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DoD Media Roundtable with Col. Sutton and Col. Jaffee from the Pentagon, Arlington, Va.

Presenters: Director, Defense Center of Excellence for TBI/PTSD Col. Loree Sutton and Director, Defense Veterans Brain Injury Center Col. Michael Jaffee
April 17, 2008

            STAFF:  Good morning, everyone.  Thank you for coming. 

            The department recently established a new DOD Center of Excellence for TBI and PTSD.  That center is designed to focus on quality programs and advanced medical technology to provide unprecedented expertise in psychological health and traumatic brain injuries.  And our goal is to provide lifelong standardized and comprehensive screening, diagnosis and care for all levels of traumatic brain injury and post-traumatic stress disorder. 

            Today we have with us today to talk about this Center of Excellence Colonel Loree Sutton, the director of the Defense Center for Excellence for TBI and PTSD, and Lieutenant Colonel Mike Jaffee, the director of the Defense Veterans Brain Injury Center, and they  will answer any questions you might have about this important topic and enlighten you on what we've done so far. 

            With that -- (inaudible). 

            COL. SUTTON:  Good morning.  Thank you so much for being here today.  It's a privilege to meet with you.   

            We've had a chance to review the RAND study, which I think we're all aware is coming out today.  We're so thankful for the efforts of the RAND team.  They sat down with us and went over the results of their study.  And it's heartening to know that the results of their study are very consistent with our previous studies, both the in-house studies as well as the studies that have been published in the New England Journal of Medicine.  It's a good guidepost for us because we know we're on a journey, and for as far as we've come so far, we still have a long, long ways to go.   

            And so the points that the RAND study has illustrated in terms of the fact that we do have soldiers and sailors, airmen, Marines, who are experiencing post-traumatic stress and depression symptoms, as well as are screening positive for traumatic brain injury, we're very well aware of that, and we appreciate their efforts to inform our efforts.   

            We in just the last few months have stood up the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury. Colonel (Select) Mike Jaffee is our national director of the Defense and Veterans Brain Injury Center, and we're really engaged in a large number of activities.   

            I think you'll agree with us the time is now for a little less talk and a lot more action, whether it be in the areas of clinical, standards of care, education, training, building resilience, funding the research to identify the gaps in our knowledge that we really need to understand better, as well as to connect to our service members and their families wherever they may be across the country.  And that's a particular challenge that we're working very closely in partnership with the VA and our civilian colleagues around the country. 

            So with that, Colonel Jaffee, is there anything that you'd like to say to start off with?  Then we'll be pleased to address whatever questions or comments you may have. 

            COL. JAFFEE:  Thank you.   

            And just to reiterate the point, one, we are thankful for the study.  It tells us that this should continue to be one of our main priorities, and is our main priority, and reinforces all the hard work which is now being done, to all the people who are so interested and invested in trying to improve the quality of care and provide the best that we can for all of our wounded warriors. 

            Q     One of the findings from the RAND study was that even among those who do seek help from PTSD or major depression; only about half receive what the researchers consider minimally adequate treatment for their illnesses.  Does that tally with the research you've done?  And how worried are you by that finding? 

            COL. SUTTON:  Clearly that's a finding that concerns us.  It's very consistent with the civilian literature as well as with our own assessment of the challenges in this area.  You know, closing that gap between knowledge and practice is really one of our very top priorities.   

            And so we will redouble our efforts.  We have got initiatives that are ongoing now, thanks to the generosity of Congress over this last year in terms of allowing us to fund actually over 25 major new programs, supported by over 125 initiatives. 

            And certainly many of those get to the heart of that concern, and that is that we want to provide evidence-based care, the very highest quality care, and then to work on those barriers, whether it be the concern about medication -- you know, that was one of the factors that I was very interested in looking at, people concerned that medication might interfere with their lives.  We've got an educational challenge in front of us.   

            The second concern, in terms of our service members being concerned about the harm to their careers, a very big concern to us. We've got miles to go in transforming our culture.  You know, we can get everything else right.  We're building the team and the programs, we're funding the research and hiring new providers, and we know that even beyond all of those efforts, which are currently ongoing, we must also work to transform the culture.    

            To that end, we're so thankful that the secretary of Defense has taken the lead, actually, on one of the major barriers that many of us -- our service members and their family members -- have identified over the years.  And that has to do with the security clearance, question 21, asking about mental health.  That's in the process of being revised right now.  We think that that's going to be a big step forward to help our service members understand that seeking care, in fact, is a sign of strength.  

            Q     So as it stands right now, then, it is still -- if someone seeks care, they could then have problems with security clearances down the road?  Is that what you're saying, that that is not -- that's not something that's been resolved, it's being resolved?  

            COL. SUTTON:  Yes.  It is currently going through the interagency process.  The revision is nearing completion.  What we're challenged with is because -- you know, currently the question asks whether you've sought mental health care.  Well, this is a concern for folks. Now, I will tell you, I've been a psychiatrist for over two decades in the Army and I have spent a lot of time talking with folks; it always comes up early in treatment, the concern of, you know, "I really don't know whether I can engage in treatment because I'm worried about my career." 

            What I've told folks for years is that, you know, if you have a problem and you need help and you don't get it, chances are something will go awry with your career because bad news and difficulties and conflicts don't necessarily get better on their own.  If you do get help, yes, you'll need to honestly report on the security questionnaire, but the issue there which the security questionnaire's trying to get at is, does this person have the requisite judgment and stability and reliability to be able to execute their sensitive duties?   

            And so I have, over the years, been glad to talk about any of the security investigators to let them know what the condition of a particular service member may be.  And of course, in the vast majority of cases, treatment goes well and they're able to do fine with their careers.  But it creates a barrier in the minds of our service members who are reluctant to seek care because of that fear. 

            And so the improvement that has come out of the work of this last year has been the recognition that one of our cultural challenges is to change that questionnaire so that we can make it very clear to our folks that if the help that they have sought is due to, you know, adjustments related to combat to humanitarian mission to training to the rigors of military duty, that's not what we're talking about. We're talking about serious mental conditions that -- or any kind of physical condition that would prevent one from reliably and, you know, ably doing their duties. 

            Q     Colonel, when you talk about a cultural change, though -- if you have someone who comes out of combat with PTSD and then deals with it, is that somebody that the Army or the Air Force or any other service is going to be interested in sending back into combat where these problems could arise again and could affect performance?  Is it a cultural thing or is it a factual thing or what? 

            COL. SUTTON:  Well, there are different aspects of it, absolutely.  You know, for anyone who's coming back from combat, that's one of the reasons why we have the pre-deployment health assessments as well as we have the post-deployment health assessments and then we've recognized, through this conflict, the need to have, you know, at the three to six-month window the post-deployment health reassessment check, so that we can check in with folks, see how they're doing.  If, you know, folks are having some difficulties and whether those difficulties be at home or at work or difficulties sleeping, adjusting back to life at home, then it's incumbent upon us to make sure that they get the support that they need. 

            Q     Well, my question is somebody with a record of not a mild PTSD or trouble sleeping -- you know, we all have that -- but the serious -- a more serious PTSD, that they decide to go ahead and seek treatment and report honestly.  Isn't it logical that that would affect their career in a combat unit?  Or should it not affect their career in a combat unit? 

            COL. SUTTON:  In a majority of cases, when someone comes forward and gets the help that they need, they're able to, you know, get better and to remain on the job.  And if that job involves going back to combat then that's -- you know, what they're able to do.  We've worked very hard to help our leaders as well as our service members understand that, you know, treatment really works.  And it's a sign of strength.  And so it's both working at that culture to change the expectations and the fears as well as to educate with the factual data that would point to very positive outcomes. 

            COL. JAFFEE:  If I could follow up on that, I mean, there's a broad spectrum.  And we know that some people who are exposed to a trauma might develop the problems of post-traumatic stress disorder whereas others might not.  It sort of speaks to this broad range of susceptibility and resiliency and what have you. 

            And by that same token, there is a broad range of people and how they respond to treatment.  And some of these decisions come down to more individual.  We sort of evaluate the individual and make the best decision for them as to whether they are fit for duty to return, as opposed to having a one-size-fits-all type of policy.   

            (Audio break.)   

            (Audio break) -- then they might not be allowed to go back into combat. 

            So the decision comes into being based on an individual evaluation and comes down to clinical judgment, which makes it even more important and incumbent for that dynamic to happen, where it's important for people to come forward, so they can get that type of individualized attention, so that the clinicians can make the best type of determination and judgment. 

            Q     What the most effective treatment right now that you're finding?  And is every service member who returns being given an evaluation in that three- to six-month window?  Do they all have access to psychological help right now, or are you still short-staffed? 

            And you also mentioned that some do show signs of PTSD after going through a trauma.  Some don't.  What are you -- what have you determined causes some to succumb to PTSD and others not to?  What is the key factor that makes you resilient against PTSD? 

            COL. SUTTON:  There's a lot of questions there.  Let's see if we can unpack them one by one. 

            First of all, everyone does go through that screening at the three- to six-month mark.  And that's one way that I think has been very effective in normalizing the process; that, you know, when you go down range and you spend 12 to 15 months in a combat zone, such as our warriors are doing right now, everyone is affected by that experience.  

            I will tell you, as a psychiatrist, I would be far more worried about someone who had that experience, the 12 to 15 months, and came back saying, "Didn't affect me at all." 

            So there's an adjustment for everyone who goes down range in support of the ongoing conflicts right now in Afghanistan and Iraq. It's one of the goals that the battle mind training, for example, has been really aimed towards helping our troops, helping our families understand that those skills that were so important for protecting yourself, protecting your buddies, meeting the mission down range are skills that don't necessarily lend themselves well to living in a small town, coming back to the base, coming back and reintegrating with one's family.  You know, that vigilance, that -- you know, sort of the convoy driving, the hyper scanning of the environment -- those are all survival skills that are absolutely essential down range, but they need to be adapted and adjusted coming back. 

            So for the folks who experience post-traumatic stress, that's a much larger number of folks than actually develop the disorder.  And so part of our challenge is to help families help individuals, warriors, help communities understand what are normal reactions, the human responses to stress. 

            You know, when you're in an overwhelming, life-threatening situation -- and you know, many of us have had these experiences -- sometimes people will describe -- "it almost feels like -- you know, like I was a robot; like I, you know almost was looking at myself, like I was in a movie."  Well, that's no accident.  Your mind and body are doing what is required to survive.  If you were fully aware of the dangers that you were exposed to at that moment, you wouldn't be able to function.  And so the good news is that that's how our minds and bodies work together to maximize our ability to survive that trauma. 

            But then once you're removed from that situation of danger, that's often when it becomes very, very difficult, because the efforts that our minds and bodies and spirits make to reintegrate, if we don't understand what's happening, it's scary.  You know the flashbacks, perhaps the nightmares, the jumpiness, the natural avoidance of triggers that might bring back those uncomfortable feelings. 

            And so what we have to communicate to folks is to help them understand these are normal signs of healing from trauma.  No, you're not going crazy.  That's the underlying fear. 

            And of course when you have that fear, are you going to come forward and say, "I need help"?  No.  That's why we as leaders have got to get the word out.  It's a national educational campaign, and not just for just -- for those of us in the military and the veterans' community, but for our entire country, because these issues of stigma and of evidence-based care and of access to care and of, you know, breaking down the barriers and educating folks on the efficacy of care -- those are all things that we're in this together to really help folks better understand. 

            Q     What is the best clinical treatment for PTSD you're finding?  What combination of factors? 

            COL. SUTTON:  You know, there are a combination of factors -- in fact, we've got clinical practice guidelines that feature both exposure therapies to help folks desensitize themselves to the traumatic events.  There's also cognitive behavioral therapy, which has been very effective for a number of folks with post-traumatic stress.  There's also the eye movement desensitization.  There's a growing body of literature to support that particular therapy.   

            You'll probably remember, the Institute of Medicine recently had a report that, I think, the VA had commissioned.  One of the frustrations with that report was because of the differences in definitions and metrics and standards and, in some cases, lack of scientific rigor and comparability across many studies.   

            The only treatment that they were able to point to as being statistically significant, in its effect for PTSD, was that of the first therapy I mentioned the exposure therapies.  But we know --  

            Q     (Off mike.)   

            COL. SUTTON:  I mean, that's where you work with an individual to help them through a state of gradual, progressive, focused work so that they can over time reframe their relationship to the trauma.   

            And so sometimes for example, maybe someone has a very strong emotional reaction to the sound of helicopters.  So one of the things that we're actually funding right now, in terms of research, is we're funding some work in virtual reality where we've got some programs that feature helicopters, feature patrol scenes that are actually very reminiscent, very realistic, of the combat environment.   

            And you gradually then work with that individual so that they're able to tolerate what can be overwhelming, at first, emotional reactions.  And you help them then relate to that experience and reframe it in a way that becomes then livable and in fact even can get to the point of what we call post-traumatic growth.   

            There's been a lot of work about post-traumatic stress.  But there's also a body of literature that supports the fact that there's tremendous opportunities for human growth.   

            We would never want such tragedies to, you know, occur on that basis to lead to them.  That's not what you would want.  But in as much as we are exposed to tragedies, there is always the opportunity for growth.  And so we look to maximize those opportunities and that awareness as well.   

            Thank you.   

            Q     Colonel, I have a couple of questions.   

            You said in your opening statement that the RAND study is consistent with your previous findings.   

            Can you tell us how, in what regards and numerically is it consistent?    

            COL. SUTTON:  Sure.   

            You know, the RAND study identified, you know, somewhere between 18 and 19 percent, I think, of folks who endorsed post-traumatic symptoms and by the scale that they have used, you know, reached the threshold of screening positive for a possible disorder.   

            Of course, there was no clinical visit to confirm that, but, you know, what is heartening to us is to know that this is a guidepost for us that is consistent with other studies that we've had.  I mean, the work that Charles Hogue has done really points to, you know, somewhere in the same -- you know, 10 to 15, upwards of 20 percent.  And in the case of soldiers who have gone downrange two and three times, you know, there's a progressive increase in post-traumatic stress symptoms. 

            So the RAND study was, you know, really aimed at identifying a cross-section of folks who had deployed -- with phone surveys, they used these scales -- and whether it be post-traumatic stress or a combination of post-traumatic stress and depression and anxiety or in the case of traumatic brain injury, you know, our screens when we bring folks back from combat -- you know, it really ranges depending upon what mission the unit has taken on, whether it's a, you know, combat brigade or whether it's a support unit, but it really has ranged screening positive, 10 to 20 percent.  And the RAND study pointed to -- I think it was pretty close to 20 percent, screening positive. 

            Now that doesn't mean necessarily that they had a traumatic brain injury, but it certainly does raise the flag which calls for further clinical investigation and evaluation to really sort through and determine, you know, were you exposed to a blast event or to a concussive event of any type, whether it be, you know, falling down, being in a vehicle accident or being exposed to a blast?  And as a result of that exposure, did you experience a loss of consciousness or more commonly a change in consciousness -- you know, sort of being dazed and confused?  Soldiers will say, "Yeah, I got my bell rung." And if that's the case, then we need to document that.  And we need to find out, you know, so how are you doing now? 

            The good news is, is that in the vast majority of cases, folks will -- you know, these are young healthy troops that got, you know, very healthy brains and so in the vast majority of cases -- and this is consistent with the civilian literature -- they completely resolve over time.  But we still want to document and we still want to check in with them.   

            And this is certainly Colonel Jaffee's life work here, so I'll let him talk in more detail. 

            Thank you. 

            COL. JAFFEE:  Right.  I think the question was how is this consistent with prior studies?  So, and just to -- there's various modalities of study that the Department of Defense does.  

            Some are in-theater surveys and some are done when they come home, upon redeployment.  So when you think of just -- (we're segueing ?) with traumatic brain injury, we have done some supplemental post- deployment surveys which have shown in general that for those people exposed to combat, the screening rate is 10 to 20 percent, and then you take that screening rate and we know that half of them were actually having symptoms at the time of the survey, which just does show that the majority were indeed -- had actually improved, as expected with the known natural history of that particular -- of a concussion or a mild traumatic brain injury.  And so that those numbers seem to be consistent.   

            And one of the exciting initiatives that the Department of Defense has launched is there is now universal screening for all branches of service to make sure that everyone is getting that type of screening, and they actually reframe the questions to specifically ask about if indeed someone did have a concussion, if they were in an incident which involved a loss of consciousness or alteration of consciousness, and then asking about some of the symptoms, and that screen allows us to do a more thorough evaluation of those individuals.   

            The VA has also initiated similar types of screening to try and identify those issues from OIF or OEF who enter the VA system, to see if they also can endorse any positive aspects of a screen of traumatic brain injury, which then allows them to do more of a comprehensive evaluation to see if they are having symptoms and if those symptoms may be attributable to the concussion that they may have had in theater.   

            And so a lot of these numbers that we tend to have, they keep on clustering around kind of these same results.  So there are some consistencies even though the methodologies of how they were collected is different.  So this is why the RAND study is an important part of the big picture, with this method of doing telephone surveys farther out; that it seems to be consistent with when we actually survey the warriors right when they come home or when we survey them again three to six months later or if we actually go into theater and take a survey of the folks there.   

            So the fact that all these methodologies of surveys done at different points in time do have some internal consistencies I think is reassuring; and sort of they, I think, each reinforce one another, that tells us that this is perhaps the fairly accurate information and gives us the trajectory and priorities for us to press forward. 

            Q     Is there something between your previous studies and this RAND study that seems to be glaringly inconsistent?  I mean, what jumps at you in this RAND study that just doesn't go with what you've seen in the past? 

            COL. SUTTON:  You know, I was surprised about that concern regarding medication.  I had not seen that in our previous studies. So that was, you know, an important point that certainly we'll incorporate in our educational outreach.  I was certainly very well aware of the stigma issue and the concern related to the security questionnaire. 

            It was consistent as well with the concerns folks had in terms of what people might think of them -- their friends and their family.  I mean, we've got such a long way to go.  We've made a lot of progress, but we clearly -- clearly, we're on a journey, and we have a long way to go. 

            Q     In your previous MHAT, as of this -- as they've been progressively released, I mean, I recall briefings where you emphasized that the stigma is wearing down as you see the numbers in the surveys, because there's a greater admission that there may be stress.  But that seems to be different from here, though -- 

            COL. SUTTON:  You know, it's interesting.  In the -- the MHAT data has shown a steady -- it's not a dramatic -- but it's been a steady progress in the right direction in terms of attitudes towards seeking care.  The comparison with the RAND study -- I'm very interested -- you know, in the MHAT series, upwards of about 40 percent of folks who endorsed the fact that they needed care actually got that care.  In the RAND study, it was closer to 50 percent.  Now, don't know if those are exactly comparable populations.  I wouldn't, you know, absolutely put that in the bank as ironclad proof that it's an actual improvement, but it certainly is promising, and it adds credence as well as urgency to our continued efforts.  We've got to get the word out to folks that seeking help is a sign of strength. And so -- 

            Q     (Off mike) -- Colonel --  

            COL. SUTTON:  (Inaudible.) 

            Q     -- (off mike) -- by saying I have a lot of questions -- that the PTSD -- this is about PTSD symptoms, which is different than actual developing -- actual development of PTSD.  It's not -- I mean, because PTSD numbers are somewhere in the 5 to 7 percent range -- (off mike). 

            COL. SUTTON:  The baseline for service members who have not deployed -- it's about in the 5 to 7 percent -- for those who have deployed once, I think it goes up to about 12 percent.  For twice, I think it goes upwards 18, 19 percent.  So there's -- there certainly can be a progressive trend upwards, as you might expect with increased traumatic exposure. 

            Yes? 

            Q     Yeah, I'd like to raise a slightly different question, which is something I've heard about a lot from veterans groups, which is the -- and I guess it gets to the cultural issue we were talking about earlier -- 

            COL. SUTTON:  Yes. 

            Q     -- Which is the propensity of commanders to sometimes use the disciplinary system to deal with soldiers who might be giving them problems, difficulties, when in fact the source of their difficulties is stress that they may have experienced in combat.  

            So I'm wondering how you're addressing this problem, also. 

            COL. SUTTON:  You know, that certainly is -- it's part of the cultural terrain that we are currently seeking to understand better as well as to influence.  One of our jobs at the Center of Excellence is to really reach out across the services, across the VA, across the country and the world, in fact, to identify best practices and to bring them to the fore and then disseminate those.   

            So, for example, in the situation you're describing, one of the best practices out there that has emerged, in my mind, has to do with those commanders who are sending their legal teams down and joining their legal teams with their medical and behavioral health teams.  And so when they're considering disciplinary action for a soldier, those commanders are asking the question, okay, what do we know about this individual's combat experience?  Talk to his leadership; let's find out.  You know, does he have a positive of performance prior to combat and then had some terrifically overwhelming experience -- maybe he lost a buddy or several buddies or was exposed to repetitive blasts?   

            And where that's the case, that commander then considers the medical and the mental health judgments as well as the legal realities and figures out really what's the best, what's the fairest thing to do?  If this was a good soldier before this experience, you know, then this is clearly something that may well be related to their experience in combat.  And we have a duty, we have a duty to make sure we address those issues.  And whether the soldier stays in uniform or transitions to the community, we have a duty to make sure that that transition is supported by ongoing care and concern in the VA system and the civilian community at large. 

            Thank you. 

            Let's see -- who hasn't -- I don't remember that you had a question yet. 

            STAFF:  Yes, she has another -- (inaudible) -- we got a question. 

            Q     Okay.  Just very quickly, I'm unclear on the TBI screening. So essentially what happens is everyone is screened when they come back from combat zones for traumatic brain injury, but I don't understand what the 10 to 20 percent is.  And then, can you talk about screening, if there is any, in theater?  Are they -- 

            COL. JAFFEE:  Sure.  So we talk about -- I think your question was about post-deployment screening and -- 

            Q     And in-theater, if there is any. 

            COL. JAFFEE:  Okay.  Well, let's talk about in-theater first, and then we'll sort of take it chronologically. 

            So, in theater, there's a set of practice guidelines and a screening tool that has been developed in coordination with some of the leading concussion experts in the country.   

            It was actually -- become policy to be kind of part of the management plan for these individuals for just over a year now.  Surveys that have been done of providers in theater, they get training in this. They get training in the management of this before they go.  They get -- reinforce that training, sometimes while they're actually in theater.  Some surveys that have recently been done by the Army show that there's a pretty high utility of these devices and tools, and they've been written about and reported.   

            One screening tool which is used is called the MACE, the Military Acute Concussion Evaluation.  And what that's for is for anyone who's been in an incident where they may have been exposed to a blast or if there's any type of injury that they may have had which may, in fact, have caused a concussion, this screening tool is used to say, hey, does this person need further evaluation?  They get evaluation, and the most important priority is to identify, you know, if they've had a concussion and keep them inside the wire. 

            Q      (Off mike.) 

            COL. JAFFEE:  Sure. 

            Q     So essentially, if someone is in a blast, is exposed to a blast, they do have -- they are screened in theater.  Then when they come back, every single person that redeploys is screened here.  And then what's the 10 to 20 percent that you mentioned before?  Ten (percent) to 20 percent of those people on their redeployment experience some -- exhibit some -- 

            COL. JAFFEE:  It appears that 10 to 20 percent endorse having had at least concussion while in theater, and a majority of those actually had their concussion, and they improved.  They resolved -- so it might have been a very mild concussion. 

            Q     And that's determined -- the 10 to 20 percent is determined by a survey, like a written survey or something of a --  

            COL. JAFFEE:  Correct.  Ten to 20 percent screen positive.  So a screening does not make a diagnosis.  It just identifies those people who need further evaluation, but you have to sort of leave that out in who do you evaluate further.  And that's what we get when we do that screening.  We find that 10 to 20 percent of those people deserve that further evaluation.   

            Q     And the further evaluation is some sort of -- like a CAT scan or something to that effect, right?  Is that -- that's when it goes to a medical --  

            COL. JAFFEE:  It would be a medical evaluation, so a medical provider would sort of do a more detailed, comprehensive history and exam, and determine what further testing might be needed.  And it might be imaging, it might be neuropsychological testing, it may be other types of diagnostic testing.  But the one --  

            Q     Do you have a reason for how many -- (off mike) -- for further evaluation, how many of them, for instance, still have some sort of traumatic brain injuries? 

            COL. JAFFEE:  What we know is that 50 percent have symptoms, and that what the next step that we're trying to collect the data on is to see, of those symptoms, how many were actually from the traumatic brain injury itself.  The VA has actually done -- is ahead of us in trying to kind of get that granularity, in that they've done a chart review for their surveys and found that of the 20 percent who screened positive, when they went back, in a subsample, found that only 3 to 6 percent actually ended up with the diagnosis of, yes, these symptoms are a residual aspect of their head injury. 

            (Cross talk.)   

            One last comment that I think just reinforces Colonel Sutton's message.   

            When we talk about in-theater, what I've described to you happens as if a soldier or if a warrior accesses the medical system.  The medic gets to them.  They say, hey, doc, something happened to me; I'm not feeling quite right.   

            It really speaks to the importance though that when that happens, it really reinforces our need to educate the soldiers, educate the warriors that if they have been around a blast, that it is really important for them to get themselves checked out.  Because if they don't, then they might be suffering.  And it goes undetected and it goes unprotected.   

            So it really makes, again, it gets back to this whole cultural transformation, educational transformation, so that they can better understand what's going on.  You know, our culture is so towards performance that we think we can shake it off; if we toughen up, we can get by it.  It's very similar to the professional athlete who may not want to be taken out of the game.   

            So it really speaks to that big cultural challenge, which is one of the main challenges, in front of us, which I think Colonel Sutton expressed very eloquently.   

            Q     Having studied brain injuries for so long, Colonel Jaffee, do you find that the helmets that are being used now are adequate?  Or do you think they need to be improved?  And how should they be improved?   

            COL. JAFFEE:  Well, there's a lot of exciting initiatives going on right now, with an ongoing process improvement to look at the helmets.  And when we have helmets, we want to make sure that they can protect our warriors against bullets, against ballistic types of insults, as well as the concussive types of forces as well.   

            And one of the exciting initiatives, which is actually going on right now, is taking a look at the increased technology that has been developed from professional athletes, say, some of the increased technology in football helmets that has been designed with the insulation to better mitigate against concussive forces and be of better protection.   

            And we're trying to actually translate that technology to make further design improvements.  So I think the current generation of helmets we have is much better than the last one.  And we can certainly -- we're always trying to do even better.   

            So that's a very exciting initiative that's going on right now, trying to find the best in the current technologies we have with insulation materials and design to maximize that protection, not only against the ballistic insults but also against the concussive forces as well.   

            COL. SUTTON:  There's also a pilot test, that's going on right now, using two different types of helmet sensors, one in each brigade that are currently deployed downrange.  One's an external sensor; one's internal.  And we're going to be able to learn much more because, you know, those sensors both have an accelerometer function as well as a pressure-monitoring function.   

            So we're going to really be able, I think, to much better understand what kinds of forces our soldiers, sailors, airmen, Marines are exposed to and what we can do then to mitigate the risk. 

            Q     I'm not sure how involved you are at the Center of Excellence in the actual delivery of the health care, but I wonder if there's any focus on what's going on now and what will be going on in the next few months, where you have the normal rotation brigades coming back from Iraq and Afghanistan plus the surge brigades coming back.  Have there been steps taken to ensure that you have enough TBI specialists and mental health care providers for this increased number of troops that are coming back from 15-month deployments, which in most cases were not their first deployment? 

            COL. SUTTON:  Yes, that's a very important area.  In fact, the position that I left to assume these duties was actually as the commander of the Carl R. Darnall Army Medical Center at Fort Hood, the largest military installation in the Department of Defense.  And I can assure you that our experience over these last four to five years of knowing we've got these, you know, surges of folks coming back, and particularly now with the surge itself, it's so important to plan in advance.   

             And we've got a number of efforts that are ongoing right now. For example, we're so fortunate that over the last two years, the VA actually has hired I think it's almost 4,000 additional mental health professionals.  And they're, of course, distributed around the country, and that's going to be a huge help in supporting this veteran population.  Our own TRICARE managed support contractors -- that's Health Net, Humana and TriWest -- over the last year they've brought on almost 3,000 additional mental health professionals into the network.  And so these folks are now in place.  Our military treatment facility staffs are reaching out to them to help them understand the culture and how to relate to our service members.   

            And then within the services themselves, we've got hiring actions for over a thousand additional mental health professionals.  We have not been able to fill all of those positions yet, but we're well over 50 percent and climbing.  And what's truly been a blessing to us has been the U.S. Public Health Service's willingness to come forward and to provide 200 additional mental health professionals. 

            So it's a combination of efforts that are ongoing, the programs and initiatives that I described to you that really came out of last  year's supplemental funding, nearly $500 million that has gone out to the services.   

            Part of our job at the Center of Excellence now is to really reach out and look at these programs objectively and to determine really what's working well and where and for whom and why and under what conditions, and to prioritize those efforts, build on them, and then really to make the tough judgments where, you know, we thought it would work well but perhaps it isn't quite so effective, and to take resources away from those programs. 

            So we're working with the services in dialogue.  We're certainly joined at the hip with our VA partners.  In fact, this morning I was able to speak with a very distinguished VA clinician and researcher who's getting ready to come join our Center of Excellence as my deputy.   

            So we are clearly, clearly working in partnership, but it's not just the DA -- the DOD and VA.  We are also looking to build this global network, reaching out to civilian organizations, both treatment, advocacy, academic -- yesterday we were able to welcome on board the new Subcommittee for the Defense Health Board for Traumatic Brain Injury -- a great, distinguished group of individuals that are going to help guide our efforts.   

            And so we're on a journey, and we've come a long way.  But as I said before, we've got a long way to go.  And so that's why we're so thankful to teams, like the RAND team, that have stepped up and helped us better understand our challenges, and we look forward to continued collaboration. 

            STAFF:  Thank you. 

            COL. JAFFEE:  Thank you. 

            COL. SUTTON:  Great.

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