INFORMATION PAPER

DASG-HSZ
7 March 2010

SUBJECT: Post Traumatic Stress Disorder Prevention, Diagnosis and Treatment

1. Purpose: To provide an update on Post Traumatic Stress Disorder for the TSG Prep
Book.

2. Facts:

a. Post-Traumatic Stress Disorder is a psychiatric disorder that may occur after

exposure to trauma. Typical symptoms include hypervigilence, intrusive thoughts,
flashbacks, numbness, avoidance, and nightmares. PTSD diagnosis rates have steadily
increased from CY03 to CY08 for both deployed and nondeployed Solders. CY09 rates
have declined from their CY08 peaks. Deployed Soldier diagnosis rates have declined
from 10,137 in CY08 to 8,553 in CY09. Nondeployed Soldier diagnosis rates have
declined form 1,311 in CY08 to 1,059 in CY09. We expect the number of new cases to
be related to the number of exposed troops, the number of deployments and the overall
exposure to combat. We currently estimate that the number of Newly Identified PTSD
Cases for CY10 to be similar to CY09.

b. The Army has numerous education, identification, and treatment programs for
PTSD, including Battlemind, PDHA, PDHRA, the chain-teach program, and Respect-
mil. The most common forms of psychotherapy for Post Traumatic Stress Disorder are
cognitive-behavioral therapy and exposure therapy. Usually psychotherapy requires
approximately 10 to 20 sessions, if possible on a weekly basis. There are several
medications used to treat the symptoms of Post Traumatic Stress Disorder. These
usually include anti-depressants such as selective serotonin reuptake inhibitors, more
frequently referred to as SSRls. There a number of different types used for sleep
difficulties, including Ambien, Trazodone, and Seroquel for trauma-induced nightmares.

d. During pre-deployment, Resources available to Soldiers include buddy aid,

leadership support, chaplaincy services, primary care, and behavioral health services.
Family members are instructed on their roles, responsibilities, ways by which they may
cope more effectively, strategies for supporting their deploying Soldier, and ways to
seek professional assistance.

e. During pre-deployment and deployment, Soldiers are introduced to Combat and

Operational Stress Control concepts and resources to prepare for combat and
operational stress. It is now mandatory that all Army deploying behavioral health
providers attend Combat and Operational Stress Control training.
DASG-HSZ
SUBJECT: Post Traumatic Stress Disorder (PTSD) Screening and Soldiers

f. Since Oct 98, all Soldiers redeploying from the Theater of operations have been
required to complete the Post Deployment Health Assessment (PDHA) (DO Fonm
2796), either before leaving Theater or shortly after redeployment. The DO Fonm 2796
screens for Post Traumatic Stress Disorder, Major Depression, family issues, and
concerns about drug and alcohol abuse. The primary care provider reviews the fonm,
interviews the Soldier as required, and refers the Soldier to a behavioral healthcare
provider when indicated.

g. Since Jan 06 (retroactive to Mar 05), all Soldiers have been required to complete
the Post-Deployment Health Reassessment (DO Fonm 2900) at 90 to 180 days after
they have redeployed. Approximately 12% of Soldiers are referred to behavioral health
from the Post-Deployment Health Reassessment.

h. Another Army effort in the prevention and screening of Post Traumatic Stress
Disorder is the Post Traumatic Stress Disorder Training Course developed by US Army
Medical Command and Army Medical Department Center and School . The PTSD
Training Course is intended to provide DOD uniformed and civilian behavioral health
counselors critical clinical education and intervention tools in the identification and
treatment of Post Traumatic Stress Disorder.

i. The Army has implemented behavioral health training into primary care . All
primary care providers receive two (2), one hour blocks of instruction covering a range
of behavioral health related issues focused around Post Traumatic Stress Disorder and
Depression.
Ilb)(61
Approved by: IIbl161
- - - - -

2
 INFORMATION PAPER

DASG-HSZ
18 March 2009

SUB~JECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)

1. Purpose: To provide information regarding what medical care is available to Soldiers with
PTSD.

2. Facts:

a. Army leadership is taking aggressive, far-reaching steps to ensure an array of behavioral

health services are available to Soldiers and their Families to help those dealing with PTSD and
other psychological effects of war. Soldiers and their Families are telling senior leaders that
their behavioral healthcare is a top concern, and Army leaders are in turn making it their number
one priority.

b. The following list of continually evolving programs and initiatives are examples of the
integrated and synchronized web of behavioral health services in place to help Soldiers and
their Families heal from the effects of multiple deployments and high operational stress:

(1). The Post Deployment Health Assessment, originally developed in 1998, was revised
and updated in 2003. All Soldiers receive this on re-deployment, usually in the theater of
operations.

(2). In the fall of 2003, the first Mental Health Assessment Team (MHAT) deployed into
theater. Never before had the mental health of combatants been studied in a systematic
manner during conflict. Four subsequent MHAT's in 2004, 2005, 2006, and 2007 continue to
build upon the success of the original and further influence our policies and procedures not only
in theater but before and after deployment as well. Based on MHAT recommendations, the
Army has improved the distribution of behavioral health providers and expertise throughout the
theater. Access to care and quality of care have improved as a result. An MHAT is currently in
Iraq, and will be deploying to Afghanistan this spring.

(3). In 2004, researchers at the Walter Reed Army Institute of Research (WRAIR)
published initial results of the groundbreaking "Land Combat Study" which has provided insights
related to care and treatment of Soldiers upon return from combat experiences and led to
development of the Post Deployment Health Reassessment (PDHRA).

(4). In 2005, the Army rolled out the PDHRA. The PDHRA provides Soldiers the
opportunity to identify any new physical or behavioral health concerns they may be experiencing
that may not have been present immediately after their redeployment. This assessment
includes an interview with a healthcare provider and has been a very effective new program for
identifying Soldiers who are experiencing some of the symptoms of stress-related disorders and
getting them the care they need before their symptoms manifest into more serious problems.
We continue to review the effectiveness of the PDHRA and have added and edited questions as
needed.
DASG-HSZ
SUB..IECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)

(5). In 2006,the US Army Medical Command (MEDCOM) piloted a program at Fort Bragg,
intended to reduce the stigma associated with seeking mental health care. The Respect-Mil
pilot program integrates behavioral healthcare into the primary care setting, providing education,
screening tools, and treatment guidelines to primary care providers. It has been so successful
that medical personnel have implemented this program at fifteen sites across the Army.
Another 17 sites should implement it in 2009.

(6). Also in 2006, the Army incorporated into the Deployment Cycle Support program a
new training program developed at WRAIR called "BATrLEMIND" training. Prior to this war,
there were no empirically-validated training strategies to mitigate combat-related mental health
problems. This post-deployment training is being evaluated by MEDCOM personnel using
scientifically rigorous methods, with good initial results. It is a strengths-based approach
highlighting the skills that helped Soldiers survive in combat instead of focusing on the negative
effects of combat. Please visit www.battlemind.org for more information.

(7). MEDCOM's pursuit for improvement continues with BATTLEMIND training program
for Soldiers and spouses prior to deployments; a behavioral health web site
http://www.behavioralhealth.army.mil; creation of a Behavioral Health Proponency Office in Mar
08; and a new PTSD training course started in Jun 08.

(8). Two DVD/CDs that deal with Family deployment issues are now available: an
animated video program for 6 to 11 year olds, called "Mr. Poe and Friends," and a teen
interview for 12 to 19 year olds, "Military Youth Coping with Separation: When Family Members
Deploy." Viewing the interactive video programs with children can help decrease some of the
negative outcomes of Family separation. Parents, guardians and community support providers
will learn right along with the children by viewing the video and discussing the questions and
issues provided in the facilitator's guides with the children during and/or after the program. This
reintegration Family tool kit provides a simple, direct way to help communities reduce tension
and anxiety, and use mental health resources more appropriately, and promote healthy coping
mechanisms for the entire deployment cycle that will help Families readjust more quickly on
redeployment. Go to www.behavioralhealth.army.mil and click on children.

(9). On average 200 behavioral health personnel are deployed in support of Operation
Iraqi Freedom, and about 30 in Operation Enduring Freedom (these numbers include providers
from all the Services).

(10). In mid-July 2007 the Army launched a PTSD and mild Traumatic Brain Injury
(mTBI) Chain Teaching Program that will reach more than 1 million Soldiers, a measure that will
ensure early intervention. The objective of the chain teaching package was to educate all
Soldiers and leaders on PTSD and TBI so they can help recognize, prevent and treat these
debilitative health issues.

(11). In 2008, the DoD revised Question 21, the questionnaire for national security
positions regarding mental and emotional health. The revised question now excludes non-court
ordered counseling related to marital, family, or grief issues, unless related to violence by
members; and counseling for adjustments from service in a military combat environment.
Seeking professional care for these mental health issues should not be perceived to jeopardize
an individual's professional career or security clearance. On the contrary, failure to seek care

2
DASG-HSZ
SUBJECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)

actually increases the likelihood that psychological distress could escalate to a more serious
mental condition, which could preclude an individual from perfonning sensitive duties.

(12). We've also instituted post-traumatic stress training for our health care providers so
that they can accurately diagnose and treat combat stress injuries; we 're dedicating time and
energy toward provider resiliency training; and we have hired 250 more beha vioral health care
pro viders and over 40 marriage and family therapists in recent months to work in military
treatment facilities in the United States. We also have numerous longer-term efforts to
enhance recruitment and retention of uniformed behavioral health pro viders.

(13). In 2008, the Anny began piloting Warrior Adventure Quest 0NAQ). WAQ combines
existing high adventure, extreme sports, and outdoor recreation activities (i.e, rock climbing ,
mountain bik ing, paintball, scuba, ropes courses, skiing , and others) with a leader-led after
action debriefing (L-LAAD). The L-LAAD is a leader decompression tool that addresses the
potential impact of executing military operations and enhances cohesion and bonding among
and within small units. L-LAAD integrates WAQ and bridges operational occurrences to assist
Soldiers' transition their operational experiences into a "new norma!", enhancing military
readiness, reintegration, and adjustment to garrison or "home" life .

(14 ). The Comprehensive Soldier Fitness Program was established on 1 Oct 08, as a
Directorate in the Army G-3/517. The mission of this program is to develop and institute a
holistic, resilience building fitness program for Soldiers, Families, and Army civilians. The
program will focus on optimizing five dimensions of strength: Physical, Emotional, Social,
Spiritual, and Famil y. This holistic approach to fitness will enhance the performance (capability)
and build resilience (capacity) of the Force in this era of persistent conflict and high operational
tempo.

(15). The Army put out ACE "Ask, Care , Escort: Beginning 15 Feb 09 , the Arm y started
a "standdown" to ensure that all Soldiers learned not onl y the risk factors of suicidal Soldiers but
how to intervene if they are concerned about their buddies. The "Be yond the Front" interactive
video is the core training for this effort. It will be followed by a chain teach which focuses on a
video "Shoulder to Shoulder; No Soldier Stands Alone" and Vignettes drawn from real cases.

l1 1
COL Rltchie!lb 6 I
Approved by iL
I(bii
_II_61 1

3
 INFORMATION PAPER

DASG-HSZ
24 February 2009

SUB..IECT: Post Traumatic Stress Disorder and Traumatic Brain Injury (PTSDITBI)

1. Purpose. To provide information on the potential increase in cases of PTSDITBI

among Service members and veterans as a result of multiple deployments.

2. Facts.

a. Since 2002, there have been a total of approximately 36,256 Operation Iraqi
Freedom and Operation Enduring Freedom (OIF/OEF) Soldiers who have been
diagnosed with PTSD following deployment of greater than 30 days. The number of
new PTSD cases has more than tripled since FY04. Cumulative deployed time is
associated with increased PTSD diagnoses; Length of most recent deployment is not. It
is projected that diagnosed cases of PTSD will continue to increase in future years.

b. As of Nov 08, there were 6,751 Army TBI cases reported to the Defense Veterans
Brain Injury Center OIF/OEF. This represents an eight fold increase of reported TBI
cases since FY03. Most TBI cases resulted from Improvised Explosive Devices / Blast
injuries, and most were categorized as mild TBI. Increases in the number of mild TBI
cases have largely been due to aggressive identification efforts both in theater and as
part of Post Deployment Screening and not as a result of multiple deployments. It is
expected that this number will increase as more cases are identified.

c. Since Oct 98, all Soldiers redeploying from the theater of operations have been
required to complete the PDHA, either before leaving theater or shortly after
redeployment. The DD Form 2796 screens for PTSD, Major Depression, concerns
about family issues, and concerns about drug and alcohol abuse. The primary care
provider reviews the form, interviews the Soldier as required, and refers the Soldier to a
behavioral healthcare provider when indicated. The primary care provider may make
referrals to on-site counselors, network providers or to military treatment facilities
(MTFs). Five to 6% of Soldiers are generally referred to behavioral health at this time.

d. Since Jan 06 (retroactive to Mar 05), all Soldiers have been required to complete
the PDHRA (Form 2900) at 90 to 180 days after they have redeployed. Specific
questions about mild TBI (concussion) were added in Nov 07 for the Army. These
questions were revised and made available for all Services in May 08. If healthcare
needs are identified through the PDHRA, Soldiers are offered care through MTFs,
Veteran Administration Medical Facilities, or by private healthcare providers through
TRICARE. Approximately 12% of Soldiers are referred to behavioral health from the
PDHRA.
DASG-HSZ
SUBJECT: Post-Traumatic Stress Disorder Screening and Deployment

e. All Soldiers (AD, USAR, and ARNG) were mandated to participate in training on
mild TBI and PTSD NLT 18 Oct 07. The "Chain Teach" product was designed to
provide an overview and understanding of concussion injuries and Post Combat Stress
Reactions that may result in PTSD. Approximately 900,000 Soldiers received this
training by the end of 2007. There are a number of other training programs for Soldiers
and their Families available at www.battlemind.army.mil or
www.behavioralhealth.army.mil. The content of the "Chain Teach" has been
institutionalized through the Battlemind Training System Office (BMTS), AMEDDC&S
which has integrated this training into lifecycle mTBI and PTSD training modules that
will be incorporated into The US Army Training and Doctrine Command (TRADOC)
Programs) Programs of Instruction (POI). Mild TBI and PTSD training will occur in all
TRADOC OES and NCOES POls. In addition, the Post-Deployment and Spouses
Battlemind are available at the web sites indicated above. New training videos are in
development.

f. All Soldiers discharged for selected administrative reasons are required to receive
a mental status evaluation as per Army Regulation 635-200. A new policy was
published in May 08 directing that Soldiers being discharged for any reason related to
misconduct must be specifically screened for PTSD and mild TBI.

g. MEDCOM and AMEDDC&S have developed a PTSD Training Course intended to

provide 000 uniformed and civilian BH counselors critical clinical education and
intervention tools in the identification and treatment of PTSD. Specifically, this provides
the BH provider a broader understanding of the clinical characteristics and prevalence
of PTSD Acute and Chronic Features, medical and psychiatric co-morbidity of PTSD,
the theoretical underpinnings for this disorder and the ability to identify risk and
resiliency factors related to development of PTSD. Attendees also learn about a variety
of screening and assessment tools to accurately and reliably measure traumatic
stressors and PTSD, learn about TBI, most notably as a result of blast-related
concussion, and hear about strategies to diagnose co-morbid PTSD and TBI. Finally,
participants hear an overview about therapeutic clinical strategies for coordinated
treatment of combat-related stress issues. This course is mandatory training for all
uniformed and civilian Social Workers, Nurse Case Managers and Basic Psychiatric
Nurses.

h. Specific to TBI, two patient education brochures and 5 patient education

handouts were developed and distributed throughout U.S. Army Medical Department
(MEDCOM), staff have conducted public relations efforts at 14 conferences and 10
professional meetings, and computer-based education tools for Soldiers, Families,
providers, leaders and patients are in development. MEDCOM established a validation
program for all MEDCOM Medical Treatment Facilities (MTFs) that provide care to
Soldiers and other beneficiaries with TBI. This validation program was designed to
establish standards of care and to ensure that services, physical facilities, and staffing
levels were consistent across the Army MTFs, based on the level of care provided at
the facility. Six sites have received initial validation and review of all CONUS sites is