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Assistant Secretary of Defense for Health Affairs Winkenwerder Roundtable Discussion

Presenters: Dr. William Winkenwerder, Assistant Secretary of Defense for Health Affairs
June 30, 2004

            CDR MINTZ:  For those of you that are on the phone and we appreciate your heavy breathing.  It’s coming through out loud and clear, so [Chuckles] if you can step back from your speakerphone or put yourself on “mute,” that would be very helpful. 


            I’m Commander Mark Mintz with the Office of Public Affairs.  And here present with us is we have three guests:  Dr. William Winkenwerder who is the Assistant Secretary of Defense for Health Affairs, also with us is Lieutenant General James Peake who is the Army Surgeon General, and with us also is Colonel Charles Hoge, who is the chief of department of psychiatry and behavioral sciences at the Walter Reed Army…


            COL. HOGE:  Institute of Research.


            CDR MINTZ:  … Institute of Research.  Colonel Hoge was the primary investigator on this report that we’re going to speak about.  And we’d like to start with some comments from Dr. Winkenwerder.


            [To Winkenwerder]:  And then, sir, do you have any [inaudible] remarks, also?  OK. 


            And following Dr. Winkenwerder’s message then we will open up for questions.


            DR. WINKENWERDER:  Great.  Good afternoon, everyone.  Let me just begin by saying that we’re here today because we care about our soldiers and sailors and Marines and airmen and we care about their mental health.  We care about the total health of all of our servicemembers and that is obviously a driving factor in the initiation and the completion of this report and certainly it’s publication.  Speaking as the chief medical officer for the Department of Defense, I just want to say that we applaud from the department’s perspective the effort of the army and undertaking this study, completing it, and certainly the fact that it appears today or tomorrow in The New England Journal is certainly a top medical peer review journal. 


            From my perspective, number one, again, this shows that the army cares about its soldiers and their mental health.  There are three principal conclusions that I draw from this study and first is that it’s the first of its kind.  I think maybe that’s a fact that Dr. Hoge has shared with some of you who are on the line who he’s already spoken with today.  And it provides a much-improved understanding of the rate and type of mental health concerns before, during and after combat and to my knowledge, there has never been such a study of this type.  Is that right, Dr. Hoge?


            COL. HOGE:  That, to my knowledge, is right.


            DR. WINKENWERDER:  Secondly, I think it gives us an indication of the influence on mental health problems and concerns brought about by combat.  And we’re able to get a better picture of that.  Obviously, our understanding of that will improve over time.  And finally, it points to and describes some perceived barriers to care.  And I think the one that your study noted principally with stigma. But it also helps us to identify ways that the army and translating their important research to the Navy and the Air Force and others, can intervene to reduce those barriers. 


            There’s a couple of other important things that I conclude from the study that I think are important.  First, I was struck and I thought it was notable that in spite of, obviously, this population as a group of people that were involved, most of them, in very heavy intense combat and very difficult, stressful, gruesome, at times, experiences that the levels of the rates of certain mental health concerns are surveyed concern such as depression and anxiety and post-traumatic stress disorder, the change before and after combat was relatively small in low single digits for all of those.  And so I think that should be really encouraging to us that despite these tough experiences that these great people have experienced, that the impact on their mental well-being and their mental health appears, at least at this point to be, in the aggregate, limited. 


            But I would also say for those people that were identified and not just in this study, but we have other processes and we’ll talk about that in a minute, that we seek to identify after deployment, those individuals who are concerned about their mental health and who look like they may have mental health problems.  We are very aggressively today seeking to find those people early on to get them into counseling or treatment or group therapy or a variety of interventions.  And General Peake and Colonel Hoge can talk about those.  So this helps us to better define how to do that. 


            So anyway, so those are some of the conclusions.  I would also note to you that the department is pursuing research to better understand factors that enable individuals to withstand stressful situations and to maintain healthy – what we call a healthy mental resilience that, those are important types of studies that even people – some of our colleagues at the centers for disease control have done, looking at early life and early childhood experiences and how that affects how adults perceive and deal with stress later in life. 


            So I’ll stop with that and turn maybe for a moment to General Peake ‘cause – ask if he has any additional comments he like to make, particularly with respect to the things that the army is doing and the proactive efforts that you’ve undertaken. 


            GEN. PEAKE:  Well, I’d just say, to echo the secretary, this is all about the fact that we do want to take care of our soldiers and recognize that this is a potentially and now proven to be a stressful environment, as combat always is and that it is the kind of thing that reflects, I think, the senior leadership non-medical that allows these kinds of studies to go on.  I see some of you here, actually, that were outbriefed on the impact study that we did earlier.  And this, actually, they sort of correlate…


            COL. HOGE:   The mental health assessment team.


            GEN. PEAKE:  …to the mental health assessment team that we sent over and that we’ll go back over this summer again to do the follow-ups.  But using some of the same instruments that Dr. Hoge and his folks have put together, you look in here and you see that one of the instruments on the PTSD instrument was a VA instrument.  It talks to the fact that we’re working together with the VA in ways that I think are much better than we’ve ever done before and we’ll continue to do that. 


            And what we are really wanting to do is understand this population better and not, as in the post-Vietnam era – and I came from that era – look at it 20 years later and start to figure it out.  So we want to be proactive and prospective in this.  And when you start looking at what we’ve done already, we’ve been worried about this stigma thing.  You know it came out with the impact piece before.  And you know, I think our leadership really doesn’t feel that way.  But what you see is, you know, just – Charles and I were talking about it earlier. The notion that when people are depressed or have anxiety, they tend to perceive the world a little bit differently.  And so they do perceive these barriers whether they’re real or not, and so we got to deal with that. 


            We have set up the Army “One Source” so that you can, you know, dial a 1-800 number and have access to six mental health visits, if it takes that – counseling sessions.  And …


            DR. WINKENWERDER:  Confidentially.


            GEN. PEAKE:  Confidentially, for just sort of – you all may have them in your own companies -- I don’t know – where because it’s a corporate approach to that issue of privacy and confidentiality.  So you know, that’s just one example.  Another thing that we’ve been doing is trying to push our mental heath folks down into the units.  And so we’ve put extra mental health people into the OIF II, as an example, into Iraq so that they’re ubiquitous.  It’s not like you got to out of your way and everybody knows you’re going out of your way to seek mental health. They’re there and they’re, you know, they’re wandering around and it’s the same kind of approach that, if I drove up, I came into this side of the Pentagon and, you know, I was here on the day in 9/11.  And quickly Charles and a lot of other people brought a lot of mental health in here that just wandered around and was available.  And I think we’ve blunted a lot of issues.  Now that same approach is making mental health ubiquitously available, so that’s another way of attacking this.


            And then the other is just education and having great commanders out there that say it’s OK.  You know, we want you to get these kind of debriefings and so forth.  So you know, there’s not a single bullet solution to any of this, but it is a cultural change as well as building the trust and confidence in our soldiers that we’re serious about what we have just said here. 


            DR. WINKENWERDER:  I think, if I might -- General Peake, thank you for those comments -- just make the observation that the fact that the department and the army taking the lead for this, has done this study and it’s open.  We’re saying to the world, obviously, we have nothing to hide.  In fact, we’re very proud of the work that’s being done.  And this is about getting better.  It’s something that’s important and that our leadership recognizes is important.  And so with that, let me stop and we’ll take some questions. 


            Q:  Colonel Hoge, Kathleen Koch with CNN.  Can you tell me of all of your findings, what was the one finding that struck you most, that surprised you most?


            COL. HOGE:  I think in some respects, this study just puts numbers to what we already knew.  And I’d say there really weren’t surprises.  We have a lot of data that’s indicated the correlation between combat and mental health symptoms after coming back from combat and that’s not new.  And we also have a lot of data from mental health practice settings in general, whether it’s civilian or military, about the problems with barriers to care and stigmatization or perceived stigmatization.   So I think in some ways this study really just gave us a little bit of additional information and gave a better, more complete picture of what some of the mental health concerns are and specifically the issue of stigma and barriers to care, so that we can better approach that in terms of the care that we deliver. 


            Q:  Can you zero in on what the most important finding is then, perhaps?


            COL. HOGE:  I think the most important finding relates to the barriers to care and the fact that soldiers and Marines who we surveyed in this study with mental health concerns, frequently don’t receive any help and the reason for that is because they perceived that it will be stigmatizing if they do.  I think that that really allows us the opportunity to look at how our services are being delivered and how can we improve services and deliver the best services to soldiers and Marines that are coming back from their combat environment. 


            Q:  Yes, I’d like to ask Dr. Winkenwerder…


            DR. WINKENWERDER:  Yes. 


            Q:  Dr. Winkenwerder, Melanie Lyons (sp) with USA Today.  The recommendation was made that these mental health clinics should be integrated into primary care, that you shouldn’t have to go to a separate office to get therapy.  And also, Dr. Castro told me this six-visit business with the independent therapist is not enough to handle some of these serious mental disorders.  So what I’m wondering about is are there any plans underway to separate, or to integrate, some of these separated mental health clinics to make them less likely to be stigmatizing to the soldiers? 


            DR. WINKENWERDER:  Yes.  I’m going to let General Peake answer that question because I think he may be…


            GEN. PEAKE:  I think there’s a couple of theses to it.  One, the six mental health visits are not necessarily designed or intended to be the sole source of care.  But the point is much of this is routine reaction to normal stressors.  And part of it is how do you perceive it and do you perceive it as an illness or do you perceive it as a natural course of having that kind of stress.  And frankly, the latter is the larger chunk of it.  And so this is designed to take care of the larger chunk.  And what we, you know, we would expect is if somebody has a serious problem, they would be referred and brought back into the more comprehensive mental health system.  The…


            DR. HOGE:  The primary care…


            GEN. PEAKE:  The primary care piece is something that – you know, part of the notion is that some of these mental health symptoms will show up as somatic complaints and there’s physical complaints.  And people will be excessing because they don’t feel well and it takes people to understand that that may be a psychological manifestation.  And so I agree with you and we have actually hired 58, I think, now folks to work in the primary care clinics so that we can pick those up and get them appropriately treated.  Sometimes it’s not a matter of, “well, I don’t want to go or be seen by mental health.”  It’s just that don’t even realize that it’s a mental health kind of issue and they’re showing up in their primary care doctors.  And that’s why this DoD VA patient practice guideline, a clinical practice guideline, is an important thing and it’s one of those things that we sent out, you know, to remind everybody that we had it, A; and B, to reinforce the notion that kind of think through if somebody’s presenting with a somatic complaint that you can’t really quite understand.  Hey, there may be another component to that and it may be a mental health component. 


            [Cross Talk]


            Q:  Exactly how many of these soldiers are getting their care in these primary mental health care and primary care, compared to having to a separate mental health clinic.  Do you have any idea of that? 


            GEN. PEAKE:  Well, I guess one of Charles’ points is that we’d like to see more folks accessing either one of the systems.  And that comes out in the papers as it’s probably smaller than what we would want to be seeing right now. 


            [Cross Talk]


            Q:  But most of them still have to go to a specialized clinic, right?  They’re not getting their care in the primary care setting.  Is that correct?


            GEN PEAKE: No….


            DR. WINKENWERDER:  No, they would be getting their care in a primary care clinic, most people and out in the field.  And let me just make a couple of other points here.  This is about caring for people during a whole cycle, a continuum.  And so, we are concerned about and take steps to ensure that people are as mentally healthy and psychologically fit, before they ever go.  This is pre-deployment.  And obviously, it goes all the way back to accessing people into the armed services and ensuring that they’re psychologically fit individuals.  And then providing structure and training.  There’s evidence that structure and training helps gird one’s psychological well-being to deal with stressful events.  So that plays into this in a very important way.  I dare say that whatever the rates that we’ve experienced here of these perceived problems if you were to take a age-sex adjusted group of young college students and throw them into this circumstance that the rates would be far, far higher.  And this is because of the training and the preparation and all the good things that are being done. 


            And then on the back end, after people re-deploy, again, we’re interviewing every single individual.  Individuals have to fill out a questionnaire and meet with their provider.  All that information is entered into a central database.  And we get reports, General Peake does, I do, on a weekly basis that shows how many, you know, in percentage terms people are expressing concerns about their mental health at the time of redeployment. 


            I actually have some of those statistics.  And the good news is it’s a relatively small percentage.  What people tell us is about 3 to 5 percent of them – that’s about 6 percent in the Army…I think, a little bit lower, obviously, in the Air Force and in the Navy… but are indicating that they have a mental health concern up re-deployment.  And we know that about 80 to 90 percent of those people are getting their scheduled appointments because we follow that up.  And so if you were to compare the whole set of activities that we have into place today versus and General Peake would know this better than any of us from Gulf War I or Vietnam or any other earlier era.  There is a much more comprehensive and intensive effort to address this set of issues. 


            Let me make note of one other point here about the relationship between the Department of Defense and the Veterans Affairs Department.  And I’ll just take note of the editorial by Dr. Friedman (sp) in The New England Journal there was a commentary on the study.  And he notes in that editorial – and of course, we can’t influence what he has to say, but we’re very pleased about what he had to say and he observes that “practitioners in the Department of Defense and Veteran Affairs are sophisticated and strongly motivated to continue to improve their skills in treating post-traumatic stress disorder collaboration between mental health professionals and the Department of Defense and those in the Department of Veterans Affairs is at an all-time high.”  And so, we can’t pay people to make those kinds of good statements about the way we’re working together to deal with these issues. 


            Q:  Who is this speaking, please?


            DR. WINKENWERDER:  This is Dr. Winkenwerder. 


            Q:  Doctor, this is Eileen Kelley with the Denver Post.  Can you go back to what you were saying about the 6 percent and you said it was lower in the Air Force and in the Navy.  Are these concerns for people that are going back for OIF III?


            DR. WINKENWERDER:  No, no. no.  These are people who are – the term we use is “re-deploy.”  That means coming back after…


            Q:  Back.


            DR. WINKENWERDER:   … their service and…


            Q:  OK. 


            DR. WINKENWERDER:   … with each and every one of those individuals, we have a process in place today where we screen individuals both prior to and after deployment, asking them a pretty extensive set of questions and it goes into the very depth in the mental health area. 


            Q:  OK, so this 6 percent figure – for instance take the army, is that the overall…


            DR. WINKENWERDER:  That’s the overall, that express mental health concern. 


            Q:  OK. And…


            DR. WINKENWERDER:  So that might be different and frankly, it’s probably a little bit lower than maybe right in combat where Colonel Hoge got his data.


            Q:  And you’ve followed up to see that about 80 to 90 percent are getting their appointments? 


            DR. WINKENWERDER:  That’s right.


            Q:  That’s what you’re reporting right now?


            DR. WINKENWERDER:  That’s correct. 


            Q:  Thanks.  The soldiers that I talk to – I cover the military down here in Colorado – the soldiers I’ve spoken with at Fort Carson, as well as elsewhere are describing situations where it takes over a month to get an appointment.  I’m being told that Tricare, their guideline is to get people in within four weeks?


            DR. WINKENWERDER:  No.  Our guidelines for re-deploying servicemembers is, I believe, it’s one week or…


            Q:  One week?


            DR. WINKENWERDER:   … one or two.  I know that we created a…


            UNKNOWN:  With specialty consultations


            DR. WINKENWERDER:  With specialty consultation, it’s…


            Q:  Is that, to fill out the forms? 


            DR. WINKENWERDER:  Yeah. 


            Q:  OK, but for people that actually go to mental health on post and say, “I need to talk to a psychiatrist” and they get the initial intake screening, it is then taking a month to actually get an appointment because they’re overwhelmed. 


            DR. WINKENWERDER:  Well, you’ve made a statement and I’ll call it an allegation.  I don’t have data to support that.  And we’ll certainly be willing to look…


            Q:  Yeah.  I’m…


            DR. WINKENWERDER:   … at that. 


            Q:  … not making an allegation. 


            DR. WINKENWERDER:  Well…


            Q:  I got it through the commander, actually, at Fort Carson.  And…


            DR. WINKENWERDER:  Well, I don’t know how many – let me just push back just a little bit here.  I don’t know how many individuals you’re talking about.  I don’t have a report in front of me available.  Bottom line is that we are most interested in getting people in in a timely way and taking care of them.  And that’s what General Peake, I know who is committed to doing everyday.  If there’s…


            GEN. PEAKE:  Let me…


            DR. WINKENWERDER:  Yes.


            GEN. PEAKE:  If I can -- you know, the point is they’re not waiting a month for the intake interview from what you’re telling – from what you’re saying.


            Q:  No, no.  It’s actually to get an appointment.


            GEN. PEAKE:  Right. 


            Q:  It’s not in every case.  They’re saying they’re seeing…


            GEN. PEAKE:  No.


            Q:  … the command is saying at least two weeks but that, yes, they do know a month…


            GEN. PEAKE:  I wouldn’t be surprised.  You know, and now let me just say that if the intake interview picks up something serious that they’re really concerned about – you know, that’s a head-of-the-line kind of deal.  And I’d be really surprised if we’re not addressing those kinds of issues.


            Q:  Uh-huh


            GEN. PEAKE:  Our Tricare standard…


            [Cross Talk] 


            Q:  [inaudible] someone said they were homicidal?


            DR. WINKENWERDER:   Say it again, please?


            Q:  I talked with someone said they were homicidal? 


            DR. WINKENWERDER:   Well, if you’ve got – let me just ask ‘cause I know there’s others who want to ask questions.  If you’ve got some specific questions about that particular situation, let’s take those off line and I’m sure General Peake and others, the commander at Fort Carson will be glad to answer those questions. 


            Q:  OK. 


            Q:   Jonathan Bor from the Baltimore Sun. 


            DR. WINKENWERDER:  Yes. 


            Q:  The 58 people you talk about who were hired to work in primary care clinics, are these primary care clinics on bases here in the U.S.? 


            DR. WINKENWERDER:  Yes.


            Q:  Where are these clinics? 


            GEN. PEAKE:  They’re all over the United States. 


            DR. WINKENWERDER:  That’s General Peake. 


            GEN. PEAKE: Sorry…. 


            Q:  In the military health facilities?


            Q:  And are they mental health professionals or are they primary care doctors who have been trained in school to identify mental health problems? 


            GEN. PEAKE:  I’m thinking that most of them are social worker kind of folks. 


            [Cross Talk]


            GEN. PEAKE:  Not necessary psychologists, but social workers, case managers, oriented to be able to help guide, you know, make sure that the awareness is there within that clinic, pick them up and then help the into what other treatment might be required. 


            Q:  Do you, putting the stigma issue and the access issue aside, and I know that’s a big thing to put aside, but do you think that the services that are in place now to address the mental health problems of returning troops, do you believe that they are adequate? 


            DR. WINKENWERDER:  Yes.  I think we think they are. 


            Q:  Who is this speaking?


            DR. WINKENWERDER:  This is Dr. Winkenwerder.


            Q:  OK.  So you believe that access is the main problem? 


            DR. WINKENWERDER:  No.  I think what – not to confuse people, the issue of people coming back and what’s going on when they’re re-deployed here with what Colonel Hoge was describing in his study was in theater. Correct?


            DR. HOGE:  Just after….


            DR. WINKENWERDER:  Or just after…


            GEN. PEAKE:  I think the bottom line is we believe that there are adequate services available, the issue that has been one of the main barriers is the perception of stigma that some individuals have about coming forward to get that care and counseling. 


            Jonathan Bor:  I have one more question. 


            DR. WINKENWERDER:  Yes. 


            Q:  Could you give me the latest statistics on the number of suicides that have occurred among people in theater or those who have returned? 


            DR. WINKENWERDER:  Let us get back to you on that.  We reported that number for 2003.  I know we’re tracking it.  I think we had some preliminary information for this year, thus far, that suggested there was a down trend from what it had been in 2003.  But we’d like to make sure that we have our numbers straight before we communicate that. 


            Q:  Are those numbers I could get today? 


            DR. WINKENWERDER:  Well, we’ll look at it and see if we can them to you today. 


            Q:  And how would I go after that?


            DR. WINKENWERDER:  Well, just tell us who your name is and we’ll try to get that…


            CDR MINTZ:  If I may, at the end of the brief, I’m going to give my e-mail address.  And any questions that you have can be passed to me by e-mail and I’ll see that the doctors get them from there.


            CDR MINTZ:  We have some questions locally here as well.


            DR. WINKENWERDER:  In the room? Yeah. 


            Q:  I have two questions - one for General Peake, and one for you Colonel.  The mental health assessment team which you sent over had called for embedding mental health experts right there with combat units, was one of your number one priorities.  Have you done that, so far?


            GEN. PEAKE:  I think it was two other combat stress units over to increase the number so that they could be more available to get around and be out with the troops. And the Air Force has helped us out and we have Air Force mental health teams as well.  I don’t have the exact number, but I can get it for you.


            Q:  Or a breakdown of the number of troops.  I thought it was 4-1 [inaudible]


            GEN. PEAKE:  Charles, do you remember offhand?  I just didn’t bring that stat in, but I can get it for you.


            [Cross Talk]


            Sondra Jontz (Stars & Stripes):  Are you able to differentiate or pull out that some of these symptoms are based on seeing bad things in killings or is there any linkage to, for example, troops getting the word that they were going to be extended beyond the 12-month deployment and stuff like that?  Can those morale-type factors, are they pulled out of the deployment?  Do you have a sense of the question? 


            DR. WINKENWERDER:  For this study, we really looked at the combat experiences, you know, directly and did show that those soldiers and Marines who had higher levels of combat exposure, frequency, intensity of combat, had higher rates in mental health concerns.  And we didn’t look at deployment length or other stressors in this particular…


            Jontz:  You were able to differentiate? There were people saying I have a mental health concern based on the combat that I saw, but I’m also depressed because I’m here longer than anticipated? I’m not making myself clear, am I?


            DR. WINKENWERDER:   I think you’re asking about the relationship between other factors like length of tour and change of length…


            Q:  Those who expressed those concerns to you.


            DR. WINKENWERDER:  He did his study did not look at that.  Your question is “Could that be playing an influence?” I would say it could be.  But we don’t know because he didn’t study that.


            COL. HOGE:  In the mental health advisory team that went over there and surveyed in theater, there was a relationship between what soldiers reported about stressors like having their deployment length extended and morale and well-being.  That was reported in that mental health advisory team report. 


            Q:  But not part…..


            COL. HOGE:  But that wasn’t something that was part of this report. 


            DR. WINKENWERDER:  OK.  Any – do we want to take another question?  One more question? 


            CDR MINTZ:  Do we have any other questions in the room?  We want to make another question available to somebody on the phone?


            Q:  Yes.  Hi.  This is Raja Mishra calling from The Boston Globe.  I wanted to ask you, based on this new data, if it’s fair to say that the mental and emotional stress levels encountered by these frontline troops in Iraq that were surveyed, is approaching Vietnam-like levels?  I realize it’s kind of hard to compare, but it seems that it’s in that vicinity? 


            DR. WINKENWERDER:  Let me try to answer.  This is Dr. Winkenwerder.  The first point to note is that the vast majority, 85 to 90 percent that we’ve seen, seem not to be having any significant mental health concerns or health problems.  And that doesn’t mean that they’re not experiencing stress, obviously.  That would be the first point.  The second is from my – and Colonel Hoge can comment on this in more detail – these troops don’t represent -- and I think this is a very important point – everybody that’s serving in Iraq.


            COL. HOGE:  Right, right. 


            DR. WINKENWERDER:  These are the folks that were in the most intense types of combat situations, ground combat forces and maybe you could comment on that and then maybe…


            [Cross Talk]


            COL. HOGE:  Yes, that’s absolutely correct. 


            DR. WINKENWERDER:   …OK.  And then in terms of Vietnam, we don’t have, except looking retrospectively information that’s the point I’d made at the beginning that this is the first study of its kind where this data is being gathered, sort of real-time.  And I think you can see that in gathering the data, we’re already…. and already have since it was gathered begun to react and make adjustments and change, so that’s a real change from the past where, frankly, we didn’t know what we were dealing with until either months or years down the line. 


            COL. HOGE:  With the experience with Vietnam, those studies were conducted literally 10, 15 years after the servicemembers have served in combat.  And we really don’t have comparative data for the time point that’s included in this study, which looks at primarily at the pre-deployment and post-deployment period three to four months after returning home. 


            Q:  Right.  But I mean, the data indicates that, I mean, clearly in the Iraq conflict in terms of mental stress is much more than any other conflict, since Vietnam and that…


            COL. HOGE:  I don’t know that we know that. 


            Q:  Well, you know, you compare it to Afghanistan, to the first Gulf War.  And then you do in the study raise the Vietnam data and sort of – it suggests that it’s in that ballpark, at least for this – as you said this portion of the troops that are engaged in sort of frontline combat.


            DR. WINKENWERDER:   Well, because there weren’t the, so to speak, real-time studies done in the past, I think it would be speaking kind of with my scientific methodologic hat on which I use to be.  I would hesitate to draw that kind of conclusion because we don’t know.  I think we can certainly surmise that there is plenty of stress – we can see that.  We know that people are dealing with.  But the good and positive news and I hope people take this away from all these discussions is that the vast majority of people, nearly nine in ten it seems, are dealing with is in an effective way.  But with all of that’s said and done, we’re interested in identifying those people who perceive stress and anxiety and depression and post-traumatic stress types of disorders and getting the care and counseling to them and also identifying those things early and preventing them.  And there’s a lot of work to be done to understand what can allow – as I alluded to earlier – what can enable people to deal with stressful situations and deal with them in ways that, you know, Dr. Hoge would call, you know, mentally – I don’t know what you’d call it, mentally healthy or…


            COL. HOGE:  Resilient.


            DR. WINKENWERDER:  Resilient. 


            CMDR. MINTZ:  Doctor, I think we have one more question.  We’re going to…


            Q:  Who was the last person speaking, excuse me?


            CMDR.MINTZ:  That was Dr. Winkenwerder. 


            Q:  OK.  Great.  Thank you. 


            CMDR. MINTZ:  And this is our last question.  And if you callers – if you’ll hold on after this, I will give you my e-mail address and if you have any further questions, then you can e-mail me and I’ll pass them forward. 


            Q:   Sir, you’re talking about -- Dr. Winkenwerder, you’re talking about ways of prevention before it occurs.  You mentioned training. You can’t avoid the combat, once you’re engaged.  And you said the more you’re exposed to combat, the number of incidents increases -- I’m sorry, colonel -- it increases the likelihood that you’re going to experience stress training.  I know you guys aren’t training officers. I know you’re not involved with the training. But is that something that perhaps could be looked at as far as perhaps mitigating some way of reducing the number?


            DR. WINKENWERDER:  The question for those on the line was what can be done to mitigate either training or other modalities…


            Q:   Training to mitigate the instance of having combat stress disorder or [inaudible]…


            COL. HOGE:  What can be done? 


            Q:  [inaudible]


            GEN. PEAKE:  Well, I think – this is General Peake – the issue of tough realistic training is one of the things that our chief, General Schoomaker is hard over about because he believes that.  Now he’s an operator who has come up and in about every battle we’ve had throughout his career.  I mean, you know, in every war with the special operations.  So you know, I’ve heard him talk about the importance of high-quality training.  We are putting – and it’s a dual deal, to be honest with you.  I mean, I was just down at Camp Bullis, the medical training site in San Antonio, walking the ranges the other day.  We’re putting in a live-fire range for convoys so that the medics and the combat service supporters because in a battlefield where there are really no clear lines, you know, they’re exposed to the same things.  So it’s to give them that same kind of resiliency as well as the battle drills and so forth.   And those are being put in place all over the place right now. 


            DR. WINKENWERDER:  I think there’s another area I’ll just allude to briefly and this comes out of – again, I talked about it earlier – discussion for the Centers for Disease Control about early and it sounds like the Navy does a strange thing to be talking about in the context of this discussion, but that it seems that certain individuals are more pre-disposed to exhibiting either depression, anxiety or post-traumatic stress disorder as a result of things that happened during childhood.  And so the question is and it’s a research question, is there a point at which one could intervene during late adolescence or during early accession time into their armed services to begin to more psychologically stabilize or build mental resiliency?  And that’s obviously an important question.  And we’re looking at what might be able to do that. 


            CMDR. MINTZ:  I’m sorry.  General, you had a comment?


            GEN. PEAKE:  I’d just like to kind of go back.  I don’t know if it’s the lady from The Denver Post.  Somebody asked about the issue of adequacy and so, I mean, the reason we’re doing this study is ‘cause we want to actually understand that even better to know what is the right things to do and where are the target areas.  You know, and Dr. Winkenwerder was talking about some.  But you know, how quickly do you need to get it into mental health and those kinds of things are what we’re really after and why we’re pursuing these kind of studies with the vigor we are. 


            CMDR. MINTZ:  I’m going to have to cut if off here.  General Peake, Dr. Winkenwerder and Colonel Hoge, we thank all three of you very much for your time.  Again, I’m Commander Mark Mintz and my e-mail address is mark.mintz@osd.mil.  And my phone number, if you didn’t understand that, is 703-697-5131.  Thank you very much for your participation. 


            Q:  Could you repeat that phone number?


            CMDR. MINTZ:  It’s 703-697-5131. 


            Q:  You’re being interrupted.


            CMDR. MINTZ:  697-5131 --  5131.  OK. That’s it. 


            Q:  Thank you.


            Q:  Mark, is it OSDA?


            CMDR. MINTZ:  No.  It’s OSD…


            Q:  OSD.


            CMDR. MINTZ:  dot mil.


            Q:  Got you.  I appreciate it.  Thank you.


            CMDR. MINTZ:  Thank you. 


            Q:  Bye-bye.


            CMDR. MINTZ:   OK. Thank you.  Thank you very much. 

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