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DoD News Briefing with Mr. Casscells from the Pentagon

Presenter: Assistant Secretary of Defense for Health Affairs S. Ward Casscells
June 04, 2008
         COL. GARY KECK (director, Department of Defense Press Office): Good morning, and welcome. It is a pleasure to have with us today Dr. S. Ward Casscells, the assistant secretary of Defense for Health Affairs, and Admiral Joxel Garcia, the assistant secretary for Health at the Department of Health and Human Services. They're here to discuss the details regarding a recently signed agreement between our two departments that will provide DOD with additional mental health care providers to support our service members and their families.   With that, I'd like to turn it over to Dr. Casscells for his opening comments. Sir?
         DR. CASSCELLS: Thanks, Colonel Keck.
         Good morning. I'll be brief. We're going to announce today that the Public Health Service will be detailing us some mental health clinicians to help with the challenge we face in psychological health, PTSD, combat stress and so forth in the military.
         So here today are Admiral Joxel Garcia, the relatively new assistant secretary of Health for the Department of Health and Human Services. Thank you, Admiral Garcia, Dr. Garcia. Thanks for coming.
         And to his right, Don Wright, the principal deputy assistant secretary for Health. Dr. Wright, thank you for coming.
         From DOD, Ellen Embrey, who most of you know, the deputy assistant secretary of Defense for Force Health Protection and Readiness, and director also of Deployment Health.
         And Rear Admiral Tom McGinnis, who is the chief pharmacy officer for TRICARE and the ranking Public Health Service officer working in DOD.
         Which leads me to mention that this is not the only example of Public Health Service assisting DOD. It's well known to the public that in a public health emergency, if local authorities are overwhelmed, DOD, you know, may be called in, the National Guard, and then, you know, Army North, you know, part of the command.
             But less well known is the fact that there have been some PHS doctors and Ph.Ds who have just been doing fantastic work at DOD: the director of International Health, Warner Anderson -- "Butch" Anderson -- who is a retired Special Forces Army physician -- Indian Health Service, Public Health Service, now back here with us, for example; D.W. Chen in Force Health Deployment, PHS captain, physician. We depend critically on these two people.
         And now today we want to welcome Lieutenant Commander Ingram (sp) who was a Lieutenant Colonel in the Army, and now she has joined the Public Health Service and was sworn in this morning. Commander Ingram (sp), thank you very much for that.
         So it really -- it's very helpful to us to get the cross- fertilization from the Public Health Service.
         Mental health providers are in short supply across the country. This is no secret. It's well-established. It's a struggle to get people with the right provider in any state in the country. And it's the most sensitive and the most personalized issue in medicine. The right kind of counselor is worth his or her weight in gold and is worth more than all the medications in the pharmacy.  
         And it's difficult for people to find the hand-and-glove fit if you don't have a choice of providers. If there's just -- you know, here's your psychologist, go see him or go see her, talk about your problems, that doesn't work for everybody. People want to find somebody where they have a special rapport. So you need a choice. You need a lot of people to have a choice and we're short on people. We've really struggled with this.  
         We've been working for months and months and months trying to get more people involved in this. They don't have to be doctors. They don't have to be psychiatrists or psychologists. They need to have proven expertise -- you know, an interest in psychological well-being. They need to be good listeners, people who can give practical advice, people who know when things are not going well. And they need to know a little bit about the military.  
         These are special people. Not all of them will have Ph.D.s or M.D.s, but they'll be working with people who have that advanced training. And many of the people that Dr. Garcia has recruited to this opportunity, this detachment to the military, have had military experience.   Not all of them, but many of them.  
         So, some of you have said that we are in psychological health deficit; we've been in the beg, borrow and steal mode. I heard that this morning. I would remind you that it's no crime to steal professionals from the Public Health Service. In fact, we fully intend to return them. And we intend to return them, I think -- you know, with having gained from the experience.  
         So during a time of war, you know, there are these enormous needs to support the troops. And then afterwards -- and this war is going well, things are going to wind down -- some of these people will come back to the private sector benefiting from the experience, come back to the -- excuse me -- both the private sector and the, you know, government service and Health and Human Services. And they will benefit. At times of mass casualties and other kinds of internal deployments or humanitarian operations in another country, they will understand more about the stress of, you know -- at least this particular kind of stress. We hope it'll be educational for them.  
         It leads me to mention that when we deploy the Comfort or the Mercy, we have lots of Public Health Service doctors and nurses and nutritionists and pharmacists and so forth on those boats. So it's very good for us. We learn from them. And they -- I think they learn from us. One hand washes the other. We need them and hope they benefit from this experience.  
         So today, the cavalry riding to the rescue is the Public Health Service. And Admiral Garcia, I want to thank you publicly for your hard work in bringing scores of people to help us out on -- in this issue, this important issue of mental health.  
         Admiral Garcia.
         ADM. GARCIA: Thank you.
         Well, good morning, everybody. First, I want to acknowledge Dr. Sam "Trip" Casscells, not only a friend, but a great leader for our country, who is, as you know, the assistant secretary for Defense for Health Affairs; Ellen Embrey, his deputy; and also Rear Admiral Thomas McGinnis; my deputy, Don Wright, Dr. Don Wright, who has been doing -- he's a principal deputy of HHS, who has been also working in other areas of health care quality. And our new member of the family, lieutenant commander and her family, thank you for the gallant effort.
         I'm just going to be very brief. I'm going to explain a little of what we do and how we'll support the effort. As much as our service members have done for our country, we owe nothing less to them as they return home. So we know there's a need to provide mental health and behavioral health services to our returning combat veterans. I firmly believe -- we firmly believe that this HHS/DOD collaboration is tailored to meet such needs.
         I'm pleased that officers of the Public Health Commissioned Corps will be detailed where needed to provide these services. We are targeting close to 200 mental health officers to serve in various military treatment facilities. I have the privilege of leading the Commissioned Corps, and we are over 6,000 health professional officers that we are dedicated to our mission of promoting, protecting and advancing health and safety in our nation.
         As you can see, we are one of the uniformed services, and we work alongside our brothers and sisters in the military, but we're also working in small communities. We are also working in large communities. You will see us also, like Secretary Casscells mentioned, in other areas, in international areas as well.
         We think that -- and we believe -- it's our motto -- we're in the business, really, of improving public health and building bridges in the process through collaboration, like this one with the military. As a matter of fact, this is one of several MOUs and MOAs that we are doing to essentially improve the health of our country.
         And the officers that are going to be detailed in support of this psychological health mission will include psychiatrists, clinical psychologists, clinical social workers and psychiatric nurses. Some of the services will be counseling, family and group therapy as well as psychiatric services per se.  
             Where possible, professionals whose area or expertise is traumatic brain injury, they also would be serving there. And we will have neurologic specialists from physicians to nurses. Speech pathologists, physical therapists, mental therapists also will be assigned.  
         This will, I think, enhance the ongoing HHS and DOD scientific efforts to coordinate all the science that we know related to health and public health, mental health needs related to deployment and war- related trauma, accelerating the discovery of knowledge to improve treatment and prevent disorders. As part being the assistant secretary of Health, I also lead the Office of Public Health and Science. So this would be a partnership through all the areas of work that we have in the Commissioned Corps to provide some significant support to the DOD in how to develop better ways to deploy our officers.  
         With returning soldiers and the need for behavioral health and counseling service in mind, we have started -- the Commissioned Corps -- we have started a recruitment effort to hire additional mental health service providers, including psychiatrists, clinical psychologists, social workers, psychiatric nurse practitioners and other mental health care professionals. And we are doing this across our nation.  
         Right now one of the questions that probably you have -- how many people do you have? You're talking about 200. Well, we already have identified close to 50. So in the pipeline right now we have close to 50 behavioral health personnel. They are preparing to participate in this joint venture.  
         We, as a Commissioned Corps, we also offer a career path for mental health. So this will be part of our own strength and expertise.  
         So again, I just want to thank the leadership of DOD, the partnership of all the officers involved and all the civilians involved in this endeavor. There's different ways to serve our country, and the Commissioned Corps has been serving our country in terms of improving public health. So we are very proud that this is an effort to essentially serve not only the veterans that are coming from war, but also their families.  
         And with that, I thank you for the opportunity, and I'll give it back to you. Thank you. COL. KECK (?): (Off mike.)
         ADM. GARCIA: I assume that that means if there's any questions -- 
         Q     (Off mike) -- get the numbers straight. It's 200 from PHS?
         ADM. GARCIA: Yes. And the goal that we have identified as of now is 200 Commissioned Corps officers. As of now, we started the recruiting process, and we have identified close to 50. We are going to go across America, literally.   So on -- we're in a recruiting mode anyway. And we have been in the plus side this year. We have recruited close to 400 officers for different areas of work across our Commissioned Corps. But right now, the energy also will be to try to identify more behavioral health, more psychiatric specialists, so they can not only help our communities, but specifically support our troops.
         Q     So you have 200 planned and 50 of that 200 already --
         DR. CASSCELLS: Right, right.  
         Q     Is that right -- 
         DR. CASSCELLS: Tom, we would like to get to 200, but you know, the -- that is a rough cut, because, as you well know, we have been trying to estimate the degree to which stigma or fear of asking for help has led us to underestimate the true need. And as we -- as our campaign to reduce the stigma of asking for help, to assure people that this won't adversely impact their career progression and so forth -- as that program seems to be working, you know, we will be able to revise these numbers.
        But we know now from surveys that people are -- 
         Q     So you'd like to get the 200 -- 
         (Cross talk.)  
         DR. CASSCELLS: We may not need 200. It may be -- the true deficit may be 100. It's just -- it was, you know, a round number taken from estimating. We were making -- excuse me.  
         We were including in our assumption and our planning, that the true need was greater than the current demand for mental health and that as we got people to really talk about what was bothering them, that without fear of, you know, being labeled in some way, that there would be a surge of, you know, of people asking for mental counseling and psychological counseling.  
         So that was an estimate. We were trying to factor that -- 
         Q     As many as 200.  
         DR. CASSCELLS: Yeah. It wouldn't be higher than that.  
         Q     Okay.  
         DR. CASSCELLS: We may be okay with 100.  
         (Cross talk.)  
         ADM. GARCIA: Yeah. We have identified 50.  
         Q     When will they actually get out -- 
         ADM. GARCIA: Well, it all depends. Like the undersecretary mentioned before, it all depends: the background that you have and the expertise. It's not as simple as just identify a doctor for any specialty.  
         You have to go through a process of understanding the DOD system, understanding our system, before we deploy them officially. We don't want to send them with no background. So essentially -- 
         Q     Any sense of when they might get out --   ADM. GARCIA: Oh, I would say as soon as possible. We -- I would say the first one that we have, he's the lieutenant commander here, the commander here. But we're going to moving this in the next few weeks.  
         Q     So they'll be going to military bases around the country.  
         (Cross talk.)  
         ADM. GARCIA: Yes. And I'll be -- 
         Q     (Off mike) -- how long they'll be deployed to do that?  
         ADM. GARCIA: (Off mike) -- not a matter of one week or a time frame that we know for a fact, how much it's going to take for a community. And let's talk about our nation, per se. So it will be dependent, in terms of how much is the need and for how long.  
         Q     Does this partnership include outreach efforts? Or do you simply put these workers at bases and hope that people show up?  
         ADM. GARCIA: It's an excellent question.  
         We are going to be doing an outreach. We actually are working right now to go to our medical schools, nursing schools, all our professional trade groups to bring more people into the commissioned corps.  
         We are going to be speaking and talking about this issue, educating people across the nation on this effort, in between DOD and HHS. So this will be also an opportunity for our people, our nation to serve our nation and the people that have served us so well.  
             Q     Dr. Casscells, a few weeks ago an e-mail surfaced from a Veterans Affairs employee, a psychiatrist. It was talking about diagnosing people with adjustment disorder rather than post-traumatic stress and the allegations are that it was -- they wouldn't get as much money for their health care when they're in veteran's status. Can you talk a little bit about the Department of Defense's diagnosis of adjustment disorder, if there is one, what that entails, and is there any kind of effort that you've seen within DOD to increase the number of people with -- who are diagnosed with adjustment disorder rather than a full-blown post-traumatic stress diagnosis?
         DR. CASSCELLS: Well, you know, I'm a cardiologists, not a psychiatrist. So I would refer you to Cam Ritchie and Loree Sutton, some of the psychiatry leaders that we have -- Charlie Hogue and Carl Castro.  
         So I don't know whether there's been a change in the diagnosis of adjustment reaction, which is a general term and typically thought to be short-term, limited, versus PTSD, which can be, you know, often is a long-term condition. And I do think PTSD tends to get higher disability ratings, so that would have a cost implication. But I'm not the expert on it. We would have to refer you to General Sutton I think, for the best read-out on that.
         I do know that nothing has crossed my desk -- on the phone or on a piece of paper -- saying that, hey, we got to keep the PTSD down; the diagnosis is too expensive. That just hasn't been an issue with the whole issue here. I mean, everyone in the building -- not just the doctors, the more hardened line leaders -- they're really thinking now, these days, a lot about who's good to go, who's really ready to go, how are we monitoring them while they're over there.
         I was just in Afghanistan and I was really struck by the generals and commanders there who were asking me what I thought of the, you know, resilience of the troops and how they were holding up. And they were talking about it. Sometimes they would raise the issue. And then whenever I raised the issue, they were informed about it.  
        There's clearly been a change in the -- you know, this issue in the minds of the combatant leaders. They really understand that -- you know, of course they understand combat is stressful. They also clearly understand that some people -- it just makes their whole life; in other people, it is very stressful and sets them back. And they know that some of those people who have been set back can be brought back on their feet. So there's a real -- I'm real pleased with the way that the line officers are handling this.
         Q     (Off mike.) 
         DR. CASSCELLS: And absolutely evidence that -- I've never heard anybody say this is a dollar issue; let's keep the PTSD diagnosis down. No, no, not in the slightest.
         Long answer. I apologize. But it just -- it is a big issue for us.
         Q     What does DOD have out there now as far as psychologists, psychiatrists, social workers and so forth? I think last week General Cornum had a briefing on the suicide rate. I think they said at that time roughly 200 health care providers in DOD -- and they were sending out another 180. Do those numbers sound -- 
         DR. CASSCELLS: The Army has hired, the last I heard, about 170 new ones. They may be -- that was a month ago. They may be up close to 200.
         Q     He said that they have 200 now, hiring another 170, 180. Is that true?
         DR. CASSCELLS: Yeah, that -- you got me. I hadn't heard that. I thought 200 was it, and we were getting close to -- we're at about 170.
         (To colleagues.) Anybody know?
         MS. EMBREY (?): We're getting a -- (off mike).
         DR. CASSCELLS: Yeah. We can get back to you. Do you want us to get back to you on that? Ma'am?
         Q     Can you quantify the need for this out there?
         DR. CASSCELLS: Sorry?
         Q     Can you quantify the need -- (off mike)?
         DR. CASSCELLS: I don't have a round number. I do know that in my last -- in my trip to Afghanistan 10 days ago -- I just got back 10 days ago. General Schoomaker and I went over there -- he's the Army surgeon general -- and the Joint Staff surgeon, David Smith. None of us are psychiatrists, but we're all physicians, and we went all over that country. We were there for eight days and just talked to many, many, many people.
         And there were -- there was one unit of the -- that felt that they would be short of a psychologist soon, because that guy was coming home.
        And they were nervous about whether they would get someone of that quality coming back, because the people in that brigade had really gotten comfortable talking to that person. So -- I mean, you could fill the billet and it just wouldn't be the right person and you wouldn't be providing services. So we're watching that one closely.
         So other than that, I felt the Afghanistan combat stress situation was being handled pretty well. That doesn't mean there won't be anybody coming back stressed. (Chuckles.) You know, it's a war. I mean --
         Q     And is there some -- even a round estimate as far as -- do -- would you say, you know, 10 percent, 20 percent, half of troops who come back from combat need some sort of services, or --
         DR. CASSCELLS: You know, about 20 -- if you -- when -- Ms. Embrey has this wonderful survey she does, the Post-Deployment Health Reassessment. And about 20 percent will put down some symptom, you know, and then about half of those will be confirmed on further discussion to -- formally to have PTSD. And about half of those will feel better in a few weeks or months. And then the others we really have to work to support and get them back on their feet, make sure they're working, make sure their family understands, make sure the employer understands, make sure that their unit understands that this is not an issue of malingering, it's not an issue of -- that'll never get better, but some of them take months and months and months. And so it's a critical period there. 
         Ms. Embrey, do you want to add to that?
         MS. EMBREY: I think you answered it well. We do have a model that we use, we have to use. There's -- one of the things that the Mental Health Task Force recommended to us -- sorry, don't want to -- was to come up with a way to evaluate based on risk in the community, so community-based, risk-based models for determining what kinds of mental health and behavior health services ought to be present, based on that model.  
         So we did some very quick analysis, literature review last fall and came up with a model that hadn't been validated. It was theoretical. And we used that model to identify the resources -- the target resources for each of the services based on each installation's community- and risk-based analysis.    And that formed the basis of allocation of resources, to go hire those types of individuals, which lead to an outreach to the Public Health Service, to help fill some of those requirements in those installations.  
         In the meantime, we have a full-blown CNA study to validate that model. And so we will have a much better idea of the demand in our system based on that validated model. And that's expected to yield a product that we can begin to apply rigorously coming this fall.  
         ADM. GARCIA: Even though the question was not aimed at me, and I run the risk of getting myself in trouble, as a former public health leader at the state level, behavioral health is a continuum.  
         You have the pre-existing conditions. You have the conditions at home, at the community level, as Ms. Embrey mentioned, and then the cause and effect. And now we have better surveillance methods, of identifying who has what and what might be the cause for that.  
         Based on that, I think that this is a unique opportunity, to understand that this is not only to help our veterans coming from conflict. This is something, a model, that may be used and replicated in other instances across our nation.  
         I applaud what DOD is doing. It's going across, crossing the bridge to public health and working together. Because if this is a public health issue, it doesn't matter if you had symptoms the first week or one month later, or you have a pre-existing condition.  
         We learned a lot after September 11th. A lot of the science thought the people will come up with the symptoms the day after or a week after. And there were some things that happened after the fact. And some people did not demonstrate any condition because they had other factors.  
         So I think this is a science that is developing. We cannot even compare conflicts, because there was no surveillance for behavioral health in many conflicts in the past. This is a great effort, I think, that DOD is doing. So that's why we're so excited and supporting you.  
         (Cross talk.)    Q     You know, one issue you keep hearing, from soldiers in Iraq and commanders, is that soldiers are reluctant to talk to someone, who either hasn't been to Iraq or Afghanistan or hasn't seen combat.  
         Is this something you folks are hearing? And you know, how do you get around that? You said some of these folks, you're going to be bringing in, have experience in the military.  
         DR. CASSCELLS: I've heard that some. I've not heard it lately. And most of the people, who would be seeing these public health providers, would already have seen someone in the theater or in Landstuhl. And they may welcome a second opinion from somebody who's not in the military at all.  
         That's why we need enough providers that we can provide choice. Because people can legitimately say, I only want a women counselor. And you know, we have underreported issues there, you know, this issue in the news this week about assault, you know, is it underreported.  
        And so it's critical that you have women counselors. It's also critical that you have counselors some of whom have been in uniform and some of whom have been deployed.  
         But I love the fact that we're going to have some counselors who have not been over there and have not been in uniform. Some of these PHS volunteers have previously been in military uniform, but many have not. And I think this is great because it gives a second opinion. And these people are going to have a positive impact on the military health system. They're going to come in with suggestions. They're going to come in and chafe at military bureaucracy. They will challenge us. We look forward to that.
         Q     (Off mike) -- they like to talk among themselves, among their peers. Do the group sessions seem to be more effective, do you think?
         DR. CASSCELLS: I think the group sessions are great. You know how soldiers talk to each other. And they give practical advice. And they're not psychologically naive. They've all listened to "Dr. Phil" and all these things. They know practical psychology. They're terribly helpful. And because there's a chronic shortage -- you know, there's never been enough mental health support in the military. That's why decades ago group therapy began in the military, to address this issue, to take advantage of the fact that they're living together all the time, and secondly, the fact that they have a different experience from the civilians and we're short on psychiatrists and psychologists.
         So, yes, the group sessions are terribly helpful, but they're not for everybody. There are some people who can only speak to one person because they're just very afraid that the word would get out that they're showing signs of weakness. You know, it's not one size fits all.
         Do you want to add to that?
         MS. EMBREY: Only briefly. The department has not -- is committed to having a comprehensive program to support psychological health. And we've always had individuals -- behavioral health specialists in our system, but what we didn't necessarily have was a focus on the prevention and the building of resilience to prevent mental health problems. And so a major part of the initiative within the department over the last year has been to establish a full continuum of care which addresses pre-clinical outreach, involves the line, educating the line, educating personnel to understand and recognize signs and symptoms and to take pre-clinical approaches -- well-educated, well- informed individuals within the unit and with augmented -- you know, credentialed individuals providing support along the pre-clinical environment. And then once individuals see symptoms that really do need clinical care, there is an encouragement from the line. It's a real focus on the line involvement.
         So that building of recognition about behavioral health issues and the investment and research on building resilience -- understanding the differences in individuals, as Dr. Casscells talked about -- how do you recognize those differences and how do you build people back up? That's the subject of a significant amount of research that we're investing in right now with our interagency partners. And that is why this comprehensive program is very important to us. We would like to prevent it from happening in the first place.  
         So that is the expansion of the DOD program. And we're also expanding capacity in the identification area, in the treatment area, and in the follow-up area. So I hope that answers your questions.
         Q     Thank you.  
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