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Submission For The Record 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.