Font Size Down Font Size Up Reset Font Size

Sign Up for Committee Updates

 

Hearing Transcript on Understanding and Preventing Veteran Suicide

Printer Friendly Version

Committee on Veterans' Affairs, Health Subcommittee,Understanding and
Preventing Veteran Suicide, 12-2-11

 

 

UNDERSTANDING AND PREVENTING VETERAN SUICIDE

 



HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON VETERANS' AFFAIRS

U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

FIRST SESSION


DECEMBER 2, 2011


SERIAL No. 112-36


Printed for the use of the Committee on Veterans'
Affairs

 

 

U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON, DC:  2012


For sale by the Superintendent of
Documents,  U.S. Government Printing Office

Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; DC
area (202) 512-1800

Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 20402-0001

 



COMMITTEE ON VETERANS' AFFAIRS


JEFF MILLER, Florida, Chairman

  CLIFF STEARNS, Florida

DOUG LAMBORN, Colorado

GUS M. BILIRAKIS, Florida

DAVID P. ROE, Tennessee

MARLIN A. STUTZMAN, Indiana

BILL FLORES, Texas

BILL JOHNSON, Ohio

JEFF DENHAM, California

JON RUNYAN, New Jersey

DAN BENISHEK, Michigan

ANN MARIE BUERKLE, New York

TIM HUELSKAMP, Kansas

MARK E. AMODEI, Nevada

ROBERT L. TURNER, New York
BOB FILNER, California, Ranking

CORRINE BROWN, Florida

SILVESTRE REYES, Texas

MICHAEL H. MICHAUD, Maine

LINDA T. SÁNCHEZ, California

BRUCE L. BRALEY, Iowa

JERRY MCNERNEY, California

JOE DONNELLY, Indiana

TIMOTHY J. WALZ, Minnesota

JOHN BARROW, Georgia

RUSS CARNAHAN, Missouri
 

 

 

Helen W. Tolar,
Staff Director and Chief Counsel


SUBCOMMITTEE ON HEALTH

ANN MARIE BUERKLE, New York,
Chairwoman

CLIFF STEARNS, Florida

GUS M. BILIRAKIS, Florida

DAVID P. ROE, Tennessee

DAN BENISHEK, Michigan

JEFF DENHAM, California

JON RUNYAN, New Jersey
MICHAEL H. MICHAUD, Maine,
Ranking

CORRINE BROWN, Florida

SILVESTRE REYES, Texas

RUSS CARNAHAN, Missouri

JOE DONNELLY, Indiana

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House,
public hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains
the official version.
Because electronic submissions are used
to prepare both printed and electronic versions of the hearing record,
the process of converting between various electronic formats may
introduce unintentional errors or omissions. Such occurrences are
inherent in the current publication process and should diminish as the
process is further refined.

 

       

C O N T E N T S

December 2, 2011


Understanding and Preventing Veteran Suicide

OPENING STATEMENTS

Chairwoman Ann Marie Buerkle

    Prepared statement of Chairwoman Buerkle

Hon. Michael H. Michaud., Ranking Democratic Member

    Prepared statement of Congressman Michaud

Hon. David P. Roe, Republican Member

Hon. Silvestre Reyes, Democratic Member, prepared statement of


 

WITNESSES

Commander René A. Campos, USN (Ret.), Deputy Director,
Government Relations, Military Officers Association of America

    Prepared statement of
Commander Campos

Tom Tarantino, Senior Legislative Associate, Iraq and Afghanistan Veterans of
America

    Prepared statement of Mr.
Tarantino

Thomas J. Berger, Ph.D., Executive Director, Veterans Health Council, Vietnam
Veterans of America

    Prepared statement of Dr.
Berger

Joy J. Ilem, Deputy National Legislative Director, Disabled American Veterans

    Prepared statement of Ms. Ilem

Margaret C. Harrell, Ph.D., Senior Fellow and Director, Joining Forces
Initiative Center for a New American Security

    Prepared statement of Dr.
Harrell

Katherine E. Watkins, M.D., Senior Natural Scientist, The RAND Corporation

    Prepared statement of Dr.
Watkins

Jan E. Kemp, RN, Ph.D., National Mental Health Director for Suicide Prevention,
Veterans Heath Administration, U.S. Department of Veterans Affairs

    Prepared statement of Dr. Kemp

Accompanied by:

Antoinette Zeiss, Ph.D. Chief Consultant for Mental Health Veterans Health
Administration U.S. Department of Veterans Affairs

 


SUBMISSIONS FOR THE RECORD

Colonel Carl Castro, Ph.D., Director, Military Operational
Medicine Research Program, U.S. Army Medical Research and Materiel Command, and
Chair, Joint Program Committee for Operational Medicine, Department of the Army,
U.S. Department of Defense

Paula Clayton, M.D., Medical Director, American Foundation for Suicide
Prevention

Lieutenant Colonel Michael Pooler, USA, Deputy Chief of Staff, Personnel, Maine
Army National Guard

Richard McCormick, Ph.D., Senior Scholar, Center for Health Care Policy, Case
Western Reserve University, Cleveland, OH

John E. Toczydlowski, Esq., Philadelphia, PA

 


MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

Hon. Michael H. Michaud,
Ranking Democratic Member, Subcommittee on Health,
Committee on Veterans' Affairs to Col Carl Castro, Ph.D., Director,
Military Operational Medicine Research Program Research Area Directorate
III, U.S. Army Medical Research & Material Command, U.S. Department of
Defense.

Response from Col Carl Castro,
Ph.D., Director, Military Operational Medicine Research Program Research
Area Directorate III, U.S. Army Medical Research & Material Command, U.S.
Department of Defense, to Hon. Michael H. Michaud, Ranking Democratic
Member, Subcommittee on Health, Committee on Veterans' Affairs.

 


UNDERSTANDING AND PREVENTING VETERAN SUICIDE


Friday, December 2, 2011

U. S. House of Representatives,

Subcommittee on Health,

Committee on Veterans' Affairs,

Washington, DC.

The subcommittee met, pursuant to notice, at
10:04 a.m., in Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle
[chairwoman of the subcommittee] presiding.

Present:  Representatives Buerkle, Stearns,
Roe, Michaud, Reyes, and Donnelly. 

OPENING STATEMENT OF CHAIRWOMAN BUERKLE

Ms. BUERKLE.  Good morning. 

And welcome to this morning's Subcommittee on
Health hearing.  Today we meet to search for answers to the most haunting of
questions:  What leads an individual who honorably served our Nation, out of
helplessness and hopelessness, to take their own life, and how do we prevent
such a tragedy from happening to one who has bravely worn the uniform and
defended our freedom? 

Suicide is undoubtedly a complex issue, but
it is also a preventable one, and I am deeply troubled by its persistent
prevalence in our military and veteran communities.  The statistics are
sobering:  Eighteen veterans commit suicide each day, with almost a third
receiving care from the Department of Veterans Affairs at the time of their
death.  Each month, there are 950 veterans being treated by the VA who attempt
suicide.  The number of military suicides has increased since the start of
Operations Enduring Freedom and Iraqi Freedom, with data from the Department of
Defense indicating servicemembers took their life at an approximate rate of
one every 36 hours from 2005 to 2010.  We continue to hear tragic stories
despite significant increases in recent years in the number of programs and
resources devoted to suicide prevention among our servicemembers and our veterans. 

Today we will hear from the VA that they are
making strides in identifying at‑risk servicemembers and veterans and
providing treatment for mental health and other disorders that can lead to
suicide.  Yet no matter how great our programs or services are, if they do
not connect with those who are in need, they do no good at all.  The VA and the
DOD continue to struggle with persistent obstacles, including data limitations,
cultural stigma, access issues, a lack of partnerships with community
providers, and outreach that relies on the servicemember, veteran, or loved one
to initiate treatment. 

We must do more to reach out to our veterans
inside and outside of the VA and DOD health care systems to ensure that all
those who need help get it.  They have earned it, and they deserve it before
time runs out. 

Until a family no longer must bear the pain
of losing a loved one, we are failing, and not enough is being done. 

I thank you all very much for joining us this
morning.  And now it gives me pleasure to introduce and recognize the ranking
member, Mr. Michaud. 

OPENING STATEMENT OF HON. MICHAUD, RANKING DEMOCRATIC
MEMBER

Mr. MICHAUD.  Thank you very much,
Madam Chair. 

I, too, would like to thank everyone for
attending today's hearing.  It is a tragedy that our servicemembers and
veterans survive the battlefield abroad only to return home and fall to suicide.  Since
2007, this committee has held five hearings regarding this issue of veterans
suicide, and the figures continue to increase at an alarming rate, far greater
than the comparable suicide rate among the general population.  The Center for
a New American Security in their recent publication study, entitled
"Losing the Battle:  The Challenges of Military Suicide," says that
from 2005 to 2010, servicemembers took their own lives at a rate of
approximately one every 36 hours.  This statistic is troubling, but it
pales compared to the VA's estimate that one veteran dies by suicide every
80 minutes. 

While I commend the VA's effort to reduce the
suicide rate, particularly with the success of its veterans crisis hotline,
challenges still remain.  Through this hearing, we will examine the steps the
VA is taking to strengthen data collection to pinpoint veterans who may be at
risk and to offer effective intervention.  In this process, we will also seek
to better understand the reasons why more and more servicemembers and veterans
are taking their own lives, and what VA and DOD are doing to put a stop to more
suicides. 

I would like to thank our panelists for
appearing before us this morning.  Particularly, I would like to commend Dr.
Kemp for her leadership.  Under her direction, the VA has made great strides in
its suicide prevention efforts.  Dr. Kemp's work is award‑winning, and
she has been named Federal Employee of the Year in 2009. 

I would also like to thank Maine Army
National Guard for submitting written testimony and for their effort to ensure
that every soldier has access to care that they need.  The Maine Army National
Guard already has a close working relationship with the suicide prevention
staff at Togus VA Hospital.  This is a relationship that must be replicated at
the national level, through cooperation between the VA and the DOD. 

Unfortunately, as the Maine Army National
Guard testimony points out, too many soldiers, including those not eligible for
VA benefits and those who do not have health insurance, struggle to find care. 
I look forward to hearing from all our witnesses today to discuss how we can
improve the access to treatment and prevention efforts to best serve our
Nation's veterans. 

I want to thank you, Madam Chair, for having
this very important hearing today and look forward to working with you as we
move forward to address these very critical issues.  I yield back the balance
of my time. 

Ms. BUERKLE.  Thank you very much. 

Before we begin, I would like to yield just a
moment to Dr. Roe, who I understand has a special constituent in the audience
that he would like to recognize. 

OPENING STATEMENT OF HON. ROE

Mr. ROE.  Thank you, Madam Chairman. 

And thank you for holding this hearing.  It
is actually not a constituent.  He is somebody I actually met on the phone at
first and then had a chance, the privilege to meet him in Memphis last fall. 

And Ron, would you stand, please? 

Madam Chairman, this is Ron Zelaski.  He is a
veteran of the Marine Corps.  And he walked across America barefooted to raise
awareness for veteran suicides.  And as he walked he wore a large sign that you
will see displayed in this committee room stating that 18 vets a day commit
suicide.  In order to bring attention to PTSD in the military, given today's
hearing topic, I wanted to make sure that we invited this veteran and recognize
his tremendous efforts on the military suicide and PTSD. 

Ms. BUERKLE.  Without objection.

Mr. ROE.  Thank you. 

And Ron, just from another veteran, and a
veteran that just returned from Afghanistan about 6 weeks ago, the way
that this is treated today, the way PTSD is acknowledged and treated today is
totally different than the end of Vietnam, when I got out of the military. 

And I think we had a vacuum of 20 years
of which we ignored our veterans, and you being one of them, me being one of
them.  That is not happening now, and it is not happening now thanks to people
like yourself, who took the time out to make this tremendous sacrifice for your
fellow veterans. 

So I want to thank you, and I want this room
to give Mr. Zelaski a great round of applause. 

I yield back. 

Ms. BUERKLE.  Thank you, Dr. Roe. 

And thank you, Mr. Zelaski, for being
here, for your service to our Nation, and for what you are doing to raise
awareness on behalf of our veterans. 

Before I welcome our first panel, I would like to express my extreme disappointment that the National Institute of
Mental Health declined to participate as a witness this morning in our second
panel.  Although a formal letter of invitation to testify was sent on November 7,
committee staff was informed on November 23 that bureaucratic
obstacles in clearing a statement would prevent the agency from being a part of
today's discussion. 

I find this unacceptable, especially given
NIMH's partnership with the Department of Army to administer the largest study
on suicide and behavioral health in the military, "The Army Study to
Assess Risk and Resilience in Servicemembers."  Our military deserves
better. 

In addition, I would like to note that
unfortunately our Department of Defense witness, Colonel Castro, is unable to
be with us this morning due to an illness.  Today we will begin this serious
discussion.  Given its importance and the critical need for VA and DOD to work
together in collaboration I fully expect to follow up with additional hearings
and oversight that will include DOD as a partner in the
new year. 

Now, I would like to invite our first panel
to the witness table.  It is always a pleasure to welcome the members of our
veterans service organizations to share their expertise with us.  With us today
are Commander Rene Campos, the deputy director of government relations for the
Military Officers Association of America; Mr. Tom Tarantino, a senior
legislative associate for the Iraq and Afghanistan Veterans of America; Dr.
Thomas Berger, the executive director of the Veterans Health Council for the
Vietnam Veterans of America; and Ms. Joy Ilem, the deputy national
legislative director for the Disabled American Veterans. 

Thank you all very much for joining us this
morning for this very important conversation. 

 

Ms. BUERKLE.  Commander Campos, we will start with you.  Please
proceed. 




STATEMENTS OF COMMANDER RENE A. CAMPOS, USN (RET.), DEPUTY DIRECTOR,
GOVERNMENT RELATIONS, MILITARY OFFICERS ASSOCIATION OF AMERICA; TOM TARANTINO,
SENIOR LEGISLATIVE ASSOCIATE, IRAQ AND AFGHANISTAN VETERANS OF AMERICA; THOMAS
J. BERGER, PH.D., EXECUTIVE DIRECTOR, VETERANS HEALTH COUNCIL, VIETNAM VETERANS
OF AMERICA; AND JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, DISABLED
AMERICAN VETERANS.

STATEMENT OF COMMANDER RENE A. CAMPOS, USN (RET.)

Commander CAMPOS.  Madam Chairman and
distinguished members of the subcommittee, on behalf of the 370,000 members of
the Military Officers Association of America, I am grateful for the opportunity
to present testimony on MOA's observations concerning the VA suicide prevention
programs and efforts. 

MOA thanks the subcommittee for its interest
in this extremely difficult issue and for your commitment to the health and
well‑being of our veterans and military families.  In conducting my
research for this hearing, we were really struck by the tremendous amount of
work that has been done, the steadfast determination of the VA central office
staff, and Secretary Shinseki's personal involvement in synchronizing the
agency's suicide prevention efforts is quite visionary.  The two most
impressive initiatives are the VA suicide prevention campaign, and thanks to
Dr. Kemp, the National Veterans Crisis Line. 

Despite the improvements, the VA concedes
barriers still exist to advancing suicide prevention to the level needed. 
Veterans and family members we talked to have seen great progress in improving
policies and programs.  But they have seen it at the national level.  They
don't always see these programs and policies implemented consistently across
all VA medical facilities. 

Here are some of the experiences veterans and
their families have told us.  One caregiver spouse of a veteran with PTSD said
that it took the VA 2 months to schedule an appointment just to get a fee‑based
referral for her husband, who had some difficulty with sleeping.  Now the
veteran must wait until May 2012 for the VA to do a required sleep study. 
The caregiver questions why it has taken almost a year for the VA to give her
husband the care he needs, especially since the VA knows that difficulty
sleeping is a risk factor, and her husband has a history of suicide attempts. 

Another caregiver spouse of a veteran with
PTSD and TBI told us that when my husband attempted suicide in March, the VA
doctor told me to go to the ER, but the ER had no beds and said he may have to
wait 24 hours before one was available.  They gave me no alternatives.  I
was scared, and no one in the VA did anything to help us or help me know what
to do in a situation like that. 

Finally, one severely disabled veteran with
TBI said that he was frustrated because his provider seldom talked to him or
asked him how he is doing.  He usually talked to the caregiver:  I just want
them to know that I can contribute to my care.  When they don't talk to me, it
makes me feel like they don't care about me. 

MOA urges Congress to take immediate action
on three recommendations which will further enhance VA's suicide prevention
efforts as well as address other systemic issues.  One, require VA and DOD to
establish a single strategy and joint suicide prevention office that reports
directly to the department secretaries through the senior oversight committee. 
Congress has been VA's and DOD's greatest champion on promoting collaboration
after Walter Reed.  We need that level of oversight now. 

Two, authorize funding to expand VHA mental
health capacity and capability in order to improve access and delivery of
quality and timely care and information.  There needs to be research that
includes a longitudinal study of the economic and societal costs of veteran
suicide in this country. 

And three, authorize additional funding to
expand outreach and marketing efforts to encourage enrollment of all eligible
veterans in VA health care, with special emphasis on the Guard and Reserve,
rural veterans, and high‑risk populations.  In other words, there needs
to be a long‑term investment in outreach and marketing to improve VA's
image and its brand if we are going to attract veterans to the system. 

MOA believes that there is a business case
for addressing suicide that should consider the impact of national security and
the long‑term costs to society of failing to do so.  We have no doubt,
with the will and the sense of urgency from Congress, the administration, DOD,
and the military services and VA, we can win the war on suicide.  After all,
our veteran and military medical systems have eliminated some tremendous
barriers, with unprecedented results in saving lives on and off the
battlefield.  We owe these heroes and their families our full commitment, and
eliminate remaining barriers to mental health care so they can obtain the
optimal quality of life. 

MOA's encouraged by the significant progress
made by the VA.  We thank the subcommittee for your leadership and your support
in helping our Nation's veterans and their families.  Thank you. 

[The statement of Commander Campos appears in the Appendix.]



Ms. BUERKLE.  Thank you, Commander
Campos. 

Mr. Tarantino, you may proceed.

STATEMENT OF TOM TARANTINO

Mr. TARANTINO.  Thank you, Madam
Chairwoman, Ranking Member Michaud, members of the committee. 

On behalf of Iraq and Afghanistan Veterans of
America's 200,000 member veterans and supporters, I want to thank you for
inviting me to speak on this pressing issue facing veterans and their families,
and that is the staggeringly high rate of suicide, not just amongst veterans,
but servicemembers as well. 

My name is Tom Tarantino, and I am the senior
legislative associate for IAVA.  I proudly served in the Army for
10 years, beginning my career as an enlisted Reservist, and ending as an
active duty cavalry officer.  Throughout these 10 years, my single most
important duty was to take care of other soldiers.  In the military, they teach
to us have each other's back both on the battlefield and off.  Although my
uniform is now a suit and tie, I have been proud to work with Congress to
continue to have the backs of America's veterans and servicemembers. 

Today's hearing on suicide really couldn't
have come at a more critical time.  The Defense Department recently reported
that 468 active duty and Reserve soldiers, sailors, airmen, and Marines
committed suicide in 2010.  Overall, the DOD tracked 863 suicide attempts, and
the rate for veterans is likely much higher.  Although we have this limited
data about servicemembers, there remains a fundamental gap when it comes to
understanding veteran suicide.  One of the greatest challenges in understanding
and preventing veteran suicide is this lack of full data.  If we don't know the
entirety of the problem, how could we ever hope to solve it? 

Even in this age of information and
technology, we have no way of tracking veterans, unless they interact with some
social service that happens to ask about their military service.  Frankly, this
is unacceptable.  To address this problem, we have to look a little bit outside
the box.  IAVA recommends that we need to collect this data, and we should do
it by expanding existing services, like the Centers for Disease Control and
Prevention's National Violent Death Reporting System. 

Currently, the CDC collects data on all
manner of violent deaths, including suicide, in 16 States.  Veteran status can
be reported to the CDC, either through the death certificate or by information
collected by the medical examiner.  If we expand this database to all 50 States
and require medical examiners to report veteran status to the CDC, then we can
get a much clearer picture of the problem and know where to better target our
limited resources. 

A critical step to understanding how we can
stop veteran and servicemembers suicides is to understand that suicide itself
is not the whole issue.  Suicide is the tragic conclusion of the failure to
address a spectrum of challenges that veterans face.  These challenges are not
just mental health injuries.  They include challenges finding employment,
reintegrating into family and community life, dealing with health care and
benefits bureaucracies that, frankly, are almost as traumatic as the injuries
themselves. 

Fighting suicide is not just about preventing
the act of suicide.  It is about providing a soft and productive landing for
veterans when they return home.  The problems of mental health care in the VA
system have been pretty well documented.  The VA reports that 18 veterans in
their care commit suicide every day, and wait times for mental health care, as
Commander Campos mentioned, are still unacceptably high.  And there is just not
enough mental health care providers to meet the need. 

We also know that many veterans may not be
seeking care because of the stigma attached to mental health injuries. 
Multiple studies confirm that veterans are concerned about seeking care because
it could impact their career both in and out of the military. 

To combat this, IAVA recommends that the VA
and the DOD partner with experts in the private and nonprofit community to fund
a robust, aggressive outreach campaign.  This campaign needs to focus on
directing veterans to services, such as the veterans centers, as well as local
community‑based and State‑based services.  It should be integrated
into local campaigns, such as San Francisco's new veterans 311 campaign for
their city.  This campaign needs to be well funded and reflect the best
practices and expertise of both the mental health and the advertising fields. 

It drives me nuts every time the VA asks me,
how do you reach out to veterans?  I tell them stop reaching out to veterans. 
Reach out to people.  And why are you asking me?  Go ask the people who know
how to sell toothpaste.  They can put your campaign in front of 40 million
eyeballs.  Me, not so much. 

Providing a smoother transition from the
military to civilian world is critical in preventing veteran suicide.  Ensuring
veterans access to mental health care is connected to other issues that can
contribute to a veterans' sense of stability throughout their transition home. 
We must tackle the other contributing factors, such as employment and
homelessness, that could increase the risk of veterans who are vulnerable to
suicide. 

The responsibility of building a support
network doesn't necessarily lie with the military and the veterans' families
alone.  Preventing veteran suicide is about easing the transition from military
to civilian life.  And it is our collective responsibility as a community.  Our
veterans are not just readjusting to their families or connecting with other
veterans; they are coming back to jobs.  They are using the G.I. Bill to go to
school and study at local colleges.  And they are seeking care and services
from businesses and providers across the community and outside of the veterans
network. 

We must focus on extending this understanding
not just to spouses, but also to society at large.  Teachers and professors
should know what students of theirs are veterans or the children of veterans
and servicemembers.  Businesses should invest in the leadership of returning
veterans by hiring them.  Health care providers must understand the injuries
facing these incredible men and women. 

By promoting awareness, we can ensure that
our entire community is able to support veterans throughout their transition
back to civilian life and help stem this tide of veteran suicide.  By
accurately measuring the problem, by improving access to mental health care,
and tackling the transition from military to civilian life and creating a
robust community of support, we may be able to significantly reduce the number
veterans that attempt to commit suicide every year. 

Veteran suicide does not have a silver bullet
solution.  No one bill is going to solve this problem.  But better practices
are out there.  And we don't want to have to ask ourselves if there was
something more we could have done.  Thank you very much for your time and
attention.  I will be glad to take your questions. 

[The statement of Mr. Tarantino appears in the Appendix.]



Ms. BUERKLE.  And thank you,
Mr. Tarantino. 

Dr. Berger, you may proceed.

STATEMENT OF THOMAS J. BERGER, PH.D.

Mr. BERGER.  Good morning, Madam
Chairman, Ranking Member Michaud, and members of the House Veterans' Affairs
Subcommittee on Health.  Vietnam Veterans of America thanks you for the
opportunity to present our views on understanding and preventing veteran
suicide.  We want to also thank you for your overall concern about the mental
health care and issues affecting America's troops and veterans. 

I beg your indulgence.  When I got up this
morning to get ready to come down here, I turned on my little BlackBerry here,
and I had a message from a colleague who lives in the north central States of
the U.S.  My colleague is also the mayor of a small town in this State, and a
member of VVA National Board.  And this is the message I received this
morning:  Sergeant so and so, 31 years old, from, will be buried at
Arlington Cemetery.  U.S. Army, two tours in Iraq, one tour in Afghanistan. 
Walked into the emergency room at, in this particular city and the State, and
stated to a nurse on duty that someone outside needed help.  He went outside
and shot himself in the chest.  On his arm was a note.  He had written his
blood type, A‑negative, and he had written, "Please use my organs
for someone more worthy than me." 

I am a little bit upset this morning to come
in, obviously, and talk about this issue after receiving this email this
morning.  We have been here before.  We are 10 years into the war, ladies
and gentlemen.  I appreciate the comments of my colleagues here, and I won't
belabor the fact that there have been some excellent efforts made by Dr. Kemp
and her division there.  And I will leave it at that.  But I will try to take
the rest of my allotted time and talk about VVA's concern with suicide within
the system. 

It is very challenging, as we have heard, to
determine an exact number of suicides.  Many times suicides are not reported,
and it is very difficult to determine whether or not a particular individual's
death was intentional.  For a suicide to be recognized, obviously examiners
must be able to say that the deceased meant to die.  And there are other
factors that contribute to the difficulty, including differences among States
as to who is mandated to report a death, as well as changes over time in the
coding of mortality rates.  But those aren't the problems. 

The problems, okay, and VVA has long believed
in the links between PTSD and suicide, and in fact, there is plenty of research
studies out there to suggest that suicide risk is highest in persons with
PTSD.  Others claim that suicide risk is higher in individuals because of
related psychiatric conditions.  But a study published by the National Co‑Morbidity
Survey showed that PTSD alone out of six anxiety diagnoses was significantly
associated with suicide ideation or attempts. 

Now, some studies point to PTSD as the cause
of suicide, suggesting that high levels of intrusive memories can also predict
the relative risk of suicide.  Anger and impulsivity are two more factors that
are on the list and, as you well know, are part of the symptomology for PTSD. 

Other research says that the most significant
predictor of both suicide attempts and preoccupation with suicide is combat‑related
guilt, particularly amongst Vietnam vets. 

All of this brings us full circle to what VVA
has been saying for at least the last 6 years.  If both DOD and VA were to
use the PTSD assessment protocols and guidelines, as strongly recommended by
the Institutes of Medicine back in 2006, then our veteran warriors would
receive the accurate mental health diagnoses needed to assess their suicide
risk status. 

Thank you.  I will be glad to answer any
questions.

[The statement of Mr. Berger appears in the Appendix.]



Ms. BUERKLE.  Thank you, Dr. Berger. 

Ms. Ilem, you may proceed.

STATEMENT OF JOY ILEM

Ms. ILEM.  Thank you, Madam Chair and
members of the subcommittee. 

I am pleased to present the DAV's views on
suicide prevention efforts in the Department of Veterans Affairs.  We
appreciate the subcommittee's continued focus on this difficult issue and on
the effectiveness of VA's mental health services. 

Suicide is a complex phenomenon, one in which
VA and DOD have struggled in finding preventative solutions and effective
strategies in the shadow of wars.  DAV observes that VA and DOD have made
visible and positive efforts to address the unique challenges in meeting the
mental health needs of post‑deployed active military personnel and newly
returning veterans. 

Both agencies are populated with dedicated
practitioners and specialists, researchers, policymakers, and other leaders who
continue developing new approaches to address suicide and attend to the other
serious emotional and behavioral consequences of war.  However, despite these
obvious efforts and the notable progress they have registered, it is clear that
more needs to be done. 

All the experts tell us that effective
suicide prevention must begin with strategies for routine mental health
screening and early intervention for everyone, accompanied by ready access to
comprehensive primary care and specialty treatments for any suspected serious
problems identified.  If not readily addressed, or untreated, problems of these
types can easily compound and become chronic.  Delay in treatment may lead to a
host of personal and social problems, including early discharge from the
military or other job loss, family breakup, homelessness, criminal
incarceration, and even suicidal thoughts and actions. 

In our opinion, VA has made valid efforts for
early identification and effective treatment of behavioral problems in
returning war veterans.  Likewise, Congress provided VA significant increases
in resources to institute system‑wide changes, expand mental health
staffing, integrate mental health services into its primary care system,
develop a specific suicide prevention program, expand programs for PTSD,
substance use disorders, and training on evidence‑based psychotherapies. 

As we understand it, the goal of VA's
strategy is to promote healthy outcomes and strengthen family unity, with a
focus on recovery.  In addition to the goal of recovery, VA has now adopted a
patient‑centered model of care.  These are the changes veterans say they
want, and we believe all of these efforts are moving VA in the right
direction.  But over the past several years, a number of congressional hearings
have been held, studies conducted, and informal surveys done related to the
effectiveness of VA mental health services, including questions about how to
alleviate the known access problems, stigma, gaps in services, and other
identified barriers to VA care.  The results help us frame the problem, but
they do not solve it. 

Based on the number of factors all of us are
keenly aware of, it appears that real challenges still block VA's goals of
meeting the most severe needs of a minority of new veterans who require
intensive therapies and who consume significant blocks of time of VA
practitioners.  In VA, these are the same professionals who must also meet the
mental health needs of a large population of older veterans with chronic and
severe mental illness in a constrained resource environment. 

Growth in demand for mental health services
impacts all of VA's providers and patients.  Unfortunately, it appears that VA
is still struggling to figure out the right balance to ensure it identifies
those few crucial cases with a high risk of suicide, while still meeting the
needs of other new veterans and the older chronically ill populations in a
clinically appropriate way for all, all while preventing suicides as the most
pressing public issue. 

With even more troops returning home by the
end of the year and many who will likely transition to veteran status, this is
an extremely complex mandate to meet, yet VA is attempting to do it and must
succeed. 

In closing, DAV believes VA is moving in an appropriate direction, but must
find a way to hear directly from veterans
trying to gain access to the system to better understand their unique needs and
desires for treatment and services, and then tailor programs accordingly.  We
also believe that listening to veterans' feedback and making necessary changes
are going to be essential to recreating a VA mental health system that meets veterans
where they are, that works for them, and is effective in achieving the
recoveries they all seek. 

Likewise, VA leadership must acknowledge and
address the challenges its providers are bringing to light.  We encourage VA
leadership to build on that knowledge to come, and to be more forthcoming in
dealing with the challenges it faces.  But despite DAV's concerns as expressed
here in my written statement, we do recognize the lifelong dedication of the
leaders of VA's Office of Mental Health and VA practitioners in the field. 

We appreciate their tireless commitment to
improving the system for all veterans in need, old and new. 

Madam Chairman, this completes my statement. 
I am happy to answer any questions you may have. 

[The statement of Ms. Ilem appears in the Appendix.]



Ms. BUERKLE.  Thank you very much, and
thank you to all of our panelists.  I will now yield myself 5 minutes for
questions. 

Dr. Berger, you mentioned that for years your organization has advocated the use of the PTSD assessment protocols and
guidelines.  Could you discuss these standards and how you think that they
would improve the situation and the quality of care for our veterans? 

Mr. BERGER.  If I may, Madam Chair, a
little bit of history.  The VA itself commissioned a group of some of the most
distinguished mental health experts in the country, including some people who
are on the staff of the VA itself, some years ago, in the early 2000s, about
2005 or so, to take a look at and develop a series of guidelines and protocols
to diagnose and assess PTSD.  They did so.  And in my written testimony, I have
the link to that document. 

Subsequently, there was no directive in any
aspect or area of the VA to utilize this document that they had paid all this
money for and utilized the time and services of these brilliant minds.  All
right.  We still have reports of people being assessed on the basis of a 30‑minute
interview, where most of the time the clinician is taking personal
information.  Those are the kinds of things that the guidelines, in our
opinion, the protocols that were developed were meant to minimize.  But they
still exist. 

Granted, since the IOM report was issued,
there are many more clinicians who aware of the guide and protocol, but largely
because of our efforts to educate them on this through our network of State
council chapters and that sort of thing.  So that is where it stands at the
present time.  And we just wish that it would be utilized by both DOD and VA. 
And we feel that if the correct assessment and diagnosis is made, then they can
move onto the suicide risk assessment, and everything should just follow
along. 

Ms. BUERKLE.  Thank you, Dr. Berger. 

I would like to think that there is no lack
of will to get to the root of this problem and to get our veterans the services
they need to avoid these suicides.  So I would ask each one of you, what to you is the biggest gap
or the biggest reason we are not getting
this problem solved?  It is getting worse instead of better.  What is the one
thing we need to focus on?  I would like to hear, if you could just tailor your
remarks so all four of you get the opportunity to respond, I would appreciate
it.  Thank you. 

We will start with Commander Campos. 

Commander CAMPOS.  Yes, ma'am.  I
think that is a very valid question.  And I think admittedly in recent
hearings, and as early as yesterday, VA admits that, and what we found in our
research is that there are definitely policies and programs in place, but the
challenge to VA is the execution and the implementation of these policies.  It
is a decentralized system.  And I think what we are hearing is that there is so
much focus now at the medical facility level of getting the numbers, and
getting people seen, and so on, that I think that it has become more of an
assembly line process.  And it is creating, I think, havoc in the system. 

And then you have the pockets of where there
aren't enough resources and staffing and facility infrastructure that the
system is overwhelmed, and the resources and the staffing and all the other
needs to support the system are not out there consistently. 

So I think for VA to get to a system of being
veteran‑centric, they are going to have to step away from focusing on
investigation, looking at the numbers, and start looking at the veterans
themselves and what their needs, and letting them be part of the discussion. 

Ms. BUERKLE.  Thank you. 

Mr. Tarantino? 

Mr. TARANTINO.  I know this is going
to kind of sound lame, but outreach and awareness.  I mean, bottom line, the VA
has good programs.  It has the crisis line.  It has the new Making Connections
program, which I think is pretty slick and pretty cool.  The problem is nobody
knows what the VA does.  Nobody barely even knows that the VA exists.  If you
go outside and pull a hundred people off the street, ask them what NASA does, I
guarantee you, you are going to get 90 of them are going to give you a pretty
decent answer.  And NASA affects a fraction of the percent of the population
directly in this country. 

Six percent of the population would be
directly affected by the VA.  You would be lucky if maybe 10 out of those
hundred would be able to tell you what VA does and what programs they have.  It
is because as a community, we are so insular.  We are insular to the veterans
community, the military community. 

As the veterans population is dynamically
shrinking, we have to stop that, and we have to change the way we think about
outreach to veterans.  And we have to reach out to families, to the community. 
Why?  There is not that many of us in my generation of veterans.  And guess
what, I am a soldier; I am also kind of a knucklehead.  I am not the one who is
going to go out and seek help.  It is going to be my girlfriend, my mom, my
best friend.  Those are the people you have to reach out to.  And that is where
we need to focus our efforts to stem the tide of this.

Ms. BUERKLE.  Thank you. 

My time has expired. 

I now yield to the ranking member, Mr. Michaud. 

Mr. MICHAUD.  Thank you very much,
Madam Chair. 

Dr. Berger, you had mentioned the fact that the VA has come full circle.  And you talked about DOD and VA using the PTSD
assessment protocol and guidelines.  That was one of his recommendations.  I
would like to ask the other three individuals whether or not you agree with that
assessment, that that is a good place to start. 

Commander CAMPOS.  I don't think I
have the expertise to really address that.  But I don't think we ever go wrong
by including VA and DOD collectively and collaboratively in addressing this
issue. 

Mr. TARANTINO.  Yes. 

Ms. ILEM.  I think what Dr. Berger
indicated, where the research indicates that direct link with higher risk of
suicide for those with PTSD.  So certainly it is absolutely critical to make
sure that people do get diagnosed or at least addressing that there is a
readjustment issue that needs to be dealt with to be able to get the proper
treatment and to avoid and prevent any further ‑‑ suicide or other
negative behaviors that can really impact them. 

Mr. MICHAUD.  Thank you. 

My next question for all of you then, we have
heard testimony about how the different VA facilities do things differently.  In
terms of accountability, oversight, monitoring, and evaluation of what the VA
is doing to implement strategies across the system so that our veterans are
getting the proper health care needs, is there anything that you think we
should be doing specifically, or advice you would have for the VA as far as the
accountability and oversight and monitoring? 

Ms. ILEM.  Dr. Schoen
has indicated that one of her goals in coming into the VA system, is the new
development of a two-pronged approach, one focused on policy issues and the
other focused on driving those policies out to the field and making sure
implementation is achieved is critical.  So I would be interested to hear more from her on the second panel
in terms of how they think that is going. 

I know VA is trying to work on the
standardization of the package that they developed for mental health to have a
robust package in place at all locations and to decrease variance.  But the absolutely critical piece is who is connecting with the field, listening to
the feedback from providers and the directors and the leadership in the field. 
Where are they having the problem in doing something, what is the problem? You
know, is it lack of staff?  Lack of resources or just a significant
increase in veterans coming in?  So I think it can be unique in every location, some places have a problem and others don't.  But having those two
offices connecting up is essential. 

Mr. BERGER.  I would like to support
my colleague in his earlier comments about outreach.  The fact of the matter is
that almost 70 percent of America's veterans do not use the VA for lots of
different reasons.  So we are not getting the word out there.  And the word
that is getting out there, or the image that is projected because of the
shortness in resources and variability and accessibility of program concerns,
the vets aren't coming in. 

VA has to do a better job in terms of its
outreach program for the stuff that it does offer to get to the veterans.  And
let's get away from this development of policies and all these other kinds of
things that seem to get in the way of actually getting out there to our
veterans and make sure that they get the message that this is the system that
was developed and is in place for them. 

Commander CAMPOS.  I did have an
opportunity to talk to a DOD mental health professional before the hearing. 
And I know that there are folks out there who really want to work closer with
VA.  I know VA wants to work closer with DOD.  And these are leadership
issues.  And this mental health professional said the best thing we can do, especially
when we know people that are at high risk when they leave the military service
is to do that warm handoff to the VA where that veteran will go to.  They want
to do it.  But again, sometimes the barriers and bureaucracies get in the way. 
And I think that there are people in the VA system who really ‑‑
who are veterans themselves, and I think they can actually probably find some
of the solutions that plague the VA bureaucracy. 

Mr. MICHAUD.  Thank you. 

Thank you, Madam Chair. 

Ms. BUERKLE.  Thank you. 

I now yield 5 minutes to the gentleman
from Tennessee. 

Mr. ROE.  Thank you.  I don't
understand why NIMH wouldn't be here.  And I think we need to have an
explanation.  That boggles my mind.  But anyway, Mr. Michaud and I, I
guess 2 and a half years ago went to Afghanistan.  And we went back to
Afghanistan about 6 weeks ago to look at where the injuries occur at the
point of the spear, follow those physical and psychological injuries to
Landstuhl ‑‑ to the forward surgical hospital, to Kabul or
Leatherneck, to Landstuhl, and this Monday, I was at Walter Reed, Bethesda. 
And next week I am meeting with Dr. Brown, who is a psychiatrist at the VA at
Mountain Home, to try to close the loop so I have made full circle. 

What is happening now in Afghanistan, and I
assume in Iraq, the 101st Airborne Division really made a real effort in TBI
and PTSD to get on top of that early.  And what they found by doing that, and I
won't go through all the things we saw, but they actually got the fighter back
in the war, back into battle sooner by being proactive in treatment.  So I
think that is being done. 

And Dr. Berger, I mean, that is heartbreaking
that email you just read.  I know that that doesn't affect one person.  That
affects that family.  That family will deal with that every Christmas for the
rest of their lives, that family member will be. 

Tom, you had mentioned about getting
information out.  Yesterday, we had, I don't know whether you know Jim Young or
not, but Google has ‑‑ you probably do ‑‑ Google
has two people DOD assigned to help in their Google search engine to get
information out, which is how a lot of young people are treated in theater, for
instance.  Many of them are in isolated places, and they use tele‑health. 
And a lot of our younger soldiers, not like me ‑‑ I mean, I
couldn't do that ‑‑ but they enjoy, or it is easier for them,
because of the stigma of PTSD, they much prefer that.  And in some instances,
that works very well.  I think that could work here Stateside very well, where you
have overly burdened VAs.  So that is one thing. 

I know there is an organization we also went
to this week, Not Alone; I am sure you are aware of them, too.  They are in 20‑something
States now, who on their own outside the VA are another resource for veterans
to reach to if they know that they are there.  So I think this new way to
approach people with this right here.  Any way.  I mean, everybody has got a
cell phone now just about in this country.  And that is one way we could
communicate better, I think. 

And Tom, if you would, I was intrigued by the
311 campaign.  What are they doing there? 

Mr. TARANTINO.  Well, as you know,
many cities have a 311 campaign that allows you to access all manner of city
services.  New York has one.  I think Houston has one, you know, Chicago.  And
in San Francisco, we were contacted by the former mayor and asked, you know, we
have a lot of veterans in San Francisco.  We have a lot of veterans services,
but we need a way to get our citizens to these services.  And so we worked with
them to develop a campaign where when you call 311, if you are a veteran, you
press ‑‑ I can't remember what the exact number is, one or
two ‑‑ and you get sent on a separate track, meaning you have
a shorter queue, you get sent to a separate track of veterans services, you
have unique access.  And that works, not just on the phone, but it works online
as well.  And I know, coming from the Bay area myself and from the State of
California, they actually do this with all their social services.  If you are a
vet, there is a separate line, there is a separate track that you go through. 
And the services are more tailored to you.  And the idea of integrating
national and VA services is the VA has the power to be omnipresent.  They have
the power to set minimum standards for care and services.  But it doesn't mean
that we can't use the multiple touch points and interactions that are actually
happening in communities that we don't know about because we are not tracking
it.  And I am not talking about contracting; we are just talking about
partnerships for care.  And I think by developing that type of model where, you
know, city services and State services have some sort of integration, or at
least have some sort of cross‑talk and communication with VA services,
then you can actually catch a lot more people before they get to that tragic
conclusion of suicide. 

Mr. ROE.  Commander Campos, we talked
with Commander Evans at Bethesda on Monday.  And she was of the opinion that a
lot of times ‑‑ I know you are looking at another layer ‑‑
but I wonder if the resources aren't there now, and instead of creating another
bureaucracy, just organize the resources that we have.  Because that was one of
the problems that they were dealing with, there were so many ways of ‑‑
you know, the veterans, wounded warriors dealing with seven, eight, nine, 10
people, and it got confusing for them.  It would be confusing for me to deal
with eight different people making rounds on me every day.  Usually, when I
made rounds in the hospital, there was a nurse and myself would come by and see
you, and you would know what was going on.  These veterans are facing multiple
people that come in to see them.  So I would like to work with you on that.  I
think that is a great idea.  But I wonder if we couldn't just organize what is
already there. 

The last thing ‑‑ and I know
my time has expired, I will be very quick ‑‑ do we know the
incidence of suicide among veterans 5, 10, 15, 20, 30 years ago?  And is
what we are doing changing it?  Are we collecting data better now than we used
to?  That is the thing that it is hard for me to understand.  You know, before,
did we just not have the information?  And are we doing a better data
collecting now making it look higher? 

Mr. BERGER.  I think there are more
States, for example, that have responded to the call to report violent deaths,
has been hinted at, more accurately than there were in my generation of
veterans.  But the fact remains that it is still, because it is some corners of
the country and some corners of the States, it is just simply not reported as a
suicide.  And until we can get some kind of way to address that, I don't know
if we are going to ‑‑

Mr. ROE.  See what I am saying?  Was
it apples to apples? 

Mr. BERGER.  Exactly. 

Mr. ROE.  My time has expired.  I
yield back. 

Ms. BUERKLE.  Thank you, Dr. Roe. 

I now yield to the gentleman from Texas,
Mr. Reyes. 

Mr. REYES.  Thank you, Madam Chair,
and thank you for calling this hearing.  And I had a question for my colleague,
Dr. Roe.  When you asked unanimous consent to enter into the record Ron's
information, is it the letter to the Veterans Committee? 

Mr. ROE.  Yes.  I think that is it. 

Mr. REYES.  If it is not, I would ask
the same unanimous consent.  And the reason is because, Ron, thank you so much
for ‑‑ I got the opportunity to talk to him yesterday.  I had
never met him before, but I had heard of him.  And so I appreciate the work
that you have done.  And in his letter to the Veterans' Affairs Committee,
there are a number of recommendations that he makes and he identifies that
track very well with what our panelists have said here this morning.  And in
the interests of transparency, I am a life member of both the VVA and the DAV. 
But I wanted to add, being a Vietnam veteran, having come back during the
tumultuous time when we were not received as well as, thank God, today's
veterans are, one of the constant questions that is asked, at least in my
district, by some of our same veterans groups is a question of, you know, with
the kind of support that ‑‑ outpouring of support that
veterans are seeing today, it is incredible that we are still going through all
of these issues.  But I try to explain to people, you know, we don't have all
the information.  Because as I, too, go to Afghanistan, Pakistan, Iraq, Kuwait;
anecdotally I get information from active duty personnel that they are still
reluctant to come forward with concerns of PTSD and sometimes TBI because they
think ‑‑ they want the military as a career, and they think it
is going to hurt their career.  I really do believe it is important, and our
ranking member here can attest to it, when we had the full committee hearing,
one of the recommendations that I made to Chairman Miller is we have to bring
in Secretary Shinseki and Secretary Panetta so that we can work on these many
recommendations that all our veterans organizations have long recognized.  We
have to have a single effort, a single program of working between the DOD and
the VA, especially today when we are looking at tough budgets.  I asked staff,
because one of the ‑‑ I have been on this committee since I
have been in Congress.  I had to take a leave of absence when I was chairman of
the Intelligence Committee.  But my interest has always been there, being a
veteran, and having, by the way, Dr. Berger, a brother that served also in
Vietnam that absolutely refuses to go to the VA.  And his rationale, and he
suffers like many of us with that jungle rot that periodically comes up because
of stress, he refuses because he says, "Listen, I served my country not so
that my country would take care of me for the rest of my life."  So he is
very independent that way.  And a number of veterans are.  In the 16th District
of Texas, I have a full‑time staff member that is actually going out
throughout the homeless population and the rescue mission and things like that
to ask people if they are veterans so we can get that information to them.  But
some of them just absolutely, for many different reasons, some of them, because
they are obviously suffering from PTSD and other types of mental illnesses,
need to be brought in. 

So I was curious, I know my time is short, in
5 minutes, with all of things that we have to deal with, it is very short,
but Dr. Berger, do you have any observations on that? 

Mr. BERGER.  Well, first of all,
Congressman, thank you for your service, and welcome home, brother. 

Mr. REYES.  Thank you. 

Mr. BERGER.  Secondly, and to be quick
about this, my colleague Tom Tarantino mentioned something that is quite
understated, and you hinted at it also, and that is the brotherhood and
sisterhood that exists between veterans out there.  Veterans talk to one
another.  And maybe we will hear something about this a little bit later on. 
But in any case, one of the ways of getting the word out is veteran to
veteran.  Okay?  Despite all the signs on the buses and late night videos and
all that sort of thing, the fact of the matter is if Tom calls me ‑‑
I know Tom ‑‑ and says, I am having some problems with this or
whatever, you know, I will talk to him, and maybe even suggest that he go ‑‑
find out where he lives and suggest that he go.  And if I know a clinician
there or whatever, and say you need to ask for ‑‑ veteran to
veteran helps a lot. 

Mr. REYES.  And Madam Chairman, if I
can just have a second, in his letter to the Veterans' Affairs Committee, Ron
also makes mention of something that Tom did.  And that is the number of times,
as he walked across the country, that mothers and wives and relatives turned around
to commiserate with him, to hug him and cry with him about their loved one that
was suffering with PTSD, or had suffered with PTSD.  All of these issues are so
important.  That is why I say, let's, if we don't do anything else in this
Congress, let's get Secretary Shinseki and Secretary Panetta here before this
committee so we can start working towards one single understanding and probably
a number of different single programs in all these different areas that are
absolutely related.  It is not always about money because, you know, we funded
that independent budget when we were in the majority every year.  And the
organizations were very grateful.  But it certainly has not brought us to a
point where we are any more successful today, regrettably. 

So thank you again, Madam Chairman. 



Ms. BUERKLE.  Thank you.  I now yield
5 minutes to the gentleman from Florida. 

Mr. STEARNS.  Thank you, Madam Chair. 
A question.  When you look at the statistics of 18 deaths from suicides per day
and then about five of the deaths from suicides per day among veterans
receiving care.  Dr. Berger, are the care we give veterans who are actually
participating in a program, is it working?  I mean, with five of the 18 deaths
per day are coming from veterans actually receiving the care, and then when you
look at the statistics where about 11 percent of those who attempted
suicide did not succeed or have made repeated attempts with an average of nine‑month
follow‑up, so the question is, does the Veterans Administration have a
program that is working? 

Mr. BERGER.  At the present time,
there is so much variability across the spectrum of mental health services, not
only in the training of the clinicians and at the programs that are available, plus
just general physical access, and I think all of that enters into it.  And so I
would say there is room for lots of lots of improvement.

Mr. STEARNS.  On a 1‑to‑10
scale, how would you rate the Veterans success in preventing suicides? 

Mr. BERGER.  Four.

Mr. STEARNS.  That is a fail. 

Mr. BERGER.  Yes, sir.

Mr. STEARNS.  So what you are really
doing this morning is indicting the Veterans Administration, which ‑‑
I understand what you are saying, and I am sympathetic, because when I read
these statistics that is alarming to think that five people of the 18 actually
are getting clinical care.  So your rating it at 4 indicates that the Veterans
Administration is not providing the services. 

Even if we get the veterans there, even if we
get the communication and the education that Tom has talked about, once they
get there, they still were not successful.  And so ‑‑ and is
it possible the reason is because there are so many programs that are not
working together, or is it possible that the actual procedures are not working
or we just don't know enough about suicide. 

Mr. BERGER.  That is correct, we don't
know if they are working.  I would point out again the accessibility.  I mean,
we heard on the Senate side the other day the difficulties that some veterans
are suffering getting into the proper treatment program.  It may be days, it
may be weeks, it can be months.  And when you have got somebody who has been
through trauma, as the research suggests, serious combat trauma, who needs
help, you can't wait 6 weeks for your initial appointment.

Mr. STEARNS.  And, in fact, if a
person has to wait, it might contribute because he gets frustrated, he or she
gets frustrated, and to say there is no hope here and I am going to have to sit
around for weeks, possibly months, is that possible? 

Mr. BERGER.  Yes, sir.

Mr. STEARNS.  What would be the
longest wait that you have experienced or that you are familiar with that a
veteran who has suicide tendency has had to wait to get treatment? 

Mr. BERGER.  Eight months.

Mr. STEARNS.  Eight months, okay. 
Because I see here it is talking about ‑‑ there is something about
9 months in some of the fact sheets here.  Well, let me ask you this:  This is
a more difficult question.  Is the suicide rate from Iraq and Afghanistan worse
than it was from Vietnam and Korea, or is it just that we don't have the data? 

Mr. BERGER.  We don't have the data,
as Congressman Roe pointed out.  The information gathering or data collection
40 years ago, 35 years ago, is a lot different than it is now, although the
technologies have improved, reporting has improved.  It is difficult to
compare.  One thing we do here is that for a couple of years after the
cessation of hostilities in Vietnam, there was an increase in suicides.  That
is more anecdotal than anything.  But at the same time we are sort of hearing
that anecdote now beginning to arise.  And I have concerns professionally when
all these folks come home, if they don't have access to what they need in terms
of mental health services, and that includes accurate scientific‑based or
evidence‑based treatment programs when they need them, we are going to
have real problems.  And we got, what, half a million coming home here in the
next month? 

Mr. STEARNS.  Right.  Well, Madam
Chair, it seems to me that we can solve as Members of Congress with money to
the administration to get an educational component so the veteran coming home
will know of its availability.  We can actually probably convince a lot of
veterans to perhaps take the test when they leave the DOD.  But what I am
worried about is once they get in the VA, you are telling me there is no
accurate information to show that the program that they have implemented is
working, there is no statistical information that has been investigated to show
how successful, and then two, in a larger sense it is not working, it is
failing.

Mr. BERGER.  Sir, if there is an
outcome measurement being conducted I am not aware of it.  And then we need to
hear from the appropriate VA officials if indeed such information exists.  And
then I might be willing to revise my grading scale.

Mr. STEARNS.  Okay.  Well, I think you
got to be honest here.  And I just want, before I close, Madam Chair, to ask
each one do they agree with Dr. Berger?  You don't have to agree with his 4
rating, but in general, do you agree with what his assessment is?  Just say yes
or no. 

Commander CAMPOS.  Yes, sir. 

Mr. TARANTINO.  Yes, sir. 

Ms. ILEM.  Yes.  Many challenges.

Mr. STEARNS.  All right.  Thank you. 
Thank you, Madam Chair.

Ms. BUERKLE.  Thank you.  I now yield
to the gentleman from Indiana, Mr. Donnelly. 

Mr. DONNELLY.  Thank you, Madam
Chair.  One of the points has been the issue of isolation and that we will work
to put programs together, but 70 percent of the vets don't want to have
that initial contact.  And Tom's point about media and reaching out and
touching other family members about getting our other vets included, what are
your ‑‑ and Dr. Berger, you talk about vet to vet, that that is the
way, or one of the ways to help get this.  For that 70 percent, what other
ideas do you have to reach out to our vets, the vets who aren't going to join
DAV or VFW or the American Legion who aren't connecting to the VA but who
struggle every day? 

Mr. TARANTINO.  Well, Congressman, I can
talk a little bit about some of the lessons we have learned from IAVA's ad
council campaign.  That was very successful in reaching out to vets and their
families who otherwise might not have paid attention.  The commercials that we
produced and the PSAs that we have produced weren't done because Tom Tarantino
or Paul Rieckhoff are smart guys, and we know what we are doing.  We do in our
space, but we are not innovators in the advertising space.  This was done
because the Ad Council brought in professionals from BBDO and Sachi &
Sachi, people who know how to communicate, people who set the standards in this
country for how we publicly communicate. 

And we were able to, over the course of a
couple of years, bring in our knowledge base from the veterans community, match
it with their knowledge base from the advertising community and create an
outreach campaign that spoke to virtually everyone who saw it, whether you are
a vet or a civilian.  And that is something that the government really doesn't
do at all, and when they do do it, they do it poorly, and it is not very well
researched and it is not focused.  And I think a lot of times we trade
expedience for quality.  You want to get this campaign out, we got to get it
out in 6 months, and that is the metric for success.  Well, a bad campaign out
soon is just still a bad campaign.  So why aren't we taking the time to focus
test this?  Why aren't we talking to industry leaders?  Why aren't we going out
into the technology community and thinking what can we do?  Where are people
communicating on line and why aren't we going there?  Why aren't we buying
targeted Facebook ads? 

Facebook, it is the most advanced advertising
platform known to man.  They know absolutely everything about you.  And it is
not an accident that all the ads that show up on the right side of your screen
are all stuff that you are interested in.  There is no reason why we can't be
reaching out in ways like that.  Using technology and using these best
practices to laser target into military communities, veterans communities,
military families, we just don't do that, and I don't know why.

Mr. BERGER.  I would just only add to
what Tom said earlier.  This is a community effort as well.  It is not just
getting the ads put together, or the outreach programs put together.  You have
to have the involvement of the community.  When you are dealing with that
element, that demographic element, almost 70 percent are not going to the
VA.  I mean, you have to have people in your community talking about this stuff
using the methodologies that are developed at the national level.

Mr. DONNELLY.  A lot of us have rural
areas too, and I think staff going out and trying to locate our vets.  And in
some of the rural areas, it is not always the easiest thing to do with the
Facebook techniques that you talk about and other techniques.  Do you know of
any, or have you heard of any specific targeted efforts in rural areas so our
vets who may be almost, or off the grid, in effect, how do we locate them? 

Ms. ILEM.  VA did bring to our
attention and gave us a demo just last week of their new Making the Connection
campaign.  I think that would be worth asking the next panel about
specifically.  It seemed in the rollout to be testimonials from veterans, from
family members and others. 

So certainly it is a Web‑based tool
with lots of resources and seems to be able to be manipulated to be tailored to
the specific person's interest.  So I think that is one way.  That definitely
could be available in the rural community.

Mr. DONNELLY.  And Madam Chair, what
are the great concerns is truly we will do everything we can as a committee as
the VA, but when 70 percent of our veterans are living their lives and we
are not touching them we have got to figure out a much better way to touch
them.  I yield back.

Ms. BUERKLE.  Thank you very much.  We
have been called to vote.  We have about 2 minutes left to vote and the votes
should take about an hour.  What we would like to do is recess this hearing
and then reconvene at around 12:15.  If you could all join us for our second
panel, please come back at 12:15 and we will reconvene this hearing.  Thank you.

[Recess.] 

Ms. BUERKLE.  We are reconvening our
hearing of the Subcommittee on Health.  If I can invite our second panel to
come to the table.  I thank you all very much for your patience for the little
bit of disruption in this morning's hearing.  Joining us on our second panel is
Dr. Margaret Harrell, Senior Fellow and Director of the Joining Forces
Initiative for the Center for a New American Security; Dr. Katherine Watkins,
Senior Natural Scientist for the RAND Corporation; Dr. Janet Kemp, the National
Suicide Prevention Coordinator for the Department of Veterans Affairs,
accompanied by Dr. Antoinette Zeiss, the Chief Consultant for Mental Health for
the U.S. Department of Veterans Affairs.  Colonel Carl Castro, as I
mentioned earlier, is not able to be with us this morning.

Ms. BUERKLE.  Thank you all very
much.  I am very eager to begin our discussion.  Dr. Harrell, if you could proceed.



STATEMENTS OF MARGARET C. HARRELL, PH.D., SENIOR FELLOW AND DIRECTOR,
JOINING FORCES INITIATIVE CENTER FOR A NEW AMERICAN SECURITY; KATHERINE E.
WATKINS, M.D., SENIOR NATURAL SCIENTIST, THE RAND CORPORATION; JAN E. KEMP, RN,
PH.D., NATIONAL MENTAL HEALTH DIRECTOR FOR SUICIDE PREVENTION, VETERANS HEATH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY ANTOINETTE
ZEISS, PH.D. CHIEF CONSULTANT FOR MENTAL HEALTH VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF MARGARET C. HARRELL

Ms. HARRELL.  Thank you.  Madam
Chairwoman, Ranking Member Michaud and members of the subcommittee, thank you
for the privilege of testifying today.  It is an honor to be here.  While the
topic at hand is suicide prevention among veterans, I must underscore the
importance of considering both veteran and service member suicide.  We can only
be sure that strides have been made when the frequency of suicide decreases
amongst both of these populations.  There is, for an example, a possibility
that a decrease in suicide among service members could represent expeditious
out processing of service members struggling with mental health wounds of war. 
Only the joint consideration of both service member and veteran outcomes will
highlight reasons for increased concern or will identify success.  Addressing
suicide among service members and veterans is vital to the health and
sustainability of the all‑volunteer force.  It will take a collaborative
effort by DOD, VA, Federal and State legislatures and communities to curb
suicide amongst those who have served.  Our leaders in the DOD and VA deserve
recognition for their actions to reduce these tragedies, and I am confident
that my co‑panel members will articulate many of the excellent efforts
taken in this regard. 

Despite their best efforts however challenges
remain.  In my submitted testimony I highlight multiple challenges and proposed
recommendations.  I focus upon four of those challenges here.  The first
challenge is the lack of accurate accounting of veteran suicide and the
reliance on incomplete and delayed data.  We recommend Congress establish
reasonable time requirements for States to provide their death data to the CDC
and that Department of Health and Human Services ensure that the CDC is
resourced sufficiently to expedite compilation of these data.  Additionally the
DOD, the VA and HHS should coordinate efforts to analyze veteran suicide data
annually.  A second challenge pertains to the national shortage of mental health
care and behavioral health care professionals, a factor linked to higher
ratings of suicide.  Congress should require the VA to establish deadlines by
which all 23 VHA regions will be manned to the recommended level of care
providers.  Additionally, and especially in the meantime, the VA should
increase their use of existing public‑private partnerships to provide
care to the extent that such partnerships would expedite evidence‑based
care to veterans. 

A third challenge pertains to the geographic
moves that are a feature of military life.  Separating service members also
often relocate their families as they leave the military.  Because mental
health care providers are licensed on a State‑by‑State basis a move
across state lines can preclude continued care from the same provider.  When a
care provider and a patient develop a relationship and that relationship is
severed by a move, individuals are often reluctant to begin treatment anew. 
Thus we recommend Congress establish a Federal preemption of State licensing
such that mental health care can be provided across State lines for those
instances in which veterans, service members or military family members have an
established preexisting care relationship. 

The fourth challenge is the decentralized
multitude of suicide prevention programs in the National Guard.  The solution
is inefficient and at risk of reduction or elimination.  Such is the case in
Minnesota where there exists both the highest number of National Guard suicides
this year and also dwindling resources to address their problem.  We recommend
the consideration of a system‑wide centrally funded prevention approach. 

In conclusion, my testimony is extracted from
a CNAS policy brief entitled Losing the Battle, the Challenge of Military
Suicide.  America is currently losing its battle against suicide by veterans
and service members.  As more troops return from deployment the risk will only
grow.  To honor those who have served and to protect the future health of the
all volunteer force, America must renew its commitment to its service members
and veterans.  The time has come to fight this threat more effectively and with
greater urgency.  Thank you for addressing your attention to this critically
important battle.

Ms. BUERKLE.  Thank you very much, Dr.
Harrell.

[The statement of Margaret Harrell appears in the Appendix.]



Ms. BUERKLE.  Dr. Watkins.

STATEMENT OF KATHERINE WATKINS, M.D. 

Dr. WATKINS.  Thank you, Chairman
Buerkle, Representative Michaud and distinguished members of the subcommittee,
it is an honor and a pleasure to be here.  I know that members frequently
get calls from their constituents about how to access VA services. 
And increasing access to care is incredibly important.  However, it is equally
important to provide good care once a veteran does access care, and it is about
this that I am going to talk to you today.  Preventing suicide is difficult. 
The best evidence we have about preventing suicide is to provide quality mental
health care. 

In this testimony, I will summarize key
results from a study conducted by RAND and the Altarum Institute on the quality
of mental health care provided by the VA to veterans with mental illness and
substance abuse disorders.  I will then propose specific steps which could be
taken by the VA to improve the quality of mental health care, steps which, if
taken, could help to reduce suicide risk among our Nation's veterans.  My
written testimony provides more detail on our specific findings and our
additional recommendations.  In response to the question by Representative
Stearns about the quality of VA care, our study actually found that the quality
of mental health and substance abuse care provided by the VA is as good or
better than the care provided by both the public and the private sector. 

However, there is still room for significant
improvement.  Let me give you an example.  Although our study found that
veterans with mental illness are assessed for suicide ideation and if they are
found to have suicide ideation are given appropriate care, providing good care
for people who are already suicidal is not enough.  It is important to provide
them good care before they become suicidal, both because providing good care is
important in its own right and because high quality care might prevent people
from becoming suicidal in the first place.  It is in this area that the VA
could improve their performance. 

My first recommendation that comes directly
from the results of our study is to increase the proportion of veterans who
receive the recommended length of pharmacotherapy.  Taking psychiatric
medications consistently and for the recommended length of time is important,
because for both depression and bipolar illness, taking psychiatric medication
prevents suicide.  We found that more than half of study veterans who began
medication treatment did not receive the recommended length of treatment, and
more than two‑thirds of those on maintenance treatment did not take their
medications consistently.  This can be improved.  There are systematic methods
for increasing adherence which the VA is not using.  For example, the use of
clinical registries which allow clinicians to track medication compliance could
be incorporated into the VA's medical record system with relatively little
effort. 

A second recommendation is to implement uniform assessment and
standardized written treatment plans.  In the case of uniform assessment, we found
that while the VA had high levels of assessment for suicide, in other areas,
performance was poor and more variable.  For example less than two‑thirds
of the mentally ill were assessed for problems with housing and employment, and
there were large differences between the best performing VISNs and the worst
performing VISNs.  This is important because homelessness and unemployment are
both risk factors for suicide.  The VA's employment policies are vague.  If you
are a veteran with mental illness who has an employment problem, it is unclear
where you should go to for help.  The VA needs to clarify what constitutes need
for housing and employment services and clearly define the role of the Veterans
Health Administration and the Veterans Benefit Administration with regard to
work and housing. 

We found that written treatment plans were
incomplete and difficult to locate, and, in some cases, did not appear to be
present at all.  This is a problem.  Written treatment plans are essential for
communication between providers because they tell providers in short succinct
ways what problems a patient has and what is being done for those problems. 
Although we understand that VA Office of Mental Health Services has recently
purchased treatment planning software implementation of the software has been
held up because of lack of computer personnel at the VA Office of Information
Technology. 

In conclusion, I would like to say that the
VA has substantial capacity to deliver mental health and substance abuse
treatment to veterans and it outperforms the private sector on most quality
indicators.  This most likely demonstrates the significant advantages that
accrue from an organized nationwide system of care.  Nonetheless, the VA is
falling short of its own implicit expectations.  Our study revealed ways in
which the VA could build upon their current system with marginal effort to
improve quality and potentially prevent suicide. 

Thank you for the opportunity to testify
today and to share the results of our research. 

Ms. BUERKLE.  Thank you, Dr.
Watkins, for your testimony. 

[The statement of Katherine Watkins appears in the Appendix.]



Ms. BUERKLE.  Dr. Kemp, if you would
like to proceed please.  Thank you. 

STATEMENT OF JAN E. KEMP

Ms. KEMP.  Chairwoman Buerkle, Ranking
Member Michaud and members of the subcommittee, thank you for the opportunity
to appear before you today to discuss VA's efforts to reduce suicide among
America's veterans.  I am accompanied today by Dr. Antoinette Zeiss, the Chief
Consultant for Mental Health.  And at this point, honestly, I am going to put down
my prepared statement and talk to you a little bit from my heart.  It has been
a very moving hearing and I think I have some important things to say.  First,
I want to thank you all for the kind words about the suicide prevention program
and my personal efforts.  And I think that speaks to the people up in
Canandaigua, New York who work 24 hours a day 7 days a week answering that
phone and making those connections, and the suicide prevention coordinators
across the country who work tirelessly to connect people into care and to
really make a difference. 

And while I truly accept your kind words for
them, because they work really hard, I have to tell you it makes me feel a
little bit like a fraud and a little bit humbled by what you have said, because
veterans are still dying by suicide, which means we have more work to do.  And
as long as one veteran any day of the year dies by suicide who is receiving
care in the VA, I haven't done my job well enough.  And I will continue to
persevere to get that job done. 

That being said, we have had some exciting
news this week.  We have recently gotten the 2009 data, and you have heard from
the other witnesses how tragic that is that it is almost 3 years old.  But we
did get the 2009 data very recently from the CDC, and have looked at that data,
balanced it up against veterans who get care within the VA system and we are
very encouraged by what we are seeing in 2009, which was a couple years after
we implemented the very beginnings of our suicide prevention program.  And it
is encouraging to know that this perceived epidemic of veteran suicide rates
that we keep hearing about truly is not happening for veterans who are getting
care in the VA, that rates in certain age groups and population groups, in
fact, are decreasing.  And when we look at our most at‑risk patients,
like you all have talked about, we are making a difference.  Those rates are
going down.  And in the group of patients who get mental health care in the VA
our suicide rates are decreasing.  And we know that is because we are paying
attention to them and we have got them involved in our enhanced package of care
and they are being followed by suicide prevention coordinates, they are getting
evidence‑based psychotherapies.  We know that treatment works and that is
extremely hopeful and is enough for us to keep going and to keep making these
changes that we are headed towards and to know we are in the right direction. 
And we have got a long ways to go.  I am not going to sit here and tell you we
think things are fine because we don't.  We have got high standards that we
have set. 

And as you have said, we are not meeting our
own standards, and we need to continue to strive to do that and then we will
set higher ones.  And that is a promise.  It also points out that there is a
group of veterans that while their rates are staying stable, we haven't seen
the decrease in.  And those are veterans who are not currently getting mental
health services.  And I think that that really makes what my good friends from
the VVA and the IAVA talked about critically important, and that is outreach. 
And the things that we have put into place so far are having an effect but we
have got to do more, and we will continue to do that and we will work with them
and get their input and their ideas.  And I don't think they actually know how
valuable they have been up to this point.  I think that the influence Tom
Tarantino and Tom Berger have had on our current campaigns has been tremendous
and we thank them for that, and we ask them to keep hanging in there with us. 

We are getting it right and we are going to
continue to get it right.  And I am going to end my testimony with a story that
maybe talks about how we do get it right.  And there are as many of these
stories as there are stories of people where we honestly get it wrong, and
somehow we have got to bridge that gap and I promise to do that.  In August of
this year, we heard from our benefits people that they got an email inquiry
from a veteran who was currently living in Germany.  And his question to them
was if I kill myself, will my wife and children still get their benefits.  And
this was an email question through our email IRIS help line. 

Having had the training and knowing that that
was a warning sign, they notified the people in the crisis line that this
veteran may be in trouble.  The people at the crisis line called this veteran
in Germany, they found him, they talked to him, they talked to his wife.  Truly
he was in a great deal of distress, he was having a lot of physical pain, he
wasn't getting the care he needed, but he thanked us for calling him and moved
on.  Something didn't sit right in the responder's mind after he hung up that
call and he called him back.  And truly, the veteran had left his house and his
wife said I don't know where he is and I can't find him.  We did track him
down.  We found him. 

In the meantime, we had contacted the wounded
warrior project people, people who also partner with us to provide services,
who arranged for transportation from Germany to the United States for this
veteran if he would agree to come.  We contacted a suicide prevention
coordinator in California who found him placement in a program.  We called him
back.  Between us and his wife, we talked him into services.  We got him on a
plane, we got him into California and as of 90 hours later he was in care,
in treatment and is alive today.  While that is an extraordinary story, again,
it is only one of many, many that we could tell over the past three years.  And
we can't stop until those stories don't need to be said anymore.  That people
get the services way head of time, they get the care that they need and that
dying by suicide is not an option for America's veterans, and that is our
goal. 

So Madam Chairwoman, thank you for the
opportunity to be here.  Our services will continue.  We greatly appreciate
your support in this area.  And Dr. Zeiss and I are prepared to answer your
questions.

Ms. BUERKLE.  Thank you very much, Dr.
Kemp.  And thank you for speaking from the heart.  So often the committee is
frustrated by folks who stick to their script and it is almost irrelevant to
the testimony that was heard before them.  So thank you very much and thank you
for what you do.

[The statement of Jan Kemp appears in the Appendix.]



Ms. BUERKLE.  Dr. Harrell, my question
to you is, in your testimony, you testified that we seem to know more about
suicide among our military rather than our veterans.  Can you explain why
you think that is? 

Ms. HARRELL.  Yes.  Thank you.  I
would be happy to.  As Dr. Kemp did note, they have recently received data for
2009, but the data that they received was for those veterans who did receive VA
care.  The estimate of 18 suicide deaths amongst our veterans every day
represents, in large part, extrapolations from the States' death data.  In
other words, there are 16 States that note on their death certificate whether
an individual who has died had served previously in the military.  For the
other 34 States, the estimate is just that, it is an estimate, it is an
extrapolation.  So not only when we say 18 deaths a day is that extrapolated
for the majority of States, but it is 3 years delayed.  And so that is why I
assert that we really don't know enough about our veterans that are dying by
suicide.  We do not, for example, know whether those deaths represent veterans
of Iraq and Afghanistan, or whether those are Vietnam veterans that are dying
by suicide.  We don't know who they are.

Ms. BUERKLE.  Thank you.  Dr. Watkins,
in your testimony, you talked about adherence to a drug
protocol and how important that is.  And you mentioned that there are no
clinical registries within the VA system.  And clinical registries are pretty
basic with regards to tracking patients and their compliance with a program. 
Can you speak to that, as well as speaking to the assessment and the
treatment plans or the lack thereof? 

Dr. WATKINS.  Well, the VA does have
registries but they are not clinical registries.  And what I mean by a clinical
registry is something that an individual clinician or an individual
administrator can use to pull up all their patients with a particular diagnosis.  So,
for example, all their patients with depression.  And then they can easily see
who has missed an appointment, who hasn't filled their medication.  And then
you could go and do outreach and try to target that particular patient.  That
is what I mean by clinical registries.  And I think that could be incorporated
into their medical record fairly easily and could go a long way to identifying
people who are dropping out of treatment. 

In terms of the assessment, when we did the study, there was no standardized
packet of assessments, so we found a lot of variability around what people were getting.  For example, I told you about the housing and
employment services.  The differences between the best performing VISNs and the
lowest performing VISN was 26 points.  So I think that there is something
being done by the best performing VISNs that is not being done by the worst
performing VISNs.  And I believe that a central directive
that says this is what an assessment should consist of, every veteran needs to
get this assessment, here are some templates that are going to help you make
sure you remember to do those assessments could really be beneficial.  Because like I
said, they do a great job.  I think 95 percent of the veterans were
assessed for suicide.  That is really terrific.  And when they found someone
who was suicidal, they got good treatment, they got appropriate referral.  But
we have to go beyond, we have to figure out how to prevent people from becoming
suicidal.  People
don't all of a sudden become suicidal, it starts before then, usually with a mental
illness.

Ms. BUERKLE.  Dr. Kemp, would you like
the opportunity to perhaps speak about if there are any initiatives in the
VA with regard to those kinds of registries
that would have a database of those who have indicated they are suicidal and on
medication? 

Ms. KEMP.  We currently have, and then
I will let Dr. Zeiss explain from a broader mental health perspective what
we are doing.  For patients who have expressed some degree of suicidal
ideation, hopefully before they become actually suicidal or have a plan, et
cetera, we do include them in what we call our high risk database.  And this
high risk designation allows us to put chart notifications on their charts so
all providers are aware of their concerns.  It pushes them into a different
level of care and enhanced package of care, we call it.  And we do monitor them
for a period of time after this designation.  The gap, as is pointed out, is
defining ways and figuring out ways to move these people into that level of
care sooner.  And to do that we have developed treatment planning, software
that Dr. Zeiss will talk about the implementation of and other mechanisms
within mental health to assess that and make that happen. 

We are excited about our recent integration of
mental health into our primary care teams with our patient‑centered model
and we have done a considerable amount of training and will continue to train
these teams of people so that perhaps we can catch people earlier in their
whole health care process where they wouldn't need to be referred to mental
health to get those kind of services and those kinds of care, that it would
happen from their primary care team.

Ms. BUERKLE.  Thank you.  My time is expired and I want to give my colleagues a chance
to ask questions and then I will come back.  I am sure I will have a
second round of questions.  I now yield to the gentleman from Maine, Mr.
Michaud. 

Mr. MICHAUD.  Thank you very much,
Madam Chair.  This question is for the panelists, all of you.  You heard VBA
earlier.  What are your thoughts on their recommendations that both the VA and
the DOD should use the PTSD protocol and guidelines suggested by the IOM, any
comments?

Ms. HARRELL.  I would like to defer
evaluation of that tool to those with specific medical expertise.  But I would
like to encourage the extent, any extent possible that the DOD and the VA join
forces on this effort.

Dr. WATKINS.  I can't speak to the
validity of that tool, but I think it would be a mistake to focus all of your
efforts on PTSD.  I actually think there are higher rates in people with
bipolar disorder, substance abuse and depression, and so it is really critical
that you look at those as well.

Ms. KEMP.  I am going to let Dr. Zeiss
talk about the PTSD tool.

Ms. ZEISS.  Well, I am glad that Dr.
Berger brought up that tool.  It was developed by the National Center for PTSD
that is part of VA.  And there are two versions of it.  One is a clinical
assessment tool and the other is for use in doing an interview in the context
of a CNP diagnostic interview.  And I have really made it a priority to try to
bring this tool into focus for our assessments.  I think it is an excellent
tool.  And I appreciate the persistence that VBA has shown in ensuring that it
stays in focus.  And since I have been chief consultant the National Center for
PTSD has a national mentoring program for PTSD to increase the consistency of
care and utilization of best practices, and they are doing training throughout
the country in use of this clinical tool. 

And we also have a study that has been
completed looking at it in the context of CNP exams that was very positive in
terms of its utility.  So there is more for us to do, absolutely, but I think
we are on that track.  I also agree with what Dr. Watkins said, that we can't
just attend to PTSD, there are other disorders that need very significant
attention.  But for those with PTSD, I do think consistent reliable valid
assessment is very important.

Ms. KEMP.  So the short answer to that
question is yes.  But in addition to that, the DOD and VA currently are
developing clinical practice guidelines along those same lines specifically for
suicide prevention.  And we will jointly implement those as soon as they are
done.

Mr. MICHAUD.  My next question
actually is for Dr. Kemp.  You have got 300 vet centers.  They provide a great
service for all veterans, as well as active duty Vet centers have active duty personnel come in on their furlough days to get
help and mental health addressed.  My concern being is,
are you fully staffed in all those vet centers with the appropriate personnel? 

Ms. KEMP.  I would have to defer that
to Dr. Batres from our readjustment counseling service.  But my experience is
yes, they are incredibly awesome and responsive people.  The readjustment
counseling service which the vet centers fall under have also developed an on‑line
peer support call center which we use at the crisis line to move callers back
and forth from and we support each other.  Another huge attribute to this
system are the soon‑to‑be 90 mobile vet centers that travel across
the country providing care to people in remote and distant areas.  I think that
the pieces are in place and if we can get them to the veterans and veterans to
them, we are well on our way to making sure things happen.

Mr. MICHAUD.  My next question
requires simply a yes‑or‑no answer.  The Military Office
Association of America recommended that it require the VA and the DOD to establish
a single strategy in a joint suicide prevention office that reports directly to
the Department secretaries through a senior oversight committee.  Do you
support that proposal? 

Ms. HARRELL.  Yes.

Dr. WATKINS.  Yes.

Ms. KEMP.  Not the way it is written.

Mr. MICHAUD.  Thank you, Madam Chair.

Ms. BUERKLE.  Thank you.  I now yield
5 minutes to the gentleman from Texas for questions. 

Mr. REYES.  Thank you, Madam
Chairman.  I was curious for your comments on what can be done to improve
outreach to our service members.  Particularly, we have heard a number of
comments today in the context of younger veterans versus the older veterans and
the lack of a tracking system.  So can you, do you have any thoughts on that,
any recommendations? 

Ms. KEMP.  Of course I have thoughts. 
We have made huge strides in the past 3 years providing outreach in different
access modes to younger veterans.  We realize that they communicate differently
and we have to go to them, we can't wait for them to come to us.  To that end,
we have developed a veterans chat service.  This is actually the first formal
announcement that this month we opened a texting service so people can text the
crisis line.  It is having a remarkable response and going really well.  We
have Facebook pages.  We monitor those pages.  We have Facebook monitors who
look for people in difficulty.  We have partnered with and contracted with a
nationally well‑known advertising firm to help us develop some messages
and new marketing strategies.  We have rebranded the suicide prevention hotline
into the veterans crisis line in order to better portray what we do and reach
people, and the results of that have been tremendous.  And we have put in PSAs
out there that have been well received, some newer ones. 

You have heard references to the Make a
Connection Campaign which is incredible actually.  And we partnered with the
entertainment council to make that happen and make that happen right.  Dr.
Sonya Batten is organizing that program and is doing an exceptional job.  But
it is the tip of the iceberg.  And I think what we need is to continue to
listen and not only listen, but get help and support from people like IAVA and
Student Veterans of America, and as Tom said, from people.  I mean, veterans
are people, and we need to listen and get their input and find out how to get
that message across.  And I don't think we are going to have an answer
tomorrow, but we have got to start putting what we know now into effect like we
have been, and just keep going and pushing and not stop putting the resources
into that area. 

I mean, it bothers me a great deal when I
hear about veterans who don't know what the VA does.  I mean, there is no
reason for that in America today.

Mr. REYES.  What about the comment, I
think it was Dr. Berger that made, which I have found to be true as well,
in terms of veterans relating to veterans?  How do we bridge that?  Is this
texting, is that intended to do that? 

Ms. KEMP.  I think it helps.  And I
think other ways that we do it are very formal and then also very informal. 
And we do have peer support processes set up at all of our facilities, we have
our vet centers who provide that vet‑to‑vet communication, we have
veterans who work on our crisis line and in our facilities who provide that vet‑to‑vet
sorts of options for people.  Right now we are working kind of behind the
scenes to develop what I am calling some buddy programs. 

Sometimes I think veterans don't need a peer
counselor or want a peer counselor, but they might want a buddy, they might
want a friend, they might want someone they can call in the middle of the night
who will go bowling with them or take a walk with them or just tell them that
things are okay.  And I think we have to help those relationships form.  So I
think we can work in arenas like that.  The veteran service organizations like
VVA have been very supportive in helping us think about those sorts of
programs. 

So I think that is the direction we have to
go.  And we have to really work with our communities.  Veterans live in
communities.  There is a move in America right now, I think, to become involved
and to make a difference and it behooves us now to help people do that.

Mr. REYES.  Thank you, Madam Chair. 
Thank you.

Ms. BUERKLE.  Thank you.  I am going
to yield myself 5 minutes for questions.  If you will indulge us, we will have
a second round of questioning.  Dr. Watkins, I was very impressed and really
struck by the fact that in your testimony, you talked about those who have committed suicide have contact with
either a primary care or a mental health provider prior to the year that they
committed suicide. 

So much of what we are talking about today is
awareness among our veterans and our military that there are services.  But now
these folks were in the system.  So I would like, if you would, to speak to
that as to were there any reasons why that would occur that they are actually
in the system, they are getting care and yet they still committed suicide. 

Dr. WATKINS.  Yes.  That study didn't
actually look at what the quality of the care that they were getting, that was
not our study, I am referring to a different one there.  But I think what it
points to is the opportunity that exists for intervention and the importance of
providing good quality care once the person walks in the door.  I think what we
know and what Dr. Kemp and Dr. Zeiss said, is that if they get to specialty
mental health care it seems like they are getting good care and the rates
of suicide are going down.  It is in the primary care settings that that is not
happening.  And so perhaps we need to focus our efforts on providing good
quality care in the primary care settings.

Ms. BUERKLE.  Based upon your
research, how would you do that within the primary
care arena? 

Dr. WATKINS.  I think one of the most important things is
registries.  So again, a way to allow the individual clinician easily, not
with the assistance of a computer programmer, but in real‑time at their desk to
be able to pull up their panel of patients and see who missed
their appointment.  Because probably it is those people who are missing
appointments or are not showing up or who are missing their medication refills,
those are probably the ones who are struggling the most.  That is a hypothesis,
but I think it makes sense.  I think that attention to infrastructure is really
critical.  The VA has a wonderful medical record system but it could do more. 
And it is amazing to me that the bottleneck seems to be the computer
programming.  Like that they have treatment planning software but it can't be
incorporated because the computer programmers ‑‑

Ms. ZEISS.  It is now.

Dr. WATKINS.  It is now?  That is
terrific.  So it took several years.  That seems unacceptable.

Ms. BUERKLE.  This question is for
Dr. Kemp.  The VA has established mandatory screening for depression.  We were
just talking about it is not all PTSD, it is depression, it is substance
abuse.  So you have mandatory screening for depression, but does VA conduct
periodic reviews to assess and to see where those patients are?



Ms. KEMP.  Those screens are done on a
minimum of an annual basis.  And if someone does screen positive for depression
or PTSD, that requires at least a basic assessment for suicide and suicide
ideation. 

Ms. BUERKLE.  Dr. Watkins, would
your registry take care of that if they had been assessed for depression, they
have been diagnosed with depression, if there was a registry in place, then
that would continue to monitor? 

Dr. WATKINS.  They would go into the
registry, and someone could follow them.  And that might be a person who you
might want to screen ‑‑ if for some reason, that person chose
to not have treatment, which some veterans may choose to not have treatment,
maybe that registry would clue the clinician in so that every month an
outreach, some kind of outreach call was done.  And the veteran ‑‑
or maybe they showed up for their podiatrist appointment.  You know, then the
podiatrist would know and might say, okay, let's check in with you and see how
you are doing.  It is that kind of wraparound services that I think ‑‑
what I call a clinical registry would help. 

Ms. BUERKLE.  Thank you. 

Dr. Kemp, just in my few seconds that I have left, section 304 of the public law
111-163, the Caregivers and Veterans Omnibus
Health Services Act of 2010, provided that the VA establish a program to provide mental
health services to members of the immediate family of OIF and OEF veterans.  I think
what we have heard this morning and this afternoon is that the family is such a
big part of this, and understanding symptoms, and what to do with all of the
information that they are perceiving.  Has this program been implemented? 

Ms. KEMP.  Yes.  We are able to
provide those services to include families in our care for veterans.  As a
matter of fact, all really high‑risk veterans are required to provide
us ‑‑ required is a loose term ‑‑ with family
contacts that we then work with to help us and help them recognize signs of
when they might be getting into trouble, when they are at higher risk. 

We are also working very closely with our
department of social work, who is working right now with SAMSA to help identify
modes of referral and to community resources for families when we are not able
to do that to assure that those services get done. 

Ms. BUERKLE.  Thank you. 

Our information is a little bit contrary to
that and indicates that that has not been implemented for the families.  So if you could
specifically, and maybe you don't have the information now, which VA centers
have you implemented that to include immediate family outreach? 

Ms. KEMP.  Yeah.  I will take those
questions, if I could, for the record, and get those responses back to you. 

Ms. BUERKLE.  Thank you very much. 

I now yield to the gentleman from Maine, the
ranking member, Mr. Michaud. 

Mr. MICHAUD.  Thank you very much. 
Yeah, I would be very interested also in seeing that information.  So what you
are saying is you have got the rules and regulations already adopted for that
section, and it is underway. 

Ms. KEMP.  It is underway. 

Mr. MICHAUD.  Are the rules and
regulations all adopted? 

Ms. KEMP.  The policies and procedures
are already in place that allow us to respond to that recommendation.  And
again, I think you are going to see, like you have heard before, that there are
varying degrees of implementation.  I think there is variability among the
system.  And we will help figure out where it is happening and where it is
not. 

Mr. MICHAUD.  I would
be very interested in that, because I am under the same understanding, that it
has not been implemented. 

I guess this one is for Dr. Watkins.  Just
reading over the testimony from Lieutenant Colonel Michael Pooler from the
Maine Army National Guard ‑‑ I am disappointed DOD is not here
today, but I don't know if you have done any studies that was raised in his
testimony, where he talks about those who buy TRICARE have a very difficult
time finding clinicians who will see them.  And many clinicians that want to
help soldiers find the process to become a TRICARE provider extremely
cumbersome.  He goes on to state that someone other than the providers needs to
maintain the TRICARE Web site to ease the frustrations soldiers find when they
are looking for help.  Have you done any research on TRICARE and the effects? 

Dr. WATKINS.  That is a great
question.  And I think that is research that needs to happen.  We don't know
the quality of care provided by TRICARE ‑‑ the quality of
mental health care provided by TRICARE or the DOD.  And that is a really
important study that I think needs to be done. 

Mr. MICHAUD.  Thank you. 

And I guess it is more of a comment, Madam
Chair, is reflecting on when we did a codel a number of years ago to Iraq and
Afghanistan, and this is a concern I have when you look at, particularly in the
Department of Defense, is every trip we have been on, I would always ask the
generals when they give us a briefing is, what are they doing personally to
help destigmatize the problem with PTSD and those that have traumatic brain
injury?  And the second part of the question is whether or not they need any
additional help.  And the response I get over and over again is the same
response we have here in D.C., is things are fine; we have got the resources we
need; we are taking care of them.  The problem being is right after that
meeting, someone with much lesser rank pulled me aside and says, we are not
getting the help that we need.  And the suggestion was that I talk to the
clergy. 

And for the rest of that trip and every other
trip since then I did talk to the clergy.  And the interesting thing is the
fact that more and more soldiers are going to them.  So evidently there is a
disconnect between those that are in the decision‑making mode to provide
help for the soldiers.  If they tell us that things are okay, and really, they
are not, and if you look at the statistics with the increased amount of
suicides among our active military today, then I think we have to look at doing
things differently, and how can we provide those services for the active
military personnel as well as our veterans?  And when I read Lieutenant Colonel Pooler's testimony with the problems that they are seeing
within the TRICARE system, I think we can do a much better job than what is
currently being done.  But if we do not have the folks that are in that
decision‑making process recognizing that, then I think we have that extra
hurdle we have to get over. 

I noticed, Dr. Watkins, you were a
little ‑‑

Dr. WATKINS.  I think you need data. 
I think you don't know.  I mean, that is really what our VA study was, was an
independent evaluation from outside the VA looking in.  And I think that is
what makes it so powerful.  Because I think you don't know what is going on, in
that you have got basically anecdotal evidence about what is going on with
TRICARE and what is going on with the DOD.  And unless you get data, you
really don't know.  And I think it speaks to what Dr. Harrell said about
suicides; you have to have data before you really know what is going on.  So I
would encourage you to think about getting data about what is happening, the
quality of mental health care provided by TRICARE and provided by the DOD. 
Because then you can go on and make a difference. 

Ms. BUERKLE.  Thank you.  I have one
last question for all three of our panelists.  Part of what we heard this
morning, and I have heard this on several occasions in other hearings, are that
there are a lot of services out there, but they are not well coordinated, and
they are not collaborating their services.  So the veteran, and Dr. Roe
mentioned it earlier, is maybe visited by 10 people at his bedside rather than
one point person.  So where is the balance in all of this?  I would like to
give all of you the opportunity to respond. 

Ms. HARRELL.  Madam Chairwoman, I am
not quite sure how to answer where the balance is in all of that.  I would
confirm your perception that there are many programs out there.  I think, in
many cases, the multitude of programs are a result of the recognition that this
is a crisis before us.  And as a result, we have programs running in parallel
with one another, inefficiencies resulting, and the risk of programs,
especially at the State level, being canceled due to competing resources. 

Dr. Watkins.  I think you need to ask
the veteran what they want.  Some veterans may want 10 people coming in.  Other
people may want one.  I think what you don't want is duplication.  And one of
the things we found in our study was that this common electronic medical
record, if you move across a VISN, across a region, like say you are a snowbird
and you move from Minnesota to Florida, your VA provider in Florida has a great
deal of difficulty accessing your records from Minnesota.  That is not easy to
do.  And so that Florida provider has to redo all the assessment.  They can't
count on, they can't learn from what has already been done before. 

So, in terms of trying to prevent
duplication, I think making a common portal or having ‑‑ a
common portal exists, but making it easier for clinicians to access the data
across VISNs or, you know, within different medical centers within a VISN, I
think would go a long way toward preventing duplication.  And that would be a
first step. 

Ms. BUERKLE.  Dr. Kemp, before you
have the opportunity to answer that question, why is it so difficult for the
information to be transferred from VISN to VISN?  If you know, or if you could
provide us with that information. 

Ms. KEMP.  Actually, I am going to
have to find out.  Because I can travel from VISN to VISN and see anyone's
record.  And I can see anyone's record from my office in Canandaigua or
Washington, D.C.  And I know from working in the field and being the clinician,
I never had difficulty finding information out about patients that were being
seen somewhere else.  So I suspect that we might have some provider education
issues that we need to address.  If the providers that Dr. Watkins talked to
were having trouble, we perhaps need to explain better how to do that.  But the
capability is there for that to happen. 

Dr. WATKINS.  My understanding is that
part of it has to do with how the patient is counted, right, who gets credit
for the patient.  And it has do with having the appropriate authority to be
able to access that common portal.  Anyway, we can ‑‑

Ms. KEMP.  It is a new problem. 

Ms. BUERKLE.  If you could, Dr. Kemp,
we would really appreciate that information and your assessment of follow‑up
to Dr. Watkins. 

Ms. KEMP.  Certainly.  Certainly. 

Ms. BUERKLE.  And did you have an
answer to the balance question? 

Ms. KEMP.  Of course.  Actually, I
think there isn't.  That is a tough question.  And I think there is a fine line
between multiple services and not coordinating those services and choices.  And
I think we sometimes lose attention to the fact that veterans do have choices. 
And they don't have to come to the VA; they don't have to get care from
particular people.  And we need to make sure they know about those choices. 

We do need to coordinate care within systems,
while still protecting patients' privacies.  And so that is a fine line that we
need to walk.  I think, most importantly, we need to know about all of the
services that are available and the programs available so that we have a wide
range of options to be able to provide people. 

Ms. BUERKLE.  Thank you. 

And I would say we talked earlier, someone
mentioned mentoring and a system like AA has, having someone stay with you. 
I know that there is a relatively new program Team Red, White, and Blue,
and that is what they believe.  They believe that that person coming out of
military, that new veteran needs someone to be with them to monitor all of
these different aspects of their life, and to really mentor them and help them
with that transition.  So it seems to me there is an appreciation of the needs
out there.  But one of the problems we have is just coordinating them all.  And then,
as Dr. Watkins mentioned, making sure it is what the veteran wants. 

I would be interested to know in your
study, Dr. Watkins, that Rand Corporation did, if there were conversations with
the veterans, are they getting what they need?  Did they identify areas where
they would like to see things a little different? 

Dr. WATKINS.  That is so interesting. 
We did do a telephone survey of 7,000 veterans, where we called them up and
asked them about their experience with VA care.  And what is interesting is
actually most veterans were really satisfied.  We also asked about timeliness,
which has to do with how long did you have to wait for an appointment?  And did
you get an appointment as soon as you wanted?  And if it was an emergency, did
you get an appointment as soon as you wanted?  And again, over half, most of
them said that their care was timely.  So, again, I think it is interesting
what data provides versus what ‑‑ because I think you will
always have some people who don't get what they need.  But when you have data,
it allows you to put it in context. 

Ms. BUERKLE.  And I think the sad part
of that is the folks who apparently needed the services who do commit suicide
aren't getting what they need. 

Dr. WATKINS.  Exactly.  It should be a
hundred percent. 

Ms. BUERKLE.  That is why we are here
today. 

Before we adjourn our hearing this afternoon,
I would like you to turn your attention to the monitors for an airing of the
VA's latest public service announcement addressing suicide
prevention.

[Video shown.]

Ms. BUERKLE.  Our message here today with this hearing is that to any servicemember, veteran, or civilian
loved one listening today, suicide is never the right answer.  If you are
hurting, hope and help are available to you at any time.  Please call the VA
crisis hotline number at 1‑800‑273‑TALK, and press one if you
are a veteran. 

With this, I ask unanimous consent that all
members have 5 legislative days to revise and extend their remarks and
include any extraneous material. 

Without objection, so ordered.  I want to
thank all of you again, to our first panel and our second panel, for being here
today, and for all of the members in the audience for joining today's
conversation. 

As I mentioned earlier, this is just the
beginning of a very important conversation.  And we will work to get DOD and
the National Institute of Mental Health in here, along with, it was suggested
by some of my colleagues that we get Secretaries Shinseki and Panetta in here
for a hearing as well.  So we will continue this conversation.  It is of the
utmost importance.  And our veterans deserve that. 

Before we adjourn, I would just like to ask you to always remember the men and women who serve our Nation so valiantly
and keep us safe. 

And to all of our veterans, this is a good
opportunity to thank them for their service.  To any veterans in the room
today, thank you very much for your service to this Nation. 

With that, our hearing is adjourned. 

[Whereupon, at 1:22 p.m., the subcommittee
was adjourned.]




 


APPENDIX


Prepared Statement of Hon. Ann Marie Buerkle, Chairwoman, Subcommittee on Health

Today we meet to search for answers to the most haunting of questions – what
leads an individual who so honorably served our nation, out of helplessness and
hopelessness, to take their own life and how can we prevent such a tragedy from
happening to one who has bravely worn the uniform and defended our freedom. 

Suicide is undoubtedly a complex issue, but it is also a preventable one and
I am deeply troubled by its persistent prevalence in our military and veteran
communities. 

The statistics are sobering – eighteen veterans commit suicide each day with
almost a third receiving care from the Department of Veterans Affairs (VA) at
the time of their death.   Each month, there are 950 veterans being
treated by the VA who attempt suicide.  The number of military suicides has
increased since the start of Operations Enduring Freedom and Iraqi Freedom
(OEF/OIF), with data from the Department of Defense (DOD) indicating
servicemembers took their lives at an approximate rate of  one every 36
hours from 2005 to 2010. 

We continue to hear tragic stories despite significant increases in recent
years in the number of programs and resources devoted to suicide prevention
among our service members and veterans.  

Today we will hear from VA and DOD that they are making strides in
identifying at risk servicemembers and veterans and providing treatment for
mental health and other disorders that can lead to suicide. 

Yet, no matter how great programs and services are, if they do not connect
with those who need them, they do no good at all.  VA and DOD continue to
struggle with persistent obstacles including data limitations, cultural stigma,
access issues, a lack of partnerships with community providers, and outreach
that relies on the service member, veteran, or loved one to initiate treatment.
 

We must do more to reach out to veterans inside and outside of the VA and DOD
health care systems to ensure that all those who need it get the help they
earned and deserve before time runs out.

 Until a family no longer must bear the pain of losing a loved one, we are
failing and not enough is being done.

I thank you all for joining us this morning. I now recognize our Ranking
Member, Mr. Michaud for any remarks he may have.

Prepared Statement of Hon. Michael H. Michaud, Ranking
Democratic Member, Subcommittee on Health

I would like to thank everyone for attending today’s hearing.

It is a tragedy that our service members and veterans survived the battle
abroad only to return home and fall to suicide.  Since 2007, this Committee has
held five hearings regarding the issue of veterans’ suicide, and the figures
continue to increase at an alarming rate, far greater than the comparable
suicide rates among the general population.

The Center for a New American Security, in a recently published study
entitled, “Losing the Battle: The Challenges of Military Suicide,” says that
from 2005 to 2010, service members took their own lives at a rate of
approximately one every 36 hours.  This statistic is troubling, but it pales in
comparison to VA’s estimate that one veteran dies by suicide every 80 minutes.

While I commend the VA’s efforts to reduce the suicide rate, particularly
with the success of its Veterans Crisis hotline, challenges still remain. 
Through this hearing, we will examine the steps the VA is taking to strengthen
data collection, to pinpoint veterans who may be at risk, and to offer effective
intervention.  In this process, we will also seek to better understand the
reasons why more and more service members and veterans are taking their own
lives and what VA and DoD are doing to put a stop to more suicides.  

I’d like to thank our panelists for appearing before us this morning. 
Particularly, I’d like to commend Dr. Jan Kemp for her leadership.  Under her
direction, the VA has made great strides in its suicide prevention efforts.  Dr.
Kemp’s work is award winning, and she was named the Federal Employee of the Year
in 2009.

I’d also like to thank the Maine Army National Guard for submitting written
testimony and for their efforts to ensure that every Soldier has access to the
care they need.  The Maine Army National Guard already has a close working
relationship with the Suicide Prevention staff at Togus VA hospital.  This is a
relationship that must be replicated on the national level through cooperation
between the VA and the DoD.  Unfortunately, as the Maine Army National Guard
testimony points out, too many soldiers—including those not eligible for VA
benefits and those who do not have health insurance—struggle to find care.

I look forward to hearing from all our witnesses today to discuss how we can
improve access, treatments, and prevention efforts to best serve our nation’s
veterans.

Thank you, Madam Chair, and I yield back.

Prepared Statement of Hon. Silvestre Reyes, Democratic Member, Subcommittee on Health

Thank you Madam
Chair and thank all of you for coming here today to talk about this issue that
is plaguing our veteran community.  It seems like every time we talk about this
issue, the problem is getting worse and not better.  The fact that there are
nearly 950 suicide attempts per month by our brave men and woman who have
served this country is more than just a problem.  It is a crisis. 

If I
remember correctly, in 2006 that is about half the number of attacks our
service members endured a month in Iraq.  Our soldiers, enabled by
congressional action, found a way to reverse that trend.  All they needed was
the right tools like mine resistant vehicles and upgraded body armor to do
their job and defeat the enemy.  We were able to get that equipment to them at
a pace most people didn’t think was possible. 

What we need
to do now is identify what tools these veterans need to fight the enemy
within.  So please help us figure out what we need to do to protect those who
have protected us, and we will do our part to ensure they get it as soon as
possible.

Prepared Statement of Commander René A. Campos, USN (Ret.),
Deputy Director, Government Relations, Military Officers Association of America

A decade
of war has placed unprecedented demands and stressors on our warriors and their
families that will leave scars and unintended consequences for generations to
come.

The
Departments of Veterans Affairs (VA) and Defense (DoD) have long been faced
with the daunting challenge of meeting a significant range of medical and rehabilitation
issues.  MOAA is particularly concerned about the exponentially growing need to
address mental health, behavioral and cognitive conditions, in light of the
rising rates of suicides, alcohol and substance use, and a variety of other issues
playing out among veterans, servicemembers and their families.

A number
of reports support our concerns:

  • 2008 VA
    “Blue Ribbon Work Group on Suicide Prevention in the Veteran Population”
  • RAND
    Health/National Defense Research Institute

            o  
2008 “The
Invisible Wounds of War”

            o  
2011 “The
War Within, Preventing Suicide in the U.S. Military”
 

            o  
2011 “Addressing
Psychological Health and Traumatic Brain Injury Among Servicemembers and Their
Families”

  • 2011 Center
    for a New American Security (CNAS) Report “Losing the Battle:  The Challenge
    of Military Suicide”
     

The
current statistics are disturbing and point to an even greater need to wage an
all out battle to end suicide.  This will require a sustained national
commitment at all levels of government if we are to rid veterans of the psychological
and traumatic physical conditions that are threatening their lives and the
health and well-being of their families.  Sadly these statistics represent the
heroes who protect our country and our freedoms:  

  • 20 percent of
    suicides in the U.S. are former servicemembers
  • One currently
    serving member died every 36 hours during the period 2005-2010
  • 18 veterans
    die a day—that is one suicide every 80 minutes

Recommendations

MOAA offers
three specific recommendations to address current barriers to care:

  • Require
    VA-DoD to establish a single strategy and a joint Suicide Prevention Office
    that reports directly to the Department Secretaries through the Senior
    Oversight Committee (SOC).
  • Authorize
    funding to expand VHA mental heath capacity and capability in order to improve
    access and delivery of quality and timely care and information.
     
  • Authorize
    additional funding to expand outreach and marketing efforts to encourage
    enrollment of all eligible veterans in VA health care, with special emphasis on
    Guard and Reserve members, rural veterans, and high-risk populations. 

MADAM CHAIRMAN AND DISTINGUISHED
MEMBERS OF THE SUBCOMMITTEE, on behalf of the 370,000 members of the Military
Officers Association of America (MOAA), I am grateful for the opportunity to
present testimony on MOAA’s observations concerning the Department of Veterans
Affairs’ (VA) suicide prevention programs and efforts.

MOAA does not receive any grants or contracts from the federal government.

MOAA
thanks the Subcommittee for its interest in this extremely difficult issue and
for your leadership in looking out for the health and well-being of our
veterans and family members.  We also commend the VA for its staunch commitment
to enhancing mental and behavioral health programs by working with DoD and
other government and non-government entities to help veterans and their
families improve their physical and psychological well being.

Overview
of VA Suicide Prevention Programs and Efforts

A number
of reports and activities have been published in the last seven years that
shine a spotlight on veteran and military suicide and VA’s prevention efforts.

In 2008,
the RAND Corporation’s Center for Military Health Policy Research released a
report on “The Invisible Wounds of War.” The report highlighted the
mental health and cognitive needs of combat veterans, focusing on three wounds:
post-traumatic stress disorder (PTSD), depression, and traumatic brain injury
(TBI). 

The
report states that, “Unless treated, PTSD, depression, and TBI can have
far-reaching and damaging consequences.  Individuals afflicted with these
conditions face higher risks for other psychological problems and for
attempting suicide…there is a possible link between these conditions and
homelessness…the consequences from lack of treatment or under-treatment can
have a high economic toll.”  

RAND
made four recommendations that get at these issues:

  1. Increase the
    cadre of providers who are trained and certified to deliver proven
    (evidence-based) care, so that capacity is adequate for current and future
    needs.
  2. Change
    policies to encourage more active duty personnel and veterans to seek needed
    care.
  3. Deliver proven,
    evidence-based care to servicemembers and veterans whenever and wherever
    services are provided.
  4. Invest in
    research to close information gaps and plan effectively.

Like
RAND, our Association believes that restoring veterans to ‘full mental health’ will
be important to reduce long-term economic societal costs.  

RAND’s Invisible
Wounds of War
was the first study of its kind to estimate that PTSD and
depression among servicemembers will cost the nation up to $6.2 billion in the
two years after deployment.  The study concludes that investing in proper
treatment would provide even larger cost savings—savings that would come from
increases in productivity, as well as from reductions in the expected number of
suicides. 

Additionally,
The Journal of Clinical Psychiatry reported that the economic burden of
depression to this country was estimated to be $43.7 billion in 1990.  By 2000
the cost burden rose to $53.9 billion, which included direct treatment costs,
lost earnings due to depression-related suicides, and indirect workplace costs.

In June
2008, the Secretary of the VA convened a Blue Ribbon Work Group on Suicide
Prevention in the Veteran Population
to
advise on the research, education and program improvements to the prevention of
suicide.  The Work Group consisted of five Executive Branch representatives,
two of which were from DoD. 

MOAA was
encouraged by the Group’s findings.  According to the report, the Veterans
Health Administration (VHA) had a comprehensive strategy in place and a number
of promising initiatives and innovations for preventing suicide attempts and
completions.

The Group
recommended that VHA:

  1. Establish
    an analysis and research plan in collaboration with other federal agencies to
    resolve conflicting study results in order to ensure that there is a consistent
    approach to describing the rates of suicide and suicide attempts in veterans.
  2. Revise and
    reevaluate the current policies regarding mandatory suicide screening
    assessments.
  3. Proceed with the planned implementation of the Category II flag (patient
    is at high risk for suicide), with consideration given to pilot testing the flag in one or more
    regions before full national implementation.
  4. Ensure that
    suicides and suicide attempts are reported and that procedures are consistent
    with broader VHA surveillance efforts.
  5. Ensure that
    specific pharmacotherapy recommendations related to suicide or suicide
    behaviors are evidence-based.
  6. Continue to
    pursue opportunities for outreach to enroll eligible veterans, and to
    disseminate messages to reduce risk behavior associated with suicide.
  7. Ensure
    confidentiality of health records.
  8. Ensure ongoing
    evaluation of the roles and workloads of the Suicide Prevention Coordinator
    positions.

This
year a Center for a New American Security (CNAS) report entitled, “Losing
the Battle:  The Challenge of Military Suicide,”
published some disturbing
statistics, noting that suicide among veterans and servicemembers present
challenges to the health of America’s all-volunteer force.   The report addressed
the obstacles for confronting suicide.  Although most of the 13 recommendations
CNAS offered are focused on DoD and the Military Services, most are applicable
to VA, such as:

  1. Ensuring transfer
    of mental health information when members relocate
  2. Eliminating the cultural stigma
    associated with mental health care
  3. Holding leaders accountable
  4. Increasing
    mental health and behavioral health care professionals, and addressing gaps in
    programs for drilling Guard and Reserve units
  5. Establishing
    reasonable time requirements for states to provide death data to the Centers
    for Disease Control (CDC), and that Health and Human Services (HHS) should
    ensure CDC is resourced sufficiently to expedite the compilation of national
    death data.  VA, DoD and HHS should coordinate annual analysis of veteran
    suicide data.
  6. Sharing of
    suicide data between VA, DoD and HHS, including discussion with Veterans
    Affairs and Armed Services Committees to develop a provision to address veteran
    suicides.    

Two
other reports were published this year by RAND’s Health/National Defense
Research Institute and sponsored by the Office of the Secretary of Defense.  The
first report, “The War Within, Preventing Suicide in the U.S. Military,”
was intended to enhance the Department’s suicide prevention programs and
efforts.  The second report, “Addressing Psychological Health and Traumatic
Brain Injury Among Servicemembers and Their Families,”
provided DoD a
comprehensive catalog of existing programs currently sponsored or funded by the
Department to address psychological health and TBI.  MOAA believes the recommendations
of these two reports are also applicable to VA:

  1. Increasing
    and improving the capacity of the mental health care system to deliver
    evidence-based care
  2. Changing policies to encourage
    more veterans and servicemembers to seek needed care
  3. Delivering evidence-based care in
    all settings
  4. Investing in research to close
    knowledge gaps and plan effectively
  5. Taking advantage of programs’
    unique capacity for supporting prevention, resilience, early identification of
    symptoms, and help seeking to meet the psychological health and TBI needs of servicemembers
    and their families
  6. Establishing clear and strategic
    relationships between programs and existing mental health and TBI care delivery
    systems
  7. Examining existing gaps in
    routine service delivery that could be filled by programs (formal needs assessment
    and gap analysis of programs)
  8. Reducing barriers faced by
    programs
  9. Evaluating
    and tracking new and existing programs, and using evidence-based interventions
    to support program efforts

VHA
mental health officials estimate there are approximately 1,600 – 1,800 suicides
per year among veterans receiving care in the health system and upwards of
6,400 per year among all veterans.  One of the key goals of VA’s Mental Health
Strategic Plan, implemented in 2004, was to reduce suicide among the veteran population. 
Out of that plan came a National Suicide Prevention Center of Excellence, a
national suicide prevention hotline, a patient record flagging system, and
suicide prevention programs in each medical facility.

Speaking
at a joint VA-DoD Suicide Prevention Conference last year, VA Secretary Eric Shinseki
said every veteran was susceptible to suicide. 

“The
emotional wounds are no less common than physical injuries; however, they are
more difficult to diagnose which adds to the challenge of suicide prevention,”
said Shinseki.  He went on to say that the
suicide problem was one of the ‘most frustrating’ leadership challenges he
faces.  “Of the 18 veterans who commit suicide each day, five of those veterans
are under the care of the VA. Losing five veterans who are in treatment every
month, and then not having a shot at the other 13 who for some reason haven’t
come under our care, means that we have a lot of work to do.”

There
are a number of predisposing risk factors associated with suicide and mental
health disorders that can be diagnosed and treated.  Some of these risk factors
include:

  • PTSD
  • Relationship
    problems
  • Financial
    difficulties
  • Substance
    abuse and addiction
  • Ongoing
    depression
  • Social
    isolation
  • Recent
    illness and/or hospitalization
  • Difficulty
    Sleeping
  • Access to
    firearms

Today, VA
has two primary program areas targeting suicide prevention, the National
Suicide Prevention Program and the Office of Mental Health Services.  Some additional
initiatives the Department has implemented include:

  • Hiring
    thousands of additional mental health providers
  • Launching a Suicide
    Prevention Campaign
  • Establishing
    a Veteran’s Crisis Line
  • Instituting a
    National Suicide Prevention Coordinator Program
  • Directing a suicide
    prevention safety plan (SPSP) and Practices for high risk patients
  • Implementing
    policy requiring annual depression screening for veterans using VA health care
  • Conducting a
    VA-DoD Suicide Conference
  • Establishing
    a VA-DoD online Suicide Prevention Resource Center

Progress
and Challenges

In conducting
our research for this hearing, MOAA was struck by the tremendous level of work
that had been done, especially in the last three years.  The steadfast
determination of the VA Central Office staff and Secretary Shinseki’s personal
involvement in synchronizing the agency’s national suicide prevention efforts
is quite visionary.

MOAA
gives VA high marks for rebranding its suicide prevention hotline and
establishing a National Veterans Crisis Line.  Dr. Janet Kemp, VA’s National
Suicide Prevention Coordinator is to be commended for standing up the suicide
hotline, earning her recognition as the 2009 Federal Employee of the Year.  The
initiative resulted in more than 5,000 immediate rescues.  The crisis line is
one of the best initiatives according to Dr. Kemp, answering over 450,000 calls
and making more than 16,000 life-saving rescues.  An anonymous chat service was
added to the crisis line and has helped more than 20,000 people.

Additionally,
in less than a year VA has expanded agreements from 18 to 48 states to have
veteran status on death certificates.  Colorado and Illinois have yet to sign
an agreement with VA.

Despite
these improvements, the VA concedes barriers still exist that challenge its
ability to advance suicide prevention to the level needed. 

According
to a VA Inspector General’s “Combined Assessment Program Summary Report: 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health
Administration Facilities,” released on March 22, 2011, the VA implemented a
number of requirements for taking care of patients identified to be at high
risk for suicide.  One requirement is that there be a written safety plan that
should be placed in the medical record, and, that a copy of the plan is given
to the patient.  The VA IG noted that generally Department’s suicide prevention
safety plans (SPSP) were comprehensive but the completion of safety plans for
all high-risk patients and the timeliness of the plans needed improvement.

In
October 2011, The Washington Post published an article titled, “VA Lacks Resources to Deal with Mental
Health, Survey Finds.”  
Thearticle
stated,  “Over 70 percent of the survey respondents to a preliminary survey of
VA social workers, nurses and doctors think the Department lacks the staff and space
to meet the growing numbers of veterans seeking mental health care.  More than
37 percent said they are unable to schedule an appointment in their clinic
within the mandated 14-day standard.”

Senator
Patty Murray (D-WA), chairwoman of the Senate Veterans Affairs Committee
requested the survey after conducting a hearing this past summer where veterans
diagnosed with mental health issues described long waits for treatment in the
VA.  In a letter to the Department, Senator Murray wrote, “While I understand
the Department has concerns that this survey is not comprehensive, after the
countless Inspector General and GAO reports, hearings, public laws,
conferences, and stories from veterans and clinicians in the field, it is time
to act.”

MOAA
could not agree more.  VA and our entire country must address barriers to
mental health if we are to win the war on suicide.

Some of
the most significant barriers that impede progress are:

  • Limitations
    on mental health capacity and capability, impacting access and quality and
    timely care (e.g., funding, resources, staffing, hours of operation,
    infrastructure).
  • Lack of total
    system accountability, oversight, monitoring and evaluation. VA Central Office
    (VACO) has a comprehensive strategy and policies, but implementation across the
    health care system is inconsistent and outcomes vary greatly. 
  • Limitations
    in data sharing and documentation of information.
  • VA and DoD
    veteran “warrior cultures”.
  • Limited opportunities
    for maximizing collaboration, cooperation, and communication to ensure
    continuity of care and services in a seamless manner.
  • Cultural and
    societal stigma prevents individuals from seeking care.
  • Experiences
    with unprofessional or uncaring VA employees who don’t treat veterans with
    compassion and respect.
  • Medical
    system policies, procedures and logistical challenges make it difficult for
    veterans and their families to understand and navigate, especially during times
    of crisis.  The VA culture tends to assume because employees understand how VA
    works, others should know as well.

Some of
these barriers are outside of VA’s span of control, as noted in the reports
mentioned above.

MOAA
believes addressing veteran suicides requires an immediate response and a unified
strategy coordinated between the VA, DoD and other federal agencies.  VA and
DoD have had difficulty over the years in keeping up with demand for medical
benefits and services from OIF/OEF veterans.  As operations start winding down
in these theaters we can expect demand to continue for a number decades, and
generations to come. 

Our
country must do all it can to help VA and DoD to ensure our servicemembers have
seamless mental health services as they separate or retire from the military—something
more than just giving them a web site or toll free number to call when they
need help. 

Veterans’
families, caregivers and children also deserve special attention because of the
tremendous burdens they must carry when dealing with the psychological wounds
of their loved ones.

Identifying
servicemembers who are at high risk and providing them treatment is critical as
these individuals will one day be veterans.  The sooner we help these individuals;
in and out of uniform the better the long-term outcomes will be for veterans,
their families and society as a whole.

What
Veterans and their Families Tell Us

Veterans
and family members we talk to have seen much progress in improving policies and
programs at the national level.  However, they don’t always see these policies and
programs implemented or interpreted consistently at all VA medical facilities.

The real
tragedy for some veterans who really need help is that they may give up or lose
trust in the system.  This may be particularly true for severely wounded, ill
or injured veterans and their families dealing with the burdens of complex
medical conditions.

Here are
what veterans and their families told us about their experiences:

PTSD
Veteran and Caregiver-Spouse

  • The veteran entered
    the VA system in 2008 as a high-risk patient for suicide and is still at risk
    today.
  • The Caregiver’s
    current issue is addressing the veteran’s difficulty sleeping.  It took the VA
    two months to schedule an appointment just to get a fee based referral outside
    the VA.  Now the veteran must wait until May 2012 for VA to do a required sleep
    study.  This Caregiver questions why it takes almost a year for her husband to
    get the care he needs, especially when VA knows that difficulty sleeping is a
    risk factor for suicide the veteran has a history of suicidal ideations. 
  • “I don’t
    trust VA.  My Federal Recovery Coordinator (FRC) and I are constantly fighting
    with people in the VAMC every step of the way.  It’s like the VA is fighting
    with itself—why can’t they just do what is right?  VA is in the business of
    saving lives and it shouldn’t be focused so much on saving money,” said the
    Caregiver.
  • Recommendations
    to improve care:
  • The FRC
    should have more authority to make things happen in the VA—they are an integral
    part of the team and likely to have a better understanding of the veteran’s
    mental condition.
  • Access to
    mental health services
  • Veterans with
    mental health issues should have greater access to fee based services if it
    takes longer than two weeks to get an appointment.
  • Veterans
    should have more control over their appointments—VA needs to do a better job of
    accommodating their schedules.

TBI
Veteran and Caregiver-Mother

  • This severely
    injured veteran with TBI and a number of physical disabilities had to wait
    weeks to get the attention of a VA provider from the time of his first thoughts
    of suicide.  It took his mother forcing the issue before VA would see him. 
  • “The VA tries
    to treat my son like other patients, but normal protocols don’t work.  He has
    half of his brain capacity; he can’t talk or communicate normally about how he
    is thinking or feeling, but he does think and feel, he just can’t communicate
    it the way most people do,” she said.
  • The Caregiver
    said, “there were been times the VA medical staff have made comments or their
    actions hurt her son deeply—one VA provider told her in front of her son that
    he would never be more than a vegetable.”  Other providers continue to try
    pushing her son to institutionalized care because that’s what the system
    normally does for veterans with this level of disability.  The veteran’s bad
    experiences at the VA have made it difficult for him to want to do any type of
    therapy today.
  • This
    Caregiver tries to keep her son as active as possible so he won’t get
    depressed.   She says he’s lonely and doesn’t have any friends so it is easy
    for him to slip into depression.  
  • Recommendations
    to improve care
  • Family-caregivers
    for a veteran with severe brain injury need access to services in times of
    crisis and need the  knowledge and tools on how to deal with suicidal
    ideations. Providers should be open to using alternative therapies or
    approaches to help veterans with communication challenges.  Providers need to
    be flexible and  may need to look outside the VA if services are not
    available.  Providers must do all they can to draw the veteran into the
    treatment. 
  • Veterans
    should always be treated with compassion and respect—never as though they are
    on an assembly line. 

PTSD/TBI
Veteran and Caregiver-Spouse

  • The veteran
    suffers from a number of serious physical conditions as well as PTSD and TBI.
  • There have
    been two incidents of suicidal ideations.  The first one was pain related.  The
    second one was in March of this year. 
  • “When my husband
    attempted suicide in March the VA doctor told me to take him to the ER.  But
    the ER had no beds and said he may have to wait 24 hours before one was
    available.  They gave me no alternatives.  I was scared and no one in the VA
    did anything to help us or help me know what to do in a situation like this,”
    said the caregiver.  She went on to tell us that the typical VA response is to
    give the patient a machine or medication.  “We just want VA to treat us like
    they care.”

Another
severely wounded veteran who is an amputee and has TBI told us he was
frustrated because his providers seldom talk to him or ask him how he’s doing. 
Their questions and comments are usually directed at his Caregiver-spouse as
though he isn’t even in the room. He said, “I just want them to know I can and
want to contribute to my care—when they don’t talk to me it makes me feel like
they don’t care about me.”

According
to all these veterans and family members, they are unaware if their veteran’s
record is flagged or ever has been a flagged as a high-risk patient or if the
medical record contains a suicide prevention safety plan.

MOAA Recommendations

MOAA
concurs with CNAS and RAND that suicide among veterans and servicemembers
challenges the health of our all-volunteer force.   CNAS points to some
compelling questions for our country to consider:

  • If
    military service becomes associated with suicide, will it be possible to
    recruit bright and promising young men and women at current rates?
  • Will parents
    and teachers encourage young people to join the military when veterans from
    their own communities have died from suicide?
  • Can an
    all-volunteer force be viable if veterans come to be seen as broken
    individuals?
  • And how
    might climbing rates of suicide affect how Americans view active-duty
    servicemembers and veterans—indeed, how service members and veterans see
    themselves?

While
MOAA supports many of the recommendations and findings in the reports, studies
and investigations mentioned above, the sheer volume of recommendations
requires prioritizing efforts for improving VA’s suicide prevention program.  Therefore,
MOAA encourages Congress to focus its attention immediately on three specific recommendations
which will further enhance VA’s suicide prevention efforts as well as help
address other systemic issues in its health care system. 

MOAA
urges:

  • Requiring
    VA-DoD to establish a single strategy and a joint Suicide Prevention Office
    that reports directly to the Department Secretaries through the Senior
    Oversight Committee (SOC).

A joint
office would be responsible for developing, implementing and integrating strategies,
policies and procedures, and providing oversight and evaluation of suicide
prevention programs and efforts. Congress needs to continue to be VA’s and
DoD’s greatest champion for promoting collaboration, cooperation and
communication across and between the two agencies.

A sense
of urgency and oversight are needed to address the issue of veteran suicide at
all levels of the government.  There needs to be a level of commitment similar
to that given to wounded warrior issues which came out of the Walter Reed Army
Medical Center incident.  VA has done a lot to engage with DoD to identify high-risk
servicemembers so that a warm hand-off can be made to facilitate continuity of
care.  But the agency acknowledges a number of challenges still exist because
of cultures and the different policies and programs that vary across the DoD
and the Military Services.     

  • Authorizing
    funding to expand VHA mental heath capacity and capability in order to improve
    access and delivery of quality and timely care and information.
     

Clearly,
reports and studies continue to highlight problems with accessing care and
shortages in mental health staffing and infrastructure.  The VA should invest
in staff training, recruiting, and retention programs in order to maintain the highest
quality work force and system of care.  Caregivers and family members should be
provided training, information and tools on how to deal with suicidal ideations
and mental health issues. 

Congress
should fund research to evaluate the efficacy of suicide prevention programs to
include a longitudinal study of the economic and societal costs of veteran
suicide in this country.

Veterans
should have more control over scheduling appointments. theVA must  be flexible
in delivering care to meet the needs of veterans, including allowing fee based
care in emergencies or when wait times exceed two weeks. 

  • Authorizing
    additional funding to expand outreach and marketing efforts to encourage
    enrollment of all eligible veterans in VA health care, with special emphasis on
    Guard and Reserve members, rural veterans, and high-risk populations. 

VA recognizes it needs to do a more effective job in working with outside
community and faith-based organizations and other government agencies, beyond
its current work with veteran and military organizations and other agency
partnerships.  The VA should reward local medical facilities for expanding
their collaborative efforts.  A long-term investment in outreach and
marketing to improve its image and VA brand is needed to more effectively target
these veteran populations.

Conclusion

MOAA
believes there is a business case to be made for addressing suicide that should
consider the impact on national security and the costs to society. 

MOAA has
no doubt that, with the will and sense of urgency from Congress, the
Administration, the DoD/Military Services, and  the VA, we can win the war on
suicide.  Our veterans and military medical systems have eliminated some
tremendous barriers with unprecedented results in saving lives on and off the
battlefield.  We owe these heroes and their families our full commitment to
eliminate remaining barriers to mental health care so they can obtain an
optimal quality of life.

MOAA is encouraged
by the significant progress made by the VA, and we thank the Subcommittee for
your leadership and support in helping our nation’s veterans and their families.

Prepared Statement of Tom Tarantino, Senior Legislative
Associate, Iraq and Afghanistan Veterans of America

On behalf of Iraq and Afghanistan Veterans of America’s 200,000
member veterans and supporters, thank you for inviting me to speak on one of
the most pressing issues facing veterans and their families: the staggeringly
high rate of suicide among services members and veterans.


My name is Tom Tarantino and I am the Senior Legislative
Associate with IAVA.  I proudly served 10 years in the Army, beginning my
career as an enlisted Reservist, and leaving service as an Active Duty Cavalry
Officer.  Throughout these 10 years, my single most important duty was to
take care of other soldiers.  In the military, they teach us to have each
other’s backs, both on and off the field of battle.  And although my
uniform is now a suit and tie, I am proud to work with this Congress to
continue to have the backs of America’s service members and veterans.


Today’s hearing on suicide could not have come at a
more critical time. The Army recently reported 30 potential suicides among
active duty soldiers and non-activated reservists in October, and 25 potential
suicides within the same group in September. These are some of the highest
numbers we have seen from the Army since it began releasing suicide data in
2009 - and that’s just one branch. The Defense Department recently reported
that 468 active duty and reserve soldiers, sailors airmen, and Marines
committed suicide in 2010. Overall, the Department of Defense tracked 863
suicide attempts. The rate for veterans is likely much higher.


Although we have this limited data about service
members, there remains a fundamental gap when it comes to understanding veteran
suicide. The VA does not regularly release data on the number of veterans that
commit suicide and there is almost no information about veteran suicide among
the forty-seven percent of veterans of Operations Enduring Freedom and Iraqi
Freedom who never interact with the VA. We therefore only have blurry snapshots
of the problem. For example, the VA estimated that in 2009, 6000 veterans
committed suicide. It has also said that on average, 950 suicides are attempted
each month by veterans who are receiving some type of VA treatment. That's an
average of 31 veterans attempting suicide per day. And again, these tragic
numbers only capture the limited segment of veterans who interact with the
VA.


One of the greatest challenges in understanding and preventing
veteran suicide is this lack of full data. If we don’t know the entirety of the
problem, how can we solve it?  Even in this age of information and
technology, we still have no way of tracking veterans unless they interact with
a social service that happens to ask about their military service.  This
is unacceptable.  To address this problem, we must think outside the box.
 IAVA recommends collecting this data by expanding existing services like
the Center for Disease Control and Preventions’ National Violent Death
Reporting System.  Currently, the CDC collects data on all manner of
violent death - including suicide - in 16 states.  Veteran status can be
reported to the CDC either through the death certificate or by information
collected by the medical examiner.  By expanding the database to all 50
states, and requiring medical examiners to report veteran status to the CDC, we
can get a clearer picture of the problem.

A critical step to understanding how we can stop veteran and
service members suicides is to understand that suicide itself is not the whole
issue. Suicide is the tragic conclusion of the failure to address the spectrum
of challenges returning veterans face. These challenges are not just mental
health injuries; they include challenges of finding employment, reintegrating
to family and community life, dealing with health care and benefits bureaucracy
and many others. Fighting suicide is not just about preventing the act of
suicide, it is about providing a “soft and productive landing” for our veterans
when they return home.


The conflicts in Iraq and Afghanistan have resulted in a
high incidence of mental health injuries among returning service members. According
to a RAND study, nearly one third of Iraq and Afghanistan veterans will develop
combat-related mental health issues.  Many of these cases will go
untreated, and if allowed to fester, develop into severe Post Traumatic Stress
Disorder.


The problems with Mental Heath Care within the VA system have been
well-documented over the past few years.  The VA reports that 18 veterans
in their care commit suicide every day.  Wait times for mental heath care
remain unacceptably high, and there are not enough mental heath providers to
meet the need.


A recent RAND survey of veterans in New York state revealed
 that many veterans face difficulty navigating the complex systems of
benefits and services available to them.  While this survey was specific
to New York veterans, the results are indicative of veterans’ experiences
nationwide. Veterans reported that they do not know how to find the services
they need or apply for the benefits they have earned. Even when they are able
to find services appropriate for their needs, many vets report frustration in
accessing these services. Some veterans report long waiting periods to get an
appointment at the VA, while others with frequent appointments have reported
having to repeatedly re-tell their stories and experiences to a number of
different providers. These delays and lack of continuity certainly cannot help
a veteran already suffering from mental health issues. This survey also
revealed difficulty in accessing services is not limited to the VA; most
respondents could not identify a state agency or non-profit that provided
direct mental health services.


We also know that many veterans may not be seeking care because of
the stigma attached to mental health injuries. Multiple studies confirm that
veterans are concerned about how seeking care could impact their careers, both
in and out of the military. Concerns include the effect on their ability to get
security clearances and how co-workers and supervisors would perceive them. It
is critical that we continue to work to reduce this stigma.


To combat this, IAVA recommends that the VA and DoD partner with
experts in the private and nonprofit sector to develop a robust and aggressive
outreach campaign.  This campaign should focus on directing veterans to
services such as Vet Centers, as well as local community and state based
services. It should be integrated into local campaigns such as San Francisco’s
veterans 311 campaign. This campaign should be well-funded and reflect the best
practices and expertise of experts in both the mental health and advertising
fields. For our part, IAVA has partnered with the Ad Council to launch a public
service awareness campaign that is focused on the mental health and invisible
injuries facing veterans of Iraq and Afghanistan. Part of this campaign focuses
on reducing the stigma of seeking mental health care. We are happy to share our
best practices from this campaign to aid in this effort.
 
Tackling Transition: Providing A Stable Environment For Veterans’
Transition



Providing a smoother transition from the military to the
civilian world is crucial in preventing veteran suicide. Ensuring veterans’
access to mental health care is connected to other issues that can contribute
to a veterans’ sense of stability throughout their transition home. We must
tackle the other contributing factors – such as unemployment and homelessness –
that could increase the risk for vets who are vulnerable to suicide.


Finding employment is one of the top challenges facing veterans
during their transition from military to civilian life. In 2010, the average
unemployment rate for OIF/OEF-era veterans was a staggering 11.5%, almost 2
percentage points higher than the national average. This rate is trending even
higher so far this year. This leaves veterans wondering where the next pay
check will come from, unable to support their families, and unsure of long-term
career prospects.  Congress wisely addressed this problem recently by
passing the VOW to Hire Heroes Act.  While this legislation is a critical
piece of the puzzle, we must remain vigilant to ensure that the critical
programs in the VOW to Hire Heroes Act are implemented.


Some veterans also struggle to find a permanent home. The VA
reported that there were more than 13,000 Iraq and Afghanistan veterans homeless
in October 2010. Having a place to call home is a foundation upon which to
build one’s life. Without a home, finding employment, maintaining
relationships, and receiving mental health care become more difficult. The
number of homeless veterans is already too high. We need to act now to end
veteran homelessness. There is no excuse.


Addressing the spectrum of challenges facing veterans during their
transition home will go a long way to create a sense of stability for veterans
that may be vulnerable to suicide. This is a place you can step up to create a
network of support for every veteran as they return home. This robust community
of support should be the first line of defense against veteran suicide.

Building A Community of Support


A community of support starts with the families of veterans and
service members. These families need to be prepared – and supported – to help
smooth the transition of their returning service member. In RAND’s study of New
York veterans, thirty-five percent of military spouses reported that they
struggled to reintegrate the returning service member into day-to-day family
life. Families also reported feeling unprepared for the return of the service
member; many noted that they did not know what symptoms and behaviors to look for.
While there are many resources currently available to assist military families,
they are often difficult to navigate and complex to understand. We need to
place more emphasis on outreach, education and support for military families so
that they in turn can support a returning service member.


The responsibility of support does not lie on our
military and veteran families alone. Preventing veteran suicide and easing the
transition from military to civilian life is our collective responsibility as a
community. Veterans consistently report difficulty relating to their civilian
peers. In a particularly poignant example, one  RAND respondent stated,


“When I’m faced with civilians who don’t understand what I’ve been
through, it’s really difficult to try [to] get on the same level with them
without making [myself] feel pathetic.”


His statement tells us two things: (1) we must connect vets to
fellow vets that have gone through similar experiences, and (2) we should raise
awareness across the civilian community about the experience of these veterans
and their families, and the challenges they face reintegrating into the
civilian world.


IAVA has been a leader in connecting veterans to their
counterparts across the country. One of the signature features of the wars in
Iraq and Afghanistan is that less than one percent of Americans have served in
either. One of IAVA’s top priorities is to connect veterans in local
communities and across the country through traditional events and our exclusive
Community of Veterans online community. Through IAVA’s awareness campaign, in
partnership with the Ad Council, we push the message to veterans that they are
not alone: there is a community of vets that understands their experiences and
has their backs.


But our veterans are not just readjusting to their families or
connecting with other veterans. They are coming back to their jobs, using their
GI Bill to study at local colleges, and seeking care and services from
businesses and providers across the country. We also must focus on extending
understanding to spouses and society at large. Teachers and professors should
know which of their students are veterans, or the children of veterans or
service members. Businesses should invest in the leadership of returning
veterans by hiring them. Health care providers must understand the injuries
facing these incredible men and women. By promoting awareness, we can ensure
that our entire community is able to support our veterans throughout their
transition back to civilian life and help stem the tide of veteran suicide.


By accurately measuring the problem, improving access to mental
health care, tackling the transition from military to civilian life, and
creating a robust community of support for our veterans, we may be able to
significantly reduce the number of veterans that attempt and commit suicide
each year. Veteran suicide does not have a “silver bullet” solution. But better
practices are out there. We don’t want to ask ourselves if there was something
more we could have done.


Thank you for your time and attention.

Prepared Statement of , Thomas J. Berger, Ph.D., Executive Director, Veterans Health Council, Vietnam Veterans of America

Chairwoman
Buerkle, Ranking Member Michaud, and Distinguished Members of the House
Veterans Affairs Subcommittee on Health, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on “Understanding and Preventing
Veteran Suicide”.  We should also like to thank you for your overall concern
about the mental health care of our troops and veterans.

Consider
the facts:  earlier this spring, troubling data showed an average of 950
suicide attempts by veterans who are receiving some type of treatment from the
VA.  Seven percent of the attempts are successful, and eleven percent of those
who don’t succeed on the first attempt try again within nine months.  These
numbers show about 18 veteran suicides a day and about five by vets receiving
VA care.  These numbers are simply unacceptable to both the veterans’ community
and the American public.

Although
statistics on suicide deaths are not as accurate as we would like because so
many are not reported, as veterans of the Vietnam War and those who care for
them, many of us have known someone who has committed suicide and others who
have attempted it. VVA believes this to be a very real public health concern
that needs solutions now.

To
be fair, since media reports of suicide deaths and suicide attempts began to
surface back in 2003, the VA has developed a number of strategies to reduce
suicides and suicide behaviors that include:  the establishment of the Veterans
Crisis Hotline and Chatline (in partnership with the Substance Abuse and Mental
Health Administration) and a social media campaign emphasizing VA crisis
support services; the creation of suicide prevention coordinator (SPCs) positions
at all VA medical facilities whose duties include education, training, and
clinical quality improvement for VHA staff members; increased screening and
monitoring of individuals who have been identified as being at high risk for
suicide; and a few research efforts utilizing cognitive-behavioral
interventions that target suicidal ideation and behaviors. While these efforts
are laudable, VVA continues to believe they have not gone far enough.

So let’s cut to the chase: it is very challenging to determine
an exact number of suicides. Some troops
who return from deployment become stronger from having survived their
experiences.  Too many others are wracked by memories of what they have
experienced.  This translates into extreme issues and risk-taking behaviors
when they return home, which is why veteran suicides have attracted so much
attention in the media.  Many times, suicides are
not reported, and it can be very difficult to determine whether or not a
particular individual's death was intentional.  For a suicide to be recognized,
examiners must be able to say that the deceased meant to die. Other factors
that contribute to the difficulty are differences among states as to who is
mandated to report a death, as well as changes over time in the coding of
mortality data (1).

In
addition, according to the American Foundation for Suicide Prevention, in more
than 120 studies of a series of completed suicides, at least 90 percent of the
individuals involved were suffering from a mental illness at the time of their
death. The most important interventions are recognizing and treating these
underlying illnesses, such as depression, alcohol and substance abuse,
post-traumatic stress and traumatic brain injury. Many veterans (and active
duty military) resist seeking help because of the stigma associated with mental
illness, or they are unaware of the warning signs and treatment options. These
barriers must be identified and overcome.

However, VVA has long believed in a link between PTSD and suicide, and
in fact, studies suggest that suicide risk is higher
in persons with PTSD.  For example, research has found that trauma survivors
with PTSD have a significantly higher risk of suicide than trauma survivors
diagnosed with other psychiatric illness or with no mental pathology (1).  There is also
strong evidence that among veterans who experienced combat trauma, the highest
relative suicide risk is observed in those who were wounded multiple times
and/or hospitalized for a wound (2). This suggests that the intensity of the combat trauma,
and the number of times it occurred, may indeed influence suicide risk in
veterans, although this study assessed only combat trauma, not a diagnosis of
PTSD, as a factor in the suicidal behavior.

Considerable debate exists about the reason for the
heightened risk of suicide in trauma survivors.   Whereas some studies suggest
that suicide risk is higher due to the symptoms of PTSD (3,4,5), others claim
that suicide risk is higher in these individuals because of related psychiatric
conditions (6,7).However, a study analyzing data from the
National Co-morbidity Survey, a nationally representative sample, showed that
PTSD alone out of six anxiety diagnoses was significantly associated with
suicidal ideation or attempts (8).  While the study also found an association
between suicidal behaviors and both mood disorders and antisocial personality
disorder, the findings pointed to a robust relationship between PTSD and
suicide after controlling for co-morbid disorders.  A later study using the
Canadian Community Health Survey data also found that respondents with PTSD
were at higher risk for suicide attempts after controlling for physical illness
and other mental disorders (9).

Some studies that point to
PTSD as the cause of suicide suggest that high levels of intrusive memories can
predict the relative risk of suicide (3).  Anger and impulsivity have also been
shown to predict suicide risk in those with PTSD (10). Further, some cognitive
styles of coping such as using suppression to deal with stress may be
additionally predictive of suicide risk in individuals with PTSD (3).

Other research looking
specifically at combat-related PTSD suggests that the most significant
predictor of both suicide attempts and preoccupation with suicide is
combat-related guilt, especially amongst Vietnam veterans (11).  Many veterans
experience highly intrusive thoughts and extreme guilt about acts committed
during times of war, and these thoughts can often overpower the emotional
coping capacities of veterans.

Researchers have also
examined exposure to suicide as a traumatic event. Studies show that trauma
from exposure to suicide can contribute to PTSD. In particular, adults and
adolescents are more likely to develop PTSD as a result of exposure to suicide
if one or more of the following conditions are true: if they witness the
suicide, if they are very connected with the person who dies, or if they have a
history of psychiatric illness (12,13,14). Studies also show that traumatic
grief is more likely to arise after exposure to traumatic death such as suicide
(15,16). Traumatic grief refers to a syndrome in which individuals experience
functional impairment, a decline in physical health, and suicidal ideation.
These symptoms occur independent of other conditions such as depression and
anxiety.

All of  this brings us full
circle to what VVA has been saying for years – if both DoD and VA were
to use the PTSD assessment protocols and guidelines as strongly suggested by
the Institutes of Medicine back in 2006 (http://iom.edu/Reports/2006/Posttraumatic-Stress-Disorder-Diagnosis-and-Assessment.aspx)
(17), our  veteran warriors
would receive the accurate mental health diagnoses needed to assess their
suicide risk status.

Once
again, on behalf of VVA National President John Rowan and our National Officers
and Board, I thank you for your leadership in holding this important hearing on
this topic that is literally of vital interest to so many veterans, and should
be of keen interest to all who care about our nation’s veterans. I also thank
you for the opportunity to speak to this issue on behalf of America’s veterans.

I
shall be glad to answer any questions you might have.


References

1. Knox, K.L. (2008).
Epidemiology of the relationship between traumatic  experience and suicidal
behaviors. PTSD Research Quarterly, 19(4).

2. Bullman, T. A., &
Kang, H. K. (1995). A study of suicide among Vietnam veterans. Federal
Practitioner, 12(3), 9-13.

3. Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide risk and coping styles in
posttraumatic stress disorder patients. Psychotherapy and Psychosomatics,
68(2), 76-81.

4. Ben-Yaacov, Y., &
Amir, M. (2004). Posttraumatic symptoms and suicide risk. Personality and
Individual Differences, 36, 1257-1264.

5. Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R., Thompson, N. J., & Meadows, L.
(1999). Partner abuse and posttraumatic stress disorder as risk factors for
suicide attempts in a sample of low-income, inner-city women. Journal of
Traumatic Stress, 12(1), 59-72.

6. Fontana, A., & Rosenheck, R. (1995). Attempted suicide among Vietnam veterans: A model of
etiology in a community sample. American Journal of Psychiatry, 152(1),
102-109.

7. Robison, B. K. (2002).
Suicide risk in Vietnam veterans with posttraumatic stress disorder.
Unpublished Doctoral Dissertation, Pepperdine University.

8. Sareen, J., Houlahan,
T., Cox, B., & Asmundson, G. J. G. (2005). Anxiety Disorders Associated
With Suicidal Ideation and Suicide Attempts in the National Comorbidity Survey.
Journal of Nervous and Mental Disease. 193(7), 450-454.

9. Sareen, J., Cox, B.J.,
Stein, M.B., Afifi, T.O., Fleet, C., & Asmundson, G.J.G. (2007). Physical
and mental comorbidity, disability, and suicidal behavior associated with
posttraumatic stress disorder in a large community sample. Psychosomatic
Medicine. 69, 242-248.

10. Kotler, M., Iancu, I.,
Efroni, R., & Amir, M. (2001). Anger, impulsivity, social support, and
suicide risk in patients with posttraumatic stress disorder. Journal of Nervous
& Mental Disease, 189(3), 162-167.

11. Hendin, H., &
Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam
combat veterans. American Journal of Psychiatry, 148(5), 586-591.

12. Andress, V. R., &
Corey, D. M. (1978). Survivor-victims: Who discovers or witnesses suicide?
Psychological Reports, 42(3, Pt 1), 759-764.

13. Brent, D. A., Perper,
J. A., Moritz, G., Friend, A., Schweers, J., Allman, C., McQuiston, L., Boylan,
M. B., Roth, C., & Balach, L. (1993b). Adolescent witnesses to a peer
suicide. Journal of the American Academy of Child and Adolescent Psychiatry,
32(6), 1184-1188.

14. Brent, D. A., Perper,
J. A., Moritz, G., Liotus, L., Richardson, D., Canobbio, R., Schweers, J.,
& Roth, C. (1995). Posttraumatic stress disorder in peers of adolescent
suicide victims: Predisposing factors and phenomenology. Journal of the
American Academy of Child and Adolescent Psychiatry, 34(2), 209-215.

15. Melhem, N. M., Day,
N., Shear, M. K., Day, R., Reynolds, C. F., & Brent, D. A. (2004).
Traumatic grief among adolescents exposed to a peer's suicide. American Journal
of Psychiatry, 161(8), 1411-1416.

16. Prigerson, H. G.,
Shear, M. K., Jacobs, S. C., Reynolds, C. F. I., Maciejewsk, P. K., Davidson,
J. R., Rosenheck, R., Pilkonis, P. A., Wortman, C. B., Williams, J. B.,
Widiger, T. A., Frank, E., Kupfer, D. J., & Zisook, S. (1999). Consensus
criteria for traumatic grief: A preliminary empirical test. British Journal of
Psychiatry, 174, 67-73.

17. Posttraumatic Stress Disorder:
Diagnosis and Assessment Subcomittee on
Posttraumatic Stress Disorder of the Committee on Gulf War and Health:
Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related
Stress. Institutes of Medicine. National Academies Press. 2006.


VIETNAM
VETERANS OF AMERICA

Funding Statement

November
29, 2011

The national organization Vietnam Veterans of
America (VVA) is a non-profit veterans' membership organization registered as a
501(c) (19) with the Internal Revenue Service.  VVA is also appropriately
registered with the Secretary of the Senate and the Clerk of the House of
Representatives in compliance with the Lobbying Disclosure Act of 1995.

VVA is not currently in receipt of any
federal grant or contract, other than the routine allocation of office space
and associated resources in VA Regional Offices for outreach and direct
services through its Veterans Benefits Program (Service Representatives). 
This is also true of the previous two fiscal years.

For Further Information,
Contact:
Executive Director for Policy and Government Affairs
Vietnam Veterans of America.

(301) 585-4000, extension 127

Prepared Statement of Joy J. Ilem, Deputy National
Legislative Director, Disabled American Veterans

On
behalf of the 1.2 million members of the Disabled American Veterans (DAV), all
of whom are wartime disabled veterans, I am pleased to present our views to the
Subcommittee on suicide prevention efforts in the Department of Veterans
Affairs (VA) and the Department of Defense (DOD).

The
increase in suicide among members of the military and veterans, and the innumerable
tragic accounts by family members struggling to deal with the aftermath of
suicide of a loved one, have raised deep concerns among military leaders, VA
health care officials and policy makers, certainly including this Subcommittee. 
Every suicide by a service member or veteran is tragic, and accentuates the
need for every effort to be made at multiple levels to prevent it. 
Unfortunately, suicide is a complex phenomenon and one that mental health
experts have struggled to find solutions and strategies to prevent. 

According
to researchers, suicide seems to most often occur due to a combination of mental
health stresses and societal triggers such as a marital or relationship breakup,
a job loss or loss of social status, and is often coupled with overuse of
alcohol or other intoxicating substances.  The same mindset that can cause a
person to take his or her own life is often the mindset that also prevents help-seeking
behavior.  Sadly, there are no easy fixes or answers to this problem, but
according to one expert, “in order to prevent suicides, the complexity of
behaviors and drivers of those behaviors need to be understood and
addressed…and this requires collecting and analyzing standardized data.”[1]

Mental
health experts note that emphasis on several critical building blocks for any
effective suicide prevention effort would be early intervention and routine mental
health screening for all post-deployed military personnel and veterans, along
with ready access to robust primary mental health care and specialty treatment
programs for post-traumatic stress disorder (PTSD) and substance-use disorder.  However,
experts also note that having sufficient mental health programs and providers
is not enough—identifying those at risk for suicide would be vital to prevention. 
Ongoing research is a critical component to assist in the development of evidenced-based
screening and risk assessment measures to accurately identify high risk
individuals, and in developing prevention strategies.  Likewise, an effective
communication strategy to increase awareness about what constitutes mental
health, aimed at changing attitudes and behaviors about seeking services for mental
health challenges, is another key component to addressing this problem.

According
to VA, its basic strategy for suicide prevention requires ready access be made
available to veterans for high quality mental health services supplemented by
programs designed to help individuals and families engage and participate in
care, and to address suicide prevention in the high-risk patients that
treatment efforts identify.[2]  VA has
put in place policies requiring clinicians to conduct routine screenings for depression,
PTSD, problem drinking and history of military sexual trauma for all veterans enrolled
in VA health care.  VA has reported that veterans who screen positive for PTSD are
more than four times as likely to indicate suicidal thoughts as veterans
without PTSD.  For these reasons, if a screening is positive for depression or
PTSD, an additional suicide risk assessment is conducted.  According to VA, for
each veteran identified as at high risk for suicide, a suicide prevention
safety plan is developed, components of an enhanced care mental health package
are implemented, and the veteran’s medical record is flagged so that all
providers are alerted to the suicide risk for the veteran.[3] 

Every
VA medical center is staffed with a suicide prevention coordinator.  VA has
recently re-branded its suicide hotline into a campaign promoting a broader “Veterans
Crisis Hotline,” which includes a chat service and a suicide prevention resource
center maintained jointly with the DOD on the internet.  VA has also been
moving forward with programs aimed at reducing stigma and getting veterans to
reach out for help.  The VA Office of Mental Health Services (OMHS) recently
rolled out its new mental health public awareness campaign called Making the
Connection
.  This unique campaign is targeted at veterans of all eras of military
service, their family members and friends and features personal testimonials
from veterans who have struggled with physical injuries and post-deployment mental
health challenges following service—and the positive outcomes they have
experienced regarding their treatment and personal recovery.  The website
offers mental health information, resources and support as a way of encouraging
veterans to seek help when needed.  The goal of the campaign is to reduce
stigma in seeking help and to build greater awareness of the numerous resources
available to improve the lives of our nation’s veterans.  DAV appreciates this
progress, and we are hopeful the new campaign is successful and improves access
and support for needed services for veterans and family members.  Despite the implementation
of these programs and policies the continuing and troubling suicide rate of
veterans still begs the question of what more can be done.

VA
estimates that there are approximately 1,600 to 1,800 suicides per year among
veterans receiving care within VHA and as many as 6,400 per year among all
veterans.  This
estimate would mean approximately 18 veterans nationally die from suicide per day and five
deaths by suicide per day among veterans receiving care in VHA.[4]
 Additionally, there are 950 suicide attempts per month among veterans
receiving care as reported by VHA suicide prevention coordinators (based on
data collected from October 1, 2008 through December 31, 2010).  In promoting its
Veterans Crisis Hotline, VA notes that, as of July 2011, it has received over
400,000 calls, of which over 5,000 were from active duty service members; VA responded
to over 16,000 chats and referred over 55,000 veterans to local VA suicide
prevention coordinators for same-day or next-day services; over 225,000 calls
received were from family members or those concerned about a loved one.  Additionally,
VA asserts that the Hotline initiated over 15,000 “rescues,” and that there
have been over 7,000 rescues of actively suicidal veterans as of April 2011.[5],[6]

VA
reports that in FY 2010, more than 1.25 million individual veterans were
treated in a VA specialty mental health program, medical center, clinic,
inpatient setting or residential rehabilitation program.  According to VHA
guidelines, all new patients requesting or referred for mental health services
must receive an evaluation within 24 hours, and undergo a more comprehensive
diagnostic and treatment planning evaluation within 14 days.  To meet
increasing mental health demand, VA has hired over 7,500 full time professional
staff since 2005, and during the last three years has trained over 4,000 staff
to provide psychotherapies with the strongest evidence for successful outcome
for PTSD, depression and other conditions.[7]   Unfortunately,
despite the significant increase in resources provided by Congress in recent
years for veterans’ mental health care and VA’s efforts to increase staff and implement
and improve its primary and specialized mental health programs, we often hear
from veterans that are experiencing difficulty gaining access to the mental
health treatment they need at a crisis point.  We agree with the Congressional
Research Service that VA’s internal policy requiring providers to make initial
assessments with 24 hours, and to begin treatments within 14 days for requested
mental health care, is probably not being carried out uniformly and
universally.[8]  For
these reasons, DAV has recently initiated an informal mental health survey of
up to 15,000 veterans focused on access to VA mental health services and the
quality of care they are receiving.  Although informal, it is our hope that the
results of this survey, publicized through our DAV social media sites to all
veterans, will provide a snapshot of veterans’ experiences, their perceptions
of access to VA mental health services, and their satisfaction levels with the
treatments and programs that VA offers.

A
comparable but much smaller query of VA mental health professionals was conducted
at the request of Senate Committee on Veterans’ Affairs following a July 2011
hearing that examined the gaps in VA mental health care.  The resulting August
2011 report, a very small sample due to the quick turnaround time requested,
queried 319 general outpatient mental health providers for each facility within
five Veterans Integrated Service Networks (VISNs); and 272 responded. 
Alarming, although not surprising based on the feedback DAV has been receiving,
over 70 percent of the respondents reported that their facilities had insufficient
mental health staff resources to meet veterans’ demands for care, and almost 70
percent indicated that their sites had shortages in physical space to
accommodate mental health services.  Nearly 40 percent reported they cannot
schedule an appointment in their own clinics for a new patient within 14 days,
and 46 percent reported that lack of off-hour appointment times was a barrier
to care.  Over 50 percent reported that growth in patient workloads contributed
to mental health staffing shortages, and more than 26 percent noted that the
demand for Compensation and Pension examinations diverted clinicians from providing
direct care.

Based
on the results of this VA internal survey and continuing reports from veterans
themselves, it appears that despite the significant progress—specifically an
increase in mental health programs and resources, and the number of mental
health staff hired by VA in recent years—significant gaps still plague VA’s
efforts in mental health care.  The impact of these gaps may fall greatest on
our newest war veterans, many of whom are in need of urgent services. 

In the active duty ranks, the Department of
Defense (DOD) has also been coordinating data collection systems, mental health
programs and research studies in an effort to reduce stigma in seeking mental
health care and to prevent suicides in the active duty force.  Some measureable
progress can be seen in the suicide rate among the services, but overall the numbers still
remain troubling.
 DOD acknowledges that providing mental health support to active duty troops is
critical in suicide prevention.  Likewise, its experts also confirm that
effective, accessible, and supportive clinical care for mental, physical, and
substance-use disorders are protective factors in preventing suicides.  For these
reasons, DOD reports it has updated its policies regarding early detection and
intervention for combat and operational stress reactions in the deployment
theaters.  In 2007, the Department initiated a surveillance system to capture
suicide data from the Services in a more central and standardized way.  In
addition to this effort, DOD reports that the Department and VA have a
developed a partnership to improve mental health access and care to service
members, veterans and their families.  For the past 10 months, DOD and VA have
been collaborating and implementing a DOD/VA joint strategy consisting of 28
strategic actions with specific milestones and outputs.  DOD has also partnered
with VA in hosting an annual suicide prevention conference that provides an
opportunity for the departments to share information and strengthen the
provider network across the two health care systems.[9] 

On this very note, DAV is disappointed to report that
Section 401 of Public Law 111-163 has not been implemented 18 months after
enactment.  This measure requires VA to amend its regulations to enable current
members of the armed forces who served on active duty in Operations Enduring or
Iraqi Freedom eligible for the readjustment counseling that VA currently provides
to veterans under title 38, United States Code, section 1721A.  We understand this
authority is still in the proposed rulemaking stage; however, we have heard this
document was recently forwarded to DOD for required joint concurrence.  Thus,
even though Congress acted, these military personnel cannot avail themselves of
a service that their peers in the veteran population have reported to be very
effective in dealing with their readjustment needs.  Because stigma and
confidentiality still remain a significant barrier for many active duty personnel
needing mental health care post- deployment, we ask VA and DOD to expedite this
mandate so the Readjustment Counseling Service can open its doors to those on
active duty who qualify for the counseling benefit.  Again, early intervention has
been found to be a key to avoiding long-term mental health conditions and other
negative outcomes related to untreated post-deployment readjustment issues.  VA’s
Vet Center Readjustment Counseling Service Program (a non-medical model) and
the more recently established Justice Program/Veterans Courts have been very
popular among veterans with a focus on peer to peer outreach and treatment
versus incarceration respectively.  VA estimates it will have approximately 300
Vet Centers operational by the end of 2011, along with 70 mobile Vet Centers
for veterans living in rural communities.[10]  We believe these
resources would be of great benefit to active duty service members who need
readjustment counseling but may not receive it due to bureaucratic delay.

DOD tasked the RAND Corporation to evaluate
information about military suicides, identify the agreed upon elements that
should be part of a state-of-the-art suicide prevention strategy, and recommend
ways to make sure the programs and policies provided by each military service
reflect the best practices.  This request culminated in a February 2011 report
from RAND, “The War Within: Preventing Suicide in the U.S. Military,” which
concluded that people with substance-use disorders and heavy alcohol users face
an increased risk for suicide, along with persons with traumatic brain injury
or head trauma, those suffering from hopelessness or experiencing certain life
events such as relationship problems.  Additionally, it was found that
availability of firearms correlates positively with suicide.  RAND researchers
reviewed a wide range of prevention programs but found that while promising
practices exist, much still remains unknown about what constitutes a best
practice.  Based on available literature and discussions with experts, RAND
indicated that a comprehensive suicide prevention program should include the
following six practices:

  • Raise
    awareness and promote self-care;
  • Identify
    those at high risk;
  • Facilitate
    access to quality care;
  • Provide
    quality care;
  • Restrict
    access to lethal means; and
  • Respond
    appropriately.

RAND made a series of 14 recommendations in its
report and noted research suggests that suicide can be prevented.  Recommendations
include: the establishment of proper tracking and data systems; research; the
delivery of high-quality care for those with behavioral health problems and
those who are at imminent risk for suicide; proper communication to ensure
potential at-risk population is informed and aware of the advantages of using
behavioral health care; determining the adequate number of behavioral health
specialists needed; and mandate training on evidence-based or state-of-the-art
treatment for mental health care providers.   

In
October 2011, the Government Accountability Office (GAO) issued a report
titled, VA Mental Health: Number of Veterans Receiving Care, Barriers Faced,
and Efforts to Increase Access,
covering veterans who used VA from FY 2006
through FY 2010.  According to the report, approximately 2.1 million unique
veterans received mental health care from VA during this period.  Although the
number steadily increased due primarily to growth in OEF/OIF/OND veterans
seeking care, GAO noted that veterans of other eras still represent the vast
majority of those receiving mental health services within VA.  In 2010 alone,
12 percent (139,167) of veterans who received mental health care from VA served
in our current conflicts, but 88 percent (1,064,363) were veterans of earlier
military service eras.  GAO noted that services for the OEF/OIF/OND group had
caused growth of two percent per year in VA’s total mental health caseload
since 2006.

Key
barriers identified in the GAO report that hinder veterans from seeking mental
health care included:  stigma, lack of understanding or awareness of mental
health care, logistical challenges to accessing care, and concerns that VA’s
care is primarily for older veterans.  GAO found that stigma is also a factor
that may discourage veterans from accessing mental health care—especially those
who have concerns that their careers could be negatively affected if employers
found out that they were receiving mental health treatment.  VA indicates it is
aware of these barriers and continues to implement efforts to increase
veterans’ access to mental health care, including its integration of mental
health services into primary care.

Clearly,
ten years of war have taken a toll on the mental health of American military
forces.  Combat stress, PTSD and other combat- or stress-related mental health
conditions are prevalent among veterans who have deployed to war environments
in Iraq and Afghanistan.  Regrettably, as was learned from our experiences in
other wars, especially the Vietnam conflict, psychological reactions to combat
exposure are common.  Experts note that if not readily addressed, such problems
can easily compound and become chronic.  Over the long term, the costs mount
due to impact on personal, family, emotional, medical, and financial damage to
those who have honorably served our nation.  Delays in addressing these
problems can culminate in self-destructive circumstances, including
substance-use disorders, incarceration, and suicide attempts.  Increased access
to mental health services for many of our returning war veterans is a pressing
need, particularly in early intervention services for substance-use disorders
and provision of evidence-based care for those with PTSD, depression, and other
consequences of combat exposure.

Unique
aspects of deployments to Iraq and Afghanistan, including the frequency and intensity
of exposure to combat, guerilla warfare in urban environments, and the risks of
suffering or witnessing violence, are strongly associated with a risk of
chronic PTSD.  Applying lessons learned from earlier wars, VA anticipated such
risks and mounted earnest efforts for early identification and treatment of
behavioral health problems experienced by returning veterans.  VA instituted
system-wide mental health screenings, expanded mental health staffing,
integrated mental health into primary health care, added new counseling and
clinical sites, and conducted wide-scale training on evidence-based
psychotherapies.  VA also has intensified its research programs in mental
health.  However, critical gaps remain today, and the mental health toll of
this war is likely to grow over time for those who have deployed more than
once, do not seek or receive needed services, or face increased stressors in
their personal lives following deployment.[11] 

Testimony
by RAND, other researchers, and VA has addressed the physical and mental health
impact of these wars based on the unique nature of the wars, particular wartime
risks and multiple military deployments for many service members.  The current
plethora of data to date on our newest generation of war veterans related to
increased rates of PTSD, depression, substance-use disorders, high risk-taking
behaviors, and traumatic brain injury are well known—but despite all the
information available, Dr. Charles W. Hoge, a leading researcher on the mental
health toll of the conflicts in Afghanistan and Iraq, observes that VA is not
reaching large numbers of returning veterans, and high percentages of veterans
who do seek care drop out of treatment.  In a recent analysis, Hoge wrote,“veterans
remain reluctant to seek care, with half of those in need not utilizing mental
health services.  Among veterans who begin PTSD treatment with psychotherapy or
medication, a high percentage drop out...with only 50% of veterans seeking care
and a 40% recovery rate, current strategies will effectively reach no more than
20% of all veterans needing PTSD treatment.[12]

DAV
agrees with Dr. Hoge’s view that VA must develop a strategy of expanding the
reach of treatment, to include greater engagement of veterans, understanding
the reasons for veterans’ negative perceptions of mental health care, and
“meeting veterans where they are.”[13] 

VA
attempts to meet the needs of wartime veterans with post-deployment mental
health challenges through two parallel treatment models:  a nationwide network
of medical centers and outpatient clinics that offer a more traditional medical
and psychiatric approach with recent integration of mental health into primary
care; and, community-based storefront Vet Centers that use a non-medical psychological
model to provide readjustment counseling and related services to combat
veterans and to their immediate families.  In some locations, the two programs
work together closely; in others, there is only limited coordination.  Veterans
are free to choose one model over the other or a combination of both services. 
However, the differences in approach may help explain why some veterans do not
pursue VA treatment, and why those who do often discontinue it.  While DAV
strongly supports the Vet Center program, we also believe VA must maintain a
robust mental health system as a part of VA medical care.  Both programs are critical to veterans
struggling with chronic mental illnesses and especially to new veterans who are
in need of readjustment services.

New
veterans generally report having had positive experiences with Vet Centers and
their staffs, a high percentage of whom are themselves combat veterans and who
convey an understanding and acceptance of combat veterans’ problems.  While
these centers do not provide mental health services in the traditional sense,
their strengths tend to fill the gaps reported by younger veterans regarding
mental health care in VA medical centers and primary care clinics. 

Dr.
Hoge echoes several of these points in urging what amounts to a call for a more
veteran-centric approach to treating PTSD and other war-related conditions:

Improving
evidence-based treatments…must be paired with education in military cultural
competency to help clinicians foster rapport and continued engagement with
professional warriors…Matching evidence-based components of therapy to patient
preferences and reinforcing narrative processes and social connections through
peer-to-peer programs are encouraged.  Family members, who have their own
unique perspectives, are essential participants in the veteran’s healing
process and also need their own support.[14]

Since
the beginning of the conflicts in Iraq and Afghanistan, VA has faced a number
of daunting challenges in providing care to a new generation of war
veterans—particularly in post-deployment readjustment and in mental health.  Initially,
the needs and expectations of OEF/OIF/OND veterans and their families proved to
be different from those of veterans who had typically been under VA care.  We
believe new veterans and their families want the DOD and VA to transform their
approaches to post-deployment mental health services, and to stress
family-centered treatment rather than focus solely on individual veterans—a
paradigm shift for VA.  Over its history, VA has concentrated primarily on the
single veteran patient to the exclusion of family in almost all cases.  But
this new generation of veterans is younger, technologically savvy, and demands
improved access to information via the Internet, access to state-of-the-art
prosthetic items, expertise in trauma care, and advanced rehabilitation
methods.  They also expect support for their family caregivers and better
transition and collaboration between DOD and VA in policies for family caregivers.
 Likewise, Congress, advocacy groups, and community stakeholders, including
groups in the private sector offering specialized services, have been very
active in pressing for change in how VA relates to community providers and how
it furnishes care in its mental health and rehabilitative services.

Last
year, the VA OMHS introduced a public health model for VA to meet the mental
health needs of OEF/OIF/OND veterans with the precept that most war veterans
will not develop chronic mental illness if VA concentrates on early
intervention, de-stigmatization,use of
effective mental health models, and makes greater outreach efforts.  The goal of
VA’s strategy is to promote healthy outcomes and strengthen families, with a
focus on resilience and recovery.  This initiative requires VA to evolve from
its more traditional medical model to an approach that would be less reliant on
establishing a diagnosis and developing a treatment plan, and more on helping
veterans and their families regain or retain an overall balance in their
physical, social and mental well-being despite the stresses of military deployments.
 Most important, the strategy calls for VA to reach out to veterans in their
communities, adjust its message, make access easier and on these veterans’
terms, and reformat programs and services to meet the needs of veterans and
their families, rather than expecting veterans to fit into VA’s traditional
array of available services.[15] 

In
preparing for this hearing, DAV observed that DOD and VA clearly have made
concerted efforts to address the challenges each Department faces in meeting
the mental health needs of post-deployment active duty personnel and wartime
veterans.  Also, both agencies are populated with dedicated mental health
experts, researchers and policymakers who continue to develop solutions to
prevent suicide and the less devastating but still serious emotional and
behavioral consequences of exposures to war.  However, despite both Departments’
obvious efforts and progress, much more needs to be accomplished to fulfill the
nation’s commitments to veterans who are challenged by serious and chronic mental
illnesses, and those needing post-deployment mental health readjustment
services.  Based on studies noted earlier in this statement, it appears DOD may
have less difficulty collecting data to analyze the need for policy changes
simply because DOD maintains access to data on the active duty population including
pertinent demographic information, recorded facts on wartime and other hardship
deployments, marital status, health information and personal stressors.  However,
DOD is burdened by a number of barriers unique to the military services that prevent
military personnel from coming forward for help.  The fear of being perceived
as “weak;” worry over losing rank; being identified as unreliable in stressful
or hazardous situations; and anxiety about being discharged in disgrace – all
these fears contribute to a reticence in military service personnel who are
struggling, from revealing their feelings to others or to seek help inside
their command structure.  DOD leaders have publicly acknowledged these types of
cultural obstacles do in fact exist and that DOD is still working to address
them systemically.

On
the other hand, VA is challenged with access to veterans’ data for those who
have not come to VHA for care.  Because veterans are private citizens, and
privacy of medical and personal information is the governing law, VA is at a
distinct disadvantage in gaining extensive data on mental health status,
suicide rates and other relevant information about the general veteran
population.   However, based on clinical and research experience with enrolled
veterans, what VA does know can be very beneficial for all veterans.  Experts
note that timely, early intervention services can improve veterans’ overall quality
of life, address substance-use problems, prevent chronic illness, promote
recovery, and minimize the long-term disabling effects of undetected and
untreated mental health problems. We encourage VA to build on that knowledge
and to be more transparent in dealing with the daunting challenges it faces in
overcoming the existing gaps in its mental health programs and in the crucial need
to address suicide, which has become so pressing.  DAV believes VA is moving in
an appropriate direction but needs to know more by learning directly from veterans
trying to access the VA system (as well as those who don’t) to better
understand their unique needs and desires for treatment and services. 
Listening to veterans’ feedback is essential to creating a system that meets
them where they are, works for them, and is effective in achieving the recovery
they seek.

As
a final thought, we recommend the Subcommittee review VA’s implementation of
sections 102-105 of the Veterans' Mental Health and Other Care Improvements Act of 2008, Public Law
110-387, a measure DAV strongly supported as a part of our Stand Up For
Veterans initiative.  These requirements, if implemented faithfully by VA, would go
a long way toward addressing many of the lingering issues discussed in this
testimony today.  Also, we recommend a close review by your professional staff
of our discussion in the FY 2012 Independent Budget (IB)on the
topics of mental health and transition needs of OEF/OIF/OND veterans, as well
as the new discussion of those subjects in the upcoming IB for FY 2013.

Madam
Chairwoman and Members of the Subcommittee, this concludes my testimony on
behalf of DAV.  I would be pleased to respond to your questions.


[1] The Hon. Jonathan Woodson, M.D.,
Asst. Secretary of Defense for Health Affairs, U.S. Department of Defense,
Testimony before the United States House of Representatives Committee on Armed
Services, Hearing on “Current Status of Suicide Prevention Programs in the
Military.” (September 9, 2011).

[2] Department of Veterans Affairs,
Fact Sheet: VA Suicide Prevention Program, Facts about Veteran Suicide. (April
2011)

[3]Antonette Zeiss, Ph.D.,
Acting Deputy Patient Care Services Officer for Mental Health, Veterans Health
Administration, U.S. Department of Veterans Affairs, Testimony before the
United States House of Representatives Committee on Veterans’ Affairs, Hearing
on “Mental Health: Bridging the Gap Between Care and Compensation for
Veterans.” (June 14, 2011).

[4]John D. Daigh, Jr., M.D.,
Assistant Inspector General for Health Care Inspections, Office of Inspector
General, U.S. Department of Veterans Affairs, Testimony before the United
States Senate Committee on Veterans’ Affairs, Hearing on “VA Mental Health Care: 
Closing the Gaps.”  (July 14, 2011).

[5] Antonette Zeiss, Ph.D., Acting
Deputy Patient Care Services Officer for Mental Health, Veterans Health
Administration, U.S. Department of Veterans Affairs, Testimony before the
United States House of Representatives Committee on Veterans’ Affairs, Hearing
on “Mental Health: Bridging the Gap Between Care and Compensation for
Veterans.” (June 14, 2011).

[6] Department of Veterans Affairs,
Fact Sheet: VA Suicide Prevention Program, Facts about Veteran Suicide. (April
2011)

[7] Antonette Zeiss, Ph.D., Acting
Deputy Patient Care Services Officer for Mental Health, Veterans Health
Administration, U.S. Department of Veterans Affairs, Testimony before the
United States House of Representatives Committee on Veterans’ Affairs, Hearing
on “Mental Health: Bridging the Gap Between Care and Compensation for
Veterans.” (June 14, 2011).

[8]Suicide, PTSD, and
Substance Use Among OEF/OIF Veterans Using VA Health Care: Facts and Figures,
Congressional Research Service, July 18, 2011

[9] The Hon. Jonathan Woodson, M.D.,
Asst. Secretary of Defense for Health Affairs, U.S. Department of Defense,
Testimony before the United States House of Representatives Committee on Armed
Services, Hearing on “Current Status of Suicide Prevention Programs in the
Military.” (September 9, 2011).

[10] Antonette Zeiss, Ph.D., Acting
Deputy Patient Care Services Officer for Mental Health, Veterans Health
Administration, U.S. Department of Veterans Affairs, Testimony before the
United States House of Representatives Committee on Veterans’ Affairs, Hearing
on “Mental Health: Bridging the Gap Between Care and Compensation for
Veterans.” (June 14, 2011).

[11] Brett T. Litz, National Center
for Post-Traumatic Stress Disorder, Department of Veterans Affairs, “The Unique
Circumstances and Mental Health Impact of the Wars in Afghanistan and Iraq,” A
National Center for PTSD Fact Sheet (January 2007).  http://www.nami.org/Content/Microsites191/NAMI_Oklahoma/Home178/Veterans3/Veterans_Articles/5uniquecircumstancesIraq-Afghanistanwar.pdf

[12] Charles W. Hoge, MD, “Interventions
for War-Related Posttraumatic Stress Disorder: Meeting Veterans Where They Are
,”
JAMA, 306(5): (August 3, 2011) 548.

[13] Ibid.

[14] Hoge, “Meeting Veterans Where
They Are,” 551.

[15] Harold Kudler, VA/DOD/State and
Community Partnerships: Practical Lessons on Implementing a Public Health Model
to Meet the Needs of OEF/OIF Veterans and Their Families, VA Course on
Implementing a Public Health Model for Meeting the Mental Health Needs of
Veterans, PowerPoint presentation (Baltimore, MD, July 28, 2010).

Prepared Statement of Margaret C. Harrell, Ph.D., Senior Fellow and
Director, Joining Forces Initiative, Center for a New American Security

Madame Chairwoman Buerkle, Ranking Member Michaud, and members of
the Subcommittee: Thank you for the privilege of testifying today. It is an
honor to be here. Military suicide, that of both service members and veterans,
is a tragedy that affects more than the individual. Each suicide devastates a
family, a unit, and a community. There are also implications beyond the local.

Military suicide is a national security issue. George Washington
said, “The willingness with which our young people are likely to serve in any
war, no matter how justified, shall be directly proportional to how they
perceive the Veterans of earlier wars were treated and appreciated by their nation.”
If Washington was correct, suicide among service members and veterans threatens
the health of the all-volunteer force. Mentors and role models, including
parents, teachers and, importantly, veterans, play a critical role in the
enlistment decisions of young men and women. We should realize that these
mentors and role models will not steer youth toward the military if they
perceive damage to service members or a failure to address the mental health
care needs of those who have served their country.

While the topic at hand is suicide prevention among veterans, I
urge the committee to recognize the importance of considering both veteran and
service member suicide. This recommendation is based upon more than the
recognition of suicide as a tragic outcome; it is based upon the pragmatic
recognition that we can only be sure that improvements have been made when the
frequency of suicide decreases amongst both of these populations. There is, for
example, a possibility that a decrease in the frequency and number of suicides
among service members could represent only expeditious out-processing of
service members struggling with mental health wounds of war. Likewise, a
decrease in veteran suicide, once we have greater visibility of these outcomes,
could reflect the shifting of suicides to the time prior to military discharge.
Only the joint consideration of both service member and veteran outcomes will
highlight reasons for increased concern or will identify success.

There does not currently exist a systematic combined analysis of
service member and veteran suicide. Neither the Department of Defense (DOD) nor
the Department of Veterans Affairs (VA) fully consider or analyze suicide in
one another’s population. Given the potential implications of veteran suicide for
the all-volunteer force, both the VA and the DOD should seek to understand
which veterans, and how many veterans, are dying by suicide. In particular, we
should recognize that veterans who left the service only shortly before they
killed themselves may have suffered from unaddressed mental health wounds
incurred while in service to their nation.

This testimony derives from a CNAS policy brief, Losing the Battle: The Challenge of Military Suicide, which discussed the stark numbers of the veterans and service
members who die by suicide every day. The policy brief also identified
obstacles to improvement and made recommendations to address these obstacles.
This testimony focuses upon the recommendations most applicable to the veteran
community.

It is important to note that the U.S. military and veteran
population cannot avoid the stark reality of suicide entirely. Service members
and veterans reflect the broader American public, which not only suffers from
suicide, but also stigmatizes mental health care. Further, some service members
enter military service with mental health challenges and we should not conclude
that serving in the military caused these suicides.

This testimony also notes that leaders in the services and the VA
deserve recognition for their actions to reduce the rate of suicide among
service members and veterans. Senior military leaders have exerted considerable
effort in recent years to acknowledge and confront the challenge of suicide.
The VA and each of the military services have emphasized the development of
suicide prevention programs, education about the risk of suicide and the most
effective ways to prevent it. The DOD suicide prevention programs, with slogans
such as “Never Leave a Marine Behind” and “Never Let Your Buddy Fight Alone,”
resonate with service members by being service-specific and embedded in their
service cultures. The services ensure that the necessary tools, such as
hotlines, are readily available. The VA’s Veterans Crisis Line is especially
important in this regard. In its first three years, the hotline received more
than 144,000 calls involving veterans and saved more than 7,000 actively
suicidal veterans.1 Challenges remain nonetheless.

Service Member and Veteran Suicide

From 2005 to 2010, service members took their own lives at a rate
of approximately one every 36 hours.2 While suicides in the Air Force, Navy and Coast Guard have been
relatively stable and lower than those of the ground forces, U.S. Army suicides
have climbed steadily since 2004. The Army reported a record-high number of
suicides in July 2011 with the deaths of 33 active and reserve component
service members reported as suicides. Suicides in the Marine Corps increased
steadily from 2006 to 2009, dipping slightly in 2010.

The VA estimates that a veteran
dies by suicide every 80 minutes,3 but is impossible, given the paucity of current data, to determine
the suicide rate among veterans with any accuracy or to understand which
veterans are dying.

The Relationship Between Military Service and Suicide

Although the number
of military suicides has increased since the start of the wars in Afghanistan
and Iraq, the prevailing wisdom has been that suicides are not linked directly
to deployment.4 However, recent analysis of Army data demonstrates that soldiers
who deploy are more likely to die by suicide.5 Data have long indicated definitive links between suicide and
injuries suffered during deployment. Individuals with traumatic brain injury
(TBI), for instance, are 1.5 times more likely than healthy individuals to die
from suicide.6 Additional factors that heighten risk include chronic pain and
post-traumatic stress disorder (PTSD) symptoms such as depression, anxiety,
sleep deprivation, substance abuse and difficulties with anger management.7
These factors are also widely associated with deployment
experience in Afghanistan and Iraq.

Some psychiatric experts argue that there is an indirect
relationship between suicide and military service during wartime. In the
psychiatric field, one school of thought, known as the interpersonal
psychological theory of suicide, suggests that the following three “protective”
factors preclude an individual from killing oneself: belongingness, usefulness
and an aversion to pain or death.8 Any one of these protective factors normally is sufficient to
prevent suicide. Traditionally, military service has had a protective quality:
Military service members have been less likely to die by suicide than
civilians. It appears now, however, that the nature of military service –
especially during wartime – may weaken all three protective factors.9 The cohesion and camaraderie of a military unit can induce intense
feelings of belonging for many service members. Time away from the unit,
however, may result in a reduced or thwarted sense of belonging, as individuals
no longer have the daily support of their units and feel separate and different
from civilians. This is especially true for Guardsmen, Reservists, and for
veterans.

The responsibility inherent in military service, the importance of
tasks assigned to relatively junior personnel and the high level of interaction
among unit members establish the importance and usefulness of each unit member,
particularly in an operational environment. In contrast, the experience of
living in a garrison environment (for active component personnel) or returning
to a civilian job (for Guardsmen, Reservists and veterans) or, worse,
unemployment, can introduce feelings of uselessness. Individual accounts of
military suicide both in the media and in interviews with us echo this
sentiment. Over and over, these accounts show that individuals withdrew, felt
disconnected from their units and their families, and perceived themselves as a
burden.

The third protective factor –
an aversion to pain or death – is especially important in considering military
suicide, because military service is one of the few experiences that can
override this factor. Repeated exposure to military training as well as to
violence, aggression and death dulls one’s fear of death and increases
tolerance for pain.10 Thus, the very experience of being in the military erodes this
protective factor, even for service members who have not deployed or
experienced combat, in part because service members experience pain and
discomfort from the beginning of their training.11 By removing some of the protective factors of suicide, therefore,
military service, especially during wartime, may predispose an individual
toward suicide.

Challenges and Recommendations

There are obstacles to addressing suicide that should be resolved.
Some of these obstacles are especially difficult to eliminate. Many of the
recommendations we have made pertain specifically to service member suicide,
for two reasons. First, we know more about service member suicide than about
suicide amongst veterans. The lack of understanding about suicide among
veterans reduces the likelihood of actionable recommendations. Second, reducing
the challenges to mental health among service members should also improve the
mental health of recently discharged veterans.

Challenge I: Americans lack a complete accounting of veteran suicide. The
estimation of veteran suicides is extrapolated from extremely limited data.
Specifically, states provide death data to the Centers for Disease Control
(CDC) for inclusion in the National Death Index, but only 16 U.S. states
indicate veteran status in their data.12 The number of veteran suicides from the remaining 34 states is
extrapolated to estimate the overall number of veteran suicides.13 Further, the current numbers are extrapolated from three year-old
data.

An effort is underway to match
the Social Security numbers in the national death data with DOD files to
identify veterans included in the data. This effort provides the capability to
analyze the data and characterize the veteran victims of suicide. It will thus
be possible to quantify veteran suicide and contribute an understanding of the
number of suicides among Post-9/11 veterans, as compared with veterans of earlier
generations. This analysis could also permit an understanding of whether
veterans kill themselves soon after leaving the military.

Recommendation: Given the potential
implications of veteran suicide for the all-volunteer force, the DOD should
seek to understand which veterans, and how many veterans, are dying by suicide.
In particular, the DOD, as well as the VA and the country at-large, should
recognize that many veterans who left the service only shortly before they
killed themselves may have suffered from unaddressed mental health wounds
incurred while in service to their nation. Congress should establish reasonable
time requirements for states to provide death data to the CDC, and the
Department of Health and Human Services (HHS) should ensure that the CDC is
resourced sufficiently to expedite compilation of national death data. The DOD,
the VA and HHS should coordinate efforts to analyze veteran suicide data and
should conduct these analyses annually.

Challenge II: As service members return home from deployment, they complete a
post-deployment health assessment (PDHA). As part of this assessment, they are
asked questions about their physical and mental health, such as, “Did you
encounter dead bodies or see people killed or wounded during this deployment?”
and “During this deployment, did you ever feel that you were in great danger of
being killed?” There are also self-evaluative questions, such as, “Are you
currently interested in receiving information or assistance for a stress,
emotional or alcohol concern?” While we do not question the contents of the
assessment, its administration has been problematic.

A 2008 study found that when
Army soldiers completed an anonymous survey, reported rates of depression,
PTSD, suicidal thoughts and interest in receiving care were two to four times
higher as compared to the PDHA. Likewise, our interviews with veterans
uncovered numerous accounts of returning service members whose unit leaders
advised them to fabricate answers. Individuals across all services have been
told, “If you answer yes to any of those questions, you are not going home to
your family tomorrow.” This may be factually correct, but it neglects to inform
service members of the implications of answering untruthfully – namely, that
they will have difficulty receiving treatment or compensation for mental health
problems that appear after their service. As an improvement, the 2010 National
Defense Authorization Act requires trained medical or behavioral health
professionals to conduct the PDHA evaluations individually and face-to-face, in
the hope that service members will respond honestly to a trained health
professional. 14

Recommendation: Unit leaders should encourage members to complete the PDHA
truthfully and should underscore that an honest answer will allow them to link
any future mental health problems requiring treatment to their military
service. This is especially important for veterans, as the PDHA informs
decisions regarding their eligibility for mental health care after they
separate from service.

Challenge III: There is a national shortage of mental health care and behavioral
health care professionals, a factor linked to higher rates of suicide.
According to the VA, suicide rates decreased by 3.6 deaths per 100,000 in seven
regions15 where staff numbers increased to levels recommended in the 2008
Veterans Health Administration Handbook.16 Sixteen regions are still not manned to these levels, however.
Additionally, for the Army, only 80 percent of the psychiatrist and 88 percent
of the social worker and behavioral health nurse positions are filled. With
respect to psychologists, 93 percent of positions are filled.17 Military hospital commanders have temporary authority to hire
psychologists and social workers and behavioral health nurses on an as-needed
basis, but a shortage of care providers precludes them from easily filling that
gap. This shortage is a national issue, which affects the availability of care
providers for the DOD and the VA. It also affects veterans’ families, who seek
treatment from the civilian health care system to cope with the strain of
reintegration.

Recommendation: Congress should
permanently establish expedited or direct hire authority allowing military
hospitals to hire behavioral health care providers. Congress should require the
VA to establish deadlines by which all twenty-three VHA regions will be manned
to the recommended levels of behavioral health care providers. Additionally,
and especially in the meantime, the VA should increase their use of existing
public-private partnerships to provide mental health care, to the extent that
such partnerships would expedite evidence-based care to veterans.

Challenge IV: Permanent change of station (PCS) moves are a feature of military
life. Individuals also often relocate their families as they leave the
military. However, because professional organizations license mental health
care providers on a state-by-state basis, a geographical move across state
lines can preclude continued care from the same provider. When a care provider
and a veteran, service member or family member invest in developing a care
relationship, and that relationship is severed by a move, patients are often
reluctant to begin treatment anew.

Recommendation: Congress should establish a federal pre-emption of state licensing
such that mental health care can be provided across state lines for those
instances in which military service members or family members have an
established pre-existing care relationship.

Challenge V: The programs and services designed to understand and reduce
service member and veteran suicide should complement one another and gain both
efficiency and effectiveness from interacting synergistically. Obtaining
veteran suicide data and understanding the circumstances surrounding
individuals who die by suicide depends on the states and the HHS, as well as on
the participation of the VA and the DOD. 18 Within DOD, the military services and components do not regularly
and consistently share information. Information should also be shared between
the House Armed Services Committee (HASC) and the Senate Armed Services
Committee (SASC), who interact primarily with DOD and the Senate Committee on
Veteran Affairs and the House Veterans Affairs Committee, who interact
primarily with the VA..

Recommendation: The DOD, the VA and
HHS should share data and information pertaining to suicide. The military
services’ leaders should meet regularly to discuss issues and approaches
pertaining to suicide, and to share lessons learned. The Senate Committee on
Veterans Affairs and the House Veterans Affairs Committee should embrace the
opportunity to work with the SASC and HASC, with the intent of developing
provisions for the NDAA to address the problem of veteran suicide.

Challenge VI: The health and survival of service members hinges on the removal
of the stigma associated with mental health care. This stigma exists in both
military and civilian culture. In the military, it prevents many service
members from seeking help to address mental health care issues; 43 percent of
soldiers, sailors, airmen and Marines who took their own lives in 2010 did not
seek help from military treatment facilities in the month before their deaths.19
The percentage of service members seeking help has improved – from 40 percent in 2008 and
36 percent in 2009 to 57 percent in 2010 – but the stigmatization of mental
health care remains an issue.20 Military leaders recognize the importance of removing this stigma.
Indeed, recently retired Chairman of the Joint Chiefs of Staff Admiral Mike
Mullen identified the stigma of PTSD as the greatest challenge confronting
troops returning from war in Iraq and Afghanistan,21 and other DOD leaders at the highest levels have urged service
members to seek mental health care as needed. Nevertheless, the stigma
persists.

This culture is unlikely to
change quickly. Leaders have not provided sufficient guidance about how to
remove the stigma associated with depression and suicidal thoughts, and they
have not consistently disciplined service members who belittle or ridicule
members with mental health issues.22 Removing the stigma for PTSD, an invisible injury, will be
especially difficult, given that some service members do not even consider TBI,
which is physically evident and recognizable, a “real injury.”23 Yet the stigma must be removed to address and treat PTSD and TBI,
both of which are linked to suicide. The effect of military culture will also
inform and bear upon the perspectives and behavior of veterans even after they
leave the military service.

Recommendation: Military leaders must eliminate the stigma associated with mental
health care and hold unit leaders accountable for instances in which
individuals are ridiculed for seeking treatment.

Challenge VII: Misuse of prescription medication is another obstacle to
addressing the problem of military suicide. Approximately 14 percent of the
Army population is currently prescribed an opiate.24 Forty-five percent of accidental or undetermined Army deaths from
2006 to 2009 were caused by drug or alcohol toxicity,25 and 29 percent of Army suicides between 2005 and 2010 included
drug or alcohol use.26

Data collected from
civilian populations indicate that adults aged 18-34 are the most likely to
have attempted drug-related suicides,27 and that 58.9 percent of drug-related suicide attempts resulting
in visits to an emergency room involve psychotherapeutic drugs.28 Another 36 percent of emergency room visits for suicide attempts
involve pain medications.29 If we anticipate similar rates among military service members, it
is important to address the excess prescription medicine among military service
members. Yet, there is no opportunity to do so. When military doctors prescribe
an alternative medication or dosage from what a service member was previously
prescribed, there is no request made for the service member to return the
remainder of his or her prior medication. Instead, military doctors dispense additional
medications, because only law enforcement personnel can conduct “take-back”
programs for medications. On January 26, 2011, the Army Vice Chief of Staff
requested that the Drug Enforcement Administration (DEA) permit the Army’s
military treatment facilities and pharmacies to accept excess prescription
medicine for disposal.30 The request was denied.

Recommendation: The DEA should
grant the DOD authority to accept and destroy excess prescription medication
from military service members. Given this authority, the Office of the Army
Surgeon General should initiate an effort with the Navy, Air Force and Coast
Guard surgeon generals to develop policies and practices regarding how best to
account for, and regain possession of, excess prescription medications. Such a
drug take-back program will be targeted to the military services, but could
also help ensure that service members do not transition out of the military
with surplus prescription medications.

Challenge VIII: The DOD approach to suicide prevention depends heavily on what experts
refer to as “gatekeeper strategies.” The Army, for example, asserts that
“[t]here is no other aspect of [its suicide prevention] that is more important
for preventing negative outcomes than the vigilance of the individual
commander, supervisor, Soldier, law enforcement agent or program/service
provider. Leaders, supervisors, and ‘Buddies’ represent the first level for
surveillance of high risk behavior.”31 Although medical and academic experts identify gatekeeper
approaches as one of the most promising strategies,32 the limitations of this approach are notable for the Guard and
Reserve, where there are long monthly gaps between drill periods when leaders
and peers do not have the opportunity to watch for warning signs. Yet studies
indicate that even the smallest amount of contact can reduce the risk of
suicide.33 These findings suggest that even postcards or text messages from
unit leaders between drill weekends can help prevent suicides.

Recommendation: The DOD should
address weaknesses in gatekeeper-based programs for drilling Guard and Reserve
units. Specifically, Guard and Reserve units should develop a leadership
communication plan that addresses the stresses on units and details the
frequency and method (written, electronic or telephone) by which small unit
leaders should remain in contact with their subordinates. Leaders should pay
closer attention to this communication following a deployment. Such
communication could especially help save the lives of our country’s “affiliated
veterans,” those who periodically return to uniform, either for drill or
mobilization and deployment.

Challenge IX: Assessing which suicide prevention strategies are effective
requires systematic efforts to understand military suicide. Yet these efforts
are thwarted by the existence of too many programs. Suicide prevention programs
in the National Guard are a decentralized multitude that the Adjutant General
(TAG) of each state and U.S. territory initiates and manages. This grassroots
solution is inefficient given that, while some states had more suicides than
others, overall the Army National Guard averages slightly more than one suicide
per state annually. Although the individual programs may use evidence-based
approaches, it will be difficult to demonstrate which suicide prevention
programs are effective with the military community or efficacious in reducing
suicide, because the small numbers do not support rigorous analysis. Even more
important, these programs risk reduction or elimination due to dwindling state
resources. This is the case of Minnesota, where there exists both the highest
number of National Guard suicides, and also dwindling resources to address
their problem.34

Recommendation: The National Guard
should reduce the number of unique suicide prevention programs, and consider
adoption of a systemwide, centrally funded, prevention approach.

Conclusion

Addressing suicide among service members and veterans is integral
to the fitness and sustainability of the all-volunteer force. It will take a
collaborative effort by DOD, VA, federal and state legislatures, and
communities to curb suicide among those who have served the United States. The
military must take better care of its own. Although a goal of no suicides is
unachievable, the increasing number of suicides is unacceptable. Additionally,
although the benefits and services available from the VHA will likely remain
the best system of care for veterans, the DOD has moral responsibility to
acknowledge and understand former service members.

The CNAS policy
brief, from which my comments are extracted, is entitled Losing the Battle: The Challenge of Military Suicide. America is currently losing its battle against suicide by
veterans and service members. As more troops return from deployment, the risk
will only grow. To honor those who have served and to protect the future health
of the all-volunteer force, America must renew its commitment to its service
members and veterans. The time has come to fight this threat more effectively
and with greater urgency. Thank you for addressing your attention to this
critically important battle.


1 Text refers to period from July 2007 to March 2010. Department of
Veterans Affairs, Fact Sheet: VHA Suicide Prevention Program, Facts About
Veteran Suicide.

2 Department of Defense, “The Challenge and the Promise:
Strengthening the Force, Preventing Suicide, and Saving Lives,” Final Report of
the DOD Task Force on Prevention of Suicide by Members of the Armed Forces (August
2010), provides data through 2009. The 2010 data are from the Department of
Defense, Department of Defense Suicide Event Report, Calendar Year 2010 Annual Report (September 2011).

3 Department of Veterans Affairs, Fact Sheet: VHA Suicide Prevention
Program, Facts About Veteran Suicide (March 2010).

4 This relationship has not been evident in prior analyses and is
not evident in suicide data from the Navy, Air Force, Marine Corps or Coast
Guard.

5 Sandra A. Black et al., “Prevalence and Risk Factors Associated
with Suicides of Army Soldiers 2001-2009,” Military
Psychology
23 no. 4 (July 2011), 433-451.

6 Department of Veterans Affairs, Memorandum from Deputy Under
Secretary for Health for Operations and Management, “Recent VHA Findings
Regarding TBI History and Suicide Risk” (October 29, 2009) Department of Veterans
Affairs, Memorandum from Deputy Under Secretary for Health for Operations and
Management, “Recent VHA Findings Regarding TBI History and Suicide Risk”
(October 29, 2009).

7 Sandra A. Black et al., “Prevalence and Risk Factors Associated
with Suicides of Army Soldiers 2001-2009,” 442; and E. C. Harris and B.
Barraclough, “Suicide as an Outcome for Mental Disorders: A Meta-analysis,” British Journal of Psychiatry
170 no. 3
(March 1997), 205-228.

8 Thomas Joiner, Why People Die by Suicide (Cambridge, MA: Harvard University Press, 2007).

9 See the discussion of these effects in Edward A. Selby et al.,
“Overcoming the Fear of Lethal Injury: Evaluating Suicidal Behavior in the
Military through the Lens of the Interpersonal-Psychological
Theory of Suicide,” Clinical Psychology Review 30 no. 3 (April
2010), 298-307.

10 Craig J. Bryan et al., “Challenges and Considerations for Managing
Suicide Risk in Combat Zones,” Military Medicine 175 no. 10 (October 2010), 713-718; and Edward A. Selby et al.,
“Overcoming the Fear of Lethal Injury.”

11 C. J. Bryan et al., “A Preliminary Test of the Interpersonal-Psychological
Theory of Suicide Behavior in a Military Sample,” Personality and Individual Differences
48 no. 3 (February 2010), 347-350.

12 The states are Alaska, Colorado, Georgia, Kentucky, Maryland,
Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode
Island, South Carolina, Utah, Virginia and Wisconsin.

13 Even if all states indicate veteran status, suicides will still be
underreported because of the vulnerability of civilian death data to the social
stigma of suicide.

14 The National Defense Authorization Act for FY 2010, Public Law
111-84, sec. 70.

15 The Veteran Health Administration (VHA) is a subordinate organization
to the Department of Veterans Affairs. The VHA is divided into 23 regions
called Veterans Integrated Service Networks.

16 Department of Veterans Affairs, Veterans Health Administration
Handbook 1160.01 (September 11, 2008)

17 Army personnel numbers are as of July 2011, from communication
with Army Medical Command representative (September 29, 2011).

18 The CDC is subordinate to the HHS.

19 Fifty-seven percent of DOD suicides were seen at a military
treatment facility in the month prior to their deaths. Department of Defense, Department of Defense Suicide Event Report, Calendar Year 2010 Annual Report (September 2011), 23.

20 Department of Defense, Department of
Defense Suicide Event Report
, Calendar Year 2009 Annual
Report (2010), 29; and Department of Defense, Department of
Defense Suicide Event Report
, Calendar Year 2008 Annual
Report (2010), 26.

21 Stephanie Gaskell, “Stigma of Posttraumatic Stress Disorder Is
Greatest Challenge of Returning Troops: Mullen,” Daily News (April 19, 2010).

22 See, for example, the following news article for a publicized
account of such ridicule:
http://www.q13fox.com/news/kcpq-suicide-rate-spiking-at-joint­baselewismcchord-20110817,0,1023250.story.

23 The authors interviewed veterans who did not mention their own TBI
in response to the question, “Were you physically wounded during deployment?”
When interviewees mentioned TBI in subsequent conversations, they
would typically explain that their initial answer only included “real injuries.

24  U.S. Army, Health Promotion Risk Reduction
Suicide Prevention Report
(August 2010), 45. Also, the
Army estimates that 30,401 soldiers would test positive for a medical review
officer–reviewable drug, with 3,925 representing illicit use. Ibid., 44.

25 Ibid., 4.

26 Ibid., 43.

27 2004 data, as reported by Substance Abuse and Mental Health
Services Administration, The OAS Report: Suicidal
Thoughts, Suicide Attempts, Major Depressive Episode & Substance Use among
Adults
34 (2006), 5, http://www.oas.samhsa.gov/2k6/suicide/suicide.pdf,
as of September 9, 2011.

28 Substance Abuse and Mental Health Services Administration, The OAS Report: Suicidal Thoughts, Suicide Attempts, Major
Depressive Episode & Substance Use among Adults
, 6.

29 Substance Abuse and Mental Health Services Administration, The OAS Report: Suicidal Thoughts, Suicide Attempts, Major
Depressive Episode & Substance Use among Adults
, 6.

30 Peter W. Chiarelli, Vice Chief of Staff, U.S. Army, letter to
Joseph T. Rannazzisi, Deputy Assistant Administrator, Drug Enforcement
Administration, Office of Diversion Control (January
26, 2011).

31 U.S. Army, Health Promotion Risk Reduction
Suicide Prevention Report
, 46.

32 Mann et al., “Suicide Prevention Strategies: A Systematic Review.”

33 Alexandra Fleischmann et al., “Effectiveness of Brief Intervention
and Contact for Suicide Attempters: A Randomized Controlled Trial in Five
Countries,” Bulletin of the World Health Organization 86 no. 9 (September 2008), 703-709.

34 Mark
Brunswick, “Anti-Suicide Program for Military Runs Low: Shortfall Comes as
Minnesota Guard Fights High Suicide Rates,” Star Tribune,
October 2, 2011.

Prepared Statement of
Katherine E. Watkins, Senior Natural Scientist, The RAND Corporation
a

Suicide Prevention Efforts and Behavioral Health Treatment in the
Veterans Health Administration b

Chairman
Buerkle, Representative Michaud, and distinguished members of the Committee,
thank you for inviting me to testify today. It is an honor and pleasure to be
here. In this testimony, I will briefly summarize the evidence that mental
illness has a strong association with suicide and that providing high-quality
behavioral health treatment can reduce the risk of both attempted and completed
suicide. Then I will describe the results of a recent study of the quality of
behavioral health care provided by the Veterans Health Administration (VHA) to
veterans with mental illness and substance use disorders and discuss the
implications of this study’s findings for suicide prevention. I will conclude
by proposing specific steps which VHA could take to improve the quality of care
provided to veterans with mental illness and substance use disorders--steps
which, if taken, could further reduce suicide risk among our nation’s veterans.

While
suicide remains a rare event that is difficult to predict, studying the
characteristics of individuals who attempt and complete suicide allows us to
identify common risk factors and thus direct efforts toward prevention.
Research studies have shown that over 90 percent of suicide victims have a diagnosable
mental illness.1-5 In the veteran population, depressive disorders, post-traumatic
stress disorder (PTSD), bipolar I disorder and drug and alcohol disorders are
risk factors for both attempted and completed suicide.6-10  In one
study, among veterans being treated at a VA hospital after a suicide attempt, a
review of their medical records indicated that 31.8 percent had a diagnosed alcohol
disorder, 21.8 percent had a drug use disorder, 21.2 percent had a psychotic disorder, and
18.5 percent had a depressive disorder.10 Another study of veterans who
completed suicide showed that bipolar disorder posed the greatest estimated
risk of suicide among men, and substance use disorders posed
the greatest risk among women.11 While most individuals with mental
illness do not complete suicide, the strong association between mental
disorders and suicide suggests that among those with vulnerability to suicide,
untreated or worsening mental disorders may be causally related to suicide.
Examples of vulnerability include a genetic predisposition to suicide and
hopelessness.12-15

Identification
and treatment of mental disorders is important because appropriate treatment
for mental disorders may reduce the risk of suicide. Most of the data
supporting this assertion come from cross-sectional studies which show an
association between treatment and reduced risk. Among veterans who received a
new diagnosis of depression, suicide attempt rates were lower among patients
being appropriately treated with antidepressants than among those who were not.16,17
Among individuals with bipolar disorder, continued treatment with
mood-stabilizing drugs is associated with a decreased rate of completed suicide
compared to brief or interrupted treatment with these medications, and the rate
of suicide decreases consistently with the number of additional prescriptions.18
Lithium and clozapine, two important pharmacotherapies for mental disorders,
may have specific suicide-prevention qualities.19,20 There are no
studies of whether appropriate treatment for PTSD or for substance use
disorders reduces suicide risk, although intoxication can exacerbate
impulsivity and hopelessness, and many suicide attempts occur in the context of
substance use.6 This is an area where further research is needed. A
recent RAND review of suicide prevention efforts in the US military concluded
that the strongest empirical evidence for preventing suicide involved providing
high-quality mental health treatment.21

The
majority of individuals who die by suicide have contact with either a primary
care or mental health provider in the year prior to the suicide, and nearly
half have contact in the month before suicide.22
In one study of veterans who had contact with VA treatment services and who
completed suicide, all were outpatients at the time of death, 60 percent were
hospitalized for psychiatric reasons in the year before death and 83 percent of those
who were hospitalized completed suicide within two months of hospital
discharge.6 In another study of 968 veterans who completed suicide
in the community, 22 percent had received health care in the VA system in the year
prior to death; of these, 58 percent had not seen a mental health professional.23
These studies suggest that there are opportunities for health care providers to
intervene, provide appropriate care, and possibly prevent suicide.

In 2005, the VA commissioned RAND
and the Altarum Institute to conduct a comprehensive evaluation of the VA.’s
mental health and substance use treatment system.24-26 The results
reported below describe care provided in fiscal years (FY) 2007 and 2008. We do
not have data on whether the quality of care has changed since then.

In FY 2008 there were 906,394
veterans receiving care at the VHA for one or more of the following diagnoses:
schizophrenia, bipolar I disorder, PTSD, major depressive disorder, and
substance use disorders. Although they represented approximately 3.8 percent of the
estimated number of all living veterans and 16.5 percent of all veterans who used VHA
services in FY 2008, they accounted for 34.4 percent of all VHA costs. Approximately
half had either multiple mental health conditions or a co-existing physical
condition. The majority of utilization and costs were for the treatment of
physical health conditions.

To evaluate quality of care, the research team developed 88
performance indicators,27 or measures of the quality of care. We
used indicators to assess the degree to which recommended care was delivered
and to identify gaps in quality. Some indicators applied only to a single
diagnosis, such as antidepressant use in major depression, and some applied
across diagnoses, such as assessment for suicide ideation. Where there was
sufficient sample size, we evaluated performance by Veterans Integrated
Service Network (VISN) , age, gender, rural/urban residence and Operation
Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) status.

Below
I discuss study findings as they may relate to suicide prevention. Results are
reported as VHA national averages. VISN level performance was estimated to
identify average VISN performance and to test whether each VISN was
significantly above or below the average VISN performance. A list of VISN
number and region is provided at the end of the document (see Table 1).
Evidence-based treatments are treatments that have been demonstrated through
research to be effective.

Evidence-Based Treatment for Major Depression

Among
veterans with major depression, treatment with antidepressants is associated
with decreased suicide risk. Almost half (48 percent) of veterans beginning a new
treatment episode for major depression filled prescriptions for a 12-week
supply of antidepressant medication; 20 percent did not fill any prescription for
antidepressants during the appropriate timeframe. There was a 20 percentage point
difference between the highest and lowest performing VISNs for this performance
indicator. Six VISNs (9, 15, 19, 20, 22 and 23) performed significantly better
than the VISN average. Another seven VISNs (3, 5, 7, 8, 12, 16 and 18)
performed significantly below the VISN average. Those veterans least likely to
have the requisite 12-week supply were younger, rural, and had served in
OEF/OIF. While some veterans may not want antidepressants, the observed
variation of 20 percentage points across VISNs suggests that care can, and
should, improve in those VISNs with lower rates.

To
minimize the likelihood of relapse, antidepressants need to be continued for 4
to 9 months. However, only 31.2 percent of veterans in a new episode of treatment for
major depression filled prescriptions for a 6-month supply of antidepressant
medication; and 17.1 percent filled no prescriptions for antidepressant medication.
The remaining 51.3 percent of veterans filled a prescription, but for less than a
6-month supply. While some veterans may choose to terminate treatment
prematurely, research suggests that clinical interventions such as telephone
outreach can improve medication adherence28
and outcomes. Adherence means using the medication as prescribed.

Among all study veterans who were beginning a new episode of
treatment, only 38.3 percent received at least one psychotherapy visit. Among those
with major depression who were receiving psychotherapy, 30.9 percent received
psychotherapy that had elements of cognitive behavioral therapy, an
evidence-based treatment for major depression. For those veterans receiving
psychotherapy, increasing the delivery of evidence-based psychotherapy could
improve outcomes and decrease suicide risk.

Evidence-Based Treatment for Bipolar I Disorder

Continuous
treatment with a mood stabilizer medication is the mainstay of treatment for
bipolar I disorder and is associated with a decreased rate of completed
suicide.18,29,30 Thirty-two percent of veterans with bipolar I
disorder received continuous treatment with a mood stabilizer, 81.2 percent received
intermittent treatment and 18.8 percent did not receive any treatment with a mood
stabilizer. The difference between the highest and lowest performing VISNS was
12.1 percentage points. Seven VISNS (1, 6, 11, 15, 19, 20) had proportions that
were higher than the average VISN and an equal number of VISNS (3, 5, 8, 12,
16, 18 and 21) had proportions that were lower. Eight percent of veterans with
bipolar 1 disorder received inappropriate treatment of an antidepressant
without use of a mood stabilizer, a practice associated with higher levels of
suicidal behavior.29 Veterans over age 65 or under age 35, and
OEF/OIF veterans were at greatest risk for not receiving appropriate care.

Research
suggests that use of lithium as a mood stabilizer may have specific suicide-prevention
properties. However the therapeutic range within which the beneficial effects
of lithium outweighs its toxic effects is quite narrow, and there is
substantial clinical consensus that lithium levels should be monitored. Among
patients with bipolar I disorder who were beginning treatment with lithium,
(N=2,562 out of a total number of 65,090 with bipolar 1 disorder and 14,285
veterans in a new treatment episode), 51.6 percent received lithium drug level
monitoring in a timely manner.

Evidence-Based Treatment for PTSD

Although PTSD increases suicide risk, it is unknown whether
treatment for PTSD reduces suicide risk. This is an important area for further
research. We found that 20 percent of veterans with PTSD who were receiving
psychotherapy had documentation that at least one psychotherapy visit contained
elements consistent with cognitive behavioral therapy, an evidence-based
treatment for PTSD. Significantly fewer veterans at one VISN (VISN 10) had
documentation of any visits with elements of cognitive behavioral therapy.
Among veterans not receiving psychotherapy who were beginning a new episode of
treatment for PTSD, 26 percent received an adequate trial of selective serotonin
reuptake inhibitors, a class of antidepressants.

Evidence-Based
Treatment for Schizophrenia

Continuous treatment with
antipsychotic medication is critical for preventing relapse and
rehospitalization31 among patients with schizophrenia. Approximately 37
percent of veterans
in the schizophrenia diagnostic cohort received continuous treatment with an
antipsychotic medication. Over 80 percent filled at least one prescription for an
antipsychotic medication and 18.1 percent did not receive any antipsychotic
medication. There was significant variation across VISNs, with the percentage
difference between the highest and lowest performing VISN being almost 20
percentage points. Seven VISNs (1, 10, 11, 15, 19, 20, and 23) significantly
exceed the VISN average; an equal number of VISNs (3, 5, 7, 8, 16, 18, and 22)
had 12-month supply fill rates significantly lower than the VISN average.

Evidence-Based
Treatment for Drug and Alcohol Disorders

Numerous clinical trials have proven
brief interventions to be effective for individuals with alcohol abuse. In our
study, fifty-nine percent of veterans with alcohol abuse or dependence had
documentation that they received a brief intervention for their alcohol use,
35 percent had a documented referral to mental health specialty care, and 5
percent were
already in specialty care. Overall, 71 percent had documentation of appropriate care.
VISN 9 had a significantly lower proportion of veterans with documentation of
appropriate care. There is substantial empirical support for pharmacotherapy for
individuals with alcohol dependence. For veterans beginning treatment for
alcohol dependence, 6 percent received pharmacotherapy.

Assessment for Suicide Ideation and Employment and Housing
Problems

Identification
of and attention to psychosocial stressors are key components of high-quality
psychiatric care and may also decrease suicide risk. In cross-sectional
studies, psychosocial stressors such as unemployment are associated with
attempted and completed suicide.9,32-39
Among
the mentally ill, homelessness is also associated with suicide. In a
study of 7,224 homeless individuals with mental illness, rates of lifetime
suicide attempts were above 50 percent; 26.9 percent of the sample had a suicide attempt that
resulted in a medical hospitalization.35 While it is unknown whether
interventions to decrease unemployment and homelessness would decrease suicide
risk, attention to these issues is a critical part of quality mental health
care. Identifying whether clinical interventions to address homelessness and
unemployment among the mentally ill reduce risk is an important area for
further study.

The mental health
assessment of a new patient should include an evaluation of suicide ideation
and the patient's psychosocial support system.40,41 We found that
82 percent of veterans in the study were assessed for suicide ideation. Three VISNs
(4, 6 and 7) had significantly higher proportions of documentation of suicide
ideation assessment, and two VISNs (2 and 19) had significantly lower
proportions. Among veterans with identified suicide ideation, 96.4 percent had
documentation of appropriate follow-up.

Assessment of psychosocial needs includes finding out whether the
patient had an acceptable physical shelter and whether or not the patient had
purposeful daily activity. Among study veterans beginning a new episode of
treatment, 60 percent had documentation of an assessment of housing needs, 62
percent had
documentation of an assessment of employment needs, and 44 percent had documentation
of both assessments. Compared to the average VISN, VISN 10 had a significantly
greater proportion of veterans who had documentation of both assessments
(57.9 percent) and VISN 18 had a significantly lower proportion (31.8 percent). This
variation across VISNs (26 percentage points) was the largest for any
indicator. More veterans with a documented need were offered housing services
(81 percent) than were offered employment services (28 percent).

Supported Employment and Social Skills Training

Certain evidence-based forms of
psychosocial rehabilitation, such as social skills training, increase the
capacity of individuals with severe mental illness to live independently. Among
veterans with schizophrenia who received any psychosocial treatment, 16 percent had
documented receipt of social skills training. Supported employment is a type of
intervention that helps individuals with severe mental illness get and maintain
employment, and has a robust evidence base. Among veterans with bipolar
disorder, schizophrenia or major depression with psychosis, 1.9 percent used supported
employment during the study period. While there was variation across VISNS, no
VISN was higher than 3 percent.

Summary and Recommendations

In
general, the quality of care provided by the VHA is as good as or better than
public or privately-funded care, and of note, most veterans with mental illness
are being assessed for suicide and receiving appropriate follow-up. However, in
other areas, the quality of care does not meet implicit VA expectations, and
there is significant room for improvement. The best evidence to date regarding
suicide prevention supports providing quality mental health care. Therefore our
recommendations address how the VHA might improve the quality of care for
veterans with mental illness and substance use disorders, which may decrease
suicide risk.

Increase
proportion of veterans who receive recommended length of pharmacotherapy.

More than half of study veterans who began
medication treatment did not receive the recommended length of treatment, and
more than two-thirds of those on maintenance treatment were non-adherent. This
is important because adherence to medication improves outcomes and decreases
suicide risk.

Clinical
registries are tools that individual clinicians and administrators can access
in real time, without technical assistance, and use to systematically monitor
symptoms and improve adherence. Clinical registries are not the same as the
registries the VA currently has for psychosis and depression. The use of clinical
registries is an area with strong potential for quality improvement, since they
can be used to track individuals with a specified set of health conditions over
time in order to assess how a patient is responding to treatment and whether
they are missing appointments or medication refills.

Recommended Strategies: We recommend
that the VHA take the following steps:

  1. Investigate the basis for low rates of medication adherence
    among the veteran population, with an emphasis on strategies to improve
    continuity.
  2. Conduct an environmental scan to identify best practices
    related to clinical registries, with a particular focus on
    mental-health-specific implementation.
  3. Procure or develop a clinical registry module for the VA.’s
    medical records system that minimizes the need for additional data entry and
    maintains ease of use and high-level tracking of evidence-based care.
  4. Provide training in, and establish formal expectations for, use of
    registries.

Increase
proportion of veterans with documented assessment of housing and employment
needs and establish responsibility for housing and employment services.

Less than
two-thirds of veterans with one of the five mental illnesses studied have a
documented assessment of their housing and employment needs. Housing and
employment policies lack sufficient detail to identify whether the Veterans
Health Administration or the Veterans Benefits Administration is responsible
for services. 

Recommended
Strategies:
Two
actions are recommended:

  1. Develop a standardized documentation template for assessment
    of psychosocial needs.42
  2. Clarify what constitutes need for housing and employment
    services, and clearly define the role of the VHA and the Veterans Benefits
    Administration with regard to work and housing.

Establish
formal expectations for quality measures.

For most
mental health treatments, there are no agreed-upon benchmarks to distinguish
between levels of performance. Without articulated benchmarks, it is not
possible to come to definitive judgments about quality or to judge whether the
VA is meeting performance expectations.

Recommended
Strategies:
We
recommend the following actions:

  1. The VA should use a combination of empirical evidence on
    current performance, expert opinion, and performance data from comparable
    systems to set target benchmarks. At minimum, this benchmark should be the
    performance of the best-performing VISN.
  2. Performance expectations should include a specific definition
    of the evidence-based treatment and what counts as meeting the benchmark.

Implement standardized,
individualized treatment planning documents.

Treatment
plans are incomplete and difficult to locate. In some cases they may not exist.
There is no standardized way of documenting patient participation in treatment
decisions.

Recommended
Strategies:
Two
actions are recommended:

  1. Implement and require the use of standardized, individualized
    treatment-planning documents that may be linked to problems most often
    associated with a particular diagnosis, services being offered, and the patient’s goals for recovery. The VHA Office of Mental Health Services has recently
    purchased treatment-planning software but dissemination has been held up
    because of lack of personnel to integrate the software with the current
    electronic health record.
  2. Incorporate the capacity for patients to comment on and
    document their participation in treatment planning.

Prioritize efforts to make patient’s entire health record
accessible through a common portal, both across and within VISNs.

Some VISNs have an electronic health record
system that allows any provider within the VISN to access the patient's chart
in real time. Other VISNs do not have this capability and it is difficult to
access health records across VISNs. This difficulty can potentially impair the
quality of care veterans receive if they move or receive treatment in multiple
locations.

Recommended
Strategy:

1.
Prioritize efforts to make patients.’ entire health records accessible through
a common portal to allow unfettered access and input by all clinicians caring
for them across medical centers and VISNS in real time. The VA should direct
the Office of Information Technology to ensure that clinicians can access
patient data, regardless of where the patient receives care.

Develop
and disseminate national standards for evidence-based treatments.

It is
important that treatments be delivered with fidelity, or as they were designed
to be delivered. Evidence-based treatments for which the VHA Office of Mental
Health Services has disseminated written national standards appear to be
implemented with more fidelity than treatments for which the VHA has not
disseminated national standards. Specifying what is expected when a particular
evidence-based treatment is delivered is an important first step in ensuring
treatment fidelity and effectiveness.

Recommended
Strategies:

  1. Develop and disseminate national implementation standards for
    evidence-based treatments.
  2. Use results from the extensive research conducted by VA
    implementation-science researchers to address the gaps identified by the
    evaluation. The VA is unique in that it

has a number
of health-services research and development programs, as well as
quality-improvement programs. Better communication between VA researchers and
VA clinical services could help make use of VA expertise in this area.

Conduct
additional research using the linked data set developed by the evaluation.

Despite
the comprehensiveness of our evaluation, a great deal more could be learned. We
observed significant variations in performance across every characteristic we
examined, sometimes by more than 25 percentage points. Understanding the cause
of these variations could allow the VHA to develop strategies to help
lower-performing VISNS improve. Knowledge of which practices and
quality-improvement strategies are associated with the greatest increases in
quality (outcomes) per unit cost could help the VA become more efficient.

Some
priority areas for further research suggested by our results are below.

  1. What is the basis for variations in care that we observed? To
    what extent are they a function of poor documentation rather than variation in
    performance?
  2. What can be learned from high-performing or low-performing
    sites?
  3. What are the costs associated with quality improvement?
  4. How can high quality be achieved in the most cost-efficient
    manner?

We do not
know how suicide can be prevented, but the best evidence to date supports
providing quality mental health care. The VA has substantial capacity to
deliver mental health and substance use treatment to veterans with mental
illness, and it outperformed the private sector on most quality indicators,
which most likely demonstrates the significant advantages that accrue from an
organized, nationwide system of care. Nonetheless, the VA is falling short of
its own implicit expectations for providing the highest quality of care for our
nation.’s veterans. Our study revealed ways in which the VA could build upon
its current system of care with marginal effort to improve quality and
potentially prevent suicides.

Thank
you again for the opportunity to testify today and to share the results of the
research. Additional information about our study findings related and
recommendations can be found at: http://www.rand.org/pubs/technical_reports/TR956.html

Table 1: Total FY 2008 VA Mental Health Program Evaluation
Veterans, by VISN

VISNF

 VISN
Name

1

New
England Health Care System

2

VA
Health Care Network Upstate New York

3

VA
New York/New Jersey Health Care System

4

VA
Stars and Stripes Health Care Network

5

VA
Capitol Health Care Network

6

Mid-Atlantic
Health Care Network

7

VA
Southeast Network

8

Florida/Puerto
Rico Sunshine Health Care Network

9

VA
Mid-South Health Care Network

10

VA
Health Care System of Ohio

11

Veterans
in Partnership Network

12

VA
Great Lakes Health Care Network

15

VA
Heartland Network

16

South
Central VA Health Care Network

17

VA
Heart of Texas Health Care Network

18

VA
Southwest Health Care Network

19

VA
Rocky Mountain Network

20

VA
Northwest Network

21

VA
Sierra Pacific Network

22

VA
Desert Pacific Health Care Network

23

VA
Midwest Health Care Network

 


References

1 Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological
autopsy studies of suicide: A systematic review. Psychological
Medicine. 2003;33(3):395-405.

2 Harris EC, Barraclough B. Suicide as an outcome for mental
disorders. A meta-analysis. The British Journal of
Psychiatry. Mar 1997;170:205-228.

3 Wilcox HC, Conner KR, Caine ED. Association of alcohol and
drug use disorders and completed suicide: An empirical review of cohort
studies. Drug and Alcohol Dependence. 2004;76
Suppl:S11-19.

4 Mann JJ. A current perspective of suicide and attempted
suicide. Annals of Internal Medicine. Feb 19
2002;136(4):302-311.

5 National Institute of Mental Health. Suicide in the U.S.:
Statistics and prevention. 2010; http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and­prevention/index.shtml.

6 Kleespies
PM, AhnAllen CG, Knight JA, Presskreischer B, Barrs KL, Boyd BL, Dennis JP. A
study of self-injurious and suicidal behavior in a veteran population. Psychological
Services. 2011;8(3):236-250.

7 Brenner LA,
Betthauser LM, Homaifar BY, Villarreal E, Harwood JE, Staves PJ, Huggins JA.
Posttraumatic stress disorder, traumatic brain injury, and suicide attempt
history among veterans receiving mental health services. Suicide
and Life-Threatening Behavior. Aug 2011;41(4):416-423.

8 Guerra VS,
Calhoun PS. Examining the relation between posttraumatic stress disorder and
suicidal ideation in an OEF/OIF veteran sample. Journal of Anxiety
Disorders. Jan
2011;25(1):12-18.

9 Lemaire CM,
Graham DP. Factors associated with suicidal ideation in OEF/OIF veterans. Journal
of Affective Disorders. 2011;130(1-2):231-238.

10 Weiner J,
Richmond TS, Conigliaro J, Wiebe DJ. Military veteran mortality following a
survived suicide attempt. BMC Public Health. 2011;11:374.

11 Ilgen MA,
Bohnert AS, Ignacio RV, McCarthy JF, Valenstein MM, Kim HM, Blow FC.
Psychiatric diagnoses and risk of suicide in veterans. Archives
of General Psychiatry. Nov
2010;67(11):1152-1158.

12 Brent DA,
Mann JJ. Family genetic studies, suicide, and suicidal behavior. American
Journal of Medical Genetics Part C Seminars in Medical Genetics. Feb 15
2005;133C(1):13-24.

13 Courtet P,
Guillaume S, Malafosse A, Jollant F. Genes, suicide and decisions. European
Psychiatry. Jun
2010;25(5):294-296.

14 McMillan D,
Gilbody S, Beresford E, Neilly L. Can we predict suicide and non-fatal
self-harm with the Beck Hopelessness Scale? A meta-analysis. Psychological
Medicine. 2007;37(6):769-778.

15Tsai
SJ, Hong CJ, Liou YJ. Recent molecular genetic studies and methodological
issues in suicide research. Progress in Neuro-Psychopharmacology and
Biological Psychiatry. 2011;35(4):809-817.

16 Gibbons RD,
Amatya AK, Brown CH, Hur K, Marcus SM, Bhaumik DK, Mann JJ. Post-approval drug
safety surveillance. Annual
Review of Public Health. 2010;31:419-437.

17 Gibbons RD,
Brown CH, Hur K, Marcus SM, Bhaumik DK, Erkens JA, Herings RM, Mann JJ. Early
evidence on the effects of regulators' suicidality warnings on SSRI
prescriptions and suicide in children and adolescents. American
Journal of Psychiatry. 2007;164(9):1356-1363.

18 Sondergard
L, Lopez AG, Andersen PK, Kessing LV. Mood-stabilizing pharmacological
treatment in bipolar disorders and risk of suicide. Bipolar
Disordorders. 2008;10(1):87-94.

19 Cipriani A,
Pretty H, Hawton K, Geddes JR. Lithium in the prevention of suicidal behavior
and all-cause mortality in patients with mood disorders: A systematic review of
randomized trials. American
Journal of Psychiatry. 2005;162(10):1805-1819.

20 Meltzer HY,
Bobo WV. Pharmacological management of suicide risk in schizophrenia. In:
Tatarelli R, Pompili M, Girardi P, eds. Suicide in schizophrenia. Hauppauge,
NY: Nova Biomedical Books; 2007:275-302.

21 Ramchand R,
Acosta J, Burns RM, Jaycox LH, Pernin CG. The war within: Preventing
suicide in the U.S. military. Santa Monica, CA: RAND Corporation;2011.

22Luoma
JB, Martin CE, Pearson JL. Contact with mental health and primary care
providers before suicide: a review of the evidence. American
Journal of Psychiatry. Jun
2002;159(6):909-916.

23 Basham C,
Denneson LM, Millet L, Shen X, Duckart J, Dobscha SK. Characteristics and VA
health care utilization of U.S. Veterans who completed suicide in Oregon
between 2000 and 2005. Suicide
and Life-Threatening Behavior. Jun 2011;41(3):287-296.

24 Watkins KE,
Keyser DJ, Smith B, Mannle TE, Kivlahan DR, Paddock SM, Mattox T,
Horvitz-Lennon M, Pincus HA. Transforming mental healthcare in the Veterans
Health Administration: A model for measuring performance to improve access,
quality, and outcomes. Journal
for Healthcare Quality. Nov-Dec
2010;32(6):33-42; quiz 42-33. PMC­Journal-In Process.

25 Watkins KE,
Pincus HA, Paddock S, Smith B, Woodroffe A, Farmer C, Sorbero ME,
Horvitz-Lennon M, Mannle T, Jr., Hepner KA, Solomon J, Call C. Care for
veterans with mental and substance use disorders: good performance, but room to
improve on many measures. Health Affairs. Nov
2011;30(11):2194-2203.

26 Watkins KE,
Smith B, Paddock SM, Mannie TE, Woodroffe A, Solomon J, Sorbero M, Farmer C,
Hepner KA, Adamson D, Forrest L, Call C, Pincus HA. Program
evaluation of VHA mental health services: Capstone report (Contract # GS 10
F-0261K).
Alexandria, VA: Altarum Institute and RAND-University of Pittsburgh Health
Institute 2010.

27 Watkins KE,
Horvitz-Lennon M, Caldarone LB, Shugarman LR, Smith B, Mannle TE, Kivlahan DR,
Pincus HA. Developing medical record-based performance indicators to measure
the quality of mental healthcare. Journal for Healthcare
Quality. 2011;33(1):49­67.
PMID 21199073.

28 Haynes RB,
Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication
adherence. Cochrane
Database of Systematic Reviews. 2008(2):CD000011.

29 Rihmer Z.
Pharmacological prevention of suicide in bipolar patients --a realizable
target. Journal
of Affective Disorders. Nov
2007;103(1-3):1-3.

30 Yerevanian
BI, Koek RJ, Mintz J, Akiskal HS. Bipolar pharmacotherapy and suicidal behavior
Part 2. The impact of antidepressants. Journal of Affective
Disorders. Nov
2007;103(1-3):13-21.

31 Kane JM.
Review of treatments that can ameliorate nonadherence in patients with
schizophrenia. The
Journal of Clinical Psychiatry. 2006;67 Suppl 5:9-14.

32 Blakely TA,
Collings SC, Atkinson J. Unemployment and suicide. Evidence for a causal association?
Journal
of Epidemiology and Community Health. Aug 2003;57(8):594-600.

33 Mäki N,
Martikainen P. A register-based study on excess suicide mortality among
unemployed men and women during different levels of unemployment in Finland. Journal
of Epidemiology and Community Health. 2010. http://jech.bmj.com/content/early/2010/10/21/jech.2009.105908.long.

34 Prigerson
HG, Desai RA, Liu-Mares W, Rosenheck RA. Suicidal ideation and suicide attempts
in homeless mentally ill persons: age-specific risks of substance abuse. Social
Psychiatry and Psychiatric Epidemiology. Apr 2003;38(4):213-219.

35Desai
RA, Liu-Mares W, Dausey DJ, Rosenheck RA. Suicidal ideation and suicide
attempts in a sample of homeless people with mental illness. Journal
of Nervous and Mental Disease. 2003;191(6):365-371.

36 Eynan R,
Langley J, Tolomiczenko G, Rhodes AE, Links P, Wasylenki D, Goering P. The
association between homelessness and suicidal ideation and behaviors: Results
of a cross-sectional survey. Suicide and Life-Threatening Behavior. 2002;32(4):418-427.

37
Sundararaman R, Panangala SV, Lister SA. Suicide prevention among
veterans. Washington,
DC: Congressional Research Services;2008.

38 Fitzpatrick
KM, Irwin J, Lagory M, Ritchey F. Just thinking about it: Social capital and
suicide ideation among homeless persons. Journal of Health Psychology.
2007;12(5):750-760.

39Mäkinen
IH, Wasserman D. Labour market, work environment and suicide. Oxford
Textbook of Suicidology and Suicide Prevention. New York, NY: Oxford
University Press; 2009.

40 American
Psychiatric Association. Practice
Guidelines for the Treatment of Psychiatric Disorders Compendium. Washington,
D.C.: American Psychiatric Association;2006.

41 Veterans
Administration, Department of Defense. Management of persons with
psychoses.
Washington DC: Veterans Health Administration, Department of Veterans Affairs,
and Health Affairs, Department of Defense;2004.

42 First MB,
Pincus HA, Schoenbaum M. Issues for DSM-V: adding problem codes to facilitate
assessment of quality of care. American Journal of Psychiatry. 2009;166(1):11­13.


a  The opinions and conclusions expressed in this testimony are the
author's alone and should not be interpreted as representing those of RAND or
any of the sponsors of its research. This product is part of the RAND
Corporation testimony series. RAND testimonies record testimony presented by
RAND associates to federal, state, or local legislative committees;
government-appointed commissions and panels; and private review and oversight
bodies. The RAND Corporation is a nonprofit institution that helps improve
policy and decisionmaking through research and analysis. RAND’s publications
do not necessarily reflect the opinions of its research clients and sponsors.

b This
testimony is available for free download at
http://www.rand.org/pubs/testimonies/CT370.html.

Prepared Statement of Jan E. Kemp, RN, Ph.D., National
Mental Health Director for Suicide Prevention, Veterans Heath Administration,
U.S. Department of Veterans Affairs

Chairwoman
Buerkle, Ranking Member Michaud, and members of the Subcommittee:  Thank you
for the opportunity to appear before you today to discuss the Department of
Veterans Affairs’ (VA) efforts to reduce suicide among America’s Veterans.  I
am accompanied today by Antonette Zeiss, Ph.D., Chief
Consultant for Mental Health, VHA.  My testimony today will
cover four areas:  first, recent data on suicidality in Veterans and VA’s
Suicide Prevention Program; second, VA’s Veterans Crisis Line and Veterans Chat
(an online resource); third, VA’s outreach and informational awareness efforts
to reduce suicide among Veterans; and finally, VA’s impact on reducing suicide
among high risk Veterans.

Let me begin by
saying how very important this issue is to VA and all of us in the VA health
community.   We believe even one suicide among our Servicemembers or Veterans
is one too many.   According to the recently released “Charting the Future of
Suicide Prevention: A 2010 Progress Review of the National Strategy and
Recommendations for the Decade Ahead” prepared by the Suicide
Prevention Resource Center and Suicide Prevention Action Network, the
Veterans Health Administration (VHA) has “developed a comprehensive strategy to
address suicides and suicidal behavior that includes a number of initiatives
and innovations that hold great promise for preventing suicide attempts and
completions.”  The Review was developed by the Suicide Prevention Resource
Center (a national suicide prevention education organization),with funding 
from the Department of Health and Human Services (HHS) Substance Abuse and
Mental Health Services Administration (SAMHSA) for the National Action Alliance
for Suicide Prevention.  The Action Alliance is the public-private partnership
advancing the National Strategy for Suicide Prevention and was launched in
September 2010.    The Review cites VA
as becoming one of the most vibrant forces in the U.S. suicide prevention
movement, implementing multiple levels of innovative and state-of-the-art
interventions, backed up by a robust research capacity.  We have initiated
several programs that put VA in the forefront of suicide prevention for the
nation.  Chief among these are:

  • Establishment of a national
    Crisis Line, Chat Service, and texting option, including a major
    advertising campaign to provide the Crisis Line phone number and Web site to
    all Veterans and their families;
  • Placement of Suicide
    Prevention Coordinators (SPC) at all VA medical centers;
  • Development of an enhanced
    package of care for high risk Veterans;
  • Expansion of mental
    health services;
  • Integration of primary
    care and mental health services; and
  • Creation of a new “Make
    the Connection” campaign to help make it easier to seek mental health
    assistance.

I will discuss these
initiatives in detail later in my testimony.

VA’s Suicide Prevention
Program

In response to
the urgent need for suicide prevention efforts, VA has significantly expanded
its suicide prevention program since 2005, when it initiated the Mental Health
Strategic Plan and the Mental Health Initiative Funding.  In 2006, VA provided
training on evidence-based interventions for suicide and provided funding to
begin integrating mental health care into primary care settings and expanding
services at community-based outpatient clinics (CBOC) for treatment of mental
health conditions such as post-traumatic stress disorder (PTSD), and substance
use disorders (SUD).  In 2007, VA began providing specific funding and training
for each facility to have a designated SPC; it also held the first Annual
Suicide Awareness and Prevention Day and opened the Veterans Crisis Line (then
referred to as the National Veterans Suicide Prevention Hotline) in partnership
with SAMHSA.

VA
also established access standards that require prompt evaluation of new
patients (those who have not been seen in a mental health clinic in the last 24
months) with mental health concerns.  New patients are contacted by a clinician
competent to evaluate the urgency of the Veteran’s mental health needs within
24 hours of their first referral.  If it is determined that the Veteran has an
urgent care need, appropriate arrangements (e.g., an immediate admission) are
made.  If the need is not urgent, the patient must be seen for a full mental
health diagnostic evaluation and development and initiation of an appropriate
treatment plan within 14 days.  VA accomplishes its access standards more than
95 percent of the time.  In 2007, VA initiated system-wide suicide assessments
for those Veterans screening positive for PTSD and depression in primary care;
instituted training for Operation S.A.V.E. (which trains non-clinicians to
recognize the SIGNS of suicidal thinking, to ASK Veterans questions about
suicidal thoughts, to VALIDATE the Veteran’s experience, and to ENCOURAGE the
Veteran to seek treatment); and required SPCs to begin tracking and reporting
suicidal behavior.  In addition, VA added more SPCs in its larger medical
centers and CBOCs, doubling the number of dedicated suicide prevention staff in
the field.  By 2008, VA had re-established a monitor for mental health
follow-up after patients were discharged from inpatient mental health units,
developed an on-line clinical suicide risk training program, and held a fourth
regional conference on evidence-based interventions for suicide.

 VA
also added the development of an enhanced package of care for high risk
patients.  Evidence clearly demonstrates that once a person has manifested
suicidal behavior, he or she is more likely to try it again.  As a result, VA also has put in place sensitive procedures to enhance care for
Veterans who are known to be at high risk for suicide.  Whenever Veterans
are identified as surviving an attempt or are otherwise identified as being at
high risk, they are placed on the facility high-risk list and their chart is
flagged such that local providers are alerted to the suicide risk for these
Veterans.  In addition, the SPC will contact the Veteran’s primary care
and mental health provider to ensure that all components of an enhanced care
mental health package are implemented.  These include a review of the
current care plan, addition of possible treatment elements known to reduce
suicide risk, ongoing monitoring and specific processes of follow-up for missed
appointments, individualized discussion about means reduction, identification
of a family member or friend with the Veteran’s consent (either to be involved
in care or to be contacted, if necessary), and collaborative development with
the Veteran of a written safety plan to be included in the medical record and
provided to the Veteran.  In addition, pursuant to VA policy, SPCs are
responsible for, among other things, training of all VA staff who have contact
with patients, including clerks, schedulers, and those who are in telephone
contact with Veterans, so they know how to get immediate help when Veterans
express any suicide plan or intent. 

The enhanced
care package also includes mandates for follow-up after the high risk
designation and safety planning.  In 2009, VA launched the Veterans Chat Service
to create an online presence for the Veterans Crisis Line..  VA developed and
disseminated training programs for safety planning and has continued to monitor
all of these efforts and implement facility-specific strategies over the past
few years.  VA has also released new training programs concerning issues in
specific populations, such as geriatrics and women. 

VA has augmented the original SPC placement at every
facility and large CBOCs with additional suicide prevention team staff, and
these staff members are an important component of our mental health
staffing.  The SPCs ensure local planning and coordination of mental
health care and support Veterans who are at high risk for suicide, provide
education and training for VA staff, do outreach in the community to educate
Veterans and health care groups about suicide risk and VA care, and provide
direct clinical care for Veterans at increased risk for suicide.  One of
the main mechanisms to access enhanced care provided to high risk patients is
through the Veterans Crisis Line, and the linkages between the Crisis Line and
the local SPCs.  For example, when a Veteran, in crisis, calls the Crisis
Line, he or she is provided a referral for immediate care, a high risk flag is
placed on the chart and the Veteran is provided high risk services.  The Crisis
Line staff follows up to assure that this care is provided.  . 

VA cannot
accomplish this mission alone; instead, it works in close collaboration with
other local and Federal partners, including SAMHSA in the Department of Health
and Human Services (HHS), and brings together the diverse resources within VA,
including individual facilities such as the Center of Excellence in
Canandaigua, New York and a Mental Illness Research and Education Clinical
Center in Veterans Integrated Service Network (VISN) 19 (Denver, CO).  We also
work closely with community agencies across the country. The DoD and VA are working
together on a number of issues and the VA is a member of the DoD Suicide
Prevention and Risk Reduction Workgroup. The DoD/VA Nomenclature and Data
Working Group is moving toward common definitions of fatal and non-fatal
suicide events, and working toward a joint data base to better capture the
impact of suicide on the military community as a whole.           

During fiscal year (FY) 2011,
VA’s SPCs reported 16,976 suicide attempts among patients and non-patients, 779
of which were fatal (4.5 percent).  One of the premises of the VA suicide
prevention program is that we can make a difference in Veterans who have
attempted suicide and are known to be at high risk.  The percentage of those
who died from suicide (and reported by VA’s Suicide Prevention Coordinators)
with a report of previous suicide attempts decreased from 31 percent in FY 2009
to 27 percent in FY 2010 and FY 2011. This suggests that the strategy of
implementing the enhanced care package with our high risk patients has been
effective. 

It is not
possible to determine if the reported cases are representative of suicidality
in VA’s patient population, but we do know that suicidality can be both an
acute and a chronic condition.  Those who survive attempts are at high risk for
reattempting and dying from suicide within a year, so it is essential that we
engage survivors in intensified treatment to prevent further suicides.  It is
precisely because of this concern that VA has initiated the post-discharge
follow-up for patients leaving its inpatient mental health units.  The data
reported above include self-reporting of previous suicide attempts that have
not been validated by VA, and all estimates are based on events reported in the
SPC database and may not represent the complete number of suicide attempts
among Veterans.  Also, the records of suicide attempts for 136 Veterans were
incomplete and omitted from this analysis.

VA’s Vet Centers
also fulfill a critical role in reducing the risk of Veteran suicide.  Vet Centers promote access to care by helping Veterans and
families overcome barriers that impede them from utilizing other benefits or
services.  Vet Centers remain a unique and proven component of care by
providing an alternate door for combat Veterans not ready to access the VA
health care system.  There are currently 296 Vet Centers operating with
four more scheduled to open by the end of 2011.  This will bring the total to
300 Vet Centers across the country and in surrounding territories (the U.S.
Virgin Islands, Puerto Rico, Guam, and American Samoa).  Thirty-nine (39)
of these Vet Centers are currently located in rural or highly rural
areas.  In addition, seventy (70) Mobile Vet Centers provide early access
to returning combat Veterans through outreach to a variety of military and
community events, including demobilization activities. 

Crisis Line and Veterans
Chat Service

VHA’s Crisis Line started in July 2007, and the
Veterans Chat Service was started in July 2009.  To date the Crisis Line
has:

  •  Received over 500,000 calls;
  •  Initiated over 18,000 rescues;
  •  Referred over 73,000 Veterans to local VA SPCs, for same day or
    next day services;
  •  Answered calls from over 6,700 Active Duty Servicemembers;
  •  Responded to over 31,000 chats; and
  •  Initiated a pilot program that uses text messaging that is
    reaching a new group of Veterans who are much more likely to use text messaging
    than to call.

The Crisis Line has
20 active phone lines and is staffed with mental health professionals and
support staff to provide services 24 hours, 7 days a week, 365 days a year. After
receiving a call from a Veteran, Servicemember or family member, the responder
conducts a phone interview to assess the Veteran’s emotional, functional, and
psychological condition.  The responder then determines the level of the call,
namely whether it is emergent, urgent, routine, or informational.

Calls requiring
emergency services necessitate keeping the caller (or the person about whom the
caller is concerned) safe; urgent care requires same day services at a local VA
facility; and routine calls require a consultation by the local SPC.  Consults
occur if a Veteran consents to a consultation or if emergency services are
required; these consults are simply alerts to the SPC and do not mean the
Veteran is suicidal.  Even if the Veteran is already engaged in treatment, a
consultation can be done to alert the SPC to changes in the Veteran’s
circumstances or to other needs he or she may have. 

The online
version of the Crisis Line, the Veterans Chat Service, enables Veterans, family
members and friends to chat anonymously with a trained VA counselor.  If the
counselor determines there is an emergent need, the counselor can take
immediate steps to transfer the visitor to the Hotline, where further
counseling and referral services can be provided and crisis intervention steps
can be taken.  Veterans Crisis Line and Chat Service are intended to reach out
to all Veterans, whether they are enrolled in VA health care or not. 

Outreach and Awareness of
VA’s Suicide Prevention Efforts

This
past year, VA looked hard at its plan to communicate to Veterans and their
families the highlights of the Suicide Prevention program as well as those of
the Crisis Line and Chat Service.  VA and SAMHSA continue to work together to
ensure all Americans in emotional distress or suicidal crisis have a single
confidential number (1-800-273-8255) to call for help.  After much deliberation
and consultation with Veterans and users, VA determined that to reach more
Veterans and to relay the message that treatment works, it wouldstrategically
rebrand the national Veterans Suicide Prevention Hotline   An important
component of this comprehensive effort involved a new name:  Veterans Crisis
Line
, which establishes a unique identity for this critical service. 
Research informed VA’s decision to rebrand the service as a crisis line, thus
lowering the threshold from “suicide” to “crisis” for Veterans, Servicemembers,
and their families to encourage them to make that critical first call for
help.  The rebranding is an integrated national outreach effort to increase
awareness and use of the Veterans Crisis Line and confidential online chat
service, support and promote broader VA suicide prevention efforts, and promote
help-seeking behaviors among Veterans at risk of suicide and other mental
health problems.  The new messaging reinforces the confidentiality of the
Veterans Crisis Line for Veterans, Servicemembers, and their families, who may
be the first to realize a Veteran is in crisis.  Messaging efforts also involve
all Service branch representatives to provide messages and “looks” to materials
that are Servicemember specific.

As discussed
previously, VA’s SPCs do a tremendous amount of work to raise awareness about
warning signs associated with suicide and the availability of treatment and
support.  For example, in a typical month, VA’s SPCs provide approximately 700 informational
and outreach programs in their local communities.  As a result, VA identifies
approximately 1,500 high risk Veterans a month and adds them to the High Risk
List.  Between 90 and 95 percent of these Veterans complete safety plans and
are involved in the enhanced care package.

In
addition to these measures, VA has been aggressively advertising this
information and improving outreach to Veterans and family members alike.  Suicide
prevention outreach needs to use carefully tailored and targeted messaging.  Unlike
outreach for many other health issues which rely on underscoring the prevalence
of the problem, outreach for suicide prevention that emphasizes rising suicide
rates among Veterans runs the risk of normalizing suicidal behaviors, helping
to convince Veterans in crisis that considering suicide is a normal or even
expected response to their challenges—and possibly leading to an increase in
suicide attempts.  Through our messaging efforts, VA provides effective and
safe outreach that focuses on affirming Veterans' strength and resilience and
reinforcing help-seeking behavior.

In
recent years, VA has supported a series of public education campaigns designed
to increase awareness of crisis resources and promote seeking help among
Veterans experiencing distress.  VA has evaluated each of these campaigns in an
effort to understand the impact of public education efforts on calls to crisis
services and attitudes related to crisis service use.  In a series of studies, VA
evaluated the impact of implementation of the Veterans Crisis Line on total
call volume to VA and non-VA crisis services, comparisons of call volume in
campaign implementation and control communities, and associations
between exposure to public education campaign media and willingness to use
crisis services when experiencing distress.  Results from these assessments
have demonstrated strong relationships between implementation of the Veterans
Crisis Line and increased use of VA and non-VA toll-free crisis services,
significantly increased call volume in communities where concentrated public
education campaigns have been implemented, and an increased willingness to use
crisis services following exposure to public education media.  Together,
results from these studies provide consistent evidence of the impact of public
education campaigns on awareness and use of crisis services.  VA is continuing
to assess the impact of public education campaigns for both the Veterans Crisis
Line and the Make the Connection campaign in a series of studies designed to
measure the impact of repeated exposure to media material among high risk and
general populations and the efficacy of media messages tailored to individual
histories.  A total of four Public Service Announcements have been
released and widely distributed.   VA spends approximately $4.5 million on this
public awareness campaign annually.

VA’s Impact on Reducing
Suicide

On
the macro level, one way to evaluate the impact of VA mental health care and VA’s
suicide prevention program is to evaluate suicide rates.  However, before
addressing this issue, it is important to consider who accesses VA health
care.  For this, it is useful to refer to findings on those Veterans returning
from Afghanistan and Iraq who participated in the Post-Deployment Health
Re-Assessment (PDHRA) program administered by DoD.  Between February 2008 and
September 2009, approximately 119,000 returning Veterans completed PDHRA
assessments using the most recent version of DoD’s PDHRA form.  Of the more
than 101,000 who screened negative for Post-Traumatic Stress Disorder (PTSD),
43,681 (43 percent) came to VA for health care services.  Among 17,853 who
screened positive for PTSD, 12,674 (71 percent) came to VA for health care
services.  These findings demonstrate that Veterans screening positive for PTSD
were substantially more likely to come to VA for care.  Findings about
depression were similar.  Both sets of findings support earlier evidence that
those Veterans who come to VA are those who are more likely to need care and to
be at higher risk for suicide.  The increased risk factor for suicide among
those who came to VA is often referred to as a case mix difference.  We
have just received the 2009 death data from the National Death Index and have
begun to look at these numbers in relationship to Veterans who receive care in
VA.  We are encouraged by these data, which indicate that there is no increase
in rates among VA users despite national increases, especially in middle-aged
men.  We believe that this indicates that our strategies are having an effect. 
There are some overall positive indicators that include:

  • Suicide
    rates among Veterans who use VA health care have decreased since 2001.
  • There
    is a decrease in suicide rates among Veterans under 30 who use VA health care
    relative to Veterans who do not use VA services, in those states that report
    through the National Violent Death Reporting System (NVDRS)..
  • There
    is a recent decrease in rates in men aged 40-59 receiving care from VA relative
    to rates of men of this age in America as a whole.

Specific information
obtained from the 2009 data, for Veterans who use VA health care, includes:

  •  In
    FY 2009, the suicide rate per 100,000 person-years among all VA health care
    users was 35.9, as compared to 36.6 in FY 2008.  Among males, it was
    38.3, versus 38.7 in FY 2008.  Among females, , it was 12.8, versus 15.0
    in FY 2008.
  • In
    FY 2009, there were 22 suicides among male Operation Enduring Freedom/Operation
    Iraqi Freedom (OEF/OIF) Veterans age 18-24.  The suicide rate in this
    group was 47.1 per 100,000.  By comparison, in FY 2008, there were 32
    suicides and a rate of 75.4 per 100,000.
  • In
    FY 2009, the suicide rate among individuals with mental health or substance use
    disorder diagnoses was 56.4 per 100,000, as compared to 23.5 among patients
    without these diagnoses.  The resulting rate ratio was 2.4.  This
    continues a steady trend of reducing rate ratios observed since FY 2001, when
    the rate among patients with mental health or substance use disorder diagnoses
    was 78.0 as compare to 24.7 among patients without these diagnoses (rate ratio
    of 3.2)

VA’s Ongoing Research to Identify Risk Factors for
Suicide Prevention and Treatment

VA’s research
portfolio includes studies focused on identifying risk factors for suicide,
prevention, and treatment.  Risk factors being studied include co-morbid
disorders, medications, and behaviors.  A few specific examples include:

  • In
    one study, VA researchers seek to determine the prevalence of suicide ideation,
    plans, and attempts resulting in medical treatment among Veterans currently
    enrolled in VA’s health care system.  The researchers will also collect data on
    a limited number of established risk factors and characteristics unique to
    military service that can be used to understand correlates of non-fatal
    suicidal behaviors.
  • A
    VA Suicide and Self-Harm Classification System and Clinical Tool is being
    evaluated to determine the feasibility for implementation in diverse VA
    treatment settings and to assess its impact on health care system processes
    pertaining to the assessment and management of suicide risk.
  • The VISN 2 Center of Excellence, in Canandaigua, NY, in collaboration with the
    National Center for Homelessness among Veterans, is conducting a study of risk
    factors for suicide among Veterans with a history of homelessness or housing
    instability. Characteristics of service utilization, the independent effect of
    homelessness, and differences in risk associated with psychiatric diagnoses are
    being studied through the use of homeless intake assessments, non-fatal suicide
    event data, and data obtained from the National Death Index.
  • VA
    researchers are determining the role of a brain chemical called serotonin in
    suicide and seek to discover whether alterations in levels of this chemical
    impact suicide.
  • The
    Suicide
    Assessment
    and Follow-up
    Engagement:
     Veteran
    Emergency
    Treatment
    Project (SAFE VET) is a clinical demonstration project that focuses on providing
    a brief intervention and follow-up for suicidal Veterans who present to the
    Emergency Department and Urgent Care Services and who do not require
    hospitalization.  This study also permits us to longitudinally follow risk
    factors in Veterans identified as being at moderate risk for suicide.
  • Motivational
    Interviewing to Prevent Suicide in High Risk Veterans is a study to test the
    efficacy of an adaptation of Motivational Interviewing to Address Suicidal
    Ideation (MI-SI) on the severity of suicidal ideation in psychiatrically
    hospitalized Veterans at high risk for suicide.  The researchers also are
    examining the impact of MI-SI on risk factors for suicide in Veterans, such as
    treatment engagement and psychiatric symptoms.
  • Many
    completed studies addressing suicide epidemiology have been published by VA
    investigators, providing important information related to risk factors. 
  • VA
    is also doing extensive work in traumatic brain injury (TBI), including how
    Veterans with a TBI may be at risk for mental health issues and suicide.  Our
    work in TBI will also give us a broader knowledge about suicide in general. 

Conclusion

Madam Chairwoman,
as my testimony demonstrates, VA’s efforts to provide comprehensive suicide
prevention services are comprehensive and continuously improving.  Since our
suicide prevention effort began in 2005 we have revisited it often to make sure
it continues to meet our Veterans’ needs, made adjustments when necessary, and
will continue to do so as new research helps us uncover new ways to prevent
these tragedies.  It is clear our mission will not be fully achieved until
every Veteran contemplating suicide is able to secure the services he or she
needs.  The Department appreciates Congressional support of our work in this
area.  I am prepared to answer your questions.

Prepared Statement of Colonel Carl Castro, Ph.D., Director,
Military Operational Medicine Research Program, U.S. Army Medical Research and
Materiel Command, and Chair, Joint Program Committee for Operational Medicine,
Department of the Army, U.S. Department of Defense

Madam
Chairwoman, Members of the Committee, thank you for the opportunity to discuss
the joint Department of Defense (DoD) and Department of Veterans Affairs’
(VA’s) efforts to advance our understanding of how to prevent suicide. We
acknowledge Congress’ concern and thank you for your support, which allows the
DoD and VA to continue their commitment to better understand suicide and
develop effective prevention and treatment interventions based on that
knowledge. Our efforts demonstrate our obligation and dedication to the men and
women of our Armed Forces, to their Families who serve with them, and to the
millions of military personnel who have served us in the past.

Suicide is a significant public health
problem, identified as the third leading cause of death in young people and the
11th overall leading cause of death in the U.S.
population. Traditionally, military suicide rates have been significantly lower
than general population rates. However, in 2008, Army suicide rates
(19.6/100,000) exceeded the age-adjusted civilian rate and outnumbered combat
deaths for the first time since 2003 (Armed Forces Medical Examiner, 2008).
However, the reason for the increase in Army suicides remains unknown.

Rigorous
empirical research is necessary to understand why military suicides occur and
how to identify and help individuals at risk for suicide. Only evidence-based
empirically validated methods for screening, assessment, prevention and
treatment interventions will be successful in preventing suicides. There are currently
no validated suicide screening and assessment measures.

Military Suicide
Prevention Research Program

In 2007, Defense Health Program (DHP)
funding supported multiple military suicide research studies that were initial
studies to test brief cognitive therapy for treating individuals who had been
hospitalized for suicide attempt. In 2008, DHP funding was dedicated to several
military suicide studies focused on developing our ability to optimize
screening and assessment of risk, psychotherapeutic treatments, and methods to
decrease suicide. In the next few years, the results of these studies will be
available to inform policy recommendations as well as methods for preventing
and treating suicidal individuals. Almost all of the DHP funded military suicide
research studies include VA involvement, including either VA principal
investigators, VA recruitment sites, or VA collaborators on the research team.

In March
2009, the US Army Medical Research and Material Command’s (USAMRMC) Military
Operational Medicine Research Program (MOMRP) and the Army Surgeon General’s
office led a series of workshops with leading suicidologists and military and
federal stakeholders, including the VA, to determine the state of science of
suicide prevention research. The workshops led to the development of a research
strategy with recommendations provided to MOMRP and the Joint Program
Committee, which is composed of DoD, National Institutes of Health, and VA
leadership as well as academic representatives. The research recommendations
were in 4 focused areas: suicide risk screening and assessment; universal
prevention training; indicated interventions to manage suicide behavior; and
recommendations for revisions to the Post Deployment Health Assessment and Post
Deployment Health Reassessment. The workshops also involved the U.S. Army
Public Health Command (PHC), which has resources dedicated to epidemiological
study and tracking of Army suicides.

The DoD developed and implemented a
Military Suicide Prevention Research Program, which represents an approximately
$110 million investment, since 2008. Following the recommendations generated
from the workgroups, and consistent with the Army and DoD suicide prevention
strategies, the Military Suicide Prevention Research Program employs a comprehensive
strategic approach to provide evidence-based, rigorously evaluated, screening,
assessment, and suicide prevention interventions. The DoD and VA collaborate on
many aspects of the Military Suicide Prevention Research Program, which also
involves extensive collaboration among other government organizations,
academia, and national organizations such as the American Foundation for
Suicide Prevention and the American Association for Suicidology Research.

Military Suicide Research
Consortium

In September 2009, the DoD
established a first of its kind, multidisciplinary Military Suicide Research
Consortium (MSRC).  This effort is funded by the Office of the Assistant
Secretary of Defense for Health Affairs, managed by the USAMRMC, and co-directed
by Dr.

Peter Gutierrez, of the
Veterans Integrated Service Network 19 Mental Illness Research Education and
Clinical Center of the Denver Veterans Affairs Medical Center, and Dr. Thomas
Joiner, of Florida State University. The co-directors are world renowned
experts in suicidology. The MSRC was initially funded in the amount of $17
million with the aim of enhancing the military’s ability to quickly
identify individuals and units at risk for suicide and provide effective

evidence-based prevention and treatment strategies.

The MSRC includes core infrastructure as well as
funded research efforts aimed at rapidly developing and validating effective
suicide screening, assessment, and prevention interventions. The studies that
are funded by the MSRC are all required to use a minimum set of common measures
so that data can be pooled across the studies. This larger data pool can then
be analyzed to determine empirically if there are different sub-types of
suicide, a vital question to answer for both improvement of assessment
techniques and developing targeted interventions. The participating VA
researchers are on the cutting edge of suicide prevention and treatment
research.  The MSRC complements the Army Study to Assess Risk and Resilience
(Army STARRS) in Servicemembers effort which is primarily descriptive
(epidemiologic) in focus.

Army STARRS

In order to better understand the factors related to
suicide, the Department of the Army and the National Institute of Mental Health
(NIMH) are involved in an ongoing multidisciplinary collaboration to conduct a
large scale epidemiological study of suicide in the military.  This effort is
being led by Dr. Robert Ursano from the Uniformed Services University of the
Health Sciences and Dr. Murray Stein from the University of California, San
Diego. This $65 million project ($50 million from Army and $15 million from
NIMH) is the largest epidemiologic study of mental health, psychological
resilience, suicide risk, suicide-related behaviors and suicide deaths in the
military.  The findings from this effort will be used to inform current and
future suicide prevention efforts to enhance their effectiveness.

Way Ahead

Despite the current investment in suicide prevention
research, there is much more work to be done in the area of suicidology. The
strategic research plan calls for further DoD and VA collaboration to conduct
research that comprehensively addresses necessary components: screening and
surveillance; prevention training; assessment, treatment, and management of suicidal
individuals. Future research will focus on developing evidence-based universal
prevention (e.g., peer based, family based, community based,
military-ecologically based). Additionally, current prevention efforts need to
be evaluated for effectiveness.

Future research is also needed to establish
psychometrically sound, theory-driven screening measure(s). Basic science to
validate underlying psychological and biopsychological theories of suicide will
help to drive prevention and treatment efforts. Further research is required to
establish evidence-based indicated interventions to prevent and manage suicide
behavior (e.g., caring outreach, collaborative assessment and management,
safety planning, collaborative care models, etc.) across clinical care settings
(e.g., Emergency Department, Behavioral Health, Primary Care, etc.).

Madam Chairwoman and Committee members, the DoD continues work with the VA to
perform and manage world-class medical research and development for a population
that demands and deserves the best care available.  Thank you again for the
Congress’ and this Committee’s continued support and commitment to research
dedicated to ensuring our Warfighters are getting the best empirically proven
cutting edge training and services. And thank you for the opportunity to be with
you today.  I look forward to your questions.

Prepared Statement of Paula Clayton, M.D., Medical Director, American Foundation for
Suicide Prevention

Chairwoman Buerkle, Ranking
Member Michaud, and members of the Committee. Thank you for inviting the
American Foundation for Suicide Prevention (AFSP) to provide a written
statement on the issue of suicide and suicide prevention among our nations veterans. 
My name is Paula Clayton.  I am AFSP’s medical director.   As such, I work with
AFSP’s Scientific Council to oversee the research and educational programs of
the foundation and to apply evidenced based knowledge to these programs and to
the programs that deal with suicide prevention.

Prior to becoming medical
director, I was an academician.  I trained in psychiatry and joined the
faculty at Washington University School of Medicine in St. Louis Missouri and
then became chairman of the department of psychiatry at the University of
Minnesota School of Medicine, a job I held for nearly 20 years.  That was
followed by becoming a professor of psychiatry at the University of New
Mexico.  In all positions, my research, teaching and patient care
concentrated on patients with major depression and bipolar illness and those
who were recently bereaved.  Since approximately 15% of patients diagnosed
with a mood disorders die by suicide, the outcome of suicide is one I and all
psychiatrists work to prevent.  Becoming medical director of the
foundation was a natural extension of my accumulation of knowledge about the
subject.

AFSP is the leading national not-for-profit,
grassroots organization exclusively dedicated to understanding and preventing
suicide through research, education and advocacy, and to reaching out to people
with mental disorders and those impacted by suicide.  You
can see us at www.asfp.org.

To fully achieve our
mission, AFSP engages in the following Five Core Strategies, (1)
Funds
scientific research, (2) Offers educational programs for professionals, (3) Educates
the public about mood disorders and suicide prevention, (4) Promotes policies
and legislation that impact suicide and prevention, (5) Provides programs and
resources for people with mental disorders and for survivors of suicide, and
involves them in the work of the foundation.

We are pleased today to focus in my statement
on identifying at-risk veterans, data collection, providing effective
intervention and treatment, and meeting the on-going challenges of veteran suicide
prevention.

Chairwoman Buerkle, Ranking
Member Michaud, suicide in America today is a public health crisis.  Consider
the facts:

  • More than 36,000 people died by
    suicide in 2008, the last year of the CDC report. And these numbers have been
    rising yearly.
  • Approximately 20% of these deaths
    were veterans, although they only make up 1% of our population.
  • Suicide is the 4th leading cause
    of death in the United States for adults 18 - 65 years old and is the third
    leading cause of death in teens and young adults from ages 15 - 24. 
  • Male veterans are twice as likely
    to die by suicide as male non-veterans. On average 18 veterans commit suicide
    each day, which means that every 80 minutes a veteran dies by suicide. Sadly,
    only five of these veterans are in the care of the VA.
  • Men account for 80 percent of all
    completed suicides in America.
  • Depression, alcohol and substance
    abuse, Post Traumatic Stress Disorder and traumatic brain injury are real
    medical conditions.

We need to convince veterans
that seeking help for mental illness and substance abuse problems is a sign of strength
not weakness. The keys to improving these statistics are reducing the stigma
associated with mental illness, encouraging help-seeking behavior, and being
aware of warning signs and treatment options.

Suicide is the result of
unrecognized and untreated mental disorders.  In more than 120 studies of a
series of completed suicides, at least 90% of the individuals involved were
suffering from a mental illness at the time of their deaths. The most common is
major depression, followed by alcohol abuse and drug abuse, but almost all of
the psychiatric disorders have high suicide rates.

So the major risk factors for
suicide are the presence of an untreated psychiatric disorder (depression,
bipolar disorder, generalized anxiety and substance and alcohol abuse), the
history of a past suicide attempt and a family history of suicide or suicide
attempts. The most important interventions are recognizing and treating these
disorders.  Veterans have strong biases against doing that.  These must be
identified and overcome.

Whether a civilian or a
veteran, there are signs that healthcare professionals look for, what we call
risk factors.  In addition to those above, they include:

  • Difficulties in a personal
    relationship;
  • A history of physical, sexual or
    emotional abuse as a child;
  • Family discord; 
  • Recent loss of a loved one;
  • A recent arrest;
  • Sexual identity issues;
  • Availability of firearms.

Protective factors or
interventions that work, again in the general population and for veterans
include:

  • Regular consultation with a
    primary care physician;
  • Effective clinical care for mental
    and physical health, substance abuse;
  • Strong connections to family and
    community support;
  • Restricted access to guns and
    other lethal means of suicide.

The VA has adopted a broad
strategy to reduce the incidence of suicide among veterans.  This strategy is
focused on providing ready access to high quality mental health and other
health care services to veterans in need.  Congress needs to fund the VA to
deal with these current and future mental health care needs in the next five,
ten, fifteen and twenty years. This effort is complemented by helping
individuals and families engage in care and addressing suicide prevention in
high risk patients.  The VA cannot do it alone, and groups like the American
Foundation for Suicide Prevention are helping in this important effort. AFSP is
pleased to report that while our country and the VA have a long way to go, help
is available.

In the summer of
2007 the VA began a crisis line for veterans and military service members,
in conjunction with the National Suicide Prevention Lifeline (1-888-273-TALK).
Veterans, military service members, and persons who are calling about someone
in either of these populations are directed to press “1,” thereby having their
call directed to a team of crisis line counselors at the VA in Canandaigua, NY.
In the first three years, more than 144,000 calls were received at this call
center, and the volume of calls to the Veterans Crisis Line has continued to
grow. Although it is not possible to accurately estimate the number of lives
that have been saved as a direct result of the Veterans Crisis Line, call
records maintained by the VA point to the diverse needs that are being met
among the target population by this well-trained, skillful corps of counselors.

In 2009, the VA
began offering an online Veterans Chat service to augment the Veterans Crisis
Line and provide access to information and services to veterans, military
personnel and their loved ones who prefer internet-based communication to the
telephone. In mid-2010, AFSP and the VA began discussing whether completing an
online assessment instrument prior to engaging with a Chat Counselor might help
users more easily and specifically communicate their needs and problems to the Counselor,
thereby increasing the quality of the Chat. Such an option was thought to have
particular potential for those veterans and service members who find it
difficult to identify and clearly describe what they are feeling and
experiencing. These discussions led to the launch of the Veterans Self-Check
Quiz in April 2011. This program is an adaptation of AFSP’s highly successful,
evidence-based Interactive Screening Program, an anonymous, web-based method
for identifying college and university students who are at-risk for suicide,
and connecting them to a counselor who can engage them to get treatment. This
program is based on the premise that at-risk persons often have beliefs and
attitudes which create barriers to treatment, which must be addressed and
resolved before the person will be responsive to offers of help.   

For the last
seven months, the Veterans Self-Check Quiz has been offered on the National
Suicide Prevention Lifeline website as a third way of getting help, the first
two being calling the Crisis Line or directly contacting the online Veterans
Chat service. A link provided on the Lifeline homepage directs the user to an
AFSP-developed secure website where the user can anonymously complete an online
questionnaire that deals with depression, stress, drug and alcohol use, PTSD,
traumatic brain injury, and suicidal thoughts and behaviors. Submitting the
Self-Check Quiz generates a signal to the Chat Counselors in Canandaigua, NY
that a Quiz has been received and needs to be responded to. The user is
directed to stay on the website to receive the Counselor’s personal response,
which typically occurs in 15-30 minutes. Educational and informational
materials and videos can be accessed directly from the website and perused by
users while they are waiting.

In their responses,
Chat Counselors provide feedback to the user about Quiz answers of particular
concern and make recommendations about help-seeking. Users are particularly
encouraged to explore options by entering into a Chat with the counselor, using
a link to the Veterans Chat service. A Reference Code, which is automatically assigned
to each Self-Check Quiz and communicated to both the user and counselor, allows
tracking of those users who come into a Chat directly from the Self-Check Quiz.

In the initial
six months of the program, almost 6,000 Self-Check Quizes were submitted, the
large majority of which were from veterans. A high percentage of the submitted
Quizes suggested serious suicide risk. Using the Reference Codes, one-third of
those who submitted the Quiz could be identified as having engaged in a
follow-up Chat. A significant increase in Chat volume that paralleled the
introduction of the Self-Check Quiz suggests that many more users may have
entered a Chat days or maybe even weeks after submitting the Quiz without
providing the Reference Code that would have signaled that a Quiz had been
submitted. Analysis of the data from the initial 6-month period has just begun
and results will be reported as soon as these are available.

AFSP applauds the
VA in its use of this innovative, proactive approach to reach out to veterans
and service members who, for a variety of reasons, are not themselves
initiating contact with the VA as they are struggling with mental health
problems. We look forward to continuing this collaboration with the VA, using
the findings from the pilot implementation to make enhancements to the program,
and exploring ways to make this outreach effort even more effective.

In this regard,
we might consider experimenting with a small-scale implementation of the
program at a local VA medical center or other facility. AFSP’s campus-based
Interactive Screening Program has shown that a mental health professional in
the Counseling Center of the student’s own university can very effectively use
the anonymous online interactions to help students address their barriers to
help-seeking and engage them to pursue in-person treatment, at least initially
with that same counselor. It is worth exploring whether the Self-Check Quiz
could be effectively used on the local level to reach out to and engage veterans
to seek treatment for mental health problems that put them at risk for suicide.

The VA has gone on to develop
other suicide prevention programs and to educate their health workers about suicide
risk factors and ways to intervene.

Unfortunately, they face
enormous challenges. 

First of all, only about one-third
of our veterans are in VA care.  Those who are employed frequently choose
to use the private insurance their employers provide and are therefore not in
the VA care system.  Others are unemployed; a condition in itself
associated with higher suicide rates. Even tracking these men and women is
difficult, much less gathering information about the deaths.

Second, a number of veterans
are homeless or perhaps in jail, and they need a different intervention plan.
The VA now reports that 107,000 veterans are homeless on any given night. 

In order to meet the multiple
challenges that the VA faces in both suicide education and prevention, AFSP
recommends consideration of the following four research initiatives and or interventions.

Number one, the most
informative way to learn about suicides is through an investigation, after
death, called a “psychological autopsy.”  This procedure, as referred to
earlier, allows investigators to go in to a home in the month after the
suicide, and using a structure interview, to question all the family members,
physicians, perhaps friends and clergy, about the events that were occurring at
the time of the suicide.  It allows the investigator to decide, putting
all the interviews together, what were the signs and symptoms that the veteran
was displaying prior to his death.  Was he depressed, sleeping poorly,
losing weight, talking about being a burden, becoming more irritable?  Was
he drinking, using drugs, prescription or otherwise, that may have contributed
to his mood and his lack of control?  Was he fighting with his family,
isolating, in an accident, ill, in pain, been arrested or had trouble with the
law?  Given that information on a randomly chosen group of veterans, the
VA could develop a clearer picture of the mental disorders that lead a veteran
to suicide and plan intervention programs based on those findings. I am not
sure we even know the means by which veterans die by suicide.  Although in
most of the 120 psychological autopsy studies done they are concentrated in one
city or country, it is possible to train several teams to do this for the
country, thereby allowing a “team ready” approach to the issue.  If they
found, for instance, that 15% of the veterans had enough behavioral problems
that the police were called, then training policeman to be particularly careful
and aware on such a call that this may be a veteran in trouble and in need of a
psychiatric evaluation would be paramount.  The police, in many states,
are able to take people who are dangerous to themselves and others to an
evaluation facility.

Number two, another proven
successful intervention is to train primary care physicians and nurse
assistants to diagnose and treat depressed patients with antidepressants. 
There are at least four communities where this has shown to decrease the
suicide rate, the most impressive being one carried out by the World Health
Organization in four different underdeveloped countries.  The VA could and
should begin immediately to train the collateral primary care and ER physicians
and their personnel to recognize and treat depression or alcohol or substance
abuse and every veteran’s chart should have this information in front or on the
screen as it is opened.  There are also drug screens and liver function
tests that might lead a caregiver to suspect there is a drug or alcohol abuse
problem.  Knowing, from the psychological autopsy study, what the veteran
is suffering from would help plan this intervention, too.

Number three, we need to give
our veterans “real” jobs.  Dr. Peter Kramer of Brown University recently wrote,
“The Best Medicine Just Might Be a Job.”  He reports that study after study
correlates unemployment with suicidality. When soldiers leave the military,
they lose what the service provides: purpose, focus, achievement, responsibility,
and the factor that the Center for New American Security report calls
“belongingness.”  The workplace can be stressful, but especially for the
mentally vulnerable, there is no substitute for what jobs offer in the way of
structure, support and meaning.

Number four, many studies
have indicated that preventing easy access to lethal means, like firearms, is
an effective way to prevent suicide. Soldiers are taught to use guns and most
have them available.  Just as it is believed that physicians, as professionals,
have knowledge and easy access to other lethal means (drugs) and therefore have
the highest suicide rates of any profession, veterans have the knowledge of and
access to guns, another lethal means.  VA hospital and all medical
personnel should be taught to ask veterans about whether they have guns in
their houses and encourage the doctor or others to discuss with at-risk veterans
and their family members how to store the guns safely, with gunlocks or
separated ammunition and guns, or even encourage temporary removal of the
weapon. A program could be planned for medical personnel and others on what
they should ASK A VET?

AFSP would like to commend the
US Department of Veteran Affairs and Dr. Jan Kemp for their leadership and
vision in constructing and implementing this program designed to help our
veterans contemplating suicide. They and we still have much more to do. We urge
this subcommittee, the full committee and the entire Congress to fully support the
VA and Dr. Kemp in their important efforts by funding them at the highest
levels possible, not just next year, but for many more years in the future. 
This is essential: once we identify veterans needing help, VA professionals
must be available to assist them now, tomorrow, next week.

Chairwoman Buerkle, Ranking Member
Michaud, suicide among veterans is an absolute crisis.  Depression can be
fatal.  Excessive drinking or drug use can be fatal.  The fatality is mainly by
suicide.  Culturally sensitive but sustained efforts with multiple approaches
offer our best hope to get veterans into treatment.  We must reduce this fatal
outcome.  The American Foundation for Suicide Prevention is ready and willing
to offer our expertise and advice to the US Department of Veterans Affairs,
this Committee and to all members of Congress as you make the important
decisions on how to reduce suicide among our veterans.

Prepared Statement of Lieutenant Colonel Michael Pooler,
USA, Deputy Chief of Staff, Personnel, Maine Army National Guard

Thank you, Congressman Michaud for
allowing the Maine Army National Guard to submit written testimony on suicide. Suicide prevention is taken very seriously in the Maine Army National Guard from the top
down.  Unfortunately, since
2009, the Maine Army National Guard has had two suicides. Though we do not have specific numbers, we know that numerous interventions have occurred that have saved lives. As training continues, interventions will increase. Leaders across the state are keenly aware of the problem and are working together to reduce
the stigma and create a
help-seeking environment.
We view the increase in interventions as confirmation that our attempt to
create an environment where Soldiers, families and commanders recognize the
signs of suicide and ask for help without fear of retribution as very positive
progress.

Support
Staff and Organizational Training

Our support staff consists of a
variety of federal and contracted personnel. Our primary federal employees
consist of two Army National Guard chaplains, a Suicide Prevention Program
Manager, one Army National Guard behavioral health officer, and two substance
abuse personnel. Our primary contracted personnel are: a Director of
Psychological Health, two Military Family Life and Children Consultants, a
Military One Source representative, a Personal Financial Counselor and several Family
Program contractors who run a 24/7 assistance hotline. Each has a part in finding
help for our Soldiers and Families.

The Army National Guard has a Resiliency,
Risk Reduction and Suicide Prevention (R3SP) Campaign Plan designed to
coordinate various programs to ensure our Soldiers bounce back from adversity.
A critical part of this is the Comprehensive Soldier Fitness program with
Master Resiliency Trainers and Resiliency Training Assistants. These Soldiers support
unit commanders in training Soldiers to be resilient through various means.
Another component of the R3SP program is the Suicide Prevention Program
Manager, who is the conduit between the National Guard Bureau and the State of
Maine to coordinate and facilitate intervention training.  Applied Suicide Intervention Skills
Training (ASIST) is conducted
semi-annually for selected service members.  ASIST has
strategically placed trained Soldiers
in units across the state to be the eyes and ears of commanders to observe the
signs of suicide and provide interventions for those with suicidal ideation. 
ASIST is enhanced by Ask,
Care, Escort (ACE),
an Army-wide intervention program.  ACE teaches every Soldier the warning signs
of suicide, how to ask the suicide question, the nature of care needed by a
suicidal Soldier, and when and how to escort such Soldiers to health care professionals
to save lives.  ACE is unit led, supported by unit commanders, and promotes a
“buddy-care” mentality that encourages help-seeking by those going through
crises or struggling with addictions.  ACE is a mandatory one-hour training
block taught annually at the company level.

Suicide prevention takes many forms. 
Since relationship issues and substance abuse are frequently associated with
suicidal thinking and behavior, we have stepped up efforts to strengthen relationships and reduce alcohol and drug abuse.  Our
chaplains conduct four to five Strong Bonds events annually aimed at married
couples and single Soldiers to build healthy and enduring relationships.  Our
Counter Drug Program works tirelessly
to educate and influence Soldiers,
recruits, and families in the dangers and warning signs of addiction. 

We also have the Maine Military and
Community Network which works with clergy, law enforcement, and volunteer
groups to support our Soldiers and families. A key component of this is the
Maine Military Clinical Outreach Network where we train clinicians on the
military culture and attempt to find civilian providers to see our Soldiers at
a free or reduced rate. The Governor’s Military and Community Leadership
Council also works at the policy level to coordinate comprehensive support for all
our service members in Maine.

Access
to assistance

The
Army National Guard is organized to train and deploy Soldiers; therefore, we do
not have any staff dedicated to treat our Soldiers. Our staff is trained help Soldiers
find treatment; however, as a rural state, treatment options are limited and
our only access to a military medical treatment facility is in another state.

Nationally
in the Army National Guard, in 2009 and 2010, roughly one half of Soldiers that
committed suicide did not deploy, which determines VA eligibility.[i]

VA eligible Soldiers. We have a close working relationship with the great Suicide Prevention staff at Togus VA Hospital and the regional Vet Centers.  The staff is easy to reach, ready
to help, and eminently qualified.  They have become a reliable and competent resource
and benefit for us; however,
from our perspective, they seem to be extremely understaffed.

Non VA eligible Soldiers that buy
TRICARE.
We are
finding that many Soldiers with suicidal ideations have not deployed, so they
are not eligible for VA support. Even though Soldiers are eligible to buy
TRICARE at a very reasonable price, most do not. However, even those that buy
TRICARE, have a very difficult time finding clinicians who will see them. Many
clinicians that want to help Soldiers find the process to become a TRICARE
provider extremely cumbersome and the $27.50/hour reimbursement does not cover
basic overhead, so we lack the number of counseling providers needed for our Soldiers.
There needs to be a concerted effort to recruit and retain not only behavioral
health providers, but also the gatekeepers to support the primary care
providers. Also, someone other than the providers needs to maintain the TRICARE
websites to ease the frustrations Soldiers find when looking for help. Much of the
information on the website is outdated.

Soldiers
without health insurance.
Obviously, this is a population that creates the
biggest challenge. Our staff works tirelessly contacting providers to find
someone to help at a reduced rate or free.

What
Works.

The
most effective approach is to create an environment where Soldiers feel they
can ask for help without fear of repercussion or stigma and we work to
continuously improve this environment. We provide the training to recognize the
signs, where to get help and how to get Soldiers the support needed.

Community
coordination and support allow the Guard to find the resources available for
our Soldiers. This has saved lives.

Contractors
provide continuity of support because our full time force of Soldiers will eventually
deploy.

Respectfully submitted.


[i]
R3SP Update, 29 JAN 11, Army National Guard Bureau, COL Greg Bliss

Statement of Richard McCormick, Ph.D., Senior Scholar,
Center for Health Care Policy, Case Western Reserve University, Cleveland, OH

Suicide is a tragedy. It is the
ultimate ending for some of the very large numbers of veterans who face the
challenges and problems that result from deployment and combat.

The Department of Veterans Affairs
(VA) and the Department of Defense (DoD) have worked hard to develop programs
to reduce suicidal behavior among returning service members and veterans. Still,
the challenge remains to discover and implement additional measures to further
reduce the risk of suicidal behavior.

Research has established that the suicide of a
particular individual is very difficult to predict and anticipate.  We do,
however, have increasingly knowledge about the conditions that precede and
contribute to suicidal behavior and other serious emotional problems, such as
PTSD and depression, in veterans and service members. These include notably:

  •  Problems in marital and other important relationships
  •  Hazardous use of alcohol and other drugs
  •  Risky/impulsive behaviors including: gambling, hazardous driving,
    and outbursts of angry behavior

Research has
shown that all of these problems occur in returning service members and
veterans, and that all are related to the degree of exposure to stress during
time in service and immediately after.

The harmful
use of alcohol is a major public health problem, and is a particularly serious
problem for those serving in the current war on terror. A recent report on
48,481 active duty, reserve and national guard indicates that rates of heavy
weekly drinking (9%), binge drinking (53.4%) , and problems related to alcohol
use (15.2%) were particularly high in Reserve and National Guard members  who
are veterans immediately after return from deployment (Jacobsen, Ryan, Hooper,
et al, 2008). Both the degree of exposure to combat and the degree of exposure
to human trauma are related to increased drinking (Kilgore et al, 2008; WIlk et
al 2010). Surveys of active duty military members have noted that between 6.3%
and 8.1% report at least one gambling related problem in their lifetime
(Steenbergii et al 2008). In a study of returning OIF/OEF service members, the
intensity of combat experience and exposure to violent human trauma were
predictive of verbal and physical aggression towards others three months after
deployment (Kilgore et al, 2008). Aggressive and unsafe driving are significant
problems for active duty members (Kilgore et al 2008). Even controlling for age
personnel deployed to Iraq have higher rates of dangerous driving than older
veterans.

These problems
are often among the first indicators of serious distress. If left unattended
they can fester and expand to other areas of the veteran’s life and
functioning. As the problems snowball, helplessness and hopelessness can set
in, leading to suicidal behavior.

A comprehensive program of early prevention for
suicide and other serious emotional problems should include readily accessible,
hassle-free assistance with these problems.  Historically, the Vet Centers have
been more assertive in addressing these early problems than has the VA core
medical care system. With some notable exceptions, VA medical centers and
clinics have traditionally focused on diagnosable pathology. If services such
as marital counseling or early intervention into hazardous drinking exist, they
may be embedded in other programs.

Further complicating the prevention effort is a
lack of awareness, and at times limited motivation, of the veteran to address
the early precursor problems. Present programs, including the Vet Centers, rely
on the veteran seeking help for a self-identified problem.  

More can and needs to be done to
identify and offer early intervention for problems which have been demonstrated
to be related to later serious emotional problems and suicidal behavior.         

The first practical steps would be to build on
current efforts in the VA and DoD to screen for early occurring problems.  VA
currently screens all patients in primary care for hazardous alcohol use,
depression and PTSD. Positive screens for depression and PTSD are expected to
trigger further screening and intervention, including identifying and
addressing suicidal behavior. Returning service members, including those in
reserve components, are screened immediately after deployment and again within
90 days for general mental health issues, including PTSD and alcohol use. VA
outreach workers are present at screens for those in the reserve components
when they are conducted at their home training sites.

Short reliable and valid screening tools exist
for other early identifiable problems including relationship issues, problem
gambling and other risky behaviors. Screening for these additional problems
would raise the awareness of veterans, significant others and providers of
care. It would also assure that a conversation is initiated about these
problems and early intervention considered n all venues where veterans may be
encountered, including primary care settings and outreach efforts.

Screening is a necessary, but not sufficient,
step in a comprehensive prevention effort. Still greater challenges exist in
assuring that those who screen positively are in fact engaged into an
appropriate level of intervention. Hazardous alcohol use provides the currently
best documented example of this issue.  A recent study of 1508 OIF/OEF veterans
using VA medical, surgical or mental health services found that 40% screened
positive for hazardous alcohol use (Calhoun, Elter, Jones, et al, 2008).  This
study also documented that only 31% of those who screened positively for an
alcohol use problem ever received a follow-up intervention to address the
problem.

This lack of follow-up
underscores the need to assure that readily accessible intervention services
exist, and that all providers are aware of them and able to seamlessly refer to
them.

VHA’s recent efforts
to increase the placement of mental health staff in primary care settings
provides the platform to deliver accessible services to intervene with these
early problems. 

Suicide prevention efforts in
VA and DoD could be enhanced by the following:

  • Expand screening efforts to include a wider variety of problems
    and behaviors that are potentially related to serious emotional problems
    including suicidality
  • Assure that readily accessible services are available to
    intervene immediately when a problem is identified, and that these services are
    widely advertised to both veterans and providers
  • Assure that all staff understand that addressing these behaviors
    is a critical part of providing comprehensive health care prevention services
    in the health care setting, they are not someone else’s responsibility
  • Increase the awareness of veterans and their significant others
    about these early indicator problems and urge them to bring them up with their
    health care provider (this could include, for example, handouts in primary care
    areas)
  • Conduct periodic quality assurance studies assessing whether
    veterans screening positively for problems actually access interventions
    services

Expanding
screening efforts and establishing robust marital/relationship programs,
specific programs addressing hazardous drinking, and programs tailored to other
risky behaviors would involve further funding. Establishing these programs is
part of our responsibility to restore returning veterans to full function. It
needs to be done immediately, since the need is now before they can fester into
additional serious issues, including, for some, suicidal behavior.  This
immediate investment is also the wise fiscal choice, since it will offset not
only human suffering, but future greater healthcare costs.


References:

Preliminary
Normative Data for the Evaluation of Risks
Scale-Bubble Sheet Version (EVAR-B) for Large-Scale
Surveys of Returning Combat Veterans MAJ
William D. S. Killgore, MS USAR; COL Carl A. Castro, MS USA; COL Charles W.
Hoge, MC USA, MILITARY MEDICINE, 173, 5:452, 2008

Gambling and Health Risk-Taking
Behavior in a Military Sample:

Timothy A. Steenbergii, PhD*;
James P. Whelan, PhDf; Andrew W. Meyers, PhDf;

Robert C. Klesges, PhDf;
Margaret DeBon, PhD, Military Medicine [Mil Med],
ISSN: 0026-4075, 2008 May; Vol. 173 (5), pp. 452-9.

Lifetime Prevalence of
Pathological Gambling Among American Indian and Hispanic
American Veterans:

Joseph Westermeyer, MD, PhD,
MPH, Jose Canive, MD, Judith Garrard, PhD, Paul Thuras, PhD, and James
Thompson, MD, MPH,  Am J Public Health. 2005;95:860–866.

Daghestani, A.
N., Elenz, E., & Crayton, J. W. (1996). Pathological gambling in hospitalized
substance abusing veterans. Journal of Clinical Psychiatry, 57, 360–363.

Levens S., Dyer A. M., Zubritsky
C., Knott K., Oslin D. W. Gambling among older,
primary-care patients. An important public health issue. Am J
Geriatr Psychiatry 2005; 13: 69–76.

Factors associated with
pathological gambling at 10-year follow-up in a national
sample of middle-aged men,
Jeffrey F. Scherrer, Wendy S.
Slutske, Hong Xian, Brian Waterman, Kamini R. Shah1, Rachel Volberg& Seth A. Eisen, Addiction, 102, 970–978,
2007

Post-combat invincibility:
Violent combat experiences are associated with increased
risk-taking propensity following deployment: William
D.S. Killgore a,*, Dave I. Cotting , Jeffrey L. Thomas a, Anthony L. Cox, Dennis
McGurk , Alexander H. Vo , Carl A. Castro , Charles W. Hoge .Journal of Psychiatric Research 42 (2008) 1112–1121

Relationship of combat experiences to
alcohol misuse among U.S. soldiers returning from the Iraq war:Wilk JE;
Bliese PD;
Kim PY;
Thomas JL;
McGurk D;
Hoge CW,
Drug
And Alcohol Dependence, 2010 Apr 1; Vol. 108 (1-2), pp. 115-21.

Hazardous alcohol use and
receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq
and Afghanistan.;
Calhoun PS;
Elter JR;
Jones ER Jr;
Kudler H;
Straits-Tröster K, J Clin Psychiatry 2008
Nov; Vol. 69 (11), pp. 1686-93.

Alcohol use and alcohol-related
problems before and after military combat deployment;
Jacobson IG;
Ryan MA;
Hooper TI;
Smith TC;
Amoroso PJ;
Boyko EJ;
Gackstetter GD;
Wells TS;
Bell NS, JAMA: The Journal Of The American
Medical Association, 2008 Aug 13; Vol. 300 (6), pp. 663-75.

Statement of John E. Toczydlowski, Esq., Philadelphia, PA

Mr. Chairman and Honorable Members of the Committee:

 My name is John Toczydlowski.  I am not a veteran, but I am from a military family, my father,
my grandfather and my uncles having proudly served.  Today, I am here to speak
with you specifically about my father, who served in Vietnam from 1964-1970.  He
committed suicide on December 17, 2010 as the result of post-traumatic stress
disorder and physical ailments directly related to his service in Vietnam.

Three specific
questions need answers.  One, how and why did this happen? Two, how can we
prevent or reduce the number of incidences of veteran suicide in the future? 
Three, how can we aid surviving family members if and when veteran suicide
occurs?

  1. Background

Little did I know
my father’s death on December 17, 2010 was set in motion in 1964.  My father
volunteered for service in Vietnam, and entered the conflict in army security. 
I know very little about his specific activities in the war; as you will hear
later, he did not often speak of these events.  I do know that he provided
bombing coordinates for American offensives and worked in/on special operations.

When my father returned
home in 1970, it was to an unpopular war, a wife, the thought of a soon-to-be
adopted son (me), and no knowledge, instruction or education on benefits or
help from the Department of Defense or the Veterans Administration, aside from
the GI bill.  For years and years, my father suffered with the memories of war
without solace or outlet.  Except for anger. And temper. And smoking. And
alcoholism.  In fact, every night, my father drank between 6-12 beers trying to
drown out his memories.

In 1992, my father
first tried to kill himself, overdosing on prescription drugs.  Luckily for
him, and for my mother, brother and I, he survived.  We did not, however, all
live happily ever after.  Still not realizing the scope of the problem, still
not being aware of potential treatment and support options, and with my father
still not discussing the core of the problem, we made it only four (4) short
years before he once again attempted suicide.  This time, he went into a
program and began seeing a psychiatrist, Timothy C. Smith, M.D.

From 1996 until my
father’s employment with the Veterans Administration in 2003, he treated with
Dr. Smith and never once mentioned his Vietnam service.  Call it denial or call
it guilt – whichever, he was either too proud or too wounded to talk.  I attach
to this record a letter from Dr. Smith outlining his treatment and diagnosis in
2003; I find it instructive as to the depth both of my father’s post traumatic
stress disorder and his efforts to hide it, bury it and deny it.

Once my father began
working in the Philadelphia office of the Veterans Administration, he learned
that he was not alone, as the thought for over 33 years.  He began to speak
with other veterans, learn of the benefits and services available to him, and
realize that help would and could be had.  Of course, work at the VA was a
double-edged sword for my father; while he found a built-in support group, each
and every story from Vietnam, Iraq and Afghanistan worsened his PTSD symptoms. 
But he rallied.

The rally slowly came
to an end as my father’s physical limitations began to catch up with him. 
After several hospitalizations and with a clearly declining mental faculty, my
mother came home on December 17, 2010 to find my father dead from two bullet
wounds.  This fight, many years longer than the one in Vietnam, was over.

  1. How and
    Why Did This Happen?

We will never know for
sure exactly what happened to my father.  The evidence, however, leads to a few
simple conclusions.  One, my father certainly endured the “horrors of war,”
both with regard to his own activities that might have resulted in collateral
damage to the civilian population in Vietnam and seeing his own army-mates die.
 As time went on, the few people he held close from Vietnam also wasted away
and died from illness, some related to the war and some not. Two, upon his
return to the United States, his feelings of guilt and isolation were increased
and ratified.  He came home as an unpopular soldier in an unpopular war.  He
knew little or nothing of potential benefits available to him, other than the
G.I. Bill, which he used to complete his college education at night.  He never
spoke to my mother or anyone else about what he did in Vietnam, where he went or what he saw, internalizing it all and “protecting” us from it.  Three,
once my father began applying for benefits, there were impediments at every
step.  He filed multiple appeals to obtain his 100% disability rating for a
service-connected disability.  He fought for recognition of the ill effects of
Agent Orange.  At every turn, there were obstacles…it was as though he was fighting
another war.

  1. How do we
    Help Reduce the Number of Veterans’ Suicides?

In order to reduce the
number of veteran suicides, the first step is better record-keeping.  We all
know the statistics put out by the Veterans Administration: an Iraq/Afghanistan
veteran kills himself every 80 minutes.  Vietnam-era suicides were once thought
to be in the 50,000-100,000 range, though testimony on the subject from the CDC
and others estimates the number to be approximately 9,000.  On the other hand,
the data points being used in any such studies are old, are based on limited
tracking statistics, fail to account for new understanding of the impact of
Agent Orange, PTSD, and other illnesses, and generally need to be extrapolated
from unreliable data.  We need a better record-keeping system in order to
specifically identify the causes of death among veterans.

The second step
requires a better support group for veterans, whether from the military itself,
the government or both.  Isolation is clearly at the heart of many veterans’
issues, including suicide.  From the weeks just before discharge through the
return home, all efforts should be made to keep the veteran engaged. 
Counseling.  Benefit instruction. Support groups. Even before discharge,
perhaps military cohesion units would be of benefit.  We thrust our military
back into civilian society ill-equipped to deal with the many issues
confronting them: employment, disability, family…how do we possibly expect them
to transition well?

Step three is to ease
the obstacles placed in front of veterans in applying for and receiving their
benefits.  As this Committee is aware, the long-standing view of the process is
one of benevolence and paternalism between the Veterans Administration and the
veterans.  This view, in light of budgetary constraints and more complex
claims, is no longer valid or appropriate.  In terms of disability claims alone
(ignoring, for the moment, any other claims, including surviving spouse claims,
death benefit claims, etc.), the backlog of cases has risen to approximately
756,000 (as of April 2011).  The number of claims over 125 days old totals
approximately 450,000.  Veterans wait an average of six months to receive
entitled benefits.  My mother is nearly one year out from her husband’s death,
and she is still no closer to receiving a decision on her DIC benefits. 
Thankfully, she has social security and life insurance to keep her afloat in
the meantime, a luxury many other widows do not have.

The nightmare does
not end there.  Over 20% of these claims are on appeal Appeals take an average
of 527 days to forward to the initial appellate level (the BVA), with another
274 days for the BVA to process the appeal.  The remand rate of cases going
forward from the BVA to the CAVC approaches an astonishing 80%. 

In an effort to
allow for the earlier intervention of lawyers into the process, Congress passed
The Veterans Benefits, Health Care and Information Technology Act of 2007. 
Interestingly, the Veterans Administration and Disabled American Veterans were
two of the most ardent opposers of this legislation.  Why?  The reasons
are too numerous to count, but the simplistic belief is the veterans’
organizations want to keep control, keeping claims out of the hands of lawyers,
and the Veterans Administration is consistently working at counter-purposes
with its own veterans.  Veterans are entitled to due process, and, frankly, it
is not the reality for most.  More efforts need to be made to appropriately and
fairly evaluate claims in a more efficient and effective manner.

  1. How
    Surviving Families Cope?

As the son of a
man who committed suicide, I can tell you that the questions never go away. 
Why didn’t I see?  What could I have done?  What if I made one more call, or
came by the house one more time?  The last thing survivors need to cope with is
the morass of an outdated, outmoded and unfriendly bureaucracy.

My father had the
benefit of working for the Veterans Administration.  Had he not, I am not sure
I would have been able to get off the ground in terms of identifying proper
benefits.  Death benefits.  DIC.  Funeral benefits.  Life Insurance. TSP.  The
list goes on and on, and each winds up in a different location with different
forms.  Can you image the barriers to those with limited technological access,
little education, and little experience dealing with the government?  Those
with no money get no help from the lawyers either, as fees are not applicable
until the first level of appeal.

The requirements
to receive these benefits can be onerous as well.  The DIC requires, for
example, that a veteran die of a service-related disability for which he was
100% disabled for a period of ten years or longer.  Well, what about the
veteran who commits suicide as the result of PTSD but did not receive his 100%
disability rating until 8 years before his death due to filing 4 appeals?  Is
that system fair to the memory of the injured veteran?  To his family?

  1. Conclusory
    Remarks

Abraham Lincoln, in his
second inaugural address, said: “To care for him who shall have borne the
battle and for his widow and his orphan.”  Our Veterans Administration, our
non-profit support organizations and our government need to do eliminate the
feelings of isolation and abandonment our veterans feel when returning from
service; educating our veterans in the financial, medical and other benefits
available to them; and removing unnecessary and unfair impediments to receipt
of those benefits and the due process due veterans.  While we will likely never
eliminate veteran suicide, a more friendly, more caring process will certainly
go a long way in reducing the increased risk factors.  Thank you.

 


MATERIAL SUBMITTED FOR THE RECORD

Hon. Michael H. Michaud,
Ranking Democratic Member, Subcommittee on Health,
Committee on Veterans' Affairs to Col Carl Castro, Ph.D., Director,
Military Operational Medicine Research Program Research Area Directorate III,
U.S. Army Medical Research & Material Command, U.S. Department of Defense.

December 5, 2011

COL Carl Castro, Ph.D.

Director, Military Operational Medicine Research Program

U.S. Army Medical Research and Material Command, and

Chair, Joint Program Committee for Operational Medicine

U.S. Department of Defense

1400 Defense Pentagon

Washington DC 20301-1400

Dear COL Castro:

In reference to our Subcommittee on Health Committee hearing
entitled “Understanding and Preventing Veteran Suicide” that took place on December
2, 2011, I would appreciate it if you could answer the enclosed hearing
questions by the close of business on Friday, January 20, 2012.

In an effort to reduce printing costs, the Committee on
Veterans’ Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full committee and
subcommittee hearings.  Therefore, it would be appreciated if you could provide
your answers consecutively and single-spaced.  In addition, please restate the
question in its entirety before the answer.

Due to the delay in receiving mail, please provide your
response to Jian Zapata at jian.zapata@mail.house.gov,
and fax your responses to Jian at 202-225-2034.  If you have any questions,
please call 202-225-9756.

                                                          Sincerely,

                                                          Michael
H. Michaud

                                                          Ranking
Democratic Member

Subcommittee on
Health

CW:jz

Questions for the
Record from the

House Committee on
Veterans’ Affairs

Subcommittee on
Health

Hearing on Understanding
and Preventing Veteran Suicide

 

Questions for the Record

 1.     It has
been clearly demonstrated that DoD and VA must work together to address issues
that face both departments, particularly suicide, mental health and substance
abuse treatment.  Given such demonstrated need:   

a.     Please
provide the Committee with a detailed explanation of any joint efforts by both
departments to collect data on suicides or to do a comprehensive study on
suicides.  If there have not been any efforts, please explain the lack of such
efforts.

 2.     What
is being done to address the unique mental health care needs of recently
returning service members?

3.     What
can be done to improve outreach to service members and veterans needing mental
health care services, especially those veterans most at-risk?

4.     What
are your thoughts on the Military Officers Association of America’s
recommendation to:  Require VA-DoD to establish a single strategy and a joint
Suicide Prevention Office that reports directly to the Department Secretaries
through the Senior Oversight Committee (SOC)?

5.     Many of
the experts have stated that early intervention is critical in the prevention
and treatment of mental health conditions such as Post Traumatic Stress
Disorder.  What programs do the Departments have in place to flag, intervene
and monitor at risk service members who are transitioning to VA?  Is there a
“warm hand-off”?

6.    
At the September 9, 2011, House
Committee on Armed Services hearing on suicide prevention programs in the
military, Dr. Jonathan Woodson, Assistant Secretary of Defense for Health
Affairs at DoD, mentioned the DoD/VA Integrated Mental Health Strategy (IMHS)
that they have been working to put in place over the last 10 months. 

a.    
Can you comment further on what
was recommended?  Of the numerous action items outlined in this strategy, what
pieces are still outstanding?

7.     The Maine
National Guard submitted testimony for the record in which they outline their
Resiliency, Risk Reduction and Suicide Prevention Campaign Plan.  What sort of
resiliency training is DoD incorporating in its prevention efforts?

8.     How many
more mental health providers are needed to meet demand?

9.     What
do you need from us to assist you in addressing the mental health issues of
today?

Response from Col Carl Castro,
Ph.D., Director, Military Operational Medicine Research Program Research Area
Directorate III, U.S. Army Medical Research & Material Command, U.S. Department
of Defense, to Hon. Michael H. Michaud, Ranking Democratic Member, Subcommittee
on Health, Committee on Veterans' Affairs.

Member: Congressman
Michaud

Witness: USA COL
Castro

Question: #1

Question:  It has been clearly demonstrated that DoD and VA
must work together to address issues that face both departments, particularly
suicide, mental health and substance abuse treatment. Given such demonstrated
need:a) Please provide the Committee with a detailed explanation of any joint
efforts by both departments to collect data on suicides or to do a
comprehensive study on suicides. If there have not been any efforts, please
explain the lack of such efforts.

Answer:  The DoD and the VA have
been working together for some time to address the issue of suicide prevention,
as well as those associated high risk behaviors that surround both fatal and
non-fatal suicide events.  The DoD and VA currently share data in multiple
instances.  In particular, the DoD/VA Suicide Nomenclature and Data Working
Group has developed an action plan to create a joint DoD/VA Suicide Data
Repository that will merge existing data from multiple sources to create common
identifiers and data elements, fill gaps in knowledge, identify common risk
factors, and present a longitudinal view across the active and veteran
populations.  This effort will result in a single source for all suicide events
and self-directed violence across the Departments as well as help inform
programs and policies related to suicide prevention in the future.  

Question: #2

Question:  What is being done to address the unique mental
health care needs of recently returning service members?

Answer:  The Department of Defense
(DoD) has revised its deployment mental health assessment process to provide
comprehensive person-to-person mental health assessments at pre-deployment and
within 6 months, 1 year, and 2 years after return from deployment.  These
procedures comply with requirements in the National Defense Authorization Act (NDAA)
for Fiscal Year 2012 (Section 702).  The three post-deployment mental health
assessments must be performed either by licensed mental health professionals or
by designated personnel trained and certified to perform the assessments. 
These mental health assessments include an analysis of self-reported responses
to mental health questions on symptoms of depression, posttraumatic stress
disorder (PTSD), and alcohol misuse; detailed follow-up on positive responses
to previous mental health diagnoses and medication use; and exploration of other
reported emotional, life stress, or mental health concerns.  During a
confidential dialog with the Service member, the provider would conduct an
assessment of the risk for suicide or violence, offer education on relevant
mental health topics, administer brief interventions, and make recommendations
for follow-up assessment and care, when indicated.

After
returning home from deployment, help for any mental health issues, including
depression and PTSD, is available through the Military Health System for active
duty and retired Service members, or through the Department of Veterans Affairs
(VA) for non-retired veterans.  Active duty, National Guard, and Reserve
Service members who separate and who served in support of a contingency
operation are eligible for TRICARE’s Transitional Assistance Management Program
(TAMP), which provides health benefits for 180-days to assist Service members
and their families with the transition to civilian life.  Partnerships with the
VA exist, such as the Recovery Coordination Program, where Recovery Care
Coordinators assist with Service member transition from DoD to VA care,
treatment, and rehabilitation.  The DoD inTransition programis
a free, voluntary, and confidential coaching and assistance program that provides a bridge of support for Service members while
they are transitioning between healthcare systems or providers. 

Each
Service has a comprehensive program to address the reintegration needs of
wounded, ill, and injured Service members, including the Army
Wounded Warrior Program, the Marine Wounded Warrior Regiment, Navy’s Safe Harbor Program, and the Air Force Wounded Warrior
Program.  Across DoD, the Military Family Life Consultants program helps
prevent family distress by providing education and information on family
dynamics, parent education, available support services, and the effects of
stress and positive coping mechanisms.  Military OneSource has counselors
standing ready 24/7 by phone and email and are available for

face-to-face counseling.  The DoD Yellow Ribbon Reintegration Program was
established to address the needs of National Guard and Reserve Service members
and their families by facilitating access to support and reintegration
services.  The Defense Centers of Excellence for Psychological Health and
Traumatic Brain Injury (DCoE) has a number of education and outreach programs,
to include DCoE’s Outreach Center, “24/7 Help,” which provides information and
resources on psychological health and traumatic brain injury, and the
Afterdeployment.org Web site that assists Service members and their families in
managing

post-deployment challenges. 

The Services have each developed garrison and training
programs to mitigate the effects of combat-related stress.  The Army
implemented the Comprehensive Soldier Fitness Program Army-wide; the Air Force
uses the Landing Gear program; the Navy has an Operational Stress Control
program; and, the Marine Corps uses a program called Operational Stress Control
and Readiness, or “OSCAR.”  Each of these programs seeks to prepare Service
members to better cope with combat and deployment stress before, during, and
after deployment.  On a more holistic level, the Office of the Chairman of the
Joint Chiefs of Staff has promoted the Total Force Fitness model to address the
need for a synchronized, DoD-wide approach to strengthen resilience and
maintain optimal military force readiness.  This model advocates that leadership
at all levels of DoD take steps to strengthen the comprehensive health of Service
members across eight domains (Behavioral, Social, Physical, Environmental,
Medical, Spiritual, Nutritional, and Psychological) and to subsequently
establish holistic fitness programs within their commands and organizations.

Question: #3

Question:  What can be done to improve outreach to service
members and veterans needing mental health care services, especially those
veterans most at-risk?

Answer:  :  In order to facilitate early identification of
and referral for mental health concerns, DoD employs a robust, prospective,
person-to person mental health surveillance program.  VA and DoD are jointly
reviewing mental health screening policies and procedures with the end goal of
tracking and optimizing follow-up on positive screens for posttraumatic stress
disorder (PTSD),  suicidal and homicidal ideation, alcohol abuse and
dependence, and depression.  Enhanced case management and follow-on support of
Service members will serve to eliminate gaps in care between DoD and civilian
medical facilities. 

In addition, DoD provides many outreach and early
intervention programs to ensure continuity of care, to raise awareness among
Service members, to train civilians treating Service members, and to increase
leadership involvement in behavioral health efforts.  Examples of these
programs include:

  • inTransition: A voluntary program supporting Service
    members moving between health care systems or providers while receiving
    behavioral health care.  inTransition offers information, non-medical
    counseling, education, and advice services for eligible beneficiaries,
    encouraging them to make use of available behavioral health services.  The
    program employs a “warm hand-off” technique in referring and following up
    with Service members and Veterans. 
  • Yellow Ribbon Reintegration Program (YRRP) is a program
    that assists Guard and Reserve Service members and their families to
    connect with local resources before, during, and after deployments, especially
    during the reintegration phase.  Yellow Ribbon events (the Returning
    Warrior Workshops developed by the Navy Reserve) typically take place in
    non-military venues.  Local VA facilities have a strong presence at these
    events, often enrolling Service members in VA health care and scheduling
    appointments when needed.
  • The Real Warriors Campaign (www.realwarriors.net)
    is a public education campaign that reinforces the notion that seeking
    help is a sign of strength.  It was launched by DCoE to combat stigma related to seeking mental health
    treatment in the military.
  • Afterdeployment.org (www.afterdeployment.org)
    was developed by DCoE, with an emphasis on 'normalizing' post-deployment
    adjustment problems, and encouraging help-seeking behavior among service
    members and veterans with invisible wounds. 
  • VA launched a mental health outreach campaign called Make
    the Connection (www.MakeTheConnection.net)
    which was designed to increase awareness and trust in VA’s mental health
    services and aims to reduce stigma about seeking mental health services. 
  • VA’s Readjustment Counseling Service (RCS) Mobile Vet
    Center program is another initiative to help meet this commitment.  As a
    successful, long-running behavioral health support program, Mobile Vet
    Centers provided outreach and readjustment counseling services at 1,800
    events in FY2010 and 3,600 events in FY2011.  The events were national,
    State, or locally organized events, including demobilization events for
    Active duty service members.  DOD and VA are working together to expand
    the program to increase the mental health services available to service
    members and Veterans, especially those in rural areas.  RCS put an
    additional 20 Mobile Vet Centers (MVCs) into service.

A recently completed Report to Congress entitled “A Study of
Treatment of Active and Reserve Components for Post-Traumatic Stress Disorder”
noted several areas where outreach for Service members can be further
strengthened, including:

·        Expanding existing programs that provide for early identification
and treatment, such as the Re-Engineering Healthcare In Primary Care Program
(REHIP) which enables DoD primary care providers to screen and treat
health-seeking patients in primary care clinics for PTSD, suicidal ideation,
and depression while integrating behavioral health care providers into routine
medical care. 

·       
Embed mental health providers into line units alongside leadersto facilitate communication between line leaders and PH resources.

·       
Increase awareness, via targeted outreach, about the impact of
mental health diagnoses on one’s career.  Barriers to seeking treatment
may be reduced by educating Service members that a mental health diagnosis does
not always equate to medical retirement or separation from the military.

Finally,to advance the integration of mental health services
into primary care, DOD and VA held a joint conference titled, "Behavioral
Health/Mental Health Services Roll Out in the Medical Home: Clinical, Administrative
and Implementation Priorities and Best Practices." The conference brought
together 305 clinical, administrative and research leaders from VA and DOD
facilities across the country to share lessons learned and to encourage growth
of integrated care services in the VA and DOD.

Question: #4

Question:  What are your thoughts on the Military Officers
Association of America's recommendation to: Require VA-DoD to establish a
single strategy and a joint Suicide Prevention Office that reports directly to the
Department Secretaries through the Senior Oversight Committee (SOC)?

Answer:  We agree that the DoD
and VA need to work closely together to address the suicide issue, and have
already organized to meet that goal.  The DoD and the VA have been working together
for some time to address the issue of suicide prevention, as well as those
associated high risk behaviors that surround both fatal and non-fatal suicide
events.  The DoD established a Defense Suicide Prevention Office (DSPO) to
serve as a focal point for collaboration with the VA and provide oversight for
the strategic development, implementation, standardization, and evaluation of
DoD suicide programs, policies, surveillance activities.  The DSPO will also
have a full time VA liaison staff member embedded with the DoD team to assist
in identifying and addressing high risk transition population issues. 

For example, the DoD and VA
currently share data in multiple instances.  In particular, the DoD/VA Suicide
Nomenclature and Data Working Group has developed an action plan to create a
joint DoD/VA Suicide Data Repository that will merge existing data from
multiple sources to create common identifiers and data elements, fill gaps in
knowledge, identify common risk factors, and present a longitudinal view across
the active and veteran populations.  This effort has been briefed to the Senior
Oversight Committee and its associated subcommittees.  The objective is to
provide a single source for all suicide events and self-directed violence
across the Departments as well as help inform programs and policies related to
suicide prevention in the future. 

Question: #5

Question:  Many of the experts have stated that early
intervention is critical in the prevention and treatment of mental health
conditions such as Post Traumatic Stress Disorder. What programs do the
Departments have in place to flag, intervene arid monitor at risk service
members who are transitioning to VA? Is there a "warm hand-off'?

Answer:  In order to facilitate early identification of and
referral for mental health concerns, the Department of Defense (DoD) employs a
robust, prospective, person-to person mental health surveillance program.  Mandatory
mental health assessments are conducted before deployment (Pre-Deployment
Health Assessment or Pre-DHA), and after deployment (Post Deployment Health
Assessment or PDHA; Post Deployment Health Reassessment or PDHRA; and one- and
two-years post-deployment as part of the Periodic Health Assessment or PHA).  The
Department of Veterans Affairs (VA) and DoD is jointly reviewing mental health
screening policies and procedures, including the PDHA/PDHRA/PHA, with the end
goal of tracking and optimizing follow-up on positive findings.

DoD provides many outreach and early intervention programs
to ensure continuity of care, to raise awareness among Service members, to
train civilians treating Service members, and to increase leadership
involvement in behavioral health efforts.  These programs include:

·        
inTransition:
Managed by the Defense Centers of Excellence (DCoE) for Psychological Health
and Traumatic Brain Injury, inTransition is a voluntary program supporting
Service members moving between health care systems or providers while receiving
behavioral health care.  The program employs a “warm hand-off” technique in
referring and following up with Service members and Veterans.  Additional
Information can be found at:(http://www.health.mil/InTransition/default.aspx). 

·        
Yellow Ribbon Reintegration Program
(YRRP):Another significant DoD/VA outreach and prevention program is
the YRRP.  The YRRP is a program that assists Guard and Reserve Service members
and their families to connect with local resources before, during, and after
deployments, especially during the reintegration phase.  Yellow Ribbon events
(the Returning Warrior Workshops developed by the Navy Reserve) typically take
place in non-military venues.  Local VA facilities have a strong presence at
these events, often enrolling Service members in VA health care and scheduling
appointments when needed.

·        
VA Suicide Hotline:Veterans Crisis Line
(started July 2007) and Chat Service (started July 2009) are intended to reach
out to all Veterans and Service members, whether they are enrolled in VA health
care or not.  The Crisis Line is staffed with mental health professionals and
support staff to provide 24-hours services.  After receiving a call, the
responder conducts a phone interview to assess psychological condition.  The
responder then determines whether the call is emergent, urgent, routine, or
informational.  Calls requiring emergency services necessitate keeping the
caller safe; urgent care requires same day services at a local VA facility; and
routine calls require a consultation by the local Suicide Prevention
Coordinator (SPC).  The online version of the Crisis Line, the Veterans Chat
Service, enables Veterans, Service members, family members and friends to chat
anonymously with a trained VA counselor.  If the counselor determines there is
an emergent need, the counselor can take immediate steps to transfer the
visitor to the Crisis Line, where further counseling and referral services can
be provided and crisis intervention steps can be taken.  

Question: #6

Question:  At the September 9,2011, House Committee on Armed
Services hearing on suicide prevention programs in the military, Dr. Jonathan
Woodson, Assistant Secretary of Defense for Health Affairs at DoD, mentioned
the DoD/VA Integrated Mental Health Strategy (IMHS) that they have been working
to put in place over the last 10 months.a) Can you comment further on what was
recommended? Of the numerous action items outlined in this strategy, what
pieces are still outstanding?

Answer:  An important activity within the DoD/VA Integrated
Mental Health Strategy (IMHS) focuses on exploring methods to disseminate
knowledge of suicide risk and prevention practices through prevention programs,
coordinated training and collaboration with entities outside of DoD and VA.

The following activities have been completed thus far:

·   To assist in
the dissemination of suicide prevention practices, programs, and tools, the DoD
Suicide Prevention and Risk Reduction Committee (SPARRC) website <www.suicideoutreach.org/sparrc>was launched
in October 2010. The website streamlines suicide prevention resources for easy
access to a clearinghouse of information. It serves as a comprehensive resource
with access to hotlines, treatments, programs, forums and multimedia tools
designed to support all Service members, Veterans, families and health
professionals. Additionally, the website includes links to Service-specific
suicide prevention resources, as well as reliable and accurate information on a
range of suicide prevention related topics.

·   The 2011 DoD/VA
Annual Suicide Prevention Conference was held in Boston, Massachusetts on March
13-17, 2011. The theme of this conference was "All the Way Home:
Preventing Suicide among Service Members and Veterans." The conference
provided an opportunity to disseminate practical tools and innovative research
in the area of suicide. In addition, it educated representatives from across
DoD and VA on the current practices and studies related to suicide prevention.
Four tracks were offered to focus on practical applications and innovations:
clinical, multi-disciplinary, family/peer to peer, and research. 

The 2012 DoD/VA Annual Suicide
Prevention Conference will be held in Washington DC on June 20-22, 2012. The
theme of this conference will be "Back to Basics: Enhancing the Well-Being
for our Service Members, Veterans, and their Families". Three tracks will
be offered: clinical, research, and practical applications.

Suicide prevention related activities that are in progress
include:

·   Dissemination
of a toolkit intended to provide DoD/VA program managers with the tools to
empower family members to play a more significant role in the DoD/VA suicide
prevention effort.  The toolkit includes an inventory and evaluation of current
suicide prevention communications to families, and highlights key programs that
are effective in providing information to this target audience. It also
provides a variety of approaches for DoD, the Services, and VA to optimize the
communication to families of Service members and Veterans about the warning
signs of suicidal behavior and the range of resources families have at their
disposal to obtain the help they need.

·   Data will be
collected in February and March 2012 to inventory and review National Guard and
Reserve suicide prevention, intervention, and post-vention programs. The data
will be used to populate a resiliency and prevention program database intended
to avoid duplication of effort, permit ease of reporting to leadership and
facilitate their expanded implementation should that be indicated.

Question: #7

Question:  The Maine National Guard submitted testimony for
the record in which they outline their Resiliency, Risk Reduction and Suicide
Prevention Campaign Plan. What sort of resiliency training is DoD incorporating
in its prevention efforts?

Answer:  The Chairman of the Joint Chiefs of Staff has
issued guidance that institutes “The Total Force Fitness (TFF)” framework as
the over-arching DoD wellness and resiliency training model. The TFF framework
is the methodology for understanding, assessing, and maintaining the fitness of
the Armed Forces. The TFF framework consists of eight domains and five guiding
tenets.  The TFF domains include Physical, Environmental, Medical and Dental Fitness,
Nutritional, Spiritual, Psychological, Behavioral and Social Fitness. The
tenets include the belief that fitness should strengthen resilience in
families, communities and organizations. The TFF framework and its tenets are
designed to keep Service members resilient and flourishing in the current
environment of sustained deployment and combat operations as serves as a basis
for resiliency training across the Department.

Resiliency training currently includes the Army's Comprehensive
Soldier Fitness (CSF) Program, the Navy's Total Family Fitness and the Combat
Operational Stress Program, the Air Force’s Total Airman Comprehensive Fitness
Program, and the Army National Guard Resiliency, Risk Reduction and Suicide
Prevention (R3SP) program.  The Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury (DCoE) has also played an active role in
shaping the Department’s suicide prevention and resiliency training efforts,
and holds a yearly Warrior Resilience Conference targeted for the senior NCO
cadre. 

Question: #8

Question:  How many more mental health providers are needed
to meet demand?

Answer:  The Military Health System (MHS) Chief Human
Capital Office has established a methodology to determine the gap differential
in Mental Health Provider staffing. This methodology establishes a standardized
means of comparing the differences between the manpower positions authorized
and assigned (positions filled) in occupations which include:  Psychologists,
psychiatrists, social workers, mental health nurses, mental health nurse
practitioners, tech/counselors, and other mental health providers.

Within the DoD, we review the status on a quarterly basis
and this review includes Army, Navy, Air Force, and JTF-CAPMED military,
civilian, and contractors staffing. The latest update which reflects status as
of 4Q11 (as of September 30, 2011) is shown.   Our gap is determined by
comparing the authorized numbers with the assigned numbers. The Services then
develop an action plan to close the gap.

MHS -WIDE

Needs

Assigned

Percent filled

Psychologist

1726.5

2063

119.5%

Psychiatrist

823.5

771

93.6%

Social Worker

2547

2349

92.2%

Mental Health Nurse

600

618

103.0%

Mental Health Nurse Practitioner

92

59

64.1%

Other Licensed MH Provider

59

64.5

109.3%

Tech/Counselor

3372

2959

87.8%

Total

9220

8884

96.3%

Within the MHS, a three year review of mental health
provider staffing reveals a 34.8 % increase from FY09 through FY11. We
anticipate a growing need for additional mental health provider staffing due to
emerging requirements.

2009

2010

2011

Psychologist

      1,520

      1,815

     2,063

Psychiatrist

        652

        758

        771

Social Worker

      1,789

      2,082

     2,349

Nursing (including NP)

        570

        580

        677

Other Licensed MH Provider

          97

          66

          65

Tech Counselor

      1,962

      2,199

     2,959

GRAND TOTAL

      6,590

      7,500

     8,884

 

From FY09 through FY11 +34.8% increase

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Whether more authorized mental health billets are needed to
meet demand can only be answered by each military Service.  As they make those
decisions, the Services have access to the Psychological Health Risk-Adjusted
Model for Staffing (PHRAMS), an application developed to forecast psychological
health staffing requirements/needs in the Military Health System.

The PHRAMS application and user guide were first released to
the Services in January 2010 for use in planning for future psychological
health staffing needs.  Updates to PHRAMS have been ongoing, with version 4
estimated for release to the Services in August 2012.

July 2010, GAO Report 10-696 “Enhanced Collaboration and
Process Improvements Needed for Determining Military Treatment Facility Medical
Personnel Requirements” cited PHRAMS as representing “the culmination of a
collaborative manpower requirements effort to develop a standardized, more
consistent approach across the Services for determining mental health personnel
requirements.”  The report also stated “Key organizational issues, like
strategic workforce planning, are most likely to succeed if, at their outset,
top program and human capital leaders set the direction, pace, and tone and
provide a clear, consistent rationale for the transformation.

Question: #9

Question:  What do you need from us to assist you in
addressing the mental health issues of today?

Answer:  Recent advances in the study of suicide and its
treatment in Veterans and Active Duty Service members, which stem from the
assiduous support of Congress and the American people, may herald a turning
point in the management of this longstanding public health problem.  The
assistance of the House Veterans Affairs Committee has been instrumental in
this effort.  Ongoing attention to this matter will be essential to maintaining
the momentum our labors have fostered to date.

We are learning that military members represent a unique
cohort with respect to suicide.  Military suicide rates have been far more
variable than age-adjusted civilian rates.  On balance, military rates have
been consistently lower than civilian rates since collection of these data was
initiated.   This regular finding was attributed to a “warrior effect,” that
embraces discipline, fidelity to peers, resilience, rigorous accession
standards, and pursuit of an honorable mission.  However, the excursions of
Army suicides to rates above the civilian rate, and military suicides exceeding
combat deaths, raise important questions for military and civilian leaders.

Editorials by well-regarded researchers in top psychiatric
publications, including the Journal of the American Psychiatric Association and
the Journal of the American Academy of Child and Adolescent Psychiatry, express
a view that suicide may be the next public health menace needing to be
systematically categorized and managed.  Leaders in many fields have come to
realize that suicide is a multifactorial problem that cuts across disciplines. 
Optimization of personnel policy, attunement to unit cohesion, resilience and
personal accountability for behavior, intrepid leadership, and focused
evidence-based medical interventions, based on real-time data, will all be part
of a solution. 

The fruits of our initial data collection will enlighten our
intervention programs to prevent suicide.    DoD/VA efforts, which have been
fostered by the abiding support of your committee, are leading the way on
research fronts.  The DoD’s Military Suicide Prevention Research Program ($110
million investment since 2008), Army Study to Assess Risk and Resilience ($50
million from Army and $15 Million from NIMH) have already added to an
exponentially growing body of knowledge in suicidology.

Ongoing DoD/VA efforts in suicide research and treatment,
which will include validated suicide screening and assessment tools and
treatments that can be shown to save lives, will be vital to consolidating our
nascent gains.  Answers will not be simple, nor will they be related to a
stunning innovation.  However, DoD will continue to seek a measured and
multidisciplinary solution, which should be defined as a sustained decrease in
current rates to a level well below the civilian norms.