Subject: RE: Video Request: Cotton At Subcommittee on Personnel hearing
From: "Yoxall, Collin" <[email-masked]>
To: Research_D <[email-masked]>
Date: Mon, 25 Apr 2016 09:13:20 -0700

GRAHAM: Thank you. For the record, Senator Cotton served a tour of duty in combat in Iraq. I think you were a platoon leader. Is that correct? So, Senator Cotton?
COTTON: Thank you, Chairman Graham. And I can say that the system that Captain Greenhalgh described has been in effect for at least 10 years, at least in the Army.
I want to talk briefly about the relationship between traumatic brain injury and post-traumatic stress. One does not necessarily presume or infer the other. Is that correct?
(UNKNOWN): Not necessarily, sir. I think certainly if someone has been exposed in a traumatic event downrange, that resulted in a traumatic brain injury, I think the possibility is greater that they will also have comorbid post-traumatic stress along with that. And I do believe that the history of TBI sort of predisposes someone to be more vulnerable to psychological health issues down range or down the road.
And some of that has to do with the chronic effects, if that is a servicemember who has chronic effects of the TBI, developing some symptoms that are very suggestive also of psychological health issues. There's a lot of overlap there, as well.
(UNKNOWN): And I'd say patients often present to us in an undifferentiated state. They'll present maybe with the problem with suicidality, maybe a substance use disorder, maybe a pain disorder. Sometimes it's very hard for us to discern what the precipitant was.
STREET: I have nothing to add.
COTTON: Is one easier to diagnose that the other?
(UNKNOWN): From a...
COTTON: To the extent that you can separate the comorbidity of the two?
GREENHALGH: Well, so my background, sir, is primary care. So I would say certainly we see a lot of behavioral health in the primary care setting. But given that we have very strong CPGs for a lot of things that we take care of in -- you know, in military medicine and just medicine in general, when I see a patient who has a history that sort of fits within the clinical practice guideline description for a certain kind of diagnosis, I find that from the primary care perspective, the TBI is certainly an easy one to try and fit into that, you know, diagnostic realm.
COLSTON: Some of it has to do with patients that present in front of us. For Walt in a primary care setting, he's going to see a different patient population than I'll see in a psychiatric setting. One of the things that occurs to me is the science for PTSD is probably more developed than the science is for TBI. Science for TBI is really in a nascent stage, so PTSD is a little easier to discern. It's a little easier to discern from a child psychiatry standpoint, with regard to development trauma, just because the prevalence of that is so high.
STREET: And just to add, I concur that the research based on PTSD is a bit further along. And as part of that, we have existing well-validated instruments for the screening and diagnosis of PTSD. And I think those instruments are being developed for TBI, but are not as far along, haven't undergone as rigorous of tests.
COTTON: So the science for PTS is further along than TBI? Is that simply because of the volume of patients that the medical world has seen with post-traumatic stress as opposed to TBI?
COLSTON: I think it's a number of factors. The science of TBI has been really hard to get a handle on, just from the standpoint of, you know, it took -- I'll give you an example, sir. It took 20 years and $50 billion to get on top of HIV. HIV has about a dozen genes and two serotypes. The brain uses about 20,000 of the 30,000 genes in the human genome. Understanding the way the brain works, especially a brain that's traumatized, is extremely hard.
With regard to PTSD, we at least have a long history of looking at people who are traumatized and a long history of treatment interventions, so I think the science is more developed for that reason. The prevalences of both of those in DOD, the prevalence of PTSD is about 2 percent, TBI slightly lower.
STREET: I think from a historical perspective, we really became aware of PTSD following the Vietnam war. And so we've had that span of history to really think about the disorder, the diagnosis, and the treatment of the disorder. TBI is something that we've become so much more aware of during the recent conflicts in Iraq and Afghanistan.
GREENHALGH: If I could just add, sir, again, from the primary perspective, there have been versions of PTS it seems from conflicts centuries ago, as well, the idea of shell shock and things like that. I think we've gotten more of a handle on it after the Vietnam conflict. But as Captain Colston alluded to, with technology, neuroimaging capability, that really has just been a phenomenon of our generation, and so I think there's a lot of potential there.
And again, from the primary care perspective, having neuroimaging support certain diagnostic criteria for traumatic brain injury I think that's where there's a lot of potential for the science, but I agree. I think we've been describing things like PTS for quite a lot longer than we have traumatic brain injury.
COTTON: One word I think I heard you use twice, maybe three times was longitudinal. The root of that is long, which is a little worse, given the number of people who suffer from PTS or TBI. Obviously, when you're conduct a longitudinal study, it takes many years to get results. Is that something about which we should be concerned?
COLSTON: Yes, sir, but it's the only way that we can do it, because these things don't present in silos. PTS doesn't present in a silo. TBI doesn't present in a silo. So we've got to get a handle on where the patients are.
And we have a lot of efforts. We've got the Millennium Cohort Study. We've got the 15-year TBI study. We have the STARS longitudinal study on suicide. So we're looking at several hundred thousand patients now to get an idea of where patients are coming from.
GREENHALGH: And if I can add onto that, longitudinal doesn't mean that we have to wait until the study is over to start gathering data. So the 15-year study, for example, has report outs every four years. The next one is due next year. Not to mention the constant stream of data and research that is being formulated into papers and publications along the way. That's just a small example. So longitudinal, really, I think if anything, connotes a commitment to a long-term study of this, not to say that we're going to not give you any answers for 15 more years, sir.
COTTON: OK. Do you, can you, would it be productive to expand the data set to look at other occupations that might have similar risk factors, like, say, professional football, professional hockey, boxing? There may be others.
STREET: Certainly, the brain trust meeting that I described that's happening today and tomorrow is doing exactly that, and it's bringing in research from my institution, who was one of the first to identify this issue among professional football players, and taking that information and applying it to the military and veteran community. So for sure, these public-private partnerships, in which you can identify knowledge that's been gathered in other places and apply to this population I think are very promising.

From: Yoxall, Collin
Sent: Wednesday, April 20, 2016 3:18 PM
To: Research_D
Subject: RE: Video Request: Cotton At Subcommittee on Personnel hearing

System for ptsd and tbi has been in 10 years in the army. PTSD and TBI relationship? Can have one w/out the other?
Greenhalgh: no necessarly sir. Member can have underlying problems.
Colston: Service members come to us not differentiating. Present problems to us that make it hard for us to diagnos.
Street: nothing to add.

Cotton: is one easier to diagnos than the other?
Greenhalgh: we see lots of behavioral health in my field primary care. TBI is easy to put in diagnosing in primary care.
Colston: I see different patients in pycsoclogial. PTSD science is more advance than TBI.
Street: PTS research base is further along. Developing further tools for TBI.

Cotton: science is further for PTSD because of number of patients vs TBI?
Colston: science of TBI is really hard to get a handle on. HIV is easy to understand than the brian. PTSD has a deeper research history for us to draw on.
Street: we became aware of PTSD from Vietnam. TBI is more from Afghanistan and Iraq.
Greenhalgh: we have also have history going back to WWI. Having neuroimaging helps us.

Cotton: longitudinal studies take too long?
Colston: yes sir but it's the only way we can do it. Have multiple study?
Greenhlagh: just because its longitudinal doesn't mean we cant collect and access data.

Cotton: productive to expand to other fields, football, hockey?
Street: yes. I have experience taking football data and applying it to field.

From: Yoxall, Collin
Sent: Wednesday, April 20, 2016 3:17 PM
To: Research_D
Subject: Video Request: Cotton At Subcommittee on Personnel hearing

Started at the 48:49 mark. Sorry for getting off late

http://www.armed-services.senate.gov/hearings/16-04-20-current-state-of-research-diagnosis-and-treatment-for-post-traumatic-stress-disorder-and-traumatic-brain-injury

Collin Yoxall
Research Associate, DNC
Office: 202-863-8126 X8126
Mobile: 334-703-1690
[email-masked]<mailto:[email-masked]>