Ira Katz, M.D., Ph.D.
Mr. Chairman and members of the Committee, thank you for the invitation to appear before you today to discuss the Department of Veterans Affairs (VA), Veterans Health Administration (VHA) Mental Health program and suicide prevention. Accompanying me today are Dr Robert Rosenheck, Director of the Division of Mental Health Services and Outcomes Research; Dr Lawrence Adler, Director of the Mental Illness Research, Education and Clinical Center (MIRECC) in Veterans Integrated Service Network (VISN) 19; and Dr Frederick Blow, Director of the Serious Mental Illness Treatment Research and Evaluation Center (SMITREC) at the Ann Arbor VA Center for Clinical Management Research.
Mental illness is a serious disease, affecting not only the individual who has the problem, but also his or her family; and the community in which he or she lives. The symptoms that characterize mental illnesses can cause profound suffering for the patient and for others. Moderate levels of the illness are strongly associated with problems at work and at home; severe manifestations can lead to devastating outcomes such as suicide. While relatively few people with mental illnesses die from suicide, the fact that it occurs is a constant reminder that these illnesses are real, and that they can be fatal.
The Department of Veterans Affairs is determined to implement the findings of the President’s New Freedom Commission on Mental Health, which require all mental health providers to offer Americans with mental health needs world-class treatment focused on early intervention and recovery. Our comprehensive Mental Health Strategic Plan, completed in 2004, provided a blueprint for us to expand our outreach to veterans and to enhance the capacity and quality of our mental health services. To implement this plan, we have increased our expenditures for mental health services from $2 billion in 2001 to $3 billion in the current fiscal year. In addition, we have added more than 3600 new mental health staff members to our facilities since 2005, bringing the total number of VA employees working in this area to more than 10,000.
While a significant number of veterans of the conflicts in Iraq and Afghanistan have required treatment for mental health conditions on their return home, the number is well within our capabilities for providing treatment. Approximately 100,500 of the 750,000 veterans of this conflict have come to VA with a mental health condition since the beginning of the war. This represents only about 10 percent of the total number of veterans with mental health issues VA sees in any one year. Just less than half (48,559) of those veterans received at least a preliminary diagnosis of Post-Traumatic Stress Disorder or PTSD.
The 10 percent increase in patients with mental health conditions since 2002 should be balanced against the 50 percent increases in expenditures and mental health staffing in VA since 2001. Our new resources are adequate for us to address the mental health needs of returning veterans, and to enhance our mental health services for veterans of all eras. In terms of their suffering and need for effective treatment, the number of returning veterans with mental health issues is very significant; but our Department is able to meet their needs.
Suicide among veterans is a tragedy. The Department of Veterans Affairs believes that it is our obligation to work to prevent suicide both in individual patients and in the entire veteran population. Our suicide prevention activities are based on the principle that in order to decrease rates of suicide, we must provide enhanced access to high quality mental health care, and to develop programs specifically designed to help prevent suicide. We have trained all VA employees about the risk factors and warning signs of suicide, and have offered them strategies to help them deal with veterans who may be at risk of taking their own lives.
VA employees have been given the message that even strong and resilient people can develop mental health conditions. Care for those mental health conditions is readily available and should be timely provided. We know that treatment can work.
VA’s suicide prevention program includes two centers that conduct research and provide technical assistance in this area to all our locations of care. One is our new Mental Health Center of Excellence in Canandaigua, New York, which focuses in developing and testing clinical and public health intervention. The other is the VISN 19 Mental Illness Research Education and Clinical Center in Denver, which focuses on research in the clinical and neurobiological sciences. Our system of care also includes a suicide prevention call center, also in Canandaigua with suicide prevention coordinators located in each of VA’s 153 hospitals. Altogether, VA has more than 200 mental health providers whose jobs are specifically devoted to preventing suicide among veterans.
The Department has partnered with the Lifeline Program of the Substance Abuse and Mental Health Services Administration to develop a VA suicide prevention hotline. Those who call 1-800-273-TALK are asked to press “1” if they are a veteran, or are calling about a veteran. When they do so, they are connected directly to VA’s hotline call center, where they speak to a VA mental health professional with real-time access to the veteran’s medical records. In emergencies, the hotline contacts local emergency resources such as police or ambulance services to ensure an immediate response. In other cases, after providing support and counseling, the hotline transfers care to the suicide prevention coordinator at the nearest VA facility to ensure that follow-up is prompt and appropriate.
In the five weeks from October 7 to November 10, 2007, 1636 veterans and 311 family members or friends called the hotline number. These calls led to 363 referrals to suicide prevention coordinators and 93 rescues involving emergency services. Since the hotline began in July, there have been more than 6000 calls from veterans or families, more than 1300 referrals to Suicide Prevention Coordinators in VA medical centers, and more than 300 rescues, any one of which may have been life-saving.
Suicide prevention coordinators receive referrals of those at risk for suicide from both the hotline and from providers in their facilities, and ensure that care for those at risk addresses their high risk status. Coordinators educate their colleagues, veterans and families about risks for suicide, provide enhanced treatment monitoring for veterans at risk and ensure that any missed appointments are followed up on. The coordinators work with the entire staff of their medical centers to maintain awareness of those who have previously attempted suicide, and ensure that their care is enhanced.
Prevention coordinators also work with patient safety officers to conduct quarterly safety inspections of inpatient psychiatry units, and to coordinate staff education programs about suicide prevention. These coordinators are in the process of organizing a system of flags in the electronic medical record to alert providers about those at high risk, and are conducting training for community members who have frequent contact with veterans to help them recognize those at risk and encourage them to seek treatment.
Finally, VA has held two National VA Suicide Prevention Awareness Days throughout our system to focus all of our 200,000 health care employees on this issue. The first event focused on enhancing overall awareness of the issue, and the second trained all VA staff on how to work with available prevention resources, including the hotline and the suicide prevention coordinators.
VA is very much concerned about the epidemiology of suicide among veterans, and has used findings in this area to guide our prevention programs. As new data on suicide rates, risk factors for suicide and regional variations become available, we will use that data to refine our programs, and to better evaluate their level of success. In all of this epidemiological work, VA uses information from the Centers for Disease Control and Prevention’s (CDC) National Death Index currently available through the end of calendar year 2005.
VA’s Epidemiology Service has published findings from a long-term, 20 year follow-up on the health of Vietnam-era veterans. The peer-reviewed, published study reported that rates of suicide among veterans who were deployed to Southeast Asia did not differ statistically from veterans of the same era who were not deployed. A published study of veterans from the first Gulf War provided a similar finding.
VA has now completed a preliminary evaluation of suicide rates among veterans returning from Iraq and Afghanistan. From the beginning of the war through the end of 2005 there were 144 known suicides among these new veterans. This number translates into a rate that is not statistically different from the rate for age, sex, and race matched individuals from the general population.
Taken together, the population of veterans who receive care from the Veterans Health Administration have more risk factors for suicide than the general population. Although there are increasing numbers of female veterans, most veterans are male. Those who come to the VA for care tend to be older, less socio-economically well off, and more likely to have a mental health condition or another chronic illness. It is, therefore, by no means surprising that those receiving care from VA have higher suicide rates than those in the general population. Those with the greatest need for care are those who are most likely to come to VA. This increased need can be associated with increased risks. This, in fact, was one of the major factors leading to VA’s focus on suicide prevention.
Because of new enrollment criteria for veterans of the Global War on Terror, the characteristics of Iraq and Afghanistan veterans coming to VA today are different from those for veterans from prior eras. As a result, early data being evaluated by VA, suggests that while rates among OIF/OEF veterans who come to VHA for care are not different from the general population, rates among those veterans who do not come to VA appear to be higher. One possible explanation for this finding is that VA mental health care is effective, and that it can be lifesaving. Further research in this area is underway
VA’s latest data do not demonstrate an increased risk of suicide among OEF/OIF veterans compared to the age and gender matched American population as a whole. Nevertheless, one suicide among those who have served their country is too much. Available information on suicide rates and risk factors among veterans are reinforcing the importance of the work VA has done to enhance its mental health services since 2001; and the usefulness of our comprehensive program for suicide prevention.
VA has already implemented the key provisions of the Joshua Omvig Veterans Suicide Prevention Bill, which was recently signed by President Bush, and we continue to do research to develop and implement new strategies that will improve our ability to save lives by preventing suicide. VA believes that our health care system can and must serve a national model for suicide prevention, now and in the future.
Thank you for the opportunity to address the Committee. At this time, I would be pleased to answer your questions.