DR. WINKENWERDER: Okay. I'm good to go.

SILVERSTEIN: And so are we. I look at -- it's Mike Silverstein.

DR. WINKENWERDER: Hey, Mike.

SILVERSTEIN: How are you, Doctor?

DR. WINKENWERDER: Good.

SILVERSTEIN: The thing that really jumped out at me, I mean, we've done an awful lot of things on just the remarkable care of troops in theater and the job being done not just at Walter Reed or in Germany, but also down at Brooke.

But there hasn't been a lot done on PTSD, and yet it seems that the very nature of the insurgency, this would be something that's going to be an increasing concern -- the whole idea that anything can happen at any time -- and that's precisely the kind of stress that -- could you talk about the specificity of this particular war and the stress and PTSD?

DR. WINKENWERDER: Absolutely. First of all, thanks for the chance to join you this morning.

This issue of mental health and PTSD is a very important issue. It is a top concern for us, and we're doing a lot about it. We are for the first time in this conflict deploying with our deployed service members mental health teams. They are involved in ongoing mental health issues and support in theater, but they also deal with crises.

And they deal with events -- particularly, events after service members are seriously wounded or they're killed. And they go in and conduct group sessions and do assessments of people and so forth. It's very valuable. And it's all woven into the command structure as well, which I think is very important. So they operate as part of the team, not as a separate component of what we're doing.

In addition to that --

Yeah, I'm sorry. Go ahead.

SILVERSTEIN: I'm sorry.

With IEDs and, you know, the lack, to a large extent, of a front line, and the potential for violence anywhere, does this particular type of situation lend itself more to PTSD than traditional warfare?

DR. WINKENWERDER: I believe it does. I believe the uncertainty of attack, the lack of clearer front lines, and the uncertain nature of this conflict does contribute to psychological stress. We know that. This is what we call a "non-linear environment."

But on the other hand, I would say to you -- as opposed, for example, to Vietnam, our service members are far better psychologically prepared -- they're far better trained -- than the service member of the past. And that training -- particularly the group training, the preparation of what we call "battle mind," so people know, to the greatest extent possible before they go, the kinds of things they're likely to see, and of course we've had multiple -- we've had groups of service members who've deployed more than one time. So they surely know what they're likely to see.

But all of that does contribute to mental stability dealing with stress. And the experiences that people have, or the reactions that they have, are not unexpected. They would happen to most of us who are very well psychologically adjusted.

So I think it's important to realize that for most people, PTSD and other psychological reactions are normal reactions of the human mind to very stressful events. They are for the most part self-limited and time-limited. They don't go on for years. Most of the time, they don't go on for months and months. But they are there and they resolve, and they resolve, in our experience, typically better with group support, with counseling and with reassurance from people -- professionals that, you know, the individual will likely improve. Sometimes, medication is needed; sometimes more intensive therapy is needed.

There is a group of individuals -- and it is, fortunately, a relatively small subset -- who tend to have chronic problems that do last for a long time and that can get seriously in the way of their ability to do their work, in the way of relationships and their family. It can cause, you know, people to turn to substance abuse and alcohol, and those are the most tragic situations. We try, again, very hard to do everything that we can to avoid and avert those kinds of serious consequences.

SILVERSTEIN: Often, you have somebody who will experience, you know, an IED or something like that, not necessarily getting them, but maybe somebody in their convoy or something near them, and then they may rotate back home. Can -- are there symptoms that people can look for, for particularly normal reactions that become PTSD? And how do you handle that?

DR. WINKENWERDER: Yes, there are symptoms that people can look for. And one of the good things that we do today, that we did not do even during the first Gulf War, even during the conflicts in Bosnia, Kosovo, or certainly not in Vietnam, is we evaluate every single service member both before and after deployment. And the post-deployment assessment is done pretty much immediately at the time a person returns. And it involves answering a questionnaire; it's relatively detailed, and a face-to-face meeting with a medical professional.

In addition to that, we've over the last couple of years added another, third, evaluation that's done about three to six months after the service member returns, because what we found was that even though there's a certain percentage of people who will check off that they're experiencing symptoms that could be consistent with mental health problems or PTSD or physical problems, that people tend to want to get back with their family, they many times can't focus on those kinds of issues, they don't even feel them as much immediately but they begin to emerge a month, two months, three months down the line.

And so we've added this third evaluation, and through that evaluation we collect all of that information. We ask very specific questions about, you know, problems with sleep, problems with anxiety, problems with, you know, jumpiness, relationship issues, substance abuse issues. They're very -- you know, if any of us had to do it, we'd consider it pretty intrusive into our psychological well-being. But we do ask these questions, and we encourage people to be open and to be honest and, you know, share their issues so that we can help them. And that's called getting rid of the stigma of coming forward.

Now, have we been 100 percent successful at that? No. I'm sure that we continue to have some stigma, and some people who are reluctant to come forward because of the way in which they believe that it could affect their career. And that's just reality. But certainly the message that they're getting from me, from my office, from our surgeon's general, but, most importantly, the message I think they're getting today from their line leaders -- the rough and tough, you know, guys and gals that are leading their units -- is come forward. If you have issues, let's get on top of them and see if we can help you out and get you, you know, the help you need and then get, you know, back to regular duty if you have to take time off.

So that's our approach, and we have screened hundreds of thousands -- over a million, actually, in the post-deployment health assessment, because we've had several rotations of people coming back, and we're now into a hundreds of thousands of on this three-to-six-month assessment. That is because we instituted that a little bit later after the conflict began.

But we're reaching out in many, many ways. We're working with the VA as well and communicating all of this information to the VA electronically. That's something I want to emphasize is really the advances in record keeping, and that's very important because if people lose the records -- you know," What happened to you at point in time" -- and then somebody sees you a month or six months or a year or two years down the line, if they don't have that record, you know, the professional at that point is at a loss to try to figure out, you know, what did happen, what were you exposed to, what really was going on, what were your symptoms at that time.

And thank goodness, we're able to track all that pretty well today, and that's a marked success. We're really proud of that.

SILVERSTEIN: One thing I've learned about PTSD is that often three to four months after an event is when it may pop up, and by that time, somebody may be home and may be through some of these screenings but not all of them.

What's should a family look for? What are they keys that, you know, this particularly normal reaction to extreme stress -- how does it present itself?

DR. WINKENWERDER: Well, the person coming back may feel isolated, feel out of sorts, just not normal. I've talked to several people who have come back and have related this to me, including medical professionals, by the way. Doctors themselves are affected, and they're not immune to these kinds of issues.

But there, you know, can be startled reactions; looking under things all the time, and around, to see if there's any threat. You know, you're in a hyper, what's called a "hyper-vigilant state," always on the edge, anxious, worried -- you know, when you're in theater, obviously, trying to avert personal bodily attack, wounding, or death. And so your body revs up for that, and it doesn't always easily come down from that.

And so those are the kinds of things that people notice. There's additional stress that happens when there's separation for months or longer. And in many cases, if it's a male or female that's returning, their place in the household may have changed. And so they're dealing with coming back to a spouse that maybe, you know, has taken over the responsibilities. And the child or the children may have a different reaction to mom or dad. All of that is -- you know, that takes time to work through. Even though people typically stay in touch by telephone and by internet -- and I think that is a source of support, by the way, for our service members today who didn't have that, you know, a decade or two ago, but -- that helps, but it doesn't completely, by any stretch, avert some of the symptoms that we see.

SILVERSTEIN: Do most of these things heal over time? And how important is it -- or how efficacious is it to get help, to work your way through these things? And does that make it easier and more likely that the individual will heal and become whole again?

DR. WINKENWERDER: The answer is yes, in most cases, things do get better over time and there's healing, mental, psychological healing. If things like important relationships are not ruptured or people don't turn to substance abuse -- alcohol, drugs -- because they're obviously -- when you get into that direction, you can develop an addiction, a dependency -- so we try obviously to keep people away from those kinds of coping mechanisms and turn them towards other coping mechanisms, the psychological support, the group support, athletic activity, just -- time away, all of those things -- it's a healthier way to deal with these stresses.

So most people do recover, do reasonably well. But again, there are those folks who don't, and we're concerned about them. We want to identify them, because they may have trouble doing their job; they could be, you know, in some cases at the extreme a threat to themselves or other people; they may be at higher risk for suicide, though we have not seen -- I want to add at least what was related to me just recently by our Army Surgeon General -- any relationship between PTSD and suicide. We have not seen that at this point, having tried to look at that.

But we're trying everything that we know how to do to reach out. But at the end of the day, you know, this is war, and it's nasty and difficult and painful and brutal. And we -- you know, I think, again, the uncertainty, the difficulty of dealing with that, the horror of seeing people blown to bits, body parts, all of that, it's just -- you know, you can talk about it, but if you -- until you've experienced something like that, I think it's hard to put it into words.

But everything that we have learned tells us that it's better if people do talk about it than if they try to hold it all in and think that the best way is just to kind of tough it out. That tough-it-out approach tends not to work out very well, in many cases, over the long term.

SILVERSTEIN: So then I guess, you know, to wrap it up, there is a great deal more attention being placed right now to mental stress issues, and basically the baggage that our men and women are bringing home with them because of these experiences that they have faced, that the military is much more concerned with that now than they have ever been in any other war previously.

DR. WINKENWERDER: Absolutely, we are. I want to add one other just suggestion because we think it's important, and that is how the broader community reacts. I think there has been some work -- again, going back looking to -- looking back to the earlier era, Vietnam, where there was a broader negative reaction in the community to the returning service member. And that created great psychological conflict. I mean, here you have people who've gone out, sacrificed, put their life on the line, in many cases wounded, friends were killed, and then to be greeted in a negative way was very damaging.

So, fortunately, I think today we see a positive reaction about the service and the sacrifice; you know, the statement heard over and over again, which is great, we support our troops. I just think that's very important that that's the feeling, the sentiment that our service members get, and that that's reinforced with people saying nice things, "Thank you for your service," "I appreciate your service." That means a lot to people, just those little words of thanks and praise, and "Admire your courage." You know, irrespective of how one feels about the decision to have gone to war or how things have been conducted, any of that, you can leave all of that out and still, I think, get the message that we appreciate what you've done and we thank you for your service.

SILVERSTEIN: Is there anything that I haven't asked that perhaps I should have, or is there anything that you would want to add, Dr. Winkenwerder?

DR. WINKENWERDER I would just add that I'm immensely honored and privileged to be able to have served now in my sixth year, having come to this position as a civilian physician and former administrator and executive in the private health care system, a little bit unusual that someone like myself would end up in this position, but I did.

And it has been an incredibly rewarding experience, and I'm just awed by our medical professionals, our doctors, our nurses, our medics, in particular, and corps men, the ones that are out on the front lines. And by the way, the casualty rates among those groups are significant. We've lost many lives among our medics and corps men, and we have also lost nurses and physicians.

So they put their lives on the line to help their fellow service members and many times also to help an Iraqi or even to help an opponent, an insurgent or a terrorist, because they come to our hospitals and our people take care of them.

So they're doing the most noble work you can imagine, and they're just doing it really -- really, really well. And so I just want to commend all of our medical professionals in the military health system and thank them for their great work.

SILVERSTEIN: And thank you for your help and your great work as well, Doctor.

DR. WINKENWERDER: Thank you. Appreciate it.

SILVERSTEIN: Take care.

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