DTIC ADA523055: Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Annual Report 2009

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Defense Centers of Excellence
for Psychological Health and Traumatic Brain Injury
Annual Report 2009
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Defense Centers of Excellence for Psychological Health and Traumatic
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Brain Injury
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2 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Annual Report 2009 3
WELCOME LETTER
Dear Friends of DCoE:
I am pleased to have the opportunity to share with you the
Defense Centers of Excellence for Psychological Health and Traumatic Brain
Injury (DCoE) Annual Report. During the past two years, DCoE has grown from
an idea into a “center of centers” serving as the Department of Defense’s open
front door for all concerns relating to psychological health and traumatic brain
injury.
Promoting warrior resilience, recovery and reintegration has required the
direct engagement of senior stakeholders at all levels to provide public health
leadership characterized by transparency, knowledge, candor, respect and
strength. Our biggest challenge is overcoming the deadly barrier of stigma to
embrace a transformed culture where seeking help for psychological health
and traumatic brain injuries is seen as an act of courage and strength and NOT
as a weakness. Treatment works — early intervention counts.
Our warriors are coming home with multiple medical conditions requiring an
interdisciplinary holistic approach that encompasses injuries affecting the
mind, body and spirit. The injured warrior may have sustained one or more
concussive injuries, either through successive blasts or a blast followed by
direct blows. This may be compounded by psychological trauma, grief and
loss, as well as trauma related conditions including depression, pain, anxiety,
substance misuse and confl icted relationships. No one can go it alone —
we’re all in this together.
To this end, in collaboration with our growing network of global partners,
we are working toward providing the best possible resources to our service
members and their loved ones who are coping with psychological health and
traumatic brain injury concerns — now and in the future.
Thank you for joining our journey and committing to make our best even better
tomorrow and beyond for those who support and defend our nation’s freedom.
To the journey,
Loree K. Sutton, M.D.
Brigadier General, MC, USA
Director
4 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Annual Report 2009 5
DEDICATION
We dedicate this report, as we do all of the efforts of DCoE and
its component centers, to the service members, veterans and families who
defend and support our nation’s freedom. For many of our warriors, coming
home does not mean that the battle is fi nished. The battle often continues —
in hearts and minds, relationships and communities — after deployment. Our
work in the last two years and our goals for the future are aimed at supporting
our warriors and their families throughout the entire deployment cycle and
beyond. We thank each one of you for your courageous sacrifi ces, and we
pledge to forge ahead on our journey to provide you with the best possible
care and resources. There simply is no greater privilege.
This is DCoE’s fi rst annual report, covering the period from its inception in November 2007 to November 2009.
Hereafter, an annual report will be produced at the end of each fi scal year.
6 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Annual Report 2009 7
TABLE OF CONTENTS
About DCoE .....................................................................................................8
Key DCoE Accomplishments ..........................................................................11
Component Centers ......................................................................................20
Research Strategy .........................................................................................27
Future Initiatives ............................................................................................35
Get Involved with DCoE..................................................................................38
8 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Annual Report 2009 9
About DCoE
OVERVIEW
DCoE opened its doors in November 2007, and has since led a groundbreaking collaborative effort with
the Department of Veterans Affairs (VA), civilian agencies, community leaders, advocacy groups, clinical
experts and academic institutions to promote the resilience, recovery and reintegration of service members,
veterans and military families facing concerns related to psychological health (PH) and traumatic brain injury
(TBI). DCoE is part of the Department of Defense’s (DoD) Military Health System (MHS), which provides a
“continuum of care” — from initial accession to deployment to discharge — for all service members.
DCoE is fi rmly committed to ensuring that every service member, DCoE was established to meet this congressional intent and to
veteran and family member receives excellent care and support become the open front door within DoD for all PH and TBI needs.
across the spectrum of resilience, prevention, diagnosis, DCoE has embraced its mission to assess, validate, oversee
treatment, recovery and reintegration. As a “center of centers,” and facilitate prevention, resilience, identifi cation, treatment,
DCoE brings together a global network of military and civilian outreach, rehabilitation and reintegration programs for PH
expertise to establish best practices and quality standards for and TBI to ensure DoD meets the needs of service members,
the treatment of PH concerns and TBI within DoD. veterans, military families and communities.
History Organizational Structure
In 2007, due to the unprecedented pace of deployments Under the leadership of Brig. Gen. Loree K. Sutton (special
to combat environments in Iraq and Afghanistan, six assistant to the Assistant Secretary of Defense for Health
congressionally mandated task force reports highlighted the Affairs) and Deputy Director Sonja V. Batten, Ph.D. (associate
immediate need to provide enhanced health resources for chief consultant for VA/DoD Collaboration in VA’s Offi ce of
America’s service members, including care for psychological Mental Health Services), DCoE is composed of the following six
injury and TBI. In an effort to enhance outreach and coordination component centers, which provide care, support training and
among DoD, VA, other federal agencies and civilian partners, advance science through complementary missions, goals and
Congress mandated the creation of a center of excellence to objectives:
address PH and TBI issues specifi cally aligned to fi ve guiding
principles: Center for Deployment Psychology (CDP)
• Furnish strong, visible leadership and the necessary resources Promotes the training of military and mental health
• Create, disseminate and continuously update excellent professionals
standards of care
• Conduct pilot or demonstration projects to better inform Center for the Study of Traumatic Stress (CSTS)
quality standards if best practices are unavailable Provides knowledge, leadership and applications for
• Monitor and revise access, quality and program recovering from disaster and trauma
implementation to ensure highest standards and consistent
quality Defense and Veterans Brain Injury Center
• Construct a system in which each individual receives the Develops and delivers advanced TBI-specifi c
same high level of service regardless of military branch, treatment and surveillance
component, status or geographic location
10 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Annual Report 2009 11
Key DCoE Accomplishments
Deployment Health Clinical Center (DHCC) DCoE integrates its core functions across eight directorates
Improves deployment-related health through to coordinate capabilities and ensure quality of care. These
assistance, treatment, advocacy and education directorates include:
National Center for Telehealth and • Clearinghouse, Outreach and Advocacy
Technology (T2) • Communications
Leverages technology to increase access and • PH Clinical Standards of Care
advance care for warriors and their families in all • Research and Program Evaluation
locations • Resilience and Prevention
• Strategy, Plans and Programs
National Intrepid Center of Excellence (NICoE) • TBI Clinical Standards of Care
Dedicated to advanced research, diagnosis and • Training and Education
treatment planning for PH and TBI
12 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Annual Report 2009 13
In its first two years, DCoE launched a historic journey to lead the services and nation in support of
warriors, veterans and their loved ones affected by PH and TBI conditions. Success ultimately depends upon
transforming military culture to embrace a public health model of peer-to-peer support, integrative care,
translational research and community-based partnerships to maximize resilience, recovery and reintegration.
Established a “Center of Centers” consultation, advanced diagnosis, treatment planning, family-
When DCoE opened its doors in November 2007, the first centered education, clinical translational research and long-
initiative was very clear: bring together four existing centers with term follow-up for military personnel with complex PH and TBI
proven expertise on PH- and TBI-related issues to coordinate conditions. Funded through the generosity of the Intrepid Fallen
and facilitate their efforts within a collaborative framework. Heroes Fund, NICoE will open in 2010.
As an integrated group, DCoE strives to increase the overall
effectiveness of treatment, research and education in PH and Set the PH and TBI Standards for Warrior Care
TBI to meet the needs of all warriors and their families. One of DCoE’s central functions is to standardize the quality of
care available to warriors experiencing PH and TBI symptoms. To
The existing centers included the Center for Deployment ensure that this important service is carried out, DCoE actively
Psychology (CDP), Center for the Study of Traumatic Stress collaborates to establish clinical practice guidelines (CPGs),
(CSTS), Defense and Veterans Brain Injury Center (DVBIC) and which are recommendations that improve the consistency of
Deployment Health Clinical Center (DHCC). Together these available treatments based on evidence from systematic review Led Development of Global Standards of regard to everything TBI. The group generates ideas and shares
centers began to work together to maximize opportunities for and synthesis. Care for TBI experiences and expertise. Additionally, DCoE leads a TBI
warriors and families to thrive through a collaborative global Clinicians currently treat an increasingly large population of dissemination strategy workgroup that includes representatives
network promoting resilience, recovery and reintegration for PH CPGs offer clear treatment and referral recommendations wounded warriors who have sustained mTBIs. In April 2009, from the services and VA to ensure that efforts related to TBI
and TBI. to providers for the diagnosis and treatment of PH and TBI DCoE teamed with component center DVBIC to host a two- product development and dissemination are not duplicated. This
problems. DCoE has collaborated with DoD and VA to produce day consensus conference aimed at developing a guidance group also serves as a mechanism through which information
new evidence-based CPGs and refine existing ones. This is document for the services that addressed the issues of can be shared and disseminated to their respective audiences.
Created Additional Centers accomplished by participating in working groups on mild TBI assessment, intervention, programs and outcomes as they relate
To complement the collective capabilities of CDP, CSTS, DVBIC (mTBI), major depressive disorder, PTSD, substance use disorders, to cognitive rehabilitation. The conference produced cognitive
and DHCC, DCoE created and incorporated two additional chronic opioid therapy and post-deployment health evaluation rehabilitation clinical guidance that will be implemented in 14 Conducted Site Visits at MHS Facilities
centers into its network: the National Center for Telehealth and management. These working groups are brought together sites for initial trial and evaluation, after which time they may be DCoE actively participates in site visits that allow collaborative
and Technology (T2) and National Intrepid Center of Excellence regularly in varied locations across the nation and produce used throughout DoD. relationships with PH and TBI programs across the MHS. These
(NICoE). T2 is the backbone of technology advancement at valuable insights that drive consistency across locations, prevent visits serve as a vital link in bringing key research findings for
DCoE as it develops, researches, evaluates, standardizes and redundancies and share valuable information with providers DCoE actively leads two working groups on TBI. First, the Quad PH and TBI into clinical practice. Site visits provide a network
deploys new and existing technologies to improve the lives of and clinicians. In conjunction with these CPG workgroups, DCoE Service Workgroup consists of representatives from each of of expertise between DoD and VA, as well as public and private
our nation’s service members, veterans and families. NICoE will conducts workgroups to produce clinical support tools. These tools the services (Army, Navy, Air Force and Marine Corps) and is sector mental health clinicians and TBI clinicians. Working
serve as DCoE’s hub of its network of networks to provide global serve to drive adoption of CPGs by providers of PH and TBI care. led by DCoE. This group identifies unmet needs and challenges together results in standardized care, coordination of best
either within their respective services or DoD as a whole in practices and increased access to CPGs.

2007 2008
DCOE Milestones November 2007 January 2008 February 2008 March 2008 April 2008 May 2008
Advancing the DCoE headquarters opens DoD Suicide Event Report First Strategic Planning First monthly global video “Talk, Listen, Connect” DVBIC releases Clinical
(DoDSER) is deployed to Summit defines DCoE teleconference (VTC) held Phase II program is Practice Guidance for
Continuum of Care
standardize suicide data directorates (p. 18) released with Sesame mild TBI in non-deployed
(p. 17) Workshop (p. 15-16) settings
14 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Annual Report 2009 15
“
Despite our best efforts, there is still a stigma associated with seeking help for
The DCoE Outreach Center provides valuable tools, tips and
resources on all PH and TBI issues, including but not limited to
psychological injuries. To that end...the department has also launched the Real
resilience programs, suicide prevention initiatives, family and
relationship support, alcohol and substance abuse programs and
Warriors Campaign, a national multimedia public education effort designed to
tips to navigating the MHS. It is staffed by experts in the fi eld,
with advanced degrees in nursing and PH. When necessary,
combat this stigma. ”
consultants refer callers to the appropriate center within DoD,
other federal agencies or community organizations. — Secretary of Defense Dr. Robert M. Gates, October 2009
The DCoE Outreach Center can be reached by phone toll-free at
Over the past year, DCoE participated in 11 site visits focused 866-966-1020, by e-mail at [email protected] or via • Video profi les of campaign hosted feedback sessions to communicate directly
on TBI, in which subject matter experts facilitated and evaluated the online Live Chat at www.dcoe.health.mil/24-7help.aspx. warriors who have with military personnel about stigma, which informed the
the implementation of innovative practices, worked with new received care and are campaign’s developing content and provided DCoE with valuable
standards of care, participated in provider training and improved Targeted Stigma with “Real Warriors” Campaign maintaining successful insights.
clinical and administrative processes. After each visit, DCoE In May 2009, DCoE launched Real Warriors, an innovative military careers sharing
provided consultation to the site and monitored their progress in multimedia public education campaign aimed at dispelling the their experiences and Because of its progressive message, the campaign has received
making improvements. DCoE will continue its program to help stigma that is associated with seeking treatment for PH and TBI encouraging others to reach out for help. Public service signifi cant coverage in national, military and local media.
service members to receive the best possible care for TBI. issues in the military. DCoE enacted the campaign to eradicate announcements based on select video profi les have reached Appearances on CNN and “The Today Show” attest to the quality
the belief that seeking care will harm warriors’ careers, cost more than 1 million service members in 177 countries and of media coverage, but the quantity of media coverage has also
Additionally, DCoE participated in 20 PH-related site visits in the them the respect of their unit or make them appear weak, and have appeared on 141 domestic civilian stations. been signifi cant. In fact, the campaign has reached hundreds
past year that supported standardized PH care provision and to promote cultural transformation, in which asking for help is a •• 225500,,000000 ppoosstteerrss aanndd flfl yyeerrss ooff tthhoouussaannddss ooff iinnddiivviidduuaallss tthhrroouugghh bbrrooaaddccaasstt,, pprriinntt aanndd oonnlliinnee
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posts that had implemented RESPECT-Mil, a program that Dynamic communications on several fronts have directly • An innovative
integrates primary care and behavioral health care services engaged military personnel, families and health care providers. social media
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DCoE is dedicated to ensuring that when service members which has delivered and Web bookmarking on Delicious and Digg. challenges of a parent in danger, DCoE partnered with Sesame
need help, they get it immediately, day or night, and in the most the campaign’s anti- Workshop, the nonprofi t educational organization behind
effective way possible. With that in mind, DCoE launched a stigma message to Real Warriors has “Sesame Street,” to develop and distribute a series of outreach
24/7 Outreach Center to connect service members, veterans, more than 100,000 partnered with programs. The Sesame Workshop series uses recognizable
families, health care providers, military leaders and employers visitors. The Web site more than 44 characters to explain the situations that military families face
with pertinent resources and services when they need them the features empowering organizations, including federal and national organizations such in a way that young children can easily understand. Topics
most. The DCoE Outreach Center provides confi dential guidance and informative articles as well as interactive message boards as VA and the Bob Woodruff Foundation. A multifaceted outreach have focused on issues related to multiple deployments and
and information through a toll-free phone number, e-mail, fax and an online chat (which connects users with the DCoE strategy has driven continued momentum in two key ways. First, family changes that occur when a parent is injured physically
and online chat. Outreach Center). active participation in more than 30 events addressing military or psychologically. Children are able to connect and better
PH and TBI has helped build a network of advocacy. Second, the understand the situation through familiar characters, while
May 2008 June 2008 June 2008 June 2008 July 2008 August 2008 August 2008 August 2008
CSTS publishes the fi rst NICoE groundbreaking First “DCoE in Action” T2 begins study Educational DCoE Web Resilience Continuum T2 launches CDP expands enrollment
studies on human PTSD ceremony in Bethesda, newsletter published evaluating Virtual Reality site launches at Model launches (p. 17) afterdeployment.org to of “Topics in Deployment
brain tissue (p.22) Md. (p. 25) (p. 38) Exposure Therapy versus www.dcoe.health.mil provide resources to Psychology” training (p. 21)
Prolonged Exposure warriors, veterans and
Therapy (p. 25) families (p. 25)
16 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Annual Report 2009 17
and discussing their feelings. In September 2009, “Family DCoE, T2, SPARRC and the services EEAARRLLYY IINNTTEERRVVEENNTTIIOONN
Connections” won the Interactive Media Award for Best in Class collaborated to lead the creation of the
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in children’s Web sites. DoD Suicide Event Report (DoDSER),
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which standardized the collection of • Peak • Irritable • Feelings • Depression
SS performance • Feeling of guilt and anxiety II
Going forward, DCoE continues to work with Sesame Workshop suicide event details, victims’ personal • Positive overwhelmed • Decreased • Anger and
II outlook • Difficulty energy aggression NN
and is producing a third video program, which will deal with the historical information and data about • Sense of sleeping and • Anxiety • Danger to
LL purpose inability to • Loss of self or others TT
most daunting topic yet: the death of a parent. Similar to the first other potential risk factors. Each • Embraces relax appetite
II challenge • Problems • Social EE
two programs, the third will feature “Sesame Street” characters military suicide report is now filed in concentrating isolation
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helping children cope with such a devastating loss and will also the DoD Suicide Database, which was
NN Mission Stress Persistent Mission RR
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include stories from brave military families across the nation. established in January 2008. This
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DCoE is committed to helping our warriors’ families through the new database records up to 250 data
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best of times and the most difficult times. points per suicide, offering the military Medical
II
services access to standardized Education and Risk Combat Stress Treatment and
Training Mitigation Intervention Reintegration OO
data for the first time. Standardized
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parents are provided with helpful tools to foster communication. Contributed to Suicide Prevention Efforts information and reporting will allow RREECCOOVVEERRYY
This partnership produced two video programs, “When Parents The loss of any service member to suicide is tragic. DCoE is the military services to track and
Are Deployed” and “Coming Home: Military Families Cope committed to reducing the number of suicides as quickly as analyze suicide data proactively to
with Change,” as well as an interactive Web site, “Family possible by ensuring that every service member receives the improve prevention, intervention and treatment services. No units, by assessing and treating physical and psychological
Connections.” highest quality care and resources across the spectrum through other organization or mechanism has existed to develop, formally concerns early and by providing support networks for successful
resilience, prevention, diagnosis, treatment, recovery and require and monitor compliance across DoD for standardized reintegration. As part of these efforts, DCoE participated in site
The first program, “When Parents Are Deployed,” described the reintegration. To reduce the number of military suicides, it is suicide data via diligently developed systems. Additionally, visits to resilience programs in many areas across DoD. These
three stages of transition families go through when experiencing essential to develop short- and long-term plans for addressing DCoE provides a quarterly and annual report to the Secretary of visits built collaboration as well as aided in the development of
pre-deployment, deployment and homecoming. The second the effects of deployment and combat exposure on the brave Defense on the rate of suicides and prevention initiatives. program evaluation criteria.
program, “Coming Home: Military Families Cope with Change,” men and women of the armed services.
shared inspirational stories of military families coping with In January 2009, DCoE joined with VA to co-sponsor the first- To enhance resilience, maximize recovery and promote
physical, emotional and psychological injuries. More than DCoE chairs the Suicide Prevention and Risk Reduction ever joint annual conference on suicide prevention, “Building reintegration, DCoE promotes a holistic approach that integrates
400,000 DVDs of the bilingual program (English and Spanish) Committee (SPARRC), which was formed to examine military Community Connections: Suicide Prevention for the 21st physical, psychological, social and spiritual strength. DCoE
have been distributed to date. In addition, the programs are suicide, standardize reporting, collaborate with other experts Century,” to enhance awareness of best practices and treatment adapted the Marine Corps Resilience Continuum Model (above)
available for free download on iTunes to increase the number of in the field and advise on future prevention initiatives. An methods for suicide prevention. The conference brought together as a framework that wholly represents the journey of a wounded
families reached. The video programs won a prestigious CINE excellent example of federal and non-federal collaboration, leading experts in government, medicine and the private warrior from a state of illness to a state of optimal performance.
Golden Eagle Award in 2009. SPARRC includes representatives from military service suicide sector for the common goal of decreasing suicide rates. Four This model establishes a collaborative partnership between line
prevention programs, National Guard Bureau, Reserve Affairs, areas were targeted: clinical intervention, multi-disciplinary and medical leaders to ensure the use of relevant and timely
The “Family Connections” Web site Office of Armed Forces Medical Examiner, T2, VA and Substance approaches, practical applications and tools and research and tools, while also increasing the operational readiness across
(www.SesameStreetFamilyConnections.org) serves as an Abuse and Mental Health Services Administration (SAMHSA, an academics. peer, family, organizational and community systems.
ongoing initiative to help children cope with deployments, entity of NIH). SPARRC is a leading voice in the area of suicide
multiple deployments and injured parents, and allows families prevention, presenting at multiple conferences across the DCoE’s Chaplain Resilience Program Workgroup facilitates
and friends to stay in touch through messages, artwork, nation and participating in working groups on the topic. DCoE Promoted Resilience Efforts communication and cooperation between DCoE and chaplains.
photos and video clips. In addition, “Family Connections” offers also collaborates on workgroups to standardize the methods One of DCoE’s main objectives is to create a culture and The group has improved connectivity between chaplains in
communication tips for parents and videos for children that for assessing and discussing suicide throughout DoD and VA, system of resilience. A military culture based on resilience different military services and has heightened awareness of
feature favorite “Sesame Street” characters asking questions focusing on assessment tools and nomenclature. increases force readiness by strengthening individuals and Chaplain Resilience Programs. This group is a critically important
September 2008 October 2008 October 2008 October 2008 November 2008 November 2008 November 2008 November 2008
DVBIC holds Second T2 conducts first clinical DCoE co-hosts first Report titled “Section DCoE hosts first annual CSTS presents first PTSD DCoE one-year DHCC delivers 40th
Annual TBI Military training workshop for annual conference 1624, Establishment of Warrior Resilience biomarker studies anniversary cycle of Specialized Care
Training Conference DoD/VA providers on on trauma spectrum DCoE” is submitted to Conference (p. 17) Program Track II (p. 24)
Virtual Reality Exposure disorders (p. 29) Congress
Therapy for PTSD