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Witness Testimony of Commander René A. Campos, USN (Ret.), Deputy Director, Government Relations, Military Officers Association of America

A decade of war has placed unprecedented demands and stressors on our warriors and their families that will leave scars and unintended consequences for generations to come.

The Departments of Veterans Affairs (VA) and Defense (DoD) have long been faced with the daunting challenge of meeting a significant range of medical and rehabilitation issues.  MOAA is particularly concerned about the exponentially growing need to address mental health, behavioral and cognitive conditions, in light of the rising rates of suicides, alcohol and substance use, and a variety of other issues playing out among veterans, servicemembers and their families.

A number of reports support our concerns:

  • 2008 VA “Blue Ribbon Work Group on Suicide Prevention in the Veteran Population”
  • RAND Health/National Defense Research Institute

            o   2008 “The Invisible Wounds of War”

            o   2011 “The War Within, Preventing Suicide in the U.S. Military”

            o   2011 “Addressing Psychological Health and Traumatic Brain Injury Among Servicemembers and Their Families”

  • 2011 Center for a New American Security (CNAS) Report “Losing the Battle:  The Challenge of Military Suicide”

The current statistics are disturbing and point to an even greater need to wage an all out battle to end suicide.  This will require a sustained national commitment at all levels of government if we are to rid veterans of the psychological and traumatic physical conditions that are threatening their lives and the health and well-being of their families.  Sadly these statistics represent the heroes who protect our country and our freedoms:  

  • 20 percent of suicides in the U.S. are former servicemembers
  • One currently serving member died every 36 hours during the period 2005-2010
  • 18 veterans die a day—that is one suicide every 80 minutes

Recommendations

MOAA offers three specific recommendations to address current barriers to care:

  • Require VA-DoD to establish a single strategy and a joint Suicide Prevention Office that reports directly to the Department Secretaries through the Senior Oversight Committee (SOC).
  • Authorize funding to expand VHA mental heath capacity and capability in order to improve access and delivery of quality and timely care and information.
  • Authorize additional funding to expand outreach and marketing efforts to encourage enrollment of all eligible veterans in VA health care, with special emphasis on Guard and Reserve members, rural veterans, and high-risk populations. 

MADAM CHAIRMAN AND DISTINGUISHED MEMBERS OF THE SUBCOMMITTEE, on behalf of the 370,000 members of the Military Officers Association of America (MOAA), I am grateful for the opportunity to present testimony on MOAA’s observations concerning the Department of Veterans Affairs’ (VA) suicide prevention programs and efforts.

MOAA does not receive any grants or contracts from the federal government.

MOAA thanks the Subcommittee for its interest in this extremely difficult issue and for your leadership in looking out for the health and well-being of our veterans and family members.  We also commend the VA for its staunch commitment to enhancing mental and behavioral health programs by working with DoD and other government and non-government entities to help veterans and their families improve their physical and psychological well being.

Overview of VA Suicide Prevention Programs and Efforts

A number of reports and activities have been published in the last seven years that shine a spotlight on veteran and military suicide and VA’s prevention efforts.

In 2008, the RAND Corporation’s Center for Military Health Policy Research released a report on “The Invisible Wounds of War.” The report highlighted the mental health and cognitive needs of combat veterans, focusing on three wounds: post-traumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI). 

The report states that, “Unless treated, PTSD, depression, and TBI can have far-reaching and damaging consequences.  Individuals afflicted with these conditions face higher risks for other psychological problems and for attempting suicide…there is a possible link between these conditions and homelessness…the consequences from lack of treatment or under-treatment can have a high economic toll.”  

RAND made four recommendations that get at these issues:

  1. Increase the cadre of providers who are trained and certified to deliver proven (evidence-based) care, so that capacity is adequate for current and future needs.
  2. Change policies to encourage more active duty personnel and veterans to seek needed care.
  3. Deliver proven, evidence-based care to servicemembers and veterans whenever and wherever services are provided.
  4. Invest in research to close information gaps and plan effectively.

Like RAND, our Association believes that restoring veterans to ‘full mental health’ will be important to reduce long-term economic societal costs.  

RAND’s Invisible Wounds of War was the first study of its kind to estimate that PTSD and depression among servicemembers will cost the nation up to $6.2 billion in the two years after deployment.  The study concludes that investing in proper treatment would provide even larger cost savings—savings that would come from increases in productivity, as well as from reductions in the expected number of suicides. 

Additionally, The Journal of Clinical Psychiatry reported that the economic burden of depression to this country was estimated to be $43.7 billion in 1990.  By 2000 the cost burden rose to $53.9 billion, which included direct treatment costs, lost earnings due to depression-related suicides, and indirect workplace costs.

In June 2008, the Secretary of the VA convened a Blue Ribbon Work Group on Suicide Prevention in the Veteran Populationto advise on the research, education and program improvements to the prevention of suicide.  The Work Group consisted of five Executive Branch representatives, two of which were from DoD. 

MOAA was encouraged by the Group’s findings.  According to the report, the Veterans Health Administration (VHA) had a comprehensive strategy in place and a number of promising initiatives and innovations for preventing suicide attempts and completions.

The Group recommended that VHA:

  1. Establish an analysis and research plan in collaboration with other federal agencies to resolve conflicting study results in order to ensure that there is a consistent approach to describing the rates of suicide and suicide attempts in veterans.
  2. Revise and reevaluate the current policies regarding mandatory suicide screening assessments.
  3. Proceed with the planned implementation of the Category II flag (patient is at high risk for suicide), with consideration given to pilot testing the flag in one or more regions before full national implementation.
  4. Ensure that suicides and suicide attempts are reported and that procedures are consistent with broader VHA surveillance efforts.
  5. Ensure that specific pharmacotherapy recommendations related to suicide or suicide behaviors are evidence-based.
  6. Continue to pursue opportunities for outreach to enroll eligible veterans, and to disseminate messages to reduce risk behavior associated with suicide.
  7. Ensure confidentiality of health records.
  8. Ensure ongoing evaluation of the roles and workloads of the Suicide Prevention Coordinator positions.

This year a Center for a New American Security (CNAS) report entitled, “Losing the Battle:  The Challenge of Military Suicide,” published some disturbing statistics, noting that suicide among veterans and servicemembers present challenges to the health of America’s all-volunteer force.   The report addressed the obstacles for confronting suicide.  Although most of the 13 recommendations CNAS offered are focused on DoD and the Military Services, most are applicable to VA, such as:

  1. Ensuring transfer of mental health information when members relocate
  2. Eliminating the cultural stigma associated with mental health care
  3. Holding leaders accountable
  4. Increasing mental health and behavioral health care professionals, and addressing gaps in programs for drilling Guard and Reserve units
  5. Establishing reasonable time requirements for states to provide death data to the Centers for Disease Control (CDC), and that Health and Human Services (HHS) should ensure CDC is resourced sufficiently to expedite the compilation of national death data.  VA, DoD and HHS should coordinate annual analysis of veteran suicide data.
  6. Sharing of suicide data between VA, DoD and HHS, including discussion with Veterans Affairs and Armed Services Committees to develop a provision to address veteran suicides.    

Two other reports were published this year by RAND’s Health/National Defense Research Institute and sponsored by the Office of the Secretary of Defense.  The first report, “The War Within, Preventing Suicide in the U.S. Military,” was intended to enhance the Department’s suicide prevention programs and efforts.  The second report, “Addressing Psychological Health and Traumatic Brain Injury Among Servicemembers and Their Families,” provided DoD a comprehensive catalog of existing programs currently sponsored or funded by the Department to address psychological health and TBI.  MOAA believes the recommendations of these two reports are also applicable to VA:

  1. Increasing and improving the capacity of the mental health care system to deliver evidence-based care
  2. Changing policies to encourage more veterans and servicemembers to seek needed care
  3. Delivering evidence-based care in all settings
  4. Investing in research to close knowledge gaps and plan effectively
  5. Taking advantage of programs’ unique capacity for supporting prevention, resilience, early identification of symptoms, and help seeking to meet the psychological health and TBI needs of servicemembers and their families
  6. Establishing clear and strategic relationships between programs and existing mental health and TBI care delivery systems
  7. Examining existing gaps in routine service delivery that could be filled by programs (formal needs assessment and gap analysis of programs)
  8. Reducing barriers faced by programs
  9. Evaluating and tracking new and existing programs, and using evidence-based interventions to support program efforts

VHA mental health officials estimate there are approximately 1,600 – 1,800 suicides per year among veterans receiving care in the health system and upwards of 6,400 per year among all veterans.  One of the key goals of VA’s Mental Health Strategic Plan, implemented in 2004, was to reduce suicide among the veteran population.  Out of that plan came a National Suicide Prevention Center of Excellence, a national suicide prevention hotline, a patient record flagging system, and suicide prevention programs in each medical facility.

Speaking at a joint VA-DoD Suicide Prevention Conference last year, VA Secretary Eric Shinseki said every veteran was susceptible to suicide. 

“The emotional wounds are no less common than physical injuries; however, they are more difficult to diagnose which adds to the challenge of suicide prevention,” said Shinseki.  He went on to say that the suicide problem was one of the ‘most frustrating’ leadership challenges he faces.  “Of the 18 veterans who commit suicide each day, five of those veterans are under the care of the VA. Losing five veterans who are in treatment every month, and then not having a shot at the other 13 who for some reason haven’t come under our care, means that we have a lot of work to do.”

There are a number of predisposing risk factors associated with suicide and mental health disorders that can be diagnosed and treated.  Some of these risk factors include:

  • PTSD
  • Relationship problems
  • Financial difficulties
  • Substance abuse and addiction
  • Ongoing depression
  • Social isolation
  • Recent illness and/or hospitalization
  • Difficulty Sleeping
  • Access to firearms

Today, VA has two primary program areas targeting suicide prevention, the National Suicide Prevention Program and the Office of Mental Health Services.  Some additional initiatives the Department has implemented include:

  • Hiring thousands of additional mental health providers
  • Launching a Suicide Prevention Campaign
  • Establishing a Veteran’s Crisis Line
  • Instituting a National Suicide Prevention Coordinator Program
  • Directing a suicide prevention safety plan (SPSP) and Practices for high risk patients
  • Implementing policy requiring annual depression screening for veterans using VA health care
  • Conducting a VA-DoD Suicide Conference
  • Establishing a VA-DoD online Suicide Prevention Resource Center

Progress and Challenges

In conducting our research for this hearing, MOAA was struck by the tremendous level of work that had been done, especially in the last three years.  The steadfast determination of the VA Central Office staff and Secretary Shinseki’s personal involvement in synchronizing the agency’s national suicide prevention efforts is quite visionary.

MOAA gives VA high marks for rebranding its suicide prevention hotline and establishing a National Veterans Crisis Line.  Dr. Janet Kemp, VA’s National Suicide Prevention Coordinator is to be commended for standing up the suicide hotline, earning her recognition as the 2009 Federal Employee of the Year.  The initiative resulted in more than 5,000 immediate rescues.  The crisis line is one of the best initiatives according to Dr. Kemp, answering over 450,000 calls and making more than 16,000 life-saving rescues.  An anonymous chat service was added to the crisis line and has helped more than 20,000 people.

Additionally, in less than a year VA has expanded agreements from 18 to 48 states to have veteran status on death certificates.  Colorado and Illinois have yet to sign an agreement with VA.

Despite these improvements, the VA concedes barriers still exist that challenge its ability to advance suicide prevention to the level needed. 

According to a VA Inspector General’s “Combined Assessment Program Summary Report:  Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities,” released on March 22, 2011, the VA implemented a number of requirements for taking care of patients identified to be at high risk for suicide.  One requirement is that there be a written safety plan that should be placed in the medical record, and, that a copy of the plan is given to the patient.  The VA IG noted that generally Department’s suicide prevention safety plans (SPSP) were comprehensive but the completion of safety plans for all high-risk patients and the timeliness of the plans needed improvement.

In October 2011, The Washington Post published an article titled, “VA Lacks Resources to Deal with Mental Health, Survey Finds.”  Thearticle stated,  “Over 70 percent of the survey respondents to a preliminary survey of VA social workers, nurses and doctors think the Department lacks the staff and space to meet the growing numbers of veterans seeking mental health care.  More than 37 percent said they are unable to schedule an appointment in their clinic within the mandated 14-day standard.”

Senator Patty Murray (D-WA), chairwoman of the Senate Veterans Affairs Committee requested the survey after conducting a hearing this past summer where veterans diagnosed with mental health issues described long waits for treatment in the VA.  In a letter to the Department, Senator Murray wrote, “While I understand the Department has concerns that this survey is not comprehensive, after the countless Inspector General and GAO reports, hearings, public laws, conferences, and stories from veterans and clinicians in the field, it is time to act.”

MOAA could not agree more.  VA and our entire country must address barriers to mental health if we are to win the war on suicide.

Some of the most significant barriers that impede progress are:

  • Limitations on mental health capacity and capability, impacting access and quality and timely care (e.g., funding, resources, staffing, hours of operation, infrastructure).
  • Lack of total system accountability, oversight, monitoring and evaluation. VA Central Office (VACO) has a comprehensive strategy and policies, but implementation across the health care system is inconsistent and outcomes vary greatly. 
  • Limitations in data sharing and documentation of information.
  • VA and DoD veteran “warrior cultures”.
  • Limited opportunities for maximizing collaboration, cooperation, and communication to ensure continuity of care and services in a seamless manner.
  • Cultural and societal stigma prevents individuals from seeking care.
  • Experiences with unprofessional or uncaring VA employees who don’t treat veterans with compassion and respect.
  • Medical system policies, procedures and logistical challenges make it difficult for veterans and their families to understand and navigate, especially during times of crisis.  The VA culture tends to assume because employees understand how VA works, others should know as well.

Some of these barriers are outside of VA’s span of control, as noted in the reports mentioned above.

MOAA believes addressing veteran suicides requires an immediate response and a unified strategy coordinated between the VA, DoD and other federal agencies.  VA and DoD have had difficulty over the years in keeping up with demand for medical benefits and services from OIF/OEF veterans.  As operations start winding down in these theaters we can expect demand to continue for a number decades, and generations to come. 

Our country must do all it can to help VA and DoD to ensure our servicemembers have seamless mental health services as they separate or retire from the military—something more than just giving them a web site or toll free number to call when they need help. 

Veterans’ families, caregivers and children also deserve special attention because of the tremendous burdens they must carry when dealing with the psychological wounds of their loved ones.

Identifying servicemembers who are at high risk and providing them treatment is critical as these individuals will one day be veterans.  The sooner we help these individuals; in and out of uniform the better the long-term outcomes will be for veterans, their families and society as a whole.

What Veterans and their Families Tell Us

Veterans and family members we talk to have seen much progress in improving policies and programs at the national level.  However, they don’t always see these policies and programs implemented or interpreted consistently at all VA medical facilities.

The real tragedy for some veterans who really need help is that they may give up or lose trust in the system.  This may be particularly true for severely wounded, ill or injured veterans and their families dealing with the burdens of complex medical conditions.

Here are what veterans and their families told us about their experiences:

PTSD Veteran and Caregiver-Spouse

  • The veteran entered the VA system in 2008 as a high-risk patient for suicide and is still at risk today.
  • The Caregiver’s current issue is addressing the veteran’s difficulty sleeping.  It took the VA two months to schedule an appointment just to get a fee based referral outside the VA.  Now the veteran must wait until May 2012 for VA to do a required sleep study.  This Caregiver questions why it takes almost a year for her husband to get the care he needs, especially when VA knows that difficulty sleeping is a risk factor for suicide the veteran has a history of suicidal ideations. 
  • “I don’t trust VA.  My Federal Recovery Coordinator (FRC) and I are constantly fighting with people in the VAMC every step of the way.  It’s like the VA is fighting with itself—why can’t they just do what is right?  VA is in the business of saving lives and it shouldn’t be focused so much on saving money,” said the Caregiver.
  • Recommendations to improve care:
  • The FRC should have more authority to make things happen in the VA—they are an integral part of the team and likely to have a better understanding of the veteran’s mental condition.
  • Access to mental health services
  • Veterans with mental health issues should have greater access to fee based services if it takes longer than two weeks to get an appointment.
  • Veterans should have more control over their appointments—VA needs to do a better job of accommodating their schedules.

TBI Veteran and Caregiver-Mother

  • This severely injured veteran with TBI and a number of physical disabilities had to wait weeks to get the attention of a VA provider from the time of his first thoughts of suicide.  It took his mother forcing the issue before VA would see him. 
  • “The VA tries to treat my son like other patients, but normal protocols don’t work.  He has half of his brain capacity; he can’t talk or communicate normally about how he is thinking or feeling, but he does think and feel, he just can’t communicate it the way most people do,” she said.
  • The Caregiver said, “there were been times the VA medical staff have made comments or their actions hurt her son deeply—one VA provider told her in front of her son that he would never be more than a vegetable.”  Other providers continue to try pushing her son to institutionalized care because that’s what the system normally does for veterans with this level of disability.  The veteran’s bad experiences at the VA have made it difficult for him to want to do any type of therapy today.
  • This Caregiver tries to keep her son as active as possible so he won’t get depressed.   She says he’s lonely and doesn’t have any friends so it is easy for him to slip into depression.  
  • Recommendations to improve care
  • Family-caregivers for a veteran with severe brain injury need access to services in times of crisis and need the  knowledge and tools on how to deal with suicidal ideations. Providers should be open to using alternative therapies or approaches to help veterans with communication challenges.  Providers need to be flexible and  may need to look outside the VA if services are not available.  Providers must do all they can to draw the veteran into the treatment. 
  • Veterans should always be treated with compassion and respect—never as though they are on an assembly line. 

PTSD/TBI Veteran and Caregiver-Spouse

  • The veteran suffers from a number of serious physical conditions as well as PTSD and TBI.
  • There have been two incidents of suicidal ideations.  The first one was pain related.  The second one was in March of this year. 
  • “When my husband attempted suicide in March the VA doctor told me to take him to the ER.  But the ER had no beds and said he may have to wait 24 hours before one was available.  They gave me no alternatives.  I was scared and no one in the VA did anything to help us or help me know what to do in a situation like this,” said the caregiver.  She went on to tell us that the typical VA response is to give the patient a machine or medication.  “We just want VA to treat us like they care.”

Another severely wounded veteran who is an amputee and has TBI told us he was frustrated because his providers seldom talk to him or ask him how he’s doing.  Their questions and comments are usually directed at his Caregiver-spouse as though he isn’t even in the room. He said, “I just want them to know I can and want to contribute to my care—when they don’t talk to me it makes me feel like they don’t care about me.”

According to all these veterans and family members, they are unaware if their veteran’s record is flagged or ever has been a flagged as a high-risk patient or if the medical record contains a suicide prevention safety plan.

MOAA Recommendations

MOAA concurs with CNAS and RAND that suicide among veterans and servicemembers challenges the health of our all-volunteer force.   CNAS points to some compelling questions for our country to consider:

  • If military service becomes associated with suicide, will it be possible to recruit bright and promising young men and women at current rates?
  • Will parents and teachers encourage young people to join the military when veterans from their own communities have died from suicide?
  • Can an all-volunteer force be viable if veterans come to be seen as broken individuals?
  • And how might climbing rates of suicide affect how Americans view active-duty servicemembers and veterans—indeed, how service members and veterans see themselves?

While MOAA supports many of the recommendations and findings in the reports, studies and investigations mentioned above, the sheer volume of recommendations requires prioritizing efforts for improving VA’s suicide prevention program.  Therefore, MOAA encourages Congress to focus its attention immediately on three specific recommendations which will further enhance VA’s suicide prevention efforts as well as help address other systemic issues in its health care system. 

MOAA urges:

  • Requiring VA-DoD to establish a single strategy and a joint Suicide Prevention Office that reports directly to the Department Secretaries through the Senior Oversight Committee (SOC).

A joint office would be responsible for developing, implementing and integrating strategies, policies and procedures, and providing oversight and evaluation of suicide prevention programs and efforts. Congress needs to continue to be VA’s and DoD’s greatest champion for promoting collaboration, cooperation and communication across and between the two agencies.

A sense of urgency and oversight are needed to address the issue of veteran suicide at all levels of the government.  There needs to be a level of commitment similar to that given to wounded warrior issues which came out of the Walter Reed Army Medical Center incident.  VA has done a lot to engage with DoD to identify high-risk servicemembers so that a warm hand-off can be made to facilitate continuity of care.  But the agency acknowledges a number of challenges still exist because of cultures and the different policies and programs that vary across the DoD and the Military Services.     

  • Authorizing funding to expand VHA mental heath capacity and capability in order to improve access and delivery of quality and timely care and information.

Clearly, reports and studies continue to highlight problems with accessing care and shortages in mental health staffing and infrastructure.  The VA should invest in staff training, recruiting, and retention programs in order to maintain the highest quality work force and system of care.  Caregivers and family members should be provided training, information and tools on how to deal with suicidal ideations and mental health issues. 

Congress should fund research to evaluate the efficacy of suicide prevention programs to include a longitudinal study of the economic and societal costs of veteran suicide in this country.

Veterans should have more control over scheduling appointments. theVA must  be flexible in delivering care to meet the needs of veterans, including allowing fee based care in emergencies or when wait times exceed two weeks. 

  • Authorizing additional funding to expand outreach and marketing efforts to encourage enrollment of all eligible veterans in VA health care, with special emphasis on Guard and Reserve members, rural veterans, and high-risk populations. 

VA recognizes it needs to do a more effective job in working with outside community and faith-based organizations and other government agencies, beyond its current work with veteran and military organizations and other agency partnerships.  The VA should reward local medical facilities for expanding their collaborative efforts.  A long-term investment in outreach and marketing to improve its image and VA brand is needed to more effectively target these veteran populations.

Conclusion

MOAA believes there is a business case to be made for addressing suicide that should consider the impact on national security and the costs to society. 

MOAA has no doubt that, with the will and sense of urgency from Congress, the Administration, the DoD/Military Services, and  the VA, we can win the war on suicide.  Our veterans and military medical systems have eliminated some tremendous barriers with unprecedented results in saving lives on and off the battlefield.  We owe these heroes and their families our full commitment to eliminate remaining barriers to mental health care so they can obtain an optimal quality of life.

MOAA is encouraged by the significant progress made by the VA, and we thank the Subcommittee for your leadership and support in helping our nation’s veterans and their families.