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U.S. Department of Veterans Affairs Suicide Hotline.

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SEPTEMBER 16, 2008

SERIAL No. 110-104

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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
JEFF MILLER, Florida, Ranking
HENRY E. BROWN, JR., South Carolina

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



September 16, 2008

U.S. Department of Veterans Affairs Suicide Hotline


Chairman Michael Michaud
    Prepared statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member
    Prepared statement of Congressman Miller


U.S. Department of Health and Human Services, Captain A. Kathryn Power, M.Ed., USNR (Ret.), Director, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration
    Prepared statement of Ms. Power
U.S. Department of Veterans Affairs, Janet E. Kemp, RN, Ph.D., National Suicide Prevention Coordinator, Veterans Health Administration
    Prepared statement of Dr. Kemp

1-800-SUICIDE, and National Hopeline Network, Henry Reese Butler II, Founder
    Prepared statement of Mr. Butler
American Psychological Association, M. David Rudd, Ph.D., ABPP, Professor and Chair, Department of Psychology, Texas Tech University, Lubbock, TX
    Prepared statement of Dr. Rudd
MHN, A Health Net Company, San Rafael, CA, Ian A. Shaffer, M.D., Chief Medical Officer
    Prepared statement of Dr. Shaffer
National Veterans Foundation, Tyrone Ballesteros, Office Manager
    Prepared statement of Mr. Ballesteros
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior Analyst for Veterans’ Benefits and Mental Health Issues
    Prepared statement of Dr. Berger


Iraq and Afghanistan Veterans of America, Tom Tarantino, Policy Associate, statement


Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs, to Hon. James B. Peake, Secretary, U.S. Department of Veterans Affairs, letter dated September 24, 2008, and VA responses


Tuesday, September 16, 2008
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to call, at 10:00 a.m., in Room 340, Cannon House Office Building, Hon.  Michael Michaud [Chairman of the Subcommittee] presiding.

Present:  Representatives Michaud, Hare, Miller, and Buchanan.


Mr. MICHAUD.  I would like to call the Subcommittee on Health to order.  I would like to welcome everyone today.  We are here today to talk about the U.S. Department of Veterans Affairs (VA) suicide prevention hotline.  In May of 2007, the Veterans Health Administration (VHA) mental health officials estimated 1,000 veterans receiving care from VHA committed suicide each year.  Likewise, the rate of suicide among servicemembers appears to be on the rise.  The Army recently reported that suicide among active-duty soldiers this year are on pace to exceed last year's all-time record.  And that is of the general population, as well.

In July of 2007, VA collaborated with the Substance Abuse and Mental Health Service Administration (SAMHSA) to launch the VA Suicide Prevention Hotline.  This hotline is a toll-free number that is manned 24-hours a day, seven days a week.  As of September of 2008, the hotline has served nearly 33,000 veterans, family members, or friends of veterans, that resulted in more than 1,600 rescues, to prevent suicide.

Over the past year, this Committee has held many hearings examining suicide among veterans and VA strategy for suicide prevention.  Among the risk factors for suicide is post traumatic stress disorder (PTSD), a disorder that affects many veterans.  While I commend the VA for implementing a suicide prevention hotline, I would like to hear how the hotline fits in with VA's overall strategy to combat suicide.  Furthermore, I would like to investigate regarding the hotline staffing as well, and I look forward to hearing our panels today, to discuss how to improve the hotline to best serve our Nation's veterans.

I would like to now recognize Congressman Miller for any opening statement that he might have.

[The statement of Chairman Michaud appears in the Appendix.]


Mr. MILLER.  Thank you very much, Mr.  Chairman.  I appreciate you holding this hearing today to assess the VA's suicide prevention efforts, in particular the establishment of a hotline for the veterans.  There is nothing more tragic than a servicemember who has fought to defend the freedom of the United States of America to end their own life.

It is extremely disturbing to everyone that each year, VA estimates that there are about 6,500 veterans that commit suicide.  It is well-known that there are a number of factors that increase the risk for a veteran to attempt suicide.  They include combat exposure, PTSD, and other mental health problems, traumatic brain injury (TBI), and access to lethal means.

That is why it is vitally important that the VA understands and responds to the needs and risks of the veterans, especially those who are the newest generation of our combat veterans today.

Last year, we enacted Public Law 110-110, the "Joshua Omvig Veterans Suicide Prevention Act," requiring VA to establish a comprehensive program for suicide prevention among veterans.

I have other comments that I would like entered into the record, but I think it is more important that we move forward to today's discussions.  Mr. Chairman, I ask that my full statement be entered into the record, and yield back.

[The statement of Congressman Miller appears in the Appendix.]

Mr. MICHAUD.  Does any other Member have an opening statement?

If not, I would like to call our first panel, Captain Power, who is the Director of the Center for Mental Health Services in the U.S. Department of Health and Human Services (HHS).  I want to thank you very much, Ms.  Power, for your willingness to come here this morning, and I look forward to hearing your testimony.


Captain POWER.  Thank you very much, Mr.  Chairman, Mr.  Ranking Member, and Members of the Subcommittee.  Good morning, I am Kathryn Power, Director of the Center for Mental Health Services within the Substance Abuse and Mental Health Services Administration.  I respectfully request that my written statement be submitted for the record, and I am very pleased to offer testimony this morning on behalf of Dr. Eric Broderick, Assistant Surgeon General and Acting Administrator of SAMHSA, from the Department of Health and Human Services. 

And as a captain in the U.S. Navy reserve, who just recently retired, I am a veteran.

Thank you for the opportunity to describe how SAMHSA is working to prevent suicides among our Nation's veterans.  And I have the privilege of working with and developing a strong partnership with the members of the Department of Veterans Affairs.  And we now have a current interagency agreement that focuses on helping to prevent suicides by veterans.  Just last month, SAMHSA and the VA, along with the U.S. Department of Defense (DoD), sponsored a three-day conference on meeting the mental and behavioral health needs of our returning veterans and their families, with a very strong focus on suicide prevention interventions.

Suicide is a major public health problem for our Nation.  There is a suicide every 16 minutes.  Thirty-two thousand people died by suicide in 2005.  It is a leading cause of death across the lifespan among both veterans and non-veterans.  To reduce suicide nationally requires that our efforts include a sustained focus on preventing suicide across all Americans, and especially on veterans to whom we owe so much.

SAMHSA provides national leadership for suicide prevention, and it is consistent with the national strategy for suicide prevention.  We have three major prevention initiatives within the Center for Mental Health Services.  The first of these initiatives is the Garrett Lee Smith Youth Suicide Prevention Grant Program.  As of October 1st, 2008, more than 50 States, tribes, and tribal organizations, as well as 50 colleges and universities, will be receiving funding for youth suicide prevention programs through the Garrett Lee Smith Act.

The second initiative is a Suicide Prevention Resource Center, which is a national technical assistance Center that advances the field by working with States, territories, tribes, and grantees, and by developing and disseminating suicide prevention resources. 

The third major initiative is the National Suicide Prevention Lifeline, the program that has been at the centerpiece of our partnership with the Department of Veterans Affairs to establish the Veteran Suicide Prevention Hotline. 

The lifeline is a network of 133 crisis centers across the United States that receive calls from national, toll-free suicide prevention hotlines, primarily 1-800-273-TALK.  The network is administered through a grant from SAMHSA to link to Health Solutions, which is an affiliate of the Mental Health Association of New York City.

Calls to 1-800-273-TALK are automatically routed to the closest of the 133 crisis centers across the country.  Those crisis centers are independently operated and independently funded.  They all serve their local communities in 47 States, and operate their own local suicide prevention hotline numbers.  They have agreed to accept local, State, and regional calls from the National Suicide Prevention Lifeline, and receive a small stipend for doing so. 

In three States that currently do not have a participating crisis center, the calls are answered by a crisis center in a neighboring State.  All the calls are free and confidential, and are answered 24 hours a day, seven days a week.

By utilizing a national network of crisis centers with a trained staff linked through a single national toll-free hotline prevention number, the capacity to effectively respond to all callers is maximized.  Early in 2007, SAMHSA and the VA began exploring strategies for a potential collaboration.  It became quickly apparent that using the National Suicide Prevention Lifeline as a front end for the suicide prevention hotline would offer numerous, very important advantages.  Callers in crisis would hear the following message: "If you are a U.S. military veteran, or you are calling about a veteran, please press one."

On the very first day of operation, callers were able to be connected.  At both SAMHSA and VA, we have promoted the 1-800-273-TALK number, and the number of callers pressing one has increased dramatically.  They can press one and be connected to the VA Center in Canandaigua, New York, or they cannot press one and be connected to their local crisis centers.  We think that this connection is one of the best ways in which individuals who are veterans can receive follow-up services arranged by the VA's suicide prevention coordinators.  It is the best, most extensive system for providing follow-up care to individuals who call the hotline. 

We, in fact, know that in the future, we are going to continue to work with the VA to expand our efforts and to utilize the network of crisis centers to reach out to as many veterans as possible.  We, in fact, know that our support of the lifeline, including ongoing evaluation efforts, will in fact continue to help us enhance the services that are available.

I will defer to Dr. Kemp to provide you with more specific information on the call volume for the veterans hotline.  We are so pleased to have been able to work together with the Department of Veterans Affairs to help deliver the critically important messages that suicide is preventable, and that help is available.  All Americans, veterans as well as the general public, have access to the National Suicide Prevention Lifelines at any time, and especially during times of crisis, and we are committed to sustaining this vital national resource.

Mr. Chairman, Members of the Subcommittee, I thank you very much for the opportunity to appear, and I will be pleased to address any of your questions.

[The statement of Captain Power appears in the Appendix.]

Mr. MICHAUD.  Thank you very much for your testimony.  You mentioned that pressing one will connect you to the VA counselor.  How many veterans opt to connect to the local crisis center?

Captain POWER.  I believe Dr. Kemp will have those statistics, because they are really the keeper of the statistics on the veterans' information.  And we have a breakdown, but I would not want to give you the incorrect number, so I will defer to Dr. Kemp.

Mr. MICHAUD.  Okay.  And you mentioned that three States do not have it.  What are the three States?

Captain POWER.  Let me look here.  That I will probably need to get for you.  I don't have the three States.  I have the list of the 47 States in front of me.  How about if I give you the list of the 47 States?  Then we can figure it out alphabetically who is missing.  How about that, Mr. Chairman?

Mr. MICHAUD.  Okay.  We will follow up on that.

I noted in your testimony that VA had the most extensive system for providing follow-up care to suicidal hotline callers.  Are there any other areas where the VA could improve their system?

Captain POWER.  Well, I think we know that—we have discovered, actually, as we have done oversight on our network of crisis centers, that the follow-up to callers is hugely important, and we are understanding and learning more and more, and learning in a better way, the kind of follow-up that would work, and we actually are sharing that information with the VA, so that as they learn the kinds of contacts, the kinds of information, the kinds of engagement strategies that are necessary to keep veterans engaged, we are also learning that from the general public side, and I think that is information that we hope will be shared, where there are always better strategies to learn about engagement, there are always better ways to learn about how to keep people connected and keep people focused on their own survival, and moving into appreciation of their life moving forward.

So we are really exploring, with many of our other crisis centers, techniques for that kind of more intensive follow-up and research on that, and we are going to be sharing that with the VA, and they have asked to actually share that with us.

Mr. MICHAUD.  So you will be researching that more?

Captain POWER.  Absolutely, Mr. Chairman.

Mr. MICHAUD.  Even though you didn't know the number of veterans that choose to access the local counselors over VA, do you know the reasons why they would prefer a local counselor versus a VA counselor, or is that something I had better ask someone else?

Captain POWER.  Let me tell you what I remember from the most recent press releases, is that when we looked at the last year's calls, we know that there had—I think, and Jan can probably correct me if I am incorrect, but I think of the calls that were received by the hotline, there were about 55,000 calls that were received, and I think about 20,000 of them were identified as from veterans.  And she can certainly verify the numbers.  But that is what I recall from our press release at SAMHSA.

And what we find is that there are people who call who may have a family member who is a veteran, and they don't necessarily want to say that first, so they go to the local crisis center first to find that information.  And one of the things that we found through the lifeline network is that even though the local crisis centers may not have had experience with veterans, we are doing a selective training program with the lifeline and with the VA for all of the crisis centers, so that even those people who do not press one will be fully informed about the potential for veterans or veterans' family members or veterans' loved ones calling in the hotline.

So of that percentage that identify themselves as veterans, I think it was 20,000 out of the 55,000, the other members who go elsewhere oftentimes there are individuals, and as now, as a former military member and as a veteran now myself, there are times when you perhaps want to think about whether or not you want to be connected into the VA system, or you want to understand what is available in the VA system first.  And there are certainly people who may choose to say, "I really do not want to get connected with the VA system.  I really want to try some of my local resources or some of my family resources first." And those are just natural human decisions that are made.

Mr. MICHAUD.  My last question is, are there any peak periods when people tend to call in? Is it more at nighttime, in the morning, mid-afternoon?

Captain POWER.  I think there are certainly cyclical times, when you can anticipate, and I actually used to operate a hotline when I did rape crisis and domestic violence work, and there are certainly cyclical times on the calendar, certainly during periods of time during holidays, during times of high emotion; in Thanksgiving season, in Christmas season, and Hanukkah season, those seasons that might remind people about the fact that they are missing family members, or that they are having—it may be a time when the stress is raised and they think about their economic situation or their social situation.  You could really see that.

And also there are cyclical times during the 24-hour cycle, when people may be alone in the late evening hours, and may be more inclined to want to reach out to talk to someone because they are by themselves, or they are contemplating taking some action against themselves, or hurting themselves.

So yes, generally you have an understandable pattern.  And actually, that is quite local.  Generally, your local crisis centers will have a fairly good idea about their population, about the way their population responds, about what are the cultural and ethnic morays of the group that is in their crisis catchment area.  And you have a very good way of anticipating when you might have an increase or decrease in calls.

Mr. MICHAUD.  Great.  Thank you very much.

Mr. Buchanan?

Mr. BUCHANAN.  Thank you, Mr. Chairman. 

You state in your written testimony that you were at a conference last month between three organizations, VA, and the DoD, focusing on working together to prevent suicides among veterans.  What did you take away, I guess is the first question?  And what did not get addressed that you think should be addressed to improve the situation working together between these three organizations?

Captain POWER.  The conference was the second time that SAMHSA had sponsored a summit, really, on veterans' issues.  And our purpose was to focus on behavioral health issues.  We knew that many of the other organizations, of course, have responsibility; the DoD for the active duty, and the VA for veterans; for healthcare.  And we really have developed I think a very close partnership, with seeing SAMHSA as an available resource, to both the Department of Defense and Veterans Affairs Administration, in the areas of mental health, mental illness, and substance abuse and addiction.

And the first conference we sponsored basically said, "You really need to get smarter about sharing with each other the kinds of interventions that work, the kinds of strategies that are effective, and start to share with each other evidence-based practices," because frankly, the Department of Defense has some wonderful pockets of excellence on evidence-based practice that we at SAMHSA didn't know about and perhaps the Veterans Administration didn't know about. 

So the Department of the Air Force, for example, has a specific suicide prevention program.  And we found that over the years, as we shared information under our Federal partners organization, that there was really opportunity for us to speak about, with each other, and begin to share that information with States and local providers, and that was really the purpose of the conference.  We had State teams coming to the conference.  There were States that applied to come to this conference, and we have a policy academy in which the Department of Defense, SAMHSA, and the VA, and State providers and local providers, talked about what were the most effective ways of reaching out to veterans, getting them into care, getting their families knowledgeable about community services, getting them connected to local VA or regional VA services, and sharing all of those practical logistics information, as well as what are the evidence-based practices that work?  And that was really a marvelous opportunity to do that.

Mr. BUCHANAN.  Another question, coming out of the private sector, there is a saying, "If you cannot measure it, you cannot manage it." I guess from a performance standpoint at SAMHSA, what are you using to evaluate the National Suicide Prevention Lifeline?  Do private crisis hotlines utilize the same performance criteria?  So, what are we doing to make sure that we are making progress?  Do we have a way of measuring that?

Captain POWER.  There are actually two things that we are doing.  The first is the President's Management Agenda and the Department of Health and Human Services expects us to develop performance measures for our entire suicide prevention portfolio, and we have to report on those measures on a quarterly basis to the leadership at the Department of Health and Human Services.  And we look at performance measures that address the suicide rate, the suicide incidence, and suicide prevalence.  And most of that information is based on the Center for Disease Control and Prevention's (CDC's) statistics about suicide, so we respond to suicide data that is collected by CDC, and we are measured against whether or not we are able to prevent suicide in terms of the overall suicide rate.

Most of our programs, through the Garrett Lee Smith Act, have been focused on youth suicide prevention.  And so we are measuring the reduction, or we are measuring the level of youth suicide attempts, and youth suicide activity, through the data-gathering efforts of the CDC.  So we are doing that at a macro level.

At a more micro level, we have a very rigorous evaluation process that is in play for the lifeline.  And so we do a periodic evaluations of the quality of the crisis centers, and the quality of the responses, the quality of the training, the certification that the crisis centers go through.  These are all measures that we use to help evaluate the crisis center networks, and the efficacy and quality of the engagement and communication, and certainly, we measure the fact that there were a number of calls.

And the evaluations, actually, we should share the latest evaluations with you because we found that of all the reported effects of a suicide hotline were that stress and distress reduced considerably during the period of the call, that over 12 percent of the callers said that they did not complete suicide based on having a connection with a human being and having a conversation, and that the level of suicide ideation decreased over time, and having that opportunity.

So there are specific measures within the evaluation of the lifeline that we can show evidence that the intervention is working.

Mr. BUCHANAN.  My last question is what type of outreach has been conducted to inform people about the National Suicide Prevention Hotline?  What are we doing to make sure we are doing as much as we can to get the outreach out there?

Captain POWER.  We have a suicide prevention priority area for SAMHSA, and we are working in conjunction with the VA, so we do both our own development of press releases, information, pocket cards, magnetic strips, a lot of those kinds of social marketing tools that we use we give out to providers, we give out to States, hundreds and hundreds of thousands of flyers, billboards—not hundreds of thousands of billboards, but billboards, and materials that we push out to the local level, to the State level, to college campuses.  We did a particular, over half a million distribution of items after the Virginia Tech incident.  And we mobilize our resources to get that kind of information in public messaging and in social marketing.  We started to use places like Facebook and MySpace, and all of the Internet connections to get the word out about the availability of the lifeline.

And the VA has really taken on a tremendous public affairs advertising and awareness campaign about the lifeline.  And I am sure they will talk to you about that.  We are working in conjunction with them.  They have their own constituencies and networks that they want to get this information to, and SAMHSA certainly has an interest in getting the information out, just from a public health, public access, public safety perspective.

So we use the works that we have in our communication strategy at SAMHSA to get the word out.

Mr. BUCHANAN.  Thank you, Captain POWER.  Thanks for taking your time today, and I yield back, Mr. Chairman.

Mr. MICHAUD.  Thank you.  Thank you very much for your testimony.

Captain POWER.  Thank you very much.

Mr. MICHAUD.  I would ask the second panel to come forward.

On the second panel we have Dr. Tom Berger, who is from the Vietnam Veterans of America (VVA); Dr. Rudd, who is with the American Psychological Association (APA); we have Mr. Ballesteros, the Office Manager for the National Veterans Foundation; and Mr. Butler from the Kristin Brooks Hope Center; and Dr. Shaffer, who is the Chief Medical Officer of MHN.  I want to thank our panelists here this morning, and I look forward to hearing your testimony, as we deal with this very important issue.

I would like to start off with Dr. Berger and just work down the table.



Dr. BERGER.  Thank you, Mr. Chairman, Mr. Buchanan and Mr. Hare.  Vietnam Veterans of America thanks you for the opportunity to present our views on oversight of the Department of Veterans Affairs Suicide Prevention Hotline.  We should also like to thank you for your overall concern about the mental healthcare of our troops and veterans.  And with your permission, I shall try and keep my remarks brief and to the point.

The subject of suicide is extremely difficult to talk about, and it is a topic that most of us would prefer to avoid talking about.  But as uncomfortable as the subject may be to discuss, VVA believes it to be a very real public health concern in our military and veteran communities.  And 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.

As you are well aware, last week on September 9, the VA issued a press release that included information about the blue ribbon panel that Secretary Peake had formed to deal with the suicide issue in the VA.  And among the items addressed in the draft report was information on the hotline including the following: nearly 33,000 veterans, family members, or friends of veterans have called the lifeline.  And of those, there have been more than 1,600 rescues to prevent possible tragedy.

In the absence of any yet-implemented VA national suicide surveillance plan or program for veterans, the caller data seem impressive, and the VA is to be congratulated in this endeavor.  But there are some very real questions that remain to be answered.  Because one veteran rescued from suicide is certainly worth the effort. 

What is the daily window of calls?  How many calls have to be rerouted to high-volume backup call centers?  What is the definition of "rescue?" Sixteen hundred rescues represents only .048 percent of the calls.  What is the status of the rest of the calls?  Is there a follow-up or tracking procedure?  For one month, three months, six months?  How many calls are from veterans already enrolled in the VA system?  How many have attempted suicides vigorously?  And how many veterans of those callers participated in actual combat operations?

The VA deserves congratulations on the implementation of the suicide hotline, as it represents a cornerstone in strategies to reduce suicides and suicidal behaviors among veterans, and I am hoping that Dr. Kemp will provide information to answer the questions that were raised.

However, remember that the real first line of defense against suicide for the last 25 years in the veterans community has been the VA Vet Centers, the readjustment counseling service.  There is still a need to hire professional counseling staff at existing VA centers, in order that the Vet Centers have the organizational capacity to meet all of the demands and needs of other generation of combat veteran.

Furthermore, the hotline can be improved upon significantly by instituting a better tracking system, linking into VA healthcare, better identification of where the veterans have served in terms of their military service, and other significant epidemiological markers.  We encourage this Subcommittee, in particular, to exercise diligent oversight as the VA addresses the eight major recommendations of the blue ribbon workgroup on suicide prevention.

I would be glad to answer any questions you might have.  And again, I thank you on behalf of the officers,  Board, and members of VVA, for the opportunity to speak to this vital issue on behalf of America's veterans.

I would like to tell one story about the suicide hotline, and it is personal.  Some of you may recall earlier this spring about one of the History Channel, the Military Channel, showed a program detailing life, 24 hours in the day of an emergency room (ER) combat hospital, we called them the Battalion Aid stations back in Vietnam.  When Vietnam Veterans of America learned of this program, I personally called Dr. Kemp, and told her I had some concerns that the showing of this program might have an impact on the veterans community.  Dr. Kemp responded very, very positively.  In fact, for the two nights that the program ran, she hired additional counselors to man the phone lines.

Thank you.

[The statement of Dr. Berger appears in the Appendix.]

Mr. MICHAUD.  Thank you. 

Doctor Rudd?


Dr. RUDD.  Mr. Chairman and Members of the Subcommittee, I want to express my appreciation for the opportunity to testify on behalf of the 148,000 members and affiliates of the American Psychological Association regarding the newly-minted and vitally important Department of Veterans Affairs' suicide prevention hotline.

As a psychologist and a fellow veteran, the urgent need to prevent suicide among veterans has particular salience for me.  As the recently released numbers indicate, the problem of suicide among active-duty serviceman and women and military veterans continues to grow, with the suicide rate for young male veterans escalating more than double that of the general population.

What is undeniable is that psychological casualties are very much a consequence of war.  What is less clear is how the VA and mental health providers nationwide can work to meet the demand, providing appropriate and necessary mental and behavioral health care and preventative services, as an essential element of the VA system healthcare mandate.

Not only does the VA system face increasing numbers of veterans with multiple and complex mental and behavioral health problems, it is also challenged by a culture of shame, stigma, and fear, which complicate efforts to improve access to care.  Whether or not the hotline actually has overcome this is an interesting question, and I think one that warrants very careful study and scrutiny.  Misconceptions about the nature and effectiveness of mental and behavioral health care serve as a formidable barrier to engaging many veterans.  Reaching veterans in need requires creativity and flexibility.

The recently implemented hotline is an important and potentially life-saving program.  The latest usage figures confirm the need for such services, but only tell a part of the story.  VA efforts to identify and flag the health records of high-risk individuals may well also save lives, hopefully improving communication across specialty and primary care providers something this critical.

One thing that the suicide literature has revealed is that very simple things can save lives.  While I applaud the VA efforts for implementing the hotline, and am enthusiastic about the program, let me offer a few words of caution.  It is critical for the VA to study the efficacy of the program, gathering data to definitively answer critical clinical questions.  And this is consistent with what Dr. Berger just said.  We need to know that the hotline is actually reaching the highest-risk veterans.

The available literature on crisis and suicide hotlines has provided some interesting findings, and they are not always positive.  For example, in a study in which participants were aware that they were being monitored, it was discovered that 50 percent of hotline workers did not ask about suicidality during the call. And these are the same crisis centers that were referenced earlier.  That is a remarkable finding.  I think it is one that really speaks to the issue about careful training, careful monitoring, and in being sure that we track the system very well.

And if you are looking at the issue about training in overall effectiveness, I think it is important to look well beyond those numbers, in terms of a call.  We need to think about things like wait times for face-to-face appointment for people that are not already in the system, subsequent emergency room visits, as well as suicide attempts, and suicides that follow hotline access.  That ultimately is the critical question, does it reduce the number of ER visits?  Does it reduce the number of suicide attempts?  And does it reduce the number of deaths as a result of suicide?

It is important to consider how the hotline system is integrated into the existing VA system of care.  Will VA mental health and other appropriate treatment providers be notified when one of their patients makes a call to the hotline?  What and how much information is going to be transmitted about the call?  How will the hotline information be recorded in health records to facilitate tracking and outcomes assessment?  What if the individual asks for confidentiality, and does not want information to be recorded and released?

These are just a few of the questions to consider.  It is also important to remember the challenge of not just getting veterans into care, but keeping them in care.  As we learned about Vietnam, this is going to be a long-term problem, so it is more than just about improving access to care; it is about keeping people in care over the long-term.  If that happens, lives can be saved.  The efficacy of treatment for the full range of mental and behavioral health problems is actually quite impressive.  The VA also has an opportunity to be creative and expand its response to the critical problem of suicide among veterans.  This can include reaching out beyond the VA system, coordinating care with community providers, and creating innovative suicide prevention programs for veterans on college and university campuses.  You heard a little bit about that earlier in some testimony.  The breadth and depth of the problem is staggering, cutting across virtually every community in the U.S.  Many veterans enroll in a college and university after returning home, a figure that reached over half a million in 2007.  The number is expected to increase significantly in the years ahead.  College campuses are, and must remain, important places to address the issue of suicide prevention as it relates to the veteran population.

SAMHSA currently funds 50 programs nationwide in this area, and efforts are underway to allow SAMHSA to support direct services for students on campus, an increasing number of whom will be veterans, and the range of those mental health and behavioral needs can, as a result, be met.  These investments in our veterans, as well as those of other students enrolled, will go a long way towards ensuring their future success in college, as well as the health and well-being of the Nation overall.

I thank you for the opportunity to speak here today, and look forward to the chance to answer any questions that you might have.

Mr. MICHAUD.  Thank you.

[The statement of Dr. Rudd appears in the Appendix.]

Mr. MICHAUD.  Mr. Ballesteros?


Mr. BALLESTEROS.  Thank you, Mr. Chairman and Members of the Subcommittee.  On behalf of the National Veterans Foundation I would like to express our appreciation for this opportunity to appear before the Subcommittee.  I believe a short description of our organization is in order to put our concerns into perspective.

Briefly stated, the National Veterans Foundation came to existence in 1985 and was founded by Shad Meshad, a Psych officer with field experience during the Vietnam conflict, co-author of the VA Vet Center Program and currently, the President of the National Veterans Foundation.

As a component of our national toll-free lifeline, we provide training for our counselors in crisis management, including suicide prevention and intervention.  In addition, we have two staff members who are mental-health professionals trained extensively in trauma, crisis, and suicide counseling, and are on call to assist our staff answering the lifeline, and intervene and follow up as need arises.

It should be noted that in addition to not having any contractual relationships with any government agency, we are not a contracted crisis center for the National Suicide Prevention Lifeline.  More to the point, the task before this Subcommittee today, we have an area of concern we believe should be addressed by its members to ensure the Veterans Suicide Prevention Hotline is performing to its potential.  Our concern is whether or not personnel responding to calls received at the National Suicide Prevention Hotline after a veteran caller is directed to the VA Medical Center in Canandaigua, New York, have received the proper training in both suicide prevention and the causes of suicidal tendencies specific to veterans.

We do raise this concern before the Subcommittee.  Unfortunately, when our staff members called the National Suicide Prevention Lifeline to test the services offered, we were subsequently directed to the VA Center in Canandaigua.  The results were not satisfactory, at least not to standards of our organization.  The primary advice given to our staff members was to refer them to the closest VA medical facility, and advise them to hang on and be patient until the facility can contact them. 

Our concern is the reluctance of the person advising the caller to address an immediate suicidal ideation, and lack of the exploration of other means to provide the caller with immediate assistance.  This leads us to believe the personnel receiving these calls are not properly trained.  We could have simply experienced an anomaly in the system, as we are not privy to the training guidelines used by the VA, and our survey was not done with approved statistical sampling as that is not a function of our organization. 

But to ignore the problem we experienced could place veterans' lives in danger.  If the caller simply receives a telephone number, address, and directions to the closest VA Medical Center, this would be wholly inadequate by anyone's standards.  We offer the following questions to the Subcommittee, who may wish to investigate further, and which we believe can be answered in the affirmative if the proper training is provided.

Question number one: Are procedures in place to provide for follow-up communication with the caller, if the need is determined during the initial call?

Question number two: Has the attempt been made to determine whether the veteran's specific problems are the cause of the suicidal situation?  If so, was the information used to provide the caller with proper guidance?

Question three: Are there mental-health professionals trained in suicide prevention techniques and causes of suicidal tendencies specific to veterans available to immediately intervene if necessary?

And question four: Are the personnel who staff the hotline adequately trained in crisis communication, listening skills, and suicide intervention?

We simply ask that the Subcommittee ensure the procedures, protocols, and training are in place to ensure that a suicidal veteran can make a telephone call to seek help, and know that properly trained professionals will answer their call.

Our organization remains available to answer any questions you or your staff may have to provide with the additional documentation.  Mr. Chairman, again, thank you and the Subcommittee Members for allowing me to appear before you today.

[The statement of Mr. Ballesteros appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Ballesteros.

Mr. Butler?


Mr. BUTLER.  I would also like to thank you, Chairman and the Subcommittee Members, for inviting me to speak today.  My name is Reese Butler.  I am the Founder of 1-800-SUICIDE, and the National Hopeline Network.  I started 1-800-SUICIDE in response to my wife Kristin's tragic, preventable suicide on April 7th, 1998.  Prior to her death, there was no national hotline.  There was also a common misperception in America that suicide was not preventable.  Consequently, there was little motivation for potential donors and grant makers to fund such a service.  For this reason, I sold my home and used my wife's life insurance premium to create the Kristin Brooks Hope Center in her honor, and start 1-800-SUICIDE.  No national suicide hotline in 1998, and now we have too many.

Ten years ago this week, 1-800-SUICIDE went live.  Since then, the National Hopeline Network has routed more than 3 million people to help and hope.  In 2001, the Kristin Brooks Hope Center received funding from Congress to support and evaluate a national suicide hotline network for the very first time in history.  Prior to that, through 40 years of crisis hotlines' existence, there was never one single study that was considered valid.

Congress, mind you, authorized SAMHSA to support and evaluate the effectiveness of an existing suicide hotline network, not create one, not compete with one.  SAMHSA's own independent study concluded the National Hopeline Network, 1-800-SUICIDE, as owned by the Kristin Brooks Hope Center, was indeed effective.  Then contrary to the findings of the President Bush's Mental Health Commission, that called for ending duplication and maximization of resources, SAMHSA attempted to seize control over the National Hopeline Network.  And failing that, they created an anti-competitive, duplicative system, and has issued press release after press release distorting the truth about 1-800-SUICIDE and the veterans' suicide hotline, 1-800-273-TALK.

And evaluation call records demonstrates that few, if any, veterans are calling the government-controlled 1-800-273-TALK.  This is despite the fact that SAMHSA has claimed more than 22,000 veterans have called that number.  These agencies have issued press releases since the launch of the Veterans Suicide Hotline in July of 2007 that are at best, grossly misleading.  In testimony given before the House Committee on Veterans' Affairs in May of 2008, statistics about calls to 1-800-273-TALK failed to include the fact that better than 50 percent of all calls going to VA Mental Health Center of Excellence in Canandaigua, New York, originated on the 1-800-SUICIDE hotline.

Since 1-800-SUICIDE is not marketed as a VA suicide hotline, nor in our ten-year history have veterans ever called it to any noticeable level, clearly the callers cannot be as SAMHSA claims.  This is a critical point, as it drives home to the American public and Members of Congress that something effective is being done about this issue.  It takes the pressure off government services at SAMHSA and allows things to return to status quo.  Can SAMHSA demonstrate and validate the number of veterans served?  Can SAMHSA demonstrate that any veterans have been helped and linked to assistance through their control of 1-800-273-TALK and 1-800-SUICIDE?

With the vast evidence that peer counseling works more effectively, SAMHSA could instead of duplicating and competing with an existing suicide hotline, be creating or supporting the peer model which the veteran community is in great need of, as several other folks on this panel have testified.  In addition, they could, and should, be evaluating the peer line's effectiveness against the routing option on the general suicide hotline.

Due to the nature of veterans' suicide and its stigma, what impact on existing calls would there be if it was disclosed that the Federal Government was receiving personal identifiable information on callers to 1-800-273-TALK, and also while it also continues to control 1-800-SUICIDE?

Peer counseling is required for any veteran suicide hotline to be truly effective.  Law enforcement personnel die by suicide eight times more frequently than in the line of duty.  They, like their veteran counterparts, do not generally confide in the clinical setting about suicide, or in any mental health issue, but would likely open up to a peer who has had similar thoughts and experiences.

SAMHSA is spending over $33 million duplicating an existing hotline network created by the private sector, after both Congress and SAMHSA promised it would not happen.  Funding had been assured for only three years, and for three years we were told every grant cycle the funding was coming to a close.  We believed them.  In reality, SAMHSA did little more than for their contract to link to health solutions then add a voice tree on their existing 1-800-273-TALK.  When you call it, as you heard from several people already, if you or your family member are a veteran, press option one, you get a counselor.  In reality, what has been occurring is that when people call in crisis, 1-800-SUICIDE, or 273-TALK, they often are pressing one.  Why?  Because they know it will get into a counselor, any counselor, faster.

Suicide hotlines can be effective, but only when there is a genuine empathy and good connectivity with the caller and the call taker.  A study that the Federal Government funded at the cost of $1.5 million and three years prove this.  SAMHSA is waging a campaign of disinformation to discredit the Kristin Brooks Hope Center and 1-800-SUICIDE, while convincing the American public and Members of Congress they are doing something effective about suicide prevention.

Lastly, rescue by police of suicidal people is not only ineffective; it can be lethal, and it is unnecessary.  Tragically, SAMHSA pays for over 800 psychiatric emergency response teams nationwide, yet none are networked with the VA hotline, much less any of the community-based crisis hotlines. 

Meanwhile, at the Hope Center, we do ask Congress to use every means possible to persuade Secretary Leavitt to stop the campaign against 1-800-SUICIDE, return our lines to us, stop using tax dollars to unfairly compete with the private sector program that is 10 years old, highly effective, and confidential.  We would welcome working with the Veterans Administration to prevent suicide through the appropriate use of our lines, such as 1-800-SUICIDA for Spanish-speaking veterans.  And of course, our peer-to-peer veterans Hotline, 877-VET2VET.  We remain willing to work with SAMHSA for appropriate options and referrals for all risk populations, including veterans.  We stand behind our record of building effective and successful suicide prevention crisis lines and community networks.

I thank you for this opportunity to speak with you.

[The statement of Mr. Butler appears in the Appendix.]

Mr. MICHAUD.  Thank you very much.  Mr. Shaffer?


Dr. SHAFFER.  Mr. Chairman and distinguished Members of this Subcommittee, I would like to thank you for inviting us to share our experiences with the VetAdvisor Support Program.  This innovative pilot program is designed to assist Veterans Integrated Services Network (VISN) 12, Great Lakes Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, in learning about and obtaining VHA mental health services.  We appreciate the opportunity to offer our perspective on how this unique, proactive, telephonic outreach program serving veterans uses innovative solutions to help address physical and behavioral health issues common to those serving in combat.  We thank the Committee for its leadership and interest in this important issue. 

This outreach program, we believe, has the potential to assist veterans not only in VISN 12, but also in VISNs across the country.  VISN 12 recognized the need to ensure that all veterans have access to healthcare services they need via seamless transition into VHA.  To address these needs, VISN 12 established a pilot program awarded to the Three Wire, MHN team designed to reach out to these veterans.  This pilot program provides vital outreach and screening for behavioral issues that might otherwise go unrecognized and unresolved.  In addition to screening for the risk of suicide, we also screen for PTSD, traumatic brain injury, depression, substance abuse, and significant medical symptoms, all of which may be factors in suicidal risk.

VetAdvisers is a telephonic outreach program focusing on recently returned veterans within VISN 12, using contact information provided by the VA, we call these veterans and inform them of the healthcare programs available.  If the veteran agrees, we will transfer them to a licensed clinician, our care coaches, who complete the screening process using nationally-validated screens selected by VISN 12.  If the veteran prefers, we can schedule a screening for a more convenient time.

Our overall goal is to talk with and screen veterans when they have time to listen and understand the services that are available to them, and to participate in screening for these key conditions.  The results are provided to the VA, and our coaches work to motivate veterans to follow through with needed help.

The value of this telephonic outreach model is that it provides an important service, when convenient for veterans, in a less intimidating environment; one in which they may be willing to talk more candidly. Following the screening process, the care coach provides the results to appropriate individuals at the VA Medical Center, who then reach out from the appropriate clinics to the veterans.  Now, let me talk specifically about the screening for suicide, which is the focus of this hearing.  When the program began in February, 2008, care coaches provided a basic screen for thoughts of harming oneself.  About 25 percent of the individuals screened positive, but many were not suicidal.  So working with VISN 12, a more specific screen was approved to use with any veteran who screened positive on the initial screen.  This more specific assessment provides information on an individual's state of mind to better indicate potential risk, and any need for immediate intervention.  About half of the individuals who screened positive on the first screen were also positive on the more sensitive one.  Importantly, none of those were in imminent need of intervention.  However, we do reach back and have a specific contact within the VISN, who will promptly reach out and engage all of the veterans who screen positive.

Before closing, let me share some of the results and successes so far.  Results demonstrate that veterans are willing to acknowledge serious issues in a telephonic interview.  Since these screenings identify issues that might not otherwise be acknowledged, the screening provides a useful way of beginning a referral process for getting veterans needed treatment.  There has been high interest and gratitude from the veteran community for this program.  In fact, in a recent sample survey, 97 percent expressed satisfaction with the initial caller, and 86 percent expressed comfort speaking with a care coach, recognizing they are speaking about uncomfortable issues in many cases.  Fourteen percent screened positive for suicidal thinking during the initial screen, and 70 percent screened positive on one of the six screens.

Many of these veterans may not have come forward on their own until problems had become much more severe and debilitating.

In conclusion, VetAdvisor functions well as a stand-alone pilot, and is well-suited to complement a variety of VA programs and initiatives designed to contact combat veterans who have not registered or accessed services by the VA.  The program represents an excellent example of using contact services to reach a broad audience of veterans, and provide tailored support and referral back to appropriate sources within VHA.

On behalf of MHN and Three Wire Systems, I would like to thank you again for your interest in the VetAdvisor program, and for your commitment in ensuring our veterans receive the care and services they may need.  I welcome your questions.

[The statement of Dr. Shaffer appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Doctor.  And once again, I would like to thank all of our panelists this morning.  This definitely has been enlightening, and I look forward to hearing your answers to some of the questions that we have.

I will start with Dr. Rudd.  You had mentioned that the VA need to provide careful training for their hotline workers.  Could you explain what type of training that they could provide to make sure that the hotline workers are competent in handling their cases that may call in?

Dr. RUDD.  Well, I think that actually, Mr. Ballesteros mentioned som