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Submission For The Record 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.