Jan E. Kemp, RN, Ph.D.
Chairwoman Buerkle, Ranking Member Michaud, and members of the Subcommittee: Thank you for the opportunity to appear before you today to discuss the Department of Veterans Affairs’ (VA) efforts to reduce suicide among America’s Veterans. I am accompanied today by Antonette Zeiss, Ph.D., Chief Consultant for Mental Health, VHA. My testimony today will cover four areas: first, recent data on suicidality in Veterans and VA’s Suicide Prevention Program; second, VA’s Veterans Crisis Line and Veterans Chat (an online resource); third, VA’s outreach and informational awareness efforts to reduce suicide among Veterans; and finally, VA’s impact on reducing suicide among high risk Veterans.
Let me begin by saying how very important this issue is to VA and all of us in the VA health community. We believe even one suicide among our Servicemembers or Veterans is one too many. According to the recently released “Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and Recommendations for the Decade Ahead” prepared by the Suicide Prevention Resource Center and Suicide Prevention Action Network, the Veterans Health Administration (VHA) has “developed a comprehensive strategy to address suicides and suicidal behavior that includes a number of initiatives and innovations that hold great promise for preventing suicide attempts and completions.” The Review was developed by the Suicide Prevention Resource Center (a national suicide prevention education organization),with funding from the Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA) for the National Action Alliance for Suicide Prevention. The Action Alliance is the public-private partnership advancing the National Strategy for Suicide Prevention and was launched in September 2010. The Review cites VA as becoming one of the most vibrant forces in the U.S. suicide prevention movement, implementing multiple levels of innovative and state-of-the-art interventions, backed up by a robust research capacity. We have initiated several programs that put VA in the forefront of suicide prevention for the nation. Chief among these are:
- Establishment of a national Crisis Line, Chat Service, and texting option, including a major advertising campaign to provide the Crisis Line phone number and Web site to all Veterans and their families;
- Placement of Suicide Prevention Coordinators (SPC) at all VA medical centers;
- Development of an enhanced package of care for high risk Veterans;
- Expansion of mental health services;
- Integration of primary care and mental health services; and
- Creation of a new “Make the Connection” campaign to help make it easier to seek mental health assistance.
I will discuss these initiatives in detail later in my testimony.
VA’s Suicide Prevention Program
In response to the urgent need for suicide prevention efforts, VA has significantly expanded its suicide prevention program since 2005, when it initiated the Mental Health Strategic Plan and the Mental Health Initiative Funding. In 2006, VA provided training on evidence-based interventions for suicide and provided funding to begin integrating mental health care into primary care settings and expanding services at community-based outpatient clinics (CBOC) for treatment of mental health conditions such as post-traumatic stress disorder (PTSD), and substance use disorders (SUD). In 2007, VA began providing specific funding and training for each facility to have a designated SPC; it also held the first Annual Suicide Awareness and Prevention Day and opened the Veterans Crisis Line (then referred to as the National Veterans Suicide Prevention Hotline) in partnership with SAMHSA.
VA also established access standards that require prompt evaluation of new patients (those who have not been seen in a mental health clinic in the last 24 months) with mental health concerns. New patients are contacted by a clinician competent to evaluate the urgency of the Veteran’s mental health needs within 24 hours of their first referral. If it is determined that the Veteran has an urgent care need, appropriate arrangements (e.g., an immediate admission) are made. If the need is not urgent, the patient must be seen for a full mental health diagnostic evaluation and development and initiation of an appropriate treatment plan within 14 days. VA accomplishes its access standards more than 95 percent of the time. In 2007, VA initiated system-wide suicide assessments for those Veterans screening positive for PTSD and depression in primary care; instituted training for Operation S.A.V.E. (which trains non-clinicians to recognize the SIGNS of suicidal thinking, to ASK Veterans questions about suicidal thoughts, to VALIDATE the Veteran’s experience, and to ENCOURAGE the Veteran to seek treatment); and required SPCs to begin tracking and reporting suicidal behavior. In addition, VA added more SPCs in its larger medical centers and CBOCs, doubling the number of dedicated suicide prevention staff in the field. By 2008, VA had re-established a monitor for mental health follow-up after patients were discharged from inpatient mental health units, developed an on-line clinical suicide risk training program, and held a fourth regional conference on evidence-based interventions for suicide.
VA also added the development of an enhanced package of care for high risk patients. Evidence clearly demonstrates that once a person has manifested suicidal behavior, he or she is more likely to try it again. As a result, VA also has put in place sensitive procedures to enhance care for Veterans who are known to be at high risk for suicide. Whenever Veterans are identified as surviving an attempt or are otherwise identified as being at high risk, they are placed on the facility high-risk list and their chart is flagged such that local providers are alerted to the suicide risk for these Veterans. In addition, the SPC will contact the Veteran’s primary care and mental health provider to ensure that all components of an enhanced care mental health package are implemented. These include a review of the current care plan, addition of possible treatment elements known to reduce suicide risk, ongoing monitoring and specific processes of follow-up for missed appointments, individualized discussion about means reduction, identification of a family member or friend with the Veteran’s consent (either to be involved in care or to be contacted, if necessary), and collaborative development with the Veteran of a written safety plan to be included in the medical record and provided to the Veteran. In addition, pursuant to VA policy, SPCs are responsible for, among other things, training of all VA staff who have contact with patients, including clerks, schedulers, and those who are in telephone contact with Veterans, so they know how to get immediate help when Veterans express any suicide plan or intent.
The enhanced care package also includes mandates for follow-up after the high risk designation and safety planning. In 2009, VA launched the Veterans Chat Service to create an online presence for the Veterans Crisis Line.. VA developed and disseminated training programs for safety planning and has continued to monitor all of these efforts and implement facility-specific strategies over the past few years. VA has also released new training programs concerning issues in specific populations, such as geriatrics and women.
VA has augmented the original SPC placement at every facility and large CBOCs with additional suicide prevention team staff, and these staff members are an important component of our mental health staffing. The SPCs ensure local planning and coordination of mental health care and support Veterans who are at high risk for suicide, provide education and training for VA staff, do outreach in the community to educate Veterans and health care groups about suicide risk and VA care, and provide direct clinical care for Veterans at increased risk for suicide. One of the main mechanisms to access enhanced care provided to high risk patients is through the Veterans Crisis Line, and the linkages between the Crisis Line and the local SPCs. For example, when a Veteran, in crisis, calls the Crisis Line, he or she is provided a referral for immediate care, a high risk flag is placed on the chart and the Veteran is provided high risk services. The Crisis Line staff follows up to assure that this care is provided. .
VA cannot accomplish this mission alone; instead, it works in close collaboration with other local and Federal partners, including SAMHSA in the Department of Health and Human Services (HHS), and brings together the diverse resources within VA, including individual facilities such as the Center of Excellence in Canandaigua, New York and a Mental Illness Research and Education Clinical Center in Veterans Integrated Service Network (VISN) 19 (Denver, CO). We also work closely with community agencies across the country. The DoD and VA are working together on a number of issues and the VA is a member of the DoD Suicide Prevention and Risk Reduction Workgroup. The DoD/VA Nomenclature and Data Working Group is moving toward common definitions of fatal and non-fatal suicide events, and working toward a joint data base to better capture the impact of suicide on the military community as a whole.
During fiscal year (FY) 2011, VA’s SPCs reported 16,976 suicide attempts among patients and non-patients, 779 of which were fatal (4.5 percent). One of the premises of the VA suicide prevention program is that we can make a difference in Veterans who have attempted suicide and are known to be at high risk. The percentage of those who died from suicide (and reported by VA’s Suicide Prevention Coordinators) with a report of previous suicide attempts decreased from 31 percent in FY 2009 to 27 percent in FY 2010 and FY 2011. This suggests that the strategy of implementing the enhanced care package with our high risk patients has been effective.
It is not possible to determine if the reported cases are representative of suicidality in VA’s patient population, but we do know that suicidality can be both an acute and a chronic condition. Those who survive attempts are at high risk for reattempting and dying from suicide within a year, so it is essential that we engage survivors in intensified treatment to prevent further suicides. It is precisely because of this concern that VA has initiated the post-discharge follow-up for patients leaving its inpatient mental health units. The data reported above include self-reporting of previous suicide attempts that have not been validated by VA, and all estimates are based on events reported in the SPC database and may not represent the complete number of suicide attempts among Veterans. Also, the records of suicide attempts for 136 Veterans were incomplete and omitted from this analysis.
VA’s Vet Centers also fulfill a critical role in reducing the risk of Veteran suicide. Vet Centers promote access to care by helping Veterans and families overcome barriers that impede them from utilizing other benefits or services. Vet Centers remain a unique and proven component of care by providing an alternate door for combat Veterans not ready to access the VA health care system. There are currently 296 Vet Centers operating with four more scheduled to open by the end of 2011. This will bring the total to 300 Vet Centers across the country and in surrounding territories (the U.S. Virgin Islands, Puerto Rico, Guam, and American Samoa). Thirty-nine (39) of these Vet Centers are currently located in rural or highly rural areas. In addition, seventy (70) Mobile Vet Centers provide early access to returning combat Veterans through outreach to a variety of military and community events, including demobilization activities.
Crisis Line and Veterans Chat Service
VHA’s Crisis Line started in July 2007, and the Veterans Chat Service was started in July 2009. To date the Crisis Line has:
- Received over 500,000 calls;
- Initiated over 18,000 rescues;
- Referred over 73,000 Veterans to local VA SPCs, for same day or next day services;
- Answered calls from over 6,700 Active Duty Servicemembers;
- Responded to over 31,000 chats; and
- Initiated a pilot program that uses text messaging that is reaching a new group of Veterans who are much more likely to use text messaging than to call.
The Crisis Line has 20 active phone lines and is staffed with mental health professionals and support staff to provide services 24 hours, 7 days a week, 365 days a year. After receiving a call from a Veteran, Servicemember or family member, the responder conducts a phone interview to assess the Veteran’s emotional, functional, and psychological condition. The responder then determines the level of the call, namely whether it is emergent, urgent, routine, or informational.
Calls requiring emergency services necessitate keeping the caller (or the person about whom the caller is concerned) safe; urgent care requires same day services at a local VA facility; and routine calls require a consultation by the local SPC. Consults occur if a Veteran consents to a consultation or if emergency services are required; these consults are simply alerts to the SPC and do not mean the Veteran is suicidal. Even if the Veteran is already engaged in treatment, a consultation can be done to alert the SPC to changes in the Veteran’s circumstances or to other needs he or she may have.
The online version of the Crisis Line, the Veterans Chat Service, enables Veterans, family members and friends to chat anonymously with a trained VA counselor. If the counselor determines there is an emergent need, the counselor can take immediate steps to transfer the visitor to the Hotline, where further counseling and referral services can be provided and crisis intervention steps can be taken. Veterans Crisis Line and Chat Service are intended to reach out to all Veterans, whether they are enrolled in VA health care or not.
Outreach and Awareness of VA’s Suicide Prevention Efforts
This past year, VA looked hard at its plan to communicate to Veterans and their families the highlights of the Suicide Prevention program as well as those of the Crisis Line and Chat Service. VA and SAMHSA continue to work together to ensure all Americans in emotional distress or suicidal crisis have a single confidential number (1-800-273-8255) to call for help. After much deliberation and consultation with Veterans and users, VA determined that to reach more Veterans and to relay the message that treatment works, it wouldstrategically rebrand the national Veterans Suicide Prevention Hotline An important component of this comprehensive effort involved a new name: Veterans Crisis Line, which establishes a unique identity for this critical service. Research informed VA’s decision to rebrand the service as a crisis line, thus lowering the threshold from “suicide” to “crisis” for Veterans, Servicemembers, and their families to encourage them to make that critical first call for help. The rebranding is an integrated national outreach effort to increase awareness and use of the Veterans Crisis Line and confidential online chat service, support and promote broader VA suicide prevention efforts, and promote help-seeking behaviors among Veterans at risk of suicide and other mental health problems. The new messaging reinforces the confidentiality of the Veterans Crisis Line for Veterans, Servicemembers, and their families, who may be the first to realize a Veteran is in crisis. Messaging efforts also involve all Service branch representatives to provide messages and “looks” to materials that are Servicemember specific.
As discussed previously, VA’s SPCs do a tremendous amount of work to raise awareness about warning signs associated with suicide and the availability of treatment and support. For example, in a typical month, VA’s SPCs provide approximately 700 informational and outreach programs in their local communities. As a result, VA identifies approximately 1,500 high risk Veterans a month and adds them to the High Risk List. Between 90 and 95 percent of these Veterans complete safety plans and are involved in the enhanced care package.
In addition to these measures, VA has been aggressively advertising this information and improving outreach to Veterans and family members alike. Suicide prevention outreach needs to use carefully tailored and targeted messaging. Unlike outreach for many other health issues which rely on underscoring the prevalence of the problem, outreach for suicide prevention that emphasizes rising suicide rates among Veterans runs the risk of normalizing suicidal behaviors, helping to convince Veterans in crisis that considering suicide is a normal or even expected response to their challenges—and possibly leading to an increase in suicide attempts. Through our messaging efforts, VA provides effective and safe outreach that focuses on affirming Veterans' strength and resilience and reinforcing help-seeking behavior.
In recent years, VA has supported a series of public education campaigns designed to increase awareness of crisis resources and promote seeking help among Veterans experiencing distress. VA has evaluated each of these campaigns in an effort to understand the impact of public education efforts on calls to crisis services and attitudes related to crisis service use. In a series of studies, VA evaluated the impact of implementation of the Veterans Crisis Line on total call volume to VA and non-VA crisis services, comparisons of call volume in campaign implementation and control communities, and associations between exposure to public education campaign media and willingness to use crisis services when experiencing distress. Results from these assessments have demonstrated strong relationships between implementation of the Veterans Crisis Line and increased use of VA and non-VA toll-free crisis services, significantly increased call volume in communities where concentrated public education campaigns have been implemented, and an increased willingness to use crisis services following exposure to public education media. Together, results from these studies provide consistent evidence of the impact of public education campaigns on awareness and use of crisis services. VA is continuing to assess the impact of public education campaigns for both the Veterans Crisis Line and the Make the Connection campaign in a series of studies designed to measure the impact of repeated exposure to media material among high risk and general populations and the efficacy of media messages tailored to individual histories. A total of four Public Service Announcements have been released and widely distributed. VA spends approximately $4.5 million on this public awareness campaign annually.
VA’s Impact on Reducing Suicide
On the macro level, one way to evaluate the impact of VA mental health care and VA’s suicide prevention program is to evaluate suicide rates. However, before addressing this issue, it is important to consider who accesses VA health care. For this, it is useful to refer to findings on those Veterans returning from Afghanistan and Iraq who participated in the Post-Deployment Health Re-Assessment (PDHRA) program administered by DoD. Between February 2008 and September 2009, approximately 119,000 returning Veterans completed PDHRA assessments using the most recent version of DoD’s PDHRA form. Of the more than 101,000 who screened negative for Post-Traumatic Stress Disorder (PTSD), 43,681 (43 percent) came to VA for health care services. Among 17,853 who screened positive for PTSD, 12,674 (71 percent) came to VA for health care services. These findings demonstrate that Veterans screening positive for PTSD were substantially more likely to come to VA for care. Findings about depression were similar. Both sets of findings support earlier evidence that those Veterans who come to VA are those who are more likely to need care and to be at higher risk for suicide. The increased risk factor for suicide among those who came to VA is often referred to as a case mix difference. We have just received the 2009 death data from the National Death Index and have begun to look at these numbers in relationship to Veterans who receive care in VA. We are encouraged by these data, which indicate that there is no increase in rates among VA users despite national increases, especially in middle-aged men. We believe that this indicates that our strategies are having an effect. There are some overall positive indicators that include:
- Suicide rates among Veterans who use VA health care have decreased since 2001.
- There is a decrease in suicide rates among Veterans under 30 who use VA health care relative to Veterans who do not use VA services, in those states that report through the National Violent Death Reporting System (NVDRS)..
- There is a recent decrease in rates in men aged 40-59 receiving care from VA relative to rates of men of this age in America as a whole.
Specific information obtained from the 2009 data, for Veterans who use VA health care, includes:
- In FY 2009, the suicide rate per 100,000 person-years among all VA health care users was 35.9, as compared to 36.6 in FY 2008. Among males, it was 38.3, versus 38.7 in FY 2008. Among females, , it was 12.8, versus 15.0 in FY 2008.
- In FY 2009, there were 22 suicides among male Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans age 18-24. The suicide rate in this group was 47.1 per 100,000. By comparison, in FY 2008, there were 32 suicides and a rate of 75.4 per 100,000.
- In FY 2009, the suicide rate among individuals with mental health or substance use disorder diagnoses was 56.4 per 100,000, as compared to 23.5 among patients without these diagnoses. The resulting rate ratio was 2.4. This continues a steady trend of reducing rate ratios observed since FY 2001, when the rate among patients with mental health or substance use disorder diagnoses was 78.0 as compare to 24.7 among patients without these diagnoses (rate ratio of 3.2)
VA’s Ongoing Research to Identify Risk Factors for Suicide Prevention and Treatment
VA’s research portfolio includes studies focused on identifying risk factors for suicide, prevention, and treatment. Risk factors being studied include co-morbid disorders, medications, and behaviors. A few specific examples include:
- In one study, VA researchers seek to determine the prevalence of suicide ideation, plans, and attempts resulting in medical treatment among Veterans currently enrolled in VA’s health care system. The researchers will also collect data on a limited number of established risk factors and characteristics unique to military service that can be used to understand correlates of non-fatal suicidal behaviors.
- A VA Suicide and Self-Harm Classification System and Clinical Tool is being evaluated to determine the feasibility for implementation in diverse VA treatment settings and to assess its impact on health care system processes pertaining to the assessment and management of suicide risk.
- The VISN 2 Center of Excellence, in Canandaigua, NY, in collaboration with the National Center for Homelessness among Veterans, is conducting a study of risk factors for suicide among Veterans with a history of homelessness or housing instability. Characteristics of service utilization, the independent effect of homelessness, and differences in risk associated with psychiatric diagnoses are being studied through the use of homeless intake assessments, non-fatal suicide event data, and data obtained from the National Death Index.
- VA researchers are determining the role of a brain chemical called serotonin in suicide and seek to discover whether alterations in levels of this chemical impact suicide.
- The Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment Project (SAFE VET) is a clinical demonstration project that focuses on providing a brief intervention and follow-up for suicidal Veterans who present to the Emergency Department and Urgent Care Services and who do not require hospitalization. This study also permits us to longitudinally follow risk factors in Veterans identified as being at moderate risk for suicide.
- Motivational Interviewing to Prevent Suicide in High Risk Veterans is a study to test the efficacy of an adaptation of Motivational Interviewing to Address Suicidal Ideation (MI-SI) on the severity of suicidal ideation in psychiatrically hospitalized Veterans at high risk for suicide. The researchers also are examining the impact of MI-SI on risk factors for suicide in Veterans, such as treatment engagement and psychiatric symptoms.
- Many completed studies addressing suicide epidemiology have been published by VA investigators, providing important information related to risk factors.
- VA is also doing extensive work in traumatic brain injury (TBI), including how Veterans with a TBI may be at risk for mental health issues and suicide. Our work in TBI will also give us a broader knowledge about suicide in general.
Madam Chairwoman, as my testimony demonstrates, VA’s efforts to provide comprehensive suicide prevention services are comprehensive and continuously improving. Since our suicide prevention effort began in 2005 we have revisited it often to make sure it continues to meet our Veterans’ needs, made adjustments when necessary, and will continue to do so as new research helps us uncover new ways to prevent these tragedies. It is clear our mission will not be fully achieved until every Veteran contemplating suicide is able to secure the services he or she needs. The Department appreciates Congressional support of our work in this area. I am prepared to answer your questions.