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Submission For The Record of American Foundation for Suicide Prevention

Chairman Miller, 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 mental health care provided to veteran patients – particularly those who are at high-risk of suicide – through the Department of Veterans Affairs (VA) health care system.  My name is John Madigan and I am AFSP’s Vice President of Public Policy.

AFSP is the nation’s leading organization bringing together people across communities and backgrounds to understand and prevent suicide, and to help heal the pain it causes. Individuals, families, and communities who have been personally touched by suicide are the moving force behind everything we do. You can learn more by visiting www.afsp.org.

  • We strive for a world that is free of suicide.
  • We support research, because understanding the causes of suicide is vital to saving lives.
  • We educate others in order to foster understanding and inspire action.
  • We offer a caring community to those who have lost someone they love to suicide, or who are struggling with thoughts of suicide themselves.
  • We advocate to ensure that federal, state, and local governments do all they can to prevent suicide, and to support and care for those at risk.

Most, if not all suicide deaths are preventable. Suicide in America today, especially among our nation’s veterans, is major public health concern. It is estimated that approximately 22% of the 39,518 deaths by suicide in 2011 (latest available data) were completed by veterans; and, according to the 2012 VA Suicide Data Report, an average of 22 veterans die by suicide each day.

While AFSP appreciates the efforts of VA to better meet the mental health needs of veterans, particularly OEF/OIF veterans, and applaud the delivery of world class health care in many instances, we believe that VA must take further steps to ensure that veterans have timely access to the care that they have earned and deserve. Simply stated, many of our veterans are being put in greater risk of suicide while enduring unacceptably long wait times for appointments with VA mental health services.

Suicide is the result of unrecognized and untreated mental illness.  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. Suicide prevention requires a proactive approach to identify veterans who may need immediate help by understanding the risk factors and warning signs of suicide and by knowing what immediate and short term protective actions one should take.

Suicide risk factors for veterans mirror those for society in general. Often, undiagnosed mental illness such as depression or bipolar disorder and alcohol and drug dependence are major risk factors for suicide. Post-Traumatic Stress (PTS) and Traumatic Brain Injury (TBI) may compound underlying risk factors along with environmental stressors such as transition from military life, job loss, relationship issues and financial or legal problems. Other risk factors may also include the history of a past suicide attempt and a family history of suicide or suicide attempts.

Suicide risk tends to be highest when multiple factors are present in an individual with a mental illness and the most important interventions are recognizing and treating these disorders. 

If a veteran has one or more of the risk factors highlighted above, the key to preventing suicide is recognizing the warning signs of suicide such as:

  • Talking or writing about death or a wish to be dead;
  • Expressing hopelessness, feeling humiliated, trapped or desperate;
  • Losing interest in regular activities or losing the ability to experience pleasure;
  • Experiencing insomnia, intense anxiety or panic attacks;
  • Being in a state of extreme agitation or intoxication;
  • Becoming socially isolated and withdrawing from loved ones; and,
  • Looking for a way to hurt or kill oneself such as hoarding medicine, purchasing a new firearm, or searching online for suicide methods.

Whether a veteran is in immediate crisis or is just looking for help, immediate protective actions should be taken that include:

  • Not leaving the veteran alone and removing any lethal means for suicide (firearms, sharp objects, prescription drugs, and over-the-counter medicines);
  • Encouraging an open conversation about symptoms and problems with a physician or mental health provider;
  • Finding and delivering effective clinical care for mental and physical health, and seek treatment for problems with alcohol or drugs; and,
  • Providing support through the recovery process, especially during the initial period when medications and treatment plans may need fine-tuning to work.

In medicine, acute care for a critical event is standardized and delivered urgently, centered on the patient. Thus a patient with an acute cardiac event, a stroke, or involved in a serious accident, all receive immediate care, typically following a protocol derived from scientific studies and best practices. These same principles must also be applied to mental health care delivery for our nation’s veterans.

If a veteran exhibits the warning signs and have risk factors of suicide, they need to be given immediate care. If a veteran comes forward with the strength showing they are ready to receive care, they need to be able to access mental health services in a timely manner.

The need is evidenced in the 2012 VA Suicide Data Report. Figure 12 shows that among those at risk, the first four weeks following service require intensive monitoring and case management.

Figure 12 clearly demonstrates that the majority (80%) of non-fatal events occur within four weeks of receiving VHA services. An additional 10% of events occur in the second month following last VHA service visit. These findings have important implications for treatment and prevention efforts as the majority of those with report of a suicide event are active, recent VHA users. (pg. 32)

The report also showed data that showed primary care should be an integral part of suicide prevention programs.

Furthermore, nearly 50% of the individuals with a VHA service visit in the year preceding the suicide event were last seen in the outpatient primary care setting (Figure 13). This implies that primary care should be an integral component of VHA suicide prevention programs and primary care clinicians should continue to receive support and training on the identification and management of those experiencing distress.

Another 40% of those with report of one or more 33 suicide events were last seen for mental health services indicating a need for continued assessment and risk management following use of VHA services among those with known risk factors (i.e. mental health diagnosis). (pgs. 32-33)

AFSP asks Congress to consider legislative and policy proposals that will further the VA’s current efforts to prevent suicide among our nation’s veterans:

  • Funding the VA at the highest levels possible to ensure the delivery of timely, high-quality mental health care and crisis services including the Veterans Crisis Line;
  • Supporting efforts of an interoperable medical record between DoD and VA. The lack of coordinated care impairs the VA's ability to identify and respond to individuals who were high risk of suicide in the service while in the Service; and,
  • Addressing the critical shortage of mental health providers within the VA by recruiting and retaining mental health providers through bonuses, incentives and student loan reimbursement programs that would pay a portion of a provider’s loan debt for every year of service.

Chairman Miller and Ranking Member Michaud, the bottom line is delayed appointments for those seeking mental health treatment carry greater risk for suicide. If a veteran is in immediate crisis they must be referred to and receive help immediately, and, if they request an appointment for mental health services they should be seen as soon as possible and certainly within the 14-day window currently required by the VA.

The American Foundation for Suicide Prevention thanks you again for the opportunity to provide this written statement for the record and looks forward to working with the Committee and the VA to prevent suicide among our nation’s veterans.