Chairman Mitchell, Ranking Member Roe, and Distinguished Members of the HVAC Subcommittee on Oversight and Investigations, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on “Examining the Progress of Suicide Prevention Outreach Efforts at the VA”.  We should also like to thank you for your overall concern about the mental health care of our troops and veterans.

The subject of suicide is extremely difficult to talk about and is a topic that most of us would prefer to avoid.  Although statistics on suicide deaths are not as accurate as we would like because so many are not reported, as veterans of the Vietnam War and those who care for them, many of us have known someone who has committed suicide and others who have attempted it.  But as uncomfortable as this subject may be to discuss, VVA believes it to be a very real public health concern that needs solutions now.

Suicide is most often the result of unrecognized and untreated mental health injuries. Depression, Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) are three of the most common mental health injuries and conditions that can lead to suicide. The three conditions in particular are medical conditions that can be life-threatening. 

In more than 120 studies of a series of completed suicides, according to the American Foundation for Suicide Prevention, at least 90 percent of the individuals involved were suffering from a mental illness at the time of their death. The most important interventions are recognizing and treating these underlying illnesses, such as depression, alcohol and substance abuse, post-traumatic stress and traumatic brain injury. Many veterans (and active duty military) resist seeking help because of the stigma associated with mental illness, or they are unaware of the warning signs and treatment options. These barriers must be identified and overcome.

Consider the facts:  earlier this spring, troubling data showed an average of 950 suicide attempts by veterans who are receiving some type of treatment from the VA.  Seven percent of the attempts are successful, and eleven percent of those who don’t succeed on the first attempt try again within nine months.  These numbers show about 18 veteran suicides a day and about five by vets receiving VA care.  These numbers are simply unacceptable to both the veterans’ community and the American public.

To be fair, since media reports of suicide deaths and suicide attempts began to surface back in 2003, the VA has claimed to have developed prevention strategies to reduce suicides and suicide behaviors that includes:  the establishment of the Suicide Prevention Hotline in partnership with the Substance Abuse and Mental Health Administration; the institution of suicide prevention coordinator (SPCs) positions at all VA medical facilities

whose duties include education, training, and clinical quality improvement for VHA staff members; increased screening and monitoring of individuals who have been identified as being at high risk for suicide; and research efforts utilizing cognitive-behavioral interventions that target suicidal ideation and behaviors.  While these efforts are laudable, VVA continues to believe they have not gone far enough. 

In May 2008, then-VA Secretary Peake chartered “The Blue Ribbon Work Group on Suicide Prevention in the Veteran Population”.  Its function was to provide advice and consultation to him on various matters relating to research, education, and program improvements relevant to the prevention of suicide in the veteran population.  Although their report was not made public, the Work Group panel  presented a series of findings and recommendations to improve relevant VA programs, with the primary objective of reducing the risk of suicide among veterans.

The panel’s work was not made public because some in the VA claimed that even talking about suicide made it much more likely to occur among veterans and soldiers. VVA takes the view that transparency in government in general, and at the VA in particular, leads to better and more consistent application of the very evidence based medicine that is founded on peer reviewed science. It also would be in keeping with the proclaimed principles of the Administration of President Obama. Perhaps most importantly, it will lead to much more accountability in government. It is past time for the VA to make the full report public.

The Work Group report discussed eight key findings and recommendations:

Panel Finding 1. Conflicting and inconsistent reporting of veteran suicide rates were observed across various studies.

Blue Ribbon Recommendation 1: VHA should 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 among veterans.

Panel Finding 2. Suicide screening processes being implemented in VHA primary care clinics go beyond the current evidence and may have unintended effects.

Blue Ribbon Recommendation 2: The VA should revise and reevaluate the current policies regarding mandatory suicide screening assessments.

Panel Finding 3. The VA is attempting to systematically provide coordinated, intensive, enhanced care to veterans identified as being at high risk for suicide. However, the criteria for being flagged as high risk are not clearly delineated; nor are criteria for being removed from the high risk list.

Blue Ribbon Recommendation 3: Proceed with the planned implementation of the Category H flag, with consideration given to pilot testing the flag in one or more regions before full national implementation.

Panel Finding 4. The root cause analyses presented to the Work Group did not distinguish between suicide deaths, suicide attempts, and self-harming behavior without intent to die.

Blue Ribbon Recommendation 4: Ensure that suicides and suicide attempts that are reported from root cause analyses use definitions consistent with broader    VHA surveillance efforts.

Panel Finding 5. The emphasis by VHA leadership on the use of clozapine and lithium does not appear to be sufficiently evidence-based.

Blue Ribbon Recommendation 5: VHA should ensure that specific pharmacotherapy recommendations related to suicide or suicide behaviors are evidence-based.

Panel Finding 6. Efforts to improve accurate media coverage and disseminate universal messages to shift normative behaviors to reduce population suicide risk behavior are not being fully pursued.

Blue Ribbon Recommendation 6: The VA should continue to pursue opportunities for outreach to enrolled and eligible veterans, and to disseminate messages to reduce risk behavior associated with suicidality.

Panel Finding 7. Concerns about confidentiality for OIF/OEF service members treated at VHA facilities may represent a barrier to mental health care.

Blue Ribbon Recommendation 7. The issue of confidentiality of health records of OIF/OEF service members who receive care through the VHA should be clarified both for patient consent-to-care and for general dissemination to Reserve and Guard service members contemplating utilizing VHA medical system services to which they are entitled.

Panel Finding 8. The introduction of Suicide Prevention Coordinators (SPCs) at each VA medical center is a major innovation that holds great promise for preventing suicide among veterans; however, there is insufficient information on optimal staffing levels of SPCs.

Blue Ribbon Recommendation 8. In order to maximize the effectiveness of the Suicide Prevention Coordinators program, it is recommended that there be ongoing evaluation of the roles and workloads of the SPC positions.

In addition to the above central findings and recommendations, the Work Group panel identified fourteen other areas for possible action, including: 

• adopting a standard definition for suicide and suicide attempts;
• preparing a single document that details the comprehensive suicide prevention strategy;
• considering a public health approach as part of the VA framework for suicide prevention that goes beyond secondary and tertiary prevention;
• expanding the portfolio for suicide research across the VA, with suicide prevention prioritized as a research area;
• considering the establishment of an Advisory Board of key VA stakeholders involved in suicide prevention, education, treatment, and research;
• increasing VA efforts to reach out to community emergency departments to improve care for active duty service members and veterans at risk for suicide;
• continuing efforts to promote training in implementing suicide prevention programs;
• developing and implementing follow-up interventions for veterans identified as being at risk;
• working collaboratively with other federal agencies to understand the implications of new technologies for suicide prevention;
• designing and disseminating psycho-education materials for families of veterans at risk for suicide, particularly those hospitalized for suicide attempts;
• considering more intensive therapies for veterans who exhibit chronic suicidal behavior;
• more effectively integrating pastoral care services and traditional mental health services;
• implementing a gun safety program directed at veterans with children in the home; and
• analyzing entitlement changes required to allow treatment of combat-related conditions to reduce suicides in un-entitled veteran populations.

Suicide prevention, of course, starts with leadership.  However it has been almost two years since the Blue Ribbon Work Group finished its work and we have yet to see any formal action plan that addresses each of the Group’s findings and recommendations in a comprehensive, prioritized fashion.  In fact, no one outside a select circle of bureaucrats at the Veterans Health Administration (VHA) has ever seen the complete report of this panel, which was of course, funded with taxpayer dollars.

Why not?

There are no valid reasons for keeping this report a secret. The Russians do not have spy networks out looking for copies of this report, so there is no valid national security reason not to make this report available to the Congress, to veterans advocates, to VA’s own clinicians at the service delivery level, and to the public. The reason for the delay initially was to give the VHA time to design a good implementation plan to carry out all of the panel’s recommendations, and to take steps to address concerns raised by the report, it seems to us at Vietnam Veterans of America (VVA) that twenty one months is enough time to do that, even with the change in formal leadership as to the  Undersecretary of Health. Dr. Petzel has now been on the job long enough to review any such plans, and be ready to implement the recommendations in a timely way.

This subcommittee must ensure that our veterans and their families are given access to the resources and programs necessary to stem the tide of suicide. The first step in that process is knowing what has been recommended by the best medical scientists the VA could assemble to study the problem (the above referenced report), and what is being done to implement the recommendations and address the findings of those experts.

While we do not mean to distract from the basic thrust of this hearing, VVA points out that PTSD is a common condition among veterans that often leads to suicide attempts. We continue to be troubled that VHA has also not implemented, nor seemingly even tried to implement, the recommendations of the report commissioned by the VA and delivered by the Institute of Medicine (IOM) of the National Academies of Sciences (NAS) on June 16 of 2006 entitled “Posttraumatic Stress Disorder: Diagnosis and Assessment.” (http://iom.edu/Reports/2006/Posttraumatic-Stress-Disorder-Diagnosis-and-Assessment.aspx ) Even more troubling is that the Department of Defense has not tried to systematically implement these very important findings as to the best medical science can recommend as to proven techniques and procedures for accurately diagnosing and properly assessing Post traumatic Stress Disorder (PTSD). If you do not accurately diagnose and accurately assess a veterans’ (or a returning war fighters’) condition as PTSD which may be so acute that he or she is at risk of attempting to take their own life, then there is no way that you can effectively intervene or treat that American who has put their life on the line for our country. This is bad medicine, and it leaves our veterans at risk. VVA hopes that this distinguished Subcommittee will take a look at this issue, perhaps as a  follow up to this hearing.

Once again, on behalf of VVA National President John Rowan and our National Officers and Board, I thank you for your leadership in holding this important hearing on this topic that is literally of vital interest to so many veterans, and should be of keen interest to all who care about our nation’s veterans. I also thank you for the opportunity to speak to this issue on behalf of America’s veterans.

I shall be glad to answer any questions you might have.