DR. S. WARD CASSCELLS, ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS
VICE ADMIRAL DONALD ARTHUR, CO-CHAIRPERSON MENTAL HEALTH
REAR ADMIRAL JOHN MATECZUN, NAVY DEPUTY SURGEON GENERAL
MAJOR GENERAL GALE S. POLLOCK, COMMANDER U.S. ARMY MEDICAL COMMAND ANDACTING ARMY SURGEON GENERAL
MAJOR GENERAL BRUCE GREEN, AIR FORCE DEPUTY SURGEON
COLONEL ELSPETH CAMERON RITCHIE, U.S. ARMY
ELLEN EMBREY, DEPUTY ASSISTANT SECRETARY OF DEFENSE FOR FORCE HEALTH PROTECTION AND READINESS
AND SHELLEY MACDERMID, PROFESSOR OF CHILD DEVELOPMENT AND FAMILY STUDIES; DIRECTOR, THE CENTER FOR FAMILIES, PURDUE UNIVERSITY; DIRECTOR, THE MILITARY FAMILY RESEARCH INSTITUTE
DR. CASSCELLS: Good morning. Thanks for coming. I'm Ward Casscells, the assistant secretary of Defense for Health Affairs here, and I want to welcome you to this conference where we're going to talk about the latest in a long series of findings about mental health in military. This has been a pressing matter for some years, and it only seems to get more so. In fact, I dare say now it's really job one for me to make sure that we're doing everything we can to continuously improve our care here and our prevention and the follow up.
It's my pleasure here to introduce the team who put together the Mental Health Task Force report. This is not the same as the team that went to Iraq last fall, which was the 4th Army Mental Health Assessment Team and incorporated the Marine Corps for the first time. This has been a broader-based look at the problem which is now globally the number one problem in health care. The World Health Organization says that in 2010, which is very, very soon, depression alone will be the leading cause of death, and they get that figure from talking about depression as a cause of suicide, depression as a cause of heart attack and sudden cardiac death.
This is a very important issue, also, from the standpoint of the pain and suffering for the families and then the financial implications. And as all of you know, we do not have a perfect understanding of mental health and of neurological health, so this is a great challenge on the research front as well. So this has for me now become job number one, and it impacts everything we do from our determination to improve the frustrating disability process to improvements at Walter Reed, and planning our improvements in our medical education and the like.
So with that, let me say that we are going to announce the -- Admiral Arthur will announce the results of the task force. It was first organized in June of '06.
They've completed their work. The report went yesterday from the secretary of Defense, Dr. Gates, to the Congress. And we now will have six months to develop an action plan to improve things and to implement that action plan -- to begin to implement it.
I want to thank the members of this task force. I want to thank the Congress for prodding us on this. The members of the media who have been very good about getting out there and asking their own questions and holding our feet to the fire on this. But really, the doctors and nurses, therapists who have been involved in this process over the year have had plenty of energy and determination on their own in this effort. They are determined to provide the most compassionate and the most effective care in this difficult area.
The task force, as you will hear, has numerous findings that we are already studying, and we'll be taking action and responding to them formally. But there's been a lot that's happened already in each of the services. And each service is its own engine of innovation, has its own initiatives. Some work better than others. Health Affairs brings people together monthly to communicate lessons learned and to share -- as we say, "steal" ideas from the other services, because it's a competition in a way. The Army has a great suicide- prevention program, the Air Force doesn't, so on.
Those of you may have seen in The Washington Post a few days ago that in the '80s and '90s, suicide rates were higher than in the civilian sector. Now for the past -- in the '90s we got below the civilian sector, and in the first six years of this century, we remain below the civilian sector. And I think this is a credit to these programs which have said: It is your duty not to leave a battle buddy behind. If you see someone who's struggling, losing interest, no longer laughing at the funny jokes, picking at their food, it's your job to bring them in and get them care. That's part of your duty.
We're working with the line commanders to say, hey, guys, when a soldier steps up and says, "I'm really struggling. I need some guidance here," your job as a commander is to say, "There aren't any perfect people. We're a team. Let's work on this. Maybe you need some R&R. Let's talk it through. There's some confidential counseling here on a 1-800 telephone line, and here's some stuff you can read. We're going to have the 1st sergeant circle back with you. And you let me know" -- me, the commander, the platoon leader or the CG -- "if that's not working for you. Let's keep in touch. Drop in soldier, drop in."
This kind of embrace of the problem and embrace of the soldier, sailor, airman, Marine, is where the line is going. They're doing a better and better job with this. Really proud to see that we're working hard on the stigma of mental health. And Admiral Arthur and his task force have listed that as job one: continuing to work on the stigma issue. And then we got a separate issue, which is the access to qualified care.
There's only so much you can do with self care, buddy care, you know, group discussions. At some point, some people need professional care. So we've got now dozens of deployment health clinics around the country.
Great credit to Ellen Embrey, our deputy assistant secretary of Defense for Force Health Protection and Readiness, as many of you know, and she's taken a fresh look at this and really getting data. We've got these post-deployment questionnaires that you fill out when you leave theater. When I left Iraq, I filled out a questionnaire and said: Were you near an IED that went off? Are you having trouble sleeping? Are you having trouble controlling your feelings? And so forth, and so on. A lot of people check "no" because they want to get home. Ms. Embrey is making it possible to assure soldiers that even if they check "yes," they're going to get home and get the care when they get home, that they can fill this thing out honestly.
Second issue, we've got people lost to follow-up. We are getting some retired soldiers, including chaplains and psychologists, who are going to make it their business to contact people at six months and say, "I just want you to know that we haven't forgotten your service. I'm a veteran. And don't forget there are all these things available to you. And by the way, I'm here to talk to you. I struggled with this or that. And you can call me confidentially because I'm not in the chain of command." But we want to make sure that at six months, we've got everybody contacted. And so we are working toward that goal.
There are a dozen things going on, and I don't want to belabor that issue because some of them fall in the bucket of pilot programs, which Dr. David Chu has asked us to develop. Some of them are initiatives which the services have undertaken -- trial and error basis; they'll talk about that. And then the focus, though, will be on the report itself.
So let me tell you who's going to speak.
First will be Vice Admiral and physician Donald C. Arthur, who has been our Navy surgeon general and co-chair of this mental health task force along with Dr. Shelley MacDermid, who represents the six private-sector members on the task force.
They're followed by Rear Admiral John Mateczun, the U.S. Navy deputy surgeon general, also a physician; and Major General Gale Pollock, known to you, who is the acting Army surgeon general and one our nation's great nursing leaders and medical leaders; Colonel Elspeth Ritchie, known to some of you as Cam Ritchie, Army surgeon general psychiatric consultant; Ellen Embrey, deputy assistant secretary of Defense; and for the Air Force, Major General Dr. Bruce Green.
So without further ado, let me introduce Vice Admiral and Navy Surgeon General Don Arthur, who has changed the discussion for us on this by saying that by getting us to begin to think about resiliency training and psychological monitoring from the very beginning and having as a part of everything we do in health care -- and as some of you know, his own example of resiliency has been an inspiration to those of us in the medical field, in the military. And so we are delighted to accept this report and to thank publicly the Navy surgeon general.
ADM. ARTHUR: Good morning. I'm Vice Admiral Don Arthur, and this is Dr. Shelley MacDermid from Purdue.
We are the co-chairs and, along with Lieutenant General Kevin Kiley, who was the co-chair for 10 months -- I took over for him about three months ago -- co-chairs of the mental health task force, which was chartered by Congress over a year ago.
And they chartered us with looking at the entire landscape of mental health, of psychological fitness in the military services. The task force had a year to do its work, visited over 38 facilities, got testimony from veterans, from their families, from health care workers, from line leaders and took input on the website, gathered a tremendous amount of material to produce this report.
The report is entitled, "An Achievable Vision," because we feel that there are changes that need to be made. They are achievable. It will take some work, but we know that the system is dedicated to the support of servicemembers and their families.
The report is broken down into four sections. One deals with ensuring that there is a culture of support for psychological health. The second is ensuring that there is adequate access to mental health services; the third, that there are adequate resources to support those services and fourth, that the leadership of the Department of Defense, not just the health care workers but all of the leadership, focuses on the mental health of our servicemembers as a primary concern.
We focused a lot of our report on the stigma of mental health services, that we know that there is some stigma. It's a natural thing. It's a natural human emotion to look at weaknesses in one's structure, whether it's your boney weaknesses or psychological weaknesses. We are sensitive to the fact that it is difficult at times to see a mental health provider unless you feel that it is supported by your chain of command and there are no negative repercussions, either personally or professionally, for your career. So we focus on stigma and things to remove stigma from the mental health arena.
Another important focus was on the concept of resilience. We build resilience today in the services by putting our recruits through boot camp and our offices through officer indoctrination school, where we make cookie-cutter soldiers, sailors, airmen and Marines out of civilians who come to us from a wide variety of experiences in their younger lives. We make them all servicemembers with the same kind of training but don't concentrate, necessarily, on what each individuals might need, and assess whether they are highly resilient or need more training and education in resilience.
We feel that we can improve the resilience, that is the adaptability to military service. If we focus on it, it's a leadership priority, we can make better service members, and they will be better husbands, better wives, better fathers, better mothers, because they can handle stress better.
We concentrate a great deal on physical health, that is how fast can you run a mile, how many sit-ups and pushups can you do, but we don't often concentrate on the psychological health of the service member. And I think if our leaders were to concentrate on this in the cognitive battlespace that we have today, our service members will be more adaptable, less susceptible to stress. And when stress impacts a service member, that the leadership will recognize that, rightly, it is an absolutely normal reaction to combat. Anyone who goes into combat knows that you become significantly affected by the experience and post-traumatic stress reactions are normal. We would like to not have those reactions go on to be disorders.
A lot of the report focuses on access to mental health services, and some of it is prevention; some of it is treatment. For prevention, we recommend that we continue and increase the embedding of psychological health professionals into the line units that deploy. We recommend that we have psychologists in primary care clinics. Generally, we recommend that there be more availability of mental health professionals for active duty and family members, including in the TRICARE network. So we concentrate on not only treatment, but we concentrate on prevention -- much better to prevent than to treat.
Let me turn it over here to Dr. MacDermid for her comments.
MS. MACDERMID: Thank you, Admiral. As the civilian co-chair of the task force, I want to offer my assurances that the task force members did their work conscientiously and thoroughly with vigorous debate and enthusiastic gathering of data and pursuing of information.
Our overriding focus was the health and well-being of service members and their families. We did not worry too much about where stovepipes were or where they were not. We focused always on the individual service member and his or her family and how they could access the services that they need.
We found many examples of excellence. We found many hard-working providers doing a very good job under very difficult circumstances. But we also recognized that there are urgent matters that need attention. The fundamental mission of mental health in the military has changed. Operation tempo is higher, we have a war on now, and in the future, we expect that there will continue to be high operational tempo. The system must change itself to meet the demands of the future. And I know that the task force members are hoping that the military will demonstrate its ability once again to rise to a significant challenge and meet the demands of the new age for support for psychological health in the military.
I know that I and all of the other task force members, we're proud to serve in this capacity and we look forward eagerly to see the response.
ADM. ARTHUR: Thank you, Shelley.
We would like to invite the representatives of the service up now, and then we will take questions after that.
Admiral Mateczun, deputy surgeon general of the Navy.
ADM. MATECZUN: Good morning. My name is John Mateczun. I'm the deputy surgeon general of the Navy.
About a year and a half ago, the chief of Naval Operations, Admiral Mike Mullen, asked Navy medicine to take a comprehensive look at mental health of sailors that are deploying, how they're doing, how we can do better, and that resulted in a series of actions and a series of recommendations as we studied what to do about mental health. And I think that you'll see that, if we take a look at this report and the primary recommendations about dealing with access to mental health services and dealing with stigma, that what we're talking about is trying to get past barriers to care for people that need some support or help with mental health problems. So access and stigma are two of those barriers that we've spent particular time trying to figure out what to deal -- how to deal with them.
We have appointed within the Navy and Marine Corps -- each of those services has a combat and operational stress control consultant for the commandant and the chief of Naval Operations, experienced mental health personnel who have deployed repetitive times in theater and are able to provide advice at the service level.
In theater, we have embedded mental health support; for the Marines, we have OSCAR teams that are there, and the Naval Expeditionary Combat Command, which is standing up, is embedding mental health personnel for those other sailors that go into theater that are deploying as well.
Rear Admiral Bullard, who is the commander of the Naval Expeditionary Combat Command, is reviewing a warrior transition for those sailors who are coming back out of theater, where they will pause, take a time-out as they transition back so that they can think through, answer the questions on these questionnaires that you've heard about and get a chance to talk to somebody in a little bit more relaxed atmosphere about the experiences that they've had while they're in theater.
In particular, we have a number of Navy personnel from Navy medicine who provide medical support to the Marine Corps, and they see a lot of trauma in theater.
We want to make sure that we have in particular taken care of our own caregivers as they transition back from theater, and as they come back and return to work in our hospitals back here in the United States.
In terms of access, we have opened over this last year 13 deployment health centers to provide access for people that have deployment health questions, and we have about 111 people that we put into those centers. About a third of those people are mental health professionals. We intend for these deployment health centers to be located close to our deployment centers and our fleet concentration areas, and to provide non-stigmatizing portals of entry unto the health care system for mental health care. And our primary care people that work in those centers will also be receiving training in mental health. We have 13 of those centers open today. We'll be opening another four this year.
In terms of stigma and dealing with stigma, Admiral Mullen has asked that we take a comprehensive look at the problem and how to tactically approach it, through leadership, education, training and other means. The Center for Naval Analyses is doing a study now on stigma. It is a pervasive problem, not just in the military as you've heard but in our society, and we hope to find new ways to be able to deal with the questions that people have in their mind about seeking mental health support.
We have taken actions to review policies about care for mental health and what that means for deployment. We have a lot of people who may not seek mental health care appropriately. One of the results of Operation Desert Storm and the reviews that went on about mental health care after that conflict was that there were a number of people that actually deployed with diagnoses, with medications that they had received from private practitioners that we didn't know anything about.
That's not good health care. We want to make sure that those people that have diagnoses, that can deploy with those diagnoses, are able to deploy, and that we have given them the appropriate medications, treatment and whatever it is that they need, and that we're able to support them while they are deployed. We've reviewed our weapons qualifications policies and, in consonance with law enforcement agencies and the federal bureau, have modified our physical qualifications criteria so that those people who are on routine medications and doing well can continue to qualify and bear arms.
In the future, we have a couple of directions that we're going to be taking. We're going to be standing up a Center for the Study of Combat Stress that will arms that reach into research and development, clinical investigations, treatment, and as well as into education and training. We are particularly interested in studying family support needs. The Center for Naval Analysis is doing another study for us now, it takes a look not at what we think families need, but what they tell us that they need in terms of support as they come back. And we will then focus on providing that support to families. When a sailor or a Marine is deployed, if their family is having difficulties, then the sailor or Marine is not as combat-effective as they would otherwise be. And training, certainly, for all of our personnel before they go into theater, after they come back. As Dr. Casscells mentioned, we want to make sure that people are able to ask tough questions to their buddies: How are you doing? Are you doing okay? That they get the feedback that they need to continue to be mission- effective.
I'll be glad to answer any other questions you have after the other services.
ADM. ARTHUR (?): Thank you, Admiral Mateczun. I'd like to now introduce General Gale Pollock, the acting surgeon general of the Army.
GEN. POLLOCK: Good morning. I'm delighted that the DOD task force report has come out because it validates the work that we have been doing inside the Army as we've been very concerned about the mental health of our soldiers for many years now.
You know from other briefings that we have actively engaged with our soldiers in theater with the mental health advisory teams, and we've been working to improve the education for both those soldiers and their families so that they understand the significant demands of repeat deployments and exposure to combat. Both of those venues -- the repeat deployments and that increased combat exposure -- move them towards the potential of exhibiting systems of post-traumatic stress. And as we educate them about those symptoms and allow them to engage early with health care providers, we're going to be doing a significant service for them that has never been done by a military during a deployment before. Asking these questions, being actively engaged, and changing what we do in the midst of these operations, it's the first time that it's happened in history.
And I'm delighted that the concerns that we've had and tried to work on were indeed validated by what I would call the outside, because we were able to bring in our civilian experts, as well, to look at what we had done so that we didn't have to be concerned that it was -- well, it's just our perspective and perhaps we're not looking at it in a wide enough perspective. Also, the fact that they emphasize the concern of stigma, that's very, very important. But that exists across the nation. Behavioral health is not something that people often will willingly pursue, and we need to help the nation to address that. And I'm hopeful that just as in many other times the military has been able to lead the nation in making changes in our nation, we're going to be able to contribute to improving the health of our citizens and decreasing the incidences of depression and other concerns that Dr. Casscells raised.
Because of that stigma, it's very important that people have easy access. So one of the changes that we've made is a program that we've called respect.mil, in which -- instead of requiring the soldiers or the family members to go to a designated location because you're getting behavioral health, it's now done inside the primary care area so that we can do the assessment, and people can just come to the clinic for behavioral health issues the same as they would come for any physical health. Because we need to bond together the psychological and physical components of ourselves so that we can stay well.
You know that we have the combat and operational stress teams in theater and are working with people there, but I'm delighted for the support that we feel like we've gotten through the release of this report. And many of you have also been following the work that we've done to improve our processes up at Walter Reed, and I'll put in a pitch now, that we're hosting another round table this afternoon at 1:30 on the Army Medical Action Plan, and I welcome your involvement there. And I'll be happy to take questions after we complete our discussions this morning.
ADM. ARTHUR (?): Thank you very much, General Pollock.
I would now like to introduce Major General Bruce Green, who is the deputy surgeon general of the Air Force.
GEN. GREEN: Thank you and good morning. I'll keep this very short. The Air Force is very appreciative of what the task force has been able to pull together in terms of an unparalleled and far- reaching look at mental health, services provided to servicemen and their families. Our leadership overseas supports our medical mission at all levels; it's actually our privilege to care for airmen and their families, and they are indeed our most precious resource.
We continue to assess our medical programs all the time. We're very happy when we get an outside look to tell us other ways that we could be conducting business. I think that addressing the mental health needs of our members is not simply a medical issue for the Air Force; it's really a community issue. We've had very much success with the community approach, most notably with our suicide prevention programs, and we've had concerns recently with regards to whether we were providing adequate mental health services to all of our members.
We appreciate the task force's independent look. For instance, we'd already tried several instances of increasing availability of mental health services. We expanded Internet and phone access. However, the task forces kind of highlighted in the report that some of this initiatives have not worked, and some have not been implemented as we expected.
The task force has validated the 10-year initiative that involves placement of mental health providers, especially social workers and psychologists, into our clinics, in our primary care clinics, has been effective. And we'll use this report to enhance care in other ways as we focus on achieving higher standards of care.
The Air Force plans to be a very active participant as we move forward on solutions, and our airmen and their families deserve nothing less from us than the very best care.
So I'll end with that and open it up to questions. I believe I'm the last speaker.
ADM. ARTHUR: Thank you, General Green.
Let me just say what's next. What's next is, this week was our mandate to present this report to the secretary of Defense. We did that on Tuesday to the deputy secretary of Defense, the Honorable Mr. Gordon England. And yesterday Dr. MacDermid and I briefed Senators Boxers and Lieberman, as well as principal staff members for the Senate Armed Services Committee and the House Armed Services Committee. And this morning is the opportunity for the assistant secretary of Defense for Health Affairs, Dr. Casscells, to introduce this report to the general public and to you first.
So may we please take questions?
Q Sir, could you sort of balance the problem for us? Right up front the report says that the PTSD incidences are high. They're especially high in the National Guard. Do you have some historical data to compare that to previous conflicts and some explanation why it's higher in general and why it's higher particularly in the National Guard?
ADM. ARTHUR: Post-traumatic stress, combat stress, is an absolutely normal reaction to a very abnormal situation.
Combat is like nothing else that one can experience in peacetime. It is not like you see in the movies. It's not 90 minutes of a show, with 30 minutes of commercials, and the good guy wins in the end. You have a real chance of being seriously injured or killed in your service to your nation.
And we expect that everyone who comes back from combat will be significantly affected, and we want to ensure that people don't get to the point of having a post-traumatic stress disorder, because we have paid attention to that post-traumatic -- that normal reaction to combat and have provided them with adequate access, with no stigma, to be able to seek the counseling that they should rightfully need when they come back from an abnormal situation.
Why it is different in different groups, I'm not exactly sure. We didn't go into the epidemiology of that. But there's a lot that has to do with the intensity of resilience training prior to going into combat.
We certainly know that post-traumatic stress reactions are greater the closer you are to combat action. But in this conflict, you don't know where the combat action is going to occur. It could occur in the streets of Fallujah or back at the chow hall. And we've had people who have been seriously injured or killed in both venues.
So in the entire theater in Iraq we have no idea exactly who is in danger moment by moment, so it's a very challenging venue for them.
Let me take one back here. He had his hand up for quite a while.
Q Speaking of the National Guard and also the Reserves, there you have a lot of people who come back from theater, go home and they go home some place where they don't necessarily have access to the kind of support services that the active-duty military have. And I know of a number of cases where individuals have come back and had severe problems, and the only agency that was available to respond was local police because they'd threatened their wives or something like that.
So how do you see this problem? How do you plan to address this kind of a problem?
ADM. ARTHUR: We're going to address it with a greater emphasis on those people as well as those service members who were at the end of their service and are released from active service and don't stay in the Reserves. We're very concerned about how we keep track of them. So a vital aspect of this is how we keep track of the Reserves and the National Guard, and especially for Reserves and National Guard, how -- with what frequency we have them come back together as a group and assess their psychological status, assess whether we need to do some training or certain intervention.
This requires a personal contact of the leadership with the soldiers, sailors, air men and Marines and a concern for this issue. The post-deployment health reassessment is our major tool for learning if there are issues that were not obvious when someone came back, but are becoming manifest three to six months later. So we want to always be attune.
One of the recommendations, a small recommendation, of the 95 that we've contained in the report is to have all of our recruiting stations, which are available in malls throughout the country, have some information and points of contact, where if someone comes in just off the street and says, "Hey, I was an active service member, I've gotten out, but I'm really having some problems. Is there anyone I can talk to," and they will have the information needed and they can make contact with the VA or the other appropriate referral agency for them.
Q In the report you mentioned, I think, more than once that there are insufficient resources for mental health both in terms of financial resources and human resources. Can you talk to us a little bit about what level of resources are needed immediately with urgency, and what percentage of those resources, both fiscal and human, do you imagine you'll receive?
ADM. ARTHUR: We didn't try to quantify the personnel or financial resources that would be required. We did ask the services to consider a risk-adjusted, population-based model, where we would look at the populations that we were going to serve and assess the need for psychological services. An infantry unit may need more services than, say, a logistic units that's farther rearward from the forward edge of the battle. So we have asked the services to determine what their needs are based on their service requirements.
There will be some additional personnel, there will be some additional money that's going to be needed to support this effort, and I want to put that into context of the last 30 years, which is essentially my entire career of relative peacetime. Although we had Desert Storm and Grenada and Panama and Bosnia and a lot of other small conflicts, this is the first time in 30 years where we have had a sustained military conflict with multiple deployments of very high- intensity combat, not since Vietnam have we seen this level of combat.
So we have, over the last 30 years, tailored our medical system to perfectly meet the needs, or as well as possible meet the needs, of our servicemembers and their families. And with this increase in responsibility, increase in incidents of psychological need, we now find that we have not enough providers in our system, because we have not had to have that many providers for the last 30 years. So in this report we make recommendations that we have a lot of programs which prevent the post-traumatic stress disorder in the beginning, in the first place, and that way minimize the need in the future. But clearly we have a deficit in our availability of mental health providers.
Q Can you talk a little bit about the priority of PTSD? Is it something that is likely to show up later on in life? Is this a population of people that might need to be treated 10 or 15 years down the road? I'm thinking about Vietnam vets who are still having traumas. So are you thinking that this is going to be an ongoing problem even 10, 20, 30 years down the line?
ADM. ARTHUR: Well, I would say that post-traumatic stress is a problem if it's not treated properly. If you don't manage, you don't treat, you don't properly address post-traumatic stress then yes, it can certainly be a problem. For a small percentage of the population who react to stress in different ways than many of us do, it may manifest and change their lives forever. These are men and women who have undergone experiences that are unlike anything else in humankind, and I think we need to recognize and celebrate their great service. And sometimes we will have to understand through continued lifelong treatment of those who are very severely affected.
Now I also have to say that post-traumatic stress is just one part of a servicemember's exposure to combat. And we talk about combat a lot, but parenthetically I also want to say that military service by its very nature is different from the civilian sector experiences. We recently had a broken steampipe on the USS Frank Cable off Guam, and it severely injured many servicemembers and killed two. They were as severely affected by their service experience as anyone in Fallujah. So it's not just about combat. It's about military service, also.
Q If you tackle this problem now, if you treat these people now, you're going to be saving a lot of trouble down the line?
ADM. ARTHUR: If we can look at post-traumatic stress as a normal event and we can manage their psychological health better, we won't have as many problems down the line. We will restore people to as close to their normal psychological state as possible, given the fact that they will always remember their combat experiences, and it will always temper in some way how they view the world.
And you were next, I believe.
Q Sir, I wonder if I could ask Dr. MacDermid, as sort of the outside expert on this.
We talked a lot about focusing on the servicemen and the need to get over stigma. But obviously this report that came out a couple months ago about soldier attitudes toward civilians, I think, disturbed a lot of people when they saw that.
Can you talk a little bit, as you looked at the institution of the Pentagon and of the department and the services, what they're doing right and also what they're doing wrong in terms of dealing with these issues? Because it does seem to be a rather big problem that is affecting folks on the battlefield. And I'm just curious whether you found the institution of the military is treating these things properly.
MS. MACDERMID: Well, the task force has 95 recommendations about things the military might want to consider doing a little bit differently, though --
Q Can you pick out a couple, though, that you think are the most important, that need to be most urgently --
MS. MACDERMID: Well, let me respond to the first part of your question first, which is things that we were pleased about.
I think the task force was very pleased and very impressed that data are being collected from service members during deployment, and adjustments are being made. I think that really is remarkable. And there are many examples in each of the services of individual programs that are innovative and doing a good job. For example, the Air Force has been embedding mental health professionals in primary care. That was something that was cited in the report. So there are many examples.
I think overall, we have the difficulty of a heavy burden of services that are needed. In part, that also is a good news story, because in Vietnam, we didn't bring as many people home. We're lucky to have people coming home. But we have to deal with them in a different way than we did in the past.
I think there's work for Congress to do here, as well as DOD. And one of the challenges that they face is, of course, providing resources, and then DOD has to deal with its complicated structure to get resources down so that they can be distributed according to need. And that's probably one of the biggest overarching conclusions that we drew. Even though there are examples of excellence, there are many things being done well, it's not consistent enough and the system needs to be altered to do a better job of making sure that resources are placed where they are needed, when they are needed, for whom they are needed.
Q I know it's kind of an unfair question, but as the news media is wont to do, we can't list all 95 in any of our stories. I'm curious if there are a few things that as we read the report should be highlighted, things you think are most important, most urgently need to be done institutionally within the building.
MS. MACDERMID: Well, I was with you right up till the last phrase. I think the task force members would say number one, more resources are needed. And that's a job for both Congress and DOD.
Number two, service members and their families need more access to providers. For service members, that means the placement of providers closer to where they are. For family members, that means access to more providers at military treatment facilities, and it means improving the depth of the TRICARE network around the country with regard to mental health.
ADM. ARTHUR: I would add that one thing we have highlighted in the report is the value of uniformed providers, or, better said, the value of providers who have experienced the military milieu, especially combat, that they can understand the active duty and service members' families' issues better.
When I testified in front of the House Armed Services Committee a month ago, Congressman Walter Jones from North Carolina came in -- he was one of the members, and he said that he had been to Camp Lejeune to a grade school, and he asked the kids, "Is your mom or dad deployed?" And one of the young children, a second grader, said, "Yes. My dad's in Iraq, but he's not dead yet." It gives me goose bumps just to think about it, to think about the impact on families and the fact that we have to have a military system and a surrounding civilian school system that understands the military life, and that it's not normal to expect that your father might not come back. So we concentrate on the families as well.
One back here, and then I'll get right back to you.
Q (Off mike.) Did your report assess at all how the VA is doing in dealing with vets coming back? I mean, obviously a lot of these folks are going to leave the service and seek help from their VA if they seek it at all. What'd you find out about that, and are there recommendations dealing with the VA?
ADM. ARTHUR: Yes, we had a representative from the Department of Veterans Affairs on the task force, and although our task force was chartered with looking at the Department of Defense, we did feel that there was an extension to the Veterans Health Administration, and we have made some recommendations dealing with access and other issues for the VA. They are not a permanent part of the report because the report wasn't centered on the VA.
Q Can you give us a sense of how VA is doing in providing services to these folks compared to how DOD is doing? Does one have lessons to teach the other, and if so, what are they?
ADM. ARTHUR: Well, I think we all have lessons to teach each other. We view it as one continuum -- I think the VA would agree -- that every one of the VA's patients were once our patients, and I think we view the patients as being patriots and our obligation to deliver their care.
But I can't really talk about the VA's programs because I don't know enough about that. I would ask them to do that.
Q In Dr. Casscells' opening statement he mentioned that the number one health problem is depression, and this is taking over a large part of his daily job. I'm just curious why -- this study started a year ago, more than three years after the war in Iraq began, more than four years after the war in Afghanistan. We're now more than five into Afghanistan, more than four into Iraq, I mean what took so long? If this is such a tremendous problem, whey did it take the military so long to recognize it and to do something about it?
ADM. ARTHUR: Well, this was actually legislation -- Congress asked us to do this. The recognition of mental health debt that is being created by a combat situation is not new to us. We knew that it was there, and we had programs that we put into place that addressed post-traumatic stress, they addressed traumatic brain injury, they addressed depression. But we realized that they were inadequate. It took us a while to gain the data, but I think everyone realizes that the programs we now have are not adequate in terms of the number of providers, the amount of care that we need to give, and to whom we need to give it.
Q How did you recognize that it was inadequate?
ADM. ARTHUR: Well, through experience, through having people come back. And it's not just the people who we concentrated on initially, which are the people who come to our hospitals and get the care. We know what their needs are. We saw that there was an increasing number of people who come back and who don't go to the hospital, aren't recognized immediately, but have some issues. And it took us a while to recognize the full extent of that. And I think that's why this task force was created. And I think you'll find in here that this addresses it I think in as consummate a way as we can. There are a lot of very sweeping recommendations here.
Q If I could just ask one more question. There's a part in the -- building a culture of support for psychological health, it says: Some Department of Defense policies, including those related to command notification or self-disclosure of psychological health issues are overly conservative.
What do you mean by "overly conservative"?
ADM. ARTHUR: Well, whenever you seek mental health counseling right now, it's advisable to notify your command that you've gone to see a psychiatrist or gone to see someone about a broken leg or a pregnancy or anything like that. We feel that there are some services that people ought to be able to go to without notifying anyone in the chain of command. For example, bereavement or marital counseling -- we don't feel that people who access those services need to notify anyone. That is something that doesn't rise to the level of a disorder of command interest.
Q Admiral, it's one thing to say that there shouldn't be any stigma to admitting that you have a problem --
ADM. ARTHUR: That's easy to say, isn't it?
Q Yeah. But given how competitive the military is, given how much of a challenge it is to advance, to be promoted, how do you really convince service members that they won't be hurt or held back by admitting that they have any kind of stress problem?
ADM. ARTHUR: Well, that's a job for leadership, and it's a job for training of those leaders in the psychological health of their service members. If we can train leaders to understand that the physical health and the psychological health are equally important, and that if you break your leg, it's not your fault; if you get cancer, it's not your fault; if you have a post-traumatic stress reaction, it's not your fault. We are all different as human beings, and I think that those differences need to be recognized. And we have some people who are very hardy in their response to stress and others who are not. They are equally valuable as service members, and I think it's up to leadership to say to folks that post-traumatic stress reactions are an absolutely normal part of combat operations.
Q (Off mike.)
ADM. ARTHUR: Okay.
Q Can you talk a little bit about the screening in the case of the repeated deployments that are going on and also re-enlistment, and even at the recruitment level, how you gauge the mental health and the threshold if someone's already been, say, repeatedly in a combat environment? What is the threshold for knowing that they can return safely and also that they can re-enlist and maybe for looking for mental health issues at the recruitment stage?
ADM. ARTHUR: Yes, a very complicated issue.
To gauge one's psychological health is not an exact science. What we try to do is, when people have gone into combat once, we try to assess before they go again what their level of psychological health is, and it gets confounded a bit by the fact that there are a lot of service members who will minimize their reactions or their feelings because they want to go back. They want to be part of their unit, and they feel an obligation, a -- not just an obligation to the unit, but an obligation to their nation to go back. There are others who may exaggerate if they don't want to go back. So it's not an exact science.
One of the things we do want to do is try to assess early in people's careers at recruit depots and things like that, people's resilience, and see if we can't build resilience where it is perhaps lacking in some individuals.
We would like to know makes some people highly resilient and others not, and that research has not been fully done yet so that we know for sure.
We do know that leaders who are highly resilient have a lower rate of post-traumatic stress disorder cases in their battalions than leaders who are not as resilient. Those people who themselves exude confidence and are charismatic leaders of their service members will prevent, by their leadership, the post-traumatic stress disorders.
Q But there are people who are -- just to follow up, I mean, there are people who have been treated for post-traumatic stress --
ADM. ARTHUR: Yes.
Q -- who are returning --
ADM. ARTHUR: Yes.
Q -- and, you know, may be still undergoing counseling. Can you just talk about the guidelines, the concrete guidelines for that, from the -- (off mike)?
ADM. ARTHUR: Each -- yes. Each service member is an individual, and they have to be assessed as individuals. If we have somebody who is continuing to undergo treatment for post-traumatic stress disorder, and it is a significant issue, we are not going to redeploy them back into the area of stress.
I would say, though, that I would like you to understand that post-traumatic stress, even the disorder, is not a forever diagnosis. They -- it can be treated, and it can be treated very, very well and return people to full function, including combat operations.
But we want to be very conservative, because the worst thing that can happen and the thing that we don't want is to further injure a service member and that person become a casualty and weigh down the rest of the battalion when they're in theater.
STAFF: Last one.
Q Oh, actually this is a question for Admiral Mateczun.
ADM. ARTHUR: Okay.
Q I just wanted to ask a question about this pistol qualification. When was this done, the modifications to allow people who are doing well and steady on medications -- and this is --
ADM. MATECZUN: This year.
Q When this year?
ADM. MATECZUN: This year, earlier. I could get an exact date for you.
Q Not -- it's not a new thing. It's in the last six months or --
ADM. MATECZUN: Yes --
Q -- it's not something relatively new.
ADM. MATECZUN: Yes, it's within the last six months.
Q It is? Okay.
ADM. MATECZUN: Yes.
Q And has the Air Force followed suit on that or --
GEN. GREEN (?): I'm not aware of a program right now in terms of what the Navy's talking about. So I can't comment.
Q Is it -- are you allowed to carry a weapon in the Air Force if you're on a medication of that type? Do you know?
GEN. GREEN (?): We have a profiling system, and on an individual basis we make decisions as to whether someone can carry a weapon or not. It's always based on the individual.
It was the training program that I couldn't relate to, because I'm not certain what the Navy program is.
STAFF: Thanks --
Q One more --
Q Go ahead.
Q Since she said go -- (laughter) -- have you found that TRICARE's been any kind of a roadblock in this? I mean, are physicians out in other parts of the country, where you may not -- they may not have as many resources -- are they not quick to treat people because they don't want to accept TRICARE and since it doesn't provide so much money for them?
DR. CASSCELLS: Thanks for that question. We get a lot of feedback, individual reports about providers not available -- near Fort Bragg, for example. And we have to either increase the reimbursement there for -- by 10 percent above Medicare -- and General Granger will do that -- in order to persuade people to take TRICARE patients, because TRICARE does have certain requirements.
TRICARE is -- the knock used to be that it was bureaucratic. Well, they got all that fixed. They get paid really quickly; the providers do. But they're held accountable to quality standards. Some of them don't like TRICARE for that reason, because we keep raising the performance bar.
We have a communication issue where we have to remind people that if they can drive 20 miles to Durham, they can -- there are providers there who would welcome them. So a lot of it's communications, and I field lots of individual complaints like this. We follow up on them. TRICARE's not perfect. We're still working on it. There have been some barriers. Some of them are bureaucratic; some are communications.
And if I may just answer one question, this issue of how to reduce the stigma is one where we need all the input we can get. We're out there talking to soldiers, line commanders, people in the corporate world, people in the university world, Institute of Medicine. We've got two eyes open, two ears open, a lot of eyes and ears open, so we're looking for ideas on that.
But one of the messages that I'm trying to get to the line commanders and the troops is, if you look at, for example, Martin Luther, Gandhi, Beethoven, Sigmund Freud, Patton, Churchill, Abraham Lincoln, every one of them had bouts of depression through their life, and every one of them became a great success in some way. Now you wouldn't have wanted a weapon in Mozart's hands -- (laughter) -- but he made enormous contributions. So we need to incorporate this early on in our career guidance for soldiers, sailors and airmen, that you can have -- you may have a special gift. And just because you're not a perfect person doesn't mean you shouldn't be in the military. You can be in the military and make a great contribution, so there's some career guidance involved in this as well.
Admiral Arthur, thank you again for your example and all your hard work. Dr. MacDermid, members of the task force, General Pollock, thank you so much. I appreciate it.
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