Witness Testimony of Brigadier General Loree K. Sutton, M.D., Special Assistant to the Assistant Secretary of Defense for Health Affairs, Director, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, U.S. Department of Defense
Chairman Filner, Mr. Buyer, distinguished Members of the Committee; thank you for the opportunity to appear here today to talk to you about the Department of Defense’s (DoD) efforts to reduce the number of suicides across our force.
On behalf of DoD, I want to take this opportunity to thank you for your continued, strong support and demonstrated commitment to our service members, veterans, and their families.
Over the last nine years, a new era of combat emerged, where counterinsurgency and asymmetric warfare are the norm. This shift continues to place a great amount of strain on our most important resource, our service members. Despite the operational challenges facing them and their families, they remain incredibly resilient, motivated, and well-trained. The Department recognizes the need to provide the resources and programs necessary to maintain their resilience and motivation. Our core messages tell our service members and their families that they are not alone; treatment works; the earlier the intervention the better; and reaching out is an act of courage and strength.
The Department also recognizes that the total number and rate of suicides continue to rise and this is of deep concern at all leadership levels. Today, I will share with the Committee our current efforts to reduce the number of suicides across the Force, and the role of medication and suicides.
Suicide has a multitude of causes, and no simple solution. There are many potential areas for intervention, and it is difficult to pinpoint the best approach because each suicide is unique. Recognizing this, DoD is tackling the challenge using a multi-pronged strategy involving comprehensive prevention education, research, and outreach. We believe in fostering a holistic approach to treatment, leveraging primary care for early recognition and intervention, and when needed, providing innovative specialty care. The areas of focus to reduce risk include: (1) conducting data collection and analysis to detect contributing risk factors; (2) facilitating partnerships across DoD, federal agencies, and civilian organizations to increase collaboration and communication; (3) reducing stigma and increasing access to resources to provide needed care; and (4) using research to close gaps and identify best practices.
Quality data collection and analysis are critical components behind effective prevention efforts. The Department made great strides over the last 12 months on gathering critical information to understand the complexity of factors leading to suicide and ways to prevent such tragedies from occurring within our communities. Data collected by the DoD Suicide Event Report (DoDSER) tell us that we must continue to educate our population and build programs, as there continue to be multiple opportunities to intervene. For example, we are learning that 30% of individuals who died by suicide communicated their potential self harm; 49% had been seen in a medical/support clinic/program within 30 days of suicide; and 26% sought broadly defined mental health resources.
Historically, the Services used unique suicide surveillance systems. In January 2008, the National Center for Telehealth and Technology (T2), a Defense Centers of Excellence (DCoE) component center, launched the DoDSER Annual Report. The DoDSER Annual Report was developed to standardize data collection and reporting. Pulling data from all branches of the military, it captures over 250 data-points per suicide with details, summaries, and analyses of a wide range of potential contributing factors. DoDSER Annual Report data include specific demographics, suicide event details, treatment, and military history, among others. The variables are designed to map directly to the Centers for Disease Control and Prevention's National Violent Death Reporting System to support direct comparisons between military and civilian populations.
By standardizing data and reporting, DoD tracks and analyzes suicide data and contributing risk factors proactively to inform and improve future prevention, intervention, and treatment services. The DoDSER Annual Report is revised annually based on input from the Services. The data facilitate the review and evaluation of the effectiveness of suicide prevention initiatives and their execution over time. DoDSER represents the strides DoD has taken to better understand what some of the underlying factors are for suicide. The Department uses this tool to inform current efforts and initiatives.
According to the Armed Forces Medical Examiner System (AFMES), in January 2010 there were 24 confirmed suicides, all in Regular Components within the DoD. In calendar year 2009, AFMES reported that there were 312 confirmed suicides, with 286 confirmed in Regular Components and 26 confirmed in the Reserve Components. Demographic risk factors include: male, Caucasian, E-1 to E-4, younger than 25 years old, GED or less than high school education, divorced, and in the Active Duty Component. Other factors associated with suicide, which are consistent with data from civilian populations, are: substance abuse, relationship issues, and legal, administrative (Article 15), and financial problems. Although the impact of deployment is still under investigation, a majority of suicides do not occur in the theaters of operation. 16% of suicides occurred in Iraq or Afghanistan. Despite the knowledge gained and data collected, it is important to resist oversimplifying or generalizing statistics. Each suicide is as different as a person is unique.
According to AFMES, there were 26 confirmed suicides in calendar year 2009 among the Reserve Components, which include all Active Guard and Reserves. Due to the unique nature of their service, there are challenges associated with capturing all suicide completions, preparatory behavior and self harm without intent to die among National Guard and Reserve populations when they are not on active or activated status. To address this issue, DoD is examining ways to utilize information gathered from existing tracking and reporting systems including, but not limited to, insurance and benefit data. The DoD continues to support National Guard and Reserve populations through numerous initiatives to increase outreach, care, and resources on all fronts.
The numbers also tell us that prevention is not enough, as 36% of military suicides had a history of a mental disorder. The integrated efforts of prevention, intervention, and treatment are essential to DoD’s approach to tackle the challenge of suicide.
Continued collaboration with the Department of Veterans Affairs (VA) and other federal, private, and academic organizations is a key part of DoD’s overall strategy.
Conferences serve as dissemination and outreach platforms by providing local and regional coordinators with innovative ideas to implement within their communities and providing DoD and VA with the opportunity to gather feedback on communities’ needs. The annual DoD/VA Suicide Prevention Conference provides such a forum. With over 900 attendees, the 2010 conference shared practical applications, results from research and pilot studies, guidance from senior DoD and VA leaders on the way forward, and testimonies emphasizing the importance of seeking help.
We work closely with our partners at the VA to ensure that the transition out of service and into VA care is seamless and that service members, veterans, and families receive the care they deserve. The DCoE coordinates information and resources with VA’s National Suicide Prevention Lifeline (1-800-273-TALK), and National Resource Directory. As part of this partnership, DCoE worked with VA and the Substance Abuse and Mental Health Services Administration (SAMHSA) in December of 2009 to modify the introductory message on the Lifeline, so that callers are instructed to press “1” if they are a United States military veteran or Active Duty Service Member (ADSM) or are calling about one. This expansion increases the scope of services that are available to ADSMs who may be in crisis.
Collaborative care is an example of an immediate solution that DoD is aggressively implementing. According to DoDSER data, 36 percent of completed suicides had a history of a mental health condition. Providing mental health services in conjunction with primary care is an important part of our prevention strategy because early detection and intervention is a key to preventing suicide behaviors. Each Service is developing collaborative care models based on recommendations from a National Institute of Mental Health (NIMH) study. The DCoE collaborates with the Services to integrate the best practices from these models to develop consistent standards across DoD. DCoE is currently implementing a controlled trial study at six sites and 18 clinics of collaborative primary care to inform future efforts.
In August 2009, the DoD Suicide Prevention Task Force was established under the purview of the Defense Health Board. The goal of the task force is to provide recommendations to legislative and administrative bodies on suicide prevention within the military.
The Department recognizes the importance of eliminating the toxic threat of stigma by transforming its culture from reactionary to a more proactive environment by engaging leadership to encourage transparency, accountability, candor, and respect. The DoD is promoting awareness among leaders and urging them to lead by example in matters related to health and well-being. In addition, changes in policies and messages to all levels help create a safe culture to seek help. One significant change was the revision of question 21 on the questionnaire for security clearances on whether a service member has sought mental or behavioral help in the past year. DoD believes that service members should not have to deny themselves the care they need and deserve out of fear of repercussions. Our efforts to combat stigma will continue alongside our efforts to provide the best prevention, intervention and treatment options.
Additionally, DoD is undergoing a cultural transformation to push care closer to the service members and their families. An emphasis on early intervention for antecedent issues such as post-traumatic stress, depression, and substance abuse can help address needs before they develop into bigger issues that could contribute to suicides. This population based approach enables DoD to engage multiple audiences including peers, families, units, and communities to support suicide prevention, risk reduction, and overall health promotion. The Services also have programs to address needs before they develop into issues that must be addressed in a specialty care setting.
DCoE helps combat stigma through the Real Warriors Campaign, a public education initiative that reinforces the notion that reaching out is a sign of strength. Under the theme of “Real Warriors, Real Battles, Real Strengths,” this effort provides concrete examples of service members who sought care for psychological health issues and are maintaining a successful military career. While primarily focused on stigma, the Real Warriors Campaign is actively engaged in the fight against military suicide in a number of ways:
- The website prominently displays the National Suicide Prevention Lifeline on every page;
- Two video profiles of service members involved in the campaign openly discuss their struggles with suicidal ideation from a position of strength and optimism having reached out for care that is working; and
- The site allows service members, veterans, families and health professionals to confidentially reach out to health consultants around the clock through the Real Warriors Live Chat feature or by calling the DCoE Outreach Center.
The Campaign's message boards include numerous posts from service members who share their coping strategies for dealing with suicidal ideation. The site includes content that focuses on suicide prevention and substance abuse. Short, documentary-style videos illustrate the resilience exhibited by service members, their families, and caregivers.
Since the Real Warriors Campaign launched in May 2009, the website, www.realwarriors.net, saw more than 45,500 unique visitors from 127 countries, with more than 69,128 visits and 450,000 page views. The DoD believes that stigma can be defeated by encouraging and supporting service members to reach out when help is needed.
A critical component of DoD’s strategy is advancing research. As part of DoD’s research portfolio, the RAND Center for Military Health Policy Research is reviewing and cataloguing suicide prevention programs across the Services with recommendations for enhancements of current programs. The results will be released March 2010 and disseminated to inform future program development.
A pilot study that showed promise in the civilian sector is the Caring Letters Program. In a randomized clinical trial, sending brief letters of concern and reminders of treatment to patients admitted for suicide attempt, ideation, or for a psychiatric condition was shown to dramatically reduce the risk of death by suicide. In an effort to determine the applicability to military populations, the National Center for TeleHealth and Technology (T2) is piloting a program at Ft Lewis, Washington. The goals of the Caring Letters Pilot are to (1) test the feasibility of expanding the program to other military treatment facilities, (2) collect preliminary outcome data, and (3) evaluate the method of letter transmittal (email vs. postal mail). Since its inception in July 2009, 81 letters have been sent. Efforts are currently underway to plan a multi-site randomized control trial.
Department of Defense Initiatives
Many programs are currently in place to raise awareness among service members, train civilian providers supporting our service members and communities, and increase leadership involvement in behavioral health efforts. The programs are on all levels, from the national level down into local communities. These initiatives, including programs that provide face-to-face support or online support, demonstrate DoD’s multi-pronged approach and commitment to ensuring service members and families have access to the best resources. Some examples of these efforts are detailed below:
Each Service has its own suicide prevention initiatives tailored to its culture. In November 2007, DoD established the DCoE to offer a central coordinating point for activities related to psychological health concerns and traumatic brain injuries. DCoE focuses on the full continuum of care and prevention to enhance coordination among the Services, federal agencies, and civilian organizations. DCoE works to identify best practices and disseminate practical resources to affected communities. In this effort, emphasis is placed on building resilience, supporting recovery, and promoting reintegration to ensure a comprehensive, multi-faceted, and proactive approach in promoting health and wellbeing.
The Suicide Prevention and Risk Reduction Committee (SPARRC), chaired by DCoE, provides a forum for inter-Service and VA partnership and coordination. Members include Suicide Prevention Program Managers from the Services and representatives from the National Guard Bureau, Reserve Affairs, VA, Office of Armed Forces Medical Examiner, T2, Substance Abuse and Mental Health Services Administration, and others. This committee is the main venue for ensuring collaboration and consistency in system-wide communication related to suicide, risk reduction policy initiatives, and suicide surveillance metrics across the military. A SPARRC website is currently in development to serve as a “clearinghouse” for suicide prevention information, contacts, innovative approaches, and tools.
Additionally, the DCoE Outreach Center coordinates with Military OneSource, accessible by phone at 1-800-342-9647. Licensed mental health consultants are available to listen, answer questions, and refer callers to a wide range of services 24 hours a day, seven days a week, 365 days a year. Military OneSource provides services on a range of other topics including education, relocation, and parenting.
Another DoD program that encourages seeking care is inTransition, which provides a bridge of support for service members while they are transitioning between health care systems or providers. The program assigns credentialed “Supercoaches” on a one-on-one basis to service members in transition. These “Supercoaches” provide support, encouragement, and promote continued use of behavioral health services.
In an effort to increase access to resources and align with modern communication platforms, DoD is harnessing technology and social media tools. Afterdeployment.org, an interactive website developed by T2, provides service members and families behavioral health information using an anonymous platform. This mental wellness resource is designed to help service members and families manage the challenges faced after a deployment. In addition, Afterdeployment.org launched a series of free podcasts, available on iTunes, discussing a variety of mental health issues affecting service members and families. Since the rollout in August 2008, Afterdeployment.org has seen 86,083 visits to its website. Afterdeployment.org is currently developing both a mobile version of the site and a mobile application. The portability will allow access to resources regardless of location.
Telebehavioral health refers to use of telecommunications and information technology for clinical and non-clinical behavioral health care services. Telebehavioral health may include the use of videoconferencing, web-based cameras, email and telephone. T2 is exploring ways to supply timely telebehavioral health services to service members in theater and during health screenings immediately upon return to the continental United States. The use of technology provides service members and their families access to psychological health care even in the most extreme and/or remote circumstances.
Medication and Suicide Risk
The Department supports the use of psychopharmacological treatments as a key component of mental health care. Scientific evidence over the past several decades points to the role of medications in limiting the severity and duration of illness as well as for preventing relapses and recurrences. These findings have been translated into recommendations for clinicians in the VA-DoD Clinical Practice Guidelines for Major Depressive Disorder, Post-Traumatic Stress Disorder, Psychoses and Substance Use Disorder. These guidelines are updated periodically as required to reflect the most current knowledge concerning each of these conditions. Recognizing that all medications carry potential risks as well as benefits, clinicians must exercise their judgment in applying these guidelines and determining the most effective use of medications, other therapies which include Cognitive Behavioral Therapy, Cognitive Processing Therapy and/or Prolonged Exposure treatment, or a combination of medication and therapy. Therapy must be monitored, with careful attention to diagnosis, dosing, clinical response and potential adverse events.
In recent years, antidepressant medications, particularly the use of Selective Serotonin Reuptake Inhibitors (SSRIs) have been closely evaluated for the increased risk of suicide-related behaviors in adolescents and young adults associated with their use. In recognition of this risk, the FDA’s requires a “black box” warning in the product labeling of all antidepressant medications that advises clinicians to closely monitor any worsening in depression, emergence of suicidal thinking or behavior, or unusual changes in behavior, such as sleeplessness, agitation, or withdrawal from social situations. Close monitoring is especially important during the first four weeks of treatment. The FDA also recognizes that depression and other psychiatric disorders are themselves associated with increased risks for suicide.
Accordingly, the Department uses multiple tools to address the identified risk for antidepressant as well as other medications, as scientific evidence reaches the threshold for action. These methods include dissemination of safety alerts to clinicians, patient information sheets, pharmacy monitoring for harmful combinations of prescribed medications, adherence to The Joint Commission standards governing medication reconciliation, compliance with the reporting of adverse events, increasingly sophisticated use pharmacotherapeutic analysis as well as training and education programs in evidence-based modalities reflecting the most current clinical practice guidelines.
The DoDSER data base, while still maturing, provides an unprecedented repository of Service suicide surveillance data that will continue to inform our efforts. Further, we look forward to the payoff from continued research investments.
Suicide is a problem that needs solutions now. DoD is focused on rapidly translating best practices into applicable tools for service members and families. At the same time, DoD continues to improve on collaborative relationships across the Services and with national experts, collecting data, and in research efforts that will accelerate improvements in current services and programs as well as spur new innovations. In addition, DoD will also continue to evolve and leverage our population-based system to push innovations in prevention and care toward the service member and family.
DoD’s current initiatives to address the challenges placed on service members and their families are progressing, but we recognize that there is still much to be done. In order to build on our current efforts and successfully shift to a model of population-based care, we identified the following areas of additional focus.
An issue of increasing concern is suicides of military family members and how to support surviving families. At this point in time, DoD does not track suicides of military family members. However, DoD recognizes the importance of engaging and supporting this population, as their sacrifices deserve our recognition. The DoD Suicide Prevention Task Force met this year with surviving families at the Tragedy Assistance Program for Survivors (TAPS) Seminar. The DoD Task Force will provide recommendations to the Secretary of Defense and Congress. Efforts will be focused on increasing outreach to families; providing families with more education and training to recognize the signs of suicidal behavior and where to seek help; and supporting families after a suicide event. In addition, for calendar year 2010, SPARRC partnered with TAPS to form a sub-committee to identify additional needs of families and to recommend concrete solutions.
Postvention, which refers to all activities and response after a suicide event, is another area of growing attention. The goals of postvention include: (1) promote healing, (2) reduce risk of contagion, and (3) identify those at risk and connect them to help. Postvention is also viewed as a form of prevention for survivors. This year, DoD will work with the Services to promote consistent postvention protocols across programs.
Connect/Frameworks Suicide Postvention Program is a civilian program that utilizes evidenced supported protocols to promote an integrated community based response to suicides. Postvention protocols and guidelines include topics such as discussing cause and method of death; how to address needs of families; memorial service activities; and media coverage and messaging.
In addition to prevention, intervention, and treatment, DoD is shifting attention to increasing resilience. DoD promotes a holistic approach that optimizes the physical, psychological, and spiritual components of the human condition. The DoD is also piloting resilience programs in military settings to determine applicability and effectiveness within military populations. While the impact of deployment on suicide is still under investigation, it cannot be denied that an era of high operational tempo and persistent conflict increases pressure on our warriors. A comprehensive approach to enhancing resilience actively confronts the increasing stressors service members face in this environment.
2010 will also provide DoD further opportunities to demonstrate a public health model of prevention, by supporting peer-to-peer programs in the Services and continuing to increase the number of mental health providers in communities. DoD is actively engaged in hiring more mental health providers and providing them with quality and continued training.
Through our united and concerted efforts, we can continue making a change for the better. DoD recognizes the need to provide the resources and programs necessary to maintain the resilience and motivation of our service members and families. We will continue to emphasize education as we deliver our core messages. “You are not alone; treatment works; the earlier the intervention the better; and reaching out is an act of courage and strength.”
We are devoted to this effort and will continue to work aggressively to prevent the unnecessary loss of life.
With the Committee’s continued assistance and support, we will ensure our brave men and women in uniform and their families have access to the resources they require.
On behalf of the DoD, thank you for the opportunity to highlight these vital issues. I look forward to your questions.