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GAO criticizes Pentagon center for PTSD, brain injuries

Reports: Organization plagued by weak leadership, unclear priorities

This story was originally published by ProPublica.

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If you want more explanation about the military’s troubles in treating troops with traumatic brain injuries and post-traumatic stress, read no further than two recent but largely unnoticed reports from the Government Accountability Office.

It turns out the Pentagon’s solution to the problems is an organization plagued by weak leadership, uncertain priorities and a money trail so tangled that even the GAO’s investigators couldn’t sort it out. The GAO findings on the Pentagon’s Defense Centers of Excellence (DCOE) echo our own series on the military’s difficulty in handling the so-called invisible wounds of war.

“We have an organization that exists, but we have considerable concern about what it is that it’s actually accomplishing,” said Denise Fantone, a GAO director who supervised research on one of the reports. She added: “I can’t say with any certainty that I know what DCOE does, and I think that’s a concern.”

First, some background. After the 2007 scandal over poor care delivered to soldiers at the Walter Reed Army Medical Center, Congress ordered the Pentagon to do a better job treating soldiers suffering from post-traumatic stress disorder and traumatic brain injury. The Pentagon’s answer was to create DCOE. The new organization was supposed to be a clearinghouse to foster cutting-edge research in treatments.

DCOE was rushed into existence in late 2007. Since then, it has churned through three leaders, including one let go after alleged sexual harassment of subordinates. It takes more than five months to hire each employee because of the federal government’s glacial process. As a result, private contractors make up much of the center’s staff.

“DCOE’s development has been challenged by a mission that lacks clarity and by time-consuming hiring processes,” according to the first report in the GAO series, focusing on “management weakness” at DCOE.

Just as concerning, the GAO says that it can’t quite figure out how much money DCOE has received or where it has all gone. DCOE has never submitted a budget document that fully conformed to typical federal standards, according to a GAO report released last month. In one year, the center simply turned in a spreadsheet without detailed explanations.

The Defense Department says that DCOE got $168 million beginning in fiscal year 2010—but the GAO isn’t buying that number: “Because of unresolved concerns with the reliability of funding and obligations data provided by DOD (Department of Defense), we cannot confirm the accuracy of figures related to DCOE.” The GAO report reproduces this disclaimer no fewer than five times.

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DCOE concurred with the bulk of the GAO’s findings and promised to fix its accounting errors and prevent them from happening again.

In its defense, DCOE has never had an easy job. It was created on the fly and tasked to deal with some of the most complicated mental-health issues in the military’s history. In addition, it has faced stiff bureaucratic resistance, with some Pentagon officials questioning its usefulness..

The Pentagon said that DCOE was conducting a “comprehensive review” to improve its operations.

“There is still substantial work to be done,” said Cynthia O. Smith, a Pentagon spokeswoman. “We must ensure we are properly allocating resources and establishing priorities to take care of our service members.”

One telling GAO footnote suggests the extent of the obstacles the organization has faced. In Pentagon war games, the enemy is generally represented by the color red. When Congress ordered up its improvements in 2007, the Pentagon created a special committee to push through reforms that led to DCOE’s creation.

The special committee decided to call itself the “Red Cell.” Why? “The daunting task facing this team would likely make them the enemy of everyone else in the bureaucracy they sought to change,” the GAO says.

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Members of the Massachusetts National Guard secure a construction site Friday in Qalat City, Afghanistan.

About traumatic brain injury

What is it? And how does it differ from a concussion?

Traumatic brain injury, or TBI, is a sudden trauma to the brain caused by force. A severe TBI can leave a person almost incapable of functioning. But even a mild TBI — a concussion — can lead to a range of debilitating symptoms: headaches, balance problems, hearing problems, lack of self-control, mood changes, ringing in the ears, problems sleeping and memory loss. While most people recover from a mild TBI, it can take months, even years.

According to the Centers for Disease Control and Prevention, "approximately 1.7 million people sustain a traumatic brain injury annually" in the United States, and "the majority of TBIs each year are concussions or other forms of mild TBI." For some basics on the science behind TBIs, see NOVA Science Now's "Brain Trauma" video and website.

The brain injuries sustained by soldiers serving in Iraq and Afghanistan are most often caused by explosives.

How many U.S. soldiers have TBI?

The exact number is hard to pinpoint. The Pentagon says about 115,000 soldiers have mild TBI, while the RAND Corporation study Invisible Wounds of War suggests the much higher number of 400,000 total TBIs, the majority of which are mild.

How is TBI diagnosed?

Diagnosing TBI can be hard. Symptoms of moderate to severe TBI can be obvious — extended loss of consciousness and severe neurological disorders — but diagnosing a mild TBI is trickier, especially during combat. Often soldiers don't even realize they have a mild brain injury after a blast. In some cases, combat medical records are lost or destroyed in theater.

And NPR and ProPublica found that "the military’s doctors and screening systems routinely miss brain trauma in soldiers."

The military uses two basic tests to diagnose the injury: The first, the Military Acute Concussion Evaluation, or MACE, is a survey taken immediately after an injury. NPR and ProPublica found that often soldiers learn to cheat on this test because they want to return to their platoon. The second, Automated Neuropsychological Assessment Metrics, or ANAM, "failed to catch nearly half of all soldiers who had suffered a concussion, according to a recent unpublished study obtained by NPR and ProPublica. Lt. Gen. Eric Scoomaker, the Army's top medical official, recently testified in Congress that results from the test are no better than a 'coin flip.'"

Another consideration in diagnosing TBI is its comorbidity with PTSD. In a response to NPR and ProPublica, Gen. Peter W. Chiarelli, the Army vice chief of staff, said "it was a mistake to focus solely on TBIs, since many soldiers are also suffering from post-traumatic stress, or PTS[D], a debilitating psychological wound that can be caused by the intense terror of being involved in a roadside blast. ... He said the military was diagnosing and treating soldiers suffering from both wounds."

How is TBI treated?

Treatment varies widely. There's no standard treatment. Although NPR and ProPublica found that regular and consistent cognitive rehabilitation therapy techniques to compensate for decreases in mental function — benefited several veterans, this type of treatment is rarely available through military medical care. Many soldiers have sought rehabilitative treatment at private facilities. For each of the three soldiers profiled in FRONTLINE's The Wounded Platoon the most common treatment given for their diagnosed TBI was pharmacological.

There is some hope that treatment in hyperbaric oxygen chambers might aid in recovery. A study on this therapy gets underway in 2011 and will be conducted at five U.S. bases by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

The most common way to prevent chronic TBI is to rest after receiving an injury to the head. The Pentagon recently released a new policy for the treatment of TBI, which includes a mandatory 24-hour rest period after a blast, and a complete neurological assessment for soldiers who have had three concussions. If a soldier with TBI is not taken out of theater to properly recover, any additional brain injuries can exacerbate the damage. Yet, as noted above, some soldiers may not realize they have TBI, or they brush off symptoms in order to rejoin their platoon.