CAPT. DARRYN JAMES (Director, Defense Press Operations): Good morning here and good evening in Afghanistan. I'd like to welcome to the Pentagon Briefing Room for the first time two U.S. Navy physicians with Regional Command Southwest at Camp Leatherneck: Cmdr. Charles Benson and Cmdr. Keith Stuessi.
Cmdr. Benson serves as the 1st Marine Expeditionary Force psychiatrist and the 1st Marine Division deputy surgeon. He assumed his duties as director of the Combat Stress Center at Camp Leatherneck in September of last year.
Cmdr. Stuessi is the director of the Concussion Restoration Care Center at Camp Leatherneck, the first military center of its kind, which was established in August of last year with a team from Camp Pendleton.
The doctors will take some opening comments and then will take your questions, and with that, I'll turn it over to them. Gentlemen?
CMDR. BENSON: Good morning. I understand you're enjoying an awful lot of snow over there. I kind of miss it myself.
As the captain said, my name is Cmdr. Charles Benson. I'm a psychiatrist here in Task Force Leatherneck here in Helmand province, Afghanistan. And essentially I am the MEF [Marine Expeditionary Force] psychiatrist, which means I'm in charge of all the mental health assets or oversee the mental health assets and the delivery of mental health care in all of Helmand province.
And over the last couple of years the United States Marine Corps has been taking the lead at fielding a new kind concept on how we deliver mental health care, called the OSCAR Program, the Operational Stress Control and Readiness Program. And I want to tell you a little bit about that today and then take some questions about it.
The OSCAR Program consists of two parts.
The first part is OSCAR providers. That's psychiatrists and psychologists that we field with the combat team. These are organic embedded assets into the regiments and battalions of the division. And what they do is actually live with the troops, train with the troops and get out in the field with them. This allows the Marines to come forward to the psychologists and psychiatrists.
It kind of breaks down the barriers and allows them to become very effective in their jobs delivering mental health care.
The OSCAR Extender Program even goes beyond that. That special training that we deliver to medical officers, corpsmen, chaplains, religious personnel and also key leaders at the sergeant level and first sergeant level so that we can deliver some basic mental health care through those individuals to the troops out in the -- out in harm's way.
And so those folks are constantly monitoring their Marines, helping them with simple issues and also understanding at what point they need to be referred back for higher care. These two programs, I think, have generated quite a bit of success out here in Afghanistan. We're enjoying a pretty low utilization rate of mental health resources in a formal way, pretty much low medevac back to the States because of this program -- this is my feeling that that's what happening -- and a low medication utilization.
And that's the end of my opening statement. I think we're enjoying some success here, and I look forward to hearing your questions.
CMDR. STUESSI: All right. Good morning, everyone. As the captain said, my name is Cmdr. Keith Stuessi. I'm a sports medicine doctor by trade, and I'm currently the officer in charge of the Concussion Restoration Care Center here at Camp Leatherneck, Afghanistan.
I'd like to share with you a typical success story up at CRCC, which opened on August 30th, 2010. Our unique, multi-disciplinary approach is proving to be an excellent way to treat concussions, the number-one battle injury; and musculoskeletal injuries, the number-one non-battle injury.
I first saw Lance Corporal Smith on January 3rd, 2011. This was three days after he was medevaced to Bastion Role 3 Hospital because of the injuries suffered from an IED [improvised explosive device] blast while on a routine convoy traveling in an MRAP [mine resistant ambush protected vehicle].
Prior to seeing me, he was initially seen by the ER [emergency room] physician at the hospital who referred Lance Corporal Smith to the concussion team. This team, who was part of the CRCC, but is located at the hospital, consists of one psychiatrist, Lieutenant Connuso, and one psychiatry technician HM3 [hospital corpsman third class] Bennett. A responsibility of theirs is to evaluate all U.S. concussion patients that come to the Role 3 facility.
After being discharged from the hospital, Lance Corporal Smith was referred to the CRCC, which is an outpatient clinic. On his first visit, January 3rd, Lance Corporal Smith filled out a questionnaire regarding the events surrounding the blast, current symptoms and demographic data. He also was given a brief neurologic exam by one of the five corpsman that we have working for us, as well as giving an ANAM [Automated NeuropsychologicalAssessment Metric] which is a more advanced neurocognitive test we use as a tool to identify some of the areas that patients are having difficulty with by comparing his current test results with a baseline study that was established back in the States prior to his deployment.
Lance Corporal Smith and I discussed the symptoms during his initial evaluation, which were a constant headache, dizziness, trouble with concentration and sleeping, moderate low-back pain and occasional nightmares, along with repeated thoughts of the blast. Throughout the course of the next 11 days, all these symptoms were addressed by our specialists located under one roof. Cmdr. Vath, our physical therapist, helped alleviate his back pain through therapeutic exercises. Lt. Cmdr. Slater, our occupational therapist, conducted vestibular rehabilitation, helping with his dizziness. Lt. Well, our psychologist, talked with him about the nightmares and helped him deal with the trauma that he had just faced. And then I, toward the tail end of his treatment, performed acupuncture to alleviate his headaches and insomnia. Lance Corporal Smith was also given classes on concussions so he was able to better understand what was happening to him and when he was expected to get better.
In total, Lance Corporal Smith came into the CRCC for four visits during multiple -- to see multiple specialists. On days he did not have an appointment, he was staying at the Wounded Warrior facilities, which is about five-minute walk to the CRCC, where he was able to be around his peers. He was also seen on a daily basis by our clinical nurse, Cmdr. Jernigan.
During his last visit, which had been 14 days since his concussion, he was completely asymptomatic. His headaches were gone, he was sleeping and not having nightmares, his balance was normal and his low back pain had resolved. A third ANAM test was administered, and I was able to sit down and show him the results, which indicated that he was back to his baseline and ready to return to his unit. In addition, we performed an exercise stress test, which he passed with flying colors.
Lance Corporal Smith was anxious to return to his unit since his treatment began. Because of what our clinic was able to provide for him, he currently -- he is currently back where he wants to be, and his leadership is confident in his health and his ability to perform.
I hope that gives you a good overview of what we do at the clinic. And certainly we'll open up for questions.
CAPT. JAMES: Thank you for that opening statement.
We'll go ahead and start with Andrew and then work our way around the room. Go ahead, sir.
Q: Sure. This is Andrew Tilghman with Military Times. Thanks to both of you for talking to us this morning.
Dr. Benson, I think this is probably a question best directed to you. You said that there's a low medication utilization rate in the units. I'm wondering if you could just tell me, ballpark, what is that utilization rate and what are the kind of medications that are most commonly being used for what types of mental or behavioral health issues?
CMDR. BENSON: Certainly. So you have kind of two questions there.
One is, what is the medication utilization rate? I really can't answer that specifically in terms of, like, overall compared to, like, you know, if you take 100 average Marines out of the battlefield; how many of them are on medication? In general, I can give you a ballpark figure on that. That's probably somewhere between 5 [percent] and 10 percent.
On the -- I can say, however, on the folks that are seeking -- you know, get seen by a mental health provider, a psychiatrist, particularly to prescribe medication, only about 7 [percent] or 8 percent of those patients end up with medications. And typically we're talking about an SSRI [selective serotonin reuptake inhibitor] like a Prozac or a Zoloft kind of medication. And occasionally we'll use a sleep aid, something like Benadryl or Ambien. And those are the typical kind of medications that we're using. And I think if I answered your question correctly, if -- does that make sense to you, sir?
Q: Gentlemen, Charley Keyes from CNN. Thanks for doing this.
Commander Benson, I was just curious if you could say what changes you've observed in the combat stress situation since you arrived in September, and also give us some sort of ratio between military personnel and psychologists and psychiatrists that serve with you.
CMDR. BENSON: Certainly. So we have -- I'll answer the second question first. We have nine mental health providers in the theater or in our AO right now and about 25,000 troops altogether. So that's about maybe -- you know, do the math there, but like one out of every 2,500, something like that, for mental health providers to troops.
And that's a pretty standard ratio. We're actually a little rich over here compared to back in the States, where a normal ratio would be like one provider for about -- one psychiatrist for like 10,000 troops.
And in terms of changes in mental health -- or combat stress since I've arrived, realistically we haven't seen a lot of changes per se. The information that we're kind of getting back is that the Marines have been holding pretty steady in terms of their utilization rates of mental health. That really hasn't changed over the time since I've been here since September. And even going back into the data, my predecessors, that's pretty much been a consistent statement, the fact that we're just not seeing the folks having issues, talking to our OSCAR extenders. We're just seeing a pretty much low-level background kind of situation.
And most issues are being taken care of far forward. And they really don't end up becoming a psychiatric case, per se, as opposed to what may have happened before the OSCAR extender programs, where they would all have been brought in to see a mental health professional in some clinic somewhere.
Q: Hi, it's Cheryl Pellerin with American Forces Press Service. I was wondering if you could explain this -- about the OSCAR Program, how the -- how people with concussions were treated before the program and sort of how the program evolved into this new concept.
And I have a follow-on if that's okay.
CMDR. BENSON: Okay. I'm not too sure I understood the question. There was a little bit of noise there, but you were trying to ask us how the OSCAR program relates to concussion, if I understand.
It's something, I think, that Keith and I talk about an awful lot in terms of how concussion and mental health are related together. And one of the things you have to kind of remember is that when folks have a mild traumatic brain injury, sometimes their symptoms have a psychiatric flavor.
They might have difficulty sleeping. They might have nightmares. They might have anxiety along with that. And sometimes folks who have straight-up psychiatric symptoms like with depression might also have insomnia and problems that might look a mild traumatic brain injury.
So there's an awful lot of overlap and symptomatology between the two entities. We think it's important to work on these as a team, and kind of address both issues at the same time to try to get a Marine back on his feet and heading in the right direction.
Keith, would you agree with that?
CMDR. STUESSI: Yeah, I would totally agree. When -- interestingly, when we -- when I first got here in the middle of August, you know, our team consisted of the three of us, which were the sports medicine doc, myself; a physical therapist; and an occupational therapist. And then we also were given extra bodies from a surgical team out here. But we quickly realized, as Charlie said, that there is definitely a pretty significant psychological component when these Marines and sailors get concussed. And so by adding a couple of the mental health specialists to our team, I think it's been an incredible asset. I mean, just having them in the same building, being able to, you know, refer them directly to them, or just run stuff by them has been fantastic.
And we all pretty much stay on the same page. We talk about expectancy. We remind the patient they're going to get better throughout their course. And that really goes a long way into them getting back to full duty.
Q: Thank you. May I --
CAPT. JAMES: Sure, go ahead, Cheryl.
Q: Well, I just -- I wanted to know if the OSCAR Program is just a Navy or Marine program, or, if it's spreading, how far it's spread so far, or if it'll spread to other services.
CMDR. BENSON: Well, I'll be honest with you. The OSCAR Program is a Navy-Marine Corps program. It's designed to take care of Marines in a combat environment, specifically the division and the infantry units. It -- there -- as far as I understand, the Army doesn't have a program that's similar to that. And so -- and I'm not aware of any plans by the Army to implement something that's similar.
I know there's an awful lot of attention placed on the OSCAR Program. This is the first MEF deployment, a yearlong deployment, with the OSCAR, and the OSCAR Extender Program has been fully fleshed out. And so this is really the crucible for the program to see how this is working out. We think it's doing very well, and we'll have to see what -- whether or not the other services are interested in duplicating what we feel is our success.
Q: Commander, it's Sagar Meghani with the AP. With all the talk of trying to reduce stigma over the last year or so, can you give us an idea of what level of forces are perhaps seeking out the psychiatrists and trying to get some help without it kind of being pushed at them?
CMDR. BENSON: I'm sorry. I don't really understand the question. I -- you're asking about stigma, but I -- something kind of trailed off there. Could you -- could you repeat that, please?
Q: Give us an idea of what levels or numbers of Marines you've seen that have actually come and sought out help, what kind of the environment is like for them as they perhaps actually seek out some kind of help from the psychiatrists.
CMDR. BENSON: Absolutely. So, you know, your individual Marine can have a number of ways of getting help from a psychiatrist or psychologist. And usually they can -- they can approach a number of different things. One of the things that they -- the OSCAR Extender Program does is it gives them just so many different doors they can walk through.
And it's the door that's most comfortable for them, and that's the whole point. If they feel most comfortable talking to the medical officer, he is standing by. Corpsmen, the same sort of thing. Perhaps it's the chaplain. Or it might be some trusted leader that they know of, a sergeant or a staff sergeant that they admire and trust. We want to make sure that no matter which way the Marine goes, he gets the same kind of answers.
And so what's going to happen at the OSCAR Extender -- (inaudible) -- point, is they're going to evaluate the situation, try and understand and help the Marine out, but we give them certain triggers about, "Hey, when do you think the Marine might need to be seeing somebody else?" A good example would be, if the Marine says, “I'm depressed, I'm not sleeping," that might be an indication to go see the medical officer, or perhaps the Marine might say, "I'm thinking about hurting myself," that's definitely an indication to go see the medical officer, and they can get referred on into the psychologist.
But I'll be honest with you, most of the best OSCAR and OSCAR Extender Program outreach happens when it's not really a formal sort of thing. It's like when you're sitting there at breakfast and you're, you know, eating your toast, and a Marine comes down and sits across from you and says: “Hey, Doc, you got a moment?” And then you can start chit-chatting.
Or you might be standing there waiting in line or something like this, and they know you because they see you out there in the field, they understand that you can -- that you kind of relate to what they're going from, they feel more comfortable in coming to chat with you.
All of us are sort of constantly evaluating those folks who come in there and trying to decide do they need more formal evaluation. And when that happens, those doors are opened and it makes it worthwhile.
Part of the job of the OSCAR Extenders and the OSCAR Program is to decrease the stigma of coming forward to mental health. And that's part of our main message, is that, you know, when you're in combat, when you're deployed, you're going to have feelings. Things are going to come up. It's best if you talk about them, seek out help, and realize that not every time you go see the mental health provider do you end up taken away from your unit or labeled as something or perhaps given some sort of strong medication.
That doesn't happen. It really is about letting the folks know that they have a place to go, that they will be accepted and understood.
Q: Gentlemen, it's Luis Martinez with ABC News. When we're talking about the combat stress levels, there's a particular unit up in Sangin district, 3/5 [3rd Battalion, 5th Marines], that's seeing an inordinate amount of casualties and a lot of combat stress.
Are you seeing an uptick in referrals from that particular unit? Have you rushed in more counselors maybe that can help them? What are you -- in particular are you seeing with this unit?
And if I can follow up on the concussion question, what -- I heard you describe, I believe it was Corporal Smith, the 14-day treatment that he got. But what would he have received prior to your program?
CMDR. BENSON: Well, I'll go ahead and try to answer the question about 3/5 up in Sangin. You're right. They've had a heck of a deployment so far. And we've spent a lot of time looking at them and trying to understand how they're doing, what their operational stress level is. They belong to Regimental Combat Team 2 up there. One of my psychiatrists goes up there frequently and visits them. I am in frequent contact with the medical officer, Lieutenant Commander Pat Hara, up there. And there's a lot of communication back.
Every single one of the FOBs [forward operating base] at 3/5 has been through, has been visited by a psychiatrist or a psychologist. And the chaplains are also up there as well. I got three -- I've got two medical officers and an independent duty corpsman, all of them OSCAR extenders who are really kind of looking at this situation very carefully.
I'm pleased to say, however, that we really haven't seen an inordinate amount of mental health issues coming out of 3/5. Comparing them to other battalions in the AO [area of operation], to be honest with you, the rate of mental health referrals and combat stress issues have pretty much been identical to some of the other ones.
[The unit] 3/5 enjoys very good leadership, tight unit cohesion, and a fairly robust OSCAR Extender Program. To be honest with you, that's one of the good stories about this. We're just not seeing what one might expect from a unit as heavily engaged in combat as they are in terms of the, like, a combat stress reaction. And that's not because we're just not looking for it. To be honest with you, we're in the field all time looking at these guys and chatting with them to see what's going on, and we're just not seeing a different -- an increased rate or problems developing in that unit.
CMDR. STUESSI: So, sir, to answer your question, so before we actually got out here, we had a group of a couple of psychiatrists and a family practice doctor that laid the foundation for us before we actually opened up the CRCC. And they have developed a lot of the processes which we actually now have in place where they were getting referrals, doing their evaluations. And we just kind of took it a step further and, you know, refined a lot of the processes. As I've already told you, we've added some people to the mix, the mental health component certainly. So before we got out here, that's the care they would have gotten.
And I'll tell you that we are -- we are not seeing -- it's difficult to say the exact numbers, but our estimate is that we're probably seeing between 20 [percent] and 30 percent of the concussions here in theater. And so there are many ways to -- you know, to do things. And I think the good news is to pass along is that our feeling is that if you're -- if you're given time, if you're given mental rest, if you talk about what to expect, that these concussion folks do very, very well.
And we know that talking to the folks out at the battalions that they're handling, actually, most of the concussion patients that are out there. Certainly, we provide more of a specialty-type care environment, and we do feel that what we're doing is working; but even before we got out here, they were being handled by the medical officers. And the same basic principles apply. We just kind of adapted it and gave it -- gave it some more oomph, so to speak.
Q: Doctor -- or Commander Benson, there is a lot of research going on during these wars, because of these wars, about concussion and mild traumatic brain injuries down the road.
And I was wondering if you think this -- the OSCAR Program is not only better psychological care but better medical care and helps people with these injuries later -- might help these people with injuries later on, might help their brains.
CMDR. BENSON: Well, it's certainly an important point that -- and I think Keith Stuessi's research or kind of understanding about what's going on is really helping us look at this -- is that folks with mental issues of any kind, either before they get concussed or during or after they have concussions, they do worse unless those issues are addressed as well.
And so realistically, what we're doing here with the OSCAR program is that breaking down that stigma of symptomatology and stuff like that. So we hope that we're reaching out and helping the Marine both prior to the concussion and after concussion deal with the mental health issues that help them recover from their -- you know, once we deal with those issues, their TBIs [traumatic brain injury] resolve better as well.
And so yes, the OSCAR Program has a place to play in the TBI game, if you will -- not game, but the treatment of TBI patients. But it is not really geared towards identifying the symptomatology of TBIs.
There are other training programs throughout -- at every level of the Marine Corps looking at the TBI issue. To be honest with you, you'd be surprised to find how many corporals and sergeants and staff sergeants who are intimately familiar with the TBI protocols and the directive-type memorandums and all the different instructions we do to try to protect our Marines prior to and after having a mild traumatic brain injury.
Q: Yeah. This is Andrew of Military Times again. Sort of following up on my previous question about medications, I've heard, most prominently on the Army side, some concerns expressed about painkillers and benzodiazepines and maybe the overuse, overprescription -- you know, guys sharing them amongst themselves. I'm wondering if that's a concern that you hear about in your corner of the medical community and whether you feel like that has changed at all any of the prescribing habits over the past couple years.
CMDR. BENSON: Absolutely. You know, it's always surprising to me personally to hear about -- like in the psychiatry world specifically -- about benzodiazepines and heavier-duty medications being used in our troops. It's not the way I was trained. Amongst the psychiatry community that I work with, the Navy, we only have about 86 psychiatrists out there. I probably know by first name about three-quarters of them.
And realistically, when we talk, we're just not using that level of medications.
It's amazing to me that folks are saying, hey, it's going on.
I'm also -- as it was pointed out, I'm also the deputy division surgeon here for 1st Marine Division, which means that I have a supervisory role on the primary care aspect as well for the battalions and regiments. And I can tell you that it has been stressed over and over again to our battalion medical officers the importance of using these medications with restraint, if at all, and they should be very specific events that would cause somebody to use either benzodiazepines or heavy-duty narcotics for treating any sort of illness, particularly here in theater. But even back in garrison, that's something that we talk about and we educate on a continuous basis.
We monitor the use of these medications through a couple of different ways, to be honest with you. I get reports from my mental health providers on the medications they're prescribing, and I can tell you that the use of benzodiazepines are pretty low. I'm also monitoring the primary care providers -- this is the GMOs [general medical officer] and our family medicine doctors out there -- through a variety of reasons: looking at the supply requests, different sort of things like that, and also through our medical -- electronic medical records.
To be honest with you, the use of these medications is exceptionally low across. And in fact, when I see these medications that are used and I look at the documentation, to be honest with you, it's a rare event that I'm actually saying, "Oh, somebody's using this medication." I might even give them a call and ask them about it.
So we're just not seeing a high level of use. These are not wholesale sharing amongst the folks here. These are very specific events that folks might get one prescription of these medications and follow up. But I can assure you that there's no large-scale distribution of benzodiazepines, controlled substances of almost any kind here in theater.
Q: It's Luis Martinez again with ABC.
If I can go on the -- question on follow-on care in theater, mental-health-wise. The Army put out a report in a psychological and psychiatric journal, I believe this month, where they talked about a program in Iraq where they tracked soldiers who were receiving mental health care in the states and also received psychological drugs -- drug care, and then when they deployed in theater where the surgical there -- medical team there followed their care and transitioned them. And they found noticeable effects through that program.
Do you have a similar program like that, or is there consideration of doing something like that?
CMDR. BENSON: I'll be honest with you. I'm not exactly sure I know the study that you're talking about, and I don't really understand the way you described it to me, what the program actually does in terms of -- I think you said something about had -- folks who had medical -- mental health issues, and then they're being transferred into theater. I'm not sure I understand what you're -- what the -- what their program is or what the point of that is. I'm sorry.
Q: The novelty of the program was that those who were -- they were screening -- pre-deployment screening of soldiers who had -- who required mental health care. Because of that screening process, medical teams in theater could then receive their notification that these soldiers were coming their way and that they could provide follow-on care in theater during their deployment.
Is there something similar that you have?
CMDR. BENSON: Well, every Marine or sailor before they get deployed goes through a pre-deployment screening. It's fairly involved. And there's numerous parts about what's going on in that pre-deployment screening. But the thing that really is important, we feel, in almost every -- not just for mental health but any medical condition is that unit's understanding about that individual Marine.
To be honest with you, the medical officer in that battalion will -- should know about these conditions and understand them. And he's the one who's arranging for the medication supply. And that's how -- that's what's unique about the Marine Corps, is that we deploy with our organic medical assets and our organic mental health assets, so we're familiar with these folks.
To be honest with you, that's the whole idea of the OSCAR provider program, is that that OSCAR provider knows the battalions underneath then and knows the people in them and who's getting medical care. Oftentimes, he's the one who -- or he or she is the one who's providing that medical care to that Marine. So it's a seamless transition from garrison to in-theater care. They don't have to notify anybody because, well, frankly, we're going with you -- sort of stuff. That is a difference in how the Army approaches their medical care, but that's something that they would, you know, how to work around and understand that better. I understand the Marine Corps, the Navy much better than I understand the Army.
CAPT. JAMES: Charlie and Keith, I think we've taken care of all the questions we have here -- a great brief on the Navy-Marine Corps team. So I'll just turn it over to you for closing comments.
CMDR. BENSON: Well, I just -- I appreciate the time to come over here and chat with you. And thanks for coming through the snow this morning here. And certainly the folks know how to get in touch with you with any additional questions.
We're pretty proud of our mental health team here in Helmand province, and look forward to seeing if there's any additional questions from y'all.
CMDR. STUESSI: I, too, appreciate the time that we could, you know, share our successes over here. And, you know, just a couple of things. What we're doing here I think is absolutely fantastic.
We pride ourselves on expectancy, getting the Marine or soldier back to full duty, telling them to expect what -- you know, what kind of condition they're going to have here, when they're being treated. Also I think the unique thing, the multi-disciplinary approach that we're taking is very unique. It's the first time it's ever been tried in theater, and again, a success.
And then I think one of the most important things as far as I'm concerned is the fact that we are actually collecting data as we go along. We have really comprised a very large database regarding all the concussions that have come through our door. We've had about 320 folks come through now with concussions that we've returned to full duty, and we have data on every one of them.
And we're in the process of reviewing that, and so that in the future, we can take that and better treat the Marines and sailors and also use that to come up with policy for treatment both here and out at the FOBs and out in the field.
CAPT. JAMES: Thanks for your terrific efforts to take care of our Marines and sailors. Have a great day.
CMDR. STUESSI: Thank you.
CMDR. BENSON: You too.