S. HRG. 111–837 THE PROGRESS IN PREVENTING MILITARY SUI- CIDES AND CHALLENGES IN DETECTION AND CARE OF THE INVISIBLE WOUNDS OF WAR HEARING BEFORE THE COMMITTEE ON ARMED SERVICES UNITED STATES SENATE ONE HUNDRED ELEVENTH CONGRESS SECOND SESSION JUNE 22, 2010 Printed for the use of the Committee on Armed Services ( Available via the World Wide Web: http://www.fdsys.gov/ U.S. GOVERNMENT PRINTING OFFICE 64–135 PDF WASHINGTON : 2011 For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800 Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001 VerDate Aug 31 2005 09:18 Feb 05, 2011 Jkt 000000 PO 00000 Frm 00001 Fmt 5011 Sfmt 5011 Y:\BORAWSKI\DOCS\64135.TXT JUNE PsN: JUNEB COMMITTEE ON ARMED SERVICES CARL LEVIN, Michigan, Chairman ROBERT C. BYRD, West Virginia JOHN MCCAIN, Arizona JOSEPH I. LIEBERMAN, Connecticut JAMES M. INHOFE, Oklahoma JACK REED, Rhode Island JEFF SESSIONS, Alabama DANIEL K. AKAKA, Hawaii SAXBY CHAMBLISS, Georgia BILL NELSON, Florida LINDSEY GRAHAM, South Carolina E. BENJAMIN NELSON, Nebraska JOHN THUNE, South Dakota EVAN BAYH, Indiana ROGER F. WICKER, Mississippi JIM WEBB, Virginia GEORGE S. LeMIEUX, Florida CLAIRE McCASKILL, Missouri SCOTT P. BROWN, Massachusetts MARK UDALL, Colorado RICHARD BURR, North Carolina KAY R. HAGAN, North Carolina DAVID VITTER, Louisiana MARK BEGICH, Alaska SUSAN M. COLLINS, Maine ROLAND W. BURRIS, Illinois JEFF BINGAMAN, New Mexico EDWARD E. KAUFMAN, Delaware RICHARD D. DEBOBES, Staff Director JOSEPH W. BOWAB, Republican Staff Director (II) VerDate Aug 31 2005 09:18 Feb 05, 2011 Jkt 000000 PO 00000 Frm 00002 Fmt 0486 Sfmt 0486 Y:\BORAWSKI\DOCS\64135.TXT JUNE PsN: JUNEB C O N T E N T S CHRONOLOGICAL LIST OF WITNESSES THE PROGRESS IN PREVENTING MILITARY SUICIDES AND CHALLENGES IN DETECTION AND CARE OF THE INVISIBLE WOUNDS OF WAR JUNE 22, 2010 Page Chiarelli, GEN Peter W., USA, Vice Chief of Staff, U.S. Army ........................... 5 Greenert, ADM Jonathan W., USN, Vice Chief of Naval Operations, U.S. Navy ...................................................................................................................... 13 Amos, Gen. James F., USMC, Assistant Commandant, U.S. Marine Corps ...... 20 Chandler, Gen. Carrol H., USAF, Vice Chief of Staff, U.S. Air Force ................ 24 Jesse, Robert L., Acting Principal Deputy Under Secretary for Health, Vet- erans Health Administration, Department of Veterans Affairs ....................... 29 (III) VerDate Aug 31 2005 09:18 Feb 05, 2011 Jkt 000000 PO 00000 Frm 00003 Fmt 0486 Sfmt 0486 Y:\BORAWSKI\DOCS\64135.TXT JUNE PsN: JUNEB VerDate Aug 31 2005 09:18 Feb 05, 2011 Jkt 000000 PO 00000 Frm 00004 Fmt 0486 Sfmt 0486 Y:\BORAWSKI\DOCS\64135.TXT JUNE PsN: JUNEB THE PROGRESS IN PREVENTING MILITARY SUICIDES AND CHALLENGES IN DETECTION AND CARE OF THE INVISIBLE WOUNDS OF WAR TUESDAY, JUNE 22, 2010 U.S. SENATE, COMMITTEE ON ARMED SERVICES, Washington, DC. The committee met, pursuant to notice, at 9:35 a.m. in room SD– G50, Dirksen Senate Office Building, Senator Carl Levin (chair- man) presiding. Committee members present: Senators Levin, Lieberman, Akaka, Webb, McCaskill, Udall, Hagan, Begich, Burris, McCain, Inhofe, Thune, and Collins. Committee staff members present: Richard D. DeBobes, staff di- rector; and Leah C. Brewer, nominations and hearings clerk. Majority staff members present: Gabriella Eisen, counsel; Gerald J. Leeling, counsel; and Jason W. Maroney, counsel. Minority staff members present: Michael V. Kostiw, professional staff member; Diana G. Tabler, professional staff member; and Richard F. Walsh, minority counsel. Staff assistants present: Jennifer R. Knowles, Hannah I. Lloyd, and Breon N. Wells. Committee members’ assistants present: James Tuite, assistant to Senator Byrd; Nick Ikeda, assistant to Senator Akaka; Greta Lundeberg, assistant to Senator Bill Nelson; Gordon I. Peterson, assistant to Senator Webb; Tressa Guenov, assistant to Senator McCaskill; Roger Pena, assistant to Senator Hagan; Lindsay Kavanaugh, assistant to Senator Begich; Amanda Fox, assistant to Senator Burris; Anthony J. Lazarski, assistant to Senator Inhofe; T. Finch Fulton and Lenwood Landrum, assistants to Senator Ses- sions; Richard Perry, assistant to Senator Graham; and Ryan Kaldahl, assistant to Senator Collins. OPENING STATEMENT OF SENATOR CARL LEVIN, CHAIRMAN Chairman LEVIN. Good morning, everybody. The committee meets today to receive testimony on the status of our efforts to prevent military suicides and the challenges in detec- tion, treatment, and management of the so-called ‘‘invisible wounds of war,’’ which we consider to include traumatic brain injury (TBI), and concussive events, post-traumatic stress disorder (PTSD), and other combat-related psychological health concerns. (1) VerDate Aug 31 2005 09:18 Feb 05, 2011 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 Y:\BORAWSKI\DOCS\64135.TXT JUNE PsN: JUNEB 2 A hearing on military suicides was requested by Senator Inhofe several weeks ago, and we all appreciate that request. Due to our committee markup schedule, we were unable to schedule a hearing until this week. Originally, this hearing was meant to focus on Service suicide prevention policies and programs. But, given the re- cent disconcerting reports alleging poor diagnosis and treatment of servicemembers suffering from TBI and PTSD, I felt it important to broaden the scope of our discussion today to include those topics as well, especially given the fact that they can often occur concur- rently, making diagnosis of any or all of these illnesses difficult. The increase in suicides by military personnel in the last few years is alarming. In 2007, 115 Army soldiers committed suicide. In 2008, the number increased to 140, and to 162 in 2009. Simi- larly, 33 marines committed suicide in 2007, 42 in 2008, and 52 in 2009. I understand there are a number of additional cases where the Armed Forces medical examiner has not yet concluded whether the deaths are by suicide so, the 2009 numbers will likely be even higher. These increases indicate that, despite the Services’ efforts, there is still much work to be done. We must improve our suicide preven- tion efforts to reverse the number of servicemembers taking their own lives. I am greatly concerned about the increasing number of troops re- turning from combat with PTSD and TBIs, and the number of those troops who may have experienced concussive injuries that were never diagnosed. Studies indicate that mild TBI, or concussion, is associated with PTSD, depression, and anxiety. These conditions, in turn, may con- tribute to the increase in the number of suicides. One key to suicide prevention is to make greater efforts to end the stigma that too many perceive attaches when they receive men- tal health care. Another key, of course, is the proper and timely di- agnosis and treatment of TBI and PTSD, and increasing awareness of, and access to, mental healthcare resources, as well as leader- ship support for those seeking such care. We hope to hear from our witnesses today the approach that each Service and the Department of Veterans’ Affairs (VA) is tak- ing to help detect, treat, and manage psychological health prob- lems, to include PTSD and TBI. The numbers of suicides have increased in every Service, but sig- nificantly more so in the Army and Marine Corps, the two Services most heavily engaged in ground combat in Iraq and Afghanistan. Congress has recognized the strain on these ground forces, and has, over the past several years, authorized significant increases in the Active Duty end strengths for the Army and Marine Corps. It is our intent that these increases will help to relieve the stress on those forces, but we also have to make sure that we provide all the assistance that our troops need to cope with the stress that they are experiencing. The professionals tell us that common issues leading to suicide include relationship problems, financial problems, and legal prob- lems, as well as mental health issues. I know that each of the Serv- ices, as well as the VA, have programs to address those as part of the suicide prevention efforts. Undoubtedly, deployments and lack VerDate Aug 31 2005 09:18 Feb 05, 2011 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 Y:\BORAWSKI\DOCS\64135.TXT JUNE PsN: JUNEB 3 of dwell time have contributed to these underlying problems that are linked with suicides. The Army is working with the National Institute of Mental Health (NIMH) on a 5-year longitudinal study to help identify and develop intervention and mitigation strategies to help decrease the number of suicides in the Army. While this is an important effort, we cannot wait for the full 5 years to occur for these results. We must identify actions, and take them now, to reduce suicides. Gen- eral Chiarelli, we look forward to hearing about interim findings from the study, and how the Army might use those findings now to better target suicide prevention efforts. We must learn more about TBI and concussive events, and their relationship to PTSD and suicide. Unfortunately, these brain inju- ries remain relatively unknown territory in both the military and civilian medical environments. We look forward to learning more about the policies and pro- grams each Service has in place to handle incidences of TBI and concussive events, both in theater and at home. We also look for- ward to learning what policies, programs, and initiatives each of the Services and the VA has implemented and identified to ensure that our servicemembers, in both the Active Duty and Reserve com- ponents, veterans, and their families, receive all of the support that we can provide, and that our All-Volunteer Force can continue to perform its mission with the health and other services that they need and deserve. I’m pleased to welcome our witnesses.