ VA, ``VA Benefits Activity: Veterans Deployed to the Global 
War on Terror,'' Mar. 2009.
---------------------------------------------------------------------------
    More than 338,000 Iraq and Afghanistan war veterans are at risk of 
developing PTSD. According to a 2008 report by RAND, 18.5 percent of 
the 1.83 million servicemembers deployed to the Iraq and Afghanistan 
war zones are expected to return home and develop PTSD.\12\
---------------------------------------------------------------------------
    \12\ RAND, ``Invisible Wounds: Mental Health and Cognitive Care 
Needs of America's Returning Veterans,'' Apr. 17, 2008.
---------------------------------------------------------------------------
    PTSD among deployed veterans may be further exacerbated by the high 
rates of military sexual trauma (MST) among Iraq and Afghanistan war 
veterans.\13\
---------------------------------------------------------------------------
    \13\ Blumenthal, Les, ``VA Struggles to Gear Up to Care for Female 
Veterans,'' McClatchy News, May 18, 2009, http://www.mcclatchydc.com/
reports/veterans/story/37409.html.
---------------------------------------------------------------------------
    According to VA's National Center for PTSD, MST is a very serious 
problem among both female and male Iraq and Afghanistan war veterans:

          Among [Iraq and Afghanistan war] veterans, nearly one in 
        seven women, about 15 percent, who accessed care through VA 
        screened positive for MST and 0.7 percent of males also 
        reported having experienced MST. Both males and female [Iraq 
        and Afghanistan war] veterans who reported a history of MST 
        also were more likely to be diagnosed with a mental health 
        condition than patients who did not report an experience of MST 
        in their history.\14\
---------------------------------------------------------------------------
    \14\ VA, National Center for PTSD, Fact Sheet, ``Female OIF/OEF 
Veterans Report Military Sexual Trauma--Associated with Higher Rates of 
Mental Health Problems--October 2008.''

    Based on VA's estimate of 15 percent, more than 30,000 of our 
female servicemembers experienced MST while deployed to the Iraq and 
Afghanistan wars. Similarly, based on an estimate of 0.7 percent, more 
than 11,000 of our male servicemembers experienced MST while deployed 
to the two current wars. The grand total could be as high as 41,000 MST 
cases from the Iraq and Afghanistan war zones.
    VA could and should have issued new rules based on the tidal wave 
of Iraq and Afghanistan war veterans diagnosed by VA with PTSD who are 
filing disability claims against VA for PTSD, including those who 
experienced MST while deployed to war.
VA Rejected VCS Request for Streamlined PTSD Regulations
    VA missed their fifth opportunity to write new PTSD regulations 
when VCS wrote a letter to VA requesting the Department use their rule-
making authority to address the growing crisis.
    On January 26, 2009, VCS wrote VA Secretary Eric Shinseki asking VA 
to issue streamlined PTSD regulations based on the IOM report and the 
failure of VA to approve PTSD claims filed by Iraq and Afghanistan war 
veterans.
    The rule change VCS sought was simple and straightforward: we 
clearly demonstrated how science supported the rule and how veterans 
are being harmed by on-going VA failures. VCS provides a copy of our 
letter to VA for the Subcommittee's records.
    On February 27, 2009, VA's Chief of Staff, John Gingrich, wrote to 
VCS and rejected our request for streamlined PTSD claim regulation. 
Tragically and inexplicably, VA ignored the overwhelming scientific 
evidence, ignored the growing claims backlog, and ignored the pressing 
needs of our Iraq and Afghanistan war veterans. VCS provides a copy of 
VA's incomprehensible and outrageous rejection letter for your records.
    VA could and should have issued new rules based on our letter and 
the new scientific evidence.
VA Confirmed PTSD Claim Fraud is Not a Problem
    During 2005, as the number of PTSD claims filed by veterans 
continued to increase, VA leaders tasked VA's Office of the Inspector 
General to review PTSD claims that were already approved. According to 
a VA statement issued in 2005:

          The problems with these files appear to be administrative in 
        nature, such as missing documents, and not fraud. . . . In the 
        absence of evidence of fraud, we're not going to put our 
        veterans through the anxiety of a widespread review of their 
        [approved PTSD] disability claims. . . . Instead, we're going 
        to improve our training for VA personnel who handle disability 
        claims and toughen administrative oversight.\15\
---------------------------------------------------------------------------
    \15\ VA, ``No Across-the-Board Review of PTSD Cases--Secretary 
Nicholson,'' press release quoting then Secretary James Nicholson, Nov. 
11, 2005. http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1042.

    VA confirmed fraud is not a problem. Rather, poor documentation, 
poor training, and poor administrative oversight by VA were the actual 
culprits. VA could and should have instituted better documentation, 
better training, and better administrative oversight.
VA Should Launch Campaign to De-Stigmatize PTSD
    VA, Congress, and veterans groups should do more to end 
discrimination against veterans with mental health conditions. In our 
view, passage of H.R. 952 may further assist veterans by reducing the 
stigma that two medical research studies found often prevents veterans 
from seeking medical care.\16\
---------------------------------------------------------------------------
    \16\ RAND, ``Invisible Wounds: Mental Health and Cognitive Care 
Needs of America's Returning Veterans,'' Apr. 17, 2008; Hoge, Charles, 
et al., ``Combat Duty in Iraq and Afghanistan, Mental Health Problems, 
and Barriers to Care,'' New England Journal of Medicine, 2004.
---------------------------------------------------------------------------
    VCS encourages veterans with mental health conditions to reach out 
to VA for assistance. We also urge VA to be ready, willing, and able to 
assist veterans by providing both prompt mental health care and 
disability benefits when veterans seek help--especially for PTSD.
Urgent Unmet Need: Congress Should Act Now to Assist Veterans
    The scientific evidence is overwhelming: engaging in combat with 
the enemy can and does cause PTSD among some veterans. In addition, the 
scientific evidence concludes that deployment itself, without combat, 
is also linked to PTSD and suicide. Due to VA's cumbersome, complex, 
and adversarial rules for veterans diagnosed with PTSD to prove the 
existence of a combat stressor incident, VA takes longer than 6 months 
to process PTSD claims. As a result, VA's claim system becomes further 
mired in a growing backlog of benefit requests.
    VCS believes a fair and reasonable way to resolve this situation, 
keeping with VA's stated objective of putting veterans first, would be 
to define combat under the law (38 USC Sec. 1154) as deployment to any 
nation or body of water declared a war zone by the Department of 
Defense. Deployment itself, not combat with the enemy, should be 
considered the stressor for PTSD claims, as the IOM study concluded.
    In an effort to resolve VA's claim crisis, VCS urges Congress to 
pass H.R. 952 as soon as possible because of VA's continued adversarial 
policies against veterans and because VA has utterly failed to address 
the PTSD claim disaster. VA's crisis is expected to worsen 
significantly as the two current wars continue and multiple deployments 
increase.\17\ Based on VA's health care use reports indicating 10,000 
new, first-time Iraq and Afghanistan war veterans flooding into VA each 
month, VCS estimates VA may diagnose and treat total of 450,000 mental 
health patients by the end of 2013, including as many as 250,000 
diagnosed with PTSD.
---------------------------------------------------------------------------
    \17\ Tyson, Ann Scott, ``Repeat Tours Raise Risk of PTSD, Army 
Finds,'' Washington Post, Dec. 20, 2006, http://www.washingtonpost.com/
wp-dyn/content/article/2006/12/19/AR2006121901659. html.
---------------------------------------------------------------------------
    Now is the time to fix the problem of unreasonable claim delays for 
veterans with PTSD so they can receive the disability benefits needed 
and earned in a timely manner. With a new law, VA should be able to 
quickly approve tens of thousands of PTSD claims filed by Iraq and 
Afghanistan war veterans that remain mired in VA red tape. Veterans of 
other conflicts may also find justice with the passage of H.R. 952.
    VA should and could be putting disability benefits into the hands 
of deserving veterans during the current economic crisis when their 
need is most acute. A timely and proper adjudication of claims may make 
the difference between staying in a home or living on the streets for 
veterans, especially veterans deployed to a war zone with PTSD.
    Although enactment of H.R. 952 may cost billions of dollars in the 
short-term, these are entitlement payments VA will eventually pay to 
veterans and survivors. This is true because VA confirms fraudulent 
claims are nearly non-existent. VA may actually realize a cost savings 
and improved efficiency when VA employees now working on complex and 
time-consuming PTSD claims are freed up to process other disability 
compensation claims of equally deserving veterans.

                   MATERIAL SUBMITTED FOR THE RECORD
                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Ian De Planque
Assistant Director, Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, DC 20006

Dear Mr. De Planque:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed followup 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
                                                The American Legion
                                                    Washington, DC.
                                                        May 4, 2009

Honorable John J. Hall, Chairman
Subcommittee on Disability Assistance and Memorial Affairs
Committee on Veterans' Affairs
U.S. House of Representatives
337 Cannon House Office Building
Washington, DC 20515

Dear Chairman Hall:

    Thank you for allowing The American Legion to participate in the 
Subcommittee hearing on March 24, 2009, entitled ``The Nexus between 
Engaged in Combat with the Enemy and PTSD in an Era of Changing Warfare 
Tactics.'' I respectfully submit the following response to your Post-
Hearing Question:

Question 1: What is the American Legion's position on the VA rule-
making process that promulgated regulations for defining combat?

Response:

a.
      During the process of the implementation of the Congressional 
action which resulted in the creation of 38 USC Sec. 1154 VA conducted 
an examination to determine whether the phrasing used by Congress in 
passage of the Bill was significant. What VA determined was that 
Congress had, in other legislation, distinguished Combat Zone, but 
here, in this legislation, specifically described ``combat with the 
enemy,'' therefore indicating that the intent was there to 
differentiate.

b.
      The American Legion disagrees with this interpretation for a 
number of reasons, not least of which is the profound recognition that 
the conditions and expectations of warfare in 1941 were very different 
than what soldiers in later conflicts would face.

c.
      In 1941, with Europe and mainland Asia erupting into combat, but 
no direct experience of U.S. servicemembers involved, the primary 
experience of warfare to consider was World War I and the emerging 
details of World War II. World War I, as any student of basic history 
will be cognizant of, was marked by uniformed combatants, defined 
trenches of battle lines, clearly drawn across the fields of Europe in 
mud and barbed wire. Even in the emerging battlefields of World War II, 
it would become clear that the distinction between lines of battle and 
the rear echelons was widely apparent. Artillery fire did indeed bring 
the fighting to some in the rear, but the vast majority of action seen 
was by combat arms soldiers on the pointy front end of combat.

d.
      Flash forward several years and we began to see changes. Vietnam 
was marked by stealthy guerilla warfare ``behind the lines'' as well as 
what would be considered today terrorist bombings on the streets of 
Saigon. Remote forward operating bases sometimes required 
servicemembers to take up arms in activities not normally considered 
part of their military specialty. When the numbers of Infantrymen grow 
short, you must still defend your perimeter utilizing clerks, cooks, 
whoever can hold a rifle and remember their Basic Training.

e.
      As we watch the events of the modern warfare conducted by the 
United States and its allies in the Global War on Terror, nobody can 
doubt that the expectations and face of the battlefield have 
substantially changed over the last 70 years. Regularly stories are 
shown of supply clerks, of mechanics, or communications specialists and 
other servicemembers not traditionally thought of as combat soldiers 
engaging in activity against the enemies. We see IEDs detonated in the 
streets as a commonplace event. We see journalists cringe from incoming 
rocket fire, and Members of Congress and the USO wearing protective 
vests and helmets as they visit troops even in locations in the heart 
of the so called ``Green Zone'' of safety in Iraq or at Bagram Air Base 
in Afghanistan. We know that the danger is all around the brave men and 
women who fight for this country.

f.
      The American Legion believes strongly that the legislative intent 
of section 1154 (b) is to recognize the difficulties inherent in record 
keeping in combat, and to provide a means to assist the men and women 
of this country in proving the occurrence of events under these 
difficult conditions. What we have seen time and time again in the 
advocacy for veterans is that the very same conditions which make the 
proving of individual events difficult further make the proving of an 
individual's participation in the combat a great difficulty. Yet we 
know these servicemembers face these conditions day in and day out. 
Therefore it is the belief of The American Legion that the legislative 
intent, which must be recognized, or amended to specifically state 
such, is to recognize the word of these servicemembers under combat 
conditions to be true and honorable as long as they are consistent with 
the conditions and hardships of battle in the combat zone.

Question 2: What would you suggest be the standard for combat related 
stressors and who should make that determination?

Response:

a.
      This could potentially be seen as two questions. Decisions 
revolving around the adequacy of stressors to trigger PTSD are 
specifically stated in the Diagnostic and Statistical Manual of Mental 
Disorders (4th Edition, 1994. The 5th Edition is current under revision 
for estimated distribution in 2012). A medical opinion is necessary to 
determine the adequacy of a stressor event in triggering PTSD. 
Therefore, the determination as to whether a combat event ``meets the 
standard'' for PTSD in terms of severity of experience should be made 
by a medical expert.

b.
      If however, this question is interpreted to mean-what is the 
standard for determining if an incident is combat related and should 
fall under the criteria of 38 USC Sec. 1154 with regard to confirmation 
of the occurrence of the event through lay testimony alone, then one 
must examine the standard already existing to measure if claimed events 
described by a servicemember are acceptable under 1154 where combat has 
been confirmed.

   i.
         Such actions as are consistent with the circumstances, 
conditions or hardships of combat.

c.
      It is the position of The American Legion that the interpretation 
of 1154(b) should be recognized for all soldiers serving in a combat 
zone (to be adequately determined by conference with the Secretaries of 
Defense and of the Department of Veterans Affairs) when describing the 
occurrence of events ``consistent with the conditions and hardships of 
combat.'' This provision was meant to reduce the heavy burden of proof 
required in recognition of the exigencies of record keeping on the 
battlefield. It is the position of The American Legion that the 
dispersed nature of the modern non-linear battlefield has rendered the 
battlefield less clear, and thus a more broad net must be cast to 
capture the conditions the provision was intended to remedy.

Question 3: In your testimony, you stated that VA overdevelops claims. 
Can you explain this contention further and give examples of how this 
occurs?

Response:

a.
      VA is often presented with evidence, anecdotal or non-traditional 
in the sense of concrete military records, which would tend to confirm 
the veteran's statements and allow them to move on with their 
adjudication. However, they continue to ignore this information and 
continually send out for records which may or may not even exist, 
further lengthening the process through exhaustive record searches.

b.
      Furthermore, VA tends to get locked in on proving ``combat'' and 
overlook that they may have already proved the existence of an event 
specific to the veteran. Once they determine that a veteran was in a 
convoy they then have to go back to the beginning of the process and 
start tracking the events of the convoy. They continue to find more and 
more questions that need to be answered as each new piece of evidence 
is uncovered.

c.
      When VA discovers each new piece of evidence, they must then 
contact the veteran, let the veteran know they are in receipt of such 
evidence, and then seek to confirm the next piece in the puzzle rather 
than taking a holistic approach which could drastically simplify 
things.

d.
      A veteran could be sent for an exam in which the doctor confirms 
the veteran has PTSD and links it to the experiences described by the 
veteran. VA denies this claim because they don't find evidence of the 
stressor. Later, through Herculean efforts the veteran manages to prove 
that not only were they stationed at a firebase in the middle of the 
heart of the Tet Offensive. However, VA determines that they must still 
confirm that this firebase . . . in the heart of the fighting of the 
Tet Offensive, actually took fire. Eventually this is proven. Now VA 
decides to send the veteran BACK for another examination because ``now 
they can confirm the incident.'' This is obviously a needlessly lengthy 
and convoluted process for something that should be conducted more 
smoothly.

e.
      Something further to consider, which could greatly reduce the 
number of bounce back examinations described above, would be to either 
wait to conduct the examinations until the events are proven, or to 
direct the examining physicians to assume for the purposes of the 
examination, that all statements regarding stressors or incidents 
described by the veteran are true when considering their diagnosis.

   i.
         In the second part of the above example, if VA finds clear and 
convincing evidence later that the events did not occur, then that 
knowledge could be applied to assess the validity of the diagnosis. 
However, should VA determine that the events described occurred, they 
would be in possession of enough evidence to grant the claim and reduce 
the backlog by not keeping claims around needlessly in endless 
development.

Question 4: When The American Legion conducts its quality reviews with 
NVLSP, does it evaluate the accuracy and completeness of PTSD C&P 
examinations being used by the adjudicators? What issues, if any, has 
the organization been able to identify during these site visits 
regarding PTSD claims?

Response:

a.
      In conducting the quality reviews, The American Legion and NVLSP 
review all aspects of accuracy in the claims processed through the 
Regional Offices (RO's). A common theme throughout many RO's is the 
inadequacy of the exams being conducted. One of the most consistent 
problems noted in PTSD exams is that examiners are being asked to 
examine the veterans without evidence of a stressor event--leading them 
to state they cannot confirm a diagnosis without a confirmed stressor. 
Also, very often medical examiners will review the medical aspects of a 
claims file, but not the personnel portions of the file from the 
military record. In some cases, subsequent exams when an advocate has 
directed the examiner to note the patterns of behavior before and after 
the claimed stressors (for a servicemember with exemplary service 
before a stressor event and extremely derelict service afterwards) the 
examiner will note that the changes in behavior are consistent with the 
behavioral changes associated with PTSD type disorders.

b.
      However, it is also important to point out that many types of 
examinations are inadequately performed at the RO level, and end up 
being remanded by the Board of Veterans' Appeals (BVA) for the 
performance of an adequate examination. Although it is beyond the PTSD 
oriented purview of this question, an overall effort to get the 
examinations right the first time would go a long way to reducing the 
backlog by removing a lot of the cases clogging the system that could 
be removed from consideration if they were adjudicated properly the 
first time.

Question 5: In PTSD cases where the veteran does not have the required 
medals or awards, what does a service officer do to develop the claim?

Response:

a.
      To assist a veteran in developing claims of this nature, service 
officers will try to seek some additional types of information which 
may confirm the claimed stressor or incident in service.

   i.
         By combing the veteran's military files, hopefully the 
personnel records can confirm which units the veteran was assigned to 
for which dates. Then, sometimes, unit records can be obtained which 
would help establish events for non-combat servicemembers such as 
mechanics or other non-Infantry soldiers who may not have decorations 
indicating combat.

   ii.
         In the above examples, advocates often will try to track down 
information from independent research regarding which units were 
stationed where (which firebases in Vietnam for example) and then see 
if they can establish any incidents which affected the LOCATION. If a 
unit can be placed at a location when an incident occurred, the veteran 
is assumed, in the absence of clear evidence to the contrary, to have 
been present with their unit.

   iii.
         Also, sometimes a search of back issues of hometown or 
national newspapers document the occurrence of some of these issues. 
These newspaper articles would require a good deal of research to track 
down.

   iv.
         By asking the veterans to try to dig up old photos and old 
letters home which could confirm any of the claimed events. Sometimes, 
such as in the case of communications soldiers who are seconded out to 
other units to provide support in the field, a diligent service officer 
can associate the veteran with a unit they were temporarily assigned to 
by identifying the unit patches on soldiers in a photograph. Keep in 
mind such activities are very time consuming and difficult.

   v.
         As a last resort, the veteran can submit their own lay 
testimony, which VA is usually reluctant to accept, and/or the 
testimony of other witnesses who were present for the events described. 
This is a lesser course of action because 1) it can be difficult to 
find old members of the unit, especially after many, many years; and 2) 
VA must ``weigh'' the lay testimony against the balance of the case and 
generally does not accept it if there is no independent military 
records confirming the lay testimony.

Question 6: In the experiences of The American Legion Service Officers, 
does VA accept the lay statement of a veteran when he/she has not 
already met the criteria in 38 USC Sec. 1154(b) by establishing that 
they had engaged in combat with the enemy? Or, does the veteran have to 
first prove combat before VA uses the lay statement to identify the 
specific stressor?

Response:

a.
      Although this is largely anecdotal and we have no exact figures 
on this, the overwhelmingly prevalent situation is that without proving 
combat, the VA is very reluctant to accept lay evidence to confirm a 
stressor. This occurs even in situations when a veteran has presented 
stressor descriptions in detail relating stressor events which mirror 
those expressed by the veteran as a part of an examination by a 
psychiatrist. Even in cases where the psychiatrist clearly diagnoses 
PTSD and relates it to a described stressor by the veteran, unless the 
veteran can provide military records to document a combat event, VA is 
reluctant to acknowledge the stressor and grant the service connection 
for PTSD.

b.
      Sometimes a veteran will also supply supporting statements from 
other veterans who served with them in their unit. Again, the VA 
frequently does not accept these statements without independent 
confirmation in military records, citing to their requirements to weigh 
the validity of lay testimony.

c.
      The one area where there has been some success is in situations 
where the veteran may have a postmarked letter from the dates 
described, say a 1968 letter to their parents from Vietnam, which 
describes the circumstances claimed, and/or if the veteran can provide 
verifying photographs as detailed above. There have been more successes 
in establishing the credibility of this lay evidence, although even 
this is not always foolproof.

d.
      Ultimately, one of the largest difficulties in this area is that 
recognition of these types of evidence is widely inconsistent between 
not only Regional Office to Regional Office, but even Rater to Rater 
within certain RP's.

    Thank you for your continued commitment to America's veterans and 
their families.

            Sincerely,

                                 Ian De Planque, Assistant Director
                       National Veterans Affairs and Rehabilitation

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Thomas Berger, Ph.D.
Senior Analyst for Veterans' Benefits and Mental Health Issues
Vietnam Veterans of America
8605 Cameron Street, Suite 400
Silver Spring, MD 20910

Dear Mr. Berger:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed followup 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
        Questions from the House Committee on Veterans' Affairs
       Subcommittee on Disability Assistance and Memorial Affairs
    Hearing on ``The Nexus Between Engaged in Combat With the Enemy
            and PTSD in an Era of Changing Warfare Tactics''
                             March 24, 2009

    Question 1: In your testimony you cited the findings of the 
National Vietnam Veterans Readjustment Study regarding PTSD in Vietnam 
veterans. How can this study further inform Congress to better help 
future generations of veterans while still meeting the needs of Vietnam 
veterans who enter the VA disability claims processing system?

    Response: The National Vietnam Veterans Readjustment Study (NVVRS) 
is the largest nationwide psychiatric study of veterans ever conducted 
to date. Results of the NVVRS demonstrated that some 15.2 percent of 
all male and 8.5 percent of all female Vietnam theater veterans were 
current PTSD cases (i.e., at some time during 6 months prior to 
interview). Rates for those exposed to high levels of war zone stress 
were dramatically higher (i.e., a fourfold difference for men and 
sevenfold difference for women) than rates for those with low-moderate 
stress exposure. Rates of lifetime prevalence of PTSD (i.e., at any 
time in the past, including the previous 6 months) were 30.9 percent 
among male and 26.9 among female Vietnam theater veterans. Comparisons 
of current and lifetime prevalence rates indicate that 49.2 percent of 
male and 31.6 percent of female theater veterans, who ever had PTSD, 
still had it at the time of their interview. The NVVRS also found that 
African American veterans and Latino veterans not only had a higher 
rate of PTSD, but also were much less likely to seek assistance. Thus 
the NVVRS was a landmark investigation in which a national random 
sample of all Vietnam Theater and era veterans, who served between 
August 1964 and May 1975, provided definitive information about the 
prevalence and etiology of PTSD and other mental health readjustment 
problems in comparison with a random sample of those who had never 
served in the military. The study over-sampled African-Americans, 
Latinos, as well as women, enabling conclusions to be drawn about each 
subset of the veterans' population.
    Subsequently in August 2006, the preeminent research journal, 
Science, published a study by Dr. Bruce Dohrenwend and colleagues that 
included a re-analysis of the NVVRS data. After application of a 
particularly rigorous method for validating combat exposure was applied 
to the data, their re-analysis concluded that nearly one out of every 
five (18.7 percent) Vietnam veterans had experienced post-traumatic 
stress disorder (PTSD) and that nearly one out every ten (9.1 percent) 
Vietnam veterans was still suffering from chronic and disabling PTSD, 
more than 10 years after the war had ended. In VVA's opinion, this 
study only underscores our belief that the Congressionally mandated 
NVVRS followup study be conducted so that there can truly be a 
longitudinal study of Vietnam veterans that will be useful both for us 
and for the veterans who follow us.

COMPARISONS WITH OTHER STUDIES
    There are two other studies under consideration by the VA for 
establishing prevalence rates, course, and physical health outcomes 
associated with PTSD. The ``Vietnam Veteran Twin Registry'' was 
assembled some 15 years ago to conduct behavioral genetics studies. The 
goal was to determine if a wide range of psychological, neurological, 
and behavioral conditions could be related to a common genetic pattern. 
The Twin Registry was established by recruiting male-male twin pairs 
using a wide variety of approaches to identifying the pairs. However, 
VVA's concerns about this registry for establishing prevalence of PTSD 
and related problems are:

      The study is too simple to be substituted for the NVVRS.
      Twins are inherently not representative of the population 
who served in the war.
      Recruitment strategies didn't focus on random selection 
nor representativeness.
      The registry doesn't include women; only male twins are 
included.
      The registry doesn't reflect the racial and ethnic 
diversity of those who served in Vietnam. It is a registry that is 
largely and disproportionately Caucasian.
      The vast majority of the early work on the sample was 
conducted through the mail with only recent studies employing state of 
the art measurement of PTSD.

    A second ongoing study that is supported by the VA is a risk and 
resiliency study of Persian Gulf War 2 active duty military soldiers. 
This ``Deployment Health Study'' by J. Vasterling and S. Proctor is 
examining risk factors for health, mental health and cognitive 
functioning prior to and at intervals following deployment. The samples 
included in this study are also not representative of all military 
serving in OIF-OEF as they were selected based upon the willingness of 
commanders of several military bases to participate. The sample, thus, 
isn't able to answer or address questions about prevalence of PTSD or 
any condition among individuals in service in Afghanistan or Iraq. The 
sampling again is very selective and may possess significant biases 
from which erroneous conclusions could be drawn about the prevalence of 
PTSD, its nature and its course. Obviously, this study tells us nothing 
about the long-term course of PTSD in Vietnam veterans, nor the long-
term physical health implications of being afflicted with PTSD for 
decades.
    Through the initial NVVRS the American public and medical community 
has become aware of the high rates of current and lifetime PTSD, and of 
the long-term consequences of high stress war zone combat exposure, 
enabling better policies and services available to military personnel 
returning from deployments today. Because of its unique scope, the 
NVVRS has had a large effect on VA and Department of Defense (DoD) 
policies, and direct health care delivery and services planning.

    Question 1(a): Does VVA have additional recommendations for 
research to improve the disability claims process for veterans with 
PTSD?

    Response: Another noteworthy NVVRS finding was the unusually high 
number of health problems reported by veterans who served in the 
Vietnam theater of operations. This finding is consistent with a 
steadily growing body of research evidence suggesting a link between 
PTSD and physical health conditions, such as cardiovascular disorders, 
for example, as well as related mental health problems such as chronic 
depression. Therefore, in VVA's opinion, only completion of the NVVRS 
followup could best establish the bases for any additional research 
needed to improve the disability claims process for veterans suffering 
with PTSD.

    Question 2: What has been the impact to Vietnam veterans suffering 
from PTSD who have been denied compensation?

    Response: Generally the impact has been devastating, including for 
some the risk of homelessness, substance abuse, unemployment, and 
suicide. However, the most obvious impact is the loss of hope in 
achieving any meaningful quality of life, followed closely by an ever-
increasing sense of abandonment by the nation they so proudly served.
    Lastly, language for the NVVRS follow up has been included in the 
past two Congressional budget proposals, but not acted upon. More 
importantly, however, despite the law requiring it and the 
recommendation of the Institute of Medicine of the National Academies 
of Science in July 2007 that the VA move forward to complete the NVVRS 
follow up study, the VA remains obdurate in its refusal to adhere to 
the law and good sense, and complete the study as directed by the 
Congress. Therefore, the need is for Congress to obtain accountability 
from the VA in this matter, as VVA's presumption is that the current VA 
Secretary will follow the letter of the law.
    Thank you for the opportunity to provide this information, and 
please let me know if there are any additional questions.

                                            Thomas J. Berger, Ph.D.
     Senior Analyst for Veterans' Benefits and Mental Health Issues
                                        Vietnam Veterans of America

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Carolyn Schapper
Member
Iraq and Afghanistan Veterans of America
308 Massachusetts Ave., NW
Washington, DC 20002

Dear Ms. Schapper:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed followup 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman

                               __________
     Answers to Additional Questions From the March 23rd Hearing on
        ``The Nexus Between Engaged in Combat With the Enemy and
              PTSD in an Era of Changing Warfare Tactics''
               Carolyn Schapper, IAVA Veteran Spokeswoman

    Question 1: In your statement you noted that life in Iraq and 
Afghanistan is combat. Can you describe other types of stressful events 
besides rocket attacks, IED, or weapons fire that might also cause a 
servicemember to develop PTSD?

    Question 1(a): In the experiences of Iraq or Afghanistan veterans 
would you say that a stressor might be one event or could it be 
multiple events or hardships?

    Response: In my statement I stated that some of my fellow female 
servicemembers consider life in Iraq and Afghanistan as combat, and 
this statement was to imply that life on a base, for even those who do 
not leave, can be considered combat because of the constant threat of 
mortars and rocket fire, which is a very real threat. I, personally, 
did leave base and had exposure to IEDs and sniper-fire in addition to 
mortars and rockets while on base. So, there is no way that I can 
quantify what is real for people who did not have my experience.
    Regarding whether it takes one incident or several incidents to 
create a stressor significant enough to lead to PTSD it is 
unfortunately not an easy answer. I have no doubt that a person that 
was involved in one significant event that caused injury or death can 
have PTSD. Again, I cannot answer for others and how they process their 
experiences. Personally, I experienced seven significant events 
involving vehicle damage and/or enemy contact within 100 yards, which 
all factor into my PTSD. There is no way for me to remove myself from 
six of these events to determine if one of them would have led to 
adjustment issues.

    Question 2: At the hearing on March 24, 2009, you urged a stronger 
presence of women veterans' centers. How could these centers better 
assist female veterans 
file claims for PTSD when they have been in combat or experienced a sexu
al trauma?

    Response: Women Veterans' Centers can assist female veterans 
primarily through addressing comfort levels. It is not an 
understatement that women who have been traumatized by combat or MST 
can feel intimidated in relaying their experiences to males. We feel 
like we will be judged in a more skeptical manner than our male 
counterparts would be. Therefore, these centers would assist females 
just through their very existence. If women knew they had the 
opportunity to go to a VA center that routinely deals with females I 
believe more women would be likely to seek help and counseling. This 
would include having all-female PTSD groups.
    Personally I feel very uncomfortable going to the VA because of the 
predominance of males at the VA. I am the obvious ``other'' which leads 
to uncomfortable looks and questions. If I knew there would be more 
women seeking services at the VA I would not feel as uncomfortable 
going there as I do now.
    However, all this being said, I would like to point out that the VA 
does have some very significant women's services, such as a state of 
the art breast cancer research center. The VA has reached out to women 
and the issues that affect them, but there is certainly more that can 
be done to make women more willing to get the help they deserve.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Dean G. Kilpatrick, Ph.D.
Member, Committee on Veterans' Compensation for
  Posttraumatic Stress Disorder
Institute of Medicine
500 Fifth Street, NW
Washington, DC 20001

Dear Mr. Kilpatrick:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed follow-up 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
committee and subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
          Dr. Dean Kilpatrick's Response to Questions Posed by
   The Honorable John J. Hall, Chairman, Subcommittee on Disability 
 Assistance and Memorial Affairs, House Committee on Veterans' Affairs
 Pursuant to the Hearing on ``The Nexus Between Engaged in Combat With 
       the Enemy and PTSD in an Era of Changing Warfare Tactics''
                             March 24, 2009

    Question 1: What does the IOM mean by a comprehensive, consistent 
and rigorous PTSD evaluation process? Does VA have such a process?

    Response: Our IOM committee (the Committee on Veterans' 
Compensation for Post-Traumatic Stress Disorder) concluded the 
following in its report PTSD Compensation and Military Service (IOM, 
2006):

          The most effective strategy for dealing with problems with 
        self-reports of traumatic exposure is to ensure that a 
        comprehensive, consistent, and rigorous process is used 
        throughout the VA to verify veteran-reported evidence. (p. 194)

    The committee's report did not detail the elements of such a 
process but did cite examples:

          One approach to achieving this objective is routine and 
        consistent use of the full range and battery of methods 
        implemented and tested by Dohrenwend and colleagues (2006). The 
        best-practice manual for C&P examinations, written by VA 
        clinicians, already recognizes the value of careful and in-
        depth review of records (Watson et al., 2002). (p. 174)

    Although our committee did not recommend mandating use of the Best 
Practice Manual, this manual offers guidelines for assessing traumatic 
exposure that represent the type of comprehensive, consistent, and 
rigorous evaluation process that the committee recommended.

    Question 1(a): How well does VA use its own Best Practice Manual 
for PTSD C&P Exams?

    Response: Our committee did not conduct a systematic assessment of 
the content of, nor of the average length of time taken to complete, VA 
PTSD compensation and pension (C&P) examinations; and it did not 
collect data on the frequency with which the procedures contained in 
the Best Practice Manual (Watson et al., 2002) were used. However, it 
did obtain anecdotal information on the process. Testimony presented to 
the committee indicated that clinicians often feel pressured to 
severely constrain the time that they devote to conducting a PTSD C&P 
examination--to as little as 20 minutes (Arbisi, 2006)--even though the 
examination protocol suggested in the Best Practice Manual requires up 
to 3 hours to complete, with additional time needed for complex cases.
    In my opinion, this information suggests that use of the Best 
Practices Manual was not universal when the Committee conducted its 
review. In fairness to the VA, it is possible that the agency may have 
subsequently implemented some of the Committee's recommendations 
concerning C&P exams, so the best way to answer this question would be 
to ask the VA to provide current data.

    Question 2: Is the VA's regulation requiring certain awards and 
medals to document a stressor for PTSD consistent with the DSM-IV 
criteria for the diagnosis?

    Response: According to the DSM-IV criteria for the PTSD diagnosis, 
a characteristic set of symptoms must develop following exposure to an 
extreme traumatic stressor (APA, 2000). The text describing the types 
of traumatic stressors that qualify includes events that are directly 
experienced, witnessed, or learned about (IOM, 2006; p. 72). Many of 
these traumatic stressors are relevant to and can occur during military 
service (e.g., military combat; sexual assault; being kidnapped or 
taken hostage; torture; incarceration as a prisoner of war or in a 
concentration camp; severe motor vehicle accidents; observing serious 
injuries or deaths of others due to assaults, accidents or war; 
learning about serious injury or deaths of friends). Veterans who have 
experienced some of these types of traumatic stressors might receive 
awards or medals documenting their exposure, but it is unlikely that 
exposure to many of these traumatic stressors would result in awards or 
medals. In any case, the DSM-IV diagnostic criteria for PTSD do not 
require having received an award, medal, or other independent 
recognition of exposure to a traumatic stressor for that stressor to 
count as a traumatic stressor.
    The committee was not aware of an explicit VA regulation requiring 
certain awards or medals to document a stressor. It was aware that VA 
values such devices and other documentation found in military personnel 
records--duty stations and assignments, military occupational 
specialties (MOS), and related administrative information--because they 
are perceived as unbiased evidence that can corroborate or refute 
claimants' accounts. The committee noted and commented--on page 193 of 
its report--on a student guide produced by the Veterans Benefits 
Administration (VBA) for use in the training of examiners (VBA, 2005), 
stating:

          . . . a great deal of guidance is given on various service 
        medals and devices that can be used to support PTSD claims and 
        on how to use DoD resources to corroborate possible combat-
        related traumatic exposures.

    The Student Guide delineates a number of decorations that ``may 
serve as evidence that the veteran engaged in combat'' but indicates 
that the evaluation needed to support an assertion that a claimant 
served in the area in which the incident stressful event is reported to 
have occurred is to be ``made on an individual case basis following 
analysis of all the evidence of record, particularly the veteran's 
description of the events'' (p. 8).
    As my testimony indicated, much of the research that the committee 
examined calls into question whether the information available in the 
military personnel files is always adequate to evaluate trauma exposure 
and notes circumstances--notably, cases of military sexual assault--
where veterans are less likely to receive service connection for PTSD 
as a consequence of the relative difficulty of substantiating exposure 
to noncombat traumatic stressors.
    The VA's disability examination workshop for an initial evaluation 
of PTSD states that:

          [s]ervice connection for post-traumatic stress disorder 
        (PTSD) requires medical evidence establishing a diagnosis of 
        the condition that conforms to the diagnostic criteria of DSM-
        IV, credible supporting evidence that the claimed in-service 
        stressor actually occurred, and a link, established by medical 
        evidence, between current symptomatology and the claimed in-
        service stressor (IOM, 2006; p. 224; quoting the workshop 
        contained at the following Web address: http://www.vba.va.gov/
        bln/21/Benefits/exams/disexm 43.htm).

    The committee's report indicates that C&P examinations ``. . . 
differ in both scope and purpose from standard clinical examinations, 
as their core function is to provide VBA staff with the evidentiary 
foundation with which a claim for a service-connected disability can be 
rated or denied'' (IOM, 2006; p. 89). It goes on to discuss the ways in 
which C&P exams deviate from examinations that clinicians administer in 
diagnostic and treatment settings. Quoting Greenberg and Shuman (1997), 
the report notes on page 89:

          In most instances, it is not realistic, nor is it typically 
        the standard of care, to expect a therapist to be an 
        investigator to validate the historical truth of what a patient 
        discusses in therapy. . . . In contrast, the role of a forensic 
        examiner is, among other things, to offer opinions regarding 
        historical truth and the validity of the psychological aspects 
        of . . . claims. The accuracy of this assessment is almost 
        always more critical in a forensic context than it is in 
        psychotherapy (Greenberg and Shuman, p. 53).

    The requirements for documentation of a stressor for service 
connection of PTSD thus go beyond the diagnostic criteria set out in 
the DSM-IV (APA, 2000), but it must be remembered that the C&P exam has 
a different intent than the diagnostic evaluation set forth in the DSM.

    Question 3: If Congress were to redefine the criteria for 
determining combat engagement to include a theater of combat operations 
do you think it would improve the claims process or harm it?

    Response: Our IOM Committee did not address this question directly 
and did not make recommendations regarding it. Therefore, this response 
reflects my own opinion and not necessarily that of the Committee.
    In my opinion, there are two advantages to clarifying the meaning 
of ``combat with the enemy'' to include service in a theater of combat 
operations. First, this change would highlight the fact that exposure 
to the types of traumatic stressors that can cause PTSD is no longer 
limited to those with particular Military Occupational Specialties or 
who are serving at the ``front lines.'' The distinction between serving 
at the front line in a combat role and at the rear in a supporting role 
is certainly less pronounced than it was in World War II, and anyone 
serving anywhere in a theater of combat operations is at risk of 
experiencing a wide variety of stressor events capable of producing 
PTSD. Second, establishing service connection for PTSD would still 
require an examiner to gather information about the actual traumatic 
events that the veteran reported they experienced within the theater of 
combat operations and to determine if these events were causally 
related to their PTSD symptoms. It would therefore be impossible for an 
examiner to diagnose PTSD and to establish that it is service-connected 
without obtaining information about specific traumatic events that 
happened to the veteran and determining that exposure to these events 
were causally related to the PTSD and/or had aggravated preexisting 
PTSD.
    For these reasons, it is my opinion that this change would improve 
the claims process--not harm it.
References
    APA (American Psychiatric Association). 2000. Diagnostic and 
Statistical Manual of Mental Disorders DSM-IV-TR, Fourth Edition (Text 
Revisions). Washington, DC: APA.
    Arbisi PA. 2006 (July 6). Issues and Barriers to Implementation of 
Best Practice Guidelines in Compensation and Pension Examinations. 
Presentation to the Committee on Veterans' Compensation for Post 
Traumatic Stress Disorder. Washington, DC.
    Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koenen KC, Marshall 
R. 2006. The psychological risks of Vietnam for U.S. veterans: a 
revisit with new data and methods. Science 313:979-982.
    Greenberg SA, Shuman DW. 1997. Irreconcilable conflict between 
therapeutic and forensic roles. Professional Psychology: Research and 
Practice 28(1):50-57.
    IOM (Institute of Medicine). 2006. PTSD Compensation and Military 
Service. Washington, DC: The National Academies Press. [Online] 
Available: http://books. nap.edu/catalog.php?record_id=11870 [accessed 
April 20, 2009].
    VBA (Veterans Benefits Administration). 2005. Post-Traumatic Stress 
Disorder--Student Guide. Washington, DC:Department of Veterans Affairs.
    Watson P, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane T, 
Hamblen JL. 2002. Best Practice Manual for Posttraumatic Stress 
Disorder (PTSD) Compensation and Pension Examinations. [Online]. 
Available: http://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf 
[accessed April 20, 2009].

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Terri Tanielian
Study Co-Director, Invisible Wounds of War
RAND Center for Military Health Policy Research
1776 Main Street P.O. Box 2138
Santa Monica, CA 90407-2138

Dear Ms. Tanielian:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed follow-up 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
Responses of Terri Tanielian and Christine Eibner,\1\ Study Co-Director
        Invisible Wounds of War Study Team, The RAND Corporation
In Response to Questions From the House Committee on Veterans' Affairs 
       Subcommittee on Disability Assistance and Memorial Affairs
  Hearing on ``The Nexus Between Engaged in Combat With the Enemy and 
              PTSD in an Era of Changing Warfare Tactics''
                             March 24, 2009

    Chairman Hall, thank you for requesting answers to your followup 
hearing questions. My responses appear below, following each of your 
questions which are repeated here.
---------------------------------------------------------------------------
    \1\ The opinions and conclusions expressed in this testimony are 
the authors' alone and should not be interpreted as representing RAND 
or any of the sponsors of its research. This product is part of the 
RAND Corporation testimony series. RAND testimonies record testimony 
presented by RAND associates to Federal, State, or local legislative 
Committees; Government-appointed commissions and panels; and private 
review and oversight bodies. The RAND Corporation is a nonprofit 
research organization providing objective analysis and effective 
solutions that address the challenges facing the public and private 
sectors around the world. RAND's publications do not necessarily 
reflect the opinions of its research clients and sponsors.

    Question 1: The information contained in the Invisible Wounds of 
War Report is very impressive; however it seems there are still some 
unanswered questions. If you were going to recommend further study, 
what would you suggest that the VA or DoD study in order to better 
assist veterans with PTSD? What other data would we need to further 
---------------------------------------------------------------------------
develop the cost estimate model used by RAND?

    Response: We will answer each of these sub-questions in turn. 
First, our recommendations for further study:
    In many respects, the Invisible Wounds of War study raises more 
research questions than it provides answers. Better understanding is 
needed of the full range of problems (emotional, economic, social, 
health, and other quality-of-life deficits) that confront individuals 
with post-combat post traumatic stress disorder (PTSD). This knowledge 
is required both to enable the health care system to respond 
effectively and to calibrate how disability benefits are ultimately 
determined. Greater knowledge is needed to understand who is at risk 
for developing mental health problems and who is most vulnerable to 
relapse, and how to target treatments for these individuals. We also 
need to be able to accurately measure the costs and benefits of 
different treatment options so that fiscally responsible investments in 
care can be made. We need sustained research into the effectiveness of 
treatments, particularly treatments that can improve the functioning of 
individuals who do not improve from the current evidence-based 
therapies. Finally, we need research that evaluates the effects of 
policy changes implemented to address the injuries of veterans who 
served in Operations Enduring and Iraqi Freedom (OEF/OIF), including 
how such changes affect the health and well-being of the veterans, the 
costs to society, and the state of military readiness and 
effectiveness.
    Addressing these vital questions will require a substantial, 
coordinated, and strategic research effort. We see the need for several 
types of studies to address these information gaps. A coordinated 
Federal research agenda on these issues within the veterans' population 
is needed. Further, to adequately address knowledge gaps will require 
funding mechanisms that encourage longer term research that examines a 
broader set of issues than can be financed within the mandated 
priorities of an existing funder or agency. Such a research program 
would likely require funding in excess of that currently devoted to 
PTSD research through DoD and the VA, and would extend to the National 
Institutes of Health, the Substance Abuse and Mental Health Services 
Administration, the Centers for Disease Control and Prevention, and the 
Agency for Health Care Research and Quality. These agencies have 
limited research activities relevant to military and veteran 
populations, but these populations have not always been prioritized 
within their programs. Initial strategies for implementing this 
national research agenda include the following:

      A large, longitudinal study on the natural course of 
these mental health and cognitive conditions among OEF/OIF veterans, 
including predictors of relapse and recovery. Ideally, such a study 
would gather data pre-deployment, during deployment, and at multiple 
time points post-deployment. The study should be designed so that its 
findings can be generalized to all deployed servicemembers while still 
facilitating identification of those at highest risk, and it should 
focus on the causal associations between deployment and mental health 
conditions. A longitudinal approach would also make it possible to 
evaluate how use of health care services affects symptoms, functioning, 
and outcomes over time; how TBI and mental health conditions affect 
physical health, economic productivity, and social functioning; and how 
these problems affect the spouses and children of servicemembers and 
veterans. These data would greatly inform how services are arrayed to 
meet evolving needs within this population of veterans. They would also 
afford a better understanding of the costs of these conditions and the 
benefits of treatment so that the nation can make fiscally responsible 
investments in treatment and prevention programs. Some ongoing studies 
are examining these issues (Smith et al., 2008; Vasterling et al., 
2006); however, they are primarily designed for different purposes and 
thus can provide only partial answers.
      Aggressive support for research to identify the most 
effective treatments and approaches, especially for TBI care and 
rehabilitation. Although many studies are already under way or under 
review (as a result of the recent congressional mandate for more 
research on Post traumatic stress disorder (PTSD) and traumatic brain 
injury (TBI), an analysis that identifies priority-research needs 
within each area could add value to the current programs by informing 
the overall research agenda and creating new program opportunities in 
areas in which research may be lacking or needed. More research is also 
needed to evaluate innovative treatment methods, since not all 
individuals benefit from the currently available treatments.
      Evaluations of new initiatives, policies, and programs. 
Many new initiatives and programs designed to address psychological and 
cognitive injuries have been put into place, ranging from screening 
programs and resiliency training, to use of care managers and recovery 
coordinators, to implementation of new therapies. Each of these 
initiatives and programs should be carefully evaluated to ensure that 
it is effective and is improving over time. Only programs that 
demonstrate effectiveness should be maintained and disseminated.

    Second, with respect to the data that would be needed to further 
develop our cost estimates. As we highlighted in our earlier testimony, 
based on limitations in the existing literature, our model only 
considers costs incurred within the first 1 to 2 years following 
deployment. We know the consequences of PTSD, depression, and TBI can 
extend beyond 2 years; however, estimating long-term costs is difficult 
because we have limited information on the long term course of illness 
for these conditions under different treatment regimes. Longitudinal 
data on servicemembers that tracked treatment use, remission, and 
relapse would be necessary to fully understand costs.
    Another limitation of our current model is that, because we did not 
have data from either DoD or the VA, we had to estimate costs based on 
TRICARE reimbursement rates, Medicare reimbursement rates, published 
literature, and civilian sources. More detailed cost and workload data 
from DoD and VA would allow us to estimate more accurate costs figures 
overall, and for these systems in particular.
    Finally, there are many potential consequences of PTSD, TBI, and 
depression that require further study before they can be definitively 
linked to the illnesses. For example, we know that veterans with PTSD 
and depression are more likely to be homeless than other veterans. 
However, it is unclear whether PTSD and depression caused this 
homelessness. It's possible that homelessness causes depression. A 
better understanding of the causal relationship between homelessness 
and mental illness would be needed in order to confidently ascertain 
costs. A similar argument could be made for other potential 
consequences of PTSD, TBI, and depression, including family strain, 
drug and alcohol abuse, and violent behavior. A longitudinal study of 
service personnel could be used to better understand the causal 
relationship between mental health and cognitive conditions and 
downstream consequences.

    Question 2: Based on your microsimulation model, could you estimate 
the cost to Congress, if veterans who have been deployed to a theater 
of combat operations were able to enter the disability compensation 
system within months of filing a claim rather than if they are denied?

    Response: Currently, our model is not designed to answer this type 
of question. In order to understand costs to Congress, we'd need better 
information on costs to DoD and the VA, as well as any costs incurred 
by SSA (e.g. through disability payments) as well as through CMS 
(Medicaid). We'd also need a better understanding of how disability 
payments and access to VA health systems improve outcomes. Access to 
cost information from DoD and VA would enable us to partially answer 
this question. However, longitudinal data would be required to fully 
understand how veteran's benefits mitigate against the negative 
consequences of PTSD, TBI, and depression.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Rear Admiral David Smith, M.D., SHCE, USN
Joint Staff Surgeon, Office of the Chairman of the Joint Chiefs of 
    Staff
Wounded and Survivor Care Task Force
U.S. Department of Defense
1400 Defense Pentagon
Washington, DC 20301

Dear Rear Admiral Smith:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed followup 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
        Response From Rear Admiral David Smith, M.D., SHCE, USN
                       U.S. Department of Defense
              To the House Committee on Veterans' Affairs
       Subcommittee on Disability Assistance and Memorial Affairs
  Hearing on ``The Nexus Between Engaged in Combat With the Enemy and 
              PTSD in an Era of Changing Warfare Tactics''
                             March 24, 2009

    Question 1: I understand that the Defense Department has a process 
for agreeing on terms, which it publishes in a Dictionary of Military 
and Associated Terms. Can you describe how DoD develops an agreed upon 
understanding for the terms that are entered into the Dictionary, and 
are they applied consistently throughout the branches?

    Response: Joint Publication (JP) 1-02, The Department of Defense 
Dictionary of Military and Associated Terms, (aka ``the DoD 
Dictionary'') contains terms and definitions that are commonly used 
throughout the DoD, but not adequately defined for DoD purposes in 
standard English-language dictionaries. These terms broadly underpin 
joint operations, education and training; as such, JP 1-02 definitions 
are best defined and introduced in a descriptive context that 
facilitates understanding.
    Terms in JP 1-02 come from four sources, as follows:

    a.
        Joint Doctrine. The 77-volume Joint Doctrine \1\ hierarchy 
issued under CJCS Title 10 authority consists of the principles that 
guide the employment of U.S. military forces in coordinated action 
toward a common objective. It represents what is taught, believed and 
advocated as what is right (i.e., what works best). Its purpose is to 
enhance the operational effectiveness of U.S. forces. Joint Doctrine is 
neither policy nor strategy; it is authoritative guidance that is 
implemented by a commander exercising judgment regarding a specific 
circumstance. Terminology routinely emanates from recording these 
principals; certain terms are therefore both defined and described in 
context. This is the preferred method as the narrative text of the 
doctrine provides contextual meaning.
---------------------------------------------------------------------------
    \1\ The current Joint Doctrine library can be found at: http://
www.dtic.mil/doctrine/nipr_ index.html.

    b.
        Policy Issuances. Policy issuances from the Secretary of 
Defense and the CJCS (specifically DoD Directives, DoD Instructions, 
and CJCS Instructions) have the authority of orders (vice the 
authoritative advice of Joint Doctrine). Certain terms are defined and 
then briefly described in context of these issuances. (Policy issuances 
do not normally have the space to provide full contextual meaning.)

    c.
        NATO Agreed. The North Atlantic Treaty Organization issues 
Allied joint doctrine and policy. Terms that emanate from those 
issuances, when agreed to by the U.S., may be entered in JP 1-02 to 
delineate their usage in a NATO context. (This is germane when a NATO 
definition may be different than a U.S. definition. Inclusion in JP 1-
02 cues U.S. users to the differences.)

    d.
        Specifically Directed. Certain terms will be incorporated in JP 
1-02 when specifically directed by either the Secretary of Defense or 
the CJCS. This normally occurs when development efforts regarding the 
other paths to inclusion requires a specific decision in order to 
progress.

    It should be noted that not all terms defined in Joint Doctrine, in 
DoD or CJCS policy issuances, or agreed to in NATO are entered into JP 
1-02. In the staffing relative to producing these items, terms proposed 
for inclusion in JP 1-02 are specifically so marked so that they may be 
considered in a DoD-wide context. Terms having specific, vice general 
application (e.g. limited applicability), such as those used in medical 
diagnosis or administrative determinations, are not considered 
appropriate for inclusion in the DoD dictionary.
    The administrative process regarding the inclusion of terms in JP 
1-02 involves DoD-wide \2\ staffing. During the staffing process, any 
DoD component may comment on a proposal recommending approval, 
disapproval, or modification. The CJCS, through the Joint Staff J-7, is 
responsible for resolving any contentious issues that arise during 
staffing.
---------------------------------------------------------------------------
    \2\ DoD components which review Terminology proposals are the 
Office of the Secretary of Defense, the Military Departments, the CJCS 
and the Joint Staff, the Office of the Inspector General of the DoD, 
the combatant commands, the DoD agencies, field activities, and all 
other organizational entities in the DoD.

    Question 2: Thank you for your observations on the problems with 
the DoD Disability Evaluation System. How would you suggest that DoD 
and VA work to streamline the process and correct deficits? a. What 
---------------------------------------------------------------------------
legislative fixes are you anticipating from Congress?

    Response: Since the passing of the Career Compensation Act of 1949, 
DoD and VA have operated parallel systems to examine, rate and 
compensate disabled veterans. DoD's responsibility is to make fit 
versus unfit determinations; our disability ratings and compensation 
are based solely on the unfitting conditions. In contrast, VA examines, 
rates and compensates veterans based upon all service-related disabling 
conditions. There are different ground-rules and evidentiary standards 
for each, and as a result, the parallel processes produce different 
results. This duplicative system is confusing and frustrating to 
servicemembers and veterans alike. Disability compensation rules 
further compound the problem, frequently resulting in DoD benefits paid 
to servicemembers which must then be repaid before VA benefits may 
begin.
    Prior to and since the aftermath of the Walter Reed articles in 
early 2007, multiple commissions and review groups have been chartered 
to evaluate and make recommendations on the treatment, rehabilitation 
and compensation of our wounded warriors and veterans. The Dole-
Shalala, Scott and Nicholson reports, in particular, recommended 
significant reform of the Disability Evaluation and Compensation 
Systems. The DoD, VA and Military Departments established a DES pilot 
program that has streamlined within the constraints of existing 
statutes, moving to a single physical exam (done by VA for both DoD and 
VA rating purposes) and reducing the timeline for some portions of the 
process.
    However, even with the DES pilot, the DoD and VA Disability and 
Compensation Systems are still frustrating and complex, and two 
separate ratings are still required by statute. It is our belief that 
the time has come for a more revolutionary, systematic overhaul of DoD 
and VA disability evaluation and compensation policy and procedures. 
Our vision is a disability and compensation system that simultaneously 
promotes ability--with the goal of returning all servicemembers or 
veterans to either continued service in the military or transition to 
productive lives in their community while the system appropriately 
compensates service-related disability. The path to this vision is not 
yet fully mapped, but we feel it is a journey worth taking, and we ask 
for your support.
    Some of the possible elements of the transformed system were 
outlined by the Dole-Shalala and Scott commissions to include: (a) 
elimination of parallel activities, e.g., DoD to only determine fitness 
and provide annuity benefits based on longevity and rank if found unfit 
and VA to provide all disability ratings and associated benefits; (b) 
restructuring disability payments in to three components: transition, 
earning loss, and quality of life payments (transition payments to 
provide a solid base for the return of injured veterans to productive 
lives and to improve vocational, rehabilitation, and education 
completion rates. The proposed system must be transparent, relatively 
simple and understandable by the patients and beneficiaries it affects.
    This issue has been identified by the Secretary of Defense (Sec. 
Gates) and Chairman of the Joint Chiefs of Staff as an important focus 
area for DoD and VA. To achieve this vision, continuing emphasis at the 
highest levels in both departments will be key components to successful 
analysis, determination of the specific components and enabling actions 
required for implementation, and ultimate achievement of the vision.
    In addition, the VA and DoD need to continue to evaluate and 
implement ``best practices'' from the civilian medical community for 
incorporation into DES as well. Electronic records and system 
interfaces which support sharing of medical and personnel information 
between DoD, the Military Health System and VA will go a long way 
toward correcting inefficiencies and expediting processes. President 
Obama \3\ has identified this as a key focus area for his 
administration. DoD and VA are moving toward solving this part of the 
problem, although we are in the very early stages of resolution.
---------------------------------------------------------------------------
    \3\ 09 April 2009, The White House Briefing Room Press Release, 
``President Obama announces the Creation of a Joint Virtual Lifetime 
Electronic Record.''
---------------------------------------------------------------------------
    We do not have specific legislative fixes identified for the DES or 
Joint Virtual Lifetime Electronic Record issues to support the outlined 
vision at this point.

    Question 3: In reviewing the single VA/DoD exam pilot program, what 
issues still need to be addressed in order to fully institute the 
program?

    Response: The DES pilot program was established as a test-bed for 
streamlined DES processes within present statutory constructs and 
includes, but is not limited to, the single physical exam done by VA 
for both DoD and VA rating purposes. Significant, positive steps have 
occurred as a result of this test program, but frustration persists 
with a complex system which still produces ratings which are used for 
two separate purposes (DoD--unfitting condition only and VA--total 
disability rating) and often results in DoD benefits which must be 
repaid before VA benefits may begin.
    The DES pilot program is being continually refined, and expansion 
to sites outside the National Capital Regions' resource-rich 
environment is moving forward. Differing levels of resources at 
outlying locations may necessitate significant modification of 
procedures or changes altogether.
    The 2007 Dole-Shalala report made the recommendation to 
``completely restructure the disability and compensation systems'' to 
``update and simplify the disability determination and compensation 
system, eliminate parallel activities, reduce inequities, and provide a 
solid base for the return of injured veterans to productive lives.'' 
\4\ The report also recommended that DoD and VA create individualized 
recovery plans for wounded servicemembers, help them navigate the 
complex systems through improved IT infrastructure and simplified 
underlying constructs, and improve the transfer of patient information 
across systems.\5\ The DoD and VA Recovery Coordination Programs 
provide Recovery Coordinators for seriously and severely injured 
servicemembers. Standard, uniform Comprehensive Recovery Plans are 
created for each recovering servicemember by their Recovery Coordinator 
and the Recovery Team. DoD and the Services are in the process of 
improving current IT systems to incorporate these plans. We would 
contend that all of these issues require more work to institute an 
improved program.
---------------------------------------------------------------------------
    \4\ July 2007 ``Serve, Support, Simplify''; Report of the 
President's Commission on Care for America's Returning Wounded 
Warriors, pg 6.
    \5\ July 2007 ``Serve, Support, Simplify''; Report of the 
President's Commission on Care for America's Returning Wounded 
Warriors, pg 6, 25-28.

    Question 4: Does the DoD Disability Advisory Committee that VA 
---------------------------------------------------------------------------
participates on provide any guidance on how to adjudicate PTSD claims?

    Response: The DoD Disability Advisory Council (DAC) operates under 
the policy coordinating guidance of the Office of the Under Secretary 
of Defense (Transition Policy and Care Coordination) (TPCC). Its 
permanent membership includes Office of the Assistant Secretary of 
Defense (Health Affairs), Office of the Assistant Secretary of Defense 
(Reserve Affairs), Office of the Deputy General Counsel (Personnel and 
Health Policy), and Office of the Deputy Under Secretary of Defense 
(Military Community and Family Policy) (Casualty Affairs). Each 
Military Department appoints knowledgeable representatives and the 
Secretary of the Department of Veterans Affairs is also asked to 
provide representatives from the Office of the Under Secretary of 
Benefits and the Under Secretary for Health Affairs.
    The primary objectives of the DAC are to ensure fair and equitable 
determination of servicemember fitness for continued duty; ensure the 
disability determinations are uniform across the Services; ensure 
servicemembers move through the DES process expeditiously and are 
knowledgeable about the process and kept informed of the status of 
their respective cases, and that due process rules are strictly 
followed; provide oversight and advice to the Director, TPCC and USD 
(P&R) regarding the efficient and effective management of the DES, and 
provide information for accession policy review.
    The DoD is required to rate disabilities using the Veterans Affairs 
Schedule of Rating Disabilities (VASRD). The DoD Disability Advisory 
Council is the chartered venue to discuss recommendations for changes 
in the VASRD with the VA. In January 2009, the VBA reported that they 
were convening a panel of subject matter experts to evaluate the degree 
to which the VASRD adequately provides appropriate considerations for 
rating those impaired by PTSD. The VBA has stated DoD experts will be 
invited to participate with their experts to update this section of the 
VASRD; with the next meeting scheduled for May 2009.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Colonel Robert Ireland
Program Director, Mental Health Policy
Office of the Assistant Secretary of Defense for Health Affairs
U.S. Department of Defense
1400 Defense Pentagon
Washington, DC 20301

Dear Colonel Ireland:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed followup 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
   Response from Colonel Robert Ireland, U.S. Department of Defense,
              To the House Committee on Veterans' Affairs,
      Subcommittee on Disability Assistance and Memorial Affairs,
  Hearing on ``The Nexus Between Engaged in Combat With the Enemy and 
              PTSD in an Era of Changing Warfare Tactics''
                             March 24, 2009

    Question 1: In your testimony you described the diagnostic process 
using the DSM-IV criteria for PTSD. Does DoD require further stressor 
documentation for diagnosis and a disability award? What if the 
servicemember's record does not indicate a specific event?

    Question 1(a): Does DoD determine if a servicemember has been 
engaged in combat with an enemy?

    Response: Our Military Health System clinicians focus on the 
clinical aspects of diagnosis and treatment of post-traumatic stress 
disorder (PTSD), including therapeutic management of those who 
experience traumatic stress. Those who suffer psychological stress from 
a motor vehicle accident who have no significant physical injuries are 
not required to produce a police report of the mishap. In the same 
fashion, treating clinicians do not initiate investigations to confirm 
traumatic combat or deployment related exposures. Rather, if a mental 
disorder is diagnosed, medical records should document how the patient 
meets the criteria for that disorder. If specific criteria required to 
make a particular diagnosis are not documented, then it cannot be 
established by such medical records that an individual has the 
disorder.
    When PTSD is diagnosed and treated by clinicians in the military 
(to include any identified stressors), it is for treatment and clinical 
management and not for consideration of disability award. When a 
member's medical condition(s) calls into question his/her ability to 
perform military duties, a medical evaluation board reviews the 
member's case. The member's case is referred to the Service's Physical 
Evaluation Boards (PEB) if the member fails to meet Service medical 
retention standards. While the member is being evaluated in the 
Disability Evaluation System for continued military service, his/her 
treatment and clinical management of medical condition(s) continue.
    The Service's PEB determine the member's fitness for continued 
service and, if found unfit, determine the rating percentage for 
compensation and pension, according to applicable code and regulations.

    Question 2: Does DoD have Combat Stress Teams that evaluate all 
servicemembers who have been on a deployment?

    Response: It is DoD policy that all servicemembers receive 
assessments through Post-Deployment Health Assessments (PDHA) and Post-
Deployment Health Reassessments (PDHRA). Questions on these assessments 
do evaluate servicemembers' stress-related issues. Referrals for 
further evaluations or treatment are made for the servicemember, if 
indicated.
    In addition, DoD has taken a proactive stance in addressing combat 
and other military life stressors of servicemembers. Combat and 
Operational Stress teams take on essential and integral roles in the 
continuous monitoring, prevention, and mitigation of stress injuries in 
servicemembers and units throughout the deployment cycle. Based on DoD 
Instruction 6490.5, ``Combat and Operational Stress Control (COSC) 
Programs,'' policies and programs are ``implemented throughout the 
Department of Defense to enhance readiness, contribute to combat 
effectiveness, enhance the physical and behavioral health of military 
personnel, and to prevent or minimize adverse effects that may be 
associated with Combat and Operational Stress Reactions and Injuries 
(COSR/Is).''
    The Services develop and coordinate their programs and teams, 
engage line leadership throughout the development and implementation of 
programs, and maintain common principles of combat and operational 
stress management of COSRs. Examples of these ongoing efforts include 
the Army's ``Battlemind Warrior Resiliency'' COSC Detachments and 
embedded behavioral health assets within Brigade Combat Teams; the Air 
Force's ``Landing Gear'' program; and the Marine Corps Operational 
Stress Control and Readiness (OSCAR) programs. The Services COSC 
programs share common objectives for their members and include:

    1.  Preparing servicemembers for military operations;
    2.  Providing support during transitions;
    3.  Building resiliency through education and awareness;
    4.  Promoting family participation;
    5.  Reducing stigma associated with behavioral health and to 
promote psychological health; and
    6.  Assuring peer and line responsibility to ensure psychological 
health and readiness and to assure programs are socialized.

    Question 3: Does the Post Deployment Health Reassessment Program 
specifically screen for PTSD? If a servicemember is exhibiting symptoms 
of PTSD, what is the referral process?

    Response: The Post-Deployment Health Reassessment Program (PDHRA) 
is a clinical process designed to enhance the deployment-related 
continuum of care. Targeted at 3 to 6 months after returning from a 
contingency operation, the PDHRA provides education and a global health 
assessment to identify and facilitate access to care for deployment-
related physical health, mental health, and re-adjustment concerns. 
This is just one part of the DoD Health Assessment Cycle that includes 
Baseline Assessment (soon after accession), Periodic Health Assessment 
(annually), Pre-deployment Health assessment (no earlier than 60 days 
before deploying), Post-Deployment Health Assessment (within 30 days of 
return from deployment), and Separation-Retirement.
    Standardized questions covering symptoms of post-traumatic stress 
disorder (PTSD) are on the PDHRA. A primary care provider reviews the 
questions with each individual, interviews the servicemember and 
recommends additional specialty evaluation or treatment if clinically 
indicated. Quality assurance and program evaluation to assess program 
success is ongoing.
    Treatment and followup are arranged on a continuum of care model, 
building on DoD and Department of Veterans Affairs partnerships. The 
continuum ranges from the community-based support and preclinical 
counseling to referral for treatment in primary care, specialty care, 
or community-based education or counseling services, as warranted. In 
addition, the military health system added behavioral health providers 
to the staff of many primary care settings to facilitate access to low-
stigma care and support, specifically to provide referral care related 
to deployments.

    Question 4: In your testimony, you stated that DoD providers who 
administer the PDHRA will refer servicemembers to the VA Web site 
www.afterdeployment.org if they feel they would benefit from additional 
information on PTSD. Can they contact a clinician through the site or 
find peer support through blogging?

    Response: This is actually a DoD Web site that the Defense Centers 
of Excellence (DCoE) for Psychological Health and Traumatic Brain 
Injury has been collaborating on with subject matter experts from the 
Department of Veterans Affairs (VA). Beginning later this year, 
afterdeployment.org's Phase 3 development will be to provide users and 
senior leadership with interactive forums and features. Site 
enhancements will focus on incorporating innovative Web-based 
technologies, such as collaborative networking, podcasting, and 
blogging. Site design also will aim to provide users with up-to-date 
and user-friendly content-search and navigational systems. These 
features will be coordinated with the DCoE Outreach Center (866-966-
1020) to provide the user a coordinated experience in receiving 
information and resources. The DCoE Outreach Center affords 24/7 
availability of health resource consultants, although not in a direct 
clinical care role. Customers can engage one of our consultants via 
phone, email, and private chat (which will be accessible via the soon-
to-be-launched dcoeoutreach.org and realwarriors.net Web sites). Peer 
support will be available at both of these Web sites, but clinician 
care will not.

    Question 5: How does DoD identify Potentially Traumatic Events? Is 
combat stress debriefing attendance mandatory for all servicemembers 
after deployments and is participation documented in their service 
medical records?

    Response: Every servicemember can report a potentially traumatic 
event at any point of contact with the medical system. The report will 
become part of the permanent medical record. They also are prompted to 
report combat-related exposures and head injuries during the Post-
Deployment Health Assessment (PDHA) and Post-Deployment Health 
Reassessment (PDHRA) processes.
    Critical incident stress debriefing is not endorsed by DoD policy. 
Research has proven this type of intervention ineffective and 
potentially harmful. Commanders and small group leaders do conduct 
operational debriefings after combat operations, which has been found 
helpful for members to process the experience as well as to learn 
valuable operational lessons. Following deployments, all Services are 
required to provide education and a medical threat debriefing to 
returning servicemembers. These educational products are tailored to 
the specific culture and experiences of the different Services to 
improve their effectiveness. The Army uses BATTLEMIND, the Marines use 
Marine Operational Stress Training and Marine Corps Operational Stress 
Control and Readiness team training, and the Air Force uses Landing 
Gear. These programs provide information that will assist in processing 
possible trauma experienced during operational deployments, identify 
potential signs and symptoms to watch for during the reintegration 
period and beyond, and provide information about the many resources 
available for assistance. Medical threat debriefing is mandatory during 
the PDHA and education is mandated as part of the PDHRA process.

    Question 6: Has there been any concern that servicemembers 
returning from Iraq or Afghanistan are over or under reporting PTSD 
symptoms?

    Response: Two sources of data are used to estimate the prevalence 
of Post-Traumatic Stress Disorder (PTSD) among U.S. military deployers. 
These include clinically diagnosed cases of PTSD and self-reported 
symptoms of PTSD on a survey.
Diagnosed Cases of PTSD
    Between October 1, 2001, and December 31, 2008, there were 42,600 
servicemembers who were diagnosed with PTSD at some point following the 
start of a deployment in support of Operations Enduring Freedom or 
Iraqi Freedom (OEF or OIF). A case of PTSD is defined as having at 
least two outpatient visits or one or more hospitalizations at which 
PTSD was diagnosed. The threshold of two or more outpatient visits is 
used to increase the likelihood that the individual actually had PTSD. 
A single visit on record commonly reflects someone who was evaluated 
for possible PTSD, but did not meet the established criteria for the 
diagnosis.
    This number (42,600) represents 2.4 percent of the total number 
(1,769,116) of Active Duty, National Guard, and Reserve servicemembers 
who deployed for at least 30 days to OEF/OIF prior to January 1, 2009, 
according to the Defense Manpower Data Center deployment rosters.
    The number of diagnosed cases of PTSD reported above comes from the 
DoD electronic medical record system and only reflects conditions that 
are coded by the provider as PTSD. This does not include the treatment 
of PTSD symptoms that are coded as something other than PTSD.
    There are other important caveats to consider when interpreting 
these numbers. The analysis did not exclude servicemembers that had 
mental health encounters (including PTSD) prior to the first 
deployment. The analysis includes PTSD cases that occurred after a 
qualifying deployment regardless of how long after return the 
servicemember was first diagnosed--cases are not necessarily a result 
of an in-theater event. Results do not consider followup time for 
servicemembers (e.g., a servicemember who separates immediately after 
return from deployment carries the same weight as one who remained in 
service years after deployment). Identified cases only represent 
individuals who were diagnosed in a military medical treatment facility 
or where DoD was billed for medical care (e.g., TRICARE). Thus, OEF/OIF 
servicemembers who are not seeking treatment are not represented in the 
2.4 percent figure. Finally, information from Military OneSource, VA 
facilities, non-DoD insurance, and non-medical providers (clergy, etc) 
was not available. This analysis therefore likely underestimates the 
actual total number of PTSD cases.
Self-Reported Symptoms of PTSD on a Survey
    1. The Millennium Cohort study is a longitudinal stratified random 
sample of the military population followed for 20 years. Results from a 
recent study using these data indicated that 7.6 percent of cohort 
members who deployed and reported some sort of exposure to combat 
developed new onset of PTSD symptoms, compared with 1.4 percent of 
cohort members who were deployed and did not report combat exposures. 
These numbers exclude anyone with self-reported prior cases of PTSD, 
which means that servicemembers who had prior PTSD symptoms exacerbated 
by deployment would not be counted in these numbers. Furthermore, the 
cohort includes Air Force and Navy personnel, as well as Army personnel 
in a variety of support roles, many of whom would have had limited 
exposure to sustained ground combat experiences.
    2. Studies of Brigade and Regimental Combat Teams (BCTs and RCTs), 
which represent about 40 percent of the total deployed force and are 
known have greater exposure to sustained ground combat, have been 
surveyed using the same measures and scoring criteria as was used in 
the Millennium Cohort study. Investigators at the Walter Reed Army 
Institute of Research in a series of studies focused on BCTs and RCTs 
have shown that self-reported prevalence of PTSD symptoms during 
deployment and 3-12 months post-deployment ranges from 10-15 percent.
Summary
    The prevalence of clinically diagnosed cases of PTSD following a 
deployment to OEF/OIF is 2.4 percent, subject to the limitations noted 
above. Prevalence of PTSD symptoms based on self-reported surveys 
ranges from 1.4 percent (not exposed to combat) to 15 percent 
(populations exposed to sustained ground combat). As a comparison from 
previous conflicts, Dohrenwend et al.'s (2006) reanalysis of the 
National Vietnam Veteran's Readjustment Study found between 9.1 percent 
and 12.2 percent of combat-veterans met criteria for PTSD at the time 
of the evaluation, which is similar to the findings of BCTs and RCTs. 
The true prevalence of PTSD among OEF/OIF deployers is unknown but 
likely underestimated, primarily as a result of the well-documented 
presence of stigma surrounding the reporting of mental health symptoms. 
Efforts are underway to reduce the stigma of seeking mental health care 
in the military, including the launching of the Defense Centers of 
Excellence for Psychological Health and Traumatic Brain Injury's ``Real 
Warriors. Real Battles. Real Strength'' public awareness campaign in 
May of 2009. Until our efforts to change the culture related to seeking 
mental health care are more successful, our reported total cases of 
PTSD will likely continue to be somewhat of an underestimate.

    Question 7: DoD is using the VA Schedule for Rating Disabilities 
(VASRD) when determining fitness for duty and retirement for PTSD. Does 
the VASRD effectively reflect PTSD symptoms and level of impairment? 
What changes, if any, would you suggest be made to the VASRD so that it 
could be a more consistent, precise and standardized instrument for 
evaluating and rating PTSD?

    Response: The DoD is required to rate disabilities using the 
Veterans Administration Schedule for Rating Disabilities (VASRD). The 
DoD Disability Advisory Council (DAC) now includes members from the 
Department of Veterans Affairs (VA) and is the chartered venue to 
discuss recommendations for changes in the VASRD with the VA. The DAC 
recommended to the Veterans Benefits Administration (VBA) a formal 
review of the adequacy of the VASRD to effectively reflect PTSD 
symptoms and impairment. The VBA reported that they are convening a 
panel of subject matter experts for this purpose and has confirmed that 
DoD experts will be invited to participate with VA experts in updating 
this section of the VASRD; with the next meeting scheduled for May 
2009.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Bradley Mayes
Director, Compensation and Pension Service
Veterans Benefits Administration
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420

Dear Mr. Mayes:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed followup 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
                        Questions for the Record
                 The Honorable John J. Hall, Chairman,
      Subcommittee on Disability Assistance and Memorial Affairs,
                 House Committee on Veterans' Affairs,
 Nexus Between Engaged in Combat With the Enemy and PTSD in an Era of 
                        Changing Warfare Tactics
                             March 24, 2009
                     Questions for Bradley G. Mayes

    Question 1: As you acknowledged in your testimony, the language in 
section 1154 was enacted by Congress in 1941, and VA has had to base 
its rule making on it. Would you agree that 1941 language and the 
paradigm it represents is outdated and should be addressed by Congress 
to reflect a more modern era of warfare?

    Response: The purpose of section 1154 is to recognize that 
recordkeeping during combat activity is not first priority and 
particular combat events, as well as the resulting harm to the 
individuals involved, may not be documented. Therefore, Veterans who 
engaged in combat have a lowered evidentiary standard for service-
connecting disabilities incurred or aggravated during combat. We do not 
believe that this concept is outdated.
    Although the technology, tactics, circumstances, and nature of 
warfare have evolved since section 1154 was enacted, much remains the 
same. Combat military personnel continue to experience events that are 
not recorded and receive injuries that may not be treated in Theater. 
Even if a combat injury is treated in Theater, some documentation 
consists of single paper reports and servicemembers may be treated by 
more than one medical support unit. In such circumstances, there is 
significant potential for missing or late-flowing documentation that 
would support a Veteran's claim.

    Question 2: How is VA applying the benefit of the doubt rule in 
relation to section 1154(b) where it specifically states that VA shall 
accept lay evidence when there is no official record? Why does VA 
continue to develop those claims beyond the statement from the veteran? 
What constitutes sufficient evidence of combat participation?

    Response: The Department of Veterans Affairs (VA) provides Veterans 
with the benefit of the doubt in any claim-related decision where the 
evidence for and against an issue is evenly distributed. In such 
circumstances, VA regulations require that the decision be made in 
favor of the Veteran.
    With respect to section 1154(b), the Veteran's lay statement will 
establish the in-service incurrence or aggravation of a disease or 
injury if the available evidence shows engagement in combat; the 
Veteran alleges that the disease or injury was incurred in or 
aggravated in such service; and the allegations are consistent with the 
place, type, and circumstances of service. If the evidence for and 
against engagement in combat is in approximate equipoise, the Veteran 
will be given the benefit of doubt regarding any issue material to that 
determination. Awards or medals indicating combat participation, such 
as a Combat Infantryman Badge, Combat Action Ribbon, or Purple Heart 
Medal, will automatically establish combat status. When the Veteran 
claims combat participation, but there is no apparent evidence for this 
in the military records, VA will develop for evidence of combat 
participation. This involves researching the activities of the 
Veteran's unit at the time of reported combat participation. VA will 
request assistance from the Department of Defense (DoD) and the Joint 
Services Records Research Center if it is unable to find evidence of 
combat participation. When combat status is established, the lowered 
evidentiary standard established by section 1154(b) applies.

    Question 3: In a hearing last April, the Disabled American Veterans 
testified that VA has circumvented the law by conducting improper 
rulemaking through its Office of General Counsel and the adjudication 
procedures in the M21-1MR by requiring proof of combat in official 
military records. On what grounds does VA purport that it had the 
authority to redefine the intent of section 1154, which specifically 
states that no official records need be available?

    Response: VA has not circumvented the law, conducted improper 
rulemaking, or redefined the intent of section 1154(b). The statute 
provides a lowered evidentiary standard permitting use of satisfactory 
lay evidence as proof of service connection for a disease or injury 
alleged to have been incurred or aggravated if a Veteran ``engaged in 
combat with the enemy.'' This lowered evidentiary standard establishes 
sufficient ``proof'' that a claimed disease or injury was incurred or 
aggravated in active service; it is not a way for a Veteran to 
establish ``proof'' of combat participation when there is no other 
evidence of record showing combat participation. It is clear from the 
language of section 1154(b) that the phrase ``notwithstanding the fact 
that there is no official record'' is linked to the ``incurrence or 
aggravation in such service'' of a disability. It is the incurrence or 
aggravation of a disability during active service that does not require 
an official record. This is distinctly different from stating that 
there is no need for an official record or other credible evidence 
showing combat participation. With respect to M21-1MR, the procedural 
manual does not state that proof of combat must come from official 
military records. To the contrary, it is much more expansive. It 
states: ``There are no limitations as to the type of evidence that may 
be accepted to confirm engagement in combat. Any evidence that is 
probative of (serves to establish the fact at issue) combat 
participation may be used to support a determination that a veteran 
engaged in combat.''

    Question 4: Can you provide the Committee a breakdown of how many 
Veterans' claims were denied for PTSD by period of service, gender, and 
race for the last 5 years? How many are on appeal?

    Response: We are unable to provide the number of claims denied for 
post traumatic stress disorder (PTSD) for the last 5 years. The 
Veterans Benefit Administration (VBA) is converting all disability 
claims records from our legacy system benefit delivery network (BDN) to 
VETSNET. In cases where the rating is not currently in VBA's corporate 
database, the conversion creates a new ``rating'' with data from BDN. 
The ``rating'' date shows as the date of conversion, not the date the 
condition was granted or denied. Therefore, we cannot say with 
certainty when VA determined a condition to be service-connected or 
not. We also are unable to provide data concerning claims denied by 
period of service, race, or gender. Our corporate database shows that 
233,265 Veterans who filed claims for PTSD at anytime in the past were 
denied service connection for PTSD. As of September 30, 2008, there 
were 344,533 Veterans service-connected for PTSD. There are currently 
over 25,000 appeals involving PTSD.

    Question 5: What are the CPEP results on the overall quality of C&P 
exams when comparing exams conducted using templates to those conducted 
without using templates, and, specifically the results for veterans 
claiming PTSD? Please provide information on the use and frequency of 
the templates nationwide and by VISN and VAMC. What are VA's intentions 
regarding mandating the use of templates?

    Response: The compensation and pension examination program (CPEP) 
does not routinely identify the examination protocol used to prepare a 
report selected for quality review. Consequently, there is no current 
comparison data of the relative quality of template and dictated exam 
reports. However, a special study was conducted by CPEP during calendar 
2005 comparing the quality of reports prepared under the two protocols 
for PTSD examinations. The table below provides the results.


                   Examination Protocol (CY 2005 data)
                             Average Scores
------------------------------------------------------------------------
      Examination Type           Template        Dictated       p-value
------------------------------------------------------------------------
Initial PTSD                            95%             87%      0.0628
------------------------------------------------------------------------
Review PTSD                             96%             85%      0.0154
------------------------------------------------------------------------


    The p-value represents the probability that an equal or greater 
difference in average scores would be found in a repeated test if the 
difference observed in this test could be ascribed to chance alone. The 
low p-values signify that it is unlikely the differences seen in this 
test are attributable to chance alone.
    Since CPEP does not routinely track template use, the latest 
available data is from October 2007. At that time, approximately 28,000 
templates were used per month. For context, the total number of 
examinations the Veterans Health Administration (VHA) conducts per 
month ranges from about 40,000 to about 70,000.
    VA recognizes the value of exam reports that are reliably thorough 
and that use language designed to directly support consistent 
application of the rating schedule. VA is also aware, however, that the 
template application, while useful in its current form, is not yet a 
fully mature application. Certain practical matters must be resolved 
before any systemwide mandate can be considered. Ideally, the template 
application and output will soon be sufficiently superior to the 
traditional exam worksheet/dictation approach that no mandate of 
template use would be necessary. Clinicians would simply choose 
templates because they are more efficient and assure all exam issues 
are addressed. Rating Veterans service representatives (RVSR) and other 
users would prefer template-generated reports because they are more 
thorough, uniformly constructed, and easier to navigate than 
worksheets. Mandating the use of templates is still under discussion in 
VA, with careful consideration being accorded to issues of user 
acceptance.

    Question 6: What are the requirements for using templates for C&P 
exams by the VBA contractor? What are the results of analysis of the 
quality of exams in general and specifically for PTSD claims conducted 
by contract in comparison with exams conducted by VHA?

    Response: Two companies, QTC Management, Inc. (QTC), and MES 
Solutions (MES), conduct compensation and pension (C&P) exams. QTC uses 
a proprietary exam-reporting format that corresponds to the C&P exam 
worksheet protocol. MES also uses a proprietary exam-reporting format 
that corresponds very closely with the C&P exam worksheet protocol. VA 
does not currently anticipate any change in this arrangement. Both 
contractors post completed reports to a secure Web site for retrieval 
by the requesting regional office.
    C&P Service reviews the quality of contracted exam reports by 
quarter while CPEP reviews VHA quality. The following is the latest 
data on PTSD exam quality:


   CPEP (VHA) FY08 sample size  1,764 Initial PTSD; 1,764 Review PTSD
------------------------------------------------------------------------
       VHA Performance               FY2008           FY2009 (Sep-Dec)
------------------------------------------------------------------------
Initial PTSD                                  94%                   95%
------------------------------------------------------------------------
Review PTSD                                   91%                   86%
------------------------------------------------------------------------

    QTC and MES fiscal years run from May through April. C&P Service 
review yielded the following results. [QTC results shown cover May 
2008-January 2009; MES results cover August 2008-January 2009].

                QTC sample size:
                                   79 Initial PTSD; 15 Review PTSD
                MES sample size:
                                   14 Initial PTSD; 7 Review PTSD

------------------------------------------------------------------------
   Contractor Performance              QTC                   MES
------------------------------------------------------------------------
Initial PTSD                                98.9%                  100%
------------------------------------------------------------------------
Review PTSD                                  100%                  100%
------------------------------------------------------------------------


    Question 7: Can you tell the Committee more about the work that is 
underway to update the Rating Schedule criteria for PTSD? How is that 
work going to impact section 1154?

    Response: VBA and VHA are working together to conduct a mental 
health summit to be held sometime during the fourth quarter of fiscal 
year (FY) 2009 or first quarter of FY 2010. The summit will include a 
diverse representation of medical professionals from the Government and 
civilian sectors. The summit will focus on determining the most up-to-
date rating criteria for all mental disorders, including PTSD. This 
work will not impact section 1154.

                                 
                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Antonette Zeiss, Ph.D.
Deputy Chief Consultant, Office of Mental Health Services
Office of Patient Care Services
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420

Dear Ms. Zeiss:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed followup 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
                        Questions for the Record
                 The Honorable John J. Hall, Chairman,
      Subcommittee on Disability Assistance and Memorial Affairs,
                 House Committee on Veterans' Affairs,
 Nexus Between Engaged in Combat With the Enemy and PTSD in an Era of 
                        Changing Warfare Tactics
                             March 24, 2009
                  Questions for Antonette Zeiss, Ph.D.

    Question 1: What is different about how the VHA conducts C&P exams 
and how it conducts standard mental health assessments as referenced in 
your testimony? What is the process for each?

    Response: A standard mental health exam is performed for treatment 
purposes, and is comprised of a clinical interview with a progress note 
and a treatment plan. Both types of exams would use the Diagnostic and 
Statistical Manual of Mental Disorders (DSM-IV) to reach a medical 
conclusion. A C&P exam, however, is a disability exam performed for 
medical-legal purposes, not for treatment, and is governed by relevant 
statutes and regulations. The exam report is used as evidence by the 
Ratings Board to make service-connection determinations and to 
determine the average loss of earning capacity due to service-connected 
conditions. The C&P exam is documented by following the approved C&P 
worksheets or by using the compensation and pension records interchange 
(CAPRI) templates. A treatment plan is not provided as part of a C&P 
exam report.

    Question 2: In your testimony, you noted that the VHA has 
implemented the IOM recommendation that approximately 2 hours be 
allocated for PTSD C&P exams. What is the current VHA average time to 
complete these exams?

    Response: CPEP does not currently collect this data, and we do not 
have a database with this information. Anecdotally, 2 hours is the 
average time in which most providers can complete a mental health C&P 
exam, allowing 1 hour for the interview and 1 hour for documentation. 
More complex cases could take longer, up to 3 or 4 hours, but rarely 
would one be completed in less than 2 hours.
    Question 3: In your testimony you mentioned that VHA is addressing 
quality and accuracy of C&P exams for PTSD through training and 
certification. Please provide the Committee the syllabus for this 
training and the process by which certification takes place. Who is the 
certifying agency and is competency being certified?

    Response: The certifying agency is the employee education system 
(EES) in cooperation with CPEP. Courses are completed and recorded in 
the learning management system (LMS). There are six C&P certification 
modules with an online test associated with each one. The courses are: 
(1) general C&P certification, (2) musculoskeletal, (3) initial PTSD, 
(4) review PTSD, (5) initial mental diseases, and (6) review mental 
Diseases. The certification process ensures that the examiner has 
completed the training module and has passed a test certifying their 
knowledge and competency in understanding the requirements of a C&P 
exam. CPEP also maintains a separate list of certified C&P providers. A 
copy of the syllabus is attached. [The copies of the syllabus are being 
retained in the Committee files.]

    Question 4: What is the status of the Best Practices Manual for 
PTSD C&P Exams? Is it mandated for all PTSD C&P exams? Are there any 
plans to continuously update the manual?

    Response: The Best Practices Manual for PTSD C&P Exams is not 
currently mandated for all PTSD C&P exams. The manual is dated June 5, 
2002, and VA does not currently plan to revise it. VA does however plan 
to update the Mental Disorders section of the VA Schedule for Rating 
Disabilities (VASRD). VA exam protocols and guidance will be modified 
consistently with any future VASRD revisions as appropriate.

    Question 5: Are the electronic templates for PTSD C&P exams 
mandated? Are they available and used consistently throughout the 
VISNs?

    Response: CAPRI templates are not mandated. VA is aware that the 
current template application is not yet a fully mature application and 
is known to present some problems in data input for providers.

    Question 6: Does VHA have designated C&P examiners for mental 
health or is it a collateral duty?

    Response: Both methods are used. This is a local decision; it is 
made on a facility basis and varies from one examining site to another. 
Some exams are completed by contract providers.

    Question 7: Do you have access to Vet Center files when reviewing 
the patient treatment record before a C&P exam?

    Response: Vet Center counseling files are completely confidential 
and are not electronic. If the Veteran chooses to share this 
information, they can request that it be sent to the regional office 
and incorporated into their claims file (C-File), thus giving the 
examiner access to the information in those cases only.

    Question 8: What feedback, if any, does VHA get from the CPEP 
office?

    Response: CPEP provides monthly and quarterly quality scores, 
assessed by using quality indicator specific findings (which allows 
facilities to target improvement efforts). In addition, CPEP provides 
narrative explanations of our decisions in cases where the facility 
disagrees with a CPEP ``unmet'' score. CPEP provides detailed 
explanations on an individual basis to providers' questions regarding 
quality indicators in order to improve exam quality.

    Question 8(a): What does VHA do with those results?

    Response: Quality scores are a performance measure for Veterans 
Integrated Service Network (VISN) directors. Practices vary, but many 
C&P facilities use the feedback for instructional purposes for their 
examiners.

    Question 8(b): Are examiners held accountable for inaccurate or 
incomplete exams?

    Response: CPEP does not hold individual examiners accountable for 
inaccurate or incomplete exams. We review and score the exam reports 
for quality indicators and for timeliness. We do not track the accuracy 
of C&P exam reports. Incomplete exams would likely be identified as 
they would score poorly on our quality review. Given the sampling 
strategy (statistically significant at the VISN level based on a full 
fiscal quarter of data), CPEP review findings are not statistically 
significant for individual examiners.

    Question 9: Are primary care providers taking a complete military 
history when a Veteran first enrolls at a VA Medical Center?

    Response: 
Primary care providers perform a complete history and physical (H&P) 
when a Veteran is first assigned to the provider. A portion of the H&P 
is seeking information about military service to ensure proper 
screening for identified Veteran-specific concerns such as traumatic 
brain injury (TBI), Agent Orange, and PTSD.

    Question 10: In an era of changing warfare and tactics, is it safe 
to say that a stressor can be the result of individual perception? For 
instance, can the hardships of war, such as witnessing extreme poverty 
and destruction also be traumatic?

    Response: The definition of a stressor as it occurs in the 
Diagnostic and Statistical Manual of the American Psychiatric 
Association, DSM-IV-TR, includes the concept that events are stressors 
because of the perception of the individual who experiences them. No 
explicit list of stressors is given. Rather, the stressor must meet two 
criteria:

    1.  ``The person experienced, witnessed, or was confronted with an 
event or events that involved actual or threatened death or serious 
injury, or a threat to the physical integrity of self or others;
    2.  The person's response involved intense fear, helplessness, or 
horror.''

    The two examples in this question, extreme poverty and destruction, 
could meet this definition, if they involve ``threatened death or 
serious injury, or a threat to the physical integrity of self or 
others,'' if the individual who perceives such situations responds with 
``intense fear, helplessness, or horror.'' For example, seeing 
destruction in which there was clear loss of life or that created new 
threats to physical safety, for example after an earthquake while 
aftershocks continue, might be considered such a stressor. Extreme 
poverty that resulted in the death or potential death of others also 
could create such an experience. The question suggests that these might 
be considered stressors because of ``changing warfare and tactics''; 
again, the identification of such events as potential stressors has 
always been a component of the DSM-IV-TR definition of PTSD. Poverty 
and destruction are characteristics of many wars, throughout human 
history, not just a consequence of ``changing warfare and tactics.'' 
The crucial issue is whether the experiences fit the parameters 
thoughtfully laid out in DSM-IV-TR in defining stressors that meet 
Diagnostic Criterion A in the overall diagnostic criteria for PTSD.

    Question 11: In its testimony, the Vietnam Veterans of America 
noted the significant contributions of the National Vietnam Veterans 
Readjustment Study to inform our understanding of disabilities related 
to service in Vietnam. Public Law 106-419 required VA to conduct the 
National Vietnam Veterans Longitudinal Study and report by October 1, 
2004, which it has not done. Please provide VA's plan and timeline for 
implementing this study to bring the Department into compliance with 
the law.

    Response: When initially completed back in 1988, the National 
Vietnam Veterans Readjustment Study (NVVRS) did make a contribution to 
better understanding disabilities, including PTSD, in Vietnam Veterans. 
Many other research studies conducted since that time have even further 
improved our knowledge of the health care needs of Vietnam Veterans.
    VA is committed to answering the questions in Public Law (P.L.) 
106-419; however, there are serious scientific concerns about using the 
National Vietnam Veterans Longitudinal Study (NVVLS) approach to 
adequately answer the questions. The concerns include:

      The NVVLS has not undergone independent scientific peer 
review to evaluate methodology, assess merit or ascertain feasibility.
      The NVVRS used a complex and unconventional method to 
diagnose PTSD that has not been used in other studies. Since the NVVRS 
serves as the basis for the NVVLS according to P.L. 106-419, this is a 
serious constraint.
      The NVVRS was not designed as a longitudinal cohort 
study, causing possible bias in followup. The feasibility of re-
connecting with the original participants of the NVVRS is unknown, but 
likely to be low as longitudinal studies plan ways to keep cohorts 
intact through continuous contacts over time to ensure high 
participation rates.

    Because of these concerns, VA has alternatively supported a broad 
portfolio of rigorous scientific studies dedicated to addressing the 
needs of the Vietnam Veteran population. Notably, the Department has 
funded major research efforts, including the Vietnam Era Twins Registry 
(VET-R) longitudinal followup study entitled, A Twin Study of the 
Course and Consequences of Post-Traumatic Stress Disorder (PTSD) in 
Vietnam Era Veterans and is planning a study entitled, Determining the 
Physical and Mental Health Status of Women Vietnam Veterans. In 
addition to ongoing research, these two studies will provide answers to 
the questions posed in P.L. 106-419, for both male and female Vietnam 
Veterans. Detailed study overviews and timelines are attached.
    On January 16, 2009, the Secretary of Veterans Affairs, wrote to 
the House and Senate Committees on Veterans' Affairs and Subcommittees 
on Military Construction, Veterans Affairs and Related Agencies, 
Committees on Appropriations, requesting that the studies proposed as 
alternatives to a followup on NVVLS be accepted in lieu of the proposed 
followup in P. L. 106-419.
    Attached are overviews and timelines for the Vietnam Era Twins 
Registry and the Long-term Health Outcomes of Women Veterans' Service 
in Vietnam:
                       Attachments to Question 11
                   VA Cooperative Studies Program 569
             A Twin Study of the Course and Consequences of
                      PTSD in Vietnam Era Veterans
                      Study Overview and Timeline

Study Overview
    The purpose of this study is to describe and characterize the long-
term course and consequences of Post-Traumatic Stress Disorder (PTSD) 
in Vietnam era Veterans. CSP #569 will estimate the impact of the 
longitudinal course of PTSD on medical and psychiatric conditions and 
on functioning and disability. CSP #569 is a followup of a national 
sample of 7,172 male Vietnam era Veteran twins who were enrolled in the 
Vietnam Era Twin (VET) Registry in 1987. These Veterans were 
diagnostically assessed for PTSD in 1992 and are known to be alive in 
2007. The study will collect new data using a structured psychiatric 
assessment to assess current PTSD and, when combined with PTSD data 
from 1992, will be used to describe the long-term course of PTSD. A 
questionnaire will be used to collect information on physical health 
such as cardiovascular disease (validated by medical record review) and 
diabetes. Assessments of mental health outcomes, including depression, 
generalized anxiety disorder and substance use disorders, will also be 
conducted. Factors that may be related to the course and consequences 
of PTSD, such as physical health, health habits, psycho-social 
measures, and health services utilization will be collected. New data 
will be combined with extensive archival data (spanning over 20 years 
of studies from the VET Registry), and analyzed using epidemiologic and 
biometrical genetic methods. It is expected that results from this 4.5-
year study will have broad implications for the health and health care 
delivered to Vietnam era Veterans as well as Veterans of recent wars. 
In addition to this specific study, many efforts have been directed 
toward updating the entire VET Registry, including seeking IRB approval 
to re-consent the entire cohort.

Study Timeline




April 2006                                                                           Planning request approved.
May 2006                                                                Planning Committee membership approved.
October 2006                                                                     Planning Committee meeting #1.
October 2006                                                  Co-principal proponents appointed; VAMC approval.
January 2007                                                                     Planning Committee meeting #2.
February 2007                                                                    Planning Committee meeting #3.
April 2007                                                                  Proposal submitted for peer review.
June 2007                                                                        Peer review; funding approval.
October 2007                                                                   Human rights committee approval.
February 2008                                                      Revision to VET Registry recommended by ORO.
March 2008                                                                                 Contractor selected.
May 2008                                                                             Protocol submitted to IRB.
July 2008                                                                          Executive committee meeting.
August 2008                                                 Registry newsletter mailing with study information.
August 2008                                              Protocol submitted for Seattle R&D Committee approval.
Sept 2008                                                     Final submission of VET Registry protocol to IRB.
October 2008                                                        Study protocol submitted to VA Central IRB.
January 2009                                                    Central IRB approval (with minor modification).
March 2009                                                                         VET-Registry consent begins.
May 2009                                                             Recruitment/enrollment begins (tentative).
Mar 2009-Jun 2011                                        Data collection via mail survey & telephone interview.
Through 2011                                                              Data and safety monitoring continues.
December 2011                                                                 Study closeout; publish findings.


                   VA Cooperative Studies Program 579
    Long-term Health Outcomes of Women Veterans' Service in Vietnam
                      Study Overview and Timeline

Background

    The VA Office of Research and Development (ORD) has aggressively 
pursued an understanding of the causes and consequences of PTSD in 
women Veterans. For example, the recently completed ``Clinical Trial of 
Cognitive Behavioral Treatment for Post-Traumatic Stress Disorder in 
Women Veterans'' was a large, multi-site randomized clinical trial 
focusing exclusively on female Veterans and active duty personnel. It 
is important because of its focus on treatment exclusively for women 
Veterans as well as the evaluation of a psychotherapy. Results were 
published JAMA February 2007 and directly impact VA PTSD treatment. In 
addition, CSP566, ``Neuropsychological and Mental Health Outcomes of 
OIF: A Longitudinal Cohort Study'' was approved for funding in 2007. 
CSP566 will use scientifically validated methods to assess the risk 
factors, prevalence, course, and consequences of PTSD, anxiety and 
depression, and traumatic brain injury (TBI) following deployment to 
Iraq, and is the first study ever that captured baseline performance 
data prior to military service for long-term follow up. VA Central IRB 
approval was obtained on February 19, 2009. In Spring 2008, VA senior 
leadership determined that these activities were not sufficient to meet 
the demands of fully understanding the course and consequences of PTSD 
in Vietnam era women, thus, CSP579 was approved for planning and is 
described below.

CSP579 Overview

    ORD is planning a large-scale, cross-sectional study to assess 
general and mental health status and health service utilization in the 
population of women Vietnam Veterans. Many studies have examined the 
effects of combat or military service in male Veterans; less is known 
however about the consequences of military service for women, 
especially those who served during the Vietnam era. CSP579 will focus 
on determining prevalence of physical and mental disorders, including 
PTSD, and the possible relationship with Vietnam war-time and war-zone 
experience in women Veterans. The prevalence of medical conditions, 
including cardiovascular disease, diabetes, neurologic disease, and 
gender specific cancers, will be determined, and the relationship 
between PTSD and functional status. This information will be valuable 
in understanding the current mental and physical health care status of 
women who served in the military during the Vietnam era and determining 
their health care needs. The study planning Committee is comprised of 
scientific experts in epidemiology, women's health, health services, 
and psychological health, and is informed by women Vietnam Veterans 
including representatives on the planning Committee. Prior to the 
formal planning process, multiple discussions and meetings have taken 
place: to solicit stakeholder input and potential interest, to meet 
with Women in Military Service to America Foundation, to identify 
questions of interest, and to define the population parameters.
    In addition to the women's study described here, ORD recommends 
pursuit of multiple scientific approaches to meet the intent of the 
legislation to ``help the VA to better understand the long-term mental 
health and social needs of Vietnam Veterans'' and to ``prepare the VA 
for the long-term needs of Iraq and Afghanistan Veterans who are 
returning in record numbers with PTSD.'' Meeting these comprehensive 
goals require multiple, peer-reviewed studies. ORD has long been 
studying the Vietnam Veteran population and their needs, and more 
recently has aggressively supported studies to evaluate the newest 
generation of Veterans. All told, these studies will help VA clearly 
understand the needs of the Veteran population, and also provide the 
best treatment our health care system can provide. The following 
provides the timelines for CSP566 and CSP579:

CSP566 Study Timeline




Prior to 2006                                  Initial baseline, cohort development and data collection managed
                                                                                      under DoD administration.

2005                                                                                                           Letter of intent approved for planning longitudinal data
                                                                                                     collection
                                                                                       under VA administration.

2006                                                      Planning Committee meetings and protocol development.
                                               Study publication JAMA, pre and post deployment Time 1 findings.

2007                                                                                      Approved for funding.

2008                                                                                          Kick-off meeting.
                                                         Executive committee approved and EC meetings convened.
                                                          Submission to VA Central IRB (approved on 2/19/2009).

2009                                                                                 Subject enrollment begins.

2009-2011                                                Data collection continues; data and safety monitoring.

2012                                                                         Study closeout; results published.



CSP579, Long-term Health Outcomes of Women Veterans' Service in Vietnam 
        Study Timeline (Draft)

    May and June 2008 VA conducted individual phone calls with senior 
representatives of stakeholder groups.




July 2008                                                        VA convened conference call with stakeholders.

August 2008                                                  VA CSP coordinating center (CSPCC) began planning.

October 2008                                                                 Co-principal proponents appointed.

October 2008                                                           Planning committee membership developed.

October 2008                                           Weekly telephone conference calls begin with study team.

November 2008                                       Plan to develop cohort, including validation and recruitment
                                                                                                      strategy.

December 2008                                         First planning committee meeting to define specific aims,
                                                                            sampling strategy, and methodology.

Dec 2008-Apr 2009                                                   Planning committee develops study proposal.

February 2009                                        Second planning committee meeting to finalize protocol and
                                                                                               proposed budget.

April 2009                                                      Proposal submission for scientific peer review.

June 2009                                                      Scientific panel to review proposal and consider
                                                                                    recommendation for funding.



After proposal is approved for funding:




Summer 2009                                           Administrative startup; solicit bids for survey contract.

September 2009                                        Finalize protocol and survey contract. Submit protocol to
                                                                                        human rights committee.

October 2009                                         Protocol submission to VA Central IRB. Protocol submission
                                                                                              to R&D committee.

November 2009                                          Appoint executive committee. Incorporate IRB suggestions
                                                                             (plan for resubmission if needed).

December 2009                                                                            Hold Kick-off meeting.

January 2010-2011                                        Recruitment/enrollment data collection/Data and safety
                                                                                                    monitoring.

2012                                                                          Study closeout; publish findings.



    Question 12: At the hearing, you testified that primary care 
providers have been instructed to screen all generations of Veterans 
for a Traumatic Brain Injury (TBI), PTSD, and Substance Abuse. Please 
provide a breakdown of those screened who have TBI, PTSD, or Substance 
Abuse by period of service, gender, and race.

    Response: Data are available to address some, but not all of the 
information requested. The standard is that all Veterans should receive 
initial screening for TBI, PTSD and substance use disorder (SUD).
    PTSD and SUD. The following tables provide information on the 
percent of all Veterans screened by gender and race for PTSD and SUD in 
FY 2008. Empty cells denote no users of VA services who needed a screen 
completed in the timeframe covered. Overall, VA screened 86 percent of 
all Veteran patients due for PTSD screening and 91 percent of all 
Veteran patients due for SUD screening. Since Veterans have the right 
to refuse to participate in screening, this represents a likely upper 
limit on the level of screening that can be obtained:


--------------------------------------------------------------------------------------------------------------------------------------------------------
                               Percent of Veterans Screened for PTSD, by Age group, Gender, and Race/Ethnicity, in FY 2008
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                              Amer.                     Hispanic  Hispanic
                                                                             Indian    Asian    Black     Black     White    White     Unknown    TOTAL
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30                                                           female         *        *        *         *         *     100%         77%    78.3%
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30                                                             male         *        *     100%         *         *     100%         82%    83.1%
--------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55                                                              female      100%     100%      82%         *       50%      68%         84%    81.4%
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55                                                                male      100%      75%      84%       62%       56%      81%         84%    82.9%
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55                                                             Unknown         *        *        *         *         *        *         94%    94.4%
--------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55                                                            female         *        *      80%         *       75%      85%         81%    82.7%
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55                                                              male       88%      83%      86%       61%       52%      86%         87%    86.7%
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55                                                           Unknown         *        *        *         *         *        *         94%    94.3%
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                            Grand Total--PTSD                                                                     85.6%
--------------------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------------------
                               Percent of Veterans Screened for SUD, by Age group, Gender, and Race/Ethnicity, in FY 2008
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                              Amer.                     Hispanic  Hispanic
                                                                             Indian    Asian    Black     Black     White     Unknown    White    TOTAL
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30                                                           female         *        *     100%         *                   89%     100%    90.0%
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30                                                             male         *        *     100%         *      100%         87%      88%    86.9%
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30                                                          Unknown         *        *        *         *         *         66%        *    66.7%
--------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55                                                              female      100%     100%      86%      100%       93%         88%      83%    87.2%
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55                                                                male       90%      86%      84%       92%       82%         89%      86%    88.0%
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55                                                             Unknown         *        *        *         *         *         96%        *    95.5%
--------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55                                                            female      100%     100%      83%      100%       90%         91%      92%    91.4%
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55                                                              male       93%      89%      88%       86%       86%         91%      91%    91.4%
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55                                                           Unknown         *        *     100%         *         *         91%        *    91.1%
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              Grand Total--SUD                                                                    90.6%
--------------------------------------------------------------------------------------------------------------------------------------------------------


    The second part of the question involves how many of those screened 
received a diagnosis of PTSD or SUD. By use of a randomized sample of 
all patients seen in primary care, the Office of Quality and 
Performance is currently tracking the results of the screen of Veterans 
for PTSD. To be ``eligible'' for the screen, the Veteran must not have 
a diagnosis of PTSD as a focus for care in the past 12 months; plus for 
those who separate from service, the screen is performed annually for 
the first 5 years after separation and then every 5 years thereafter. 
The sample does not distinguish between ``new'' to VHA or Veterans in 
ongoing care. The sample also does not record gender, race/ethnicity, 
or era of service.
    A FY 2008 sample included chart reviews of approximately 116,000 
Veterans who met the above criteria. Of those, 97 percent were screened 
for PTSD and 6.5 percent screened positive. Of those with a positive 
screen, results indicate that 39 percent received a complete evaluation 
by the time of the chart review (i.e., the others were in the process 
of a full evaluation but were not yet completed). Of those with a 
completed evaluation, 11.7 percent had a new diagnosis of PTSD, 12.5 
percent were found to have had a diagnosis of PTSD greater than 1 year 
ago and had apparently recurred, and 75.7 percent were not found to 
have PTSD and were false positives. There must be caution in the 
interpretation of this data. It cannot be used to estimate the 
prevalence of PTSD in the full population, as the full population of 
Veterans is not seen within VHA. In addition, the screen process does 
not account for those patients in whom the clinician determines a 
diagnosis based on presentation of symptoms by the patient outside the 
screening process. These data do provide information that the screen is 
a worthwhile process to assist in the identification of patients with 
PTSD.
    A comparable chart review process is underway in the Office of 
Quality and Performance for Substance Use Disorder, but data are not 
available at this time.
    TBI. Reported diagnostic data are only applicable to the VA 
patients--a population actively seeking health care--and do not 
represent Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 
or other Veterans not enrolled for VHA health care. Further, VA does 
not screen all generations of Veterans for TBI, but does screen all 
Veterans from OEF/OIF. Compliance with TBI screening for OEF/OIF 
Veterans is a VA measure of performance. From April 2007-January 31, 
2009, VA has screened 270,022 OEF/OIF Veterans for possible TBI, of 
which 17,179 have been confirmed with a diagnosis of mild TBI. 
Demographic information is as follows:


----------------------------------------------------------------------------------------------------------------
                                                                     Screened for TBI  Definitive TBI Diagnosis*
----------------------------------------------------------------------------------------------------------------
Total                                                                        270,022                     17,179
----------------------------------------------------------------------------------------------------------------
American Indian or Alaska Native                                               2,389                        218
                                                                   ---------------------------------------------
                                                                                0.9%                       1.3%
----------------------------------------------------------------------------------------------------------------
Asian                                                                          5,106                        238
                                                                   ---------------------------------------------
                                                                                1.9%                       1.4%
----------------------------------------------------------------------------------------------------------------
Black or African American                                                     38,196                      1,907
                                                                   ---------------------------------------------
                                                                               14.1%                      11.1%
----------------------------------------------------------------------------------------------------------------
Native Hawaiian or Other Pacific Islander                                      2,851                        198
                                                                   ---------------------------------------------
                                                                                1.1%                       1.2%
----------------------------------------------------------------------------------------------------------------
White                                                                        155,492                     10,999
                                                                   ---------------------------------------------
                                                                               57.6%                      64.0%
----------------------------------------------------------------------------------------------------------------
Declined to Answer                                                             3,945                        318
                                                                   ---------------------------------------------
                                                                                1.5%                       1.9%
----------------------------------------------------------------------------------------------------------------
Unknown                                                                        2,372                        195
                                                                   ---------------------------------------------
                                                                                0.9%                       1.1%
----------------------------------------------------------------------------------------------------------------
Missing                                                                       59,671                      3,106
                                                                   ---------------------------------------------
                                                                               22.1%                      18.1%
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Total                                                                        270,022                     17,179
----------------------------------------------------------------------------------------------------------------
      Female                                                                  33,560                        912
                                                                   ---------------------------------------------
                                                                               12.4%                       5.3%
----------------------------------------------------------------------------------------------------------------
      Male                                                                   236,345                     16,260
                                                                   ---------------------------------------------
                                                                               87.5%                      94.7%
----------------------------------------------------------------------------------------------------------------
      Unknown                                                                    117                          7
----------------------------------------------------------------------------------------------------------------
* Attachment to Question #11.


                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      April 7, 2009

Maureen Murdoch, M.D., MPH
Core Investigator, Center for Chronic Disease Outcomes Research
Minneapolis Veterans Affairs Medical Center
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420

Dear Ms. Murdoch:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcom- 
mittee on Disability Assistance and Memorial Affairs hearing on 
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era 
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly 
appreciate if you would provide answers to the enclosed followup 
hearing questions by Monday, May 4, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
committee and subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Ms. Megan Williams by fax at (202) 225-2034. If you have any 
questions, please call (202) 225-3608.

            Sincerely,
                                                       John J. Hall
                                                           Chairman
                               __________
                        Questions for the Record
                  The Honorable John J. Hall, Chairman
       Subcommittee on Disability Assistance and Memorial Affairs
                  House Committee on Veterans' Affairs
 Nexus Between Engaged in Combat With the Enemy and PTSD in an Era of 
                        Changing Warfare Tactics
                             March 24, 2009
                Questions for Maureen Murdoch, M.D., MPH

    Question 1: The studies you have conducted raised great concern 
over how fairly VA evaluates and compensates Veterans for PTSD. Other 
studies since yours seem to replicate your findings. So, in regard to 
women Veterans, how can VA do a better job of meeting their needs in 
the compensation process?

    Response: Since my data were collected almost 10 years ago, it is 
unclear whether those findings still pertain. In addition, the 
discrepancy in rates of service connection between men and women that I 
described seemed to be less an issue of gender and more one of combat 
exposure versus sexual assault. For example, men who reported sexual 
assault were as unlikely as sexually assaulted women to be service 
connected for PTSD. Rates of service connection for combat-exposed men 
and women were roughly the same. Near the time of my research, VBA 
liberalized the evidentiary standard for service connecting PTSD 
related to sexual assault, and it launched several training initiatives 
to train claims processors on how to process claims related to personal 
assault. VBA also has a women's advisory group whose job is to alert 
leadership about emerging issues related to women Veterans, and women 
Veterans coordinators at all regional offices to assist women Veterans 
in developing their claims. Before making additional recommendations 
for changing the way VBA processes sexual assault claims, I would 
suggest that my research be updated and replicated. Of course, 
eradicating military sexual assault would be the very best strategy for 
dealing with these issues.

    Question 2: Does VA need to do additional research and track female 
Veterans during the claims process, especially in cases of military 
sexual trauma?

    Response: VA tracks granted claims for post-traumatic stress 
disorder (PTSD) due to personal trauma, but does not capture 
information about the nature of the verified in-service stressor(s) 
when a Veteran is awarded service-connected disability compensation for 
PTSD. VA defines personal trauma as events of human design that 
threaten or inflict harm that have lingering physical, emotional, or 
psychological symptoms. Military sexual trauma (MST) is one of the 
potential causes for PTSD. However, MST may also be a factor in the 
development of other service-related conditions, such as physical 
injury or depression.

    Question 2(a): What else might you suggest for research?

    Response: The VA disability system is second only to Social 
Security Disability Insurance in terms of scope and size, and I believe 
there are a great number of fruitful questions related to VA's 
disability system that researchers could explore. Replicating my 
earlier study to see if gender and race disparities in rates of PTSD 
service connection still exist might be one obvious avenue of research. 
I believe the most innovative, vibrant, and helpful research tends to 
come through specific calls to the field, e.g., in the form of requests 
for proposals (RFP). RFPs tend to attract very bright and creative 
researchers while emphasizing the importance of the topic. Any 
submitted proposals also benefit by being subjected to scientific peer-
review, thus ensuring rigor.

    Question 3: You also noted a finding of racial disparities among 
Veterans and PTSD awards, but did not draw a conclusion as to what was 
causing those disparities. Can you provide any further insights in 
these areas? Has there been any follow-up to that finding or are there 
plans to study these rating imbalances by race?

    Response: Again, keep in mind that the data is 10 years old and I 
was unable to draw a conclusion as to what caused the racial disparity. 
The difference did not seem to be related to racial differences in PTSD 
symptoms, levels of self-reporting functioning, or combat exposures. I 
am currently examining the long-term impact of receiving or not 
receiving PTSD service connection on outcomes such as PTSD symptom 
severity and work, role, and social functioning. I plan to see if race 
interacts with PTSD service connection to affect outcomes. However, I 
am not aware of any follow-up findings or plans by others to examine 
race imbalances.