UNCLASSIFIED

FINAL VERSION

STATEMENT BY

COLONEL GREGORY A GAHM
CHIEF, DEPARTMENT OF PSYCHOLOGY
MADIGAN ARMY MEDICAL CENTER
FORT LEWIS, WASHINGTON

COMMITTEE ON VETERANS AFFAIRS

UNITED STATES SENATE

FIRST SESSION, 110TH CONGRESS

MENTAL HEALTH CONCERNS OF VETERANS

17 AUGUST 2007

NOT FOR PUBLICATION
 UNTIL RELEASED BY THE
 COMMITTEE ON VETERANS AFFAIRS
 

Senator Murray and distinguished members of the Committee, thank you for providing me the opportunity to address the broad range of mental health concerns affecting our Service Members and Veterans.  As Chief of the Department of Psychology at Madigan Army Medical Center I am proud to oversee the delivery of care provided by my psychologists to the Service Members and Family Members served by Madigan.  I am also proud of our ongoing initiatives to reach out and support the psychological health of Service Members, Veterans, and their Family Members.  While our work at Fort Lewis has been recognized by the recent DoD Mental Health Task Force report, the Government Accounting Office, the Military Child Education Council, and positively reviewed in the press, we also recognize that we must continue to expand the services we offer and ensure that we remain committed to improving the compassionate care we provide.

  Our actions must consistently honor the service of our Soldiers.  Concerns regarding Soldiers separated for personality disorders, especially given the potential impact on future care for the psychological injuries of these veterans, are being addressed by the Army. The media and Congress have alleged that Soldiers have been unfairly discharged under Chapter 5-13, Personality Disorders (PD), when they should have been afforded the opportunity to undergo a Medical Evaluation Board.  The acting Army Surgeon General directed a review of all Soldiers discharged for personality disorders in 2006 who had served in OIF or OEF.    The results of this review still need to be presented to Army leadership, but some initial guidance for behavioral health providers has already been issued to the field. 

Additionally, the Government Accountability Office (GAO) is in the process of auditing the Department of Defense with regard to the issue of administrative separation for a personality disorder diagnosis.  To prepare, the GAO chose to visit Fort Lewis last month, not to address concerns, but rather to visit a positive model and consult with our psychologists, psychiatrists, and attorneys to learn about our processes in order to plan for their audit.   While we strive to consistently act in the best interest of the Soldier, we agree with Army leadership that "even one misdiagnosis is too many." As our Surgeon General testified to the House Committee on Oversight and Government Reform in May, we recognize we are an imperfect organization, and are actively striving to ensure every Soldier receives the respect and outstanding care they deserve.

One of the many recognized initiatives that exemplify outstanding care to Service Members is Fort Lewis' implementation of the DoD's Post Deployment Health Re-Assessment, or PDHRA.  The PDHRA process identifies physical and psychological health concerns for Service Members 90 to 180 days following redeployment.  The PDHRA process at Fort Lewis is called the Soldier Wellness Assessment Pilot Program, or SWAPP.  This program goes well beyond the DoD's basic mandated PDHRA process to provide a reset of the Soldier physically, spiritually, and mentally.  Of particular note, every Soldier who completes SWAPP is provided the opportunity to meet that same day with a psychologist or master's level clinician.  The Soldier and mental health provider work collaboratively to define needs, address concerns, assist with smooth redeployment, and connect the Soldier with any additional resources that might be needed.  

After evaluating the process, we can say without question that "SWAPP works".  Barriers to care fall.  Every Soldier connects with a behavioral health clinician -there are no dead end referrals.  As evidence of this, utilization rates for Fort Lewis' Stryker Brigade following redeployment in Fall 2005 reached the same Behavioral Health utilization rates (31%) in six months as was observed in one year in a population study completed by Colonel (Dr.) Charles Hoge and colleagues in 2006.   In addition, Post-SWAPP Soldiers made an average of 5.3 visits during that time compared to an average of 3.4 visits found in the same one-year naturalistic study. Hoge, et.al, (2006) reported that only 50% of those who were referred based on positive PDHA responses were seen by a Behavioral Health provider, versus 100% of those who are seen through the SWAPP process. 

Perceived stigma regarding mental health care drops when every Soldier follows the same process and meets with a behavioral health clinician.  Dr. Hoge's 2004 New England Journal of Medicine study identified mental health stigma as the most significant barrier to care for Soldiers.  Preliminary local analysis suggests that there is a drop in perceived mental health stigma for those individuals who are seen immediately after SWAPP compared to those who are seen prior to SWAPP or those who were seen later than a month after SWAPP.  Additionally, SWAPP satisfaction survey data suggests that 13% of Soldiers seen in SWAPP were uncomfortable seeking mental health care prior to the SWAPP process, a number that was cut to less than half that following SWAPP.

SWAPP goes beyond addressing the needs of returning Soldiers.  At Fort Lewis, this same process is provided to all Soldiers prior to their deployment as well.  Pre-deployment SWAPP addresses the specific needs of Soldiers prior to their departure and seeks to buttress the resiliency of the Soldiers preparing to face the rigors of deployment.  We are excited to continue SWAPP at Fort Lewis and look forward to working with the Army Medical Department to bring SWAPP to additional Army facilities.

In addition to SWAPP, Ft Lewis has many initiatives  to reach out to Soldiers and their families.  These include programs linking up our psychologists with the local schools to offer both programs for the students directly and training and support for the teachers and counselors in helping to deal with the effects of deployment.  We are providing mental health care managers in numerous settings including our Warrior Transition Brigade to insure Soldiers have ready access to the helping resources.

We are also leveraging technology in several exciting ways.  One of our efforts involves the development and deployment of an internet based resource to reach out to all Service Members and their families to assist them after deployment.  The National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2006 authorized a pilot project of Internet-based tools aimed at identifying and treating Post Traumatic Stress Disorder (PTSD) and other mental health conditions.  The Office of the Assistant Secretary of Defense (Health Affairs) has designated the Army as the project lead and I'm pleased that the Army Behavioral Health Technology Office (ABHTO) at Madigan Army Medical Center is leading the DoD project team.  Partners in this very important initiative include the VA's National Centers for PTSD in Massachusetts, California, and Hawaii, the Center for Deployment Psychology, and other military organizations and sites.  The web application we are developing, afterdeployment.org, addresses multiple critical variables in caring for the military family. The significant incidence of post-deployment mental health problems is exacerbated by limited provider availability, geographic proximity to services, scheduling challenges, and stigma. Afterdeployment.org offers a quality service that in many cases will provide an alternative to traditional face-to-face care.  Afterdeployment.org is designed as a modularized and highly engaging self-care, online solution.  The need for this tool has been highlighted by recent reports that a significant percentage of service members and their families do not seek help despite meeting the criteria indicating a need for mental health services.  Afterdeployment.org helps fill the gap by delivering tailored assessments and portable services available online anytime and anywhere.  User anonymity is a key component, and will facilitate user comfort when engaging with the range of psychoeducational materials, self-assessment tools, and workshop exercises that the site will provide. 
The programs available through the website target the following 12 areas: (1) combat stress and triggers, (2) conflict at work, (3) re-connecting with family and friends, (4) moods, (5) anger, (6) sleep, (7) substance abuse, (8) stress management, (9) resiliency of kids, (10) spiritual guidance, (11) living with physical injuries, and (12) health and wellness.  The website design was tested in structured interviews with service members in February and some modifications were made as a result of the feedback.    The afterdeployment.org pilot version will be released for user testing in September, 2007 with continuing development through FY08. 

In order to further improve our ability to reach out to all of our beneficiaries, the AMEDD, in coordination with OSD Health Affairs (HA), is expanding our capacity to deliver tele-behavioral health care. Madigan Army Medical Center was recently approved to become a ‘hub' for regional telebehavioral health care and I have been asked by HA to work with them to initiate a National Center for TelePsychological Health & Technology.  These services will augment the care available to our Service Members and Veterans and improve access to those in underserved areas.

Virtual Reality treatments for PTSD represent another area where we are leveraging new technologies in exciting ways to help our Soldiers. Building upon development efforts supported by the US Army Medical Research & Materiel Command's Telemedicine and Advanced Technology Research Center (TATRC) and the Office of Naval Research we have worked collaboratively with the Institute for Creative Technology (ICT) at the University of Southern California to initiate both research and treatment programs utilizing this technology. While still in its early stages, this technology offers great promise for improving the treatments we offer our Soldiers. 

Ft Lewis has consistently been a leader in Army efforts to provide the best possible care to our Soldiers. In 2005 we initiated open access mental health clinics. In an effort to insure that every barrier to care was removed, we converted our primary behavioral health clinic access for Soldiers from one that required an appointment to one that allowed Soldiers to walk-in and be seen the same day. To efficiently support this, we again leveraged technology to automate the capture of patient data via kiosks using the locally developed Automated Behavioral Health Clinic (ABHC) program which allows for more comprehensive data gathering while supporting providers in efficiently reviewing and considering this data in providing care. In 2006 we further extended this availability by opening our Soldier Readiness Clinic out of the main hospital, which made it easier for Soldiers to access. In addition, we initiated a primary care consultation model within our Soldier Family Medicine Clinics to directly support the primary care provider in their delivery of comprehensive health care and to provide an additional venue by which behavioral health care is available to our Soldiers.

Senator Murray, thank you for the opportunity to participate in this important discussion with you and the members of this Committee.  Thank you for holding this hearing and thank you for your continued support of the Army Medical Department and the Warriors that we are honored to serve.