M. David Rudd, Ph.D., ABPP
Mr. Chairman and members of the Subcommittee, I want to express appreciation for the opportunity to testify on behalf of the 148,000 members and affiliates of the American Psychological Association regarding the newly implemented and vitally important Department of Veterans Affairs’ (VA) suicide prevention hotline. As a psychologist and 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 service men and women and military veterans continues to grow, with the suicide rate for young male veterans escalating to more than double that of the comparable 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 meet the demand. Providing appropriate and necessary mental and behavioral health care and preventive services is an essential element of the VA healthcare system mandate.
As has become evident, the unique characteristics of this war, including multiple deployments and intensive combat exposure, have resulted in arguably the greatest mental health challenge ever experienced by the military and VA. The RAND Corporation study released this past year confirms the magnitude of the problem, estimating that anywhere from a quarter to a third of previously deployed veterans present with mental health problems following discharge. Most prominent among the problems are major depression, post-traumatic stress disorder (PTSD), traumatic brain injury (TBI) and substance abuse, with many veterans experiencing multiple problems simultaneously and delaying or rejecting mental health care. Although we have known for some time that veterans with major depression, PTSD and substance abuse problems are at elevated risk for suicide, recent data on TBI are of particular concern. Estimated suicide rates for veterans with PTSD are in the range of 3-4 times that of the general population, along with markedly higher suicide attempt and ideation rates. One of the most troubling aspects of TBI as a suicide risk factor is the limited scientific foundation on which to formulate approaches to both assessment and treatment.
Not only does the VA face increasing numbers of veterans with multiple and complex mental and behavioral health problems, it is also challenged by a culture in which stigma, shame, and fear compound and complicate efforts to improve access to care. 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 VA suicide hotline is an important and potentially lifesaving program. The latest usage figures confirm the need for such services. VA efforts to identify and flag the health records of high risk individuals may well also save lives, hopefully improving the communication across specialty and primary care providers. One thing the suicide literature has revealed is that simple things can save lives.
While I applaud the VA for implementing the suicide 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 hotline, gathering data to definitively answer critical clinical questions. The available literature on crisis and suicide hotlines has provided some surprising findings, not always positive. For example, in a study in which participants were aware they were being monitored, it was discovered that 50 percent of hotline workers did not ask about suicidality during the call. And this was on a suicide hotline! It will thus be essential for the VA to provide careful training and monitoring in order to enhance and ensure effectiveness of the hotline. In addition to providing numbers on overall usage, i.e. total number of calls, it will be important for the VA to track outcomes, including wait times for a face-to-face appointment, subsequent emergency room visits, suicide attempts, and suicides that follow hotline access.
Similarly, 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 has made a call to the hotline? What (and how much) information will they receive about the call? How will 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 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 to providers but finding ways to provide ongoing care, as needed. If that happens, lives can be saved. The efficacy of treatment for the full range of mental and behavioral health problems is impressive.
The VA has an opportunity to be creative and expand its response to the critical problem of suicide among veterans. This could 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. The breadth and depth of the problem is staggering, cutting across virtually every community in the United States. Many veterans will enroll in a college or university after returning home, a figure that reached half a million in 2007. That number is expected to increase significantly in the years ahead. College campuses are and must remain important places to address issues such as suicide prevention as it relates to our veteran population. The Substance Abuse and Mental Health Services Administration (SAMHSA) currently supports education and outreach efforts related to suicide prevention on college campuses, and there are over 50 programs currently on campuses across the country designed to create greater awareness about suicide and strengthen suicide prevention. Still more can be done. Efforts are underway to allow SAMHSA to support direct services for students on campus, an increasing number of whom will be veterans, so that the range of their mental and behavioral health needs can be met. These investments in our veterans, as well as other students in need, will go a long way toward ensuring their future success in college, as well as the health and well being of our nation in the future.
Thank you. I appreciate the opportunity to speak with you today and welcome the chance to respond to questions.