Mr. Chairman, Ranking Member, and members of the subcommittee, I thank you for the opportunity to share my views and concerns on the very important issue of the VA's national suicide prevention outreach efforts, which are based on the reported success of a pilot program that encouraged veterans at-risk for suicide to call the VA suicide hotline. 

I have several concerns about the current suicide prevention outreach efforts:

1. that it is being called a success when there is little evidence of that,
2. that it is a non-evidenced-based strategy, and
3. that it intervenes with the problem of suicide at the moment of crisis rather than providing a more proactive and systematic approach.  

I will first address each of these in turn.  Following that, I will present a number of suggestions for alternative strategies:

1. Make VA enrollment automatic and universal
2. Integrate and coordinate DoD and VA their health care transition
3. Hire more mental health care providers
4. Give the VA a budget that will not require outsourcing of services
5. Reinstitute VA counseling for incarcerated veterans 
6. Establish Veterans Programs in the nation's prisons
7. Support Community Living projects like Valley Forge Village and most importantly,
8.  Establish more Vet Centers

1. My first concern is that the stated purpose of these hearings is based on the assumption that the pilot suicide hotline program was a success. 

In 2008, Lisette Mondello, Assistant Secretary for Public and Intergovernmental Affairs for the VA, reported to this committee that the pilot program, a televised public service announcement and posters placed on area trains and buses encouraging veterans considering suicide to call the VA's suicide hotline, had produced a 50 to 100 percent increase in calls from the area where the advertising ran.[1] 

The 50 to 100 percent increase may sound substantial, but it actually refers to only eight more calls a week in the D.C. area, nine more in Northern Virginia, and 17 more in Maryland.  And there is no indication that even those small numbers are indicative of success.  For one thing, Assistant Secretary Mondello's statement fails to acknowledge that calls to the VA's hotline more than doubled in the first six months of 2008 nationwide, independent of the Washington metro ad campaign.[2]  Second, rather than a measure of the pilot's success, that increase in calls can also be interpreted as a warning that failures of our military and veterans' mental health care systems were leaving increasing numbers of the men and women who so desperately need them on the brink of crisis.  Thus, my first concern is whether this program should in fact be considered successful.  In other words, is it working? 

2. That there is no viable data to suggest that it is brings me to my second concern:  that this is not an evidence-based strategy.

In the fall of 2008, the VA's blue ribbon panel of experts recommended that the VA "apply evidence-based research" in their intervention efforts.  In January 2009, VA's Health Services Research and Development Service (HSR&D) published a pamphlet called "Strategies for Suicide Prevention in Veterans" in which the authors state categorically that they "found no studies that assessed the specific effectiveness of any hotlines."[3]  The peer review comments (Appendix D[4]) specifically chide the VA for withholding data describing the impact of their national suicide prevention hotline. 

In April 2010, Dr. Janet Kemp, the national suicide-prevention coordinator for the VA, proudly told the American Forces Press Service that the advertising campaign, now in 124 cities nationwide, had increased the hotline call volume to about 10,000 calls a month, or about 25 percent in two years.  

But she offered no information about who is calling, what era and branch of service they represent, how many of those callers have attempted suicide in the past, what kind of follow-up procedures are in place, how many of the callers are already enrolled in the VA system, how many are re-routed to back-up call centers, and nothing to back up her claim that the calls to the hotline were responsible for stopping 7000 in-process suicides.

Instead of data, Dr. Kemp offered an anecdote about a veteran who was in the process of writing a suicide note when he happened to notice a poster with the hotline number on it and placed the call.  "He's now alive and well and telling his story of success."[5]

This is not evidence-based intervention. 

In June of 2010, doctors from the Los Angeles VA and the RAND Corp. did a systematic review of suicide prevention programs developed for military and veterans world wide.  This program is not listed among them.  The review found that all of the programs developed for the military reported declines in suicides and suicide attempts, but all were so badly designed, so inadequately documented and the data so poorly analyzed that "it was not possible to infer causality from the reported associations."   And they found no studies focusing on veterans.  Their conclusion that "(t)here is an urgent need for continued research in this area" seems restrained.[6]    

These hearings are evidence that the VA is still asking Congress to take this program seriously, yet in two years they have produced nothing to back up their claim that what they are doing is working.  In fact, there is no way to distinguish between those callers who have been driven to their limits by service-related injuries and those who have been driven to their limits by the failure of the VA to deliver the care and support that are so desperately needed.

While there is a lack of convincing evidence that the hotline has been successful as an suicide intervention strategy, there is no lack of evidence that it has not.  Military suicides have continued to rise across all branches of service:  in 2009, the suicide rate in the Marine Corps was 24-per-100,000; it was 23 in the Army; 15.5 in the Air Force;  and 13.3 in Navy, all, by the way, higher than in 2008[7] and all significantly higher than the civilian suicide rate which has held steady at 11.1 for some years.[8]   The VA acknowledges that 18 veterans take their lives every day, the same number the VA accepted in 2007 when confronted with the CBS investigation.[9] That is 6570 veteran suicides a year, or almost 60,000 in the nine years since these wars began.[10] 

ch) My final concern with the hotline program is its centrality to the VA's suicide prevention efforts. I take no issue with a hotline, only with the suggestion that it is anything more than an eleventh-hour prayer.  Rather than waiting until veterans are at the edge of the precipice and relying on haphazard message to pull them back, the VA should be focusing their attention on evidence-based interventions, interventions with documented histories of success.

In 2008, when the pilot was announced, CBS News quoted David Rudd, a former army psychologist, warning that after the posters and the public service ads have directed veterans to turn to the VA for help, the VA had best be prepared to deliver.  Specifically, they had best reduce delays and provide the services that will keep veterans in care.  "Those are the things we know reduce death rates.”[11]

A 2008 RAND Corporation report warned that fully a third of returning veterans were suffering from posttraumatic stress injuries.[12]  In 2008, that was 300,000 troops.  In 2010, over 2 million troops have been deployed in Iraq and Afghanistan, and a third is just shy of 700,000, a number that continues to grow.[13]  The magnitude of that crisis requires a response of commensurate magnitude.  A hotline doesn't belong at the top of the list.  

In that vein, the following are offered as an incomplete list of suggestions for evidence-based interventions that prioritize prevention rather than crisis management, and avoid raising hopes and expectations that will not be met.  Perhaps even more to the point, invest in programs that offer the hope of dignity and independence.   

1. Make VA enrollment automatic and universal.

In 2008, Congressman Harry Mitchell, who has been instrumental in pushing the VA to improve its suicide outreach, told CBS News, "We can't just wait for veterans to come to us, we need to bring the VA to our veterans."[14]  The VA should take him at his word.  When service members are being processed out of the military, when they are cut loose and sent home, the VA should be sitting in the room signing them up, simply and automatically. 

Posttraumatic stress injuries are unique among anxiety disorders in that they are significantly associated with suicide, suicidal ideation and attempts.[15]  If suicide prevention is the issue, it is surely counter productive to make access to support and services dauntingly complicated and selectively exclusive.  Especially if betrayal of expectations and frustration with what are perceived to be gratuitously forbidding procedures are going to exacerbate their posttraumatic stress symptoms and make disaster more likely. 

It is also well understood that the stigma associated with mental health issues prevents those who need it most from asking for help.  Especially with new veterans, the VA should take advantage of the anonymity of universality.  If everybody does it, nobody is exposed.  

Contrary to popular belief, currently, only about 20 percent of all of America's veterans are enrolled in the VA and make use of their health care services.  Far too many are excluded, far too many are daunted and overwhelmed, and far too many need help with the process.  The VA has recently been pointing out that if there is any cause for optimism in the recent suicide data it is that it appears that veterans using VA health care seem increasingly less likely to take their own lives than those who did not.[16][17]

So make it accessible.  Make enrollment simple and automatic and universal.  The new rules streamlining the process for filing disability claims is a long overdue improvement, but already the posturers are lining up wagging fingers and tongues about how veterans are gaming the system and taking advantage of easy handouts.[18] There will be Fraud! There will be Malingering! There will be Chronic Dependency! And there will be Budget Deficits!

Shame on their selective memories.  It has only been five years since the VA was directed to review the claims files of the 72,000 most fragile, most vulnerable (most expensive to maintain) veterans, those with 100 percent disability ratings for posttraumatic stress.  After a review of a sample 2100 of those files, a review that was so stressful that one veteran was driven to suicide, the Inspector General's report found not a single case of fraud on the part of a veteran.  What it did find was an administrative mess.  Then-Secretary Nicholson called off the review and promised to improve VA employee claims handling and administrative oversight.[19]

When there is real fraud at the VA, it is almost always at the top and very expensive, not just in dollars, but in lives.[20]   And though the VA declined to be the object of a lawsuit in 2007, it was not because they were innocent of the charges leveled against them, but because of a legal technicality that prevented the lawsuit from proceeding.[21]

And as to budget deficits, the RAND Corporation estimates the costs of the psychological and neurological injuries suffered by Iraq and Afghanistan veterans at between $4 and $6.2 billion, just in the first two years after combat. Providing proper evidence-based care for all of these veterans would lower that cost to society by about 27 percent.[22] 

2. Integrate and coordinate DoD and VA their health care transition.

There is no logical or moral justification for the chasm that is allowed to exist between the two agencies—only an apparently territorial one and the ubiquitous financial one.  Both agencies are confronting the same terrible problem with suicide, and their attempts at intervention have produced the same disappointing results.  There will be fewer suicides, on whichever side of the tally sheet they are finally counted, if soldiers and veterans who are at-risk for suicide aren't allowed to get lost in the system—or worse, to it.  

If the DoD wanted enlisted men and women to know about the programs that will be available to them after they leave the service, they have a captive audience.  Veterans who left the service years ago and veterans who left months ago tell the same story:  suicide awareness and intervention options are touched on in a single sentence, at the last minute, as a footnote in an overwhelmingly condensed out-processing ordeal.[23] 

One recently returned veteran compared the suicide awareness presentations given at out-processing to pharmaceutical ads on TV:  don't pay any attention to this list of lethal side effects that we are reading through as fast as we can; just keep your eye on the seductive fantasy payoff:  happiness, health, sanity, and especially home. 

If suicide awareness and intervention options are important to both agencies, perhaps some thought should be given to how and when and with what degree of seriousness and urgency they are presented by the military and then what the VA can do to follow-up and reinforce the message. 

Perhaps more to the point, after years of stalling, the VA and the DoD have yet to implement a fully interoperable electronic health record systems.   It is those who are most at risk who most need continuity of care, and continuity of care is exactly what gets lost in the tug of war over whose software system is going to win. 

3. Hire more mental health care providers.

The significant association of posttraumatic stress injuries with suicide[24] makes the availability of adequate numbers of trained providers key to any suicide intervention strategy.  It is not enough to say that an additional 2000 or 4000 or 6000 have been hired, if at-risk veterans are not seen in a timely fashion and given care that lives up to best-practice standards. 

If experienced therapists continue to leave both the military and the VA because they can get higher paying, less stressful jobs in the private sector, then the budget for mental health services must include higher salaries and incentives to induce them to stay.[25]  If younger, less experienced providers are more easily available, then they must be hired immediately, as it will take time to train them in cultural competencies essential to establishing the trusting relationships with veterans that will keep them in care. 

In fact, if a hotline generates 50,000 calls a day, 100,000, and the services and support advertised are not actually available, it can only add to a caller's despair, and may even make it more likely that he or she will give up.  

4. Give the VA a budget that will not require outsourcing of services.

Contracting out the responsibilities of the VA may be an attractive short-term solution to a very real problem, but it is a solution that leaves the 3 million veterans who live in rural areas that are underserved by VA facilities particularly vulnerable.  

In three short years, Project HERO, run by Humana, has expanded from an experimental pilot program specifically charged with providing health care to rural veterans into an entity providing a full range of services in metropolitan areas—in direct competition with established VA Medical Centers. The Business Section of the Milwaukee Journal referred to that phenomenon as "big business for Humana, Inc."[26]The VA is dependent on Project HERO for 30 percent of their fee-based contracts nationwide,[27]and so far they have managed to keep providers "stepping up" and "doing the right thing," but the more dependent the VA gets on Humana, the less leverage they will have over their service delivery and fees.  

Humana was generously excused for their slow start, for the time it took to establish a network of providers, but it is still ostensibly on trial, and already it is "not living up to its contractual obligations for timely referrals and communication with FB (fee-based) providers" at the Orlando VMHC.[28] In June, the VA Inspector General found that veterans were waiting for referrals, for appointments, for test results, and for medical record updates for up to three months.

Furthermore, the new website of the Office of Management and Budget, PaymentAccuracy.gov, which showcases federal "high-error" programs, included Project Hero in their June audit, identifying  $11.6 million in potentially erroneous payments.[29]

Outsourcing VA services delays the construction of new VA facilities and the training and hiring of VA staff.  Vet Centers will not be established, VA mental health teams will stop building travel to Community Based Clinics into their schedules, the burgeoning fleet of mobile VA clinics will be side-lined rather than expanded. 

The wars in Iraq and Afghanistan have drawn heavily on recruits from rural areas, and the need for VA services will only continue to grow.  The Reserve is also largely drawn from those same communities and already exceptionally at -risk for suicide.  In 2009, Army Reserve suicides were up 26 percent.[30]

For all its challenges and problems, the VA still manages to deliver the best medical care to the most people at the best price in the country. Humana never promised to be cheaper, only to give the VA a chance to catch up with the overwhelming needs of a rapidly expanding veteran population. Rural veterans at-risk for suicide need reliable, accessible mental health services.  The VA should be funded at the levels required to put that system in place. 

5. Reinstitute VA counseling for incarcerated veterans. 

Current regulations restrict VA from providing counseling to incarcerated veterans because it is the duty of "another government agency," in this case the criminal justice system, to provide that care.  They don't. 

The most recent Bureau of Justice estimate of incarcerated veterans in 2007 was 228,700,[31] many, perhaps most, as a result of their untreated, service-related psychic injuries. That is only an estimate though.  No one actually knows because the federal government doesn't require prison authorities to ask.[32]

Prison is a terrible place for veterans suffering from posttraumatic injuries.  Left untreated, PTSD predictably gets worse and becomes chronic, making one of two scenarios far more likely: recidivism or suicide.   The suicide rate in jails is an astonishing 47 per 100,000. The Army's is now 23 per 100,000, and everyone agrees that is a crisis.  

And no one knows how many of the suicides in jails and prisons are veterans, but an article published last year in the Journal of the American Academy of Psychiatry and Law, points to the "absolute dearth of data," and suggests that "defining the scope of this problem should be an absolute priority."[33]

To whatever extent PTSD and TBI and the other emotional, cognitive, and behavioral consequences of such injuries account for criminal behaviors, throwing this vulnerable population behind bars, where they will not get treatment, is compounding the risk that they will not survive.  The probability that the produces an excess of suicides should be reason enough for the VA to re-institute counseling for incarcerated veterans. 

6. Establish Veterans Programs in the nation's prisons.

The relatively new phenomenon of veterans' courts is a laudable attempt to intervene in an historical injustice.  Veterans with service-connected mental injuries whose symptomatic behaviors get them in trouble with the law can opt into a treatment program rather than going to jail or prison.  But those courts can't yet begin to deal with the numbers and only a few are willing to accept veterans whose crimes are considered violent.

In the meantime, veterans with felony convictions are more likely to be unemployed or homeless, both of which contribute to hopelessness and despair.

In 1993, New York State had Veterans' Programs in 19 of its facilities that offered VA substance abuse and PTSD counseling, and education and job training opportunities. They had a documented recidivism rate of 8.9 percent after five years for veterans who completed the program, compared to 51.6 percent for non-veterans. 

Those programs have been eviscerated or killed, but the model exists and would be a valuable component of any suicide intervention strategy. 

7. Support Community Living projects like Valley Forge Village

Valley Forge Village,[34] outside of the Twin Cities, is a 240-acre community for that will house 200 veterans coping with mental health conditions and cognitive impairments and their families.  As conceived, it will be a place for veterans to go to heal and learn new skills. Organic farming and sustainable practices will be taught in a therapeutic setting. Residents can go to school in the surrounding area and business start-up skills and development training are an integral part of the program.

Valley Forge Village is one of a growing number of privately funded intentional communities that will serve as models for the future.  The combination of therapy,  and farming in a peaceful, therapeutic, predominately peer environment is one the VA might do well to watch.  As a suicide intervention strategy, it holds great promise.   

8. Establish more Vet Centers

For 25 years, Vet Centers have been the first line of defense against suicide.  They are walk-in clinics, designed to be less intimidating than the large VA medical centers.  They are largely staffed by veterans, and unlike the big medical centers, they offer counseling to veterans regardless of discharge status and to their family members as well. 

It is family members who are most likely to notice behaviors or attitudes suggestive of suicidal ideation, and Vet Center counselors can help them decide how best to help.  It is the families who are best positioned to encourage traumatized veterans, especially those who are in denial about or ashamed of their mental health issues,  to get the help they need. 

Vet Center counselors are specifically trained to deal with combat- and other service-related issues, and they are fluent in with necessary cultural competencies.  They offer an array of social support services, employment and addiction counseling, sexual trauma and family counseling, as well as housing and legal support. 

Vet Centers are not the answer to the homelessness and unemployment problems that so disproportionately affect the veteran community, and it is the co-occurrence of multiple issues that is most likely to leave a veteran feeling the despair and hopelessness that can lead to self-destructive behaviors.[35] 

Expanding this system of small, local, largely veteran staffed, walk-in clinics, as General Shinseki has proposed, is an evidence-based suicide intervention strategy that has an undeniable documented history of success. 

Advertising the existence of the Vet Centers and the services they provide would help to prevent veterans from ever reaching the crisis state in which a call to a suicide hotline appears to be the only option. 

[1] House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations, Lisette M. Mondello, Assistant Secretary for Public and Intergovernmental Affairs, U.S. Department of Veterans Affairs, September 23, 2008.  http://veterans.house.gov/Media/File/110/7-15-08/Demvaqfrs.htm

[2]  "Calls To Veterans' Suicide Hot Line Double," Jul 28, 2008.  http://cbs3.com/national/veterans.affairs.suicide.2.781329.html

[3] "Strategies for Suicide Prevention in Veterans." www.hsrd.research.va.gov/publications/.../Suicide-Prevention-2009.pdf

[4] "Strategies for Suicide Prevention in Veterans," Appendix D:  The VA National Center for Suicide Prevention and the MIRECC in Denver may have at least some published data describing the impact of the recent VA national suicide prevention hotline. This would obviously be the most relevant information, yet there was no mention of this in the project synthesis. It would be helpful if the document states explicitly one way or another if there is any recent data to be factored from either of these VA suicide preven­tion centers, either in the literature, in press or otherwise.  www.hsrd.research.va.gov/publications/.../Suicide-Prevention-2009.pdf

[5] Donna Miles. "VA officials strive to prevent veteran suicides'" American Forces Press Service, 4/23/2010.  http://www.af.mil/news/story.asp?id=123201368

[6] Steven C. Bagley, MD, MS, Brett Munjas, BA, and Paul Shekelle, MD, PhD.  "A Systematic Review of Suicide Prevention Programs for Military or Veterans Suicide and Life-Threatening Behavior," 40(3), June 2010, p. 263-4.  www.hsrd.research.va.gov/publications/.../Suicide-Prevention-2009.pdf

[7] Gregg Zoroya, "No Letup in Marine attempted Suicides," USA Today, June 8, 2010. http://www.usatoday.com/news/military/2010-06-07-marine-suicides_N.htm

[8] Suicide Facts.  http://www.athealth.com/Consumer/issues/factsuicide.html

[9] Armen Keteyian. "VA Hid Suicide Risk, Internal E-Mails Show:  Follow-Up Reporting On Exclusive Investigation Reveals Officials Hid Numbers, April 21, 2008.
http://www.cbsnews.com/stories/2008/04/21/cbsnews_investigates/main4032921.shtml

[10] http://www.chron.com/disp/story.mpl/nation/6428651.html

[11] Pia Malbran, "VA To Test Suicide Public Service Ads," July 14, 2008.
http://www.cbsnews.com/stories/2008/07/14/cbsnews_investigates/main4260904.shtml

[12] Tanielian, T., and Jaycox, L.H. (2008). Invisible Wounds of War Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: Rand Corporation. Accessed July 1, 2008. http://www.rand.org/pubs/monographs/MG720/

[13] VCS Fact Sheet:  Consequences of Iraq and Afghanistan Wars.  Updated March 13, 2010 using documents obtained from the Department of Veterans Affairs (VA) under the Freedom of Information Act (FOIA).

[14] "Calls To Veterans' Suicide Hot Line Double." http://cbs3.com/national/veterans.affairs.suicide.2.781329.html

[15] The Relationship Between PTSD and Suicide - National Center for PTSD http://www.ptsd.va.gov/professional/pages/ptsd-suicide.asp

[16] http://www.cbsnews.com/stories/2010/01/11/national/main6083072.shtml

[17] Interestingly, the number of veterans under VA care who took there own lives in 2007, five, is the same number cited by the VA in 2005. 

[18] Allan Breed, "Tide of new PTSD cases raises fears of fraud: Some veterans have learned to game the system to get disability payments," May 2, 2010.  http://www.msnbc.msn.com/id/36852985/ns/health-mental_health/page/2/Tide of new PTSD cases raises fears of fraud

[19] No Across-the-Board Review of PTSD Cases – Secretary Nicholson, Public and Intergovernmental Affairs, November 10, 2005, http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1042

[20] The scandal at Walter Reed ( http://www.washingtonpost.com/wp-dyn/content/article/2007/03/04/AR2007030401394.html), was followed by stories of VA using veterans as guinea pigs in dangerous drug trials (http://www.washingtontimes.com/news/2008/jun/17/va-testing-drugs-on-war-veterans/), and then by the revelation that VA employees had taken $24 million in bonuses (http://www.veteranstoday.com/2009/08/21/va-24-million-bonus-scandal/), to the multiple scandals that resulted in the "retirement" of the director of the Philadelphia VA (http://www.vawatchdog.org/10/nf10/nffeb10/nf021710-6.htm).  Just Google VA scandal.

[21]Veterans For Common Sense et al. v. Peake, Case No. C 07 3758, U.S.D.C. (N.D. Cal. 2007) http://www.veteransptsdclassaction.org/

[22] Terri Tanielian and Lisa H. Jaycox, Eds., “Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery,” RAND, 2008: http:/www.rand.org/pubs/monographs/MG720/. p.17

[23] I have only heard variations on what is essentially the same story from veterans:  "They try to fill your head at the last formation before the weekend, the last day before you get out.  Everybody's trying to sit in the back of the room, just waiting for a smoke break, with shades on because we'd drunk too much the night before because we were going home and what were they going to do to us anyway?  Give us an Article 15?"  "VA eligibility, Tri Care, the GI Bill, and a million other things were covered.  The suicide hotline got one sentence."  Did he still have all the handouts he got in his ACAP[23] folder?  "I took what was important, the GI Bill and Tri Care stuff and tossed the rest without reading it." 

[24] The Relationship Between PTSD and Suicide - National Center for PTSD http://www.ptsd.va.gov/professional/pages/ptsd-suicide.asp

[25] Paul Rieckhoff, "A Memo to Obama from America's Vets," Military.com, November 06, 2008.  http://www.military.com/opinion/0,15202,178674,00.html

[26] Ed Green, New Veterans unit could be big business for Humana Inc. - June 1, 2007. http://louisville.bizjournals.com/louisville/stories/2007/06/04/story6.html

[27] Dennis Douda, "Expanding Private Medical Care For Veterans," (WCCO), Feb 19, 2009. http://wcco.com/health/project.hero.veterans.2.939294

[28] Healthcare Inspection Inadequate Coordination of Care Orlando VA Medical Center Orlando, Florida-- Report Number 10-00219-180, 6/24/2010. http:// www4.va.gov/oig/54/reports/VAOIG-10-00219-180.pdf

[29] Alice Lipowitz, "Agencies Faulty Claims make OMB site hit list," June 25, 2010, http://washingtontechnology.com/Articles/2010/06/25/OMB-sets-up-new-Web-site-to-track-improper-payments-by-agencies.aspx?Page=2 

[30]  Danny Spatchek, "Chiarelli: suicides down, but not enough," Jun 25, 2010. http://www.army.mil/-news/2010/06/25/41363-chiarelli-suicides-down-but-not-enough/

[31] Christopher Mumola and Margaret E. Noonan, "Justice involved Veterans," Bureau of Justice Statistics, Power Point presentation: The VHA National Veterans Justice Outreach Planning Conference, Dec. 2, 2008 Baltimore.

[32] In 1994, a few concerned members of Congress managed to get a provision attached to the Violent Offender Incarceration and Truth in Sentencing Incentive which would have rewarded the operators of correctional facilities for adopting policies that would identify the veterans among their inmates.  Those incentive grants were passed, but they were rescinded by the Gingrich Congress before they were ever implemented. 

[33] Hal S. Wortzel, MD, Ingrid A. Binswanger, MD, MPH, C. Alan Anderson, MD and Lawrence E. Adler, MD.  "Suicide Among Incarcerated Veterans," J Am Acad Psychiatry Law 37:1:82-91 (2009).  http://www.jaapl.org/cgi/content/full/37/1/82

[34] http://www.valleyforgecenter.org/

[35] Steven C. Bagley, MD, MS, Brett Munjas, BA, and Paul Shekelle, MD, PhD.  "A Systematic Review of Suicide Prevention Programs for Military or Veterans Suicide and Life-Threatening Behavior," 40(3), June 2010, p. 263-4.  www.hsrd.research.va.gov/publications/.../Suicide-Prevention-2009.pdf