[House Hearing, 110 Congress] [From the U.S. Government Publishing Office] [H.A.S.C. No. 110-137] HEARING ON NATIONAL DEFENSE AUTHORIZATION ACT FOR FISCAL YEAR 2009 AND OVERSIGHT OF PREVIOUSLY AUTHORIZED PROGRAMS BEFORE THE COMMITTEE ON ARMED SERVICES HOUSE OF REPRESENTATIVES ONE HUNDRED TENTH CONGRESS SECOND SESSION __________ MILITARY PERSONNEL SUBCOMMITTEE HEARING ON BUDGET REQUEST ON THE MENTAL HEALTH OVERVIEW __________ HEARING HELD MARCH 14, 2008 [GRAPHIC] [TIFF OMITTED] TONGRESS.#13 U.S. GOVERNMENT PRINTING OFFICE 45-131 WASHINGTON : 2009 ----------------------------------------------------------------------- For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, Washington, DC 20402-0001 MILITARY PERSONNEL SUBCOMMITTEE SUSAN A. DAVIS, California, Chairwoman VIC SNYDER, Arkansas JOHN M. McHUGH, New York LORETTA SANCHEZ, California JOHN KLINE, Minnesota NANCY BOYDA, Kansas THELMA DRAKE, Virginia PATRICK J. MURPHY, Pennsylvania WALTER B. JONES, North Carolina CAROL SHEA-PORTER, New Hampshire JOE WILSON, South Carolina NIKI TSONGAS, Massachusetts David Kildee, Professional Staff Member Jeanette James, Professional Staff Member Rosellen Kim, Staff Assistant C O N T E N T S ---------- CHRONOLOGICAL LIST OF HEARINGS 2008 Page Hearing: Friday, March 14, 2008, Fiscal Year 2009 National Defense Authorization Act--Budget Request on the Mental Health Overview 1 Appendix: Friday, March 14, 2008........................................... 55 ---------- FRIDAY, MARCH 14, 2008 FISCAL YEAR 2009 NATIONAL DEFENSE AUTHORIZATION ACT--BUDGET REQUEST ON THE MENTAL HEALTH OVERVIEW STATEMENTS PRESENTED BY MEMBERS OF CONGRESS Davis, Hon. Susan A., a Representative from California, Chairwoman, Military Personnel Subcommittee.................... 1 McHugh, Hon. John M., a Representative from New York, Ranking Member, Military Personnel Subcommittee........................ 3 WITNESSES Casscells, Hon. S. Ward, M.D., Assistant Secretary of Defense for Health Affairs................................................. 4 Gannaway, Maj. Bruce, U.S. Army.................................. 33 Gannaway, Sarah.................................................. 35 Gutteridge, Richard G., Chief Warrant Officer IV, U.S. Army...... 38 MacDermid, Dr. Shelley M., MBA, Ph.D., Co-Chair, Defense Health Board Task Force on Mental Health, Director, The Center for Families at Purdue University, and Director, Military Family Research Institute............................................. 11 Robinson, Vice Adm. Adam M., USN, Surgeon General, U.S. Navy..... 7 Roudebush, Lt. Gen. (Dr.) James G., USAF, Surgeon General, U.S. Air Force...................................................... 9 Scheuerman, Christopher M., Sr., Master Sgt. (Ret.), U.S. Army... 30 Schoomaker, Lt. Gen. Eric B., USA, M.D., Ph.D., The Surgeon General of the U.S. Army and Commander, U.S. Army Medical Command........................................................ 5 APPENDIX Prepared Statements: Casscells, Hon. S. Ward, M.D................................. 64 Davis, Hon. Susan A.......................................... 59 Gutteridge, Richard G........................................ 129 MacDermid, Dr. Shelley....................................... 120 McHugh, Hon. John M.......................................... 62 Robinson, Vice Adm. Adam M................................... 92 Roudebush, Lt. Gen. (Dr.) James G............................ 108 Scheuerman, Christopher M., Sr............................... 126 Schoomaker, Lt. Gen. Eric B.................................. 82 Documents Submitted for the Record: [There were no Documents submitted.] Witness Responses to Questions Asked During the Hearing: Mrs. Boyda................................................... 137 Mr. Jones.................................................... 138 Mr. McHugh................................................... 137 Questions Submitted by Members Post Hearing: [There were no Questions submitted post hearing.] FISCAL YEAR 2009 NATIONAL DEFENSE AUTHORIZATION ACT--BUDGET REQUEST ON THE MENTAL HEALTH OVERVIEW ---------- House of Representatives, Committee on Armed Services, Military Personnel Subcommittee, Washington, DC, Friday, March 14, 2008. The subcommittee met, pursuant to call, at 9:06 a.m. in room 2118, Rayburn House Office Building, Hon. Susan A. Davis (chairwoman of the subcommittee) presiding. OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE Mrs. Davis. The meeting will come to order. I want to welcome you all to this hearing today. The purposes of our hearing are many and diverse. First, we will receive an update on how the Department of Defense (DOD) has implemented the recommendations of the Defense Task Force on Mental Health. The Task Force was mandated by Congress in the 2006 National Defense Authorization Act (NDAA), and was charged to both assess the military mental health care system and to make recommendations on how to improve it. Second, we will have an opportunity to hear about the findings of the Army's Mental Health Advisory Team (MHAT)-V. The results of other MHATs have provided great insight into the mental health needs of our military because the teams conduct their research and interviews on the ground in Afghanistan and Iraq. Finally, we will have the opportunity to hear about what individual mental health needs are and are not being met from service members and family members. Today, we will have two panels, and we greatly welcome both of these panels here today. The first panel before us now includes Dr. Ward Casscells, the Assistant Secretary of Defense for Health Affairs; Lieutenant General Eric Schoomaker, Surgeon General of the Army; Vice Admiral Adam Robinson, Surgeon General of the Navy; Lieutenant General James Roudebush, Surgeon General of the Air Force; and Dr. Shelley MacDermid, the Director of the Center for Families at Purdue University, the Co-Director of the Military Family Research Institute and the Co-Chair of the Department of Defense Task Force on Mental Health. These senior medical leaders will tell us what has changed since our last hearing and what they are doing now and what they have planned for the future. Dr. MacDermid will help frame these responses in relation to the findings and recommendations of the Task Force. Welcome to you all. I do want to say that, if you can stay for the second panel, we would greatly appreciate that, and we certainly do not want anyone to think that our second panel is under any influence from the first, but we really would appreciate it, if it is possible, for you would stay. Perhaps there would be some questions that would be directed to you after they have had a chance to speak, as well. The second panel will have two currently serving soldiers-- Chief Warrant Officer IV Richard Gutteridge and Major General Gannaway, who have been treated for mental health conditions and are willing to share their experiences. Thank you both for your courage and for being willing to testify. We are also very fortunate that we will hear from the spouse of one of these soldiers, Mrs. Sarah Gannaway, so we can understand the experience from the family's point of view as well as we can learn what mental health services our family members require. Finally, Mr. Christopher Scheuerman will share with us a story of his son, Private First Class (PFC) Jason Scheuerman, who committed suicide in Iraq in 2005. I think this story is very painful for all of us to hear, but it is illustrative of how the system failed a soldier, and it will provide us some insights into just how comprehensive and integrated military mental health services need to be. To all of the witnesses on the second panel, again, thank you so much for your willingness to share such intimate and painful experiences with us and to help ensure that others do not have to suffer as much. All of the members of this subcommittee remain unanimous in their support for our service members and for their families. With multiple, long-term deployments now the norm for our military, mental health is more important than ever. It weighs heavily upon the readiness of our force, on our ability to retain combat veterans and on our obligation to care for those who volunteer to serve our Nation. At our last mental health hearing, I made it clear that this was going to be a long process. It will take a sustained effort from all concerned for the foreseeable future to make required changes to the Defense Health Program. We will face challenges in recruiting or training additional mental health providers. We will encounter institutional resistance from those who think the current system is adequate. We will also face fiscal challenges, great fiscal challenges. The structural and cultural changes needed will require significant and continuing financial outlays, but our service members and their families deserve no less. Finally, I would like to make mention of the fact that all of the second panel witnesses and many of the topics for the first panel are in some way connected to the Army, and this is not because we feel that the Army is the only service that faces mental health challenges. Far from it. We feel that all of the services need to be better. In fact, we will hear from all of the services about the different programs that they have. So why then is the Army figuring so prominently in hearing? Well, first, the Army has the largest number of personnel in both Afghanistan and in Iraq. Second, the Army has undertaken a number of self-assessments on mental health issues and has unselfishly shared them. Finally, when the staff of the subcommittee interviewed potential witnesses, there were those with experiences that really stood out as excellent examples of what improvements have been made and of what still needs to be done. By random chance, those happen to be in connection to the Army. It would be a disservice to the Army to assume that these coincidences single it out as having more problems than any other services. Instead, I think we need to be grateful to the Army that so much information is available to help us guide our discussions. Once again, I welcome you all today. I look forward to a very fruitful discussion. I would like to turn to the ranking chair, Mr. McHugh, for his introductory remarks. [The prepared statement of Mrs. Davis can be found in the Appendix on page 59.] STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE FROM NEW YORK, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE Mr. McHugh. Thank you very much, Madam Chairman. I have an extensive opening statement that I will submit for the record for its inclusion in its entirety. I just want to very briefly echo your words of welcome. Some of our panelists are appearing for the second time this week. That seems to me to be beyond cruel and unusual punishment, but I think it speaks very well of their devotion to these mental health and health concerns that we all share. We are very grateful to have such a distinguished first panel. Dr. MacDermid, particularly, thank you for your work on the Task Force. We look forward to hearing your comments, of course, and look forward to hearing from our good Secretary, as well as the Surgeons General, as to how we can work together and provide these very critical services. I would echo the statements and the Chair's remarks about our particular appreciation for the second panel. These good folks will provide us with a particularly important, a particularly unique perspective on, I know, what we all recognize as a challenge. Recognition is critical; it is the first step in providing these services. But we have got a ways to go. Hopefully, today's hearing can help us take a few more steps down that path. So, with that, again thank you for being here. I look forward to everyone's comments. Madam Chair, I will yield back. Mrs. Davis. Thank you, Mr. McHugh. [The prepared statement of Mr. McHugh can be found in the Appendix on page 62.] Mrs. Davis. Dr. Casscells, would you like to begin? STATEMENT OF HON. S. WARD CASSCELLS, M.D., ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS Dr. Casscells. Thank you, Madam Chairwoman and Mr. McHugh. We appreciate the opportunity to come before you again and report on our response to the problems which have manifested themselves and, particularly, to respond to the guidance we got from you almost a year ago. As you say, Mr. McHugh, we are making progress, and we do have a ways to go. We are pleased that we on our end, on the military side, at least, have agreement on the road by which to get there, and we have had plenty of advice, particularly from Dr. MacDermid and her colleagues on the Task Force and throughout the academic world. I think we are grappling with this about as hard as we can. We have been generously funded by Congress. We hope to reach a place where our program that we have stood up now will begin at the earliest stage of a member's career, as Dr. MacDermid recommended in her report, in the Mental Health Task Force report, and will continue throughout the career and will include improved screening, because not everyone needs to be a warfighter. People can serve in other ways. It will include what we call resiliency training, so that people can become stronger in mind as they do in body. It will include better monitoring so that we can begin to find people, identify them when they are struggling. Currently, we are already charging their battle buddies, their enlisted leaders and their company commanders to identify people who are struggling; and we are pleased that the line has recognized that this is important. But early detection is important so that people can get three hots and a cot, or even medications in some cases, recover, and return to the fight. You know, sometimes it is just a misunderstanding that needs to be clarified. So this is terribly important, early detection. Treatment is a struggle. We do not really know very well what treatments work. We recognize this, and we are committed now to taking a hard look at these treatments and comparing them. In the fields of psychology, psychiatry, psychiatric social work, we have struggled in reaching common definitions and standards and in agreeing on the way ahead and in agreeing on how to collect data, what data to collect, and we are making major progress in this, led by Colonel (Promotable) Loree Sutton, M.D., an Army doctor, who is coordinating these efforts. So treatment needs a lot of work, and then rehabilitation and reintegration. This is the spectrum of the things we are trying to do. It is my job as the cheerleader and coach to make sure we have got the right players in the field, that they have got the right playbook, that they understand the playbook. Occasionally, of course, if we are not scoring goals, I have got to shuffle the play and call in some plays from the sidelines. That is my job as the steward of quality and oversight responsibility. I am pleased to tell you, ma'am and sir, that we have a terrific team on the field now, and we are moving down the field. We are going to have, I think, a standard in mental health care over the next few years, which will be the best in the world, back in the days when the military led the world in mental health, and we will be defining ``trauma'' as a continuum of mind and body. In so doing, by intervening early, we will actually reduce costs because we recognize now that depression and post-tramatic stress disorder (PTSD), while they only affect about 20 percent of the returning soldiers and marines and sailors and airmen, actually account for about 80 percent of the problems and the costs. When you look at the operational errors that you alluded to, ma'am, these can be very expensive indeed. So, with this early intervention and with these programs that you have helped us with, I think we are on the edge of a new era in military psychology and psychiatry, and we are pleased today to take your questions and answer them to the best of our ability and to get your advice. Thank you very much. Mrs. Davis. Thank you. [The prepared statement of Dr. Casscells can be found in the Appendix on page 64.] Mrs. Davis. General Schoomaker. STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, USA, M.D., PH.D., THE SURGEON GENERAL OF THE U.S. ARMY AND COMMANDER, U.S. ARMY MEDICAL COMMAND General Schoomaker. Well, Chairwoman Davis, and Ranking Member McHugh and distinguished members of the personnel subcommittee, thank you for this opportunity to come here today and to discuss the Army's efforts to improve mental health care for our soldiers and family members. Army leadership strongly supports efforts to improve the quality and access to mental health services, and they have been actively leading to eliminate the stigma associated with seeking mental health care. As you know, this stigma is not just found in the Army. It is not just found in the military. It is a national concern that needs to be addressed across all communities. Ma'am, I really appreciate your earlier comments about, although this appears to be centered on Army patients and Army issues, this is really a problem for the Nation as a whole. Our soldiers in our Army are doing truly amazing work. It is demanding. It has a high operational tempo, as you know, today, but our soldiers and our families are stressed. We appreciate your bringing soldiers and families here for this hearing today, and I want to personally extend my appreciation to these soldiers for publicly coming forward and for discussing their experiences. I am often asked why I cannot order soldiers to come forward and talk to you about their issues, and of course, I cannot do that. But when experienced soldiers and families want to come forward and give us their issues, it helps us to dispel stigma; it helps us to identify problems, resistant problems, that we can overcome. So I extend my admiration and appreciation to them. The global war on terror has placed increased operational demands on our military force. We know that repeated and extended deployments have led to increased stress on families and on individual soldiers and have led to other psychological effects of war, such as depression, anxiety, withdrawal, and social isolation or have led to symptoms of post-traumatic stress, which we also know, if not identified and addressed promptly--as we learned in prior wars, notably in Vietnam--may evolve into a more resistant psychological---- Mrs. Davis. General, excuse me. If you could just bring the mike a little closer---- General Schoomaker. Yes, ma'am. Mrs. Davis. Thank you. General Schoomaker. Post-traumatic stress--that is post- combat stress and stresses of trauma--if not addressed promptly will result in a much more resistant psychological injury known as post-traumatic stress disorder. Let me assure you that the Army is absolutely committed to ensuring that all soldiers and families are healthy, both physically and psychologically, as Dr. Casscells has addressed. Today, on your second panel, you are going to hear from two members of the Walter Reed Warrior Transition Brigade, Major Bruce Gannaway and Chief Warrant Officer IV Richard Gutteridge, as well as from Sarah Gannaway, Major Gannaway's wife. As I have said, I really appreciate their coming forward and talking to you about their issues and about our continued problems. I believe that as an Army and as a Department of Defense we have embraced the recommendations of the DOD Task Force on Mental Health and of the Mental Health Advisory Teams that we have now sent out for the past five years. We are striving to truly provide the best mental health care for our soldiers and for their families. I would like to touch upon just a few of those initiatives that I know are making a profound impact on soldiers and families. First of all, you have already alluded to these Mental Health Advisory Teams. These are a groundbreaking achievement. Never before has a military or a fighting force studied the psychological strains of combat as intensely during the conflict. Sometimes it is not pleasant to hear what we have found--self-assessment is not often pleasant--but it is important that we hear their unvarnished feedback so that we can take the necessary steps to improve; and we have done that. Second, the Army's unprecedented leaders' chain teaching was a powerful initiative that started at the very top of the Army. It simultaneously and powerfully addresses leadership, our culture and advocacy. We have trained over 900,000 soldiers in a massive educational effort that began in the summer and fall of 2007. We are now incorporating that into all of our soldier and leader training programs. Next, we have the Battlemind Training program. This is an outgrowth of our Mental Health Advisory Teams. It focuses on building fitness and resilience. The findings of the latest MHAT-V indicate that Battlemind is hitting the target and is making soldiers less susceptible to combat stress and is building resilience. Finally, we have our Re-Engineering Systems for the Primary Care Treatment of Depression and PTSD in the Military (RESPECT-MIL) program, which addresses access from different perspectives to include primary care. I do not bring up these points to say that we are solving everything, but we do have a focused, reasoned approach. I applaud Congress and this committee for standing up the Task Force on Mental Health in 2006. I applaud Congress for directing the establishment of our Center of Excellence for Psychological Health and Traumatic Brain Injury. I look forward to continuing to work with you in improving the delivery of mental health services and in answering your questions today. Thank you. Mrs. Davis. Thank you very much. [The prepared statement of General Schoomaker can be found in the Appendix on page 82.] Mrs. Davis. Admiral Robinson. STATEMENT OF VICE ADM. ADAM M. ROBINSON, USN, SURGEON GENERAL, U.S. NAVY Admiral Robinson. Madam Chairwoman, Representative McHugh and distinguished members of the committee, I appreciate the opportunity to share with you Navy Medicine's efforts in preventing, diagnosing and treating psychological health issues affecting our active duty and Reserve sailors and marines and their families. As the provider of medical services for both the Marines and Navy, we have to be prepared to meet the needs of these similar and yet unique military populations. My colleague, Rear Admiral Bill Roberts, who is seated behind me, currently serves as the Medical Officer of the Marine Corps. We share a vision on how to meet the needs of marines both in theater and in garrison. We also work very closely with our aligned leadership, the Chief of Naval Operations and the Commandant, to implement Navy/Marine centered care initiatives to address everything from combat stress to predeployment training and wounded marine care. Since the beginning of the global war on terror, Navy Medicine has been continuously adapting to meet the short- and long-term psychological health needs of service members and of their families before, during, and after deployment. We are well aware of the fact that the number and length of deployments have the potential to impact the mental health of service members as well as the well-being of their families. The current operational tempo is unprecedented. Our experiences in previous conflicts, most notably Vietnam, suggest that delays in seeking mental health services increase the risks of developing mental illness and may exacerbate physiological symptoms. This is also the case for individuals who may be considering suicide. Although suicide rates in the Navy and Marine Corps have not significantly fluctuated in recent years, we remain vigilant of the potential long-term impact our mission requirements will have on the physical and mental health of our sailors and marines and their families. In response to the recommendation by the DOD Mental Health Task Force, Navy Medicine expanded or, when necessary, developed programs to address the four interconnected goals outlined in the report. The goals include, one, build a culture of support for psychological health; two, ensure a full continuum of care is available; three, allocate sufficient and appropriate resources; four, empower the leadership to advocate for a culture of psychological health. Reducing the stigma associated with seeking psychological health services is a critical component of our efforts to build and to strengthen the culture that supports psychological health. To reduce stigma, we have expanded our training efforts in collaboration with the Chief of Naval Personnel. These training programs are available at each career training point and help educate service members on the importance of not delaying psychological health services. The same way physical conditioning prepares sailors and marines for the rigors and challenges of high-tempo operational deployments, we are psychologically preparing service members and their leaders to build resiliency, which will help manage the physical and psychological stresses of battle. The Marine Corps' Marine Operational Stress Surveillance and Training Program, MOSST, includes briefings, health assessments and tools to deal with combat and operational stress. The MOSST Program includes warrior preparation, warrior sustainment, warrior transition which happens immediately before marines return home, and warrior resetting. In addition to training sailors, marines and their families to identify the signs of stress in themselves and in their colleagues, we are expanding caring-for-the-caregiver training programs for psychological health, traumatic brain injury and post-traumatic stress disorder. To ensure the full continuum of mental health care services are available to sailors and marines, we have made psychological health screening an effective and normal part of military life before, during, and after deployments. Since the late 1990's, Navy Medicine has embedded mental health professionals with operational components of the Navy and of the Marine Corps. Clinical psychologists have been regularly embarked aboard all of our aircraft carriers and have become a valuable member of ship's company. Not only have mental health assets helped crews deal with the stresses associated with living in isolated and unique conditions, but medevacs and administrative discharges for conditions typically managed by mental health personnel have decreased. Having a mental health professional who is easily accessible and who is going through many of the same challenges has increased operational and battle readiness aboard these floating platforms, saving lives as well as hundreds of thousands of dollars in operational costs. For the Marines, Navy Medicine Division psychiatrists who are stationed with marines developed OSCAR teams, Operational Stress Control and Readiness, which embed mental health professionals as organic assets in operational units. OSCAR teams provide early intervention and prevention support through all of the phases of deployment. The same team providing care in garrison also deploys with the unit, which improves cohesion and helps to minimize stigma. Since the beginning of Operations Enduring Freedom and Iraqi Freedom, mental health-related medical evacuations for marines have been significantly lower among units supported by OSCAR. Currently, there is strong support for making these programs permanent and for ensuring that they are resourced with the right staff and funding. To meet the goals of allocating sufficient and appropriate resources to address the mental health needs of sailors and marines, we have made mental health professionals more easily accessible by bringing the portals of care closer to the service members. Beginning in 2006, Navy Medicine established deployment health centers to serve as nonstigmatizing points of entry at high fleet and Marine Corps concentration areas and to augment primary care services offered at the Military Treatment Facility (MTFs) or in garrison. Staffed by primary care providers and mental health teams, the centers are designed to provide care for marines and sailors who self-identify mental health concerns on the post-deployment assessment and reassessment. We now have 17 such clinics up from 14 last year. In urgent or extraordinary situations, Navy Medicine meets the psychological health needs of sailors and marines in their communities by deploying Special Psychiatric Rapid Intervention Response Teams, SPRINT. These teams have been in existence for over 15 years, and provide short-term mental health and emotional support immediately after a disaster, with the goal of preventing long-term psychiatric dysfunction or disability. The team may provide educational and consultative services to local supporting agencies for long-term problem resolution. A new program for Navy SEALS, seabees and marines is called FOCUS. Families Overcome and Coping Under Stress is aimed at families most at risk, and it will be located at marine bases at Camp Pendleton, Camp Lejeune, Twentynine Palms, and Okinawa. This program is a prevention, very early intervention program consisting of 10 to 12 counseling sessions with a team of specially trained counselors. Mrs. Davis. Admiral, could I ask you to try and wrap up quickly? We have to rush because we have a vote coming, and I want to be sure we get everybody in. Thank you. Admiral Robinson. Yes, ma'am. In summary, let me say that we in Navy Medicine and in the Marine Corps are doing everything to make sure that we look at the behavioral health needs of our service members and of their families, that we have a culture that is of psychological health, that we destigmatize as much as possible the effects of seeking psychological help, and that we think that patient- and family-centered care is the essence of the standard of care that we give to our patients. Thank you. Mrs. Davis. Thank you very much. [The prepared statement of Admiral Robinson can be found in the Appendix on page 92.] Mrs. Davis. Dr. MacDermid. Dr. MacDermid. I do not want to make you late for your vote. Mrs. Davis. Oh, I am sorry. General Roudebush. Go ahead, General. I am sorry. STATEMENT OF LT. GEN. (DR.) JAMES G. ROUDEBUSH, USAF, SURGEON GENERAL, U.S. AIR FORCE General Roudebush. Madam Chairwoman, Ranking Member McHugh and distinguished members of this subcommittee, I welcome the opportunity to speak with you today concerning the Air Force and the Air Force's medical focus on the operational stress that our airmen are enduring both at home and in harm's way in combat, and our efforts and activities to, one, prevent and, two, to treat as quickly and as effectively as possible when these do occur. Your Air Force is America's force of first and last resort to guard and to protect our Nation. To that end, we Air Force medics work directly for our line to address our Air Force's top priorities--winning today's fight, taking care of our people and preparing for tomorrow's challenges. The future strategic environment is complex and uncertain, but be assured that your Air Force and your Air Force Medical Service are ready for today's challenges and are preparing for tomorrow. It is important to understand that every Air Force base, at home station and deployed, is an operational platform; and Air Force medicine supports warfighting capabilities at each of our bases. It begins with our Air Force medical treatment facilities that provide combatant commanders a healthy, fit force, capable of withstanding the physical and mental rigors associated with combat and with other military missions. Our emphasis on fitness and prevention has led to the lowest disease, nonbattle injury rate in history. The daily delivery of health care at our medical treatment facilities maintains critical skills that guarantee our readiness to provide that healthy, fit force and to care for our families, to respond to our Nation's call supporting our warriors in harm's way, and to provide humanitarian assistance to countries around the world. To execute these broad missions, the services--the Air Force, the Navy and the Army--must work together interoperably and interdependently. Every day, together, we earn the trust of our All-Volunteer Force and their families, and we value that trust above all else. Today, we are here to address the psychological health needs of our airmen and of their families. The Air Force and the Air Force Medical Service is focused on the psychological needs of our airmen and reducing the effects of operational stress. Post-traumatic stress disorder is low in the Air Force, diagnosed at less than one percent of our deployers, but it is no less important. Every airman affected deserves the best care available. The Air Force Suicide Prevention Program is also a commander's program that has achieved a 28 percent decrease in Air Force suicides since its inception in 1996. All airmen receive annual suicide training. This year, we released the front lines supervisors' course as an added tool for commanders. We continue to use a community approach centered on effective detection and treatment, and it is working. The entire constellation of our psychological health programs are continuously being refined for better support to our airmen and to their families. In closing, Madam Chairwoman, I am humbled by and am intensely proud of the daily accomplishments of the men and women of the United States Air Force Medical Service. The superior care routinely delivered by Air Force medics and our joint partners, the Army and the Navy, is a product of preeminent medical research training programs and a culture of personal and professional accountability. With your help and the help of this committee, the Air Force will continue our focus on the health of our warfighters and of their families. I thank you and look forward to your questions. Mrs. Davis. Thank you, General. [The prepared statement of General Roudebush can be found in the Appendix on page 108.] Mrs. Davis. Dr. MacDermid. STATEMENT OF DR. SHELLEY M. MACDERMID, MBA, PH.D., CO-CHAIR, DEFENSE HEALTH BOARD TASK FORCE ON MENTAL HEALTH, DIRECTOR, THE CENTER FOR FAMILIES AT PURDUE UNIVERSITY, AND DIRECTOR, MILITARY FAMILY RESEARCH INSTITUTE Dr. MacDermid. Good morning, ma'am. Chairwoman Davis, Representative McHugh, distinguished members of the subcommittee, and others, I am honored to be here today. I must hasten to correct, however, the reference to my task force. I was one of only 14 people who worked long and hard on these issues, and I want to especially acknowledge the exemplary leadership demonstrated by both General Kiley and Admiral Arthur, who are not here today. I have submitted a full report of the Task Force for the record. As you know, the report presented an achievable vision for supporting the psychological health of military members and their families. [The information referred to is retained in the committee files and can be viewed upon request.] Dr. MacDermid. The Task Force made 95 recommendations, almost all of which were endorsed by the Secretary of Defense; and I know that many dedicated people have been working very hard on the recommendations, many of whom are in this room. Many of the recommendations were targeted for completion by May 2008, just a few short weeks from now. I would like to identify a few issues that I am especially eager to hear about in terms of progress. The first is TRICARE. The Task Force recommended several specific changes needed to ensure that the TRICARE system could provide adequate care. I have prepared an example for you today, and I have learned in the period right before the testimony that I do not need that paragraph anymore. Dr. Casscells assured me that this particular issue will be taken care of shortly, so I will let that paragraph go, and we can talk about other things, if you wish, later. The second issue I would like to address is the supply of professionals who are well prepared to provide the prevention, assessment, treatment, and follow-up services to military members and to their families who require care. A question Admiral Arthur and I are often asked is, how many more professionals are needed to meet the need. The Task Force did not answer this question, and Admiral Arthur and I never answered this question because it required the development of a new model for allocating the staff who support psychological health, specifically a risk-adjusted, population- based system. The existing staff allocation system is based on relative value units that undercount prevention activities and unmet demand. The Task Force recommended that staff, instead, be allocated according to the size of a population in a given area, be adjusted according to the presence of risks, such as combat deployments and other challenging conditions. According to the Secretary of Defense's work plan released in September, the new model has been designed, and that should make it possible to identify quite precisely where sufficient staff are in place to meet the estimated need, where the numbers are insufficient and by how much. I am also eager to learn about successes in recruiting and in retaining mental health professionals. The Task Force received numerous indications that it is difficult to get and to keep highly qualified mental health professionals. I hope that the importance of the individuals who do that work is being recognized by very strong efforts to recruit and retain them, including incentives and opportunities for career development. Also, in the area of staffing, I am eager to hear about changes in contracting procedures. The Task Force made site visits to 38 installations where we heard over and over again that contracting mechanisms were cumbersome and delayed, making it difficult to keep staff, and in general, it interfered with the ability to offer good care. While Congress has been helpful in allocating funds, I am eager to hear whether the right mix has been provided. Substantial funds have been allocated on a nonrecurring basis, which makes it difficult to assess infrastructure issues and makes it difficult to hire the best staff. The Task Force report emphasized that the shortcomings we observed were not caused by the protracted conflicts in which the United States is now engaged and are unlikely to disappear when they end. Nonrecurring funds, while helpful, do not allow the fundamental challenges to be addressed. Finally, as someone who has devoted her life to studying and advocating for families, I will close by saying that I am especially eager to hear how services for family members have been improved since the Task Force submitted its report. We have made several specific recommendations in this area. For example, we wanted to be sure that parents or others caring for wounded or injured service members could easily get access to installations' care managers or other services. Because they have no official status as family members within military systems, parents sometimes face barriers which systematically disadvantage young, unmarried service members. We also recommended that the substantial delays many children were experiencing in accessing care be addressed. We recommended that inequities between families who were nearby and who could receive their treatment at military treatment facilities and families who were far away and had to rely on TRICARE be eliminated. I am eager to hear about progress in all of these areas. In conclusion, Madam Chairman and distinguished members, I appreciate your sustained attention to these issues. I also very much appreciated the prompt and detailed plans submitted by the Secretary of Defense, but many weeks have elapsed, and I know the strong sense of urgency we all feel pales before the daily struggles that confront many military families. I am very much looking forward to the day the plans are fully implemented. That concludes my remarks. Mrs. Davis. Thank you very much. [The prepared statement of Dr. MacDermid can be found in the Appendix on page 120.] Mrs. Davis. Dr. MacDermid, you mentioned a number of things that you would like to hear. I think those are the same things that we also would be eager to hear. I wonder if, perhaps, our witnesses could--as quickly as possible, I think--just address--there are issues around processing and being able to get the mental health professionals out there without undue delays. I wonder if you could address that quickly, whether there was a better system or whether you think that those issues have been addressed. I know there was another issue, I think around TRICARE and paperwork. I am assuming that, maybe, you had a conversation about that. Dr. MacDermid. Dr. Casscells assured me that issues regarding restrictions and intensive outpatient services are in the process of being removed, so that is one specific TRICARE recommendation that it sounds like has been taken care of. Mrs. Davis. Okay. We will be eager to follow up on that as well. Then the access for families to receive mental health services as well. Dr. Casscells, would you like to pick that up? Dr. Casscells. Madam Chairwoman, the biggest effort here is the Army's effort to hire 200 mental health workers. That has been an intense effort. As you know, in the country at large, we have squeezed mental health for some time now, and getting people into uniform or getting them in as contractors is a challenge. The Army is over halfway there, and the Army Surgeon General will speak to that, Dr. Schoomaker. I would say that we have been working to reduce barriers in the Pentagon of which there are numerous bureaucratic obstacles to identifying people, to getting policies in place that identify the characteristics of the people we need. Certainly, we have been looking to find alternatives--you know, deputizing people to be involved in care whether it is, you know, internists, such as myself, or nurses or medics. I think Dr. Schoomaker could tell you we will be training the 68 Whiskeys shortly in Battlemind Training. So this has, by necessity, become everyone's job--the line officers', the enlisted leaders'--and we increasingly involve the family members. This is a communication effort. Just last night, I got an e-mail from an enlisted soldier to her sergeant, and the sergeant had sent it up the chain, and it came over to me, saying, Why don't we have a website where family members of soldiers with PTSD can communicate with each other and share tips? Well, we have been developing that darned thing for months, and it is going to be launched soon. So--in addition to MilitaryOneSource.com, we are developing these services, so we are on the move. We are a little more than halfway there in terms of hiring people. Further details that are Army-specific I will leave to General Schoomaker. Mrs. Davis. Okay. Thank you. Dr. Schoomaker. General Schoomaker. Really quickly, ma'am, there are three areas, that I think Dr. MacDermid raised, that we can talk about quickly. The first is the supply of professionals. As the Secretary mentioned, we, the Army, last year went out with a risk- adjusted, population-based model across our communities. As you know, Army Medicine is organized into regional commands: The regions each have individual installations within them. Each of those regions then went out to individual installations center around communities and where our Army was. They were asked what additional mental health resources they needed. In the continental United States, we estimated a need for about 268 mental health professionals. We at this point have contracted for about 150 of those who are at work around the Army, civilians. Our problem in many of those places is, quite frankly, as Congressman McHugh knows from Fort Drum, that it is very difficult in some of our communities to hire and to recruit in these rural populations. The second issue I would speak to is about access for family members, and especially nontraditional family members. One of the benefits and successes of the Army Medical Action Plan has been to identify nontraditional family members and to provide invitational travel orders and access to parents, to fiancees, to best friends, to buddies. That has been successful. In the NDAA 2008, you included some provisions for defining these family members in a nontraditional way, and we appreciate the help that you have given us on that. Finally, I would just like to address the fact that, as my colleague Admiral Robinson talked about, we really focus on beginning at the primary care level in delivering care. So primary care providers, family medicine doctors, nurse practitioners, physician assistant (PAs), and internists are a part of this equation; and we are training those folks just as aggressively as we are acquiring mental health. Mrs. Davis. Thank you. I think, perhaps, we will address later on in the hearing whether there is a special category that we might point to as well and think about, in terms of those who have served, who perhaps would entertain a different career than they had before, where they have some skills that could be utilized in this way. I wonder if you could just take a look at how long it is taking in the application process for some of these mental health professionals to come into the system because, you know, there is a very important vetting process of looking at the prior experience that they have had; but that seems to be a prolonged process in many communities, and people will wait around just so long for that to be completed. It concerns me. It seems to be taking a long time in several situations. Thank you very much. Mr. McHugh. Mr. McHugh. Thank you, Madam Chair. Let us talk a little bit more about recruiting. General Schoomaker just mentioned rural areas. It seems that we have our challenges throughout the system. One of the recommendations of the Task Force was in noting that the Department has the authority to adjust reimbursement rates across the board. Yet, my understanding is, to this point, there have been no adjustments in the use of that authority to increase reimbursement rates for mental health services. Dr. Casscells, have you had an opportunity to think about that a little bit? Might that not be helpful in gaining access? Dr. Casscells. Mr. McHugh, I think that we did adjust them in Fort Bragg, around Fayetteville, but many times when we have gotten calls about the lack of access in a given area, it has been a misunderstanding about the rules and about the fact that people are actually permitted to get coverage 25 miles away and so forth and so on. A lot of these things are miscommunications that get clarified. So we have not made as many adjustments in the local--you know, in the micro-regional reimbursement rates as we thought we would when our effort began. There really have been just a few. I can get back to you with more detail if you think that would be helpful. If we have overlooked some, we would like to hear about them. [The information referred to can be found in the Appendix beginning on page 137.] Mr. McHugh. Well, of course, we would very much appreciate your getting back to us. I am reacting just intuitively. More money usually gets you more things--I do not know; that is the way I was brought up, I guess. Clearly, what we do hear about TRICARE in general--and I know all of you are very well aware of this--is that reimbursement rates amongst medical professionals is a disincentive in many instances. I would defer to Dr. MacDermid. That was kind of at the core of the Task Force recommendation, was it not? Dr. MacDermid. It was. Although, to be fair, I must report that this is what providers told us on our site visits. We did not have the authority or the ability to really do a systematic comparison of data from hospitals. We were able to actually get data from one hospital about TRICARE versus other payers. This was not part of a negotiated rate, so we were given to believe that they were sort of the normal rates that you would expect from TRICARE. The TRICARE rates were less than half of any of the other payers, which is very puzzling when you think about the legal requirements for how TRICARE rates are pegged. We do not understand it. It is possible that when mental health is a carve-out in the contract, that somehow that affects reimbursement rates. It is a puzzle. So I believe that in that recommendation, we did not explicitly say rates should be raised. I think what we said was, it needs to be looked at carefully and that, in particular, there needs to be conscious scrutiny of mental health issues because there are certain gaps in procedures that mean that mental health does not get exactly the same kind of scrutiny that other kinds of medical care do. Mr. McHugh. Okay. I appreciate that. Mr. Secretary, if you get a chance to look a bit more in detail at what has happened in those areas where you have changed rates, I think that would be helpful to us. Regardless of what the rates are, if you do not have the professionals in a particular geographic area, you are not going to be able to gain access. In fact, when Secretary Winter appeared before the full committee, he talked about the need for increased bonuses for doctors, nurses, et cetera. The Task Force mentions that very fact as well. If you look at the recently passed National Defense Act, the 2008 act, if our math is correct, we currently have authorized bonuses. For a new board-certified doctor who signs to a four-year commitment, the pay for just that signing up is $824,000. What do we need to do beyond that? Dr. Casscells. Sir, I am sorry. I have taken down your last task there. Could you rephrase that? Mr. McHugh. Okay. You have got to be able to recruit. The Task Force said and Secretary Winter mentioned in his testimony before the full committee that increased bonuses could be helpful in recruiting not just mental health care, but health care professionals across the board. The new 2008 National Defense Act authorizes a new board-certified doctor who makes a four-year commitment a signing bonus of $824,000. What do we need to do beyond that kind of bonus option to help meet that recruiting need where the Task Force and others are telling us we need to put into place more bonuses? Dr. Casscells. Thank you, sir. I agree with Secretary Winter. I did not hear his testimony. As you know, the retention bonuses and the recruiting bonuses have both been pretty effective. We really got them there last year just in time. It has been effective for trauma surgery, for example. We may well need to do more for psychiatry and psychology, not just in the bonuses but in letting people know about them, and also in signaling that this is a culture that really welcomes, you know, people to come in midcareer, that welcomes people who are passionate about mental health. There is a cultural disconnect that we are trying to get past as well, so it is not just a matter of assigning some extra DOD dollars. There is also the issue of outreach here, and we are working hard on that--scheduling meetings with the American Psychological Association, with the psychiatrists, with the American Medical Association (AMA), and in going to campuses. We have a whole program that we are getting ready to launch in this, because we have got to get the word out. Mr. McHugh. Well, I thank you. My time has expired. I would just say, if I may, Madam Chair, that, obviously, we would value your guidance. I cannot speak for the subcommittee, let alone for the full committee, but we do have a history of trying to be sensitive to those kinds of needs on targeted bonuses and pay. So specific recommendations would be of great value as we go forward. Thank you, Madam Chair. Mrs. Davis. Thank you, Mr. McHugh. I would echo your comments as well, though in terms of reimbursement, because that is an ongoing problem that I hear about, particularly in the San Diego community, as well as just the burden of paperwork. That does discourage people from getting involved and from getting into the system. Ms. Boyda. Mrs. Boyda. Thank you, Madam Chairwoman. I think, as my second year of Congress begins--you know, this was such an important issue back in the district. We have Fort Riley and Fort Leavenworth, so I feel like we are really coming together to address these issues; and understanding them is very important. General Schoomaker, I very much appreciate your help in dealing with some very specific areas of concern that we have. At some other point--not right now--I would like to talk about some potential mental health provider issues that might be available as a good thing at Fort Riley, that we might be doing. It is not appropriate to talk about it now, but it would be when it is timely. General Schoomaker. Yes, ma'am. Mrs. Boyda. So I would like to talk about that sooner than later, if we could. You know, I have heard that the Army did this--what do you call the training when you do it level by level? General Schoomaker. Our Battlemind Training, ma'am? Mrs. Boyda. Yes, but do you have a process when everybody trains somebody down---- General Schoomaker. Oh, leader chain teaching. Mrs. Boyda. Chain teaching. Thank you very much. That is complete at this point? General Schoomaker. Yes, ma'am. That was executed in the early fall of last year. It went through the entire force. The Chief and the Secretary then challenged me to institutionalize that. What do we do next? We have done it once over the force. A considerable amount of the force, as you know, is deployed in Iraq and Afghanistan. Efforts were made to bring that right down into the deployed force. What we need to do, now that new soldiers have come on board and that troops have rotated, is to institutionalize that across Army training; and we are doing exactly that with every soldier as they go through the non-commissioned officer (NCO) training program or officer training program. Every health professional, as well, goes through a series of individual Battlemind Training focused on resilience and mental health issues identification as well as group training. Mrs. Boyda. Are the other branches of service doing that as well? The Marines? Admiral Robinson. We have a combat operational stress program that is similar, but we embed it from the recruitment all the way through the war college. We have, as I labeled in my statement, the MOSST process, which is the Marine Operational Stress and Surveillance Training, which is a method to train the lowest level and also the midlevel commanders. Also to make sure that the commanders are absolutely engaged and are also empowered to have a psychological health climate, additionally, we have embedded with our marine units psychological and psychiatric professionals who are there, who become a part of the unit, so that it is no longer a referral to medical. Those people are actually in the operational units. We do the same thing on the Navy side by putting in psychologists and social workers, but particularly psychologists, on board our ships so we have them there. We also have our chaplains who for the longest time have been quite effective here and who are still very effective. Every once in a while, I have to make sure that I mention them, because they have been doing this since the beginning of the Marine Corps and the Navy---- Mrs. Boyda. Probably before that, too. Admiral Robinson. Well, I am just talking about the services, but the key is that they have been doing it, and we continue to do that. Mrs. Boyda. Thank you very much. Admiral Robinson. Yes, ma'am. Mrs. Boyda. What I was wondering, General Schoomaker, is, now that we have implemented that, is there any follow-up to see what its efficacy has been if we challenge the system or have we measured anything afterwards to see how effective that has been? General Schoomaker. Yes, ma'am. In the most recent Medical Health Advisory Team report, MHAT-V, you will see that there was a focused question. We did not do a formal scientific study, but we had a certain number of soldiers in that study who were deployed who had received Battlemind Training, and a certain number who had not; and it gave us an opportunity--it gave the team an opportunity to see, was there an outcome in improvement. In fact, there was. Those soldiers who received Battlemind Training self-reported that their anxiety and that the psychological consequences of the deployment in combat operations were less intrusive than---- Mrs. Boyda. If there is a summary of that anywhere, I just would like to---- General Schoomaker. Yes, ma'am. It is part of the MHAT-V. Mrs. Boyda. For the record, the whole thing about suicide rates.You know, I get a lot of questions, clearly about high school retention, or recruits, and all of these sorts of standard questions that we all get about this. Just for the record, I would love to see what the suicide rates are for the Army and for the Marines and be able to compare it to what that was before we went into Iraq. General Schoomaker. Yes, ma'am. We will follow that closely. [The information referred to can be found in the Appendix beginning on page 138.] Mrs. Boyda. Thank you. Mrs. Davis. Thank you. Mr. Murphy. Mr. Murphy. Thank you, Madam Chairman. I saw that the 2004 New England Journal had the numbers of 16 percent of Iraq veterans have major depression, anxiety or post-traumatic stress disorder. Would you all like to elaborate on that? Do you think that is an accurate number? Do you think it is higher? I would enjoy your comments. General Schoomaker. That was a derivative of, again, one of the earlier iterations of the mental health advisory team, and that alluded to the incidence among redeploying units of symptoms associated with post-traumatic stress. And in every one of these four, I try to make sure that we highlight the fact that this is post-traumatic stress symptoms, that it is not well-established post-traumatic stress disorder, which is what most political people and the press often reports on. That is a mental health diagnosis from unresolved, unidentified and untreated symptoms of post-traumatic stress, which can result from combat, from major childhood trauma, from national disaster, motor vehicles, any amount of--any cause of stress. What that report showed us was that soldiers redeploying from a combat zone, depending upon their exposure to combat and trauma, had somewhere between 10 and 30 percent rates of symptoms associated with post-traumatic stress, but that if we do not screen for and promptly treat would, we feared, emerge or evolve into or mature into post-traumatic stress disorder. Our experience is that with good screening after the fact--and this is, in fact, why Dr. Casscells's predecessor mandated a policy of post-deployment health reassessment at the 90- to 180-day period. You will hear our soldiers talking later about the fact that at redeployment, frankly, the reintegration excitement obscures many of these symptoms, but 90 to 180 days later they emerge, and families see this, unit leaders see this. And so we screen for the symptoms and then address the symptoms through specific treatment. Mr. Murphy. And I apologize, General. I thought that Chief Gutteridge's written testimony so far has been very enlightening to us. But what do you think as far as the number; is that accurate? General Schoomaker. I think that accurately reflects it. I think it would be higher in units that have higher combat exposure, and it would be lower in those that don't. In the unit that may be restricted to the FOB, to a forward operating base, and not work outside the wire and not work in an area of intense combat, I think you would expect that it would be lower. Mr. Murphy. How about as far as the majority of our soldiers now and our troops and our marines are married, unlike in Vietnam, how about that it is not so--it is not just the individual trooper that is affected and that might suffer from this, but it is also the family members. What have we done as a Department of Defense to help and assist the families as well? I know I applaud the 90- to 120-day review for the troopers, but what are we doing for the families as well? If you could elaborate on that, I would appreciate it. General Schoomaker. I will say quickly, and then my colleagues can speak to the family center care, as the Army does, too, that we extend battlemind training to the families. We recognize that families are often the first to identify problems with redeploying soldiers and try to make them obviously a part of the solution as well as a recipient for the services. Army has spent a fair amount of effort as well into providing marital and family counselors on our installations, and that has been very effective. In other words, to go to the root causes of many of our problems, you spoke earlier, Madam Chairwoman, about suicide. We know that one of the major causes of--or precipitants of suicide is a ruptured relationship with the wife, husband, girlfriend and the like, or was the Army itself. We know that misconduct that results in, let's say, Uniform Code of Military Justice (UCMJ) can precipitate a suicidal gesture in a soldier who sees their relationship with the Army as one of their most important and fragile relationships. Mr. Murphy. Roger, sir, I am tracking that. But I think my question is more specific. Let me ask, is there some type of mandatory screening where we contact and be proactive in contacting the spouses to make sure that they are okay? I know the centers there that it seems like react to the ones who call or come to the doors or the website. But is there the screening of the spouses, of the loved ones of our troopers? General Schoomaker. I think the operative word there is ``mandate.'' We don't have authority to mandate for family members, but we certainly offer the services to those families, and we make them--we sensitize them to the need for them to receive that care. Yes, sir. General Roudebush. And I think we can speak to the activities particularly on departure and then reintegration. For the Air Force we used very much a community-based approach which is inclusive of the families. And the commanders are-- that remain at the station of origin are also responsible for tracking with those family members during the period of deployment to assure that the needs are being met, that the issues are there. I agree with General Schoomaker, there is not a mandate for that, but our programs are structured to do that. And I would offer, relative to the screening tools, the postdeployment survey and the resurvey 90 to 180 days out, those have been continually refined to increase the sensitivity to elicit any symptoms; to assure that if assistance is required, that we get those folks to the assistance that is needed in the most expeditious way. Admiral Robinson. Congressman Murphy, the Navy has two programs, Navy Medicine--actually it is Navy/Marine Corps, because the Marine Corps key volunteer member and also the Navy ombudsman work with families and work with families predeployment and postdeployment. There is nothing mandated, but there is certainly a close relationship. I think we are trying to get a little bit more proactive, especially in the Special Ops community which have huge numbers of deployments related to other folks, and that is the focus program which is the families overcoming and coping under stress. And that is a program we are trying to get into place that will do counseling and very, very early intervention with families, because we know that deployment time, length of deployment and also number of deployments are direct factors in psychological stress. And we--we are trying to deal with that using that program. Mr. Murphy. Doctor--ma'am, can he just answer? He had his hand up real quick. Dr. Casscells. Dr. Casscells. Thank you for your service. I can tell you are politely hinting at this issue that we have not yet got a rigorous program to identify all of the lost sheep, particularly among the Reserve who are drilling Individual Mobilization Augmentee (IMAs). I am one of them, Guard. Guardsmen, guardswomen. And they go home, and they sometimes either don't have a family, or the family has got plenty of other things for them to do besides, you know, offer a shoulder to cry on. So I am talking to all of our chaplains together in a few weeks and asking them for their help in reaching out to these people and making sure that the family is doing okay and that the servicemember is doing okay, because if we don't hear back from them on our postdeployment health reassessment tool, and we--about a quarter of them, they are--go home, and we don't hear from them. We have got to reach out and identify every single one of them. And how to do that, you know, because they move, it is not that easy. But we are working on it. So thank you. Mr. Murphy. Thank you. Mrs. Davis. Thank you, Mr. Murphy. Mr. Johnson, actually when we were at Camp Lejeune and in Mr. Jones's district there, we did see some aggressive follow- up. I think some of that can be done. And I think certainly that is a possibility. Mr. Jones, thank you. Mr. Jones. Madam Chairwoman, thank you very much. Dr. Casscells, it is good to see you again as well as other members of the panel. I have got a question, but I will just read a couple things in this article that is in the Post. ``Care for Injured Vets Rises Questions''--I know a lot of this deals with the VA. You are not the Veterans Administration (VA), that I understand. But I want to make a point because of this article. There is a book that I just ordered that I would hope I could recommend to anyone: The Three Trillion Dollar War. It is an analysis of the cost of the war and what the cost will be after the war. And I think any American, quite frankly, should read this book. I wish I could buy it for them, but I can't. But the point of this is that the--Dr. Cross with the VA said during this week, and this is March 8: Lawsuit hearings at 120,000 vets from Iraq and Afghanistan using VA care for potential mental health problems. Obviously they are now under the care at the VA, but they were in the military. And that is the point that my colleagues have been making. And nearly 68,000 of them have potential PTSD. We did hear--and I agree with the Chairman, I think the committee that did attend, going out at Camp Lejeune, was very impressed with many good things that are happening. There are many challenges, as well as there are with you. I want to know a little bit more about how you recruit. You mentioned this earlier that you were going to be more aggressive, but is it a problem for the Department of Defense to go on university bases--Mr. Etheridge from North Carolina has joined us. He is not on this committee, but obviously he has an interest, or he wouldn't be here. We have one of the strongest university systems in America in North Carolina, and the president of the university system is Erskine Bowles, who used to be the Chief of Staff to Bill Clinton, and he is a fine, fine gentleman. I would like to know how you do recruit these mental health professionals or these graduates of mental health programs at the university. And is there good cooperation? Or do you have the stigma that you do at some universities, well, this is the military, and then they bring in this idea of the war, whether they are for or against it. Can you tell me, explain to the committee a little bit how you do recruit these health professionals at universities and colleges? Dr. Casscells. Congressman Jones, thanks for this. Recruiting is strong in North Carolina, I am happy to tell you, like it is in Texas, and we have trouble at my alma maters, both at Yale and Harvard, to get people to join up. I am working personally on that. And, you know, for a while there, some universities wanted to keep us off campus until they were reminded that they receive Federal funding, and that has been helpful. Of course, we would rather have people enthusiastic and, you know, welcome our recruiters, and their recruiting is not done by Health Affairs or by the Surgeons General. We assist in that. And we are doing things like helping with a movie, you know, called Fighting for Life. It is just launching out nationwide about our medical school, for example. So there are lots of ways we can be active in this. The bonuses, of course, are one of them. At the end of the day, a big part of it is individuals recruiting friends and colleagues. And so we are trying to get across the idea that everyone is a recruiter, everyone is a recruiter. And it is a privilege and an adventure to serve. And I will tell you, I love telling that story because, for me, joining the Army Reserve and being deployed at 53, 54 years old, and at 55, it has been the adventure of a lifetime, and it is so rewarding. It is the easiest story to tell. But there is a lot of information out there, and getting through--getting the information out and getting heard is a challenge. But bonuses, bonuses are there. The recruiting dollars are there. Would more help? Sure, more would help. I don't know of any statutory barriers that you could help us with, but if you could think of some suggestions, my gosh, recruiting and retention are on the edge for us, on the edge, sir. Mr. Jones. Well, General, would you like to speak to this as well? General Schoomaker. Well, I was going to say we can't promise any Army doctor who is recruited in the Army that they are going to eventually become the Assistant Secretary of Defense for Health Affairs, but we certainly want that as part of the career track. So the Army and the Air Force, I will speak for the Army medical system, because you are really talking about two different programs. One is recruitment of civilian, government service employees. That is what we talked about earlier. That is a program that is done through the recruitment of any government service employees. We have done a targeting recruiting for those, and that really powered down contracting in the hiring of those folks, and vetting other credentials to individual treatment facilities in our regions. For uniforms, we have a very aggressive program on recruiting that is linked to the recruiting community of the Army, but is increasingly carved out to address the specific markets of health professionals, because as Dr. Casscells said, it is a health professional that recruits another health professional. We are in over 100 medical schools, for example, in the country today and nursing schools. We have got great programs out there. We are very well supported. Some programs are obviously better than some other programs. But I think Army, Navy and Air Force all have very aggressive programs. Quite frankly, frankly, the Health Professional Scholarship Program today for medical students is an example--for nursing students and dentists--is one of the most generous and best programs available and offers them careers that are unprecedented. Mrs. Davis. Thank you. Ms. Tsongas. Ms. Tsongas. Thank you for your testimony, and it is encouraging to hear the serious work you are putting in to addressing this. The question I have--and again, this is to play off the recent trip we had to Camp Lejeune where we met with many who had been wounded--was the issue of how--as you recruit civilians into the military either in a contracted way or to become part of the military to deal with mental health, how do you sensitize these professionals to a world they may not understand? I heard from a young soldier that there is a hesitancy to go to physicians who have no understanding of what they experience, you know, who have not experienced war, who are not a product of the military, and who don't have the credibility to really help them with the challenges they face. Is there a training program, something as you bring people in so that they do understand what a unique--post-traumatic stress syndrome is obviously a function of service in war, but if you haven't experienced war yourself, if you are not the product of the military, you may not really understand how to go about helping these young people. So I wondered, do you have something in place to work that through as you--so that these professionals can be effective in the work they are trying to do? General Schoomaker. Yes, ma'am. You said ``soldier,'' but you have visited a Marine camp, so I am going to be real quick. I am the soldier up here, and the Marines are represented, of course, by Admiral Robinson. Ms. Tsongas. This just happened to be the particular young people we met with, but I am sure this is across all the services. General Schoomaker. Yes, ma'am. First of all, for the individual combatant, individual soldier, and his or her family, we talked earlier about the teaching that took place across the Army that has now touched 800,000 to 900,000 soldiers from the top of the Army, the Chief of Staff, to the newest private. For health care professionals, especially those who are going into deployment, we now require a combat operational stress training course that is conducted at our Army Medical Department Center and school in San Antonio. This has been very successful. We have also piloted that program to be given to our combat medics, who we have now trained about 800 of our newest combat medics in identification of issues having to do with mental health in the theater of operation. But that is an effort, as the Navy has done and others, to standardize the training that is given to professionals going into the theater of operation to sensitize them specifically to the challenges of mild concussive brain injury as well as post- traumatic stress and anxiety associated with it. General Roudebush. Yes, ma'am. Likewise in the Air Force we perform that training for our uniform members, certainly, as part of their predeployment training, and for those that are going to be in theater specifically to be sure they are fully up on the traumatic brain injury and those activities. For the civilian providers that we bring on, we train them as well in the diagnostic issues of post-traumatic stress disorder, tramatic brain injury (TBI). They are not left out of that at all. Now, there is not necessarily a formal enculturation process. But as we bring those folks into our clinics, hospitals and medical centers, they become very much part of the team. And everything that happens within that venue, they are a full-up round within it. So they are brought along as part of that health care delivery team. Ms. Tsongas. I guess a follow-up question might be, then, do you see a resistance on the part of those being treated to working with civilian--people who have been primarily in the civilian world to help them deal with their mental health challenges? Or is it--I mean, just given the lack of experience some of these professionals may not have had in a theater of war. I mean, is there a resistance, or can you supplement it, offset it in other ways, or is it just the reality that you have to--given the difficulty of recruiting and getting mental health professionals, finding the ones you need, that you have to make do with the best you can? General Roudebush. Ma'am, I would turn that around. And as opposed to resistance, which there may be, I would suggest that there is a preference for these individuals to see parts of the team that they resonate with and identify with. Providers in uniform are within our direct care system. For those that we are not able, for whatever reason, to treat within the direct care system, I believe it is incumbent on us to manage their care and to assure that their needs are being met wherever that care is being delivered. And that is part of the responsibility of that medical group commander and staff. Ms. Tsongas. Thank you. Admiral Robinson. Congresswoman Tsongas, there is no question that Marine Corps, Navy, Active Duty and families would rather see uniformed psychiatrists and uniform mental health providers. That is not always the case because we don't always have enough of them. But there is no question that they have made this clear to me as the Surgeon General of the Navy, and to the Medical Office of the Marine Corps and other leaders. That is number one. Number two, if you read Heidi Kraft, who is a former Navy psychologist who has written a book, Rule Number Two, and she emphasizes that very point that you are making. There is a sensitivity, and there is an understanding and there is a connection that you have. I think that as--and this is specifically civilian mental health workers who are coming into our facilities and working, and civilian mental health members who are through the TRICARE who are actually out. Now, this is the heart of the problem because that is in the community. But people coming into our facilities can certainly get orientation and indoctrination into some of the stresses and some of the conditions that the patients and families have. But to be very honest with you, no one is going to give what someone in uniform can give you under comparable conditions. Someone in uniform that has experience and has been with you is going to be more effective. Ms. Tsongas. Thank you. Mrs. Davis. Doctors, I am going to have to move because, we are going to really end up--run out of time, and we want our second panel to come forward. Ms. Shea-Porter. Ms. Shea-Porter. Thank you. And I will try to be very quick about this. My question is what percentage of people who need treatment are falling through the cracks right now? I have read different estimates of the number of untreated or undertreated soldiers and family members. Would anyone like to take a guess at what you think the number we are missing? Dr. Casscells. Ms. Shea-Porter, we don't have an exact answer, as you might expect, because some of the people who most need care are most afraid because of the nature of mental stress. People who are not just stressed, as Dr. Schoomaker said, but have stress disorder are people who are not seeing clearly in many cases. They are blaming themselves. They are afraid that if they ask for help, they will be stigmatized, lose their security clearance, lose their, you know, weapon if they are in theater, for example. They are afraid of letting down the team. They are afraid that they won't be promoted. They are also afraid of losing their civilian job. In the case of the reservists, this is terribly important, because one of the--some of the collateral damage of all this attention to psychological health and mental and combat stress is that some employers are using this as an excuse not to rehire, not to keep those jobs open. And I have to emphasize to them over and over again that even though, let's say, suicide rates have increased in this past year in the longest war in our history, they are still just below the civilian levels. And when our guys and gals come home, their rates of domestic abuse, of misdemeanors, felonies, broken marriages, and drug abuse, this all remains well below the civilian levels. We are very proud of this. Ms. Shea-Porter. Well, I have to say, it is confusing, because I, too, am reading all of the numbers. And I know not too long ago a major newspaper had a headline saying that mental illness was the number two illness now for our troops who have seen combat. Dr. Casscells. Yes, ma'am. It is because we have just about eliminated most of these infectious causes. Accidents are way down, what we call disease and nonbattle injury way down, you know, a lot of better protective equipment. You know, prevention is the best thing we have got. We have tried--trying harder to assign people to the right military occupational specialties, to identify them early when they are struggling. And the residue is--we do have people who really wanted to serve their country. They are young. They don't have much track record. They get into the situation of combat stress. It is hard for them, and they have--they struggle to recover from it. Ms. Shea-Porter. Thank you. And I would agree with that, but I think we are missing a large number of them still. Dr. Casscells. We are. Ms. Shea-Porter. What I am reading, and what I am hearing, and then what I am seeing in other reports, there seems to be a huge difference. But anyway, the point I wanted to make is I know we are following traditional and some nontraditional methods of reaching out to troops and also to their families, but I think that we could extend this. And I was going to ask you, I know in my own State of New Hampshire, community organizations are working to find them. But I also wonder if we have a just kind of practical right-on-the-ground-level way of outreach by putting up information in places where these young soldiers and their young families tend to go, which is fast-food restaurants and laundromats and places where they might not have any connection with the military at all, but they are hanging around for a couple of minutes, and they have a chance to see-- see a sign there for them. Is there any effort at all being made to reach out on a very basic level, which is where people tend to go today? Dr. Casscells. Yeah. We just asked our colleagues at Personnel and Readiness, for example, to put on every shopping bag in the Post Exchange (PX) and commissary a note about the website and telephone number where you can go to get help. We have not done it at McDonald's. This is the kind of thing we need to test and, you know---- Ms. Shea-Porter. I encourage you to do that because that is the common denominator where people gather, especially young families who might be afraid to approach the military. General Schoomaker. Ma'am, if I could make one point. I appreciate your question for a different reason, and it has to do with definitional. We are using words here that I think are highly charged. We talked earlier with Congressman Murphy about the fact that on the one hand we report symptoms, but they are interpreted as a full-blown mental illness. What we are being very, very sensitive about and going after very aggressively are the earliest symptoms of stress, which I think the public should not interpret as resistant forms of well-established and highly intrusive disorders and mental illness. I think that there is a problem there. Ms. Shea-Porter. I understand the difference. So I do know what you are saying. And certainly most soldiers and their families are doing---- General Schoomaker. The other thing I would say real quickly, and I think the Chief talked about this, a large number, in some cases the majority, of our most affected soldiers have not been deployed at all. Ms. Shea-Porter. Yes. General Schoomaker. They were carrying into service these problems. Ms. Shea-Porter. If I could make one last point, please. The other thing I would like to add is I do know there are some--some glitches on, say, pay and other problem areas that are causing extra stresses on these families and contribute to this sense of an ill ease or problems, and perhaps we need to look closer within our--their own structure and see if there are ways we can alleviate the pressure on these families who have a spouse or relative serving overseas and then have to struggle internally with pay issues or just problems, to help in that department, too. Thank you very much. Mrs. Davis. Thank you. Dr. Snyder. Dr. Snyder. Thank you, Madam Chairwoman. Sorry I was a little late getting here. Dr. MacDermid, I would like to ask you a series of questions, a few questions comparing what your opinion is of the opportunities for quality care, comparing those opportunities between the military family today and a nonmilitary family in America, if that is a fair question. So if I am a military family with an autistic child, do I have a better chance or a less chance of finding care in the military versus not being a military family? Dr. MacDermid. Well, you are certainly asking me to stretch my area of expertise a little bit, but I think a very safe answer is it depends a great deal on where you are. As you know---- Dr. Snyder. The problem with military families is they may be in 6 places in 10 years and get a great set of--we were talking about that the other day. Dr. MacDermid. Sure. I do know that the military does have explicit procedures in place to try to accommodate the needs of families with special needs children. Dr. Snyder. My second scenario is part of the same answer then. If I was a military family with a child with schizophrenia, say, a teenager with schizophrenia, would my opportunity be better or worse than if I was a nonmilitary family for getting care? Dr. MacDermid. I think, frankly, with schizophrenia it is tougher. Dr. Snyder. Tougher for a military family? Dr. MacDermid. It is tougher than autism, I think, because, for example, autism, schools are used to dealing with kids with autism, and they have individualized experience plans. And military and civilian kids both, because it is a much more common sort of disorder, schools are more used to dealing with it. Kids with diagnosable psychiatric disorders are in tough shape in both military and civilian worlds because there aren't that many child psychiatrists. Dr. Snyder. Excuse me for interrupting. Dr. MacDermid. Certainly. Dr. Snyder. We have short time. I want to ask--I appreciate your comments. If I am a military family, and I have a teenager with either an alcohol or a drug problem, what are my opportunities for appropriate rehabilitation and treatment for a military family compared with a nonmilitary family? Dr. MacDermid. Based on the task force's work, I am fairly confident in saying you have a more difficult time in the military, and in particular if you don't have access to a military treatment facility. Dr. Snyder. I wanted to ask--this will be my last question, Madam Chairman, and get a response from each person. And again, I think I missed a lot of this discussion about how we go about increasing our mental health providers. You need to recruit more military people, you can hire more civilian folks, or you contract. And I wanted to ask you all's opinion of the contracted aspects of it. I think there was some reference-- General Schoomaker, I think you talked about some policy hurdles. I want to know specifically what things need to be changed or improved either statutorily or by the policies that you all have control over to enhance and quicken your ability to have some agility with regard to contracting for mental health services. We will start with you, Admiral, and just go down the line. Admiral Robinson. I think the first thing we would need to do is to make sure that we hire mental health or any other professionals that we have on more than one or two-year money. In other words, I can't retain people unless they understand that this is a job that they can have for a duration of time, duration that is longer than one or two years. The second thing is part of the problem with mental health professionals, I think, is the longitudinal problem that we have in the longitudinal studies on health care professionals, and that is I am not sure that there are--there are--certainly is a shortage. I am not sure if we are going to be that successful in getting the numbers to come into the military even on the civilian side unless we have other incentive programs that make it nice for them to come in. In other words, they have opportunities, and they are doing just what our dentists are doing: They are looking at the other opportunities. But I think that the major thing is that we need to have a career pathway for our contract professionals that shows that we are interested in them over a long period of time, and that when we bring them into our system, we have them for a period of time. And I don't think we have been able to do that very well. That is my one issue. Dr. Casscells. Dr. Snyder, as one doctor to another, I just say that our shortest route to getting services is to look beyond the M.D.'s and even beyond the Ph.D.'s and to get more nurse practitioners, more---- Dr. Snyder. I am talking about the issue of contracting those. Dr. Casscells. Yes, sir. That relates to whether we are-- what authorities we have and what restrictions we may have in terms of our credentialing and criteria. We have some barriers, I think, to getting more counselors involved, and I think this is terribly important because we have relatively few psychiatrists and psychologists. And we have a largely male structure in the military. And we have got a lot of young guys, and some of them from broken homes. We really need to--and we are looking at this now to getting the counselors we need, and they are not--they are not going to typically be contracted M.D.'s and Ph.D.'s. It is going to be a broader group of counselors. I am not sure we need any statutory relief on this. We are looking at this. The Army is doing a great job. They have got 150, as you have just heard, but we may need more. We are getting close to where we have enough, and that plus getting the family involved more, the battle buddies, the regular doctors, you know, deputy mental health people, may be enough. But we certainly need to take a broad look at this. Contracting in general, you know, my feeling is that we don't need a whole lot more of this military-to-civilian conversion. What we need is help on our recruiting. And I am not sure this is a statutory issue. We just have to focus on it. Mrs. Davis. Thank you. I want to thank all of you very much for being here with the panel. As I said earlier, we welcome you to stay because there may be some questions that we have as a follow-up to any of the comments that the witnesses make. And I know that we have a lot more questions, and we will hope to follow up with those in the future. Clearly there has been progress, and we commend you all for that. We are in a different place. But we also know that we have a long way to go to be sure that we are taking proper care of the men and women who serve us. So thank you very much. And if we can move as quickly as possible for the next panel, that would be terrific. We will get going. Mr. Jones. Madam Chairman, before you start, could we ask Dr. Casscells to give to the committee a list of the universities and how many mental health professionals were hired from each university, say, going back to 2006--or 2005--I guess 2006 would be appropriate--just to get an idea, if you don't mind. Thank you. [The information referred to can be found in the Appendix beginning on page 138.] Mrs. Davis. I would be happy to, Mr. Jones. Thank you. I am delighted that you are here. It is very important. I wanted to ask unanimous consent that Mr. Bob Etheridge, the Congressman from North Carolina, could introduce Mr. Scheuerman, who is on the panel. He is a constituent and a gentleman that Mr. Etheridge had a lot of opportunity to work with over the past few years. So, Mr. Etheridge. Mr. Etheridge. Thank you, Madam Chair, and Chairwoman Davis, and Ranking Member and other members of the panel. Let me thank you for allowing me to be here with you today and sit in on this very important hearing on this very important subject. And I deeply appreciate your courtesy for allowing me to join you today and introduce my constituent Chris Scheuerman from Sanford, North Carolina. Chris is a soldier's soldier and an American hero. He retired as a Special Forces master sergeant and continues to train soldiers at Fort Bragg. Chris Scheuerman represents the finest tradition of an American soldier where duty, honor, and country it is not a mere slogan, but a way of life. Beyond his personal service, Chris continues to serve his country by raising a family of soldiers. The unspeakable pain, though, that this family has endured highlights a troubling problem in today's Army where far too many soldiers conclude that suicide is their best option. On July 30, 2005, Private First Class Jason Scheuerman, deployed with the 3rd Infantry Division at Forward Operating Base Normandy in Iraq, died from a self-inflicted gunshot wound from his M-16 rifle. He was 20 years old. I am no expert in mental health care, but it is clear the system failed Private Scheuerman and is failing other soldiers. The way the Army withheld information from the Scheuerman family about the circumstances surrounding Jason's death betrays his service, intent on treating this as a public relations problem rather than a mental health problem. I am hopeful that this is beginning to change, and I commend this committee for examining policy options to achieve that very change. And I thank you. When I first talked to Chris about his son's case and read the documents that he was forced to obtain through the Freedom of Information Act, frankly I was flabbergasted. That is not the United States Army that I know. As a young man, I served as an enlisted man at Fort Bragg and several other bases, and for many years I have had the honor of representing that base and its surrounding communities. Just last month I made my third trip to Iraq to visit with our troops in the field, and I made a point to meet with mental health professionals there to talk with them. I am extremely proud of our men and women in uniform. Of course, military life is tough, and necessarily so, yet the chain of command must always treasure the lives and well-being of individual soldiers. That system failed Jason Scheuerman in the most important way possible. I personally spoke with Army Secretary Peter Geren about Jason's case, and to the great credit Secretary Geren immediately requested an investigation by the Army's inspector general into this case. This investigation is ongoing, and I thank you for that. It is now the duty of Congress and especially this committee to examine the policies' shortcomings that this case brings to light. We must learn from the mistakes made here and go forward with better policies and systems to protect our soldiers in the field. So I implore the committee to listen to the words of this true patriot and to take actions to put in place a better system so that we can arrest the disturbing trends that soldiers' suicides have brought to us and prevent other families from suffering the pain that the Scheuermans have endured every day for 2-1/2 years. Madam Chair, I stand ready to help, and I thank you for allowing me this courtesy. Mrs. Davis. Thank you. I appreciate your being here as well and making the introduction of Mr. Scheuerman. And Major and Mrs. Gannaway, we are very happy to have you here, and Chief Gutteridge. Mr. Scheuerman, would you like to start, please? STATEMENT OF CHRISTOPHER M. SCHEUERMAN, SR., MASTER SGT. (RET.), U.S. ARMY Mr. Scheuerman. Thank you, ma'am. I would like to thank Chairwoman Davis, the distinguished members of the subcommittee for allowing me to testify on an issue that has tragically been personalized in my life. I would like to thank Congressman Etheridge and his staff for their support and dedication. In July of 2005, my son, PFC Jason Drew Scheuerman, after losing his battle with depression, decided to take his life while fighting the war on terrorism in Iraq. Jason was 20 at the time of his death. I address you today not only as a father of a soldier who took his own life while serving our Nation, but also as a veteran, a combat veteran, with 20 years of service as an enlisted man and an officer in Army medicine. Though it is difficult to discuss the events proceeding my son's death, I believe it can serve as a catalyst to help us better understand and treat soldiers battling depression and mental illness. Not all suicides caused by depression are preventable, but most of them are. In an article dated January this year, Colonel Richie, the consultant for psychiatry to the Surgeon General, stated, we have got multiple portals to care through chaplains, through primary care, through behavioral health and through leadership. We also need to make sure the family members know who to call if they are worried about their soldiers. Three weeks prior to Jason's death, we called his unit after receiving a suicidal e-mail and pleaded for help, not knowing if our soldier was alive. We knew how to call. Jason was seen by his chaplain, who had earlier witnessed him sitting alone with his head bobbing up and down on his rifle. He later said in a sworn statement that he believed Jason to be possessed by demons and obsessed with suicide. He did nothing. Jason was ignored by his primary care provider. It was common knowledge throughout the unit leadership that Jason was experiencing problems. The leadership had been told that Jason had been seen sitting in his bunk with the muzzle of his weapon in his mouth. He was never seen by his battalion medical officer. He did nothing. After being on suicide watch, Jason was sent to an Army psychologist. The Army psychologist never contacted Jason's unit to hear of prior suicidal gestures. He relied solely on standardized tests; misdiagnosed and dismissed Jason back to his unit with recommendations that caused more harm than good. He made the situation worse. All of the access to care portals that Colonel Richie speaks of today existed in 2005, and they failed miserably. The first step in reversing the growing trend in soldier suicide is accountability. If a soldier has an environmental injury such as frostbite or heat stroke, and a subsequent investigation shows that to be preventable, then a commander and a leader is relieved. The same standard or accountability should exist for suicide. If a suicide is shown to be preventable, then people need to be held accountable; leaders need to be relieved. I believe if we hold people accountable and leaders are relieved, at that point we will see a significant statistical decrease in soldier suicide. Any program that we execute is only as good as the people who are running the program. Without accountability, we are going to be doomed to failure. Jason desperately needed a second opinion after his encounter with the Army psychologist. The Army did offer him that option, but at his own expense. How is a PFC in the middle of Iraq supposed to get to a civilian mental health care provider at his own expense? How alone my son must have felt. He had nowhere to go. I believe a soldier should be afforded the opportunity to a second opinion by a teleconference with a civilian mental health care provider of their own choice. Any standardized test that the soldiers take can be faxed or sent by secured e-mail to that provider, and then the soldier and the licensed mental health care provider can talk via webcam or other technology available. The civilian providers do not have to be in theater. They can be here, home in the States. This civilian provider can provide the checks-and-balances element from here. I know if that were available on the day Jason was seen, he would have most probably been with us today. There was a great disparity between the observations made by Jason's chaplain and the psychologist. Jason's chaplain clearly believed him to be extremely troubled and told Jason's mother in a conversation after his death that they had been watching Jason for some time. Jason's psychologist stated that he was capable of feigning mental illness in order to manipulate his command. There must be a mechanism put into place when there is such a discrepancy of opinion. A hotline should be established where a concerned member of the telecare team, be it the leadership, the chaplain or mental health care, can call when there is such a disagreement. And a board can be convened to review the specifics of the case, to ensure soldier safety, to make sure that no mistakes are made. Additionally, when a provider is examining a potentially suicidal soldier, it should be mandatory for them to call the family to gather pertinent background information. Who knows their soldier better? Who better to recognize a change than a spouse or a parent? We knew Jason was having problems. If they had called us, there would have been a different outcome. I believe these two simple steps will save lives. The last two years have been an ongoing struggle to gather documents and information to finally realize all the missed opportunities to save our son. None of these documents were given to us freely. I had to make multiple Freedom of Information Act requests in order to receive the documents. I would never know what would come when I got home from work, what I would receive in the mail. Initially the Army told me that Jason left no suicide note. I came home from work one day, there was a package in my mailbox. I opened it up. As I went through it, I found Jason's suicide note and read it. If we as a family were not willing to investigate the circumstances of Jason's death, we would never know how bad it had become for our son. I propose an independent panel made up of professionals from outside the Department of Defense, both medical and psychological forensic experts and trained investigators, do a retrospective analysis of all theater suicides to find other mistakes and/or commonalities so we can learn and improve from our understandings. The document that the Army uses to learn from suicides, the Army's suicide event report, was filled out by the psychologist that failed my son. Opportunities to learn from mistakes have been lost. Our family's loss could have been a powerful training tool for our soldiers and their leaders. We could have used Jason's story to recognize both the obvious and subtle signs of depression, mental illness and suicidality. I believe we always learn more from our failures than our successes. I would like to thank the committee for their efforts in providing funding, support, and bringing focus to this very important issue, something that I believe we as a Nation must get a grip on. Thank you. Mrs. Davis. Thank you very much, Mr. Scheuerman. [The prepared statement of Mr. Scheuerman can be found in the Appendix on page 126.] Mrs. Davis. And Major Gannaway and then Mrs. Gannaway. Thank you. STATEMENT OF MAJ. BRUCE GANNAWAY, U.S. ARMY Major Gannaway. Good morning. My name is Bruce Gannaway. I am a wounded warrior recovering at Walter Reed Army Medical Center. Mrs. Davis. Major, could you please bring the mic a little closer. Major Gannaway. I am an infantry major that was in command of a cavalry troop when I was wounded on December 21, 2007, in south Baghdad. I apparently triggered an Improvised Explosive Device (IED) during dismounted operations. The injuries I suffered from the blast include an amputated left foot, a large vascular wound to my right leg, and the most difficult injury is the amputation of my left middle finger and multiple broken bones in my left hand. This is the most difficult wound because it affects everything that I do from typing, dressing, eating and a whole range of other daily living tasks. My experience after I was wounded brought me through the medical evacuation system. I was initially treated at the combat support hospital in Baghdad. I was then evacuated from Baghdad, through Balad, Iraq, through Landstuhl, Germany, to Walter Reed. The trip took approximately four days from injury to my arrival in the United States. I was an inpatient at Walter Reed on ward 57 from December 25 through January 18, 2008, when I became an outpatient and moved into the Malone House on the Walter Reed campus. Subsequently I chose to move to Silver Spring, Maryland, and I am currently renting a house in order to provide a better place for my family to raise our daughter. I am receiving care as an outpatient at the Military Advanced Training Center, or MATC. Mrs. Davis. Major, could I ask you to move your mic just a little bit closer? We just really want to hear you. Thanks. Major Gannaway. I am receiving care as an outpatient at the Military Advanced Training Center, or MATC, at Walter Reed, to include occupational and physical therapy. Also while at Walter Reed, my wife and I decided to take advantage of the mental health services offered at Walter Reed. We have a good, strong and stable marriage with good communication between us. Even though my wife is a health care provider and is used to working with trauma, an amputation is still a life-changing event. We decided that we should take advantage of the therapy that is provided to facilitate our communication with each other during this stressful time. We meet with a psychiatrist once a week, and occasionally either one of us will meet with him individually. My initial encounter with mental health was as an inpatient at Walter Reed. Walter Reed has a Blast Protocol where every servicemember that has been injured due to a blast is screened by most of the major disciplines to include speech, dental, optometry, and, of course, mental health. However, my impression with mental health evaluation was a quick question and answer (Q&A) session that was conducted very early on in my hospitalization, and I was still pretty heavily sedated. This session is the litmus test to see if I needed additional mental health intervention other than the weekly walk-through of the ward by a mental health specialist prior to the weekend. My peers in the MATC are all amputees. The typical population in the MATC is generally younger than I am. These soldiers or marines may or may not be married. Their faith, economic and social backgrounds are varied. Therefore, I am not the typical wounded warrior. I am too old, and I have too much rank. I have the self-confidence to be my own advocate to deal with the rotating providers who are carrying huge caseloads and to work with the supporting staff to get the appointments that I need. Many of the physicians that I see carry impractically large caseloads; consequently I often do not see the same provider from appointment to appointment and frequently need to get worked in because there is no scheduled time available. I am married to a health care provider and I have a stable marriage. I also have previous experience with occupational and physical therapy due to a motorcycle accident that I was involved in approximately 10 years ago. Again, my experience is with the amputee center, the MATC, at Walter Reed. I cannot speak to how mental health services interacts with other departments or wards at Walter Reed. I do want to state that I believe that I have received excellent health care during this recovery. Recommendations for mental health: You are fighting a culture and a stigma. The wounded warrior population in the MATC is young, inexperienced with mental health, and does not want to be perceived as weak. The stigma is better than it was when I first joined the service. Had I stated that I was going to counseling, my peers would have assumed that I was either crazy or headed for divorce. Mental health needs to be brought to where the groups of wounded warriors already are. Make mental health a part of their normal routine or a part of something they are already required to do. Mental health specialists should make early and frequent visits to the wounded warriors while they are an inpatient and follow them while they are an outpatient. A way to do this at the MATC would be just like the chaplain does. The chaplain makes routine visits to wounded warriors while they are an inpatient, and there he establishes a relationship with the soldiers and marines while they are on ward 57. The chaplain then follows us to the occupational and physical therapy rooms in the MATC while we are an outpatient. I understand from speaking with a therapist at the MATC that mental health had previously attempted without much success to establish support groups that met on a weekly basis. I think the support groups are already established within the patient population. There are patients and family members that are always at therapy and interact with each other. Use that connection right there. There is a friendly group that already communicates and shares with each other. If a mental health specialist has already established a good, friendly relationship with the group, they will be able to easily move in and out of the group as they circulate the therapy rooms. Thank you for your time here today. I am grateful for the care that I have received. It is truly a combat multiplier that soldiers and marines are confident that if injured, they will receive excellent medical care. Our wounded warriors deserve nothing less. Mrs. Davis. Thank you, Major. Mrs. Gannaway. STATEMENT OF SARAH GANNAWAY Mrs. Gannaway. My name is Sarah Tate Gannaway. I am here today with a dual role. I am an Army spouse, military family member, and I am also a health care provider. I am an occupational therapist with expertise in critical care medicine. I also have been active in the Army life of my soldier. I have been involved with the Readiness Group, with Army family team building, and with a host of other military programs. I consider myself fairly experienced in the Army lifestyle. And I have also chosen to seek out more information about the health care that I do receive within the Army medical system. This is both personal and professional interests. My comments today pick up some on what has already been discussed by the previous panel. The challenges that I see within the Army medical system are some of what I would like to discuss today. I also do want to give--I have a short discussion about some of the improvements that I have seen over the years within the Army medical system, specifically within mental health. I am going to use the term ``TRICARE'' as a universal for Army medical care. I use the term ``TRICARE'' because that is what our insurance is called. TRICARE has both military uniformed providers, the civilian contractors, and a component of health care insurance on the economy, which would be a civilian provider who is not connected to a military treatment facility. Some of the challenges that I see in TRICARE are both for the mental health care services, but also for the physical health care services, some of the family medical providers that were discussed earlier today. Probably the biggest challenge that I see within TRICARE is the issue of reimbursement, as was discussed earlier. I am not privy to the information of what the dollar-for-dollar reimbursement is for health care services or civilian providers on the economy, but as Dr. MacDermid mentioned, it is somewhat lower than some of what the other insurance companies do provide. The perception within civilian providers on the economy is that TRICARE does not pay, and since TRICARE does not pay, why should we see military families? That proves to be a large challenge for military families because the military health care system is overworked, extremely understaffed. It is difficult to recruit civilian providers to become TRICARE providers if you don't reimburse. And the reimbursement is not comparable to what other private insurance companies pay. Within the uniformed services and the military treatment facilities, there is difficulty getting connected to military providers. There just are not enough of them. The hiring process to become a contract provider is onerous. It takes a very long period of time. You have to be extremely persistent. And while many of these contract providers do have a heart for Army families, having a heart for Army families only takes you so far. If you can go to your local hospital or go to your local group practice and make more money and work fewer hours and have a smaller, more manageable caseload, it is ridiculous not to. Most of the contract providers within military families just struggle. The caseloads are enormous, upwards of 800 people in some cases. It is very difficult to establish a patient/physician relationship when you have 800 people that you are responsible for. It is also very difficult to establish that relationship when you don't see the same provider from appointment to appointment. That is something that family members struggle with, but it is also something that our uniform services struggle with, and it is simply a product of uniformed providers deploying and there not being enough contract providers. These guys have to have a break, and if you are able to get an appointment, you take what you can get. The consequence of that is that you spend a lot of time telling your story over and over again. Without a physician relationship and some continuity, you waste a lot of time, and that is unfortunate. The referral process for care, specialty care, is very slow and very cumbersome. This is applicable both for mental health care services on the outside, but also getting physical specialty care referrals. There are some rather unusual policies within some of the military treatment facilities that do make it a little bit more complicated to get care. At the facility where we were most recently stationed, you could not get a physician--or a prescription refill or a lab result unless you had an office visit, and that is wasteful for the patient's time, but it is also wasteful for the physician's time if you have to go to see the physician just to get a refill on something innocuous, like a prenatal vitamin. That does combine to make a shortage of office visits. I have personally had the experience of calling day after day after day, attempting to get an appointment, and being told that no appointments were available, call again tomorrow. This is complicated by the reluctance of some military treatment facilities to provide referrals to receive care on the economy, which is also complicated by the fact that you sometimes struggle to find a physician on the economy who will see you because the reimbursement is low. One of the things that I have noticed in the last several years is TRICARE used to have a nurse call line, a 1-(800) number, to call in if you had a question or if you had a concern or if you had a sick child and you needed to get a little bit of guidance from an experienced professional about whether or not you need to take your child to a doctor. That nurse call line has been dissolved. Consequently, people are bringing their children to the emergency room, taking themselves to the emergency room, attempting to get a same-day appointment for things that maybe were not necessarily needed for an office visit. There are some improvements that are already in place specifically related to military health care, military mental services that were mentioned earlier. Military OneSource is a great resource that offers six office visits without a need for a referral from a physician. All you do is call Military OneSource, and they refer you out to a provider in your community. It is a little bit like an Employee Assistance Program. Military OneSource offers six visits. They do need to be renewed, which means you have to be able to get an appointment with your primary care physician in order to get the renewal, which brings you back to the cycle of trying to get an appointment. TRICARE has recently developed a self-referral process so that you can call your local psychologist or licensed professional counselor and ask for an appointment. Through that program, you can get 8 to 12 visits. That is a vast improvement over what had been in place before, because you self-refer. You do not need to get a referral from your physician. After those 8 to 12 visits, though, you do have to get a renewal from a primary care physician. There are some recommendations that I offer for you today, specifically--well, broadly for military medicine but also specifically for the mental health care. Streamlining the hiring process will make it easier to get contractors, not just contract physicians but also allied health professionals, your licensed clinical social workers, your masters in social work (MSWs), even allied health people--the therapists and the nurses. Offering a competitive salary to compete with the facilities in the community is very helpful because it makes it easier to get physicians and to get allied health professionals. There was some discussion earlier about a large signing bonus for physicians, but those programs are harder to come by if you are allied health, and there are more allied health people than there are physicians. Streamlining the referral process to make it easier to get care on the economy when a military treatment facility cannot offer care would be very useful. Receiving a referral is time- consuming. It has to be done very specifically, and it has to be done by name. If the civilian provider that you request by name is no longer accepting new TRICARE patients, then you start your referral process over, and that lengthens the time that it takes to get your care. I would recommend that the military treatment facilities each reexamine their local policies to determine if there are some policies in place that make it more difficult for families to receive care, an example being the necessity to have an office visit in order to get a referral for prescriptions. Increasing reimbursement to civilian providers on the economy would make it more appealing to them to see military families. When I received my obstetrical care when I was pregnant with my daughter, the physician practice that I used had 10 physicians. They were all listed as TRICARE providers on the TRICARE Web site. However, only one of them was accepting new TRICARE patients, and that was not the one I wanted to see. So my choice was find another physician or change the physician in the practice that I was willing to see. Reinstating the nurse care line would be beneficial for families just as a resource, but also to help alleviate some of the burden of same-day appointments or of the seeking of same- day appointments within military treatment facilities. Finally, increasing the number of authorized visits for mental health services offered through Military OneSource and through the TRICARE self-referral program would also be useful to families and would take some of the burden off the military treatment facilities. Mrs. Davis. Thank you very much. I appreciate it. Your recommendations are helpful. Chief Gutteridge. STATEMENT OF CHIEF WARRANT OFFICER IV RICHARD G. GUTTERIDGE, U.S. ARMY Chief Gutteridge. Chairwoman Davis, Ranking Member McHugh, distinguished members, especially Congressmen Snyder and Murphy, and fellow veterans--Mr. Scheuerman, I am sorry for your loss. It was nice hearing from you, Major Gannaway, as well as from your spouse. I wish my wife of 18 years, Kathrin, were here, but she cannot join me. I returned from my latest Iraqi Freedom tour in February of 2007. I was very happy to return to my wife and two sons in Germany. The homecoming was very sweet. I was required to complete a post-deployment health assessment during the post- deployment phase after returning. At that point, I did not have problems that needed immediate attention. Completing the needed forms was a ticket to begin leave. I did not want to be delayed in starting my leave. I had plans. I began to clear my unit in Freiburg, Germany. The 1st Brigade of the 1st Army Division was casing its colors and returning to the States. Freiburg was closing. While on my stay in Germany, I executed a consecutive overseas tour, COT, and moved to Ansbach, Germany. While I was in-processing my new unit, I was informed that I failed to complete the 90-day post- deployment health reassessment (PDHRA). At this point, I was required to complete the survey. I now had been back from Iraq for about four months. I had started to have nightmares, and I was constantly reminded of being back in Iraq. I had intrusive, horrible thoughts about what happened in Iraq. I was finding myself easily becoming angry at little things. I was also having trouble sleeping, and I began to withdraw from my family. I considered the PDHRA more honestly this time. A medical doctor in Ansbach reviewed this assessment. As a result of reviewing this document with me, the doctor told me that I had chronic PTSD and combat stress. I was then referred to behavioral health in Ansbach. I then called and made an appointment. I began therapy sessions with a nurse practitioner psychiatrist in early August of 2007. I was pleased with the one-on-one therapy I was receiving. As a result of one of my earliest sessions, the nurse practitioner recommended that I adjust my Citalopram, otherwise known as Celexa, medication. I was told to call the clinic, if needed, after this adjustment. My condition worsened. I continued to have nightmares, and I felt as though I was losing control. I called the clinic in Ansbach a week later to see the nurse again. The nurse was on leave, and her next appointment was not for 20 days. I then inquired about seeing a doctor, and I was told that the next available appointment was 21 days from then. I then told the receptionist that I would drive to Landstuhl Hospital to see a doctor 2.5 hours away. I was told that was not possible. She then told me that she would place a telephonic referral for me to speak to a doctor who is deploying soon from Vilseck, Germany and who has 72 hours to contact me. I was then asked if I was suicidal. The only way to get immediate help was to be suicidal. I was not suicidal, and I told her so. At this point, I was very frustrated and angry. I then e-mailed the wounded warrior hotline--the Wounded Soldier Family hotline is what it is actually called--and stated that I need help now. I expressed the fact that I was a senior warrant officer with 24 years of Active Duty and that I had served in Iraq during Desert Storm and that I had two extended Iraqi Freedom tours. If this is how I was being treated, I asked how a young infantry soldier would be treated. Shortly thereafter, I received a phone call from the hotline. I then received a phone call that evening from the doctor who had my telephonic referral. We discussed my condition, and he made recommendations concerning my medication. I began to feel better. Weeks later, I continued my one-on-one care with the nurse practitioner. As time went on, anniversaries of traumatic events that occurred in Iraq began to come around. October and November were particularly disturbing. Reliving the horrors of evacuating fallen soldiers' and marines' remains, as well as searching through body bags for dog tags and watching soldiers die, was too much. I became more withdrawn and distant from my family. I was having what I was later told to be suicidal ideations. I also began to increase my use of alcohol to cope. I am not proud of this, and it is very difficult to admit. My life almost ended on Christmas Day. I no longer had a desire to continue. I felt as though my condition would never change. I just wanted to be like before, but I could not fathom this. Late Christmas evening, I found my nurse practitioner at home, and told her what was going on. I felt relieved in calling her, but I knew that, as soon as I placed the call, my career would be over. After I assured her that I was safe, she told me to come see her the following morning in her office. I drove to her office alone, and we met. She then told me that I needed help that she could not give. I was then advised that I could go to Landstuhl on my own or else I would be forced to. Seeing no way out, I gave in. I then opened her office door to see my wife with one of my suitcases. She was accompanied by my brigade commander and a chaplain. Reality kicked in. I was on my way to Landstuhl in a van with my brigade commander and the chaplain. I was very sad to leave my wife in the parking lot on such short notice. I never felt more alone in my life. Upon arriving at Landstuhl, I was admitted to the inpatient psychiatry ward, Ward IX Charlie. I was issued a hospital gown and socks that had tread woven into the soles. My entire belongings were inventoried. Once I snapped on the hospital bracelet, reality really set in. Having to be observed 24 hours a day, shuffling around in socks while being behind locked doors marked ``elopement risk'' was very humbling. I was observed twice daily for the next seven days for signs of alcohol withdrawals and was having to answer simple questions and was being instructed to hold my hand steady to be observed for shaking. Having to be watched by a private 1st class while shaving and eating with plastic utensils was humiliating. The only hope was the fresh-air breaks--having two quick cigarettes in succession while standing out in the cold German air, wearing socks and a hospital gown, under the constant supervision of one of the staff. These smoke breaks were the only event to look forward to. I soon realized that the purpose of my being in a lockdown ward was for my own safety. I quickly became assimilated, and I have nothing but great respect and admiration for all of the personnel who work on Ward IX Charlie in Landstuhl. As New Year's Day 2008 approached, I was told by one of the psychiatrists that he was recommending that I be medically retired and sent to Walter Reed to out-process the Army via the Warrior Transition Brigade. I was told that I would receive PTSD care after I was separated, at a Veterans Administration facility. I was heartbroken. I did not want to retire. I cried for the first time since returning from Iraq. I was able to have my wife and two sons come to say goodbye to me. I flew to Walter Reed by Medevac flight on New Year's Day. I had never been to Walter Reed, but I had heard the stories. I was very apprehensive upon arriving. I was very apprehensive. Upon arriving by bus to Walter Reed after the Medevac flight landed at Andrew's Air Force Base, I was allowed a quick smoke before being escorted to the hospital. I was then taken to Ward 54, the inpatient psychiatry ward at Walter Reed. Knowing the initial drill from having been at Landstuhl lessened my apprehension of in-processing the ward. I was soon back in the hospital again, and I received a new bracelet. I was now able to wear shoes without laces instead of socks. That was refreshing. Ward 54 had many patients. I soon reacquainted myself with a few of the soldiers I had met at Landstuhl. They assured me that Ward 54 was cool. I felt much better then. I soon began talking with psychiatrists and psychologists. They were very kind and understanding. I immediately expressed my desire not to be medically retired. I was then advised that I would be my best advocate. I then made a decision to make the best of the situation. I participated in group therapy and followed orders. I made friends with my fellow patients. The staff was courteous and professional. The smoke breaks continued to be all that I looked forward to, those and the phone calls that I could make to my wife. I was then made aware of the Specialized Care Program at Walter Reed that was specifically geared toward PTSD. Upon receiving this information, I made up my mind that getting into that program was my goal for getting better and for staying in the Army. I had hope for the first time in weeks. I continued the therapy on Ward 54. I quickly became disgruntled with the initial-entry soldiers that were also in Ward 54. These trainees were learning to be soldiers and were admitted to Ward 54 for various reasons. I soon became disenchanted with the group therapy after having to listen to people less than half my age complaining that they could not adapt to the Army, could not get along with their drill sergeants, et cetera. My disdain for this element on Ward 54 was shared with the other combat veterans who had PTSD issues. We soon branched off into our own groups and shared our stories. I felt relieved that I was not the only one experiencing the same problems with PTSD. I worked toward my next goal of being moved to Ward 53, the outpatient psychiatry ward at Walter Reed. My whole being was focused on continuing my care. After almost 2 weeks on Ward 54, I was released to Ward 53 and moved to Abrams Hall. This time, I almost cried tears of joy. Ward 53 was a breath of fresh air. The staff was very friendly and accommodating. The atmosphere was very refreshing, hopeful and professional. I made my intentions very clear early on of wanting to be inducted into the Specialized Care Program specifically geared toward the treatment of PTSD. I then began a series of interviews with psychiatrists and psychologists as well as with social workers from the Deployment Health Clinical Center here at Walter Reed. Initially, I was discouraged because I felt that I did not make the cut during the final phase of the process, but I did, indeed, begin the program on February 4th of this year. The Specialized Care Program was awesome. From the very first day, I knew I was in the right place. I looked at the other seven soldiers in the program, and I saw the same worn, haggard, distant look that I became accustomed to seeing in the mirror each morning. The three-week, intense PTSD program provided an overall health assessment as well as an understanding and recognition of symptoms of PTSD. I also learned how to normalize my reactions to combat experience. Learning coping skills such as breathing techniques and Yoga Nidra, coupled with one-on-one therapy with passionate mental health providers, helped to reduce my hyperarousal and vigilance. Group therapy with my fellow PTSD sufferers was what made the biggest difference by providing mutual support. I can now manage my depression and grief associated with PTSD. I am now aware of self-care and available resources. I feel like a husband and a father again. The program saved me. I owe my Dr. my life. I often contemplate my reintegration when I return to duty at my unit in Germany. I am not worried about my being stigmatized. I am worried about how my wife and sons will be treated once the small, close-knit community knows the truth about my mysterious three-month absence. I describe the perception of PTSD not as a stigma but as akin to having leprosy. Lepers are avoided, looked down upon and ostracized. Lepers also live and die slowly together in their own community. Lepers only have each other. PTSD sufferers are lepers without lesions. We are like discarded pennies on the ground. No one picks up pennies. Only shiny quarters are retrieved. Many of my fellow PTSD sufferers long for outward physical injuries, to be accepted here at Walter Reed. Looking normal or healthy on the outside is hard to explain in a hospital environment. There are no photo opportunities on the psych ward for politicians or celebrities. There is no prosthetic for a lost soul. I am sorry for your loss, Major. Some concepts that would improve the image of PTSD sufferers seem fairly simple. I do know the infrastructure of hospital psychiatry wards were designed for peacetime. No one expected this to be a long war, five years and counting. Segregating soldiers who have PTSD and combat stress from patients who are hospitalized for noncombat-related issues is paramount. The mutual support that PTSD sufferers receive from each other is incredibly therapeutic. It is very difficult to discuss PTSD issues in an open forum containing patients who are not suffering from PTSD in a psychiatric environment. I also feel that substance abuse and PTSD are not compatible. My abstinence from alcohol is a driving force in my accelerated recovery in coping with PTSD. It is very easy for PTSD sufferers to cope the wrong way by using illegal drugs, by huffing inhalants or by abusing alcohol. I feel that substance abuse counselors need to be incorporated into the PTSD recovery program, not isolated in a distant building away from the group therapy. They have to be part of the same program of recovery, not separate or in parallel programs. One feeds the other. I feel very strongly about this. The Warrior Transition Brigade (WTB) is an outstanding success, in my opinion. My only recommendation would be to slowly replace the initial group of cadre with noncommissioned officers and junior officers who are still viable in the Army but who are offered or forced into medical retirement. Having these nondeployable experts who have navigated the environment here at Walter Reed would pay huge dividends. Simply keep them here. Make the offer. Let them continue to contribute. The present cadre is dedicated, but you can only truly learn about programs and assistance that are available here if you have walked the walk. There are tremendous benefits available here that soldiers in the WTB discover on their own. Word of mouth soon spreads, enabling soldiers to enjoy sporting events, to learn to play the guitar and to kayak, to take advantage of airline miles donated, and to obtain items such as toiletries and clothing from the Red Cross. The benefits are endless. Finally, many soldiers celebrate their second birthday, or their ``life day,'' on the day that they survived being wounded in Iraq or Afghanistan. I do not celebrate that September day that I was shot by a sniper in the Anbar Province. I celebrate the day that I was enrolled in the Specialized Care Program for PTSD here at Walter Reed. In the words of Colin Powell, ``I will never not be a soldier.'' Thank you for this opportunity to tell my story. [The prepared statement of Chief Gutteridge can be found in the Appendix on page 129.] Mrs. Davis. Thank you very much. Thank you to all of you. This has been stirring, truly, to hear your stories. Mr. Scheuerman, of course we regret your loss greatly, and I am so impressed that out of your tragic story you have looked to what could be done to help other families, and that is greatly appreciated. We have a vote coming up. What I would like to do is to probably start with a question or two, but I am hoping that members can come back. As you know, we often give our witnesses about five minutes apiece, and you can tell that we did not want to stop you at all within your testimony because it is all so important to us to hear from you, and we greatly appreciate that. Your story of renewal, Chief, gives great hope, I think, to many, many people who have suffered as you have. We are always very, very happy to hear from all of you as to what has happened and the interaction of spouses as well. If there is one, I guess, message if people are not able to come back or are not able to go on with the hearing--you have all had a recommendation or two about partly how we make certain that there is an opportunity to have a second opinion, you know, to have somebody there who can speak up and say, ``Hey, wait a minute. You know, I have seen something that you all are not seeing, and I need to be able to share that.'' Chief, somebody could have just kind of written you off, and I think that you were about ready to write yourself off at one point, and we need to try and intervene. Is there one particular recommendation that you feel that you just want to make certain that you have just hit home with us so hard? If you would like to--you know, I do not want you to have to repeat what you said but, rather, just make certain that we have heard it. Mr. Scheuerman. Mr. Scheuerman. Yes, Chairwoman Davis. All of the soldiers who are serving in Iraq, they do have the option to get a second opinion, and they sign the paperwork that their commander gives them, and it says at their own expense. It is impossible for them to do that, but they must be afforded that opportunity. I had been in Army medicine for a long time prior to when I retired. You see a lot of patients. It takes a lot of time. You make mistakes. Mistakes are made. There has to be a check and balance. The only thing that I can think of that would cure that problem would be a hotline, a telephone number, that either the soldier could call or someone within the chain of command could call, or anyone with contact to that soldier who recognizes something that no one else sees. They can call that number, and then that soldier can get help. There has to be a safety net, and I do not believe that right now there is a safety net for the ones who fall through. Mrs. Davis. Major Gannaway. Major Gannaway. As a commander in Iraq, troopers are constantly surrounded by their peers, and it is leader business to make sure that your soldiers are taken care of physically and mentally. Really, the system failed in your case, sir. I am very sorry about that. Battle buddies, squad leaders, platoon sergeants, platoon leaders, commanders, chaplains, all have to be involved in the lives of our soldiers and make sure that they are taken care of. On the rehabilitation side, some of these wounds are life- altering, and I understand how soldiers go into depression and abuse. I can see how they can go down the road of illegal drugs and alcohol and start down that downward spiral. I believe if mental health were more involved in the daily life of the soldiers, it would remove some of the stigma. Instead of having to go to another part of the hospital and speak to somebody in a white coat, if they came down to Iraq with the soldiers during their therapy and talked to their therapist, I think they would have a better understanding of how the soldier is doing. Mrs. Davis. Thank you. Mental health screening for everybody? Just routine? Major Gannaway. During recovery, yes. Mrs. Davis. Okay. Mrs. Gannaway. I guess, as a spouse, is there one thing that you would like us to particularly focus on either when leaving or returning from a deployment that is important? Mrs. Gannaway. My recommendation would be to continue the efforts to increase availability of services. Second opinions or first opinions are sometimes very difficult to get because the providers are overwhelmed, and there is just not enough to go around. That is a challenge that is not exclusive to post- deployment units. It is a challenge that is universal across Army medicine. So my recommendation would be to solve the problems related to staffing, because more staff who are better trained and who are less overburdened will be better able to meet the needs of Army families. Mrs. Davis. Chief Gutteridge. Chief Gutteridge. Yes, ma'am. You know, we can embed journalists in units. That is very popular. Why can't we embed more mental health providers? You are right, Madam Shea-Porter. People do have a resistance to talk to somebody about combat stress or things that happen in combat when that person has not been there. When you are a soldier in Iraq and you come off a mission and you are told that, hey, there is a rotating team of mental folks who are here to talk to everybody, first of all, you are tired; you are hungry; you need to restock ammo; you need to preventive maintenance checks & services (PMCS) your vehicles; you need some sleep; and you are a member of a team. If you are taken out of that team even for 20 or 30 minutes to talk to somebody who is an outsider, number one, you are setting yourself up to be ostracized. What I found that worked best in my unit, the 136th Infantry--we were in a remote area of the Anbar Province--was our battalion surgeon, Dr. Rumbaugh. Having a medical doctor who has a good rapport with soldiers and having those medics who have a good rapport with soldiers makes a huge difference. Once again, the only time you are going to be able to get well in a combat environment is to be taken out of that environment and to miss out on what is going on and to leave your buddies behind and to have a vacuum that has to be filled because you are not there. If you had a professional mental health-type person at least the battalion level in units, people who are actually deployed with you, who eat the same food, who suffer the same mortar attacks, who cry when you lose soldiers--they are just a part of you, just like that surgeon is. Chaplains are capable of that, but they are not trained for it. Quite frankly, chaplains are hit and miss when it comes to traumatic events such as that. That would be my recommendation, if we could embed mental health professionals at least at the battalion level who are down with the guys who are suffering. Thank you. Mrs. Davis. Thank you very much. We have about six minutes on that vote, Members. Then it is going to be about a half hour, I think, before we are going to be able to return. Is everyone able to do that? Are you able to stay? Because I know members will be happy to come back. Okay. Thank you again very, very much for being here. [Recess.] Mrs. Davis. Thank you all for returning. We are here, we think at least, for quite a number of minutes, and we are going to go through and make certain that all of the members have a chance to at least ask a question, and then we will try and finalize the hearing after that. Mr. McHugh. Mr. McHugh. Thank you, Madam Chair. I really do not have any questions. This is my 16th year in Congress, my 16th year on this full Armed Services Committee. I have heard a lot of testimony, but rarely have I heard a panel come with more well-thought-out, very straightforward suggestions. I want to thank you all for your service. Mr. Scheuerman, you have my deepest sympathy on your loss. I will tell you, as you acknowledged, Bob Etheridge is concerned deeply about this. Hopefully, your efforts with him can get you some answers. I think that is the least this Nation owes you. I can tell each and every one of you that the things you have said here today and your appearances here today will help another soldier, sailor, marine, airman, not have to face the challenges and difficulties and the heartbreak that you have. So thank you for being with us, and thank you for having the courage to step forward. I know it was probably not easy, but it is one of the bravest things that anybody could do, and we thank you so much for that. So, with that, Madam Chair, I will be honored and pleased just to sit and listen and learn some more as we go through the rest of the panel. Mrs. Davis. Thank you, Mr. McHugh. Mr. Jones. Mr. Jones. Madam Chairman, thank you very much. I have had a chance to speak to several of the panelists, and I join Mr. McHugh. I do, in a way though, want to ask Mr. Scheuerman and, actually, each one of you. Your son, Jason--and let me very quickly--I had a grandfather who was gassed at the Battle of the Argonne Forest and who took his own life when he was 31. I never knew him, and my daddy never talked much about him, but I did get his records. I know the mental pain and alcohol and drug abuse that became part of his life and ended his life early. I really do not understand--you know, I cannot help you. I wish I could help you and your wife and your family. I want to know how important--at least at some point you mentioned the chaplain; the major did; the warrant officer did. Did the chaplain see Jason's anguish? He was there to spiritually counsel him, but was he in a position where he could or did he reach up to the officers and say, ``This young man has trouble''? Mr. Scheuerman. Sir, the chaplain did observe Jason, and saw that he was having troubles, and made a recommendation that Jason get a psychological evaluation. Mr. Jones. Now, you might have said that in your testimony, and I just missed it. Okay. From that point forward of the chaplain's making the recommendation, is that when you were saying that nothing seemed to move forward to help Jason? Mr. Scheuerman. At that point, there was a total breakdown in communication. Once Jason was sent to see the psychologist, the psychologist never called back to the unit. There was no communication between the psychologist, the chain of command or the chaplain. Had the psychologist called back to the unit, he would have heard the stories of Jason's laying in his bunk with the muzzle of his weapon in his hand, of Jason's sitting in the corner with his head bobbing up and down on his rifle, of Jason's sleeping at the command post in a fetal position. He would have heard those stories, and perhaps his assessment of Jason would have been much different than ``feigning mental illness in order to manipulate his command.'' Mr. Jones. Madam Chairman, I think this committee should ask for an investigation, quite frankly, of why when the chaplain made this request that it was dropped. I will tell you that I think truthfully that this--not just because of this family--but you just cannot not hear the cries of someone who is so anguished. If the chaplain went to his superior or to the ranking member of the military leadership and said ``This young man needs help'' and somebody did not do his job--I am going to tell you that I asked for an investigation when Chaplain Stertzbach was removed from his chapel in Iraq for praying over the body of a deceased soldier in the name of Jesus Christ, and they removed him. I think we need to ask for an investigation as to why this happened, so it will not happen again. I do not know if I can make that request, but I would like to make it. Mrs. Davis. Thank you, Mr. Jones. There is an active investigation. Is that correct, Mr. Scheuerman, as far as you know? Mr. Scheuerman. Right now, with the help of Congressman Etheridge, Congressman Etheridge asked Secretary Geren, the Inspector General of the Army, to conduct an investigation, and they are conducting that investigation at this time, sir. Mr. Etheridge. Madam Chair, if the gentleman would yield-- -- Mr. Jones. Yes, I yield to the gentleman. Mr. Etheridge [continuing]. Secretary Geren has initiated an Inspector General (IG) investigation that is ongoing. What the committee might want to do, Madam Chair, is just follow up and take a special interest in that, because I know the Secretary has just been absolutely outstanding in this. He did not hesitate. He said we are going to do it and that it is going to be ongoing and that we are going to get to the bottom of it. The committee might want to see the report when it is completed. He has expressed an interest, and I think that would be most appropriate at this time. We will go ahead and let that investigation move along because it is ongoing at this point. Mr. Jones. Madam Chairman, since it is my time and I am about to lose it, I want to thank the gentleman from North Carolina for what you have already done. That is all I was trying to do is to make sure that we see the report so that we have a better understanding of what was not done so that it does not happen in the future. To the major and to the warrant officer and to your lovely wife, thank you for being here. May this county never forget that you have earned this benefit, and I will continue, as long as I am here with my colleagues, to fight and to make sure that Americans--instead of sending money overseas to help other countries, how about let's take care of those who have served this Nation in the military. I thank you. I yield back. Mrs. Davis. Thank you, Mr. Jones. We certainly will follow up with the investigation. We want to check and see when that is going to be available. I think many of the questions, of course, that you have raised in terms of communication are critical, and we need to be sure that we move forward and learn from them. Also, I think you mentioned an accountability piece, and I think that is an important one as well. Thank you. Dr. Snyder. Dr. Snyder. Thank you. Mr. Scheuerman, do you have other family members with you here today? Mr. Scheuerman. Yes. My wife, Anne, is here, sir. Dr. Snyder. I wanted to acknowledge your presence. We appreciate your being here today. I know this can be a difficult time to go through this, but it is very helpful to us and to other soldiers and soldiers' families. Thank you for being here also. Mr. Scheuerman. She has been my therapist, sir. Dr. Snyder. Mr. Scheuerman, you said one thing that I did not understand and that I have not heard before. When you talked about having to have some kind of written request for a second opinion, I did not understand that. Repeat that for me again, please. Mr. Scheuerman. When Jason received his command referral to go see the psychologist, it is a Department of Defense directive that they be read off their rights. One of their rights is to a second opinion at their own expense as a Department of Defense directive. If I may, as far as the investigation, all of the information that we got through the FOIA requests--and there were multiple FOIA requests, and they all came in piecemeal. It was our family that had to go through the Criminal Investigation Division (CID) report, that had to go through the 15-6 investigation, that had to go through the psychological medical records to put all of the pieces together to say, ``This is wrong. There were mistakes made.'' The Army had already closed that case and had moved on. Dr. Snyder. As you may have picked up in some earlier discussion, I am a family doctor, and we should be a lot smarter than--those were big warning signs; 25 years ago, I look back at some of the things that we would have missed in some of our colleagues, but those were very glaring warning signs, and it is absolutely appropriate to try to figure out what happened because, if it happened to your son, it is happening to other people, not just in the military but out of the military. Mrs. Gannaway, I appreciate the thoroughness of your discussion, but I am not sure--I thought that was a discussion just of someone who, you know, sat next to a hospital bed or went to counseling sessions with your husband, because you really had some much better systems analysis than most of us House Members. How did you get up to speed on a lot of these issues? Is there a group of folks you are working with or is this just something you have been poking around in on your own? Mrs. Gannaway. I have a vested interest in this issue---- Dr. Snyder. Sure. Mrs. Gannaway [continuing]. Because of being an Army family member but also because of my experience professionally in the medical community---- Dr. Snyder. As an occupational therapist. Mrs. Gannaway [continuing]. As an occupational therapist. I ask a lot of questions. I have been frustrated at times by some of the difficulty that I have had navigating the Army medical system. I did have a life prior to being in the Army, and had my own health insurance through a private company, and found it to be much more simple to use. My health care at our most recent duty station was provided at a satellite clinic. Initially, I had a relationship with one physician whom I saw on a regular basis when I needed it. The Army renegotiated the contract with that group of physicians, and he chose to leave. At that time, I got into a cycle of seeing different physicians and different providers over and over and over again. When that happened, I really started to pay attention to some of the things that I saw that could benefit from improvement. Dr. Snyder. Your comments were really helpful. Major Gannaway, in your statement, you talked about the culture of the young, which is that young folks do not like to acknowledge problems. It seems to me that we need to also be dealing with that culture before people get hurt or sick. I mean the fact that somebody goes out, you know, at age 22, never having been overseas, never having been exposed to the kinds of things that you all have been, and putting away five beers on a Friday night and joking about it on Saturday morning is a problem. I mean, we may think that is the culture of the young, but it is an unhealthy culture. Is it your experience in the military that we are addressing those kinds of things outside of the experience of people's being hurt or injured? Major Gannaway. I believe the military is getting better at addressing substance abuse problems and mental health issues and at reducing the stigma of acknowledging mental health with their servicemembers. It is not to a level where it is completely accepted to go see a mental health professional, and it may not be that way in civilian society yet either, but we are working toward it. A lot of that simply just comes down to leadership within a unit. Dr. Snyder. Chief, I am out of time, so you do not have to hear me ask the question if you are still smoking, so---- Chief Gutteridge. But I am not under any type of performance-enhancing drugs at this time. Mrs. Davis. Thank you. I want to turn to Congressman Etheridge. Thank you very much for joining us. We appreciate that, particularly as you work through and help Mr. Scheuerman in this investigation. Thank you. Mr. Etheridge. I thank the gentlelady. Thank you for letting me join the panel, and thank you to all of you for letting me have the opportunity to make a comment, and to really ask a question. I join all of my colleagues here this morning in saying that in the years I have served in this body--and I have not been on the Armed Services, I have served on a number of other committees, even though I represent Fort Bragg and Fort Pope. I have a deep and abiding interest in having served in the military in Vietnam. A lot of the situations that you have talked about this morning, a number of my fellow soldiers who came back from Vietnam suffered from, and we should never let that happen in America again. I just want to make a couple of points and get a comment because it seems to me--before I came to Congress, I ran a pretty good-sized organization. I was a State superintendent of schools. It was a lot people. It is hard changing a big organization that has a culture that is just there, and it takes time to change it. It seems to me that we are living in a really different time in the world today than we were 20 years ago or even 15 years ago. As we start this process in our leadership in the military, from the top all the way down to the company commander and to the last trooper, we are going to change our culture, and that culture has to change to be accountable for more than just the weapons and the equipment. We have got to be accountable for people's health and for their mental health. It seems to me, Madam Chair, that that has to be something we encourage, that the mental health piece has to be a part of this process of keeping our soldiers safe and healthy. I believe that Mr. Scheuerman mentioned earlier that if that were a part of the requirement of leadership, that accountability piece, that it would be treated a whole lot differently. So I would encourage us to look at that. Each one of you in one way or another has said that. You may have said it in different ways, but that is really what you are saying. I think we need to hear it, and those of us in Congress need to take the actions, and we need to take whatever action it takes to get the system changed. I think one other thing was this whole issue of second opinions. I do hope we find out what that is, because it seems to me if I am a PFC in Baghdad or wherever I might be, and I am asked to have a second opinion and I have got to pay for it, number one, it may not be available; number two, you sure cannot get it there; and third, there ought to be a hotline. Chief, if you had not had your hotline, I shudder to think where you would be today. Thank you for being able to get to it and to call. We do need to make that available. For a lot of these young folks, as has been indicated, this is their first time away from home in some cases. For many of them, it is the first time they have ever been overseas. I think, Major, you touched on it, on the whole mental health issue, but it is all a total health issue. When we are in the States, we worry about speeding and driving, et cetera, and drinking, but the same has to be true of the total mental health overseas. Finally, I would be interested in your comments at least on two issues. One is this whole issue of the total accountability to include things like mental health and others. Second, what do we do to change the culture? Because that is an important part. It is a part of the training, but it is also a part of the continual retraining. I would be interested in any of your comments because you have been through it, each one of you, in one way or another. I hope that you would be instructive, to help us. Chief Gutteridge. Congressman Etheridge, one thing that I would recommend is, if you do have a mental health issue, you either go to a behavioral health clinic or you go to a mental health clinic. If you have the symptoms of, let's say, combat stress or of PTSD and where you are not quite yet diagnosed with PTSD, we could change the culture by simply changing the name. Instead of behavioral health--we could still keep that, but we could have a subset or a smaller compartment that is, perhaps, combat stress. You know, everybody loves the word ``combat.'' You attach that to anything, it is acceptable; it is manly; it is okay. So, if you have combat stress and someone else tells you that you have a mental illness, you are going to pick combat stress every time. So I think it is something as simple as changing the wording of the programs, of the buildings, even the sign on the door or the number in the phone book. It is just how it is called. Just relate it somehow to combat or to operational stress as opposed to behavioral health. That would be my recommendation. Mr. Etheridge. Language is important. Chief Gutteridge. Yes, sir. Major Gannaway. Sir, you touched on the total system. You know, a leader is responsible for his soldiers' actions. He is responsible for making sure that he is up to date on his dental, on his shots, and so that includes a mental health screening. I think a way to reduce the stigma of mental health would be to make it part of a soldier's normal routine. Normalize it. If they have more exposure to it on a routine basis--predeployment, during deployment, post-deployment, and during train-up--it will lose some of the stigma and become more acceptable. Mr. Scheuerman. The Army has dealt with a lot of cultural changes in the past, sir, from sexual discrimination, racial integration, drunk driving. The Army has gone through a lot of cultural change, and a key to the Army's dealing with those cultural changes has been a near zero tolerance for anyone's not getting with the program. There was a time when I was a young soldier when, if you were caught drunk driving in Fayetteville, your 1st sergeant would come pick you up, and you would be on extra duty for 14 days. That was it. They tolerated it. Once they stopped tolerating it, you did not see so many drunk drivers in Fayetteville. Sexual discrimination was almost rampant when I first joined the Army. The culture changed. The Army changed. They no longer tolerated it. It went away. Stigma against mental health in the Army exists today because we allow it to. If we do not tolerate it, it will go away. Chief Gutteridge. Sir, may I add one thing? Those are great points. What I would like to add is that one of the things that I am most proud of from being in the Army is that it is a value- based culture. If you look back in history, it is the military and it is the Army that were the tip of the spear in changing society--segregation, dealing with different types of discrimination. We can do it. The Army can do it. The Army can lead society down the correct path of taking away the stigma. I look forward to that, and I think it can happen. Mr. Etheridge. Thank you very much. You have been very powerful today. It has been very instructive and very helpful. Madam Chair, thank you. Thank you for this hearing, and thank you for letting me join. I yield back. Mrs. Davis. Thank you very much. I just have a few very quick questions. I wanted to go to you, Chief Gutteridge, because you mentioned that we might want to capture those individuals who have gone through these experiences and who were not necessarily in the mental health fields to begin with, but who perhaps could be trained appropriately. If I recall, I think that even our first panel questioned whether or not there is, you know, a new group of counselors that we might look to who could add to or be part of this new cadre that you spoke of. I wonder if you wanted to just comment briefly on that. Where do you see that coming from? How realistic, I guess, do you think that is? Chief Gutteridge. Well, ma'am, to be very simple, drunks help other drunks not be drunks anymore. Mutual support in PTSD is absolutely critical. If you are in a group with just a couple of folks--they could be Vietnam-era veterans, they could be World War II--it is that common bond. The only people who understand that are people who have been in that situation. Now, I understand you have to have a master's degree in, let's say, social work in order to be a counselor at certain places. I understand that procedure, and that is very important. But if you could have some sort of informal PTSD support groups or combat stress support groups, much like you have with bereavement for lost soldiers--of course, there is nothing worse than losing a child, and I am not going to downplay that at all. It is mutual support, and where we could in some way create an environment where, ``hey, you know, there is a lunchtime meeting over here for guys who want to talk about combat stress and see how they are doing.'' Yes, it is doable. Mrs. Davis. Thank you. I think in many ways, I probably want to carry that a little bit further, in that it may be that some people are particularly talented, who may not have known that, to be able to work with other servicemembers, and that we may need to think about helping them develop that in an educational setting so that they could go back and even be at higher levels, whether it is social work or psychologists or psychiatrists, in the future. I just wonder whether we want to look to--and have people looking out for those individuals who, in fact, may have thought about separating from the service but who might be able to even stay in, in a different way. It all takes money, of course, but I was interested in what you had to say. Quickly, I wanted to just follow up about the safeguards that you all talked about and how critical it is to have them in place. One of the concerns that we have heard is whether we, in fact, have those safeguards; if a servicemember's chain of command tries to override a medical recommendation that a servicemember not be deployed, for example, or if there is a desire to keep people moving--constant deployments--and yet, that servicemember really is suffering, and that recommendation hasn't been adhered to that they not be deployed. Is that something in your experiences that you have seen in any way? Are you aware of people who are continuing to be deployed who, even in your own estimation, should not be? Chief Gutteridge. I have not had that experience, ma'am. Mrs. Davis. Major, is there anything you could just add to that in terms of what we ought to be looking for? Major Gannaway. When I was a commander, dealing with a soldier's medical problems was very critical to combat readiness. You do not wait until the last day to make sure the soldier has his shots. You know, you start looking six months out and start identifying problems and go after them. If a soldier needs to go to the dentist, you get him there. So, if there are problems and you pay attention to your soldiers and you get to know them and their families, you identify those problems and try to take care of them and deal with them before it is time to walk out the door and deploy. Mrs. Davis. Mr. Scheuerman, did you want to comment? You have obviously spoken with families who, perhaps, have suffered as you have. Is there anything you would like to add to that? Mr. Scheuerman. It is the most difficult thing in the world to lose your child. It was the worst day of my life and Anne's also. The only thing that I really want to say to the panel is, this is a problem that we have to get grips with because, as our kids come home this is only going to get worse. As they leave the service and they are not under daily supervision, this is only going to get worse. So we have to find a way to make this better. I do not want another set of parents to have to experience what we have. I think we, as a Nation, can do it. Mrs. Davis. Thank you. I know that we are all better off having heard from you today, and we know that we also have issues within our general culture around mental illness, and we are trying to deal with that as well. Mental health parity is just one example. Hopefully, the services in many ways may be able to lead the way, actually, for the country on this one, and that would be a very good thing. Thank you all very much for joining us. We look forward to moving on with these issues, to addressing them critically and very seriously. Your presence, again, does make a difference. Thank you. [Whereupon, at 12:35 p.m., the subcommittee was adjourned.] ======================================================================= A P P E N D I X March 14, 2008 ======================================================================= ======================================================================= PREPARED STATEMENTS SUBMITTED FOR THE RECORD March 14, 2008 ======================================================================= [GRAPHIC] [TIFF OMITTED] 45131.001 [GRAPHIC] [TIFF OMITTED] 45131.002 [GRAPHIC] [TIFF OMITTED] 45131.003 [GRAPHIC] [TIFF OMITTED] 45131.004 [GRAPHIC] [TIFF OMITTED] 45131.005 [GRAPHIC] [TIFF OMITTED] 45131.006 [GRAPHIC] [TIFF OMITTED] 45131.007 [GRAPHIC] [TIFF OMITTED] 45131.008 [GRAPHIC] [TIFF OMITTED] 45131.009 [GRAPHIC] [TIFF OMITTED] 45131.010 [GRAPHIC] [TIFF OMITTED] 45131.011 [GRAPHIC] [TIFF OMITTED] 45131.012 [GRAPHIC] [TIFF OMITTED] 45131.013 [GRAPHIC] [TIFF OMITTED] 45131.014 [GRAPHIC] [TIFF OMITTED] 45131.015 [GRAPHIC] [TIFF OMITTED] 45131.016 [GRAPHIC] [TIFF OMITTED] 45131.017 [GRAPHIC] [TIFF OMITTED] 45131.018 [GRAPHIC] [TIFF OMITTED] 45131.019 [GRAPHIC] [TIFF OMITTED] 45131.020 [GRAPHIC] [TIFF OMITTED] 45131.021 [GRAPHIC] [TIFF OMITTED] 45131.022 [GRAPHIC] [TIFF OMITTED] 45131.023 [GRAPHIC] [TIFF OMITTED] 45131.024 [GRAPHIC] [TIFF OMITTED] 45131.025 [GRAPHIC] [TIFF OMITTED] 45131.026 [GRAPHIC] [TIFF OMITTED] 45131.027 [GRAPHIC] [TIFF OMITTED] 45131.028 [GRAPHIC] [TIFF OMITTED] 45131.029 [GRAPHIC] [TIFF OMITTED] 45131.030 [GRAPHIC] [TIFF OMITTED] 45131.031 [GRAPHIC] [TIFF OMITTED] 45131.032 [GRAPHIC] [TIFF OMITTED] 45131.033 [GRAPHIC] [TIFF OMITTED] 45131.034 [GRAPHIC] [TIFF OMITTED] 45131.035 [GRAPHIC] [TIFF OMITTED] 45131.036 [GRAPHIC] [TIFF OMITTED] 45131.037 [GRAPHIC] [TIFF OMITTED] 45131.038 [GRAPHIC] [TIFF OMITTED] 45131.039 [GRAPHIC] [TIFF OMITTED] 45131.040 [GRAPHIC] [TIFF OMITTED] 45131.041 [GRAPHIC] [TIFF OMITTED] 45131.042 [GRAPHIC] [TIFF OMITTED] 45131.043 [GRAPHIC] [TIFF OMITTED] 45131.044 [GRAPHIC] [TIFF OMITTED] 45131.045 [GRAPHIC] [TIFF OMITTED] 45131.046 [GRAPHIC] [TIFF OMITTED] 45131.047 [GRAPHIC] [TIFF OMITTED] 45131.048 [GRAPHIC] [TIFF OMITTED] 45131.049 [GRAPHIC] [TIFF OMITTED] 45131.050 [GRAPHIC] [TIFF OMITTED] 45131.051 [GRAPHIC] [TIFF OMITTED] 45131.052 [GRAPHIC] [TIFF OMITTED] 45131.053 [GRAPHIC] [TIFF OMITTED] 45131.054 [GRAPHIC] [TIFF OMITTED] 45131.055 [GRAPHIC] [TIFF OMITTED] 45131.056 [GRAPHIC] [TIFF OMITTED] 45131.057 [GRAPHIC] [TIFF OMITTED] 45131.058 [GRAPHIC] [TIFF OMITTED] 45131.059 [GRAPHIC] [TIFF OMITTED] 45131.060 [GRAPHIC] [TIFF OMITTED] 45131.061 [GRAPHIC] [TIFF OMITTED] 45131.062 [GRAPHIC] [TIFF OMITTED] 45131.063 [GRAPHIC] [TIFF OMITTED] 45131.064 [GRAPHIC] [TIFF OMITTED] 45131.065 [GRAPHIC] [TIFF OMITTED] 45131.066 [GRAPHIC] [TIFF OMITTED] 45131.067 [GRAPHIC] [TIFF OMITTED] 45131.068 [GRAPHIC] [TIFF OMITTED] 45131.069 [GRAPHIC] [TIFF OMITTED] 45131.070 [GRAPHIC] [TIFF OMITTED] 45131.071 [GRAPHIC] [TIFF OMITTED] 45131.072 [GRAPHIC] [TIFF OMITTED] 45131.073 [GRAPHIC] [TIFF OMITTED] 45131.074 [GRAPHIC] [TIFF OMITTED] 45131.075 ? ======================================================================= WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING March 14, 2008 ======================================================================= RESPONSE TO QUESTION SUBMITTED BY MR. MCHUGH Dr. Casscells. By law, title 10, United States Code (U.S.C.), section 1079(h)(1), as implemented by title 32, Code of Federal Regulations (CFR), Part 199.14(j), TRICARE's reimbursement rates for all medical services from individual health care providers are tied to Medicare reimbursement rates for such services through the CHAMPUS Maximum Allowable Charge (CMAC) system, a nationally determined allowable charge level that is adjusted by locality indices and is equal to or greater than the Medicare Fee Schedule amount. TRICARE adjusts its reimbursement rates, as necessary, to maintain the statutorily required relationship with Medicare's reimbursement rates. Often, network providers have committed in their independent agreements with our Managed Care Support Contractors (MCSCs) to accept reimbursement rates lower than CMAC. That is a business decision each provider makes independently. Non-network providers may, under the same statutory requirements, charge the same percentage as the Medicare limiting percentage for non- participating Medicare providers, which is currently 15 percent above the CMAC rate. In the case of individual providers or particular Common Procedural Terminology codes, there are statutory provisions permitting TRICARE to raise its reimbursement rates up to 15 percent above the CMAC level upon official determination of the existence of network inadequacy (10 U.S.C. 1097b(a), as implemented by 32 CFR 199.14(j)) or to increase them without any specified limitation in cases of severe access to care deficiencies (10 U.S.C. 1079(h)(5), as implemented by 32 CFR 199.14(j)). In those areas where severe access problems are demonstrated, TRICARE has the authority to waive, on a case-by-case basis, the CMAC levels for providers beyond the 15 percent for network providers. To date, TRICARE Management Activity has received one request for a locality based waiver for mental health services. The request was for all psychiatric services in the code range of 90800-90899 for patients age 18 and under in zip code 33040 in Key West, Florida. The amount of increase requested was 50 percent and was approved on January 7, 2008. In early 2008, a comprehensive review was conducted of our reimbursement rates compared to commercial and Medicaid rates as well as a review of access to mental health care. Access to care in all three regions was found to be adequate. [See page 15.] ______ RESPONSES TO QUESTIONS SUBMITTED BY MRS. BOYDA General Schoomaker. The suicide rates (per 100,000) for the U.S. Marine Corps from calendar year 1999 through calendar year 2007 are as follows: 1999-15.0 2000-13.9 2001-16.7 2002-12.5 2003-13.4 2004-17.5 2005-14.4 2006-12.9 2007-16.5 A comparison of the four years prior to Operation Iraqi Freedom (OIF) and four years after the commencement of OIF follows. Calendar year 2003 is excluded because it was a partial year as OIF commenced in March 2003. Average Annual Suicide Rate 1999-2002--14.525 2004-2007--15.325 The difference between the average annual suicide rate from 1999- 2002 is not statistically significant from the average annual suicide rate from 2004-2007 (t-test=0.289.) [See page 18.] General Schoomaker. Army and United States Marine Corps (USMC) Suicide Rates before and after onset of Operation Iraqi Freedom: Year ARMY USMC 2001 9.0 16.7 2002 11.5 12.5 2003 11.4 13.4 2004 9.6 17.5 2005 12.7 14.4 2006 15.3 12.9 2007 16.8 16.5 * Suicide rates reported as number of suicides per 100,000 per year ** USMC rates are typically higher due to greater percentage of young males, and more variable due to being a smaller population. [See page 18.] ______ RESPONSE TO QUESTION SUBMITTED BY MR. JONES Dr. Casscells. We have data for military active duty physicians. Psychiatrists are a subset of that group. The majority of Physicians are accessed through the Uniformed Services University of the Health Sciences (USUHS) and the Health Professions Scholarship program (HPSP). Approximately 14% of accessions are from USUHS, 82% from HPSP and 4% are direct accessions. In terms of medical schools that produce active duty military physicians, the number one school is USUHS. The following table is a list of the top 25 (two-way tie for 25) civilian medical schools, ranked by the number of HPSP scholarships: ---------------------------------------------------------------------------------------------------------------- Medical Schools Location # HPSP ---------------------------------------------------------------------------------------------------------------- Lake Erie College of Osteopathic Medicine Erie, PA 68 ---------------------------------------------------------------------------------------------------------------- Philadelphia College of Osteopathic Medicine Philadelphia, PA 67 ---------------------------------------------------------------------------------------------------------------- Edward Via Virginia College of Osteopathic Medicine Blacksburg, VA 63 ---------------------------------------------------------------------------------------------------------------- Kansas City Univ of Medicine and Bio Sciences Kansas City, MO 57 ---------------------------------------------------------------------------------------------------------------- A.T. Still University of Health Sciences Kirksville, MO 49 ---------------------------------------------------------------------------------------------------------------- Nova Southeastern Univ of Osteopathic Medicine Fort Lauderdale, FL 48 ---------------------------------------------------------------------------------------------------------------- Des Moines University-Osteopathic Medical Center Des Moines, IA 44 ---------------------------------------------------------------------------------------------------------------- Midwestern University at Glendale Glendale, AZ 43 ---------------------------------------------------------------------------------------------------------------- Touro University of Osteopathic Medicine SF San Francisco, CA 42 ---------------------------------------------------------------------------------------------------------------- West Virginia School of Osteopathic Medicine Lewisburg, WV 31 ---------------------------------------------------------------------------------------------------------------- New York University New York, NY 23 ---------------------------------------------------------------------------------------------------------------- Midwestern University in Illinois Downers Grove, IL 20 ---------------------------------------------------------------------------------------------------------------- Georgetown University Washington, DC 18 ---------------------------------------------------------------------------------------------------------------- Boston University Boston, MA 16 ---------------------------------------------------------------------------------------------------------------- University of Illinois at Chicago Chicago, IL 14 ---------------------------------------------------------------------------------------------------------------- Philadelphia College of Osteopathic Med @ GA Atlanta, GA 14 ---------------------------------------------------------------------------------------------------------------- Howard University Washington, DC 14 ---------------------------------------------------------------------------------------------------------------- Western University of Health Sciences Pomona, CA 14 ---------------------------------------------------------------------------------------------------------------- Eastern VA Medical College of Hampton Roads Norfolk, VA 13 ---------------------------------------------------------------------------------------------------------------- University of Texas--All Campuses Combined TX 11 ---------------------------------------------------------------------------------------------------------------- Temple University Philadelphia, PA 11 ---------------------------------------------------------------------------------------------------------------- Creighton University Omaha, NE 11 ---------------------------------------------------------------------------------------------------------------- Wright State University Dayton, OH 6 ---------------------------------------------------------------------------------------------------------------- Ohio State University Columbus, OH 6 ---------------------------------------------------------------------------------------------------------------- University of North Texas HSC Fort Worth, TX 5 ---------------------------------------------------------------------------------------------------------------- Meharry Medical College Nashville, TN 5 ---------------------------------------------------------------------------------------------------------------- [See page 29.]