[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

UNDERSTANDING AND
PREVENTING VETERAN SUICIDE

=======================================================================

HEARING

before the

SUBCOMMITTEE ON HEALTH

of the

COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

FIRST SESSION

__________

DECEMBER 2, 2011

__________

Serial No. 112-36

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Printed for the use of the Committee on Veterans' Affairs

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COMMITTEE ON VETERANS' AFFAIRS

JEFF MILLER, Florida. Chairman

CLIFF STEARNS, Florida BOB FILNER, California. Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York

Helen W. Tolar, Staff Director and Chief Counsel

______

SUBCOMMITTEE ON HEALTH

ANN MARIE BUERKLE, New York. Chairwoman

CLIFF STEARNS, Florida MICHAEL H. MICHAUD, Maine. Ranking
GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida
DAVID P. ROE, Tennessee SILVESTRE REYES, Texas
DAN BENISHEK, Michigan RUSS CARNAHAN, Missouri
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey

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.

C O N T E N T S

__________

December 2, 2011

Page

Understanding and Preventing Veteran Suicide..................... 1

OPENING STATEMENTS

Chairwoman Ann Marie Buerkle..................................... 1
Prepared statement of Chairwoman Buerkle..................... 37
Hon. Michael H. Michaud, Ranking Democratic Member............... 2
Prepared statement of Congressman Michaud.................... 37
Hon. David P. Roe, Republican Member............................. 3
Hon. Silvestre Reyes, Democratic Member, prepared statement of... 38

WITNESSES

Commander Rene A. Campos, USN (Ret.), Deputy Director, Government
Relations, Military Officers Association of America............ 4
Prepared statement of Commander Campos....................... 38
Tom Tarantino, Senior Legislative Associate, Iraq and Afghanistan
Veterans of America............................................ 6
Prepared statement of Mr. Tarantino.......................... 45
Thomas J. Berger, Ph.D., Executive Director, Veterans Health
Council, Vietnam Veterans of America........................... 8
Prepared statement of Dr. Berger............................. 48
Joy J. Ilem, Deputy National Legislative Director, Disabled
American Veterans.............................................. 9
Prepared statement of Ms. Ilem............................... 50
Margaret C. Harrell, Ph.D., Senior Fellow and Director, Joining
Forces Initiative Center for a New American Security........... 21
Prepared statement of Dr. Harrell............................ 57
Katherine E. Watkins, M.D., Senior Natural Scientist, The RAND
Corporation.................................................... 22
Prepared statement of Dr. Watkins............................ 63
Jan E. Kemp, RN, Ph.D., National Mental Health Director for
Suicide Prevention, Veterans Heath Administration, U.S.
Department of Veterans Affairs................................. 24
Prepared statement of Dr. Kemp............................... 71

Accompanied by:

Antoinette Zeiss, Ph.D. Chief Consultant for Mental Health
Veterans Health Administration U.S. Department of
Veterans Affairs

SUBMISSIONS FOR THE RECORD

Colonel Carl Castro, Ph.D., Director, Military Operational
Medicine Research Program, U.S. Army Medical Research and
Materiel Command, and Chair, Joint Program Committee for
Operational Medicine, Department of the Army, U.S. Department
of Defense..................................................... 77
Paula Clayton, M.D., Medical Director, American Foundation for
Suicide Prevention............................................. 79
Lieutenant Colonel Michael Pooler, USA, Deputy Chief of Staff,
Personnel, Maine Army National Guard........................... 82
Richard McCormick, Ph.D., Senior Scholar, Center for Health Care
Policy, Case Western Reserve University, Cleveland, OH......... 84
John E. Toczydlowski, Esq., Philadelphia, PA..................... 86

MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

Hon. Michael H. Michaud, Ranking Democratic Member,
Subcommittee on Health, Committee on Veterans' Affairs to
Col. Carl Castro, Ph.D., Director, Military Operational
Medicine Research Program Research Area Directorate III, U.S.
Army Medical Research & Materiel Command, U.S. Department of
Defense...................................................... 89
Response from Col. Carl Castro, Ph.D., Director, Military
Operational Medicine Research Program Research Area
Directorate III, U.S. Army Medical Research & Materiel
Command, U.S. Department of Defense, to Hon. Michael H.
Michaud, Ranking Democratic Member, Subcommittee on Health,
Committee on Veterans' Affairs............................... 90

UNDERSTANDING AND
PREVENTING VETERAN SUICIDE

----------

FRIDAY, DECEMBER 2, 2011

U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:04 a.m., in
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle
[chairwoman of the Subcommittee] presiding.
Present: Representatives Buerkle, Stearns, Roe, Michaud,
Reyes, and Donnelly.

OPENING STATEMENT OF CHAIRWOMAN BUERKLE

Ms. Buerkle. Good morning.
And welcome to this morning's Subcommittee on Health
hearing. Today we meet to search for answers to the most
haunting of questions: What leads an individual who honorably
served our Nation, out of helplessness and hopelessness, to
take their own life, and how do we prevent such a tragedy from
happening to one who has bravely worn the uniform and defended
our freedom?
Suicide is undoubtedly a complex issue, but it is also a
preventable one, and I am deeply troubled by its persistent
prevalence in our military and veteran communities. The
statistics are sobering: Eighteen veterans commit suicide each
day, with almost a third receiving care from the Department of
Veterans Affairs at the time of their death. Each month, there
are 950 veterans being treated by the VA who attempt suicide.
The number of military suicides has increased since the start
of Operations Enduring Freedom and Iraqi Freedom, with data
from the Department of Defense indicating servicemembers took
their life at an approximate rate of one every 36 hours from
2005 to 2010. We continue to hear tragic stories despite
significant increases in recent years in the number of programs
and resources devoted to suicide prevention among our
servicemembers and our veterans.
Today we will hear from the VA that they are making strides
in identifying at-risk servicemembers and veterans and
providing treatment for mental health and other disorders that
can lead to suicide. Yet no matter how great our programs or
services are, if they do not connect with those who are in
need, they do no good at all. The VA and the DoD continue to
struggle with persistent obstacles, including data limitations,
cultural stigma, access issues, a lack of partnerships with
community providers, and outreach that relies on the
servicemember, veteran, or loved one to initiate treatment.
We must do more to reach out to our veterans inside and
outside of the VA and DoD health care systems to ensure that
all those who need help get it. They have earned it, and they
deserve it before time runs out.
Until a family no longer must bear the pain of losing a
loved one, we are failing, and not enough is being done.
I thank you all very much for joining us this morning. And
now it gives me pleasure to introduce and recognize the Ranking
Member, Mr. Michaud.

OPENING STATEMENT OF HON. MICHAUD, RANKING DEMOCRATIC MEMBER

Mr. Michaud. Thank you very much, Madam Chair.
I, too, would like to thank everyone for attending today's
hearing. It is a tragedy that our servicemembers and veterans
survive the battlefield abroad only to return home and fall to
suicide. Since 2007, this committee has held five hearings
regarding this issue of veterans suicide, and the figures
continue to increase at an alarming rate, far greater than the
comparable suicide rate among the general population. The
Center for a New American Security in their recent publication
study, entitled ``Losing the Battle: The Challenges of Military
Suicide,'' says that from 2005 to 2010, servicemembers took
their own lives at a rate of approximately one every 36 hours.
This statistic is troubling, but it pales compared to the VA's
estimate that one veteran dies by suicide every 80 minutes.
While I commend the VA's effort to reduce the suicide rate,
particularly with the success of its veterans crisis hotline,
challenges still remain. Through this hearing, we will examine
the steps the VA is taking to strengthen data collection to
pinpoint veterans who may be at risk and to offer effective
intervention. In this process, we will also seek to better
understand the reasons why more and more servicemembers and
veterans are taking their own lives, and what VA and DoD are
doing to put a stop to more suicides.
I would like to thank our panelists for appearing before us
this morning. Particularly, I would like to commend Dr. Kemp
for her leadership. Under her direction, the VA has made great
strides in its suicide prevention efforts. Dr. Kemp's work is
award-winning, and she has been named Federal Employee of the
Year in 2009.
I would also like to thank Maine Army National Guard for
submitting written testimony and for their effort to ensure
that every soldier has access to care that they need. The Maine
Army National Guard already has a close working relationship
with the suicide prevention staff at Togus VA Hospital. This is
a relationship that must be replicated at the national level,
through cooperation between the VA and the DoD.
Unfortunately, as the Maine Army National Guard testimony
points out, too many soldiers, including those not eligible for
VA benefits and those who do not have health insurance,
struggle to find care. I look forward to hearing from all our
witnesses today to discuss how we can improve the access to
treatment and prevention efforts to best serve our Nation's
veterans.
I want to thank you, Madam Chair, for having this very
important hearing today and look forward to working with you as
we move forward to address these very critical issues. I yield
back the balance of my time.
Ms. Buerkle. Thank you very much.
Before we begin, I would like to yield just a moment to Dr.
Roe, who I understand has a special constituent in the audience
that he would like to recognize.

OPENING STATEMENT OF HON. ROE

Mr. Roe. Thank you, Madam Chairman.
And thank you for holding this hearing. It is actually not
a constituent. He is somebody I actually met on the phone at
first and then had a chance, the privilege to meet him in
Memphis last fall.
And Ron, would you stand, please?
Madam Chairman, this is Ron Zelaski. He is a veteran of the
Marine Corps. And he walked across America barefooted to raise
awareness for veteran suicides. And as he walked he wore a
large sign that you will see displayed in this committee room
stating that 18 vets a day commit suicide. In order to bring
attention to PTSD in the military, given today's hearing topic,
I wanted to make sure that we invited this veteran and
recognize his tremendous efforts on the military suicide and
PTSD.
Ms. Buerkle. Without objection.
Mr. Roe. Thank you.
And Ron, just from another veteran, and a veteran that just
returned from Afghanistan about 6 weeks ago, the way that this
is treated today, the way PTSD is acknowledged and treated
today is totally different than the end of Vietnam, when I got
out of the military.
And I think we had a vacuum of 20 years of which we ignored
our veterans, and you being one of them, me being one of them.
That is not happening now, and it is not happening now thanks
to people like yourself, who took the time out to make this
tremendous sacrifice for your fellow veterans.
So I want to thank you, and I want this room to give Mr.
Zelaski a great round of applause.
I yield back.
Ms. Buerkle. Thank you, Dr. Roe.
And thank you, Mr. Zelaski, for being here, for your
service to our Nation, and for what you are doing to raise
awareness on behalf of our veterans.
Before I welcome our first panel, I would like to express
my extreme disappointment that the National Institute of Mental
Health declined to participate as a witness this morning in our
second panel. Although a formal letter of invitation to testify
was sent on November 7, committee staff was informed on
November 23 that bureaucratic obstacles in clearing a statement
would prevent the agency from being a part of today's
discussion.
I find this unacceptable, especially given NIMH's
partnership with the Department of Army to administer the
largest study on suicide and behavioral health in the military,
``The Army Study to Assess Risk and Resilience in
Servicemembers.'' Our military deserves better.
In addition, I would like to note that unfortunately our
Department of Defense witness, Colonel Castro, is unable to be
with us this morning due to an illness. Today we will begin
this serious discussion. Given its importance and the critical
need for VA and DoD to work together in collaboration I fully
expect to follow up with additional hearings and oversight that
will include DoD as a partner in the new year.
Now, I would like to invite our first panel to the witness
table. It is always a pleasure to welcome the members of our
veterans service organizations to share their expertise with
us. With us today are Commander Rene Campos, the deputy
director of government relations for the Military Officers
Association of America; Mr. Tom Tarantino, a senior legislative
associate for the Iraq and Afghanistan Veterans of America; Dr.
Thomas Berger, the executive director of the Veterans Health
Council for the Vietnam Veterans of America; and Ms. Joy Ilem,
the deputy national legislative director for the Disabled
American Veterans.
Thank you all very much for joining us this morning for
this very important conversation.
Ms. Buerkle. Commander Campos, we will start with you.
Please proceed.

STATEMENTS OF COMMANDER RENE A. CAMPOS, USN (RET.), DEPUTY
DIRECTOR, GOVERNMENT RELATIONS, MILITARY OFFICERS ASSOCIATION
OF AMERICA; TOM TARANTINO, SENIOR LEGISLATIVE ASSOCIATE, IRAQ
AND AFGHANISTAN VETERANS OF AMERICA; THOMAS J. BERGER, PH.D.,
EXECUTIVE DIRECTOR, VETERANS HEALTH COUNCIL, VIETNAM VETERANS
OF AMERICA; AND JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS.

STATEMENT OF COMMANDER RENE A. CAMPOS, USN (RET.)

Commander Campos. Madam Chairman and distinguished Members
of the Subcommittee, on behalf of the 370,000 members of the
Military Officers Association of America, I am grateful for the
opportunity to present testimony on MOA's observations
concerning the VA suicide prevention programs and efforts.
MOA thanks the Subcommittee for its interest in this
extremely difficult issue and for your commitment to the health
and well-being of our veterans and military families. In
conducting my research for this hearing, we were really struck
by the tremendous amount of work that has been done, the
steadfast determination of the VA central office staff, and
Secretary Shinseki's personal involvement in synchronizing the
agency's suicide prevention efforts is quite visionary. The two
most impressive initiatives are the VA suicide prevention
campaign, and thanks to Dr. Kemp, the National Veterans Crisis
Line.
Despite the improvements, the VA concedes barriers still
exist to advancing suicide prevention to the level needed.
Veterans and family members we talked to have seen great
progress in improving policies and programs. But they have seen
it at the national level. They don't always see these programs
and policies implemented consistently across all VA medical
facilities.
Here are some of the experiences veterans and their
families have told us. One caregiver spouse of a veteran with
PTSD said that it took the VA 2 months to schedule an
appointment just to get a fee-based referral for her husband,
who had some difficulty with sleeping. Now the veteran must
wait until May 2012 for the VA to do a required sleep study.
The caregiver questions why it has taken almost a year for the
VA to give her husband the care he needs, especially since the
VA knows that difficulty sleeping is a risk factor, and her
husband has a history of suicide attempts.
Another caregiver spouse of a veteran with PTSD and TBI
told us that when my husband attempted suicide in March, the VA
doctor told me to go to the ER, but the ER had no beds and said
he may have to wait 24 hours before one was available. They
gave me no alternatives. I was scared, and no one in the VA did
anything to help us or help me know what to do in a situation
like that.
Finally, one severely disabled veteran with TBI said that
he was frustrated because his provider seldom talked to him or
asked him how he is doing. He usually talked to the caregiver:
I just want them to know that I can contribute to my care. When
they don't talk to me, it makes me feel like they don't care
about me.
MOA urges Congress to take immediate action on three
recommendations which will further enhance VA's suicide
prevention efforts as well as address other systemic issues.
One, require VA and DoD to establish a single strategy and
joint suicide prevention office that reports directly to the
department secretaries through the senior oversight committee.
Congress has been VA's and DoD's greatest champion on promoting
collaboration after Walter Reed. We need that level of
oversight now.
Two, authorize funding to expand VHA mental health capacity
and capability in order to improve access and delivery of
quality and timely care and information. There needs to be
research that includes a longitudinal study of the economic and
societal costs of veteran suicide in this country.
And three, authorize additional funding to expand outreach
and marketing efforts to encourage enrollment of all eligible
veterans in VA health care, with special emphasis on the Guard
and Reserve, rural veterans, and high-risk populations. In
other words, there needs to be a long-term investment in
outreach and marketing to improve VA's image and its brand if
we are going to attract veterans to the system.
MOA believes that there is a business case for addressing
suicide that should consider the impact of national security
and the long-term costs to society of failing to do so. We have
no doubt, with the will and the sense of urgency from Congress,
the administration, DoD, and the military services and VA, we
can win the war on suicide. After all, our veteran and military
medical systems have eliminated some tremendous barriers, with
unprecedented results in saving lives on and off the
battlefield. We owe these heroes and their families our full
commitment, and eliminate remaining barriers to mental health
care so they can obtain the optimal quality of life.
MOA's encouraged by the significant progress made by the
VA. We thank the Subcommittee for your leadership and your
support in helping our Nation's veterans and their families.
Thank you.
[The prepared statement of Commander Campos appears on p.
38.]
Ms. Buerkle. Thank you, Commander Campos.
Mr. Tarantino, you may proceed.

STATEMENT OF TOM TARANTINO

Mr. Tarantino. Thank you, Madam Chairwoman, Ranking Member
Michaud, Members of the Committee.
On behalf of Iraq and Afghanistan Veterans of America's
200,000 member veterans and supporters, I want to thank you for
inviting me to speak on this pressing issue facing veterans and
their families, and that is the staggeringly high rate of
suicide, not just amongst veterans, but servicemembers as well.
My name is Tom Tarantino, and I am the senior legislative
associate for IAVA. I proudly served in the Army for 10 years,
beginning my career as an enlisted Reservist, and ending as an
active duty cavalry officer. Throughout these 10 years, my
single most important duty was to take care of other soldiers.
In the military, they teach to us have each other's back both
on the battlefield and off. Although my uniform is now a suit
and tie, I have been proud to work with Congress to continue to
have the backs of America's veterans and servicemembers.
Today's hearing on suicide really couldn't have come at a
more critical time. The Defense Department recently reported
that 468 active duty and Reserve soldiers, sailors, airmen, and
Marines committed suicide in 2010. Overall, the DoD tracked 863
suicide attempts, and the rate for veterans is likely much
higher. Although we have this limited data about
servicemembers, there remains a fundamental gap when it comes
to understanding veteran suicide. One of the greatest
challenges in understanding and preventing veteran suicide is
this lack of full data. If we don't know the entirety of the
problem, how could we ever hope to solve it?
Even in this age of information and technology, we have no
way of tracking veterans, unless they interact with some social
service that happens to ask about their military service.
Frankly, this is unacceptable. To address this problem, we have
to look a little bit outside the box. IAVA recommends that we
need to collect this data, and we should do it by expanding
existing services, like the Centers for Disease Control and
Prevention's National Violent Death Reporting System.
Currently, the CDC collects data on all manner of violent
deaths, including suicide, in 16 States. Veteran status can be
reported to the CDC, either through the death certificate or by
information collected by the medical examiner. If we expand
this database to all 50 States and require medical examiners to
report veteran status to the CDC, then we can get a much
clearer picture of the problem and know where to better target
our limited resources.
A critical step to understanding how we can stop veteran
and servicemembers suicides is to understand that suicide
itself is not the whole issue. Suicide is the tragic conclusion
of the failure to address a spectrum of challenges that
veterans face. These challenges are not just mental health
injuries. They include challenges finding employment,
reintegrating into family and community life, dealing with
health care and benefits bureaucracies that, frankly, are
almost as traumatic as the injuries themselves.
Fighting suicide is not just about preventing the act of
suicide. It is about providing a soft and productive landing
for veterans when they return home. The problems of mental
health care in the VA system have been pretty well documented.
The VA reports that 18 veterans in their care commit suicide
every day, and wait times for mental health care, as Commander
Campos mentioned, are still unacceptably high. And there is
just not enough mental health care providers to meet the need.
We also know that many veterans may not be seeking care
because of the stigma attached to mental health injuries.
Multiple studies confirm that veterans are concerned about
seeking care because it could impact their career both in and
out of the military.
To combat this, IAVA recommends that the VA and the DoD
partner with experts in the private and nonprofit community to
fund a robust, aggressive outreach campaign. This campaign
needs to focus on directing veterans to services, such as the
veterans centers, as well as local community-based and State-
based services. It should be integrated into local campaigns,
such as San Francisco's new veterans 311 campaign for their
city. This campaign needs to be well funded and reflect the
best practices and expertise of both the mental health and the
advertising fields.
It drives me nuts every time the VA asks me, how do you
reach out to veterans? I tell them stop reaching out to
veterans. Reach out to people. And why are you asking me? Go
ask the people who know how to sell toothpaste. They can put
your campaign in front of 40 million eyeballs. Me, not so much.
Providing a smoother transition from the military to
civilian world is critical in preventing veteran suicide.
Ensuring veterans access to mental health care is connected to
other issues that can contribute to a veterans' sense of
stability throughout their transition home. We must tackle the
other contributing factors, such as employment and
homelessness, that could increase the risk of veterans who are
vulnerable to suicide.
The responsibility of building a support network doesn't
necessarily lie with the military and the veterans' families
alone. Preventing veteran suicide is about easing the
transition from military to civilian life. And it is our
collective responsibility as a community. Our veterans are not
just readjusting to their families or connecting with other
veterans; they are coming back to jobs. They are using the GI
Bill to go to school and study at local colleges. And they are
seeking care and services from businesses and providers across
the community and outside of the veterans network.
We must focus on extending this understanding not just to
spouses, but also to society at large. Teachers and professors
should know what students of theirs are veterans or the
children of veterans and servicemembers. Businesses should
invest in the leadership of returning veterans by hiring them.
Health care providers must understand the injuries facing these
incredible men and women.
By promoting awareness, we can ensure that our entire
community is able to support veterans throughout their
transition back to civilian life and help stem this tide of
veteran suicide. By accurately measuring the problem, by
improving access to mental health care, and tackling the
transition from military to civilian life and creating a robust
community of support, we may be able to significantly reduce
the number veterans that attempt to commit suicide every year.
Veteran suicide does not have a silver bullet solution. No
one bill is going to solve this problem. But better practices
are out there. And we don't want to have to ask ourselves if
there was something more we could have done. Thank you very
much for your time and attention. I will be glad to take your
questions.
[The prepared statement of Mr. Tarantino appears on p. 45.]
Ms. Buerkle. And thank you, Mr. Tarantino.
Dr. Berger, you may proceed.

STATEMENT OF THOMAS J. BERGER, PH.D.

Mr. Berger. Good morning, Madam Chairman, Ranking Member
Michaud, and members of the House Veterans' Affairs
Subcommittee on Health. Vietnam Veterans of America thanks you
for the opportunity to present our views on understanding and
preventing veteran suicide. We want to also thank you for your
overall concern about the mental health care and issues
affecting America's troops and veterans.
I beg your indulgence. When I got up this morning to get
ready to come down here, I turned on my little BlackBerry here,
and I had a message from a colleague who lives in the north
central States of the U.S. My colleague is also the mayor of a
small town in this State, and a member of VVA National Board.
And this is the message I received this morning: Sergeant so
and so, 31 years old, from, will be buried at Arlington
Cemetery. U.S. Army, two tours in Iraq, one tour in
Afghanistan. Walked into the emergency room at, in this
particular city and the State, and stated to a nurse on duty
that someone outside needed help. He went outside and shot
himself in the chest. On his arm was a note. He had written his
blood type, A-negative, and he had written, ``Please use my
organs for someone more worthy than me.''
I am a little bit upset this morning to come in, obviously,
and talk about this issue after receiving this email this
morning. We have been here before. We are 10 years into the
war, ladies and gentlemen. I appreciate the comments of my
colleagues here, and I won't belabor the fact that there have
been some excellent efforts made by Dr. Kemp and her division
there. And I will leave it at that. But I will try to take the
rest of my allotted time and talk about VVA's concern with
suicide within the system.
It is very challenging, as we have heard, to determine an
exact number of suicides. Many times suicides are not reported,
and it is very difficult to determine whether or not a
particular individual's death was intentional. For a suicide to
be recognized, obviously examiners must be able to say that the
deceased meant to die. And there are other factors that
contribute to the difficulty, including differences among
States as to who is mandated to report a death, as well as
changes over time in the coding of mortality rates. But those
aren't the problems.
The problems, okay, and VVA has long believed in the links
between PTSD and suicide, and in fact, there is plenty of
research studies out there to suggest that suicide risk is
highest in persons with PTSD. Others claim that suicide risk is
higher in individuals because of related psychiatric
conditions. But a study published by the National Co-Morbidity
Survey showed that PTSD alone out of six anxiety diagnoses was
significantly associated with suicide ideation or attempts.
Now, some studies point to PTSD as the cause of suicide,
suggesting that high levels of intrusive memories can also
predict the relative risk of suicide. Anger and impulsivity are
two more factors that are on the list and, as you well know,
are part of the symptomology for PTSD.
Other research says that the most significant predictor of
both suicide attempts and preoccupation with suicide is combat-
related guilt, particularly amongst Vietnam vets.
All of this brings us full circle to what VVA has been
saying for at least the last 6 years. If both DoD and VA were
to use the PTSD assessment protocols and guidelines, as
strongly recommended by the Institutes of Medicine back in
2006, then our veteran warriors would receive the accurate
mental health diagnoses needed to assess their suicide risk
status.
Thank you. I will be glad to answer any questions.
[The prepared statement of Mr. Berger appears on p. 48.]
Ms. Buerkle. Thank you, Dr. Berger.
Ms. Ilem, you may proceed.

STATEMENT OF JOY ILEM

Ms. Ilem. Thank you, Madam Chair and Members of the
Subcommittee.
I am pleased to present the DAV's views on suicide
prevention efforts in the Department of Veterans Affairs. We
appreciate the Subcommittee's continued focus on this difficult
issue and on the effectiveness of VA's mental health services.
Suicide is a complex phenomenon, one in which VA and DoD
have struggled in finding preventative solutions and effective
strategies in the shadow of wars. DAV observes that VA and DoD
have made visible and positive efforts to address the unique
challenges in meeting the mental health needs of post-deployed
active military personnel and newly returning veterans.
Both agencies are populated with dedicated practitioners
and specialists, researchers, policymakers, and other leaders
who continue developing new approaches to address suicide and
attend to the other serious emotional and behavioral
consequences of war. However, despite these obvious efforts and
the notable progress they have registered, it is clear that
more needs to be done.
All the experts tell us that effective suicide prevention
must begin with strategies for routine mental health screening
and early intervention for everyone, accompanied by ready
access to comprehensive primary care and specialty treatments
for any suspected serious problems identified. If not readily
addressed, or untreated, problems of these types can easily
compound and become chronic. Delay in treatment may lead to a
host of personal and social problems, including early discharge
from the military or other job loss, family breakup,
homelessness, criminal incarceration, and even suicidal
thoughts and actions.
In our opinion, VA has made valid efforts for early
identification and effective treatment of behavioral problems
in returning war veterans. Likewise, Congress provided VA
significant increases in resources to institute system-wide
changes, expand mental health staffing, integrate mental health
services into its primary care system, develop a specific
suicide prevention program, expand programs for PTSD, substance
use disorders, and training on evidence-based psychotherapies.
As we understand it, the goal of VA's strategy is to
promote healthy outcomes and strengthen family unity, with a
focus on recovery. In addition to the goal of recovery, VA has
now adopted a patient-centered model of care. These are the
changes veterans say they want, and we believe all of these
efforts are moving VA in the right direction. But over the past
several years, a number of congressional hearings have been
held, studies conducted, and informal surveys done related to
the effectiveness of VA mental health services, including
questions about how to alleviate the known access problems,
stigma, gaps in services, and other identified barriers to VA
care. The results help us frame the problem, but they do not
solve it.
Based on the number of factors all of us are keenly aware
of, it appears that real challenges still block VA's goals of
meeting the most severe needs of a minority of new veterans who
require intensive therapies and who consume significant blocks
of time of VA practitioners. In VA, these are the same
professionals who must also meet the mental health needs of a
large population of older veterans with chronic and severe
mental illness in a constrained resource environment.
Growth in demand for mental health services impacts all of
VA's providers and patients. Unfortunately, it appears that VA
is still struggling to figure out the right balance to ensure
it identifies those few crucial cases with a high risk of
suicide, while still meeting the needs of other new veterans
and the older chronically ill populations in a clinically
appropriate way for all, all while preventing suicides as the
most pressing public issue.
With even more troops returning home by the end of the year
and many who will likely transition to veteran status, this is
an extremely complex mandate to meet, yet VA is attempting to
do it and must succeed.
In closing, DAV believes VA is moving in an appropriate
direction, but must find a way to hear directly from veterans
trying to gain access to the system to better understand their
unique needs and desires for treatment and services, and then
tailor programs accordingly. We also believe that listening to
veterans' feedback and making necessary changes are going to be
essential to recreating a VA mental health system that meets
veterans where they are, that works for them, and is effective
in achieving the recoveries they all seek.
Likewise, VA leadership must acknowledge and address the
challenges its providers are bringing to light. We encourage VA
leadership to build on that knowledge to come, and to be more
forthcoming in dealing with the challenges it faces. But
despite DAV's concerns as expressed here in my written
statement, we do recognize the lifelong dedication of the
leaders of VA's Office of Mental Health and VA practitioners in
the field.
We appreciate their tireless commitment to improving the
system for all veterans in need, old and new.
Madam Chairman, this completes my statement. I am happy to
answer any questions you may have.
[The prepared statement of Ms. Ilem appears on p. 50.]
Ms. Buerkle. Thank you very much, and thank you to all of
our panelists. I will now yield myself 5 minutes for questions.
Dr. Berger, you mentioned that for years your organization
has advocated the use of the PTSD assessment protocols and
guidelines. Could you discuss these standards and how you think
that they would improve the situation and the quality of care
for our veterans?
Mr. Berger. If I may, Madam Chair, a little bit of history.
The VA itself commissioned a group of some of the most
distinguished mental health experts in the country, including
some people who are on the staff of the VA itself, some years
ago, in the early 2000s, about 2005 or so, to take a look at
and develop a series of guidelines and protocols to diagnose
and assess PTSD. They did so. And in my written testimony, I
have the link to that document.
Subsequently, there was no directive in any aspect or area
of the VA to utilize this document that they had paid all this
money for and utilized the time and services of these brilliant
minds. All right. We still have reports of people being
assessed on the basis of a 30-minute interview, where most of
the time the clinician is taking personal information. Those
are the kinds of things that the guidelines, in our opinion,
the protocols that were developed were meant to minimize. But
they still exist.
Granted, since the IOM report was issued, there are many
more clinicians who aware of the guide and protocol, but
largely because of our efforts to educate them on this through
our network of State council chapters and that sort of thing.
So that is where it stands at the present time. And we just
wish that it would be utilized by both DoD and VA. And we feel
that if the correct assessment and diagnosis is made, then they
can move onto the suicide risk assessment, and everything
should just follow along.
Ms. Buerkle. Thank you, Dr. Berger.
I would like to think that there is no lack of will to get
to the root of this problem and to get our veterans the
services they need to avoid these suicides. So I would ask each
one of you, what to you is the biggest gap or the biggest
reason we are not getting this problem solved? It is getting
worse instead of better. What is the one thing we need to focus
on? I would like to hear, if you could just tailor your remarks
so all four of you get the opportunity to respond, I would
appreciate it. Thank you.
We will start with Commander Campos.
Commander Campos. Yes, ma'am. I think that is a very valid
question. And I think admittedly in recent hearings, and as
early as yesterday, VA admits that, and what we found in our
research is that there are definitely policies and programs in
place, but the challenge to VA is the execution and the
implementation of these policies. It is a decentralized system.
And I think what we are hearing is that there is so much focus
now at the medical facility level of getting the numbers, and
getting people seen, and so on, that I think that it has become
more of an assembly line process. And it is creating, I think,
havoc in the system.
And then you have the pockets of where there aren't enough
resources and staffing and facility infrastructure that the
system is overwhelmed, and the resources and the staffing and
all the other needs to support the system are not out there
consistently.
So I think for VA to get to a system of being veteran-
centric, they are going to have to step away from focusing on
investigation, looking at the numbers, and start looking at the
veterans themselves and what their needs, and letting them be
part of the discussion.
Ms. Buerkle. Thank you.
Mr. Tarantino.
Mr. Tarantino. I know this is going to kind of sound lame,
but outreach and awareness. I mean, bottom line, the VA has
good programs. It has the crisis line. It has the new Making
Connections program, which I think is pretty slick and pretty
cool. The problem is nobody knows what the VA does. Nobody
barely even knows that the VA exists. If you go outside and
pull a hundred people off the street, ask them what NASA does,
I guarantee you, you are going to get 90 of them are going to
give you a pretty decent answer. And NASA affects a fraction of
the percent of the population directly in this country.
Six percent of the population would be directly affected by
the VA. You would be lucky if maybe 10 out of those hundred
would be able to tell you what VA does and what programs they
have. It is because as a community, we are so insular. We are
insular to the veterans community, the military community.
As the veterans population is dynamically shrinking, we
have to stop that, and we have to change the way we think about
outreach to veterans. And we have to reach out to families, to
the community. Why? There is not that many of us in my
generation of veterans. And guess what, I am a soldier; I am
also kind of a knucklehead. I am not the one who is going to go
out and seek help. It is going to be my girlfriend, my mom, my
best friend. Those are the people you have to reach out to. And
that is where we need to focus our efforts to stem the tide of
this.
Ms. Buerkle. Thank you.
My time has expired.
I now yield to the Ranking Member, Mr. Michaud.
Mr. Michaud. Thank you very much, Madam Chair.
Dr. Berger, you had mentioned the fact that the VA has come
full circle. And you talked about DoD and VA using the PTSD
assessment protocol and guidelines. That was one of his
recommendations. I would like to ask the other three
individuals whether or not you agree with that assessment, that
that is a good place to start.
Commander Campos. I don't think I have the expertise to
really address that. But I don't think we ever go wrong by
including VA and DoD collectively and collaboratively in
addressing this issue.
Mr. Tarantino. Yes.
Ms. Ilem. I think what Dr. Berger indicated, where the
research indicates that direct link with higher risk of suicide
for those with PTSD. So certainly it is absolutely critical to
make sure that people do get diagnosed or at least addressing
that there is a readjustment issue that needs to be dealt with
to be able to get the proper treatment and to avoid and prevent
any further--suicide or other negative behaviors that can
really impact them.
Mr. Michaud. Thank you.
My next question for all of you then, we have heard
testimony about how the different VA facilities do things
differently. In terms of accountability, oversight, monitoring,
and evaluation of what the VA is doing to implement strategies
across the system so that our veterans are getting the proper
health care needs, is there anything that you think we should
be doing specifically, or advice you would have for the VA as
far as the accountability and oversight and monitoring?
Ms. Ilem. Dr. Schoen has indicated that one of her goals in
coming into the VA system, is the new development of a two-
pronged approach, one focused on policy issues and the other
focused on driving those policies out to the field and making
sure implementation is achieved is critical. So I would be
interested to hear more from her on the second panel in terms
of how they think that is going.
I know VA is trying to work on the standardization of the
package that they developed for mental health to have a robust
package in place at all locations and to decrease variance. But
the absolutely critical piece is who is connecting with the
field, listening to the feedback from providers and the
directors and the leadership in the field. Where are they
having the problem in doing something, what is the problem? You
know, is it lack of staff? Lack of resources or just a
significant increase in veterans coming in? So I think it can
be unique in every location, some places have a problem and
others don't. But having those two offices connecting up is
essential.
Mr. Berger. I would like to support my colleague in his
earlier comments about outreach. The fact of the matter is that
almost 70 percent of America's veterans do not use the VA for
lots of different reasons. So we are not getting the word out
there. And the word that is getting out there, or the image
that is projected because of the shortness in resources and
variability and accessibility of program concerns, the vets
aren't coming in.
VA has to do a better job in terms of its outreach program
for the stuff that it does offer to get to the veterans. And
let's get away from this development of policies and all these
other kinds of things that seem to get in the way of actually
getting out there to our veterans and make sure that they get
the message that this is the system that was developed and is
in place for them.
Commander Campos. I did have an opportunity to talk to a
DoD mental health professional before the hearing. And I know
that there are folks out there who really want to work closer
with VA. I know VA wants to work closer with DoD. And these are
leadership issues. And this mental health professional said the
best thing we can do, especially when we know people that are
at high risk when they leave the military service is to do that
warm handoff to the VA where that veteran will go to. They want
to do it. But again, sometimes the barriers and bureaucracies
get in the way. And I think that there are people in the VA
system who really--who are veterans themselves, and I think
they can actually probably find some of the solutions that
plague the VA bureaucracy.
Mr. Michaud. Thank you.
Thank you, Madam Chair.
Ms. Buerkle. Thank you.
I now yield 5 minutes to the gentleman from Tennessee.
Mr. Roe. Thank you. I don't understand why NIMH wouldn't be
here. And I think we need to have an explanation. That boggles
my mind. But anyway, Mr. Michaud and I, I guess 2 and a half
years ago went to Afghanistan. And we went back to Afghanistan
about 6 weeks ago to look at where the injuries occur at the
point of the spear, follow those physical and psychological
injuries to Landstuhl--to the forward surgical hospital, to
Kabul or Leatherneck, to Landstuhl, and this Monday, I was at
Walter Reed, Bethesda. And next week I am meeting with Dr.
Brown, who is a psychiatrist at the VA at Mountain Home, to try
to close the loop so I have made full circle.
What is happening now in Afghanistan, and I assume in Iraq,
the 101st Airborne Division really made a real effort in TBI
and PTSD to get on top of that early. And what they found by
doing that, and I won't go through all the things we saw, but
they actually got the fighter back in the war, back into battle
sooner by being proactive in treatment. So I think that is
being done.
And Dr. Berger, I mean, that is heartbreaking that email
you just read. I know that that doesn't affect one person. That
affects that family. That family will deal with that every
Christmas for the rest of their lives, that family member will
be.
Tom, you had mentioned about getting information out.
Yesterday, we had, I don't know whether you know Jim Young or
not, but Google has--you probably do--Google has two people DoD
assigned to help in their Google search engine to get
information out, which is how a lot of young people are treated
in theater, for instance. Many of them are in isolated places,
and they use telehealth. And a lot of our younger soldiers, not
like me--I mean, I couldn't do that--but they enjoy, or it is
easier for them, because of the stigma of PTSD, they much
prefer that. And in some instances, that works very well. I
think that could work here Stateside very well, where you have
overly burdened VAs. So that is one thing.
I know there is an organization we also went to this week,
Not Alone; I am sure you are aware of them, too. They are in
20-something States now, who on their own outside the VA are
another resource for veterans to reach to if they know that
they are there. So I think this new way to approach people with
this right here. Any way. I mean, everybody has got a cell
phone now just about in this country. And that is one way we
could communicate better, I think.
And Tom, if you would, I was intrigued by the 311 campaign.
What are they doing there?
Mr. Tarantino. Well, as you know, many cities have a 311
campaign that allows you to access all manner of city services.
New York has one. I think Houston has one, you know, Chicago.
And in San Francisco, we were contacted by the former mayor and
asked, you know, we have a lot of veterans in San Francisco. We
have a lot of veterans services, but we need a way to get our
citizens to these services. And so we worked with them to
develop a campaign where when you call 311, if you are a
veteran, you press--I can't remember what the exact number is,
one or two--and you get sent on a separate track, meaning you
have a shorter queue, you get sent to a separate track of
veterans services, you have unique access. And that works, not
just on the phone, but it works online as well. And I know,
coming from the Bay area myself and from the State of
California, they actually do this with all their social
services. If you are a vet, there is a separate line, there is
a separate track that you go through. And the services are more
tailored to you. And the idea of integrating national and VA
services is the VA has the power to be omnipresent. They have
the power to set minimum standards for care and services. But
it doesn't mean that we can't use the multiple touch points and
interactions that are actually happening in communities that we
don't know about because we are not tracking it. And I am not
talking about contracting; we are just talking about
partnerships for care. And I think by developing that type of
model where, you know, city services and State services have
some sort of integration, or at least have some sort of cross-
talk and communication with VA services, then you can actually
catch a lot more people before they get to that tragic
conclusion of suicide.
Mr. Roe. Commander Campos, we talked with Commander Evans
at Bethesda on Monday. And she was of the opinion that a lot of
times--I know you are looking at another layer--but I wonder if
the resources aren't there now, and instead of creating another
bureaucracy, just organize the resources that we have. Because
that was one of the problems that they were dealing with, there
were so many ways of--you know, the veterans, wounded warriors
dealing with seven, eight, nine, 10 people, and it got
confusing for them. It would be confusing for me to deal with
eight different people making rounds on me every day. Usually,
when I made rounds in the hospital, there was a nurse and
myself would come by and see you, and you would know what was
going on. These veterans are facing multiple people that come
in to see them. So I would like to work with you on that. I
think that is a great idea. But I wonder if we couldn't just
organize what is already there.
The last thing--and I know my time has expired, I will be
very quick--do we know the incidence of suicide among veterans
5, 10, 15, 20, 30 years ago? And is what we are doing changing
it? Are we collecting data better now than we used to? That is
the thing that it is hard for me to understand. You know,
before, did we just not have the information? And are we doing
a better data collecting now making it look higher?
Mr. Berger. I think there are more States, for example,
that have responded to the call to report violent deaths, has
been hinted at, more accurately than there were in my
generation of veterans. But the fact remains that it is still,
because it is some corners of the country and some corners of
the States, it is just simply not reported as a suicide. And
until we can get some kind of way to address that, I don't know
if we are going to----
Mr. Roe. See what I am saying? Was it apples to apples?
Mr. Berger. Exactly.
Mr. Roe. My time has expired. I yield back.
Ms. Buerkle. Thank you, Dr. Roe.
I now yield to the gentleman from Texas, Mr. Reyes.
Mr. Reyes. Thank you, Madam Chair, and thank you for
calling this hearing. And I had a question for my colleague,
Dr. Roe. When you asked unanimous consent to enter into the
record Ron's information, is it the letter to the Veterans
Committee?
Mr. Roe. Yes. I think that is it.
Mr. Reyes. If it is not, I would ask the same unanimous
consent. And the reason is because, Ron, thank you so much
for--I got the opportunity to talk to him yesterday. I had
never met him before, but I had heard of him. And so I
appreciate the work that you have done. And in his letter to
the Veterans' Affairs Committee, there are a number of
recommendations that he makes and he identifies that track very
well with what our panelists have said here this morning. And
in the interests of transparency, I am a life member of both
the VVA and the DAV. But I wanted to add, being a Vietnam
veteran, having come back during the tumultuous time when we
were not received as well as, thank God, today's veterans are,
one of the constant questions that is asked, at least in my
district, by some of our same veterans groups is a question of,
you know, with the kind of support that--outpouring of support
that veterans are seeing today, it is incredible that we are
still going through all of these issues. But I try to explain
to people, you know, we don't have all the information. Because
as I, too, go to Afghanistan, Pakistan, Iraq, Kuwait;
anecdotally I get information from active duty personnel that
they are still reluctant to come forward with concerns of PTSD
and sometimes TBI because they think--they want the military as
a career, and they think it is going to hurt their career. I
really do believe it is important, and our Ranking Member here
can attest to it, when we had the full Committee hearing, one
of the recommendations that I made to Chairman Miller is we
have to bring in Secretary Shinseki and Secretary Panetta so
that we can work on these many recommendations that all our
veterans organizations have long recognized. We have to have a
single effort, a single program of working between the DoD and
the VA, especially today when we are looking at tough budgets.
I asked staff, because one of the--I have been on this
committee since I have been in Congress. I had to take a leave
of absence when I was chairman of the Intelligence Committee.
But my interest has always been there, being a veteran, and
having, by the way, Dr. Berger, a brother that served also in
Vietnam that absolutely refuses to go to the VA. And his
rationale, and he suffers like many of us with that jungle rot
that periodically comes up because of stress, he refuses
because he says, ``Listen, I served my country not so that my
country would take care of me for the rest of my life.'' So he
is very independent that way. And a number of veterans are. In
the 16th District of Texas, I have a full-time staff member
that is actually going out throughout the homeless population
and the rescue mission and things like that to ask people if
they are veterans so we can get that information to them. But
some of them just absolutely, for many different reasons, some
of them, because they are obviously suffering from PTSD and
other types of mental illnesses, need to be brought in.
So I was curious, I know my time is short, in 5 minutes,
with all of things that we have to deal with, it is very short,
but Dr. Berger, do you have any observations on that?
Mr. Berger. Well, first of all, Congressman, thank you for
your service, and welcome home, brother.
Mr. Reyes. Thank you.
Mr. Berger. Secondly, and to be quick about this, my
colleague Tom Tarantino mentioned something that is quite
understated, and you hinted at it also, and that is the
brotherhood and sisterhood that exists between veterans out
there. Veterans talk to one another. And maybe we will hear
something about this a little bit later on. But in any case,
one of the ways of getting the word out is veteran to veteran.
Okay? Despite all the signs on the buses and late night videos
and all that sort of thing, the fact of the matter is if Tom
calls me--I know Tom--and says, I am having some problems with
this or whatever, you know, I will talk to him, and maybe even
suggest that he go--find out where he lives and suggest that he
go. And if I know a clinician there or whatever, and say you
need to ask for--veteran to veteran helps a lot.
Mr. Reyes. And Madam Chairman, if I can just have a second,
in his letter to the Veterans' Affairs Committee, Ron also
makes mention of something that Tom did. And that is the number
of times, as he walked across the country, that mothers and
wives and relatives turned around to commiserate with him, to
hug him and cry with him about their loved one that was
suffering with PTSD, or had suffered with PTSD. All of these
issues are so important. That is why I say, let's, if we don't
do anything else in this Congress, let's get Secretary Shinseki
and Secretary Panetta here before this committee so we can
start working towards one single understanding and probably a
number of different single programs in all these different
areas that are absolutely related. It is not always about money
because, you know, we funded that independent budget when we
were in the majority every year. And the organizations were
very grateful. But it certainly has not brought us to a point
where we are any more successful today, regrettably.
So thank you again, Madam Chairman.
Ms. Buerkle. Thank you. I now yield 5 minutes to the
gentleman from Florida.
Mr. Stearns. Thank you, Madam Chair. A question. When you
look at the statistics of 18 deaths from suicides per day and
then about five of the deaths from suicides per day among
veterans receiving care. Dr. Berger, are the care we give
veterans who are actually participating in a program, is it
working? I mean, with five of the 18 deaths per day are coming
from veterans actually receiving the care, and then when you
look at the statistics where about 11 percent of those who
attempted suicide did not succeed or have made repeated
attempts with an average of 9-month follow-up, so the question
is, does the Veterans Administration have a program that is
working?
Mr. Berger. At the present time, there is so much
variability across the spectrum of mental health services, not
only in the training of the clinicians and at the programs that
are available, plus just general physical access, and I think
all of that enters into it. And so I would say there is room
for lots of lots of improvement.
Mr. Stearns. On a 1-to-10 scale, how would you rate the
Veterans success in preventing suicides?
Mr. Berger. Four.
Mr. Stearns. That is a fail.
Mr. Berger. Yes, sir.
Mr. Stearns. So what you are really doing this morning is
indicting the Veterans Administration, which--I understand what
you are saying, and I am sympathetic, because when I read these
statistics that is alarming to think that five people of the 18
actually are getting clinical care. So your rating it at 4
indicates that the Veterans Administration is not providing the
services.
Even if we get the veterans there, even if we get the
communication and the education that Tom has talked about, once
they get there, they still were not successful. And so--and is
it possible the reason is because there are so many programs
that are not working together, or is it possible that the
actual procedures are not working or we just don't know enough
about suicide.
Mr. Berger. That is correct, we don't know if they are
working. I would point out again the accessibility. I mean, we
heard on the Senate side the other day the difficulties that
some veterans are suffering getting into the proper treatment
program. It may be days, it may be weeks, it can be months. And
when you have somebody who has been through trauma, as the
research suggests, serious combat trauma, who needs help, you
can't wait 6 weeks for your initial appointment.
Mr. Stearns. And, in fact, if a person has to wait, it
might contribute because he gets frustrated, he or she gets
frustrated, and to say there is no hope here and I am going to
have to sit around for weeks, possibly months, is that
possible?
Mr. Berger. Yes, sir.
Mr. Stearns. What would be the longest wait that you have
experienced or that you are familiar with that a veteran who
has suicide tendency has had to wait to get treatment?
Mr. Berger. Eight months.
Mr. Stearns. Eight months, okay. Because I see here it is
talking about--there is something about 9 months in some of the
fact sheets here. Well, let me ask you this: This is a more
difficult question. Is the suicide rate from Iraq and
Afghanistan worse than it was from Vietnam and Korea, or is it
just that we don't have the data?
Mr. Berger. We don't have the data, as Congressman Roe
pointed out. The information gathering or data collection 40
years ago, 35 years ago, is a lot different than it is now,
although the technologies have improved, reporting has
improved. It is difficult to compare. One thing we do here is
that for a couple of years after the cessation of hostilities
in Vietnam, there was an increase in suicides. That is more
anecdotal than anything. But at the same time we are sort of
hearing that anecdote now beginning to arise. And I have
concerns professionally when all these folks come home, if they
don't have access to what they need in terms of mental health
services, and that includes accurate scientific-based or
evidence-based treatment programs when they need them, we are
going to have real problems. And we got, what, half a million
coming home here in the next month?
Mr. Stearns. Right. Well, Madam Chair, it seems to me that
we can solve as Members of Congress with money to the
administration to get an educational component so the veteran
coming home will know of its availability. We can actually
probably convince a lot of veterans to perhaps take the test
when they leave the DoD. But what I am worried about is once
they get in the VA, you are telling me there is no accurate
information to show that the program that they have implemented
is working, there is no statistical information that has been
investigated to show how successful, and then two, in a larger
sense it is not working, it is failing.
Mr. Berger. Sir, if there is an outcome measurement being
conducted I am not aware of it. And then we need to hear from
the appropriate VA officials if indeed such information exists.
And then I might be willing to revise my grading scale.
Mr. Stearns. Okay. Well, I think you got to be honest here.
And I just want, before I close, Madam Chair, to ask each one
do they agree with Dr. Berger? You don't have to agree with his
4 rating, but in general, do you agree with what his assessment
is? Just say yes or no.
Commander Campos. Yes, sir.
Mr. Tarantino. Yes, sir.
Ms. Ilem. Yes. Many challenges.
Mr. Stearns. All right. Thank you. Thank you, Madam Chair.
Ms. Buerkle. Thank you. I now yield to the gentleman from
Indiana, Mr. Donnelly.
Mr. Donnelly. Thank you, Madam Chair. One of the points has
been the issue of isolation and that we will work to put
programs together, but 70 percent of the vets don't want to
have that initial contact. And Tom's point about media and
reaching out and touching other family members about getting
our other vets included, what are your--and Dr. Berger, you
talk about vet to vet, that that is the way, or one of the ways
to help get this. For that 70 percent, what other ideas do you
have to reach out to our vets, the vets who aren't going to
join DAV or VFW or the American Legion who aren't connecting to
the VA but who struggle every day?
Mr. Tarantino. Well, Congressman, I can talk a little bit
about some of the lessons we have learned from IAVA's ad
council campaign. That was very successful in reaching out to
vets and their families who otherwise might not have paid
attention. The commercials that we produced and the PSAs that
we have produced weren't done because Tom Tarantino or Paul
Rieckhoff are smart guys, and we know what we are doing. We do
in our space, but we are not innovators in the advertising
space. This was done because the Ad Council brought in
professionals from BBDO and Sachi & Sachi, people who know how
to communicate, people who set the standards in this country
for how we publicly communicate.
And we were able to, over the course of a couple of years,
bring in our knowledge base from the veterans community, match
it with their knowledge base from the advertising community and
create an outreach campaign that spoke to virtually everyone
who saw it, whether you are a vet or a civilian. And that is
something that the government really doesn't do at all, and
when they do do it, they do it poorly, and it is not very well
researched and it is not focused. And I think a lot of times we
trade expedience for quality. You want to get this campaign
out, we got to get it out in 6 months, and that is the metric
for success. Well, a bad campaign out too soon is just still a
bad campaign. So why aren't we taking the time to focus test
this? Why aren't we talking to industry leaders? Why aren't we
going out into the technology community and thinking what can
we do? Where are people communicating online and why aren't we
going there? Why aren't we buying targeted Facebook ads?
Facebook, it is the most advanced advertising platform
known to man. They know absolutely everything about you. And it
is not an accident that all the ads that show up on the right
side of your screen are all stuff that you are interested in.
There is no reason why we can't be reaching out in ways like
that. Using technology and using these best practices to laser
target into military communities, veterans communities,
military families, we just don't do that, and I don't know why.
Mr. Berger. I would just only add to what Tom said earlier.
This is a community effort as well. It is not just getting the
ads put together, or the outreach programs put together. You
have to have the involvement of the community. When you are
dealing with that element, that demographic element, almost 70
percent are not going to the VA. I mean, you have to have
people in your community talking about this stuff using the
methodologies that are developed at the national level.
Mr. Donnelly. A lot of us have rural areas too, and I think
staff going out and trying to locate our vets. And in some of
the rural areas, it is not always the easiest thing to do with
the Facebook techniques that you talk about and other
techniques. Do you know of any, or have you heard of any
specific targeted efforts in rural areas so our vets who may be
almost, or off the grid, in effect, how do we locate them?
Ms. Ilem. VA did bring to our attention and gave us a demo
just last week of their new Making the Connection campaign. I
think that would be worth asking the next panel about
specifically. It seemed in the rollout to be testimonials from
veterans, from family members and others.
So certainly it is a Web-based tool with lots of resources
and seems to be able to be manipulated to be tailored to the
specific person's interest. So I think that is one way. That
definitely could be available in the rural community.
Mr. Donnelly. And Madam Chair, what are the great concerns
is truly we will do everything we can as a committee as the VA,
but when 70 percent of our veterans are living their lives and
we are not touching them we have to figure out a much better
way to touch them. I yield back.
Ms. Buerkle. Thank you very much. We have been called to
vote. We have about 2 minutes left to vote and the votes should
take about an hour. What we would like to do is recess this
hearing and then reconvene at around 12:15. If you could all
join us for our second panel, please come back at 12:15 and we
will reconvene this hearing. Thank you.
[Recess.]
Ms. Buerkle. We are reconvening our hearing of the
Subcommittee on Health. If I can invite our second panel to
come to the table. I thank you all very much for your patience
for the little bit of disruption in this morning's hearing.
Joining us on our second panel is Dr. Margaret Harrell, Senior
Fellow and Director of the Joining Forces Initiative for the
Center for a New American Security; Dr. Katherine Watkins,
Senior Natural Scientist for the RAND Corporation; Dr. Janet
Kemp, the National Suicide Prevention Coordinator for the
Department of Veterans Affairs, accompanied by Dr. Antoinette
Zeiss, the Chief Consultant for Mental Health for the U.S.
Department of Veterans Affairs. Colonel Carl Castro, as I
mentioned earlier, is not able to be with us this morning.
Ms. Buerkle. Thank you all very much. I am very eager to
begin our discussion. Dr. Harrell, if you could proceed.

STATEMENTS OF MARGARET C. HARRELL, PH.D., SENIOR FELLOW AND
DIRECTOR, JOINING FORCES INITIATIVE CENTER FOR A NEW AMERICAN
SECURITY; KATHERINE E. WATKINS, M.D., SENIOR NATURAL SCIENTIST,
THE RAND CORPORATION; JAN E. KEMP, RN, PH.D., NATIONAL MENTAL
HEALTH DIRECTOR FOR SUICIDE PREVENTION, VETERANS HEATH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS,
ACCOMPANIED BY ANTOINETTE ZEISS, PH.D. CHIEF CONSULTANT FOR
MENTAL HEALTH VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS

STATEMENT OF MARGARET C. HARRELL

Ms. Harrell. Thank you. Madam Chairwoman, Ranking Member
Michaud and Members of the Subcommittee, thank you for the
privilege of testifying today. It is an honor to be here. While
the topic at hand is suicide prevention among veterans, I must
underscore the importance of considering both veteran and
servicemember suicide. We can only be sure that strides have
been made when the frequency of suicide decreases amongst both
of these populations. There is, for an example, a possibility
that a decrease in suicide among servicemembers could represent
expeditious out processing of servicemembers struggling with
mental health wounds of war. Only the joint consideration of
both servicemember and veteran outcomes will highlight reasons
for increased concern or will identify success. Addressing
suicide among servicemembers and veterans is vital to the
health and sustainability of the all-volunteer force. It will
take a collaborative effort by DoD, VA, Federal and State
legislatures and communities to curb suicide amongst those who
have served. Our leaders in the DoD and VA deserve recognition
for their actions to reduce these tragedies, and I am confident
that my co-panel members will articulate many of the excellent
efforts taken in this regard.
Despite their best efforts however challenges remain. In my
submitted testimony I highlight multiple challenges and
proposed recommendations. I focus upon four of those challenges
here. The first challenge is the lack of accurate accounting of
veteran suicide and the reliance on incomplete and delayed
data. We recommend Congress establish reasonable time
requirements for States to provide their death data to the CDC
and that Department of Health and Human Services ensure that
the CDC is resourced sufficiently to expedite compilation of
these data. Additionally the DoD, the VA and HHS should
coordinate efforts to analyze veteran suicide data annually. A
second challenge pertains to the national shortage of mental
health care and behavioral health care professionals, a factor
linked to higher ratings of suicide. Congress should require
the VA to establish deadlines by which all 23 VHA regions will
be manned to the recommended level of care providers.
Additionally, and especially in the meantime, the VA should
increase their use of existing public-private partnerships to
provide care to the extent that such partnerships would
expedite evidence-based care to veterans.
A third challenge pertains to the geographic moves that are
a feature of military life. Separating servicemembers also
often relocate their families as they leave the military.
Because mental health care providers are licensed on a State-
by-State basis a move across state lines can preclude continued
care from the same provider. When a care provider and a patient
develop a relationship and that relationship is severed by a
move, individuals are often reluctant to begin treatment anew.
Thus we recommend Congress establish a Federal preemption of
State licensing such that mental health care can be provided
across State lines for those instances in which veterans,
servicemembers or military family members have an established
preexisting care relationship.
The fourth challenge is the decentralized multitude of
suicide prevention programs in the National Guard. The solution
is inefficient and at risk of reduction or elimination. Such is
the case in Minnesota where there exists both the highest
number of National Guard suicides this year and also dwindling
resources to address their problem. We recommend the
consideration of a system-wide centrally funded prevention
approach.
In conclusion, my testimony is extracted from a CNAS policy
brief entitled Losing the Battle, the Challenge of Military
Suicide. America is currently losing its battle against suicide
by veterans and servicemembers. As more troops return from
deployment the risk will only grow. To honor those who have
served and to protect the future health of the all volunteer
force, America must renew its commitment to its servicemembers
and veterans. The time has come to fight this threat more
effectively and with greater urgency. Thank you for addressing
your attention to this critically important battle.
Ms. Buerkle. Thank you very much, Dr. Harrell.
[The prepared statement of Margaret Harrell appears on p.
57.]
Ms. Buerkle. Dr. Watkins.

STATEMENT OF KATHERINE WATKINS, M.D.

Dr. Watkins. Thank you, Chairman Buerkle, Representative
Michaud and distinguished Members of the Subcommittee, it is an
honor and a pleasure to be here. I know that members frequently
get calls from their constituents about how to access VA
services. And increasing access to care is incredibly
important. However, it is equally important to provide good
care once a veteran does access care, and it is about this that
I am going to talk to you today. Preventing suicide is
difficult. The best evidence we have about preventing suicide
is to provide quality mental health care.
In this testimony, I will summarize key results from a
study conducted by RAND and the Altarum Institute on the
quality of mental health care provided by the VA to veterans
with mental illness and substance abuse disorders. I will then
propose specific steps which could be taken by the VA to
improve the quality of mental health care, steps which, if
taken, could help to reduce suicide risk among our Nation's
veterans. My written testimony provides more detail on our
specific findings and our additional recommendations. In
response to the question by Representative Stearns about the
quality of VA care, our study actually found that the quality
of mental health and substance abuse care provided by the VA is
as good or better than the care provided by both the public and
the private sector.
However, there is still room for significant improvement.
Let me give you an example. Although our study found that
veterans with mental illness are assessed for suicide ideation
and if they are found to have suicide ideation are given
appropriate care, providing good care for people who are
already suicidal is not enough. It is important to provide them
good care before they become suicidal, both because providing
good care is important in its own right and because high
quality care might prevent people from becoming suicidal in the
first place. It is in this area that the VA could improve their
performance.
My first recommendation that comes directly from the
results of our study is to increase the proportion of veterans
who receive the recommended length of pharmacotherapy. Taking
psychiatric medications consistently and for the recommended
length of time is important, because for both depression and
bipolar illness, taking psychiatric medication prevents
suicide. We found that more than half of study veterans who
began medication treatment did not receive the recommended
length of treatment, and more than two-thirds of those on
maintenance treatment did not take their medications
consistently. This can be improved. There are systematic
methods for increasing adherence which the VA is not using. For
example, the use of clinical registries which allow clinicians
to track medication compliance could be incorporated into the
VA's medical record system with relatively little effort.
A second recommendation is to implement uniform assessment
and standardized written treatment plans. In the case of
uniform assessment, we found that while the VA had high levels
of assessment for suicide, in other areas, performance was poor
and more variable. For example less than two-thirds of the
mentally ill were assessed for problems with housing and
employment, and there were large differences between the best
performing VISNs and the worst performing VISNs. This is
important because homelessness and unemployment are both risk
factors for suicide. The VA's employment policies are vague. If
you are a veteran with mental illness who has an employment
problem, it is unclear where you should go to for help. The VA
needs to clarify what constitutes need for housing and
employment services and clearly define the role of the Veterans
Health Administration and the Veterans Benefit Administration
with regard to work and housing.
We found that written treatment plans were incomplete and
difficult to locate, and, in some cases, did not appear to be
present at all. This is a problem. Written treatment plans are
essential for communication between providers because they tell
providers in short succinct ways what problems a patient has
and what is being done for those problems. Although we
understand that VA Office of Mental Health Services has
recently purchased treatment planning software implementation
of the software has been held up because of lack of computer
personnel at the VA Office of Information Technology.
In conclusion, I would like to say that the VA has
substantial capacity to deliver mental health and substance
abuse treatment to veterans and it outperforms the private
sector on most quality indicators. This most likely
demonstrates the significant advantages that accrue from an
organized nationwide system of care. Nonetheless, the VA is
falling short of its own implicit expectations. Our study
revealed ways in which the VA could build upon their current
system with marginal effort to improve quality and potentially
prevent suicide.
Thank you for the opportunity to testify today and to share
the results of our research.
Ms. Buerkle. Thank you, Dr. Watkins, for your testimony.
[The prepared statement of Katherine Watkins appears on p.
63.]
Ms. Buerkle. Dr. Kemp, if you would like to proceed please.
Thank you.

STATEMENT OF JAN E. KEMP

Ms. Kemp. Chairwoman Buerkle, Ranking Member Michaud and
Members of the Subcommittee, thank you for the opportunity to
appear before you today to discuss VA's efforts to reduce
suicide among America's veterans. I am accompanied today by Dr.
Antoinette Zeiss, the Chief Consultant for Mental Health. And
at this point, honestly, I am going to put down my prepared
statement and talk to you a little bit from my heart. It has
been a very moving hearing and I think I have some important
things to say. First, I want to thank you all for the kind
words about the suicide prevention program and my personal
efforts. And I think that speaks to the people up in
Canandaigua, New York who work 24 hours a day 7 days a week
answering that phone and making those connections, and the
suicide prevention coordinators across the country who work
tirelessly to connect people into care and to really make a
difference.
And while I truly accept your kind words for them, because
they work really hard, I have to tell you it makes me feel a
little bit like a fraud and a little bit humbled by what you
have said, because veterans are still dying by suicide, which
means we have more work to do. And as long as one veteran any
day of the year dies by suicide who is receiving care in the
VA, I haven't done my job well enough. And I will continue to
persevere to get that job done.
That being said, we have had some exciting news this week.
We have recently gotten the 2009 data, and you have heard from
the other witnesses how tragic that is that it is almost 3
years old. But we did get the 2009 data very recently from the
CDC, and have looked at that data, balanced it up against
veterans who get care within the VA system and we are very
encouraged by what we are seeing in 2009, which was a couple
years after we implemented the very beginnings of our suicide
prevention program. And it is encouraging to know that this
perceived epidemic of veteran suicide rates that we keep
hearing about truly is not happening for veterans who are
getting care in the VA, that rates in certain age groups and
population groups, in fact, are decreasing. And when we look at
our most at-risk patients, like you all have talked about, we
are making a difference. Those rates are going down. And in the
group of patients who get mental health care in the VA our
suicide rates are decreasing. And we know that is because we
are paying attention to them and we have them involved in our
enhanced package of care and they are being followed by suicide
prevention coordinates, they are getting evidence-based
psychotherapies. We know that treatment works and that is
extremely hopeful and is enough for us to keep going and to
keep making these changes that we are headed towards and to
know we are in the right direction. And we have a long ways to
go. I am not going to sit here and tell you we think things are
fine because we don't. We have high standards that we have set.
And as you have said, we are not meeting our own standards,
and we need to continue to strive to do that and then we will
set higher ones. And that is a promise. It also points out that
there is a group of veterans that while their rates are staying
stable, we haven't seen the decrease in. And those are veterans
who are not currently getting mental health services. And I
think that that really makes what my good friends from the VVA
and the IAVA talked about critically important, and that is
outreach. And the things that we have put into place so far are
having an effect but we have to do more, and we will continue
to do that and we will work with them and get their input and
their ideas. And I don't think they actually know how valuable
they have been up to this point. I think that the influence Tom
Tarantino and Tom Berger have had on our current campaigns has
been tremendous and we thank them for that, and we ask them to
keep hanging in there with us.
We are getting it right and we are going to continue to get
it right. And I am going to end my testimony with a story that
maybe talks about how we do get it right. And there are as many
of these stories as there are stories of people where we
honestly get it wrong, and somehow we have to bridge that gap
and I promise to do that. In August of this year, we heard from
our benefits people that they got an email inquiry from a
veteran who was currently living in Germany. And his question
to them was if I kill myself, will my wife and children still
get their benefits. And this was an email question through our
email IRIS help line.
Having had the training and knowing that that was a warning
sign, they notified the people in the crisis line that this
veteran may be in trouble. The people at the crisis line called
this veteran in Germany, they found him, they talked to him,
they talked to his wife. Truly he was in a great deal of
distress, he was having a lot of physical pain, he wasn't
getting the care he needed, but he thanked us for calling him
and moved on. Something didn't sit right in the responder's
mind after he hung up that call and he called him back. And
truly, the veteran had left his house and his wife said I don't
know where he is and I can't find him. We did track him down.
We found him.
In the meantime, we had contacted the wounded warrior
project people, people who also partner with us to provide
services, who arranged for transportation from Germany to the
United States for this veteran if he would agree to come. We
contacted a suicide prevention coordinator in California who
found him placement in a program. We called him back. Between
us and his wife, we talked him into services. We got him on a
plane, we got him into California and as of 90 hours later he
was in care, in treatment and is alive today. While that is an
extraordinary story, again, it is only one of many, many that
we could tell over the past 3 years. And we can't stop until
those stories don't need to be said anymore. That people get
the services way ahead of time, they get the care that they
need and that dying by suicide is not an option for America's
veterans, and that is our goal.
So Madam Chairwoman, thank you for the opportunity to be
here. Our services will continue. We greatly appreciate your
support in this area. And Dr. Zeiss and I are prepared to
answer your questions.
Ms. Buerkle. Thank you very much, Dr. Kemp. And thank you
for speaking from the heart. So often the Committee is
frustrated by folks who stick to their script and it is almost
irrelevant to the testimony that was heard before them. So
thank you very much and thank you for what you do.
[The prepared statement of Jan Kemp appears on p. 71.]
Ms. Buerkle. Dr. Harrell, my question to you is, in your
testimony, you testified that we seem to know more about
suicide among our military rather than our veterans. Can you
explain why you think that is?
Ms. Harrell. Yes. Thank you. I would be happy to. As Dr.
Kemp did note, they have recently received data for 2009, but
the data that they received was for those veterans who did
receive VA care. The estimate of 18 suicide deaths amongst our
veterans every day represents, in large part, extrapolations
from the States' death data. In other words, there are 16
States that note on their death certificate whether an
individual who has died had served previously in the military.
For the other 34 States, the estimate is just that, it is an
estimate, it is an extrapolation. So not only when we say 18
deaths a day is that extrapolated for the majority of States,
but it is 3 years delayed. And so that is why I assert that we
really don't know enough about our veterans that are dying by
suicide. We do not, for example, know whether those deaths
represent veterans of Iraq and Afghanistan, or whether those
are Vietnam veterans that are dying by suicide. We don't know
who they are.
Ms. Buerkle. Thank you. Dr. Watkins, in your testimony, you
talked about adherence to a drug protocol and how important
that is. And you mentioned that there are no clinical
registries within the VA system. And clinical registries are
pretty basic with regard to tracking patients and their
compliance with a program. Can you speak to that, as well as
speaking to the assessment and the treatment plans or the lack
thereof?
Dr. Watkins. Well, the VA does have registries but they are
not clinical registries. And what I mean by a clinical registry
is something that an individual clinician or an individual
administrator can use to pull up all their patients with a
particular diagnosis. So, for example, all their patients with
depression. And then they can easily see who has missed an
appointment, who hasn't filled their medication. And then you
could go and do outreach and try to target that particular
patient. That is what I mean by clinical registries. And I
think that could be incorporated into their medical record
fairly easily and could go a long way to identifying people who
are dropping out of treatment.
In terms of the assessment, when we did the study, there
was no standardized packet of assessments, so we found a lot of
variability around what people were getting. For example, I
told you about the housing and employment services. The
differences between the best performing VISNs and the lowest
performing VISN was 26 points. So I think that there is
something being done by the best performing VISNs that is not
being done by the worst performing VISNs. And I believe that a
central directive that says this is what an assessment should
consist of, every veteran needs to get this assessment, here
are some templates that are going to help you make sure you
remember to do those assessments that could really be
beneficial. Because like I said, they do a great job. I think
95 percent of the veterans were assessed for suicide. That is
really terrific. And when they found someone who was suicidal,
they got good treatment, they got appropriate referral. But we
have to go beyond, we have to figure out how to prevent people
from becoming suicidal. People don't all of a sudden become
suicidal, it starts before then, usually with a mental illness.
Ms. Buerkle. Dr. Kemp, would you like the opportunity to
perhaps speak about if there are any initiatives in the VA with
regard to those kinds of registries that would have a database
of those who have indicated they are suicidal and on
medication?
Ms. Kemp. We currently have, and then I will let Dr. Zeiss
explain from a broader mental health perspective what we are
doing. For patients who have expressed some degree of suicidal
ideation, hopefully before they become actually suicidal or
have a plan, et cetera, we do include them in what we call our
high risk database. And this high risk designation allows us to
put chart notifications on their charts so all providers are
aware of their concerns. It pushes them into a different level
of care and enhanced package of care, we call it. And we do
monitor them for a period of time after this designation. The
gap, as is pointed out, is defining ways and figuring out ways
to move these people into that level of care sooner. And to do
that we have developed treatment planning, software that Dr.
Zeiss will talk about the implementation of and other
mechanisms within mental health to assess that and make that
happen.
We are excited about our recent integration of mental
health into our primary care teams with our patient-centered
model and we have done a considerable amount of training and
will continue to train these teams of people so that perhaps we
can catch people earlier in their whole health care process
where they wouldn't need to be referred to mental health to get
those kind of services and those kinds of care, that it would
happen from their primary care team.
Ms. Buerkle. Thank you. My time is expired and I want to
give my colleagues a chance to ask questions and then I will
come back. I am sure I will have a second round of questions. I
now yield to the gentleman from Maine, Mr. Michaud.
Mr. Michaud. Thank you very much, Madam Chair. This
question is for the panelists, all of you. You heard VBA
earlier. What are your thoughts on their recommendations that
both the VA and the DoD should use the PTSD protocol and
guidelines suggested by the IOM, any comments?
Ms. Harrell. I would like to defer evaluation of that tool
to those with specific medical expertise. But I would like to
encourage the extent, any extent possible that the DoD and the
VA join forces on this effort.
Dr. Watkins. I can't speak to the validity of that tool,
but I think it would be a mistake to focus all of your efforts
on PTSD. I actually think there are higher rates in people with
bipolar disorder, substance abuse and depression, and so it is
really critical that you look at those as well.
Ms. Kemp. I am going to let Dr. Zeiss talk about the PTSD
tool.
Ms. Zeiss. Well, I am glad that Dr. Berger brought up that
tool. It was developed by the National Center for PTSD that is
part of VA. And there are two versions of it. One is a clinical
assessment tool and the other is for use in doing an interview
in the context of a CNP diagnostic interview. And I have really
made it a priority to try to bring this tool into focus for our
assessments. I think it is an excellent tool. And I appreciate
the persistence that VBA has shown in ensuring that it stays in
focus. And since I have been chief consultant the National
Center for PTSD has a national mentoring program for PTSD to
increase the consistency of care and utilization of best
practices, and they are doing training throughout the country
in use of this clinical tool.
And we also have a study that has been completed looking at
it in the context of CNP exams that was very positive in terms
of its utility. So there is more for us to do, absolutely, but
I think we are on that track. I also agree with what Dr.
Watkins said, that we can't just attend to PTSD, there are
other disorders that need very significant attention. But for
those with PTSD, I do think consistent reliable valid
assessment is very important.
Ms. Kemp. So the short answer to that question is yes. But
in addition to that, the DoD and VA currently are developing
clinical practice guidelines along those same lines
specifically for suicide prevention. And we will jointly
implement those as soon as they are done.
Mr. Michaud. My next question actually is for Dr. Kemp. You
have 300 vet centers. They provide a great service for all
veterans, as well as active duty Vet centers have active duty
personnel come in on their furlough days to get help and mental
health addressed. My concern being is, are you fully staffed in
all those vet centers with the appropriate personnel?
Ms. Kemp. I would have to defer that to Dr. Batres from our
readjustment counseling service. But my experience is yes, they
are incredibly awesome and responsive people. The readjustment
counseling service which the vet centers fall under have also
developed an on-line peer support call center which we use at
the crisis line to move callers back and forth from and we
support each other. Another huge attribute to this system are
the soon-to-be 90 mobile vet centers that travel across the
country providing care to people in remote and distant areas. I
think that the pieces are in place and if we can get them to
the veterans and veterans to them, we are well on our way to
making sure things happen.
Mr. Michaud. My next question requires simply a yes-or-no
answer. The Military Office Association of America recommended
that it require the VA and the DoD to establish a single
strategy in a joint suicide prevention office that reports
directly to the Department secretaries through a senior
oversight committee. Do you support that proposal?
Ms. Harrell. Yes.
Dr. Watkins. Yes.
Ms. Kemp. Not the way it is written.
Mr. Michaud. Thank you, Madam Chair.
Ms. Buerkle. Thank you. I now yield 5 minutes to the
gentleman from Texas for questions.
Mr. Reyes. Thank you, Madam Chairman. I was curious for
your comments on what can be done to improve outreach to our
servicemembers. Particularly, we have heard a number of
comments today in the context of younger veterans versus the
older veterans and the lack of a tracking system. So can you,
do you have any thoughts on that, any recommendations?
Ms. Kemp. Of course I have thoughts. We have made huge
strides in the past 3 years providing outreach in different
access modes to younger veterans. We realize that they
communicate differently and we have to go to them, we can't
wait for them to come to us. To that end, we have developed a
veterans chat service. This is actually the first formal
announcement that this month we opened a texting service so
people can text the crisis line. It is having a remarkable
response and going really well. We have Facebook pages. We
monitor those pages. We have Facebook monitors who look for
people in difficulty. We have partnered with and contracted
with a nationally well-known advertising firm to help us
develop some messages and new marketing strategies. We have
rebranded the suicide prevention hotline into the veterans
crisis line in order to better portray what we do and reach
people, and the results of that have been tremendous. And we
have put in PSAs out there that have been well received, some
newer ones.
You have heard references to the Make a Connection Campaign
which is incredible actually. And we partnered with the
entertainment council to make that happen and make that happen
right. Dr. Sonya Batten is organizing that program and is doing
an exceptional job. But it is the tip of the iceberg. And I
think what we need is to continue to listen and not only
listen, but get help and support from people like IAVA and
Student Veterans of America, and as Tom said, from people. I
mean, veterans are people, and we need to listen and get their
input and find out how to get that message across. And I don't
think we are going to have an answer tomorrow, but we have to
start putting what we know now into effect like we have been,
and just keep going and pushing and not stop putting the
resources into that area.
I mean, it bothers me a great deal when I hear about
veterans who don't know what the VA does. I mean, there is no
reason for that in America today.
Mr. Reyes. What about the comment, I think it was Dr.
Berger that made, which I have found to be true as well, in
terms of veterans relating to veterans? How do we bridge that?
Is this texting, is that intended to do that?
Ms. Kemp. I think it helps. And I think other ways that we
do it are very formal and then also very informal. And we do
have peer support processes set up at all of our facilities, we
have our vet centers who provide that vet-to-vet communication,
we have veterans who work on our crisis line and in our
facilities who provide that vet-to-vet sorts of options for
people. Right now we are working kind of behind the scenes to
develop what I am calling some buddy programs.
Sometimes I think veterans don't need a peer counselor or
want a peer counselor, but they might want a buddy, they might
want a friend, they might want someone they can call in the
middle of the night who will go bowling with them or take a
walk with them or just tell them that things are okay. And I
think we have to help those relationships form. So I think we
can work in arenas like that. The veteran service organizations
like VVA have been very supportive in helping us think about
those sorts of programs.
So I think that is the direction we have to go. And we have
to really work with our communities. Veterans live in
communities. There is a move in America right now, I think, to
become involved and to make a difference and it behooves us now
to help people do that.
Mr. Reyes. Thank you, Madam Chair. Thank you.
Ms. Buerkle. Thank you. I am going to yield myself 5
minutes for questions. If you will indulge us, we will have a
second round of questioning. Dr. Watkins, I was very impressed
and really struck by the fact that in your testimony, you
talked about those who have committed suicide have contact with
either a primary care or a mental health provider prior to the
year that they committed suicide.
So much of what we are talking about today is awareness
among our veterans and our military that there are services.
But now these folks were in the system. So I would like, if you
would, to speak to that as to were there any reasons why that
would occur that they are actually in the system, they are
getting care and yet they still committed suicide.
Dr. Watkins. Yes. That study didn't actually look at what
the quality of the care that they were getting, that was not
our study, I am referring to a different one there. But I think
what it points to is the opportunity that exists for
intervention and the importance of providing good quality care
once the person walks in the door. I think what we know and
what Dr. Kemp and Dr. Zeiss said, is that if they get to
specialty mental health care it seems like they are getting
good care and the rates of suicide are going down. It is in the
primary care settings that that is not happening. And so
perhaps we need to focus our efforts on providing good quality
care in the primary care settings.
Ms. Buerkle. Based upon your research, how would you do
that within the primary care arena?
Dr. Watkins. I think one of the most important things is
registries. So again, a way to allow the individual clinician
easily, not with the assistance of a computer programmer, but
in real-time at their desk to be able to pull up their panel of
patients and see who missed their appointment. Because probably
it is those people who are missing appointments or are not
showing up or who are missing their medication refills, those
are probably the ones who are struggling the most. That is a
hypothesis, but I think it makes sense. I think that attention
to infrastructure is really critical. The VA has a wonderful
medical record system but it could do more. And it is amazing
to me that the bottleneck seems to be the computer programming.
Like that they have treatment planning software but it can't be
incorporated because the computer programmers----
Ms. Zeiss. It is now.
Dr. Watkins. It is now? That is terrific. So it took
several years. That seems unacceptable.
Ms. Buerkle. This question is for Dr. Kemp. The VA has
established mandatory screening for depression. We were just
talking about it is not all PTSD, it is depression, it is
substance abuse. So you have mandatory screening for
depression, but does VA conduct periodic reviews to assess and
to see where those patients are?
Ms. Kemp. Those screens are done on a minimum of an annual
basis. And if someone does screen positive for depression or
PTSD, that requires at least a basic assessment for suicide and
suicide ideation.
Ms. Buerkle. Dr. Watkins, would your registry take care of
that if they had been assessed for depression, they have been
diagnosed with depression, if there was a registry in place,
then that would continue to monitor?
Dr. Watkins. They would go into the registry, and someone
could follow them. And that might be a person who you might
want to screen--if for some reason, that person chose to not
have treatment, which some veterans may choose to not have
treatment, maybe that registry would clue the clinician in so
that every month an outreach, some kind of outreach call was
done. And the veteran--or maybe they showed up for their
podiatrist appointment. You know, then the podiatrist would
know and might say, okay, let's check in with you and see how
you are doing. It is that kind of wraparound services that I
think--what I call a clinical registry would help.
Ms. Buerkle. Thank you.
Dr. Kemp, just in my few seconds that I have left, section
304 of the public law 111-163, the Caregivers and Veterans
Omnibus Health Services Act of 2010, provided that the VA
establish a program to provide mental health services to
members of the immediate family of OIF and OEF veterans. I
think what we have heard this morning and this afternoon is
that the family is such a big part of this, and understanding
symptoms, and what to do with all of the information that they
are perceiving. Has this program been implemented?
Ms. Kemp. Yes. We are able to provide those services to
include families in our care for veterans. As a matter of fact,
all really high-risk veterans are required to provide us--
required is a loose term--with family contacts that we then
work with to help us and help them recognize signs of when they
might be getting into trouble, when they are at higher risk.
We are also working very closely with our department of
social work, who is working right now with SAMSA to help
identify modes of referral and to community resources for
families when we are not able to do that to assure that those
services get done.
Ms. Buerkle. Thank you.
Our information is a little bit contrary to that and
indicates that that has not been implemented for the families.
So if you could specifically, and maybe you don't have the
information now, which VA centers have you implemented that to
include immediate family outreach?
Ms. Kemp. Yeah. I will take those questions, if I could,
for the record, and get those responses back to you.
Ms. Buerkle. Thank you very much.
I now yield to the gentleman from Maine, the Ranking
Member, Mr. Michaud.
Mr. Michaud. Thank you very much. Yeah, I would be very
interested also in seeing that information. So what you are
saying is you have the rules and regulations already adopted
for that section, and it is underway.
Ms. Kemp. It is underway.
Mr. Michaud. Are the rules and regulations all adopted?
Ms. Kemp. The policies and procedures are already in place
that allow us to respond to that recommendation. And again, I
think you are going to see, like you have heard before, that
there are varying degrees of implementation. I think there is
variability among the system. And we will help figure out where
it is happening and where it is not.
Mr. Michaud. I would be very interested in that, because I
am under the same understanding, that it has not been
implemented.
I guess this one is for Dr. Watkins. Just reading over the
testimony from Lieutenant Colonel Michael Pooler from the Maine
Army National Guard--I am disappointed DoD is not here today,
but I don't know if you have done any studies that was raised
in his testimony, where he talks about those who buy TRICARE
have a very difficult time finding clinicians who will see
them. And many clinicians that want to help soldiers find the
process to become a TRICARE provider extremely cumbersome. He
goes on to state that someone other than the providers needs to
maintain the TRICARE Web site to ease the frustrations soldiers
find when they are looking for help. Have you done any research
on TRICARE and the effects?
Dr. Watkins. That is a great question. And I think that is
research that needs to happen. We don't know the quality of
care provided by TRICARE--the quality of mental health care
provided by TRICARE or the DoD. And that is a really important
study that I think needs to be done.
Mr. Michaud. Thank you.
And I guess it is more of a comment, Madam Chair, is
reflecting on when we did a codel a number of years ago to Iraq
and Afghanistan, and this is a concern I have when you look at,
particularly in the Department of Defense, is every trip we
have been on, I would always ask the generals when they give us
a briefing is, what are they doing personally to help
destigmatize the problem with PTSD and those that have
traumatic brain injury? And the second part of the question is
whether or not they need any additional help. And the response
I get over and over again is the same response we have here in
D.C., is things are fine; we have the resources we need; we are
taking care of them. The problem being is right after that
meeting, someone with much lesser rank pulled me aside and
says, we are not getting the help that we need. And the
suggestion was that I talk to the clergy.
And for the rest of that trip and every other trip since
then I did talk to the clergy. And the interesting thing is the
fact that more and more soldiers are going to them. So
evidently there is a disconnect between those that are in the
decision-making mode to provide help for the soldiers. If they
tell us that things are okay, and really, they are not, and if
you look at the statistics with the increased amount of
suicides among our active military today, then I think we have
to look at doing things differently, and how can we provide
those services for the active military personnel as well as our
veterans? And when I read Lieutenant Colonel Pooler's testimony
with the problems that they are seeing within the TRICARE
system, I think we can do a much better job than what is
currently being done. But if we do not have the folks that are
in that decision-making process recognizing that, then I think
we have that extra hurdle we have to get over.
I noticed, Dr. Watkins, you were a little----
Dr. Watkins. I think you need data. I think you don't know.
I mean, that is really what our VA study was, was an
independent evaluation from outside the VA looking in. And I
think that is what makes it so powerful. Because I think you
don't know what is going on, in that you have basically
anecdotal evidence about what is going on with TRICARE and what
is going on with the DoD. And unless you get data, you really
don't know. And I think it speaks to what Dr. Harrell said
about suicides; you have to have data before you really know
what is going on. So I would encourage you to think about
getting data about what is happening, the quality of mental
health care provided by TRICARE and provided by the DoD.
Because then you can go on and make a difference.
Ms. Buerkle. Thank you. I have one last question for all
three of our panelists. Part of what we heard this morning, and
I have heard this on several occasions in other hearings, are
that there are a lot of services out there, but they are not
well coordinated, and they are not collaborating their
services. So the veteran, and Dr. Roe mentioned it earlier, is
maybe visited by 10 people at his bedside rather than one point
person. So where is the balance in all of this? I would like to
give all of you the opportunity to respond.
Ms. Harrell. Madam Chairwoman, I am not quite sure how to
answer where the balance is in all of that. I would confirm
your perception that there are many programs out there. I
think, in many cases, the multitude of programs are a result of
the recognition that this is a crisis before us. And as a
result, we have programs running in parallel with one another,
inefficiencies resulting, and the risk of programs, especially
at the State level, being canceled due to competing resources.
Dr. Watkins. I think you need to ask the veteran what they
want. Some veterans may want 10 people coming in. Other people
may want one. I think what you don't want is duplication. And
one of the things we found in our study was that this common
electronic medical record, if you move across a VISN, across a
region, like say you are a snowbird and you move from Minnesota
to Florida, your VA provider in Florida has a great deal of
difficulty accessing your records from Minnesota. That is not
easy to do. And so that Florida provider has to redo all the
assessment. They can't count on, they can't learn from what has
already been done before.
So, in terms of trying to prevent duplication, I think
making a common portal or having--a common portal exists, but
making it easier for clinicians to access the data across VISNs
or, you know, within different medical centers within a VISN, I
think would go a long way toward preventing duplication. And
that would be a first step.
Ms. Buerkle. Dr. Kemp, before you have the opportunity to
answer that question, why is it so difficult for the
information to be transferred from VISN to VISN? If you know,
or if you could provide us with that information.
Ms. Kemp. Actually, I am going to have to find out. Because
I can travel from VISN to VISN and see anyone's record. And I
can see anyone's record from my office in Canandaigua or
Washington, D.C. And I know from working in the field and being
the clinician, I never had difficulty finding information out
about patients that were being seen somewhere else. So I
suspect that we might have some provider education issues that
we need to address. If the providers that Dr. Watkins talked to
were having trouble, we perhaps need to explain better how to
do that. But the capability is there for that to happen.
Dr. Watkins. My understanding is that part of it has to do
with how the patient is counted, right, who gets credit for the
patient. And it has do with having the appropriate authority to
be able to access that common portal. Anyway, we can----
Ms. Kemp. It is a new problem.
Ms. Buerkle. If you could, Dr. Kemp, we would really
appreciate that information and your assessment of follow-up to
Dr. Watkins.
Ms. Kemp. Certainly. Certainly.
Ms. Buerkle. And did you have an answer to the balance
question?
Ms. Kemp. Of course. Actually, I think there isn't. That is
a tough question. And I think there is a fine line between
multiple services and not coordinating those services and
choices. And I think we sometimes lose attention to the fact
that veterans do have choices. And they don't have to come to
the VA; they don't have to get care from particular people. And
we need to make sure they know about those choices.
We do need to coordinate care within systems, while still
protecting patients' privacies. And so that is a fine line that
we need to walk. I think, most importantly, we need to know
about all of the services that are available and the programs
available so that we have a wide range of options to be able to
provide people.
Ms. Buerkle. Thank you.
And I would say we talked earlier, someone mentioned
mentoring and a system like AA has, having someone stay with
you. I know that there is a relatively new program Team Red,
White, and Blue, and that is what they believe. They believe
that that person coming out of military, that new veteran needs
someone to be with them to monitor all of these different
aspects of their life, and to really mentor them and help them
with that transition. So it seems to me there is an
appreciation of the needs out there. But one of the problems we
have is just coordinating them all. And then, as Dr. Watkins
mentioned, making sure it is what the veteran wants.
I would be interested to know in your study, Dr. Watkins,
that Rand Corporation did, if there were conversations with the
veterans, are they getting what they need? Did they identify
areas where they would like to see things a little different?
Dr. Watkins. That is so interesting. We did do a telephone
survey of 7,000 veterans, where we called them up and asked
them about their experience with VA care. And what is
interesting is actually most veterans were really satisfied. We
also asked about timeliness, which has to do with how long did
you have to wait for an appointment? And did you get an
appointment as soon as you wanted? And if it was an emergency,
did you get an appointment as soon as you wanted? And again,
over half, most of them said that their care was timely. So,
again, I think it is interesting what data provides versus
what--because I think you will always have some people who
don't get what they need. But when you have data, it allows you
to put it in context.
Ms. Buerkle. And I think the sad part of that is the folks
who apparently needed the services who do commit suicide aren't
getting what they need.
Dr. Watkins. Exactly. It should be a hundred percent.
Ms. Buerkle. That is why we are here today.
Before we adjourn our hearing this afternoon, I would like
you to turn your attention to the monitors for an airing of the
VA's latest public service announcement addressing suicide
prevention.
[Video shown.]
Ms. Buerkle. Our message here today with this hearing is
that to any servicemember, veteran, or civilian loved one
listening today, suicide is never the right answer. If you are
hurting, hope and help are available to you at any time. Please
call the VA crisis hotline number at 1-800-273-TALK, and press
one if you are a veteran.
With this, I ask unanimous consent that all members have 5
legislative days to revise and extend their remarks and include
any extraneous material.
Without objection, so ordered. I want to thank all of you
again, to our first panel and our second panel, for being here
today, and for all of the members in the audience for joining
today's conversation.
As I mentioned earlier, this is just the beginning of a
very important conversation. And we will work to get DoD and
the National Institute of Mental Health in here, along with, it
was suggested by some of my colleagues that we get Secretaries
Shinseki and Panetta in here for a hearing as well. So we will
continue this conversation. It is of the utmost importance. And
our veterans deserve that.
Before we adjourn, I would just like to ask you to always
remember the men and women who serve our Nation so valiantly
and keep us safe.
And to all of our veterans, this is a good opportunity to
thank them for their service. To any veterans in the room
today, thank you very much for your service to this Nation.
With that, our hearing is adjourned.
[Whereupon, at 1:22 p.m., the Subcommittee was adjourned.]

A P P E N D I X

----------

Prepared Statement of Hon. Ann Marie Buerkle, Chairwoman, Subcommittee
on Health

Today we meet to search for answers to the most haunting of
questions--what leads an individual who so honorably served our Nation,
out of helplessness and hopelessness, to take their own life and how
can we prevent such a tragedy from happening to one who has bravely
worn the uniform and defended our freedom.
Suicide is undoubtedly a complex issue, but it is also a
preventable one and I am deeply troubled by its persistent prevalence
in our military and veteran communities.
The statistics are sobering--eighteen veterans commit suicide each
day with almost a third receiving care from the Department of Veterans
Affairs (VA) at the time of their death. Each month, there are 950
veterans being treated by the VA who attempt suicide. The number of
military suicides has increased since the start of Operations Enduring
Freedom and Iraqi Freedom (OEF/OIF), with data from the Department of
Defense (DoD) indicating servicemembers took their lives at an
approximate rate of one every 36 hours from 2005 to 2010.
We continue to hear tragic stories despite significant increases in
recent years in the number of programs and resources devoted to suicide
prevention among our servicemembers and veterans.
Today we will hear from VA and DoD that they are making strides in
identifying at risk servicemembers and veterans and providing treatment
for mental health and other disorders that can lead to suicide.
Yet, no matter how great programs and services are, if they do not
connect with those who need them, they do no good at all. VA and DoD
continue to struggle with persistent obstacles including data
limitations, cultural stigma, access issues, a lack of partnerships
with community providers, and outreach that relies on the
servicemember, veteran, or loved one to initiate treatment.
We must do more to reach out to veterans inside and outside of the
VA and DoD health care systems to ensure that all those who need it get
the help they earned and deserve before time runs out.
Until a family no longer must bear the pain of losing a loved one,
we are failing and not enough is being done.
I thank you all for joining us this morning. I now recognize our
Ranking Member, Mr. Michaud for any remarks he may have.

Prepared Statement of Hon. Michael H. Michaud, Ranking Democratic
Member, Subcommittee on Health

I would like to thank everyone for attending today's hearing.
It is a tragedy that our servicemembers and veterans survived the
battle abroad only to return home and fall to suicide. Since 2007, this
Committee has held five hearings regarding the issue of veterans'
suicide, and the figures continue to increase at an alarming rate, far
greater than the comparable suicide rates among the general population.
The Center for a New American Security, in a recently published
study entitled, ``Losing the Battle: The Challenges of Military
Suicide,'' says that from 2005 to 2010, servicemembers took their own
lives at a rate of approximately one every 36 hours. This statistic is
troubling, but it pales in comparison to VA's estimate that one veteran
dies by suicide every 80 minutes.
While I commend the VA's efforts to reduce the suicide rate,
particularly with the success of its Veterans Crisis hotline,
challenges still remain. Through this hearing, we will examine the
steps the VA is taking to strengthen data collection, to pinpoint
veterans who may be at risk, and to offer effective intervention. In
this process, we will also seek to better understand the reasons why
more and more servicemembers and veterans are taking their own lives
and what VA and DoD are doing to put a stop to more suicides.
I'd like to thank our panelists for appearing before us this
morning. Particularly, I'd like to commend Dr. Jan Kemp for her
leadership. Under her direction, the VA has made great strides in its
suicide prevention efforts. Dr. Kemp's work is award winning, and she
was named the Federal Employee of the Year in 2009.
I'd also like to thank the Maine Army National Guard for submitting
written testimony and for their efforts to ensure that every Soldier
has access to the care they need. The Maine Army National Guard already
has a close working relationship with the Suicide Prevention staff at
Togus VA hospital. This is a relationship that must be replicated on
the national level through cooperation between the VA and the DoD.
Unfortunately, as the Maine Army National Guard testimony points out,
too many soldiers--including those not eligible for VA benefits and
those who do not have health insurance--struggle to find care.
I look forward to hearing from all our witnesses today to discuss
how we can improve access, treatments, and prevention efforts to best
serve our Nation's veterans.
Thank you, Madam Chair, and I yield back.

Prepared Statement of Hon. Silvestre Reyes, Democratic Member,
Subcommittee on Health

Thank you Madam Chair and thank all of you for coming here today to
talk about this issue that is plaguing our veteran community. It seems
like every time we talk about this issue, the problem is getting worse
and not better. The fact that there are nearly 950 suicide attempts per
month by our brave men and woman who have served this country is more
than just a problem. It is a crisis.
If I remember correctly, in 2006 that is about half the number of
attacks our servicemembers endured a month in Iraq. Our soldiers,
enabled by congressional action, found a way to reverse that trend. All
they needed was the right tools like mine resistant vehicles and
upgraded body armor to do their job and defeat the enemy. We were able
to get that equipment to them at a pace most people didn't think was
possible.
What we need to do now is identify what tools these veterans need
to fight the enemy within. So please help us figure out what we need to
do to protect those who have protected us, and we will do our part to
ensure they get it as soon as possible.

Prepared Statement of Commander Rene A. Campos, USN (Ret.), Deputy
Director, Government Relations, Military Officers Association of
America

A decade of war has placed unprecedented demands and stressors on
our warriors and their families that will leave scars and unintended
consequences for generations to come.
The Departments of Veterans Affairs (VA) and Defense (DoD) have
long been faced with the daunting challenge of meeting a significant
range of medical and rehabilitation issues. MOAA is particularly
concerned about the exponentially growing need to address mental
health, behavioral and cognitive conditions, in light of the rising
rates of suicides, alcohol and substance use, and a variety of other
issues playing out among veterans, servicemembers and their families.
A number of reports support our concerns:

2008 VA ``Blue Ribbon Work Group on Suicide Prevention in
the Veteran Population''
RAND Health/National Defense Research Institute

2008 ``The Invisible Wounds of War''
2011 ``The War Within, Preventing Suicide in the U.S.
Military''
2011 ``Addressing Psychological Health and Traumatic
Brain Injury Among Servicemembers and Their Families''

2011 Center for a New American Security (CNAS) Report
``Losing the Battle: The Challenge of Military Suicide''

The current statistics are disturbing and point to an even greater
need to wage an all out battle to end suicide. This will require a
sustained national commitment at all levels of government if we are to
rid veterans of the psychological and traumatic physical conditions
that are threatening their lives and the health and well-being of their
families. Sadly these statistics represent the heroes who protect our
country and our freedoms:

20 percent of suicides in the U.S. are former
servicemembers
One currently serving member died every 36 hours during
the period 2005-2010
18 veterans die a day--that is one suicide every 80
minutes

Recommendations
MOAA offers three specific recommendations to address current
barriers to care:

Require VA-DoD to establish a single strategy and a joint
Suicide Prevention Office that reports directly to the Department
Secretaries through the Senior Oversight Committee (SOC).
Authorize funding to expand VHA mental heath capacity and
capability in order to improve access and delivery of quality and
timely care and information.
Authorize additional funding to expand outreach and
marketing efforts to encourage enrollment of all eligible veterans in
VA health care, with special emphasis on Guard and Reserve members,
rural veterans, and high-risk populations.

______

MADAM CHAIRMAN AND DISTINGUISHED MEMBERS OF THE SUBCOMMITTEE, on
behalf of the 370,000 members of the Military Officers Association of
America (MOAA), I am grateful for the opportunity to present testimony
on MOAA's observations concerning the Department of Veterans Affairs'
(VA) suicide prevention programs and efforts.
MOAA does not receive any grants or contracts from the Federal
Government.
MOAA thanks the Subcommittee for its interest in this extremely
difficult issue and for your leadership in looking out for the health
and well-being of our veterans and family members. We also commend the
VA for its staunch commitment to enhancing mental and behavioral health
programs by working with DoD and other government and non-government
entities to help veterans and their families improve their physical and
psychological well being.
Overview of VA Suicide Prevention Programs and Efforts
A number of reports and activities have been published in the last
7 years that shine a spotlight on veteran and military suicide and VA's
prevention efforts.
In 2008, the RAND Corporation's Center for Military Health Policy
Research released a report on ``The Invisible Wounds of War.'' The
report highlighted the mental health and cognitive needs of combat
veterans, focusing on three wounds: post-traumatic stress disorder
(PTSD), depression, and traumatic brain injury (TBI).
The report states that, ``Unless treated, PTSD, depression, and TBI
can have far-reaching and damaging consequences. Individuals afflicted
with these conditions face higher risks for other psychological
problems and for attempting suicide . . . there is a possible link
between these conditions and homelessness . . . the consequences from
lack of treatment or under-treatment can have a high economic toll.''
RAND made four recommendations that get at these issues:

1. Increase the cadre of providers who are trained and certified
to deliver proven (evidence-based) care, so that capacity is adequate
for current and future needs.
2. Change policies to encourage more active duty personnel and
veterans to seek needed care.
3. Deliver proven, evidence-based care to servicemembers and
veterans whenever and wherever services are provided.
4. Invest in research to close information gaps and plan
effectively.

Like RAND, our Association believes that restoring veterans to
`full mental health' will be important to reduce long-term economic
societal costs.
RAND's Invisible Wounds of War was the first study of its kind to
estimate that PTSD and depression among servicemembers will cost the
Nation up to $6.2 billion in the 2 years after deployment. The study
concludes that investing in proper treatment would provide even larger
cost savings--savings that would come from increases in productivity,
as well as from reductions in the expected number of suicides.
Additionally, The Journal of Clinical Psychiatry reported that the
economic burden of depression to this country was estimated to be $43.7
billion in 1990. By 2000 the cost burden rose to $53.9 billion, which
included direct treatment costs, lost earnings due to depression-
related suicides, and indirect workplace costs.
In June 2008, the Secretary of the VA convened a Blue Ribbon Work
Group on Suicide Prevention in the Veteran Population to advise on the
research, education and program improvements to the prevention of
suicide. The Work Group consisted of five Executive Branch
representatives, two of which were from DoD.
MOAA was encouraged by the Group's findings. According to the
report, the Veterans Health Administration (VHA) had a comprehensive
strategy in place and a number of promising initiatives and innovations
for preventing suicide attempts and completions.
The Group recommended that VHA:

1. Establish an analysis and research plan in collaboration with
other Federal agencies to resolve conflicting study results in order to
ensure that there is a consistent approach to describing the rates of
suicide and suicide attempts in veterans.
2. Revise and reevaluate the current policies regarding mandatory
suicide screening assessments.
3. Proceed with the planned implementation of the Category II flag
(patient is at high risk for suicide), with consideration given to
pilot testing the flag in one or more regions before full national
implementation.
4. Ensure that suicides and suicide attempts are reported and that
procedures are consistent with broader VHA surveillance efforts.
5. Ensure that specific pharmacotherapy recommendations related to
suicide or suicide behaviors are evidence-based.
6. Continue to pursue opportunities for outreach to enroll
eligible veterans, and to disseminate messages to reduce risk behavior
associated with suicide.
7. Ensure confidentiality of health records.
8. Ensure ongoing evaluation of the roles and workloads of the
Suicide Prevention Coordinator positions.

This year a Center for a New American Security (CNAS) report
entitled. ``Losing the Battle: The Challenge of Military Suicide,''
published some disturbing statistics, noting that suicide among
veterans and servicemembers present challenges to the health of
America's all-volunteer force. The report addressed the obstacles for
confronting suicide. Although most of the 13 recommendations CNAS
offered are focused on DoD and the Military Services, most are
applicable to VA, such as:

1. Ensuring transfer of mental health information when members
relocate
2. Eliminating the cultural stigma associated with mental health
care
3. Holding leaders accountable
4. Increasing mental health and behavioral health care
professionals, and addressing gaps in programs for drilling Guard and
Reserve units
5. Establishing reasonable time requirements for states to provide
death data to the Centers for Disease Control (CDC), and that Health
and Human Services (HHS) should ensure CDC is resourced sufficiently to
expedite the compilation of national death data. VA, DoD and HHS should
coordinate annual analysis of veteran suicide data.
6. Sharing of suicide data between VA, DoD and HHS, including
discussion with Veterans Affairs and Armed Services Committees to
develop a provision to address veteran suicides.

Two other reports were published this year by RAND's Health/
National Defense Research Institute and sponsored by the Office of the
Secretary of Defense. The first report, ``The War Within, Preventing
Suicide in the U.S. Military,'' was intended to enhance the
Department's suicide prevention programs and efforts. The second
report, ``Addressing Psychological Health and Traumatic Brain Injury
Among Servicemembers and Their Families,'' provided DoD a comprehensive
catalog of existing programs currently sponsored or funded by the
Department to address psychological health and TBI. MOAA believes the
recommendations of these two reports are also applicable to VA:

1. Increasing and improving the capacity of the mental health care
system to deliver evidence-based care
2. Changing policies to encourage more veterans and servicemembers
to seek needed care
3. Delivering evidence-based care in all settings
4. Investing in research to close knowledge gaps and plan
effectively
5. Taking advantage of programs' unique capacity for supporting
prevention, resilience, early identification of symptoms, and help
seeking to meet the psychological health and TBI needs of
servicemembers and their families
6. Establishing clear and strategic relationships between programs
and existing mental health and TBI care delivery systems
7. Examining existing gaps in routine service delivery that could
be filled by programs (formal needs assessment and gap analysis of
programs)
8. Reducing barriers faced by programs
9. Evaluating and tracking new and existing programs, and using
evidence-based interventions to support program efforts

VHA mental health officials estimate there are approximately 1,600-
1,800 suicides per year among veterans receiving care in the health
system and upwards of 6,400 per year among all veterans. One of the key
goals of VA's Mental Health Strategic Plan, implemented in 2004, was to
reduce suicide among the veteran population. Out of that plan came a
National Suicide Prevention Center of Excellence, a national suicide
prevention hotline, a patient record flagging system, and suicide
prevention programs in each medical facility.
Speaking at a joint VA-DoD Suicide Prevention Conference last year,
VA Secretary Eric Shinseki said every veteran was susceptible to
suicide.
``The emotional wounds are no less common than physical injuries;
however, they are more difficult to diagnose which adds to the
challenge of suicide prevention,'' said Shinseki. He went on to say
that the suicide problem was one of the `most frustrating' leadership
challenges he faces. ``Of the 18 veterans who commit suicide each day,
five of those veterans are under the care of the VA. Losing five
veterans who are in treatment every month, and then not having a shot
at the other 13 who for some reason haven't come under our care, means
that we have a lot of work to do.''
There are a number of predisposing risk factors associated with
suicide and mental health disorders that can be diagnosed and treated.
Some of these risk factors include:

PTSD
Relationship problems
Financial difficulties
Substance abuse and addiction
Ongoing depression
Social isolation
Recent illness and/or hospitalization
Difficulty Sleeping
Access to firearms

Today, VA has two primary program areas targeting suicide
prevention, the National Suicide Prevention Program and the Office of
Mental Health Services. Some additional initiatives the Department has
implemented include:

Hiring thousands of additional mental health providers
Launching a Suicide Prevention Campaign
Establishing a Veteran's Crisis Line
Instituting a National Suicide Prevention Coordinator
Program
Directing a suicide prevention safety plan (SPSP) and
Practices for high risk patients
Implementing policy requiring annual depression screening
for veterans using VA health care
Conducting a VA-DoD Suicide Conference
Establishing a VA-DoD online Suicide Prevention Resource
Center

Progress and Challenges
In conducting our research for this hearing, MOAA was struck by the
tremendous level of work that had been done, especially in the last 3
years. The steadfast determination of the VA Central Office staff and
Secretary Shinseki's personal involvement in synchronizing the agency's
national suicide prevention efforts is quite visionary.

MOAA gives VA high marks for rebranding its suicide prevention
hotline and establishing a National Veterans Crisis Line. Dr. Janet
Kemp, VA's National Suicide Prevention Coordinator is to be commended
for standing up the suicide hotline, earning her recognition as the
2009 Federal Employee of the Year. The initiative resulted in more than
5,000 immediate rescues. The crisis line is one of the best initiatives
according to Dr. Kemp, answering over 450,000 calls and making more
than 16,000 life-saving rescues. An anonymous chat service was added to
the crisis line and has helped more than 20,000 people.
Additionally, in less than a year VA has expanded agreements from
18 to 48 states to have veteran status on death certificates. Colorado
and Illinois have yet to sign an agreement with VA.
Despite these improvements, the VA concedes barriers still exist
that challenge its ability to advance suicide prevention to the level
needed.
According to a VA Inspector General's ``Combined Assessment Program
Summary Report: Re-Evaluation of Suicide Prevention Safety Plan
Practices in Veterans Health Administration Facilities,'' released on
March 22, 2011, the VA implemented a number of requirements for taking
care of patients identified to be at high risk for suicide. One
requirement is that there be a written safety plan that should be
placed in the medical record, and, that a copy of the plan is given to
the patient. The VA IG noted that generally Department's suicide
prevention safety plans (SPSP) were comprehensive but the completion of
safety plans for all high-risk patients and the timeliness of the plans
needed improvement.
In October 2011, The Washington Post published an article titled,
``VA Lacks Resources to Deal with Mental Health, Survey Finds.'' The
article stated, ``Over 70 percent of the survey respondents to a
preliminary survey of VA social workers, nurses and doctors think the
Department lacks the staff and space to meet the growing numbers of
veterans seeking mental health care. More than 37 percent said they are
unable to schedule an appointment in their clinic within the mandated
14-day standard.''
Senator Patty Murray (D-WA), chairwoman of the Senate Veterans
Affairs Committee requested the survey after conducting a hearing this
past summer where veterans diagnosed with mental health issues
described long waits for treatment in the VA. In a letter to the
Department, Senator Murray wrote, ``While I understand the Department
has concerns that this survey is not comprehensive, after the countless
Inspector General and GAO reports, hearings, public laws, conferences,
and stories from veterans and clinicians in the field, it is time to
act.''
MOAA could not agree more. VA and our entire country must address
barriers to mental health if we are to win the war on suicide.
Some of the most significant barriers that impede progress are:

Limitations on mental health capacity and capability,
impacting access and quality and timely care (e.g., funding, resources,
staffing, hours of operation, infrastructure).
Lack of total system accountability, oversight,
monitoring and evaluation. VA Central Office (VACO) has a comprehensive
strategy and policies, but implementation across the health care system
is inconsistent and outcomes vary greatly.
Limitations in data sharing and documentation of
information.
VA and DoD veteran ``warrior cultures''.
Limited opportunities for maximizing collaboration,
cooperation, and communication to ensure continuity of care and
services in a seamless manner.
Cultural and societal stigma prevents individuals from
seeking care.
Experiences with unprofessional or uncaring VA employees
who don't treat veterans with compassion and respect.
Medical system policies, procedures and logistical
challenges make it difficult for veterans and their families to
understand and navigate, especially during times of crisis. The VA
culture tends to assume because employees understand how VA works,
others should know as well.

Some of these barriers are outside of VA's span of control, as
noted in the reports mentioned above.
MOAA believes addressing veteran suicides requires an immediate
response and a unified strategy coordinated between the VA, DoD and
other Federal agencies. VA and DoD have had difficulty over the years
in keeping up with demand for medical benefits and services from OIF/
OEF veterans. As operations start winding down in these theaters we can
expect demand to continue for a number of decades, and generations to
come.
Our country must do all it can to help VA and DoD to ensure our
servicemembers have seamless mental health services as they separate or
retire from the military--something more than just giving them a Web
site or toll free number to call when they need help.
Veterans' families, caregivers and children also deserve special
attention because of the tremendous burdens they must carry when
dealing with the psychological wounds of their loved ones.
Identifying servicemembers who are at high risk and providing them
treatment is critical as these individuals will one day be veterans.
The sooner we help these individuals in and out of uniform the better
the long-term outcomes will be for veterans, their families and society
as a whole.

What Veterans and their Families Tell Us
Veterans and family members we talk to have seen much progress in
improving policies and programs at the national level. However, they
don't always see these policies and programs implemented or interpreted
consistently at all VA medical facilities.
The real tragedy for some veterans who really need help is that
they may give up or lose trust in the system. This may be particularly
true for severely wounded, ill or injured veterans and their families
dealing with the burdens of complex medical conditions.
Here are what veterans and their families told us about their
experiences:

PTSD Veteran and Caregiver-Spouse
The veteran entered the VA system in 2008 as a high-risk
patient for suicide and is still at risk today.
The Caregiver's current issue is addressing the veteran's
difficulty sleeping. It took the VA 2 months to schedule an appointment
just to get a fee based referral outside the VA. Now the veteran must
wait until May 2012 for VA to do a required sleep study. This Caregiver
questions why it takes almost a year for her husband to get the care he
needs, especially when VA knows that difficulty sleeping is a risk
factor for suicide and the veteran has a history of suicidal ideations.
``I don't trust VA. My Federal Recovery Coordinator (FRC)
and I are constantly fighting with people in the VAMC every step of the
way. It's like the VA is fighting with itself--why can't they just do
what is right? VA is in the business of saving lives and it shouldn't
be focused so much on saving money,'' said the Caregiver.
Recommendations to improve care:

The FRC should have more authority to make things
happen in the VA--they are an integral part of the team and
likely to have a better understanding of the veteran's mental
condition.
Access to mental health services

Veterans with mental health issues should have
greater access to fee based services if it takes longer than 2
weeks to get an appointment.
Veterans should have more control over their
appointments--VA needs to do a better job of accommodating
their schedules.

TBI Veteran and Caregiver-Mother
This severely injured veteran with TBI and a number of
physical disabilities had to wait weeks to get the attention of a VA
provider from the time of his first thoughts of suicide. It took his
mother forcing the issue before VA would see him.
``The VA tries to treat my son like other patients, but
normal protocols don't work. He has half of his brain capacity; he
can't talk or communicate normally about how he is thinking or feeling,
but he does think and feel, he just can't communicate it the way most
people do,'' she said.
The Caregiver said, ``there were been times the VA
medical staff have made comments or their actions hurt her son deeply--
one VA provider told her in front of her son that he would never be
more than a vegetable.'' Other providers continue to try pushing her
son to institutionalized care because that's what the system normally
does for veterans with this level of disability. The veteran's bad
experiences at the VA have made it difficult for him to want to do any
type of therapy today.
This Caregiver tries to keep her son as active as
possible so he won't get depressed. She says he's lonely and doesn't
have any friends so it is easy for him to slip into depression.
Recommendations to improve care

Family-caregivers for a veteran with severe brain
injury need access to services in times of crisis and need the
knowledge and tools on how to deal with suicidal ideations.
Providers should be open to using alternative therapies or
approaches to help veterans with communication challenges.
Providers need to be flexible and may need to look outside the
VA if services are not available. Providers must do all they
can to draw the veteran into the treatment.
Veterans should always be treated with compassion and
respect--never as though they are on an assembly line.

PTSD/TBI Veteran and Caregiver-Spouse
The veteran suffers from a number of serious physical
conditions as well as PTSD and TBI.
There have been two incidents of suicidal ideations. The
first one was pain related. The second one was in March of this year.
``When my husband attempted suicide in March the VA
doctor told me to take him to the ER. But the ER had no beds and said
he may have to wait 24 hours before one was available. They gave me no
alternatives. I was scared and no one in the VA did anything to help us
or help me know what to do in a situation like this,'' said the
caregiver. She went on to tell us that the typical VA response is to
give the patient a machine or medication. ``We just want VA to treat us
like they care.''

Another severely wounded veteran who is an amputee and has TBI told
us he was frustrated because his providers seldom talk to him or ask
him how he's doing. Their questions and comments are usually directed
at his Caregiver-spouse as though he isn't even in the room. He said,
``I just want them to know I can and want to contribute to my care--
when they don't talk to me it makes me feel like they don't care about
me.''
According to all these veterans and family members, they are
unaware if their veteran's record is flagged or ever has been flagged
as a high-risk patient or if the medical record contains a suicide
prevention safety plan.
MOAA Recommendations
MOAA concurs with CNAS and RAND that suicide among veterans and
servicemembers challenges the health of our all-volunteer force. CNAS
points to some compelling questions for our country to consider:

If military service becomes associated with suicide, will
it be possible to recruit bright and promising young men and women at
current rates?
Will parents and teachers encourage young people to join
the military when veterans from their own communities have died from
suicide?
Can an all-volunteer force be viable if veterans come to
be seen as broken individuals?
And how might climbing rates of suicide affect how
Americans view active-duty servicemembers and veterans--indeed, how
servicemembers and veterans see themselves?

While MOAA supports many of the recommendations and findings in the
reports, studies and investigations mentioned above, the sheer volume
of recommendations requires prioritizing efforts for improving VA's
suicide prevention program. Therefore, MOAA encourages Congress to
focus its attention immediately on three specific recommendations which
will further enhance VA's suicide prevention efforts as well as help
address other systemic issues in its health care system.
MOAA urges:

Requiring VA-DoD to establish a single strategy and a
joint Suicide Prevention Office that reports directly to the Department
Secretaries through the Senior Oversight Committee (SOC).

A joint office would be responsible for developing, implementing
and integrating strategies, policies and procedures, and providing
oversight and evaluation of suicide prevention programs and efforts.
Congress needs to continue to be VA's and DoD's greatest champion for
promoting collaboration, cooperation and communication across and
between the two agencies.
A sense of urgency and oversight are needed to address the issue of
veteran suicide at all levels of the government. There needs to be a
level of commitment similar to that given to wounded warrior issues
which came out of the Walter Reed Army Medical Center incident. VA has
done a lot to engage with DoD to identify high-risk servicemembers so
that a warm hand-off can be made to facilitate continuity of care. But
the agency acknowledges a number of challenges still exist because of
cultures and the different policies and programs that vary across the
DoD and the Military Services.

Authorizing funding to expand VHA mental heath capacity
and capability in order to improve access and delivery of quality and
timely care and information.

Clearly, reports and studies continue to highlight problems with
accessing care and shortages in mental health staffing and
infrastructure. The VA should invest in staff training, recruiting, and
retention programs in order to maintain the highest quality workforce
and system of care. Caregivers and family members should be provided
training, information and tools on how to deal with suicidal ideations
and mental health issues.
Congress should fund research to evaluate the efficacy of suicide
prevention programs to include a longitudinal study of the economic and
societal costs of veteran suicide in this country.
Veterans should have more control over scheduling appointments. The
VA must be flexible in delivering care to meet the needs of veterans,
including allowing fee based care in emergencies or when wait times
exceed 2 weeks.

Authorizing additional funding to expand outreach and
marketing efforts to encourage enrollment of all eligible veterans in
VA health care, with special emphasis on Guard and Reserve members,
rural veterans, and high-risk populations.

VA recognizes it needs to do a more effective job in working with
outside community and faith-based organizations and other government
agencies, beyond its current work with veteran and military
organizations and other agency partnerships. The VA should reward local
medical facilities for expanding their collaborative efforts. A long-
term investment in outreach and marketing to improve its image and VA
brand is needed to more effectively target these veteran populations.

Conclusion

MOAA believes there is a business case to be made for addressing
suicide that should consider the impact on national security and the
costs to society.
MOAA has no doubt that, with the will and sense of urgency from
Congress, the Administration, the DoD/Military Services, and the VA, we
can win the war on suicide. Our veterans and military medical systems
have eliminated some tremendous barriers with unprecedented results in
saving lives on and off the battlefield. We owe these heroes and their
families our full commitment to eliminate remaining barriers to mental
health care so they can obtain an optimal quality of life.
MOAA is encouraged by the significant progress made by the VA, and
we thank the Subcommittee for your leadership and support in helping
our Nation's veterans and their families.

Prepared Statement of Tom Tarantino, Senior Legislative Associate, Iraq
and Afghanistan Veterans of America

On behalf of Iraq and Afghanistan Veterans of America's 200,000
member veterans and supporters, thank you for inviting me to speak on
one of the most pressing issues facing veterans and their families: the
staggeringly high rate of suicide among servicemembers and veterans.
My name is Tom Tarantino and I am the Senior Legislative Associate
with IAVA. I proudly served 10 years in the Army, beginning my career
as an enlisted Reservist, and leaving service as an Active Duty Cavalry
Officer. Throughout these 10 years, my single most important duty was
to take care of other soldiers. In the military, they teach us to have
each other's backs, both on and off the field of battle. And although
my uniform is now a suit and tie, I am proud to work with this Congress
to continue to have the backs of America's servicemembers and veterans.
Today's hearing on suicide could not have come at a more critical
time. The Army recently reported 30 potential suicides among active
duty soldiers and non-activated reservists in October, and 25 potential
suicides within the same group in September. These are some of the
highest numbers we have seen from the Army since it began releasing
suicide data in 2009--and that's just one branch. The Defense
Department recently reported that 468 active duty and reserve soldiers,
sailors airmen, and Marines committed suicide in 2010. Overall, the
Department of Defense tracked 863 suicide attempts. The rate for
veterans is likely much higher.
Although we have this limited data about servicemembers, there
remains a fundamental gap when it comes to understanding veteran
suicide. The VA does not regularly release data on the number of
veterans that commit suicide and there is almost no information about
veteran suicide among the forty-seven percent of veterans of Operations
Enduring Freedom and Iraqi Freedom who never interact with the VA. We
therefore only have blurry snapshots of the problem. For example, the
VA estimated that in 2009, 6000 veterans committed suicide. It has also
said that on average, 950 suicides are attempted each month by veterans
who are receiving some type of VA treatment. That's an average of 31
veterans attempting suicide per day. And again, these tragic numbers
only capture the limited segment of veterans who interact with the VA.
One of the greatest challenges in understanding and preventing
veteran suicide is this lack of full data. If we don't know the
entirety of the problem, how can we solve it? Even in this age of
information and technology, we still have no way of tracking veterans
unless they interact with a social service that happens to ask about
their military service. This is unacceptable. To address this problem,
we must think outside the box. IAVA recommends collecting this data by
expanding existing services like the Center for Disease Control and
Preventions' National Violent Death Reporting System. Currently, the
CDC collects data on all manner of violent death--including suicide--in
16 states. Veteran status can be reported to the CDC either through the
death certificate or by information collected by the medical examiner.
By expanding the database to all 50 states, and requiring medical
examiners to report veteran status to the CDC, we can get a clearer
picture of the problem.
A critical step to understanding how we can stop veteran and
servicemembers suicides is to understand that suicide itself is not the
whole issue. Suicide is the tragic conclusion of the failure to address
the spectrum of challenges returning veterans face. These challenges
are not just mental health injuries; they include challenges of finding
employment, reintegrating to family and community life, dealing with
health care and benefits bureaucracy and many others. Fighting suicide
is not just about preventing the act of suicide, it is about providing
a ``soft and productive landing'' for our veterans when they return
home.
The conflicts in Iraq and Afghanistan have resulted in a high
incidence of mental health injuries among returning servicemembers.
According to a RAND study, nearly one third of Iraq and Afghanistan
veterans will develop combat-related mental health issues. Many of
these cases will go untreated, and if allowed to fester, develop into
severe Post-Traumatic Stress Disorder.
The problems with Mental Heath Care within the VA system have been
well-documented over the past few years. The VA reports that 18
veterans in their care commit suicide every day. Wait times for mental
heath care remain unacceptably high, and there are not enough mental
heath providers to meet the need.
A recent RAND survey of veterans in New York state revealed that
many veterans face difficulty navigating the complex systems of
benefits and services available to them. While this survey was specific
to New York veterans, the results are indicative of veterans'
experiences nationwide. Veterans reported that they do not know how to
find the services they need or apply for the benefits they have earned.
Even when they are able to find services appropriate for their needs,
many vets report frustration in accessing these services. Some veterans
report long waiting periods to get an appointment at the VA, while
others with frequent appointments have reported having to repeatedly
re-tell their stories and experiences to a number of different
providers. These delays and lack of continuity certainly cannot help a
veteran already suffering from mental health issues. This survey also
revealed difficulty in accessing services is not limited to the VA;
most respondents could not identify a state agency or non-profit that
provided direct mental health services.
We also know that many veterans may not be seeking care because of
the stigma attached to mental health injuries. Multiple studies confirm
that veterans are concerned about how seeking care could impact their
careers, both in and out of the military. Concerns include the effect
on their ability to get security clearances and how co-workers and
supervisors would perceive them. It is critical that we continue to
work to reduce this stigma.
To combat this, IAVA recommends that the VA and DoD partner with
experts in the private and nonprofit sector to develop a robust and
aggressive outreach campaign. This campaign should focus on directing
veterans to services such as Vet Centers, as well as local community
and state based services. It should be integrated into local campaigns
such as San Francisco's veterans 311 campaign. This campaign should be
well-funded and reflect the best practices and expertise of experts in
both the mental health and advertising fields. For our part, IAVA has
partnered with the Ad Council to launch a public service awareness
campaign that is focused on the mental health and invisible injuries
facing veterans of Iraq and Afghanistan. Part of this campaign focuses
on reducing the stigma of seeking mental health care. We are happy to
share our best practices from this campaign to aid in this effort.

Tackling Transition: Providing A Stable Environment For Veterans'
Transition
Providing a smoother transition from the military to the civilian
world is crucial in preventing veteran suicide. Ensuring veterans'
access to mental health care is connected to other issues that can
contribute to a veterans' sense of stability throughout their
transition home. We must tackle the other contributing factors--such as
unemployment and homelessness--that could increase the risk for vets
who are vulnerable to suicide.
Finding employment is one of the top challenges facing veterans
during their transition from military to civilian life. In 2010, the
average unemployment rate for OIF/OEF-era veterans was a staggering
11.5 percent, almost 2 percentage points higher than the national
average. This rate is trending even higher so far this year. This
leaves veterans wondering where the next pay check will come from,
unable to support their families, and unsure of long-term career
prospects. Congress wisely addressed this problem recently by passing
the VOW to Hire Heroes Act. While this legislation is a critical piece
of the puzzle, we must remain vigilant to ensure that the critical
programs in the VOW to Hire Heroes Act are implemented.
Some veterans also struggle to find a permanent home. The VA
reported that there were more than 13,000 Iraq and Afghanistan veterans
homeless in October 2010. Having a place to call home is a foundation
upon which to build one's life. Without a home, finding employment,
maintaining relationships, and receiving mental health care become more
difficult. The number of homeless veterans is already too high. We need
to act now to end veteran homelessness. There is no excuse.
Addressing the spectrum of challenges facing veterans during their
transition home will go a long way to create a sense of stability for
veterans that may be vulnerable to suicide. This is a place you can
step up to create a network of support for every veteran as they return
home. This robust community of support should be the first line of
defense against veteran suicide.

Building A Community of Support
A community of support starts with the families of veterans and
servicemembers. These families need to be prepared--and supported--to
help smooth the transition of their returning servicemember. In RAND's
study of New York veterans, thirty-five percent of military spouses
reported that they struggled to reintegrate the returning servicemember
into day-to-day family life. Families also reported feeling unprepared
for the return of the servicemember; many noted that they did not know
what symptoms and behaviors to look for. While there are many resources
currently available to assist military families, they are often
difficult to navigate and complex to understand. We need to place more
emphasis on outreach, education and support for military families so
that they in turn can support a returning servicemember.
The responsibility of support does not lie on our military and
veteran families alone. Preventing veteran suicide and easing the
transition from military to civilian life is our collective
responsibility as a community. Veterans consistently report difficulty
relating to their civilian peers. In a particularly poignant example,
one RAND respondent stated,
``When I'm faced with civilians who don't understand what I've been
through, it's really difficult to try [to] get on the same level with
them without making [myself] feel pathetic.''
His statement tells us two things: (1) we must connect vets to
fellow vets that have gone through similar experiences, and (2) we
should raise awareness across the civilian community about the
experience of these veterans and their families, and the challenges
they face reintegrating into the civilian world.
IAVA has been a leader in connecting veterans to their counterparts
across the country. One of the signature features of the wars in Iraq
and Afghanistan is that less than 1 percent of Americans have served in
either. One of IAVA's top priorities is to connect veterans in local
communities and across the country through traditional events and our
exclusive Community of Veterans online community. Through IAVA's
awareness campaign, in partnership with the Ad Council, we push the
message to veterans that they are not alone: there is a community of
vets that understands their experiences and has their backs.
But our veterans are not just readjusting to their families or
connecting with other veterans. They are coming back to their jobs,
using their GI Bill to study at local colleges, and seeking care and
services from businesses and providers across the country. We also must
focus on extending understanding to spouses and society at large.
Teachers and professors should know which of their students are
veterans, or the children of veterans or servicemembers. Businesses
should invest in the leadership of returning veterans by hiring them.
Health care providers must understand the injuries facing these
incredible men and women. By promoting awareness, we can ensure that
our entire community is able to support our veterans throughout their
transition back to civilian life and help stem the tide of veteran
suicide.
By accurately measuring the problem, improving access to mental
health care, tackling the transition from military to civilian life,
and creating a robust community of support for our veterans, we may be
able to significantly reduce the number of veterans that attempt and
commit suicide each year. Veteran suicide does not have a ``silver
bullet'' solution. But better practices are out there. We don't want to
ask ourselves if there was something more we could have done.
Thank you for your time and attention.

Prepared Statement of Thomas J. Berger, Ph.D., Executive Director,
Veterans Health Council, Vietnam Veterans of America

Chairwoman Buerkle, Ranking Member Michaud, and Distinguished
Members of the House Veterans Affairs Subcommittee on Health, Vietnam
Veterans of America (VVA) thanks you for the opportunity to present our
views on ``Understanding and Preventing Veteran Suicide''. We should
also like to thank you for your overall concern about the mental health
care of our troops and veterans.
Consider the facts: earlier this spring, troubling data showed an
average of 950 suicide attempts by veterans who are receiving some type
of treatment from the VA. Seven percent of the attempts are successful,
and 11 percent of those who don't succeed on the first attempt try
again within 9 months. These numbers show about 18 veteran suicides a
day and about five by vets receiving VA care. These numbers are simply
unacceptable to both the veterans' community and the American public.
Although statistics on suicide deaths are not as accurate as we
would like because so many are not reported, as veterans of the Vietnam
War and those who care for them, many of us have known someone who has
committed suicide and others who have attempted it. VVA believes this
to be a very real public health concern that needs solutions now.
To be fair, since media reports of suicide deaths and suicide
attempts began to surface back in 2003, the VA has developed a number
of strategies to reduce suicides and suicide behaviors that include:
the establishment of the Veterans Crisis Hotline and Chatline (in
partnership with the Substance Abuse and Mental Health Administration)
and a social media campaign emphasizing VA crisis support services; the
creation of suicide prevention coordinator (SPCs) positions at all VA
medical facilities whose duties include education, training, and
clinical quality improvement for VHA staff members; increased screening
and monitoring of individuals who have been identified as being at high
risk for suicide; and a few research efforts utilizing cognitive-
behavioral interventions that target suicidal ideation and behaviors.
While these efforts are laudable, VVA continues to believe they have
not gone far enough.
So let's cut to the chase: it is very challenging to determine an
exact number of suicides. Some troops who return from deployment become
stronger from having survived their experiences. Too many others are
wracked by memories of what they have experienced. This translates into
extreme issues and risk-taking behaviors when they return home, which
is why veteran suicides have attracted so much attention in the media.
Many times, suicides are not reported, and it can be very difficult to
determine whether or not a particular individual's death was
intentional. For a suicide to be recognized, examiners must be able to
say that the deceased meant to die. Other factors that contribute to
the difficulty are differences among states as to who is mandated to
report a death, as well as changes over time in the coding of mortality
data.\(1)\
In addition, according to the American Foundation for Suicide
Prevention, in more than 120 studies of a series of completed suicides,
at least 90 percent of the individuals involved were suffering from a
mental illness at the time of their death. The most important
interventions are recognizing and treating these underlying illnesses,
such as depression, alcohol and substance abuse, post-traumatic stress
and traumatic brain injury. Many veterans (and active duty military)
resist seeking help because of the stigma associated with mental
illness, or they are unaware of the warning signs and treatment
options. These barriers must be identified and overcome.
However, VVA has long believed in a link between PTSD and suicide,
and in fact, studies suggest that suicide risk is higher in persons
with PTSD. For example, research has found that trauma survivors with
PTSD have a significantly higher risk of suicide than trauma survivors
diagnosed with other psychiatric illness or with no mental
pathology.\(1)\ There is also strong evidence that among veterans who
experienced combat trauma, the highest relative suicide risk is
observed in those who were wounded multiple times and/or hospitalized
for a wound.\(2)\ This suggests that the intensity of the combat
trauma, and the number of times it occurred, may indeed influence
suicide risk in veterans, although this study assessed only combat
trauma, not a diagnosis of PTSD, as a factor in the suicidal behavior.
Considerable debate exists about the reason for the heightened risk
of suicide in trauma survivors. Whereas some studies suggest that
suicide risk is higher due to the symptoms of PTSD,\(3,4,5)\ others
claim that suicide risk is higher in these individuals because of
related psychiatric conditions.\(6,7)\ However, a study analyzing data
from the National Co-morbidity Survey, a nationally representative
sample, showed that PTSD alone out of six anxiety diagnoses was
significantly associated with suicidal ideation or attempts.\(8)\ While
the study also found an association between suicidal behaviors and both
mood disorders and antisocial personality disorder, the findings
pointed to a robust relationship between PTSD and suicide after
controlling for co-morbid disorders. A later study using the Canadian
Community Health Survey data also found that respondents with PTSD were
at higher risk for suicide attempts after controlling for physical
illness and other mental disorders.\(9)\
Some studies that point to PTSD as the cause of suicide suggest
that high levels of intrusive memories can predict the relative risk of
suicide.\(3)\ Anger and impulsivity have also been shown to predict
suicide risk in those with PTSD.\(10)\ Further, some cognitive styles
of coping such as using suppression to deal with stress may be
additionally predictive of suicide risk in individuals with PTSD.\(3)\
Other research looking specifically at combat-related PTSD suggests
that the most significant predictor of both suicide attempts and
preoccupation with suicide is combat-related guilt, especially amongst
Vietnam veterans.\(11)\ Many veterans experience highly intrusive
thoughts and extreme guilt about acts committed during times of war,
and these thoughts can often overpower the emotional coping capacities
of veterans.
Researchers have also examined exposure to suicide as a traumatic
event. Studies show that trauma from exposure to suicide can contribute
to PTSD. In particular, adults and adolescents are more likely to
develop PTSD as a result of exposure to suicide if one or more of the
following conditions are true: if they witness the suicide, if they are
very connected with the person who dies, or if they have a history of
psychiatric illness.\(12,13,14)\ Studies also show that traumatic grief
is more likely to arise after exposure to traumatic death such as
suicide.\(15,16)\ Traumatic grief refers to a syndrome in which
individuals experience functional impairment, a decline in physical
health, and suicidal ideation. These symptoms occur independent of
other conditions such as depression and anxiety.
All of this brings us full circle to what VVA has been saying for
years--if both DoD and VA were to use the PTSD assessment protocols and
guidelines as strongly suggested by the Institutes of Medicine back in
2006 (http://iom.edu/Reports/2006/Posttraumatic-Stress-Disorder-
Diagnosis-and-Assessment.aspx),\(17)\ our veteran warriors would
receive the accurate mental health diagnoses needed to assess their
suicide risk status.
Once again, on behalf of VVA National President John Rowan and our
National Officers and Board, I thank you for your leadership in holding
this important hearing on this topic that is literally of vital
interest to so many veterans, and should be of keen interest to all who
care about our Nation's veterans. I also thank you for the opportunity
to speak to this issue on behalf of America's veterans.
I shall be glad to answer any questions you might have.

______

References

1. Knox, K.L. (2008). Epidemiology of the relationship between
traumatic experience and suicidal behaviors. PTSD Research Quarterly,
19(4).
2. Bullman, T. A., & Kang, H. K. (1995). A study of suicide among
Vietnam veterans. Federal Practitioner, 12(3), 9-13.
3. Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide
risk and coping styles in posttraumatic stress disorder patients.
Psychotherapy and Psychosomatics, 68(2), 76-81.
4. Ben-Yaacov, Y., & Amir, M. (2004). Posttraumatic symptoms and
suicide risk. Personality and Individual Differences, 36, 1257-1264.
5. Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R.,
Thompson, N. J., & Meadows, L. (1999). Partner abuse and posttraumatic
stress disorder as risk factors for suicide attempts in a sample of
low-income, inner-city women. Journal of Traumatic Stress, 12(1), 59-
72.
6. Fontana, A., & Rosenheck, R. (1995). Attempted suicide among
Vietnam veterans: A model of etiology in a community sample. American
Journal of Psychiatry, 152(1), 102-109.
7. Robison, B. K. (2002). Suicide risk in Vietnam veterans with
posttraumatic stress disorder. Unpublished Doctoral Dissertation,
Pepperdine University.
8. Sareen, J., Houlahan, T., Cox, B., & Asmundson, G. J. G.
(2005). Anxiety Disorders Associated With Suicidal Ideation and Suicide
Attempts in the National Comorbidity Survey. Journal of Nervous and
Mental Disease. 193(7), 450-454.
9. Sareen, J., Cox, B.J., Stein, M.B., Afifi, T.O., Fleet, C., &
Asmundson, G.J.G. (2007). Physical and mental comorbidity, disability,
and suicidal behavior associated with posttraumatic stress disorder in
a large community sample. Psychosomatic Medicine. 69, 242-248.
10. Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger,
impulsivity, social support, and suicide risk in patients with
posttraumatic stress disorder. Journal of Nervous & Mental Disease,
189(3), 162-167.
11. Hendin, H., & Haas, A. P. (1991). Suicide and guilt as
manifestations of PTSD in Vietnam combat veterans. American Journal of
Psychiatry, 148(5), 586-591.
12. Andress, V. R., & Corey, D. M. (1978). Survivor-victims: Who
discovers or witnesses suicide? Psychological Reports, 42(3, Pt 1),
759-764.
13. Brent, D. A., Perper, J. A., Moritz, G., Friend, A., Schweers,
J., Allman, C., McQuiston, L., Boylan, M. B., Roth, C., & Balach, L.
(1993b). Adolescent witnesses to a peer suicide. Journal of the
American Academy of Child and Adolescent Psychiatry, 32(6), 1184-1188.
14. Brent, D. A., Perper, J. A., Moritz, G., Liotus, L.,
Richardson, D., Canobbio, R., Schweers, J., & Roth, C. (1995).
Posttraumatic stress disorder in peers of adolescent suicide victims:
Predisposing factors and phenomenology. Journal of the American Academy
of Child and Adolescent Psychiatry, 34(2), 209-215.
15. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C.
F., & Brent, D. A. (2004). Traumatic grief among adolescents exposed to
a peer's suicide. American Journal of Psychiatry, 161(8), 1411-1416.
16. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F.
I., Maciejewsk, P. K., Davidson, J. R., Rosenheck, R., Pilkonis, P. A.,
Wortman, C. B., Williams, J. B., Widiger, T. A., Frank, E., Kupfer, D.
J., & Zisook, S. (1999). Consensus criteria for traumatic grief: A
preliminary empirical test. British Journal of Psychiatry, 174, 67-73.
17. Posttraumatic Stress Disorder: Diagnosis and Assessment
Subcomittee on Posttraumatic Stress Disorder of the Committee on Gulf
War and Health: Physiologic, Psychologic, and Psychosocial Effects of
Deployment-Related Stress. Institutes of Medicine. National Academies
Press. 2006.

______

VIETNAM VETERANS OF AMERICA
Funding Statement
November 29, 2011

The national organization Vietnam Veterans of America (VVA) is a
non-profit veterans' membership organization registered as a 501(c)
(19) with the Internal Revenue Service. VVA is also appropriately
registered with the Secretary of the Senate and the Clerk of the House
of Representatives in compliance with the Lobbying Disclosure Act of
1995.
VVA is not currently in receipt of any Federal grant or contract,
other than the routine allocation of office space and associated
resources in VA Regional Offices for outreach and direct services
through its Veterans Benefits Program (Service Representatives). This
is also true of the previous two fiscal years.
For Further Information, Contact:

Executive Director for Policy and Government Affairs
Vietnam Veterans of America.
(301) 585-4000, extension 127

Prepared Statement of Joy J. Ilem, Deputy National Legislative
Director, Disabled American Veterans

On behalf of the 1.2 million members of the Disabled American
Veterans (DAV), all of whom are wartime disabled veterans, I am pleased
to present our views to the Subcommittee on suicide prevention efforts
in the Department of Veterans Affairs (VA) and the Department of
Defense (DoD).
The increase in suicide among members of the military and veterans,
and the innumerable tragic accounts by family members struggling to
deal with the aftermath of suicide of a loved one, have raised deep
concerns among military leaders, VA health care officials and policy
makers, certainly including this Subcommittee. Every suicide by a
servicemember or veteran is tragic, and accentuates the need for every
effort to be made at multiple levels to prevent it. Unfortunately,
suicide is a complex phenomenon and one that mental health experts have
struggled to find solutions and strategies to prevent.
According to researchers, suicide seems to most often occur due to
a combination of mental health stresses and societal triggers such as a
marital or relationship breakup, a job loss or loss of social status,
and is often coupled with overuse of alcohol or other intoxicating
substances. The same mindset that can cause a person to take his or her
own life is often the mindset that also prevents help-seeking behavior.
Sadly, there are no easy fixes or answers to this problem, but
according to one expert, ``in order to prevent suicides, the complexity
of behaviors and drivers of those behaviors need to be understood and
addressed . . . and this requires collecting and analyzing standardized
data.'' \1\
---------------------------------------------------------------------------
\1\ The Hon. Jonathan Woodson, M.D., Asst. Secretary of Defense for
Health Affairs, U.S. Department of Defense, Testimony before the United
States House of Representatives Committee on Armed Services, Hearing on
``Current Status of Suicide Prevention Programs in the Military.''
(September 9, 2011).
---------------------------------------------------------------------------
Mental health experts note that emphasis on several critical
building blocks for any effective suicide prevention effort would be
early intervention and routine mental health screening for all post-
deployed military personnel and veterans, along with ready access to
robust primary mental health care and specialty treatment programs for
post-traumatic stress disorder (PTSD) and substance-use disorder.
However, experts also note that having sufficient mental health
programs and providers is not enough--identifying those at risk for
suicide would be vital to prevention. Ongoing research is a critical
component to assist in the development of evidenced-based screening and
risk assessment measures to accurately identify high risk individuals,
and in developing prevention strategies. Likewise, an effective
communication strategy to increase awareness about what constitutes
mental health, aimed at changing attitudes and behaviors about seeking
services for mental health challenges, is another key component to
addressing this problem.
According to VA, its basic strategy for suicide prevention requires
ready access be made available to veterans for high quality mental
health services supplemented by programs designed to help individuals
and families engage and participate in care, and to address suicide
prevention in the high-risk patients that treatment efforts
identify.\2\ VA has put in place policies requiring clinicians to
conduct routine screenings for depression, PTSD, problem drinking and
history of military sexual trauma for all veterans enrolled in VA
health care. VA has reported that veterans who screen positive for PTSD
are more than four times as likely to indicate suicidal thoughts as
veterans without PTSD. For these reasons, if a screening is positive
for depression or PTSD, an additional suicide risk assessment is
conducted. According to VA, for each veteran identified as at high risk
for suicide, a suicide prevention safety plan is developed, components
of an enhanced care mental health package are implemented, and the
veteran's medical record is flagged so that all providers are alerted
to the suicide risk for the veteran.\3\
---------------------------------------------------------------------------
\2\ Department of Veterans Affairs, Fact Sheet: VA Suicide
Prevention Program, Facts about Veteran Suicide. (April 2011).
\3\ Antonette Zeiss, Ph.D., Acting Deputy Patient Care Services
Officer for Mental Health, Veterans Health Administration, U.S.
Department of Veterans Affairs, Testimony before the United States
House of Representatives Committee on Veterans' Affairs, Hearing on
``Mental Health: Bridging the Gap Between Care and Compensation for
Veterans.'' (June 14, 2011).
---------------------------------------------------------------------------
Every VA medical center is staffed with a suicide prevention
coordinator. VA has recently re-branded its suicide hotline into a
campaign promoting a broader ``Veterans Crisis Hotline,'' which
includes a chat service and a suicide prevention resource center
maintained jointly with the DoD on the internet. VA has also been
moving forward with programs aimed at reducing stigma and getting
veterans to reach out for help. The VA Office of Mental Health Services
(OMHS) recently rolled out its new mental health public awareness
campaign called Making the Connection. This unique campaign is targeted
at veterans of all eras of military service, their family members and
friends and features personal testimonials from veterans who have
struggled with physical injuries and post-deployment mental health
challenges following service--and the positive outcomes they have
experienced regarding their treatment and personal recovery. The Web
site offers mental health information, resources and support as a way
of encouraging veterans to seek help when needed. The goal of the
campaign is to reduce stigma in seeking help and to build greater
awareness of the numerous resources available to improve the lives of
our Nation's veterans. DAV appreciates this progress, and we are
hopeful the new campaign is successful and improves access and support
for needed services for veterans and family members. Despite the
implementation of these programs and policies the continuing and
troubling suicide rate of veterans still begs the question of what more
can be done.
VA estimates that there are approximately 1,600 to 1,800 suicides
per year among veterans receiving care within VHA and as many as 6,400
per year among all veterans. This estimate would mean approximately 18
veterans nationally die from suicide per day and five deaths by suicide
per day among veterans receiving care in VHA.\4\ Additionally, there
are 950 suicide attempts per month among veterans receiving care as
reported by VHA suicide prevention coordinators (based on data
collected from October 1, 2008 through December 31, 2010). In promoting
its Veterans Crisis Hotline, VA notes that, as of July 2011, it has
received over 400,000 calls, of which over 5,000 were from active duty
servicemembers; VA responded to over 16,000 chats and referred over
55,000 veterans to local VA suicide prevention coordinators for same-
day or next-day services; over 225,000 calls received were from family
members or those concerned about a loved one. Additionally, VA asserts
that the Hotline initiated over 15,000 ``rescues,'' and that there have
been over 7,000 rescues of actively suicidal veterans as of April
2011.\5,6\
---------------------------------------------------------------------------
\4\ John D. Daigh, Jr., M.D., Assistant Inspector General for
Health Care Inspections, Office of Inspector General, U.S. Department
of Veterans Affairs, Testimony before the United States Senate
Committee on Veterans' Affairs, Hearing on ``VA Mental Health Care:
Closing the Gaps.'' (July 14, 2011).
\5\ Antonette Zeiss, Ph.D., Acting Deputy Patient Care Services
Officer for Mental Health, Veterans Health Administration, U.S.
Department of Veterans Affairs, Testimony before the United States
House of Representatives Committee on Veterans' Affairs, Hearing on
``Mental Health: Bridging the Gap Between Care and Compensation for
Veterans.'' (June 14, 2011).
\6\ Department of Veterans Affairs, Fact Sheet: VA Suicide
Prevention Program, Facts about Veteran Suicide. (April 2011).
---------------------------------------------------------------------------
Madam Chairwoman and Members of the Subcommittee, this concludes my
testimony on behalf of DAV. I would be pleased to respond to your
questions.
VA reports that in FY 2010, more than 1.25 million individual
veterans were treated in a VA specialty mental health program, medical
center, clinic, inpatient setting or residential rehabilitation
program. According to VHA guidelines, all new patients requesting or
referred for mental health services must receive an evaluation within
24 hours, and undergo a more comprehensive diagnostic and treatment
planning evaluation within 14 days. To meet increasing mental health
demand, VA has hired over 7,500 full time professional staff since
2005, and during the last 3 years has trained over 4,000 staff to
provide psychotherapies with the strongest evidence for successful
outcome for PTSD, depression and other conditions.\7\ Unfortunately,
despite the significant increase in resources provided by Congress in
recent years for veterans' mental health care and VA's efforts to
increase staff and implement and improve its primary and specialized
mental health programs, we often hear from veterans that are
experiencing difficulty gaining access to the mental health treatment
they need at a crisis point. We agree with the Congressional Research
Service that VA's internal policy requiring providers to make initial
assessments with 24 hours, and to begin treatments within 14 days for
requested mental health care, is probably not being carried out
uniformly and universally.\8\ For these reasons, DAV has recently
initiated an informal mental health survey of up to 15,000 veterans
focused on access to VA mental health services and the quality of care
they are receiving. Although informal, it is our hope that the results
of this survey, publicized through our DAV social media sites to all
veterans, will provide a snapshot of veterans' experiences, their
perceptions of access to VA mental health services, and their
satisfaction levels with the treatments and programs that VA offers.
---------------------------------------------------------------------------
\7\ Antonette Zeiss, Ph.D., Acting Deputy Patient Care Services
Officer for Mental Health, Veterans Health Administration, U.S.
Department of Veterans Affairs, Testimony before the United States
House of Representatives Committee on Veterans' Affairs, Hearing on
``Mental Health: Bridging the Gap Between Care and Compensation for
Veterans.'' (June 14, 2011).
\8\ Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using
VA Health Care: Facts and Figures, Congressional Research Service, July
18, 2011.
---------------------------------------------------------------------------
A comparable but much smaller query of VA mental health
professionals was conducted at the request of Senate Committee on
Veterans' Affairs following a July 2011 hearing that examined the gaps
in VA mental health care. The resulting August 2011 report, a very
small sample due to the quick turnaround time requested, queried 319
general outpatient mental health providers for each facility within
five Veterans Integrated Service Networks (VISNs); and 272 responded.
Alarming, although not surprising based on the feedback DAV has been
receiving, over 70 percent of the respondents reported that their
facilities had insufficient mental health staff resources to meet
veterans' demands for care, and almost 70 percent indicated that their
sites had shortages in physical space to accommodate mental health
services. Nearly 40 percent reported they cannot schedule an
appointment in their own clinics for a new patient within 14 days, and
46 percent reported that lack of off-hour appointment times was a
barrier to care. Over 50 percent reported that growth in patient
workloads contributed to mental health staffing shortages, and more
than 26 percent noted that the demand for Compensation and Pension
examinations diverted clinicians from providing direct care.
Based on the results of this VA internal survey and continuing
reports from veterans themselves, it appears that despite the
significant progress--specifically an increase in mental health
programs and resources, and the number of mental health staff hired by
VA in recent years--significant gaps still plague VA's efforts in
mental health care. The impact of these gaps may fall greatest on our
newest war veterans, many of whom are in need of urgent services.
In the active duty ranks, the Department of Defense (DoD) has also
been coordinating data collection systems, mental health programs and
research studies in an effort to reduce stigma in seeking mental health
care and to prevent suicides in the active duty force. Some measureable
progress can be seen in the suicide rate among the services, but
overall the numbers still remain troubling. DoD acknowledges that
providing mental health support to active duty troops is critical in
suicide prevention. Likewise, its experts also confirm that effective,
accessible, and supportive clinical care for mental, physical, and
substance-use disorders are protective factors in preventing suicides.
For these reasons, DoD reports it has updated its policies regarding
early detection and intervention for combat and operational stress
reactions in the deployment theaters. In 2007, the Department initiated
a surveillance system to capture suicide data from the Services in a
more central and standardized way. In addition to this effort, DoD
reports that the Department and VA have a developed a partnership to
improve mental health access and care to servicemembers, veterans and
their families. For the past 10 months, DoD and VA have been
collaborating and implementing a DoD/VA joint strategy consisting of 28
strategic actions with specific milestones and outputs. DoD has also
partnered with VA in hosting an annual suicide prevention conference
that provides an opportunity for the departments to share information
and strengthen the provider network across the two health care
systems.\9\
---------------------------------------------------------------------------
\9\ The Hon. Jonathan Woodson, M.D., Asst. Secretary of Defense for
Health Affairs, U.S. Department of Defense, Testimony before the United
States House of Representatives Committee on Armed Services, Hearing on
``Current Status of Suicide Prevention Programs in the Military.''
(September 9, 2011).
---------------------------------------------------------------------------
On this very note, DAV is disappointed to report that Section 401
of Public Law 111-163 has not been implemented 18 months after
enactment. This measure requires VA to amend its regulations to enable
current members of the armed forces who served on active duty in
Operations Enduring or Iraqi Freedom eligible for the readjustment
counseling that VA currently provides to veterans under title 38,
United States Code, section 1721A. We understand this authority is
still in the proposed rulemaking stage; however, we have heard this
document was recently forwarded to DoD for required joint concurrence.
Thus, even though Congress acted, these military personnel cannot avail
themselves of a service that their peers in the veteran population have
reported to be very effective in dealing with their readjustment needs.
Because stigma and confidentiality still remain a significant barrier
for many active duty personnel needing mental health care post-
deployment, we ask VA and DoD to expedite this mandate so the
Readjustment Counseling Service can open its doors to those on active
duty who qualify for the counseling benefit. Again, early intervention
has been found to be a key to avoiding long-term mental health
conditions and other negative outcomes related to untreated post-
deployment readjustment issues. VA's Vet Center Readjustment Counseling
Service Program (a non-medical model) and the more recently established
Justice Program/Veterans Courts have been very popular among veterans
with a focus on peer to peer outreach and treatment versus
incarceration respectively. VA estimates it will have approximately 300
Vet Centers operational by the end of 2011, along with 70 mobile Vet
Centers for veterans living in rural communities.\10\ We believe these
resources would be of great benefit to active duty servicemembers who
need readjustment counseling but may not receive it due to bureaucratic
delay.
---------------------------------------------------------------------------
\10\ Antonette Zeiss, Ph.D., Acting Deputy Patient Care Services
Officer for Mental Health, Veterans Health Administration, U.S.
Department of Veterans Affairs, Testimony before the United States
House of Representatives Committee on Veterans' Affairs, Hearing on
``Mental Health: Bridging the Gap Between Care and Compensation for
Veterans.'' (June 14, 2011).
---------------------------------------------------------------------------
DoD tasked the RAND Corporation to evaluate information about
military suicides, identify the agreed upon elements that should be
part of a state-of-the-art suicide prevention strategy, and recommend
ways to make sure the programs and policies provided by each military
service reflect the best practices. This request culminated in a
February 2011 report from RAND, ``The War Within: Preventing Suicide in
the U.S. Military,'' which concluded that people with substance-use
disorders and heavy alcohol users face an increased risk for suicide,
along with persons with traumatic brain injury or head trauma, those
suffering from hopelessness or experiencing certain life events such as
relationship problems. Additionally, it was found that availability of
firearms correlates positively with suicide. RAND researchers reviewed
a wide range of prevention programs but found that while promising
practices exist, much still remains unknown about what constitutes a
best practice. Based on available literature and discussions with
experts, RAND indicated that a comprehensive suicide prevention program
should include the following six practices:

Raise awareness and promote self-care;
Identify those at high risk;
Facilitate access to quality care;
Provide quality care;
Restrict access to lethal means; and
Respond appropriately.

RAND made a series of 14 recommendations in its report and noted
research suggests that suicide can be prevented. Recommendations
include: the establishment of proper tracking and data systems;
research; the delivery of high-quality care for those with behavioral
health problems and those who are at imminent risk for suicide; proper
communication to ensure potential at-risk population is informed and
aware of the advantages of using behavioral health care; determining
the adequate number of behavioral health specialists needed; and
mandate training on evidence-based or state-of-the-art treatment for
mental health care providers.
In October 2011, the Government Accountability Office (GAO) issued
a report titled, VA Mental Health: Number of Veterans Receiving Care,
Barriers Faced, and Efforts to Increase Access, covering veterans who
used VA from FY 2006 through FY 2010. According to the report,
approximately 2.1 million unique veterans received mental health care
from VA during this period. Although the number steadily increased due
primarily to growth in OEF/OIF/OND veterans seeking care, GAO noted
that veterans of other eras still represent the vast majority of those
receiving mental health services within VA. In 2010 alone, 12 percent
(139,167) of veterans who received mental health care from VA served in
our current conflicts, but 88 percent (1,064,363) were veterans of
earlier military service eras. GAO noted that services for the OEF/OIF/
OND group had caused growth of 2 percent per year in VA's total mental
health caseload since 2006.
Key barriers identified in the GAO report that hinder veterans from
seeking mental health care included: stigma, lack of understanding or
awareness of mental health care, logistical challenges to accessing
care, and concerns that VA's care is primarily for older veterans. GAO
found that stigma is also a factor that may discourage veterans from
accessing mental health care--especially those who have concerns that
their careers could be negatively affected if employers found out that
they were receiving mental health treatment. VA indicates it is aware
of these barriers and continues to implement efforts to increase
veterans' access to mental health care, including its integration of
mental health services into primary care.
Clearly, 10 years of war have taken a toll on the mental health of
American military forces. Combat stress, PTSD and other combat- or
stress-related mental health conditions are prevalent among veterans
who have deployed to war environments in Iraq and Afghanistan.
Regrettably, as was learned from our experiences in other wars,
especially the Vietnam conflict, psychological reactions to combat
exposure are common. Experts note that if not readily addressed, such
problems can easily compound and become chronic. Over the long term,
the costs mount due to impact on personal, family, emotional, medical,
and financial damage to those who have honorably served our Nation.
Delays in addressing these problems can culminate in self-destructive
circumstances, including substance-use disorders, incarceration, and
suicide attempts. Increased access to mental health services for many
of our returning war veterans is a pressing need, particularly in early
intervention services for substance-use disorders and provision of
evidence-based care for those with PTSD, depression, and other
consequences of combat exposure.
Unique aspects of deployments to Iraq and Afghanistan, including
the frequency and intensity of exposure to combat, guerilla warfare in
urban environments, and the risks of suffering or witnessing violence,
are strongly associated with a risk of chronic PTSD. Applying lessons
learned from earlier wars, VA anticipated such risks and mounted
earnest efforts for early identification and treatment of behavioral
health problems experienced by returning veterans. VA instituted
system-wide mental health screenings, expanded mental health staffing,
integrated mental health into primary health care, added new counseling
and clinical sites, and conducted wide-scale training on evidence-based
psychotherapies. VA also has intensified its research programs in
mental health. However, critical gaps remain today, and the mental
health toll of this war is likely to grow over time for those who have
deployed more than once, do not seek or receive needed services, or
face increased stressors in their personal lives following
deployment.\11\
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\11\ Brett T. Litz, National Center for Post-Traumatic Stress
Disorder, Department of Veterans Affairs, ``The Unique Circumstances
and Mental Health Impact of the Wars in Afghanistan and Iraq,'' A
National Center for PTSD Fact Sheet (January 2007). http://
www.nami.org/Content/Microsites191/NAMI_Oklahoma/Home178/Veterans3/
Veterans_Articles/5uniquecircumstancesI
raq-Afghanistanwar.pdf.
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Testimony by RAND, other researchers, and VA has addressed the
physical and mental health impact of these wars based on the unique
nature of the wars, particular wartime risks and multiple military
deployments for many servicemembers. The current plethora of data to
date on our newest generation of war veterans related to increased
rates of PTSD, depression, substance-use disorders, high risk-taking
behaviors, and traumatic brain injury are well known--but despite all
the information available, Dr. Charles W. Hoge, a leading researcher on
the mental health toll of the conflicts in Afghanistan and Iraq,
observes that VA is not reaching large numbers of returning veterans,
and high percentages of veterans who do seek care drop out of
treatment. In a recent analysis, Hoge wrote, ``. . . veterans remain
reluctant to seek care, with half of those in need not utilizing mental
health services. Among veterans who begin PTSD treatment with
psychotherapy or medication, a high percentage drop out. . .with only
50 percent of veterans seeking care and a 40 percent recovery rate,
current strategies will effectively reach no more than 20 percent of
all veterans needing PTSD treatment.'' \12\
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\12\ Charles W. Hoge, MD, ``Interventions for War-Related
Posttraumatic Stress Disorder: Meeting Veterans Where They Are,'' JAMA,
306(5): (August 3, 2011) 548.
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DAV agrees with Dr. Hoge's view that VA must develop a strategy of
expanding the reach of treatment, to include greater engagement of
veterans, understanding the reasons for veterans' negative perceptions
of mental health care, and ``meeting veterans where they are.'' \13\
---------------------------------------------------------------------------
\13\ Ibid.
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VA attempts to meet the needs of wartime veterans with post-
deployment mental health challenges through two parallel treatment
models: a nationwide network of medical centers and outpatient clinics
that offer a more traditional medical and psychiatric approach with
recent integration of mental health into primary care; and, community-
based storefront Vet Centers that use a non-medical psychological model
to provide readjustment counseling and related services to combat
veterans and to their immediate families. In some locations, the two
programs work together closely; in others, there is only limited
coordination. Veterans are free to choose one model over the other or a
combination of both services. However, the differences in approach may
help explain why some veterans do not pursue VA treatment, and why
those who do often discontinue it. While DAV strongly supports the Vet
Center program, we also believe VA must maintain a robust mental health
system as a part of VA medical care. Both programs are critical to
veterans struggling with chronic mental illnesses and especially to new
veterans who are in need of readjustment services.
New veterans generally report having had positive experiences with
Vet Centers and their staffs, a high percentage of whom are themselves
combat veterans and who convey an understanding and acceptance of
combat veterans' problems. While these centers do not provide mental
health services in the traditional sense, their strengths tend to fill
the gaps reported by younger veterans regarding mental health care in
VA medical centers and primary care clinics.
Dr. Hoge echoes several of these points in urging what amounts to a
call for a more veteran-centric approach to treating PTSD and other
war-related conditions:
Improving evidence-based treatments . . . must be paired with
education in military cultural competency to help clinicians foster
rapport and continued engagement with professional warriors . . .
Matching evidence-based components of therapy to patient preferences
and reinforcing narrative processes and social connections through
peer-to-peer programs are encouraged. Family members, who have their
own unique perspectives, are essential participants in the veteran's
healing process and also need their own support.\14\
---------------------------------------------------------------------------
\14\ Hoge, ``Meeting Veterans Where They Are,'' 551.
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Since the beginning of the conflicts in Iraq and Afghanistan, VA
has faced a number of daunting challenges in providing care to a new
generation of war veterans--particularly in post-deployment
readjustment and in mental health. Initially, the needs and
expectations of OEF/OIF/OND veterans and their families proved to be
different from those of veterans who had typically been under VA care.
We believe new veterans and their families want the DoD and VA to
transform their approaches to post-deployment mental health services,
and to stress family-centered treatment rather than focus solely on
individual veterans--a paradigm shift for VA. Over its history, VA has
concentrated primarily on the single veteran patient to the exclusion
of family in almost all cases. But this new generation of veterans is
younger, technologically savvy, and demands improved access to
information via the Internet, access to state-of-the-art prosthetic
items, expertise in trauma care, and advanced rehabilitation methods.
They also expect support for their family caregivers and better
transition and collaboration between DoD and VA in policies for family
caregivers. Likewise, Congress, advocacy groups, and community
stakeholders, including groups in the private sector offering
specialized services, have been very active in pressing for change in
how VA relates to community providers and how it furnishes care in its
mental health and rehabilitative services.
Last year, the VA OMHS introduced a public health model for VA to
meet the mental health needs of OEF/OIF/OND veterans with the precept
that most war veterans will not develop chronic mental illness if VA
concentrates on early intervention, de-stigmatization, use of effective
mental health models, and makes greater outreach efforts. The goal of
VA's strategy is to promote healthy outcomes and strengthen families,
with a focus on resilience and recovery. This initiative requires VA to
evolve from its more traditional medical model to an approach that
would be less reliant on establishing a diagnosis and developing a
treatment plan, and more on helping veterans and their families regain
or retain an overall balance in their physical, social and mental well-
being despite the stresses of military deployments. Most important, the
strategy calls for VA to reach out to veterans in their communities,
adjust its message, make access easier and on these veterans' terms,
and reformat programs and services to meet the needs of veterans and
their families, rather than expecting veterans to fit into VA's
traditional array of available services.\15\
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\15\ Harold Kudler, VA/DoD/State and Community Partnerships:
Practical Lessons on Implementing a Public Health Model to Meet the
Needs of OEF/OIF Veterans and Their Families, VA Course on Implementing
a Public Health Model for Meeting the Mental Health Needs of Veterans,
PowerPoint presentation (Baltimore, MD, July 28, 2010).
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In preparing for this hearing, DAV observed that DoD and VA clearly
have made concerted efforts to address the challenges each Department
faces in meeting the mental health needs of post-deployment active duty
personnel and wartime veterans. Also, both agencies are populated with
dedicated mental health experts, researchers and policymakers who
continue to develop solutions to prevent suicide and the less
devastating but still serious emotional and behavioral consequences of
exposures to war. However, despite both Departments' obvious efforts
and progress, much more needs to be accomplished to fulfill the
Nation's commitments to veterans who are challenged by serious and
chronic mental illnesses, and those needing post-deployment mental
health readjustment services. Based on studies noted earlier in this
statement, it appears DoD may have less difficulty collecting data to
analyze the need for policy changes simply because DoD maintains access
to data on the active duty population including pertinent demographic
information, recorded facts on wartime and other hardship deployments,
marital status, health information and personal stressors. However, DoD
is burdened by a number of barriers unique to the military services
that prevent military personnel from coming forward for help. The fear
of being perceived as ``weak;'' worry over losing rank; being
identified as unreliable in stressful or hazardous situations; and
anxiety about being discharged in disgrace--all these fears contribute
to a reticence in military service personnel who are struggling, from
revealing their feelings to others or to seek help inside their command
structure. DoD leaders have publicly acknowledged these types of
cultural obstacles do in fact exist and that DoD is still working to
address them systemically.
On the other hand, VA is challenged with access to veterans' data
for those who have not come to VHA for care. Because veterans are
private citizens, and privacy of medical and personal information is
the governing law, VA is at a distinct disadvantage in gaining
extensive data on mental health status, suicide rates and other
relevant information about the general veteran population. However,
based on clinical and research experience with enrolled veterans, what
VA does know can be very beneficial for all veterans. Experts note that
timely, early intervention services can improve veterans' overall
quality of life, address substance-use problems, prevent chronic
illness, promote recovery, and minimize the long-term disabling effects
of undetected and untreated mental health problems. We encourage VA to
build on that knowledge and to be more transparent in dealing with the
daunting challenges it faces in overcoming the existing gaps in its
mental health programs and in the crucial need to address suicide,
which has become so pressing. DAV believes VA is moving in an
appropriate direction but needs to know more by learning directly from
veterans trying to access the VA system (as well as those who don't) to
better understand their unique needs and desires for treatment and
services. Listening to veterans' feedback is essential to creating a
system that meets them where they are, works for them, and is effective
in achieving the recovery they seek.
As a final thought, we recommend the Subcommittee review VA's
implementation of sections 102-105 of the Veterans' Mental Health and
Other Care Improvements Act of 2008, Public Law 110-387, a measure DAV
strongly supported as a part of our Stand Up For Veterans initiative.
These requirements, if implemented faithfully by VA, would go a long
way toward addressing many of the lingering issues discussed in this
testimony today. Also, we recommend a close review by your professional
staff of our discussion in the FY 201. Independent Budget (IB) on the
topics of mental health and transition needs of OEF/OIF/OND veterans,
as well as the new discussion of those subjects in the upcoming IB for
FY 2013.

Prepared Statement of Margaret C. Harrell, Ph.D., Senior Fellow and
Director, Joining Forces Initiative, Center for a New American Security

Madam Chairwoman Buerkle, Ranking Member Michaud, and Members of
the Subcommittee: Thank you for the privilege of testifying today. It
is an honor to be here. Military suicide, that of both servicemembers
and veterans, is a tragedy that affects more than the individual. Each
suicide devastates a family, a unit, and a community. There are also
implications beyond the local.
Military suicide is a national security issue. George Washington
said, ``The willingness with which our young people are likely to serve
in any war, no matter how justified, shall be directly proportional to
how they perceive the Veterans of earlier wars were treated and
appreciated by their nation.'' If Washington was correct, suicide among
servicemembers and veterans threatens the health of the all-volunteer
force. Mentors and role models, including parents, teachers and,
importantly, veterans, play a critical role in the enlistment decisions
of young men and women. We should realize that these mentors and role
models will not steer youth toward the military if they perceive damage
to servicemembers or a failure to address the mental health care needs
of those who have served their country.
While the topic at hand is suicide prevention among veterans, I
urge the Committee to recognize the importance of considering both
veteran and servicemember suicide. This recommendation is based upon
more than the recognition of suicide as a tragic outcome; it is based
upon the pragmatic recognition that we can only be sure that
improvements have been made when the frequency of suicide decreases
amongst both of these populations. There is, for example, a possibility
that a decrease in the frequency and number of suicides among
servicemembers could represent only expeditious out-processing of
servicemembers struggling with mental health wounds of war. Likewise, a
decrease in veteran suicide, once we have greater visibility of these
outcomes, could reflect the shifting of suicides to the time prior to
military discharge. Only the joint consideration of both servicemember
and veteran outcomes will highlight reasons for increased concern or
will identify success.
There does not currently exist a systematic combined analysis of
servicemember and veteran suicide. Neither the Department of Defense
(DoD) nor the Department of Veterans Affairs (VA) fully consider or
analyze suicide in one another's population. Given the potential
implications of veteran suicide for the all-volunteer force, both the
VA and the DoD should seek to understand which veterans, and how many
veterans, are dying by suicide. In particular, we should recognize that
veterans who left the service only shortly before they killed
themselves may have suffered from unaddressed mental health wounds
incurred while in service to their nation.
This testimony derives from a CNAS policy brief, Losing the Battle:
The Challenge of Military Suicide, which discussed the stark numbers of
the veterans and servicemembers who die by suicide every day. The
policy brief also identified obstacles to improvement and made
recommendations to address these obstacles. This testimony focuses upon
the recommendations most applicable to the veteran community.
It is important to note that the U.S. military and veteran
population cannot avoid the stark reality of suicide entirely.
Servicemembers and veterans reflect the broader American public, which
not only suffers from suicide, but also stigmatizes mental health care.
Further, some servicemembers enter military service with mental health
challenges and we should not conclude that serving in the military
caused these suicides.
This testimony also notes that leaders in the services and the VA
deserve recognition for their actions to reduce the rate of suicide
among servicemembers and veterans. Senior military leaders have exerted
considerable effort in recent years to acknowledge and confront the
challenge of suicide. The VA and each of the military services have
emphasized the development of suicide prevention programs, education
about the risk of suicide and the most effective ways to prevent it.
The DoD suicide prevention programs, with slogans such as ``Never Leave
a Marine Behind'' and ``Never Let Your Buddy Fight Alone,'' resonate
with servicemembers by being service-specific and embedded in their
service cultures. The services ensure that the necessary tools, such as
hotlines, are readily available. The VA's Veterans Crisis Line is
especially important in this regard. In its first 3 years, the hotline
received more than 144,000 calls involving veterans and saved more than
7,000 actively suicidal veterans.\1\ Challenges remain nonetheless.
---------------------------------------------------------------------------
\1\ Text refers to period from July 2007 to March 2010. Department
of Veterans Affairs, Fact Sheet: VHA Suicide Prevention Program, Facts
About Veteran Suicide.
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Servicemember and Veteran Suicide
From 2005 to 2010, servicemembers took their own lives at a rate of
approximately one every 36 hours.\2\ While suicides in the Air Force,
Navy and Coast Guard have been relatively stable and lower than those
of the ground forces, U.S. Army suicides have climbed steadily since
2004. The Army reported a record-high number of suicides in July 2011
with the deaths of 33 active and reserve component servicemembers
reported as suicides. Suicides in the Marine Corps increased steadily
from 2006 to 2009, dipping slightly in 2010.
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\2\ Department of Defense, ``The Challenge and the Promise:
Strengthening the Force, Preventing Suicide, and Saving Lives,'' Final
Report of the DoD Task Force on Prevention of Suicide by Members of the
Armed Forces (August 2010), provides data through 2009. The 2010 data
are from the Department of Defense, Department of Defense Suicide Event
Report, Calendar Year 2010 Annual Report (September 2011).
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The VA estimates that a veteran dies by suicide every 80
minutes,\3\ but is impossible, given the paucity of current data, to
determine the suicide rate among veterans with any accuracy or to
understand which veterans are dying.
---------------------------------------------------------------------------
\3\ Department of Veterans Affairs, Fact Sheet: VHA Suicide
Prevention Program, Facts About Veteran Suicide (March 2010).
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The Relationship Between Military Service and Suicide
Although the number of military suicides has increased since the
start of the wars in Afghanistan and Iraq, the prevailing wisdom has
been that suicides are not linked directly to deployment.\4\ However,
recent analysis of Army data demonstrates that soldiers who deploy are
more likely to die by suicide.\5\ Data have long indicated definitive
links between suicide and injuries suffered during deployment.
Individuals with traumatic brain injury (TBI), for instance, are 1.5
times more likely than healthy individuals to die from suicide.\6\
Additional factors that heighten risk include chronic pain and post-
traumatic stress disorder (PTSD) symptoms such as depression, anxiety,
sleep deprivation, substance abuse and difficulties with anger
management.\7\ These factors are also widely associated with deployment
experience in Afghanistan and Iraq.
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\4\ This relationship has not been evident in prior analyses and
is not evident in suicide data from the Navy, Air Force, Marine Corps
or Coast Guard.
\5\ Sandra A. Black et al., ``Prevalence and Risk Factors
Associated with Suicides of Army Soldiers 2001-2009,'' Military
Psychology 23 no. 4 (July 2011), 433-451.
\6\ Department of Veterans Affairs, Memorandum from Deputy Under
Secretary for Health for Operations and Management, ``Recent VHA
Findings Regarding TBI History and Suicide Risk'' (October 29, 2009)
Department of Veterans Affairs, Memorandum from Deputy Under Secretary
for Health for Operations and Management, ``Recent VHA Findings
Regarding TBI History and Suicide Risk'' (October 29, 2009).
\7\ Sandra A. Black et al., ``Prevalence and Risk Factors
Associated with Suicides of Army Soldiers 2001-2009,'' 442; and E. C.
Harris and B. Barraclough, ``Suicide as an Outcome for Mental
Disorders: A Meta-analysis,' British Journal of Psychiatry 170 no. 3
(March 1997), 205-228.
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Some psychiatric experts argue that there is an indirect
relationship between suicide and military service during wartime. In
the psychiatric field, one school of thought, known as the
interpersonal psychological theory of suicide, suggests that the
following three ``protective'' factors preclude an individual from
killing oneself: belongingness, usefulness and an aversion to pain or
death.\8\ Any one of these protective factors normally is sufficient to
prevent suicide. Traditionally, military service has had a protective
quality: Military servicemembers have been less likely to die by
suicide than civilians. It appears now, however, that the nature of
military service--especially during wartime--may weaken all three
protective factors.\9\ The cohesion and camaraderie of a military unit
can induce intense feelings of belonging for many servicemembers. Time
away from the unit, however, may result in a reduced or thwarted sense
of belonging, as individuals no longer have the daily support of their
units and feel separate and different from civilians. This is
especially true for Guardsmen, Reservists, and for veterans.
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\8\ Thomas Joiner, Why People Die by Suicide (Cambridge, MA:
Harvard University Press, 2007).
\9\ See the discussion of these effects in Edward A. Selby et al.,
``Overcoming the Fear of Lethal Injury: Evaluating Suicidal Behavior in
the Military through the Lens of the Interpersonal-Psychological Theory
of Suicide,'' Clinical Psychology Review 30 no. 3 (April 2010), 298-
307.
---------------------------------------------------------------------------
The responsibility inherent in military service, the importance of
tasks assigned to relatively junior personnel and the high level of
interaction among unit members establish the importance and usefulness
of each unit member, particularly in an operational environment. In
contrast, the experience of living in a garrison environment (for
active component personnel) or returning to a civilian job (for
Guardsmen, Reservists and veterans) or, worse, unemployment, can
introduce feelings of uselessness. Individual accounts of military
suicide both in the media and in interviews with us echo this
sentiment. Over and over, these accounts show that individuals
withdrew, felt disconnected from their units and their families, and
perceived themselves as a burden.
The third protective factor--an aversion to pain or death--is
especially important in considering military suicide, because military
service is one of the few experiences that can override this factor.
Repeated exposure to military training as well as to violence,
aggression and death dulls one's fear of death and increases tolerance
for pain.\10\ Thus, the very experience of being in the military erodes
this protective factor, even for servicemembers who have not deployed
or experienced combat, in part because servicemembers experience pain
and discomfort from the beginning of their training.\11\ By removing
some of the protective factors of suicide, therefore, military service,
especially during wartime, may predispose an individual toward suicide.
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\10\ Craig J. Bryan et al., ``Challenges and Considerations for
Managing Suicide Risk in Combat Zones,'. Military Medicine 175 no. 10
(October 2010), 713-718; and Edward A. Selby et al., ``Overcoming the
Fear of Lethal Injury.''
\11\ C. J. Bryan et al., ``A Preliminary Test of the
Interpersonal-Psychological Theory of Suicide Behavior in a Military
Sample,'' Personality and Individual Differences 48 no. 3 (February
2010), 347-350.
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Challenges and Recommendations
There are obstacles to addressing suicide that should be resolved.
Some of these obstacles are especially difficult to eliminate. Many of
the recommendations we have made pertain specifically to servicemember
suicide, for two reasons. First, we know more about servicemember
suicide than about suicide amongst veterans. The lack of understanding
about suicide among veterans reduces the likelihood of actionable
recommendations. Second, reducing the challenges to mental health among
servicemembers should also improve the mental health of recently
discharged veterans.
Challenge I: Americans lack a complete accounting of veteran
suicide. The estimation of veteran suicides is extrapolated from
extremely limited data. Specifically, states provide death data to the
Centers for Disease Control (CDC) for inclusion in the National Death
Index, but only 16 U.S. states indicate veteran status in their
data.\12\ The number of veteran suicides from the remaining 34 states
is extrapolated to estimate the overall number of veteran suicides.\13\
Further, the current numbers are extrapolated from 3-year-old data.
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\12\ The states are Alaska, Colorado, Georgia, Kentucky, Maryland,
Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma,
Oregon, Rhode Island, South Carolina, Utah, Virginia and Wisconsin.
\13\ Even if all states indicate veteran status, suicides will
still be underreported because of the vulnerability of civilian death
data to the social stigma of suicide.
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An effort is underway to match the Social Security numbers in the
national death data with DoD files to identify veterans included in the
data. This effort provides the capability to analyze the data and
characterize the veteran victims of suicide. It will thus be possible
to quantify veteran suicide and contribute an understanding of the
number of suicides among Post-9/11 veterans, as compared with veterans
of earlier generations. This analysis could also permit an
understanding of whether veterans kill themselves soon after leaving
the military.
Recommendation: Given the potential implications of veteran suicide
for the all-volunteer force, the DoD should seek to understand which
veterans, and how many veterans, are dying by suicide. In particular,
the DoD, as well as the VA and the country at-large, should recognize
that many veterans who left the service only shortly before they killed
themselves may have suffered from unaddressed mental health wounds
incurred while in service to their nation. Congress should establish
reasonable time requirements for states to provide death data to the
CDC, and the Department of Health and Human Services (HHS) should
ensure that the CDC is resourced sufficiently to expedite compilation
of national death data. The DoD, the VA and HHS should coordinate
efforts to analyze veteran suicide data and should conduct these
analyses annually.
Challenge II: As servicemembers return home from deployment, they
complete a post-deployment health assessment (PDHA). As part of this
assessment, they are asked questions about their physical and mental
health, such as, ``Did you encounter dead bodies or see people killed
or wounded during this deployment?'' and ``During this deployment, did
you ever feel that you were in great danger of being killed?'' There
are also self-evaluative questions, such as, ``Are you currently
interested in receiving information or assistance for a stress,
emotional or alcohol concern?'' While we do not question the contents
of the assessment, its administration has been problematic.
A 2008 study found that when Army soldiers completed an anonymous
survey, reported rates of depression, PTSD, suicidal thoughts and
interest in receiving care were two to four times higher as compared to
the PDHA. Likewise, our interviews with veterans uncovered numerous
accounts of returning servicemembers whose unit leaders advised them to
fabricate answers. Individuals across all services have been told, ``If
you answer yes to any of those questions, you are not going home to
your family tomorrow.'' This may be factually correct, but it neglects
to inform servicemembers of the implications of answering
untruthfully--namely, that they will have difficulty receiving
treatment or compensation for mental health problems that appear after
their service. As an improvement, the 2010 National Defense
Authorization Act requires trained medical or behavioral health
professionals to conduct the PDHA evaluations individually and face-to-
face, in the hope that servicemembers will respond honestly to a
trained health professional.\14\
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\14\ The National Defense Authorization Act for FY 2010, Public
Law 111-84, sec. 70.
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Recommendation: Unit leaders should encourage members to complete
the PDHA truthfully and should underscore that an honest answer will
allow them to link any future mental health problems requiring
treatment to their military service. This is especially important for
veterans, as the PDHA informs decisions regarding their eligibility for
mental health care after they separate from service.
Challenge III: There is a national shortage of mental health care
and behavioral health care professionals, a factor linked to higher
rates of suicide. According to the VA, suicide rates decreased by 3.6
deaths per 100,000 in seven regions \15\ where staff numbers increased
to levels recommended in the 2008 Veterans Health Administration
Handbook.\16\ Sixteen regions are still not manned to these levels,
however. Additionally, for the Army, only 80 percent of the
psychiatrist and 88 percent of the social worker and behavioral health
nurse positions are filled. With respect to psychologists, 93 percent
of positions are filled.\17\ Military hospital commanders have
temporary authority to hire psychologists and social workers and
behavioral health nurses on an as-needed basis, but a shortage of care
providers precludes them from easily filling that gap. This shortage is
a national issue, which affects the availability of care providers for
the DoD and the VA. It also affects veterans' families, who seek
treatment from the civilian health care system to cope with the strain
of reintegration.
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\15\ The Veteran Health Administration (VHA) is a subordinate
organization to the Department of Veterans Affairs. The VHA is divided
into 23 regions called Veterans Integrated Service Networks.
\16\ Department of Veterans Affairs, Veterans Health
Administration Handbook 1160.01 (September 11, 2008).
\17\ Army personnel numbers are as of July 2011, from
communication with Army Medical Command representative (September 29,
2011).
---------------------------------------------------------------------------
Recommendation: Congress should permanently establish expedited or
direct hire authority allowing military hospitals to hire behavioral
health care providers. Congress should require the VA to establish
deadlines by which all twenty-three VHA regions will be manned to the
recommended levels of behavioral health care providers. Additionally,
and especially in the meantime, the VA should increase their use of
existing public-private partnerships to provide mental health care, to
the extent that such partnerships would expedite evidence-based care to
veterans.
Challenge IV: Permanent change of station (PCS) moves are a feature
of military life. Individuals also often relocate their families as
they leave the military. However, because professional organizations
license mental health care providers on a state-by-state basis, a
geographical move across state lines can preclude continued care from
the same provider. When a care provider and a veteran, servicemember or
family member invest in developing a care relationship, and that
relationship is severed by a move, patients are often reluctant to
begin treatment anew.
Recommendation: Congress should establish a Federal pre-emption of
state licensing such that mental health care can be provided across
state lines for those instances in which military servicemembers or
family members have an established pre-existing care relationship.
Challenge V: The programs and services designed to understand and
reduce servicemember and veteran suicide should complement one another
and gain both efficiency and effectiveness from interacting
synergistically. Obtaining veteran suicide data and understanding the
circumstances surrounding individuals who die by suicide depends on the
states and the HHS, as well as on the participation of the VA and the
DoD.\18\ Within DoD, the military services and components do not
regularly and consistently share information. Information should also
be shared between the House Armed Services Committee (HASC) and the
Senate Armed Services Committee (SASC), who interact primarily with DoD
and the Senate Committee on Veteran Affairs and the House Veterans
Affairs Committee, who interact primarily with the VA.
---------------------------------------------------------------------------
\18\ The CDC is subordinate to the HHS.
---------------------------------------------------------------------------
Recommendation: The DoD, the VA and HHS should share data and
information pertaining to suicide. The military services' leaders
should meet regularly to discuss issues and approaches pertaining to
suicide, and to share lessons learned. The Senate Committee on Veterans
Affairs and the House Veterans Affairs Committee should embrace the
opportunity to work with the SASC and HASC, with the intent of
developing provisions for the NDAA to address the problem of veteran
suicide.
Challenge VI: The health and survival of servicemembers hinges on
the removal of the stigma associated with mental health care. This
stigma exists in both military and civilian culture. In the military,
it prevents many servicemembers from seeking help to address mental
health care issues; 43 percent of soldiers, sailors, airmen and Marines
who took their own lives in 2010 did not seek help from military
treatment facilities in the month before their deaths.\19\ The
percentage of servicemembers seeking help has improved--from 40 percent
in 2008 and 36 percent in 2009 to 57 percent in 2010--but the
stigmatization of mental health care remains an issue.\20\ Military
leaders recognize the importance of removing this stigma. Indeed,
recently retired Chairman of the Joint Chiefs of Staff Admiral Mike
Mullen identified the stigma of PTSD as the greatest challenge
confronting troops returning from war in Iraq and Afghanistan,\21\ and
other DoD leaders at the highest levels have urged servicemembers to
seek mental health care as needed. Nevertheless, the stigma persists.
---------------------------------------------------------------------------
\19\ Fifty-seven percent of DoD suicides were seen at a military
treatment facility in the month prior to their deaths. Department of
Defense, Department of Defense Suicide Event Report, Calendar Year 2010
Annual Report (September 2011), 23.
\20\ Department of Defense, Department of Defense Suicide Event
Report, Calendar Year 2009 Annual Report (2010), 29; and Department of
Defense. Department of Defense Suicide Event Report, Calendar Year 2008
Annual Report (2010), 26.
\21\ Stephanie Gaskell, ``Stigma of Posttraumatic Stress Disorder
Is Greatest Challenge of Returning Troops: Mullen,'' Daily News (April
19, 2010).
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This culture is unlikely to change quickly. Leaders have not
provided sufficient guidance about how to remove the stigma associated
with depression and suicidal thoughts, and they have not consistently
disciplined servicemembers who belittle or ridicule members with mental
health issues.\22\ Removing the stigma for PTSD, an invisible injury,
will be especially difficult, given that some servicemembers do not
even consider TBI, which is physically evident and recognizable, a
``real injury.'' \23\ Yet the stigma must be removed to address and
treat PTSD and TBI, both of which are linked to suicide. The effect of
military culture will also inform and bear upon the perspectives and
behavior of veterans even after they leave the military service.
---------------------------------------------------------------------------
\22\ See, for example, the following news article for a publicized
account of such ridicule: http://www.q13fox.com/news/kcpq-suicide-rate-
spiking-at-jointbaselewismcchord-20110817,0,1023250.story.
\23\ The authors interviewed veterans who did not mention their
own TBI in response to the question, ``Were you physically wounded
during deployment?'' When interviewees mentioned TBI in subsequent
conversations, they would typically explain that their initial answer
only included ``real injuries.''
---------------------------------------------------------------------------
Recommendation: Military leaders must eliminate the stigma
associated with mental health care and hold unit leaders accountable
for instances in which individuals are ridiculed for seeking treatment.
Challenge VII: Misuse of prescription medication is another
obstacle to addressing the problem of military suicide. Approximately
14 percent of the Army population is currently prescribed an
opiate.\24\ Forty-five percent of accidental or undetermined Army
deaths from 2006 to 2009 were caused by drug or alcohol toxicity,\25\
and 29 percent of Army suicides between 2005 and 2010 included drug or
alcohol use.\26\
---------------------------------------------------------------------------
\24\ U.S. Army, Health Promotion Risk Reduction Suicide Prevention
Report (August 2010), 45. Also, the Army estimates that 30,401 soldiers
would test positive for a medical review officer-reviewable drug, with
3,925 representing illicit use. Ibid., 44.
\25\ Ibid., 4.
\26\ Ibid., 43.
---------------------------------------------------------------------------
Data collected from civilian populations indicate that adults aged
18-34 are the most likely to have attempted drug-related suicides,\27\
and that 58.9 percent of drug-related suicide attempts resulting in
visits to an emergency room involve psychotherapeutic drugs.\28\
Another 36 percent of emergency room visits for suicide attempts
involve pain medications.\29\ If we anticipate similar rates among
military servicemembers, it is important to address the excess
prescription medicine among military servicemembers. Yet, there is no
opportunity to do so. When military doctors prescribe an alternative
medication or dosage from what a servicemember was previously
prescribed, there is no request made for the servicemember to return
the remainder of his or her prior medication. Instead, military doctors
dispense additional medications, because only law enforcement personnel
can conduct ``take-back'' programs for medications. On January 26,
2011, the Army Vice Chief of Staff requested that the Drug Enforcement
Administration (DEA) permit the Army's military treatment facilities
and pharmacies to accept excess prescription medicine for disposal.\30\
The request was denied.
---------------------------------------------------------------------------
\27\ 2004 data, as reported by Substance Abuse and Mental Health
Services Administration, The OAS Report: Suicidal Thoughts, Suicide
Attempts, Major Depressive Episode & Substance Use among Adults 34
(2006), 5, http://www.oas.samhsa.gov/2k6/suicide/suicide.pdf, as of
September 9, 2011.
\28\ Substance Abuse and Mental Health Services Administration,
The OAS Report: Suicidal Thoughts, Suicide Attempts, Major Depressive
Episode & Substance Use among Adults, 6.
\29\ Substance Abuse and Mental Health Services Administration.
The OAS Report: Suicidal Thoughts, Suicide Attempts, Major Depressive
Episode & Substance Use among Adults, 6.
\30\ Peter W. Chiarelli, Vice Chief of Staff, U.S. Army, letter to
Joseph T. Rannazzisi, Deputy Assistant Administrator, Drug Enforcement
Administration, Office of Diversion Control (January 26, 2011).
---------------------------------------------------------------------------
Recommendation: The DEA should grant the DoD authority to accept
and destroy excess prescription medication from military
servicemembers. Given this authority, the Office of the Army Surgeon
General should initiate an effort with the Navy, Air Force and Coast
Guard surgeon generals to develop policies and practices regarding how
best to account for, and regain possession of, excess prescription
medications. Such a drug take-back program will be targeted to the
military services, but could also help ensure that servicemembers do
not transition out of the military with surplus prescription
medications.
Challenge VIII: The DoD approach to suicide prevention depends
heavily on what experts refer to as ``gatekeeper strategies.'' The
Army, for example, asserts that ``[t]here is no other aspect of [its
suicide prevention] that is more important for preventing negative
outcomes than the vigilance of the individual commander, supervisor,
Soldier, law enforcement agent or program/service provider. Leaders,
supervisors, and `Buddies' represent the first level for surveillance
of high risk behavior.'' \31\ Although medical and academic experts
identify gatekeeper approaches as one of the most promising
strategies,\32\ the limitations of this approach are notable for the
Guard and Reserve, where there are long monthly gaps between drill
periods when leaders and peers do not have the opportunity to watch for
warning signs. Yet studies indicate that even the smallest amount of
contact can reduce the risk of suicide.\33\ These findings suggest that
even postcards or text messages from unit leaders between drill
weekends can help prevent suicides.
---------------------------------------------------------------------------
\31\ U.S. Army, Health Promotion Risk Reduction Suicide Prevention
Report, 46.
\32\ Mann et al., ``Suicide Prevention Strategies: A Systematic
Review.''
\33\ Alexandra Fleischmann et al., ``Effectiveness of Brief
Intervention and Contact for Suicide Attempters: A Randomized
Controlled Trial in Five Countries,'' Bulletin of the World Health
Organization 86 no. 9 (September 2008), 703-709.
---------------------------------------------------------------------------
Recommendation: The DoD should address weaknesses in gatekeeper-
based programs for drilling Guard and Reserve units. Specifically,
Guard and Reserve units should develop a leadership communication plan
that addresses the stresses on units and details the frequency and
method (written, electronic or telephone) by which small unit leaders
should remain in contact with their subordinates. Leaders should pay
closer attention to this communication following a deployment. Such
communication could especially help save the lives of our country's
``affiliated veterans,'' those who periodically return to uniform,
either for drill or mobilization and deployment.
Challenge IX: Assessing which suicide prevention strategies are
effective requires systematic efforts to understand military suicide.
Yet these efforts are thwarted by the existence of too many programs.
Suicide prevention programs in the National Guard are a decentralized
multitude that the Adjutant General (TAG) of each state and U.S.
territory initiates and manages. This grassroots solution is
inefficient given that, while some states had more suicides than
others, overall the Army National Guard averages slightly more than one
suicide per state annually. Although the individual programs may use
evidence-based approaches, it will be difficult to demonstrate which
suicide prevention programs are effective with the military community
or efficacious in reducing suicide, because the small numbers do not
support rigorous analysis. Even more important, these programs risk
reduction or elimination due to dwindling state resources. This is the
case of Minnesota, where there exists both the highest number of
National Guard suicides, and also dwindling resources to address their
problem.\34\
---------------------------------------------------------------------------
\34\ Mark Brunswick, ``Anti-Suicide Program for Military Runs Low:
Shortfall Comes as Minnesota Guard Fights High Suicide Rates,'' Star
Tribune, October 2, 2011.
---------------------------------------------------------------------------
Recommendation: The National Guard should reduce the number of
unique suicide prevention programs, and consider adoption of a
systemwide, centrally funded, prevention approach.
Conclusion
Addressing suicide among servicemembers and veterans is integral to
the fitness and sustainability of the all-volunteer force. It will take
a collaborative effort by DoD, VA, Federal and state legislatures, and
communities to curb suicide among those who have served the United
States. The military must take better care of its own. Although a goal
of no suicides is unachievable, the increasing number of suicides is
unacceptable. Additionally, although the benefits and services
available from the VHA will likely remain the best system of care for
veterans, the DoD has moral responsibility to acknowledge and
understand former servicemembers.
The CNAS policy brief, from which my comments are extracted, is
entitle Losing the Battle: The Challenge of Military Suicide. America
is currently losing its battle against suicide by veterans and
servicemembers. As more troops return from deployment, the risk will
only grow. To honor those who have served and to protect the future
health of the all-volunteer force, America must renew its commitment to
its servicemembers and veterans. The time has come to fight this threat
more effectively and with greater urgency. Thank you for addressing
your attention to this critically important battle.

Prepared Statement of Katherine E. Watkins, Senior Natural Scientist,
The RAND Corporation \a\
---------------------------------------------------------------------------
\a\ The opinions and conclusions expressed in this testimony are
the author's alone and should not be interpreted as representing those
of RAND or any of the sponsors of its research. This product is part of
the RAND Corporation testimony series. RAND testimonies record
testimony presented by RAND associates to Federal, state, or local
legislative committees; government-appointed commissions and panels;
and private review and oversight bodies. The RAND Corporation is a
nonprofit institution that helps improve policy and decision-making
through research and analysis. RAND's publications do not necessarily
reflect the opinions of its research clients and sponsors.
---------------------------------------------------------------------------
Suicide Prevention Efforts and Behavioral Health Treatment in the
Veterans Health Administration \b\
---------------------------------------------------------------------------
\b\ This testimony is available for free download at http://
www.rand.org/pubs/testimonies/CT370.html.
---------------------------------------------------------------------------
Chairman Buerkle, Representative Michaud, and distinguished Members
of the Committee, thank you for inviting me to testify today. It is an
honor and pleasure to be here. In this testimony, I will briefly
summarize the evidence that mental illness has a strong association
with suicide and that providing high-quality behavioral health
treatment can reduce the risk of both attempted and completed suicide.
Then I will describe the results of a recent study of the quality of
behavioral health care provided by the Veterans Health Administration
(VHA) to veterans with mental illness and substance use disorders and
discuss the implications of this study's findings for suicide
prevention. I will conclude by proposing specific steps which VHA could
take to improve the quality of care provided to veterans with mental
illness and substance use disorders--steps which, if taken, could
further reduce suicide risk among our Nation's veterans.
While suicide remains a rare event that is difficult to predict,
studying the characteristics of individuals who attempt and complete
suicide allows us to identify common risk factors and thus direct
efforts toward prevention. Research studies have shown that over 90
percent of suicide victims have a diagnosable mental
illness.\1\\-\\5\ In the veteran population, depressive
disorders, post-traumatic stress disorder (PTSD), bipolar I disorder
and drug and alcohol disorders are risk factors for both attempted and
completed suicide.\6\\-\\10\ In one study, among veterans
being treated at a VA hospital after a suicide attempt, a review of
their medical records indicated that 31.8 percent had a diagnosed
alcohol disorder, 21.8 percent had a drug use disorder, 21.2 percent
had a psychotic disorder, and 18.5 percent had a depressive
disorder.\10\ Another study of veterans who completed suicide showed
that bipolar disorder posed the greatest estimated risk of suicide
among men, and substance use disorders posed the greatest risk among
women.\11\ While most individuals with mental illness do not complete
suicide, the strong association between mental disorders and suicide
suggests that among those with vulnerability to suicide, untreated or
worsening mental disorders may be causally related to suicide. Examples
of vulnerability include a genetic predisposition to suicide and
hopelessness.\12\\-\\15\
Identification and treatment of mental disorders is important
because appropriate treatment for mental disorders may reduce the risk
of suicide. Most of the data supporting this assertion come from cross-
sectional studies which show an association between treatment and
reduced risk. Among veterans who received a new diagnosis of
depression, suicide attempt rates were lower among patients being
appropriately treated with antidepressants than among those who were
not.\16,17\ Among individuals with bipolar disorder, continued
treatment with mood-stabilizing drugs is associated with a decreased
rate of completed suicide compared to brief or interrupted treatment
with these medications, and the rate of suicide decreases consistently
with the number of additional prescriptions.\18\ Lithium and clozapine,
two important pharmacotherapies for mental disorders, may have specific
suicide-prevention qualities.\19,20\ There are no studies of whether
appropriate treatment for PTSD or for substance use disorders reduces
suicide risk, although intoxication can exacerbate impulsivity and
hopelessness, and many suicide attempts occur in the context of
substance use.\6\ This is an area where further research is needed. A
recent RAND review of suicide prevention efforts in the U.S. military
concluded that the strongest empirical evidence for preventing suicide
involved providing high-quality mental health treatment.\21\
The majority of individuals who die by suicide have contact with
either a primary care or mental health provider in the year prior to
the suicide, and nearly half have contact in the month before
suicide.\22\ In one study of veterans who had contact with VA treatment
services and who completed suicide, all were outpatients at the time of
death, 60 percent were hospitalized for psychiatric reasons in the year
before death and 83 percent of those who were hospitalized completed
suicide within 2 months of hospital discharge.\6\ In another study of
968 veterans who completed suicide in the community, 22 percent had
received health care in the VA system in the year prior to death; of
these, 58 percent had not seen a mental health professional.\23\ These
studies suggest that there are opportunities for health care providers
to intervene, provide appropriate care, and possibly prevent suicide.
In 2005, the VA commissioned RAND and the Altarum Institute to
conduct a comprehensive evaluation of the VA.'s mental health and
substance use treatment system.\24\\-\\26\ The results
reported below describe care provided in fiscal years (FY) 2007 and
2008. We do not have data on whether the quality of care has changed
since then.
In FY 2008 there were 906,394 veterans receiving care at the VHA
for one or more of the following diagnoses: schizophrenia, bipolar I
disorder, PTSD, major depressive disorder, and substance use disorders.
Although they represented approximately 3.8 percent of the estimated
number of all living veterans and 16.5 percent of all veterans who used
VHA services in FY 2008, they accounted for 34.4 percent of all VHA
costs. Approximately half had either multiple mental health conditions
or a co-existing physical condition. The majority of utilization and
costs were for the treatment of physical health conditions.
To evaluate quality of care, the research team developed 88
performance indicators,\27\ or measures of the quality of care. We used
indicators to assess the degree to which recommended care was delivered
and to identify gaps in quality. Some indicators applied only to a
single diagnosis, such as antidepressant use in major depression, and
some applied across diagnoses, such as assessment for suicide ideation.
Where there was sufficient sample size, we evaluated performance by
Veterans Integrated Service Network (VISN), age, gender, rural/urban
residence and Operation Enduring Freedom/Operation Iraqi Freedom (OEF/
OIF) status.
Below I discuss study findings as they may relate to suicide
prevention. Results are reported as VHA national averages. VISN level
performance was estimated to identify average VISN performance and to
test whether each VISN was significantly above or below the average
VISN performance. A list of VISN number and region is provided at the
end of the document (see Table 1). Evidence-based treatments are
treatments that have been demonstrated through research to be
effective.

Evidence-Based Treatment for Major Depression
Among veterans with major depression, treatment with
antidepressants is associated with decreased suicide risk. Almost half
(48 percent) of veterans beginning a new treatment episode for major
depression filled prescriptions for a 12-week supply of antidepressant
medication; 20 percent did not fill any prescription for
antidepressants during the appropriate time frame. There was a 20
percentage point difference between the highest and lowest performing
VISNs for this performance indicator. Six VISNs (9, 15, 19, 20, 22 and
23) performed significantly better than the VISN average. Another seven
VISNs (3, 5, 7, 8, 12, 16 and 18) performed significantly below the
VISN average. Those veterans least likely to have the requisite 12-week
supply were younger, rural, and had served in OEF/OIF. While some
veterans may not want antidepressants, the observed variation of 20
percentage points across VISNs suggests that care can, and should,
improve in those VISNs with lower rates.
To minimize the likelihood of relapse, antidepressants need to be
continued for 4 to 9 months. However, only 31.2 percent of veterans in
a new episode of treatment for major depression filled prescriptions
for a 6-month supply of antidepressant medication; and 17.1 percent
filled no prescriptions for antidepressant medication. The remaining
51.3 percent of veterans filled a prescription, but for less than a 6-
month supply. While some veterans may choose to terminate treatment
prematurely, research suggests that clinical interventions such as
telephone outreach can improve medication adherence \28\ and outcomes.
Adherence means using the medication as prescribed.
Among all study veterans who were beginning a new episode of
treatment, only 38.3 percent received at least one psychotherapy visit.
Among those with major depression who were receiving psychotherapy,
30.9 percent received psychotherapy that had elements of cognitive
behavioral therapy, an evidence-based treatment for major depression.
For those veterans receiving psychotherapy, increasing the delivery of
evidence-based psychotherapy could improve outcomes and decrease
suicide risk.

Evidence-Based Treatment for Bipolar I Disorder
Continuous treatment with a mood stabilizer medication is the
mainstay of treatment for bipolar I disorder and is associated with a
decreased rate of completed suicide.\18,29,30\ Thirty-two percent of
veterans with bipolar I disorder received continuous treatment with a
mood stabilizer, 81.2 percent received intermittent treatment and 18.8
percent did not receive any treatment with a mood stabilizer. The
difference between the highest and lowest performing VISNs was 12.1
percentage points. Seven VISNs (1, 6, 11, 15, 19, 20) had proportions
that were higher than the average VISN and an equal number of VISNs (3,
5, 8, 12, 16, 18 and 21) had proportions that were lower. Eight percent
of veterans with bipolar 1 disorder received inappropriate treatment of
an antidepressant without use of a mood stabilizer, a practice
associated with higher levels of suicidal behavior.\29\ Veterans over
age 65 or under age 35, and OEF/OIF veterans were at greatest risk for
not receiving appropriate care.
Research suggests that use of lithium as a mood stabilizer may have
specific suicide-prevention properties. However the therapeutic range
within which the beneficial effects of lithium outweighs its toxic
effects is quite narrow, and there is substantial clinical consensus
that lithium levels should be monitored. Among patients with bipolar I
disorder who were beginning treatment with lithium, (N=2,562 out of a
total number of 65,090 with bipolar 1 disorder and 14,285 veterans in a
new treatment episode), 51.6 percent received lithium drug level
monitoring in a timely manner.

Evidence-Based Treatment for PTSD
Although PTSD increases suicide risk, it is unknown whether
treatment for PTSD reduces suicide risk. This is an important area for
further research. We found that 20 percent of veterans with PTSD who
were receiving psychotherapy had documentation that at least one
psychotherapy visit contained elements consistent with cognitive
behavioral therapy, an evidence-based treatment for PTSD. Significantly
fewer veterans at one VISN (VISN 10) had documentation of any visits
with elements of cognitive behavioral therapy. Among veterans not
receiving psychotherapy who were beginning a new episode of treatment
for PTSD, 26 percent received an adequate trial of selective serotonin
reuptake inhibitors, a class of antidepressants.

Evidence-Based Treatment for Schizophrenia
Continuous treatment with antipsychotic medication is critical for
preventing relapse and rehospitalization \31\ among patients with
schizophrenia. Approximately 37 percent of veterans in the
schizophrenia diagnostic cohort received continuous treatment with an
antipsychotic medication. Over 80 percent filled at least one
prescription for an antipsychotic medication and 18.1 percent did not
receive any antipsychotic medication. There was significant variation
across VISNs, with the percentage difference between the highest and
lowest performing VISN being almost 20 percentage points. Seven VISNs
(1, 10, 11, 15, 19, 20, and 23) significantly exceed the VISN average;
an equal number of VISNs (3, 5, 7, 8, 16, 18, and 22) had 12-month
supply fill rates significantly lower than the VISN average.

Evidence-Based Treatment for Drug and Alcohol Disorders
Numerous clinical trials have proven brief interventions to be
effective for individuals with alcohol abuse. In our study, fifty-nine
percent of veterans with alcohol abuse or dependence had documentation
that they received a brief intervention for their alcohol use, 35
percent had a documented referral to mental health specialty care, and
5 percent were already in specialty care. Overall, 71 percent had
documentation of appropriate care. VISN 9 had a significantly lower
proportion of veterans with documentation of appropriate care. There is
substantial empirical support for pharmacotherapy for individuals with
alcohol dependence. For veterans beginning treatment for alcohol
dependence, 6 percent received pharmacotherapy.

Assessment for Suicide Ideation and Employment and Housing Problems
Identification of and attention to psychosocial stressors are key
components of high-quality psychiatric care and may also decrease
suicide risk. In cross-sectional studies, psychosocial stressors such
as unemployment are associated with attempted and completed
suicide.\9,32\\-\\39\ Among the mentally ill, homelessness
is also associated with suicide. In a study of 7,224 homeless
individuals with mental illness, rates of lifetime suicide attempts
were above 50 percent; 26.9 percent of the sample had a suicide attempt
that resulted in a medical hospitalization.\35\ While it is unknown
whether interventions to decrease unemployment and homelessness would
decrease suicide risk, attention to these issues is a critical part of
quality mental health care. Identifying whether clinical interventions
to address homelessness and unemployment among the mentally ill reduce
risk is an important area for further study.
The mental health assessment of a new patient should include an
evaluation of suicide ideation and the patient's psychosocial support
system.\40,41\ We found that 82 percent of veterans in the study were
assessed for suicide ideation. Three VISNs (4, 6 and 7) had
significantly higher proportions of documentation of suicide ideation
assessment, and two VISNs (2 and 19) had significantly lower
proportions. Among veterans with identified suicide ideation, 96.4
percent had documentation of appropriate follow-up.
Assessment of psychosocial needs includes finding out whether the
patient had an acceptable physical shelter and whether or not the
patient had purposeful daily activity. Among study veterans beginning a
new episode of treatment, 60 percent had documentation of an assessment
of housing needs, 62 percent had documentation of an assessment of
employment needs, and 44 percent had documentation of both assessments.
Compared to the average VISN, VISN 10 had a significantly greater
proportion of veterans who had documentation of both assessments (57.9
percent) and VISN 18 had a significantly lower proportion (31.8
percent). This variation across VISNs (26 percentage points) was the
largest for any indicator. More veterans with a documented need were
offered housing services (81 percent) than were offered employment
services (28 percent).

Supported Employment and Social Skills Training
Certain evidence-based forms of psychosocial rehabilitation, such
as social skills training, increase the capacity of individuals with
severe mental illness to live independently. Among veterans with
schizophrenia who received any psychosocial treatment, 16 percent had
documented receipt of social skills training. Supported employment is a
type of intervention that helps individuals with severe mental illness
get and maintain employment, and has a robust evidence base. Among
veterans with bipolar disorder, schizophrenia or major depression with
psychosis, 1.9 percent used supported employment during the study
period. While there was variation across VISNs, no VISN was higher than
3 percent.

Summary and Recommendations
In general, the quality of care provided by the VHA is as good as
or better than public or privately-funded care, and of note, most
veterans with mental illness are being assessed for suicide and
receiving appropriate follow-up. However, in other areas, the quality
of care does not meet implicit VA expectations, and there is
significant room for improvement. The best evidence to date regarding
suicide prevention supports providing quality mental health care.
Therefore our recommendations address how the VHA might improve the
quality of care for veterans with mental illness and substance use
disorders, which may decrease suicide risk.
Increase proportion of veterans who receive recommended length of
pharmacotherapy.
More than half of study veterans who began medication treatment did
not receive the recommended length of treatment, and more than two-
thirds of those on maintenance treatment were non-adherent. This is
important because adherence to medication improves outcomes and
decreases suicide risk.
Clinical registries are tools that individual clinicians and
administrators can access in real time, without technical assistance,
and use to systematically monitor symptoms and improve adherence.
Clinical registries are not the same as the registries the VA currently
has for psychosis and depression. The use of clinical registries is an
area with strong potential for quality improvement, since they can be
used to track individuals with a specified set of health conditions
over time in order to assess how a patient is responding to treatment
and whether they are missing appointments or medication refills.
Recommended Strategies: We recommend that the VHA take the
following steps:

1. Investigate the basis for low rates of medication adherence
among the veteran population, with an emphasis on strategies to improve
continuity.
2. Conduct an environmental scan to identify best practices
related to clinical registries, with a particular focus on mental-
health-specific implementation.
3. Procure or develop a clinical registry module for the VA.'s
medical records system that minimizes the need for additional data
entry and maintains ease of use and high-level tracking of evidence-
based care.
4. Provide training in, and establish formal expectations for, use
of registries.

Increase proportion of veterans with documented assessment of
housing and employment needs and establish responsibility for housing
and employment services.
Less than two-thirds of veterans with one of the five mental
illnesses studied have a documented assessment of their housing and
employment needs. Housing and employment policies lack sufficient
detail to identify whether the Veterans Health Administration or the
Veterans Benefits Administration is responsible for services.
Recommended Strategies: Two actions are recommended:

1. Develop a standardized documentation template for assessment of
psychosocial needs.\42\
2. Clarify what constitutes need for housing and employment
services, and clearly define the role of the VHA and the Veterans
Benefits Administration with regard to work and housing.

Establish formal expectations for quality measures.
For most mental health treatments, there are no agreed-upon
benchmarks to distinguish between levels of performance. Without
articulated benchmarks, it is not possible to come to definitive
judgments about quality or to judge whether the VA is meeting
performance expectations.
Recommended Strategies: We recommend the following actions:

1. The VA should use a combination of empirical evidence on
current performance, expert opinion, and performance data from
comparable systems to set target benchmarks. At minimum, this benchmark
should be the performance of the best-performing VISN.
2. Performance expectations should include a specific definition
of the evidence-based treatment and what counts as meeting the
benchmark.

Implement standardized, individualized treatment planning
documents.
Treatment plans are incomplete and difficult to locate. In some
cases they may not exist. There is no standardized way of documenting
patient participation in treatment decisions.
Recommended Strategies: Two actions are recommended:

1. Implement and require the use of standardized, individualized
treatment-planning documents that may be linked to problems most often
associated with a particular diagnosis, services being offered, and the
patient's goals for recovery. The VHA Office of Mental Health Services
has recently purchased treatment-planning software but dissemination
has been held up because of lack of personnel to integrate the software
with the current electronic health record.
2. Incorporate the capacity for patients to comment on and
document their participation in treatment planning.

Prioritize efforts to make patient's entire health record
accessible through a common portal, both across and within VISNs.
Some VISNs have an electronic health record system that allows any
provider within the VISN to access the patient's chart in real time.
Other VISNs do not have this capability and it is difficult to access
health records across VISNs. This difficulty can potentially impair the
quality of care veterans receive if they move or receive treatment in
multiple locations.
Recommended Strategy:

1. Prioritize efforts to make patients' entire health records
accessible through a common portal to allow unfettered access and input
by all clinicians caring for them across medical centers and VISNs in
real time. The VA should direct the Office of Information Technology to
ensure that clinicians can access patient data, regardless of where the
patient receives care.

Develop and disseminate national standards for evidence-based
treatments.
It is important that treatments be delivered with fidelity, or as
they were designed to be delivered. Evidence-based treatments for which
the VHA Office of Mental Health Services has disseminated written
national standards appear to be implemented with more fidelity than
treatments for which the VHA has not disseminated national standards.
Specifying what is expected when a particular evidence-based treatment
is delivered is an important first step in ensuring treatment fidelity
and effectiveness.
Recommended Strategies:

1. Develop and disseminate national implementation standards for
evidence-based treatments.
2. Use results from the extensive research conducted by VA
implementation-science researchers to address the gaps identified by
the evaluation. The VA is unique in that it has a number of health-
services research and development programs, as well as quality-
improvement programs. Better communication between VA researchers and
VA clinical services could help make use of VA expertise in this area.

Conduct additional research using the linked data set developed by
the evaluation.
Despite the comprehensiveness of our evaluation, a great deal more
could be learned. We observed significant variations in performance
across every characteristic we examined, sometimes by more than 25
percentage points. Understanding the cause of these variations could
allow the VHA to develop strategies to help lower-performing VISNs
improve. Knowledge of which practices and quality-improvement
strategies are associated with the greatest increases in quality
(outcomes) per unit cost could help the VA become more efficient.
Some priority areas for further research suggested by our results
are below.

1. What is the basis for variations in care that we observed? To
what extent are they a function of poor documentation rather than
variation in performance?
2. What can be learned from high-performing or low-performing
sites?
3. What are the costs associated with quality improvement?
4. How can high quality be achieved in the most cost-efficient
manner?

We do not know how suicide can be prevented, but the best evidence
to date supports providing quality mental health care. The VA has
substantial capacity to deliver mental health and substance use
treatment to veterans with mental illness, and it outperformed the
private sector on most quality indicators, which most likely
demonstrates the significant advantages that accrue from an organized,
nationwide system of care. Nonetheless, the VA is falling short of its
own implicit expectations for providing the highest quality of care for
our Nation's veterans. Our study revealed ways in which the VA could
build upon its current system of care with marginal effort to improve
quality and potentially prevent suicides.
Thank you again for the opportunity to testify today and to share
the results of the research. Additional information about our study
findings related and recommendations can be found at: http://
www.rand.org/pubs/technical_reports/TR956.html.

Table 1: Total FY 2008 VA Mental Health Program Evaluation Veterans, by
VISN
------------------------------------------------------------------------
VISNF VISN Name
------------------------------------------------------------------------
1 New England Health Care System
------------------------------------------------------------------------
2 VA Health Care Network Upstate New York
------------------------------------------------------------------------
3 VA New York/New Jersey Health Care
System
------------------------------------------------------------------------
4 VA Stars and Stripes Health Care Network
------------------------------------------------------------------------
5 VA Capitol Health Care Network
------------------------------------------------------------------------
6 Mid-Atlantic Health Care Network
------------------------------------------------------------------------
7 VA Southeast Network
------------------------------------------------------------------------
8 Florida/Puerto Rico Sunshine Health Care
Network
------------------------------------------------------------------------
9 VA Mid-South Health Care Network
------------------------------------------------------------------------
10 VA Health Care System of Ohio
------------------------------------------------------------------------
11 Veterans in Partnership Network
------------------------------------------------------------------------
12 VA Great Lakes Health Care Network
------------------------------------------------------------------------
15 VA Heartland Network
------------------------------------------------------------------------
16 South Central VA Health Care Network
------------------------------------------------------------------------
17 VA Heart of Texas Health Care Network
------------------------------------------------------------------------
18 VA Southwest Health Care Network
------------------------------------------------------------------------
19 VA Rocky Mountain Network
------------------------------------------------------------------------
20 VA Northwest Network
------------------------------------------------------------------------
21 VA Sierra Pacific Network
------------------------------------------------------------------------
22 VA Desert Pacific Health Care Network
------------------------------------------------------------------------
23 VA Midwest Health Care Network
------------------------------------------------------------------------

______

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Prepared Statement of Jan E. Kemp, RN, Ph.D., National Mental Health
Director for Suicide Prevention, Veterans Heath Administration,
U.S. Department of Veterans Affairs

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
database 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 would strategically
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.

Conclusion
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.

Prepared Statement of Colonel Carl Castro, Ph.D., Director,
Military Operational Medicine Research Program, U.S. Army
Medical Research and Materiel Command, and Chair, Joint Program
Committee for Operational Medicine, Department of the Army,
U.S. Department of Defense

Madam Chairwoman, Members of the Committee, thank you for the
opportunity to discuss the joint Department of Defense (DoD) and
Department of Veterans Affairs' (VA's) efforts to advance our
understanding of how to prevent suicide. We acknowledge Congress'
concern and thank you for your support, which allows the DoD and VA to
continue their commitment to better understand suicide and develop
effective prevention and treatment interventions based on that
knowledge. Our efforts demonstrate our obligation and dedication to the
men and women of our Armed Forces, to their Families who serve with
them, and to the millions of military personnel who have served us in
the past.

Suicide is a significant public health problem, identified as the
third leading cause of death in young people and the 11th overall
leading cause of death in the U.S. population. Traditionally, military
suicide rates have been significantly lower than general population
rates. However, in 2008, Army suicide rates (19.6/100,000) exceeded the
age-adjusted civilian rate and outnumbered combat deaths for the first
time since 2003 (Armed Forces Medical Examiner, 2008). However, the
reason for the increase in Army suicides remains unknown.
Rigorous empirical research is necessary to understand why military
suicides occur and how to identify and help individuals at risk for
suicide. Only evidence-based empirically validated methods for
screening, assessment, prevention and treatment interventions will be
successful in preventing suicides. There are currently no validated
suicide screening and assessment measures.

Military Suicide Prevention Research Program
In 2007, Defense Health Program (DHP) funding supported multiple
military suicide research studies that were initial studies to test
brief cognitive therapy for treating individuals who had been
hospitalized for suicide attempt. In 2008, DHP funding was dedicated to
several military suicide studies focused on developing our ability to
optimize screening and assessment of risk, psychotherapeutic
treatments, and methods to decrease suicide. In the next few years, the
results of these studies will be available to inform policy
recommendations as well as methods for preventing and treating suicidal
individuals. Almost all of the DHP funded military suicide research
studies include VA involvement, including either VA principal
investigators, VA recruitment sites, or VA collaborators on the
research team.
In March 2009, the U.S. Army Medical Research and Material
Command's (USAMRMC) Military Operational Medicine Research Program
(MOMRP) and the Army Surgeon General's office led a series of workshops
with leading suicidologists and military and Federal stakeholders,
including the VA, to determine the state of science of suicide
prevention research. The workshops led to the development of a research
strategy with recommendations provided to MOMRP and the Joint Program
Committee, which is composed of DoD, National Institutes of Health, and
VA leadership as well as academic representatives. The research
recommendations were in 4 focused areas: suicide risk screening and
assessment; universal prevention training; indicated interventions to
manage suicide behavior; and recommendations for revisions to the Post
Deployment Health Assessment and Post Deployment Health Reassessment.
The workshops also involved the U.S. Army Public Health Command (PHC),
which has resources dedicated to epidemiological study and tracking of
Army suicides.
The DoD developed and implemented a Military Suicide Prevention
Research Program, which represents an approximately $110 million
investment, since 2008. Following the recommendations generated from
the workgroups, and consistent with the Army and DoD suicide prevention
strategies, the Military Suicide Prevention Research Program employs a
comprehensive strategic approach to provide evidence-based, rigorously
evaluated, screening, assessment, and suicide prevention interventions.
The DoD and VA collaborate on many aspects of the Military Suicide
Prevention Research Program, which also involves extensive
collaboration among other government organizations, academia, and
national organizations such as the American Foundation for Suicide
Prevention and the American Association for Suicidology Research.

Military Suicide Research Consortium
In September 2009, the DoD established a first of its kind,
multidisciplinary Military Suicide Research Consortium (MSRC). This
effort is funded by the Office of the Assistant Secretary of Defense
for Health Affairs, managed by the USAMRMC, and co-directed by Dr.
Peter Gutierrez, of the Veterans Integrated Service Network 19 Mental
Illness Research Education and Clinical Center of the Denver Veterans
Affairs Medical Center, and Dr. Thomas Joiner, of Florida State
University. The co-directors are world renowned experts in suicidology.
The MSRC was initially funded in the amount of $17 million with the aim
of enhancing the military's ability to quickly identify individuals and
units at risk for suicide and provide effective evidence-based
prevention and treatment strategies.
The MSRC includes core infrastructure as well as funded research
efforts aimed at rapidly developing and validating effective suicide
screening, assessment, and prevention interventions. The studies that
are funded by the MSRC are all required to use a minimum set of common
measures so that data can be pooled across the studies. This larger
data pool can then be analyzed to determine empirically if there are
different sub-types of suicide, a vital question to answer for both
improvement of assessment techniques and developing targeted
interventions. The participating VA researchers are on the cutting edge
of suicide prevention and treatment research. The MSRC complements the
Army Study to Assess Risk and Resilience (Army STARRS) in
Servicemembers effort which is primarily descriptive (epidemiologic) in
focus.

Army STARRS
In order to better understand the factors related to suicide, the
Department of the Army and the National Institute of Mental Health
(NIMH) are involved in an ongoing multidisciplinary collaboration to
conduct a large scale epidemiological study of suicide in the military.
This effort is being led by Dr. Robert Ursano from the Uniformed
Services University of the Health Sciences and Dr. Murray Stein from
the University of California, San Diego. This $65 million project ($50
million from Army and $15 million from NIMH) is the largest
epidemiologic study of mental health, psychological resilience, suicide
risk, suicide-related behaviors and suicide deaths in the military. The
findings from this effort will be used to inform current and future
suicide prevention efforts to enhance their effectiveness.

Way Ahead
Despite the current investment in suicide prevention research,
there is much more work to be done in the area of suicidology. The
strategic research plan calls for further DoD and VA collaboration to
conduct research that comprehensively addresses necessary components:
screening and surveillance; prevention training; assessment, treatment,
and management of suicidal individuals. Future research will focus on
developing evidence-based universal prevention (e.g., peer based,
family based, community based, military-ecologically based).
Additionally, current prevention efforts need to be evaluated for
effectiveness.
Future research is also needed to establish psychometrically sound,
theory-driven screening measure(s). Basic science to validate
underlying psychological and biopsychological theories of suicide will
help to drive prevention and treatment efforts. Further research is
required to establish evidence-based indicated interventions to prevent
and manage suicide behavior (e.g., caring outreach, collaborative
assessment and management, safety planning, collaborative care models,
etc.) across clinical care settings (e.g., Emergency Department,
Behavioral Health, Primary Care, etc.).
Madam Chairwoman and Committee members, the DoD continues work with
the VA to perform and manage world-class medical research and
development for a population that demands and deserves the best care
available. Thank you again for the Congress' and this Committee's
continued support and commitment to research dedicated to ensuring our
Warfighters are getting the best empirically proven cutting edge
training and services. And thank you for the opportunity to be with you
today. I look forward to your questions.

Prepared Statement of Paula Clayton, M.D., Medical Director, American
Foundation for Suicide Prevention

Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Committee. Thank you for inviting the American Foundation for Suicide
Prevention (AFSP) to provide a written statement on the issue of
suicide and suicide prevention among our nation's veterans. My name is
Paula Clayton. I am AFSP's medical director. As such, I work with
AFSP's Scientific Council to oversee the research and educational
programs of the foundation and to apply evidenced based knowledge to
these programs and to the programs that deal with suicide prevention.
Prior to becoming medical director, I was an academician. I trained
in psychiatry and joined the faculty at Washington University School of
Medicine in St. Louis Missouri and then became chairman of the
department of psychiatry at the University of Minnesota School of
Medicine, a job I held for nearly 20 years. That was followed by
becoming a professor of psychiatry at the University of New Mexico. In
all positions, my research, teaching and patient care concentrated on
patients with major depression and bipolar illness and those who were
recently bereaved. Since approximately 15 percent of patients diagnosed
with a mood disorders die by suicide, the outcome of suicide is one I
and all psychiatrists work to prevent. Becoming medical director of the
foundation was a natural extension of my accumulation of knowledge
about the subject.
AFSP is the leading national not-for-profit, grassroots
organization exclusively dedicated to understanding and preventing
suicide through research, education and advocacy, and to reaching out
to people with mental disorders and those impacted by suicide. You can
see us at www.asfp.org.
To fully achieve our mission, AFSP engages in the following Five
Core Strategies: (1) Funds scientific research, (2) Offers educational
programs for professionals, (3) Educates the public about mood
disorders and suicide prevention, (4) Promotes policies and legislation
that impact suicide and prevention, (5) Provides programs and resources
for people with mental disorders and for survivors of suicide, and
involves them in the work of the foundation.
We are pleased today to focus in my statement on identifying at-
risk veterans, data collection, providing effective intervention and
treatment, and meeting the on-going challenges of veteran suicide
prevention.
Chairwoman Buerkle, Ranking Member Michaud, suicide in America
today is a public health crisis. Consider the facts:

More than 36,000 people died by suicide in 2008, the last
year of the CDC report. And these numbers have been rising yearly.
Approximately 20 percent of these deaths were veterans,
although they only make up 1 percent of our population.
Suicide is the 4th leading cause of death in the United
States for adults 18-65 years old and is the third leading cause of
death in teens and young adults from ages 15-24.
Male veterans are twice as likely to die by suicide as
male non-veterans. On average 18 veterans commit suicide each day,
which means that every 80 minutes a veteran dies by suicide. Sadly,
only five of these veterans are in the care of the VA.
Men account for 80 percent of all completed suicides in
America.
Depression, alcohol and substance abuse, Post-Traumatic
Stress Disorder and traumatic brain injury are real medical conditions.

We need to convince veterans that seeking help for mental illness
and substance abuse problems is a sign of strength not weakness. The
keys to improving these statistics are reducing the stigma associated
with mental illness, encouraging help-seeking behavior, and being aware
of warning signs and treatment options.
Suicide is the result of unrecognized and untreated mental
disorders. In more than 120 studies of a series of completed suicides,
at least 90 percent of the individuals involved were suffering from a
mental illness at the time of their deaths. The most common is major
depression, followed by alcohol abuse and drug abuse, but almost all of
the psychiatric disorders have high suicide rates.
So the major risk factors for suicide are the presence of an
untreated psychiatric disorder (depression, bipolar disorder,
generalized anxiety and substance and alcohol abuse), the history of a
past suicide attempt and a family history of suicide or suicide
attempts. The most important interventions are recognizing and treating
these disorders. Veterans have strong biases against doing that. These
must be identified and overcome.
Whether a civilian or a veteran, there are signs that health care
professionals look for, what we call risk factors. In addition to those
above, they include:

Difficulties in a personal relationship;
A history of physical, sexual or emotional abuse as a
child;
Family discord;
Recent loss of a loved one;
A recent arrest;
Sexual identity issues;
Availability of firearms.

Protective factors or interventions that work, again in the general
population and for veterans include:

Regular consultation with a primary care physician;
Effective clinical care for mental and physical health,
substance abuse;
Strong connections to family and community support;
Restricted access to guns and other lethal means of
suicide.

The VA has adopted a broad strategy to reduce the incidence of
suicide among veterans. This strategy is focused on providing ready
access to high quality mental health and other health care services to
veterans in need. Congress needs to fund the VA to deal with these
current and future mental health care needs in the next five, ten,
fifteen and 20 years. This effort is complemented by helping
individuals and families engage in care and addressing suicide
prevention in high risk patients. The VA cannot do it alone, and groups
like the American Foundation for Suicide Prevention are helping in this
important effort. AFSP is pleased to report that while our country and
the VA have a long way to go, help is available.
In the summer of 2007 the VA began a crisis line for veterans and
military servicemembers, in conjunction with the National Suicide
Prevention Lifeline (1-888-273-TALK). Veterans, military
servicemembers, and persons who are calling about someone in either of
these populations are directed to press ``1,'' thereby having their
call directed to a team of crisis line counselors at the VA in
Canandaigua, NY. In the first 3 years, more than 144,000 calls were
received at this call center, and the volume of calls to the Veterans
Crisis Line has continued to grow. Although it is not possible to
accurately estimate the number of lives that have been saved as a
direct result of the Veterans Crisis Line, call records maintained by
the VA point to the diverse needs that are being met among the target
population by this well-trained, skillful corps of counselors.
In 2009, the VA began offering an online Veterans Chat service to
augment the Veterans Crisis Line and provide access to information and
services to veterans, military personnel and their loved ones who
prefer internet-based communication to the telephone. In mid-2010, AFSP
and the VA began discussing whether completing an online assessment
instrument prior to engaging with a Chat Counselor might help users
more easily and specifically communicate their needs and problems to
the Counselor, thereby increasing the quality of the Chat. Such an
option was thought to have particular potential for those veterans and
servicemembers who find it difficult to identify and clearly describe
what they are feeling and experiencing. These discussions led to the
launch of the Veterans Self-Check Quiz in April 2011. This program is
an adaptation of AFSP's highly successful, evidence-based Interactive
Screening Program, an anonymous, web-based method for identifying
college and university students who are at-risk for suicide, and
connecting them to a counselor who can engage them to get treatment.
This program is based on the premise that at-risk persons often have
beliefs and attitudes which create barriers to treatment, which must be
addressed and resolved before the person will be responsive to offers
of help.
For the last 7 months, the Veterans Self-Check Quiz has been
offered on the National Suicide Prevention Lifeline Web site as a third
way of getting help, the first two being calling the Crisis Line or
directly contacting the online Veterans Chat service. A link provided
on the Lifeline homepage directs the user to an AFSP-developed secure
Web site where the user can anonymously complete an online
questionnaire that deals with depression, stress, drug and alcohol use,
PTSD, traumatic brain injury, and suicidal thoughts and behaviors.
Submitting the Self-Check Quiz generates a signal to the Chat
Counselors in Canandaigua, NY that a Quiz has been received and needs
to be responded to. The user is directed to stay on the Web site to
receive the Counselor's personal response, which typically occurs in
15-30 minutes. Educational and informational materials and videos can
be accessed directly from the Web site and perused by users while they
are waiting.
In their responses, Chat Counselors provide feedback to the user
about Quiz answers of particular concern and make recommendations about
help-seeking. Users are particularly encouraged to explore options by
entering into a Chat with the counselor, using a link to the Veterans
Chat service. A Reference Code, which is automatically assigned to each
Self-Check Quiz and communicated to both the user and counselor, allows
tracking of those users who come into a Chat directly from the Self-
Check Quiz.
In the initial 6 months of the program, almost 6,000 Self-Check
Quizes were submitted, the large majority of which were from veterans.
A high percentage of the submitted Quizes suggested serious suicide
risk. Using the Reference Codes, one-third of those who submitted the
Quiz could be identified as having engaged in a follow-up Chat. A
significant increase in Chat volume that paralleled the introduction of
the Self-Check Quiz suggests that many more users may have entered a
Chat days or maybe even weeks after submitting the Quiz without
providing the Reference Code that would have signaled that a Quiz had
been submitted. Analysis of the data from the initial 6-month period
has just begun and results will be reported as soon as these are
available.
AFSP applauds the VA in its use of this innovative, proactive
approach to reach out to veterans and servicemembers who, for a variety
of reasons, are not themselves initiating contact with the VA as they
are struggling with mental health problems. We look forward to
continuing this collaboration with the VA, using the findings from the
pilot implementation to make enhancements to the program, and exploring
ways to make this outreach effort even more effective.
In this regard, we might consider experimenting with a small-scale
implementation of the program at a local VA medical center or other
facility. AFSP's campus-based Interactive Screening Program has shown
that a mental health professional in the Counseling Center of the
student's own university can very effectively use the anonymous online
interactions to help students address their barriers to help-seeking
and engage them to pursue in-person treatment, at least initially with
that same counselor. It is worth exploring whether the Self-Check Quiz
could be effectively used on the local level to reach out to and engage
veterans to seek treatment for mental health problems that put them at
risk for suicide.
The VA has gone on to develop other suicide prevention programs and
to educate their health workers about suicide risk factors and ways to
intervene.
Unfortunately, they face enormous challenges.
First of all, only about one-third of our veterans are in VA care.
Those who are employed frequently choose to use the private insurance
their employers provide and are therefore not in the VA care system.
Others are unemployed; a condition in itself associated with higher
suicide rates. Even tracking these men and women is difficult, much
less gathering information about the deaths.
Second, a number of veterans are homeless or perhaps in jail, and
they need a different intervention plan. The VA now reports that
107,000 veterans are homeless on any given night.
In order to meet the multiple challenges that the VA faces in both
suicide education and prevention, AFSP recommends consideration of the
following four research initiatives and or interventions.
Number one, the most informative way to learn about suicides is
through an investigation, after death, called a ``psychological
autopsy.'' This procedure, as referred to earlier, allows investigators
to go in to a home in the month after the suicide, and using a
structure interview, to question all the family members, physicians,
perhaps friends and clergy, about the events that were occurring at the
time of the suicide. It allows the investigator to decide, putting all
the interviews together, what were the signs and symptoms that the
veteran was displaying prior to his death. Was he depressed, sleeping
poorly, losing weight, talking about being a burden, becoming more
irritable? Was he drinking, using drugs, prescription or otherwise,
that may have contributed to his mood and his lack of control? Was he
fighting with his family, isolating, in an accident, ill, in pain, been
arrested or had trouble with the law? Given that information on a
randomly chosen group of veterans, the VA could develop a clearer
picture of the mental disorders that lead a veteran to suicide and plan
intervention programs based on those findings. I am not sure we even
know the means by which veterans die by suicide. Although in most of
the 120 psychological autopsy studies done they are concentrated in one
city or country, it is possible to train several teams to do this for
the country, thereby allowing a ``team ready'' approach to the issue.
If they found, for instance, that 15 percent of the veterans had enough
behavioral problems that the police were called, then training
policeman to be particularly careful and aware on such a call that this
may be a veteran in trouble and in need of a psychiatric evaluation
would be paramount. The police, in many states, are able to take people
who are dangerous to themselves and others to an evaluation facility.
Number two, another proven successful intervention is to train
primary care physicians and nurse assistants to diagnose and treat
depressed patients with antidepressants. There are at least four
communities where this has shown to decrease the suicide rate, the most
impressive being one carried out by the World Health Organization in
four different underdeveloped countries. The VA could and should begin
immediately to train the collateral primary care and ER physicians and
their personnel to recognize and treat depression or alcohol or
substance abuse and every veteran's chart should have this information
in front or on the screen as it is opened. There are also drug screens
and liver function tests that might lead a caregiver to suspect there
is a drug or alcohol abuse problem. Knowing, from the psychological
autopsy study, what the veteran is suffering from would help plan this
intervention, too.
Number three, we need to give our veterans ``real'' jobs. Dr. Peter
Kramer of Brown University recently wrote, ``The Best Medicine Just
Might Be a Job.'' He reports that study after study correlates
unemployment with suicidality. When soldiers leave the military, they
lose what the service provides: purpose, focus, achievement,
responsibility, and the factor that the Center for New American
Security report calls ``belongingness.'' The workplace can be
stressful, but especially for the mentally vulnerable, there is no
substitute for what jobs offer in the way of structure, support and
meaning.
Number four, many studies have indicated that preventing easy
access to lethal means, like firearms, is an effective way to prevent
suicide. Soldiers are taught to use guns and most have them available.
Just as it is believed that physicians, as professionals, have
knowledge and easy access to other lethal means (drugs) and therefore
have the highest suicide rates of any profession, veterans have the
knowledge of and access to guns, another lethal means. VA hospital and
all medical personnel should be taught to ask veterans about whether
they have guns in their houses and encourage the doctor or others to
discuss with at-risk veterans and their family members how to store the
guns safely, with gunlocks or separated ammunition and guns, or even
encourage temporary removal of the weapon. A program could be planned
for medical personnel and others on what they should ASK A VET?
AFSP would like to commend the U.S. Department of Veteran Affairs
and Dr. Jan Kemp for their leadership and vision in constructing and
implementing this program designed to help our veterans contemplating
suicide. They and we still have much more to do. We urge this
Subcommittee, the full Committee and the entire Congress to fully
support the VA and Dr. Kemp in their important efforts by funding them
at the highest levels possible, not just next year, but for many more
years in the future. This is essential: once we identify veterans
needing help, VA professionals must be available to assist them now,
tomorrow, next week.
Chairwoman Buerkle, Ranking Member Michaud, suicide among veterans
is an absolute crisis. Depression can be fatal. Excessive drinking or
drug use can be fatal. The fatality is mainly by suicide. Culturally
sensitive but sustained efforts with multiple approaches offer our best
hope to get veterans into treatment. We must reduce this fatal outcome.
The American Foundation for Suicide Prevention is ready and willing to
offer our expertise and advice to the U.S. Department of Veterans
Affairs, this Committee and to all members of Congress as you make the
important decisions on how to reduce suicide among our veterans.

Prepared Statement of Lieutenant Colonel Michael Pooler, USA, Deputy
Chief of Staff, Personnel, Maine Army National Guard

Thank you, Congressman Michaud for allowing the Maine Army National
Guard to submit written testimony on suicide. Suicide prevention is
taken very seriously in the Maine Army National Guard from the top
down. Unfortunately, since 2009, the Maine Army National Guard has had
two suicides. Though we do not have specific numbers, we know that
numerous interventions have occurred that have saved lives. As training
continues, interventions will increase. Leaders across the state are
keenly aware of the problem and are working together to reduce the
stigma and create a help-seeking environment. We view the increase in
interventions as confirmation that our attempt to create an environment
where Soldiers, families and commanders recognize the signs of suicide
and ask for help without fear of retribution as very positive progress.

Support Staff and Organizational Training
Our support staff consists of a variety of Federal and contracted
personnel. Our primary Federal employees consist of two Army National
Guard chaplains, a Suicide Prevention Program Manager, one Army
National Guard behavioral health officer, and two substance abuse
personnel. Our primary contracted personnel are: a Director of
Psychological Health, two Military Family Life and Children
Consultants, a Military One Source representative, a Personal Financial
Counselor and several Family Program contractors who run a 24/7
assistance hotline. Each has a part in finding help for our Soldiers
and Families.
The Army National Guard has a Resiliency, Risk Reduction and
Suicide Prevention (R3SP) Campaign Plan designed to coordinate various
programs to ensure our Soldiers bounce back from adversity. A critical
part of this is the Comprehensive Soldier Fitness program with Master
Resiliency Trainers and Resiliency Training Assistants. These Soldiers
support unit commanders in training Soldiers to be resilient through
various means. Another component of the R3SP program is the Suicide
Prevention Program Manager, who is the conduit between the National
Guard Bureau and the State of Maine to coordinate and facilitate
intervention training. Applied Suicide Intervention Skills Training
(ASIST) is conducted semi-annually for selected servicemembers. ASIST
has strategically placed trained Soldiers in units across the state to
be the eyes and ears of commanders to observe the signs of suicide and
provide interventions for those with suicidal ideation. ASIST is
enhanced by Ask, Care, Escort (ACE), an Army-wide intervention program.
ACE teaches every Soldier the warning signs of suicide, how to ask the
suicide question, the nature of care needed by a suicidal Soldier, and
when and how to escort such Soldiers to health care professionals to
save lives. ACE is unit led, supported by unit commanders, and promotes
a ``buddy-care'' mentality that encourages help-seeking by those going
through crises or struggling with addictions. ACE is a mandatory 1-hour
training block taught annually at the company level.
Suicide prevention takes many forms. Since relationship issues and
substance abuse are frequently associated with suicidal thinking and
behavior, we have stepped up efforts to strengthen relationships and
reduce alcohol and drug abuse. Our chaplains conduct four to five
Strong Bonds events annually aimed at married couples and single
Soldiers to build healthy and enduring relationships. Our Counter Drug
Program works tirelessly to educate and influence Soldiers, recruits,
and families in the dangers and warning signs of addiction.
We also have the Maine Military and Community Network which works
with clergy, law enforcement, and volunteer groups to support our
Soldiers and families. A key component of this is the Maine Military
Clinical Outreach Network where we train clinicians on the military
culture and attempt to find civilian providers to see our Soldiers at a
free or reduced rate. The Governor's Military and Community Leadership
Council also works at the policy level to coordinate comprehensive
support for all our servicemembers in Maine.

Access to assistance
The Army National Guard is organized to train and deploy Soldiers;
therefore, we do not have any staff dedicated to treat our Soldiers.
Our staff is trained to help Soldiers find treatment; however, as a
rural state, treatment options are limited and our only access to a
military medical treatment facility is in another state.
Nationally in the Army National Guard, in 2009 and 2010, roughly
one half of Soldiers that committed suicide did not deploy, which
determines VA eligibility.i
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\i\ AR3SP Update, 29 JAN 11, Army National Guard Bureau, COL Greg
Bliss.
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VA eligible Soldiers. We have a close working relationship with the
great Suicide Prevention staff at Togus VA Hospital and the regional
Vet Centers. The staff is easy to reach, ready to help, and eminently
qualified. They have become a reliable and competent resource and
benefit for us; however, from our perspective, they seem to be
extremely understaffed.
Non VA eligible Soldiers that buy TRICARE. We are finding that many
Soldiers with suicidal ideations have not deployed, so they are not
eligible for VA support. Even though Soldiers are eligible to buy
TRICARE at a very reasonable price, most do not. However, even those
that buy TRICARE, have a very difficult time finding clinicians who
will see them. Many clinicians that want to help Soldiers find the
process to become a TRICARE provider extremely cumbersome and the
$27.50/hour reimbursement does not cover basic overhead, so we lack the
number of counseling providers needed for our Soldiers. There needs to
be a concerted effort to recruit and retain not only behavioral health
providers, but also the gatekeepers to support the primary care
providers. Also, someone other than the providers needs to maintain the
TRICARE Web sites to ease the frustrations Soldiers find when looking
for help. Much of the information on the Web site is outdated.
Soldiers without health insurance. Obviously, this is a population
that creates the biggest challenge. Our staff works tirelessly
contacting providers to find someone to help at a reduced rate or free.

What Works
The most effective approach is to create an environment where
Soldiers feel they can ask for help without fear of repercussion or
stigma and we work to continuously improve this environment. We provide
the training to recognize the signs, where to get help and how to get
Soldiers the support needed.
Community coordination and support allow the Guard to find the
resources available for our Soldiers. This has saved lives.
Contractors provide continuity of support because our full time
force of Soldiers will eventually deploy.
Respectfully submitted.

Prepared Statement of Richard McCormick, Ph.D., Senior Scholar, Center
for Health Care Policy, Case Western Reserve University, Cleveland, OH

Suicide is a tragedy. It is the ultimate ending for some of the
very large numbers of veterans who face the challenges and problems
that result from deployment and combat.
The Department of Veterans Affairs (VA) and the Department of
Defense (DoD) have worked hard to develop programs to reduce suicidal
behavior among returning servicemembers and veterans. Still, the
challenge remains to discover and implement additional measures to
further reduce the risk of suicidal behavior.
Research has established that the suicide of a particular
individual is very difficult to predict and anticipate. We do, however,
have increasing knowledge about the conditions that precede and
contribute to suicidal behavior and other serious emotional problems,
such as PTSD and depression, in veterans and servicemembers. These
include notably:

Problems in marital and other important relationships
Hazardous use of alcohol and other drugs
Risky/impulsive behaviors including: gambling, hazardous
driving, and outbursts of angry behavior

Research has shown that all of these problems occur in returning
servicemembers and veterans, and that all are related to the degree of
exposure to stress during time in service and immediately after.
The harmful use of alcohol is a major public health problem, and is
a particularly serious problem for those serving in the current war on
terror. A recent report on 48,481 active duty, reserve and national
guard indicates that rates of heavy weekly drinking (9%), binge
drinking (53.4%), and problems related to alcohol use (15.2%) were
particularly high in Reserve and National Guard members who are
veterans immediately after return from deployment (Jacobsen, Ryan,
Hooper, et al, 2008). Both the degree of exposure to combat and the
degree of exposure to human trauma are related to increased drinking
(Kilgore et al, 2008; WIlk et al 2010). Surveys of active duty military
members have noted that between 6.3 percent and 8.1 percent report at
least one gambling related problem in their lifetime (Steenbergii et al
2008). In a study of returning OIF/OEF servicemembers, the intensity of
combat experience and exposure to violent human trauma were predictive
of verbal and physical aggression towards others 3 months after
deployment (Kilgore et al, 2008). Aggressive and unsafe driving are
significant problems for active duty members (Kilgore et al 2008). Even
controlling for age personnel deployed to Iraq have higher rates of
dangerous driving than older veterans.
These problems are often among the first indicators of serious
distress. If left unattended they can fester and expand to other areas
of the veteran's life and functioning. As the problems snowball,
helplessness and hopelessness can set in, leading to suicidal behavior.
A comprehensive program of early prevention for suicide and other
serious emotional problems should include readily accessible, hassle-
free assistance with these problems. Historically, the Vet Centers have
been more assertive in addressing these early problems than has the VA
core medical care system. With some notable exceptions, VA medical
centers and clinics have traditionally focused on diagnosable
pathology. If services such as marital counseling or early intervention
into hazardous drinking exist, they may be embedded in other programs.
Further complicating the prevention effort is a lack of awareness,
and at times limited motivation, of the veteran to address the early
precursor problems. Present programs, including the Vet Centers, rely
on the veteran seeking help for a self-identified problem.
More can and needs to be done to identify and offer early
intervention for problems which have been demonstrated to be related to
later serious emotional problems and suicidal behavior.
The first practical steps would be to build on current efforts in
the VA and DoD to screen for early occurring problems. VA currently
screens all patients in primary care for hazardous alcohol use,
depression and PTSD. Positive screens for depression and PTSD are
expected to trigger further screening and intervention, including
identifying and addressing suicidal behavior. Returning servicemembers,
including those in reserve components, are screened immediately after
deployment and again within 90 days for general mental health issues,
including PTSD and alcohol use. VA outreach workers are present at
screens for those in the reserve components when they are conducted at
their home training sites.
Short reliable and valid screening tools exist for other early
identifiable problems including relationship issues, problem gambling
and other risky behaviors. Screening for these additional problems
would raise the awareness of veterans, significant others and providers
of care. It would also assure that a conversation is initiated about
these problems and early intervention considered in all venues where
veterans may be encountered, including primary care settings and
outreach efforts.
Screening is a necessary, but not sufficient, step in a
comprehensive prevention effort. Still greater challenges exist in
assuring that those who screen positively are in fact engaged into an
appropriate level of intervention. Hazardous alcohol use provides the
currently best documented example of this issue. A recent study of 1508
OIF/OEF veterans using VA medical, surgical or mental health services
found that 40 percent screened positive for hazardous alcohol use
(Calhoun, Elter, Jones, et al, 2008). This study also documented that
only 31 percent of those who screened positively for an alcohol use
problem ever received a follow-up intervention to address the problem.
This lack of follow-up underscores the need to assure that readily
accessible intervention services exist, and that all providers are
aware of them and able to seamlessly refer to them.
VHA's recent efforts to increase the placement of mental health
staff in primary care settings provides the platform to deliver
accessible services to intervene with these early problems.

Suicide prevention efforts in VA and DoD could be enhanced by the
following:
Expand screening efforts to include a wider variety of
problems and behaviors that are potentially related to serious
emotional problems including suicidality
Assure that readily accessible services are available to
intervene immediately when a problem is identified, and that these
services are widely advertised to both veterans and providers
Assure that all staff understand that addressing these
behaviors is a critical part of providing comprehensive health care
prevention services in the health care setting, they are not someone
else's responsibility
Increase the awareness of veterans and their significant
others about these early indicator problems and urge them to bring them
up with their health care provider (this could include, for example,
handouts in primary care areas)
Conduct periodic quality assurance studies assessing
whether veterans screening positively for problems actually access
interventions services

Expanding screening efforts and establishing robust marital/
relationship programs, specific programs addressing hazardous drinking,
and programs tailored to other risky behaviors would involve further
funding. Establishing these programs is part of our responsibility to
restore returning veterans to full function. It needs to be done
immediately, since the need is now before they can fester into
additional serious issues, including, for some, suicidal behavior. This
immediate investment is also the wise fiscal choice, since it will
offset not only human suffering, but future greater health care costs.

______

References:
Preliminary Normative Data for the Evaluation of Risks Scale-Bubble
Sheet Version (EVAR-B) for Large-Scale Surveys of Returning Combat
Veterans MAJ William D. S. Killgore, MS USAR; COL Carl A. Castro, MS
USA; COL Charles W. Hoge, MC USA, MILITARY MEDICINE, 173, 5:452, 2008.
Gambling and Health Risk-Taking Behavior in a Military Sample:

Timothy A. Steenbergii, PhD*; James P. Whelan, PhDf; Andrew
W. Meyers, PhDf;
Robert C. Klesges, PhDf; Margaret DeBon, PhD, Military
Medicine [Mil Med], ISSN: 0026-4075, 2008 May; Vol. 173 (5),
pp. 452-9.

Lifetime Prevalence of Pathological Gambling Among American Indian
and Hispanic American Veterans:

Westermeyer, MD, PhD, MPH, Jose Canive, MD, Judith Garrard,
PhD, Paul Thuras, PhD, and James Thompson, MD, MPH, Am J Public
Health. 2005;95:860-866.
Daghestani, A. N., Elenz, E., & Crayton, J. W. (1996).
Pathological gambling in hospitalized substance abusing
veterans. Journal of Clinical Psychiatry, 57, 360-363.
Levens S., Dyer A. M., Zubritsky C., Knott K., Oslin D. W.
Gambling among older, primary-care patients. An important
public health issue. Am J Geriatr Psychiatry 2005;13:69-76.
Factors associated with pathological gambling at 10-year
follow-up in a national sample of middle-aged men, Jeffrey F.
Scherrer, Wendy S. Slutske, Hong Xian, Brian Waterman, Kamini
R. Shahl, Rachel Volberg & Seth A. Eisen, Addiction, 102, 970-
978, 2007.

Post-combat invincibility: Violent combat experiences are
associated with increased risk-taking propensity following deployment:
William D.S. Killgore a,*, Dave I. Cotting, Jeffrey L. Thomas a,
Anthony L. Cox, Dennis McGurk, Alexander H. Vo, Carl A. Castro, Charles
W. Hoge Journal of Psychiatric Research 42 (2008) 1112-1121.
Relationship of combat experiences to alcohol misuse among U.S.
soldiers returning from the Iraq war: Wilk JE; Bliese PD; Kim PY;
Thomas JL; McGurk D; Hoge CW, Drug And Alcohol Dependence, 2010 Apr 1;
Vol. 108 (1-2), pp. 115-21.
Hazardous alcohol use and receipt of risk-reduction counseling
among U.S. veterans of the wars in Iraq and Afghanistan.; Calhoun PS;
Elter JR; Jones ER Jr; Kudler H; Straits-Troster K, J Clin Psychiatry
2008 Nov; Vol. 69 (11), pp. 1686-93.
Alcohol use and alcohol-related problems before and after military
combat deployment; Jacobson IG; Ryan MA; Hooper TI; Smith TC; Amoroso
PJ; Boyko EJ; Gackstetter GD; Wells TS; Bell NS, JAMA: The Journal Of
The American Medical Association, 2008 Aug 13; Vol. 300 (6), pp. 663-
75.

Statement of John E. Toczydlowski, Esq., Philadelphia, PA
Mr. Chairman and Honorable Members of the Committee:
My name is John Toczydlowski. I am not a veteran, but I am from a
military family, my father, my grandfather and my uncles having proudly
served. Today, I am here to speak with you specifically about my
father, who served in Vietnam from 1964-1970. He committed suicide on
December 17, 2010 as the result of post-traumatic stress disorder and
physical ailments directly related to his service in Vietnam.
Three specific questions need answers. One, how and why did this
happen? Two, how can we prevent or reduce the number of incidences of
veteran suicide in the future? Three, how can we aid surviving family
members if and when veteran suicide occurs?

1. Background
Little did I know my father's death on December 17, 2010 was set in
motion in 1964. My father volunteered for service in Vietnam, and
entered the conflict in army security. I know very little about his
specific activities in the war; as you will hear later, he did not
often speak of these events. I do know that he provided bombing
coordinates for American offensives and worked in/on special
operations.
When my father returned home in 1970, it was to an unpopular war, a
wife, the thought of a soon-to-be adopted son (me), and no knowledge,
instruction or education on benefits or help from the Department of
Defense or the Veterans Administration, aside from the GI bill. For
years and years, my father suffered with the memories of war without
solace or outlet. Except for anger. And temper. And smoking. And
alcoholism. In fact, every night, my father drank between 6-12 beers
trying to drown out his memories.
In 1992, my father first tried to kill himself, overdosing on
prescription drugs. Luckily for him, and for my mother, brother and I,
he survived. We did not, however, all live happily ever after. Still
not realizing the scope of the problem, still not being aware of
potential treatment and support options, and with my father still not
discussing the core of the problem, we made it only four (4) short
years before he once again attempted suicide. This time, he went into a
program and began seeing a psychiatrist, Timothy C. Smith, M.D.
From 1996 until my father's employment with the Veterans
Administration in 2003, he treated with Dr. Smith and never once
mentioned his Vietnam service. Call it denial or call it guilt--
whichever, he was either too proud or too wounded to talk. I attach to
this record a letter from Dr. Smith outlining his treatment and
diagnosis in 2003; I find it instructive as to the depth both of my
father's post-traumatic stress disorder and his efforts to hide it,
bury it and deny it.
Once my father began working in the Philadelphia office of the
Veterans Administration, he learned that he was not alone, as the
thought for over 33 years. He began to speak with other veterans, learn
of the benefits and services available to him, and realize that help
would and could be had. Of course, work at the VA was a double-edged
sword for my father; while he found a built-in support group, each and
every story from Vietnam, Iraq and Afghanistan worsened his PTSD
symptoms. But he rallied.
The rally slowly came to an end as my father's physical limitations
began to catch up with him. After several hospitalizations and with a
clearly declining mental faculty, my mother came home on December 17,
2010 to find my father dead from two bullet wounds. This fight, many
years longer than the one in Vietnam, was over.

2. How and Why Did This Happen?
We will never know for sure exactly what happened to my father. The
evidence, however, leads to a few simple conclusions. One, my father
certainly endured the ``horrors of war,'' both with regard to his own
activities that might have resulted in collateral damage to the
civilian population in Vietnam and seeing his own army-mates die. As
time went on, the few people he held close from Vietnam also wasted
away and died from illness, some related to the war and some not. Two,
upon his return to the United States, his feelings of guilt and
isolation were increased and ratified. He came home as an unpopular
soldier in an unpopular war. He knew little or nothing of potential
benefits available to him, other than the GI Bill, which he used to
complete his college education at night. He never spoke to my mother or
anyone else about what he did in Vietnam, where he went or what he saw,
internalizing it all and ``protecting'' us from it. Three, once my
father began applying for benefits, there were impediments at every
step. He filed multiple appeals to obtain his 100 percent disability
rating for a service-connected disability. He fought for recognition of
the ill effects of Agent Orange. At every turn, there were obstacles .
. . it was as though he was fighting another war.

3. How do we Help Reduce the Number of Veterans' Suicides?
In order to reduce the number of veteran suicides, the first step
is better record-keeping. We all know the statistics put out by the
Veterans Administration: an Iraq/Afghanistan veteran kills himself
every 80 minutes. Vietnam-era suicides were once thought to be in the
50,000-100,000 range, though testimony on the subject from the CDC and
others estimates the number to be approximately 9,000. On the other
hand, the data points being used in any such studies are old, are based
on limited tracking statistics, fail to account for new understanding
of the impact of Agent Orange, PTSD, and other illnesses, and generally
need to be extrapolated from unreliable data. We need a better record-
keeping system in order to specifically identify the causes of death
among veterans.
The second step requires a better support group for veterans,
whether from the military itself, the government or both. Isolation is
clearly at the heart of many veterans' issues, including suicide. From
the weeks just before discharge through the return home, all efforts
should be made to keep the veteran engaged. Counseling. Benefit
instruction. Support groups. Even before discharge, perhaps military
cohesion units would be of benefit. We thrust our military back into
civilian society ill-equipped to deal with the many issues confronting
them: employment, disability, family . . . how do we possibly expect
them to transition well?
Step three is to ease the obstacles placed in front of veterans in
applying for and receiving their benefits. As this Committee is aware,
the long-standing view of the process is one of benevolence and
paternalism between the Veterans Administration and the veterans. This
view, in light of budgetary constraints and more complex claims, is no
longer valid or appropriate. In terms of disability claims alone
(ignoring, for the moment, any other claims, including surviving spouse
claims, death benefit claims, etc.), the backlog of cases has risen to
approximately 756,000 (as of April 2011). The number of claims over 125
days old totals approximately 450,000. Veterans wait an average of 6
months to receive entitled benefits. My mother is nearly 1 year out
from her husband's death, and she is still no closer to receiving a
decision on her DIC benefits. Thankfully, she has social security and
life insurance to keep her afloat in the meantime, a luxury many other
widows do not have.
The nightmare does not end there. Over 20 percent of these claims
are on appeal Appeals take an average of 527 days to forward to the
initial appellate level (the BVA), with another 274 days for the BVA to
process the appeal. The remand rate of cases going forward from the BVA
to the CAVC approaches an astonishing 80 percent.
In an effort to allow for the earlier intervention of lawyers into
the process, Congress passed The Veterans Benefits, Health Care and
Information Technology Act of 2007. Interestingly, the Veterans
Administration and Disabled American Veterans were two of the most
arden opposers of this legislation. Why? The reasons are too numerous
to count, but the simplistic belief is the veterans' organizations want
to keep control, keeping claims out of the hands of lawyers, and the
Veterans Administration is consistently working at counter-purposes
with its own veterans. Veterans are entitled to due process, and,
frankly, it is not the reality for most. More efforts need to be made
to appropriately and fairly evaluate claims in a more efficient and
effective manner.

4. How Surviving Families Cope?
As the son of a man who committed suicide, I can tell you that the
questions never go away. Why didn't I see? What could I have done? What
if I made one more call, or came by the house one more time? The last
thing survivors need to cope with is the morass of an outdated,
outmoded and unfriendly bureaucracy.
My father had the benefit of working for the Veterans
Administration. Had he not, I am not sure I would have been able to get
off the ground in terms of identifying proper benefits. Death benefits.
DIC. Funeral benefits. Life Insurance. TSP. The list goes on and on,
and each winds up in a different location with different forms. Can you
image the barriers to those with limited technological access, little
education, and little experience dealing with the government? Those
with no money get no help from the lawyers either, as fees are not
applicable until the first level of appeal.
The requirements to receive these benefits can be onerous as well.
The DIC requires, for example, that a veteran die of a service-related
disability for which he was 100 percent disabled for a period of 10
years or longer. Well, what about the veteran who commits suicide as
the result of PTSD but did not receive his 100 percent disability
rating until 8 years before his death due to filing 4 appeals? Is that
system fair to the memory of the injured veteran? To his family?

5. Conclusory Remarks
Abraham Lincoln, in his second inaugural address, said: ``To care
for him who shall have borne the battle and for his widow and his
orphan.'' Our Veterans Administration, our non-profit support
organizations and our government need to do eliminate the feelings of
isolation and abandonment our veterans feel when returning from
service; educating our veterans in the financial, medical and other
benefits available to them; and removing unnecessary and unfair
impediments to receipt of those benefits and the due process due
veterans. While we will likely never eliminate veteran suicide, a more
friendly, more caring process will certainly go a long way in reducing
the increased risk factors. Thank you.

MATERIAL SUBMITTED FOR THE RECORD

Hon. Michael H. Michaud, Ranking Democratic Member, Subcommittee
on Health, Committee on Veterans' Affairs to Col Carl Castro, Ph.D.,
Director, Military Operational Medicine Research Program Research
Area Directorate III, U.S. Army Medical Research & Material Command,
U.S. Department of Defense
December 5, 2011

COL Carl Castro, Ph.D.
Director, Military Operational Medicine Research Program
U.S. Army Medical Research and Material Command, and
Chair, Joint Program Committee for Operational Medicine
U.S. Department of Defense
1400 Defense Pentagon
Washington DC 20301-1400

Dear COL Castro:

In reference to our Subcommittee on Health Committee hearing
entitled ``Understanding and Preventing Veteran Suicide'' that took
place on December 2, 2011, I would appreciate it if you could answer
the enclosed hearing questions by the close of business on Friday,
January 20, 2012.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively and single-spaced. In
addition, please restate the question in its entirety before the
answer.
Due to the delay in receiving mail, please provide your response to
Jian Zapata at jian.zapata@mail.house.gov, and fax your responses to
Jian at 202-225-2034. If you have any questions, please call 202-225-
9756.

Sincerely,

Michael H. Michaud
Ranking Democratic Member
Subcommittee on Health

CW:jz

______

Questions for the Record from the
House Committee on Veterans' Affairs Subcommittee on Health
Hearing on Understanding and Preventing Veteran Suicide
Questions for the Record
1. It has been clearly demonstrated that DoD and VA must work
together to address issues that face both departments, particularly
suicide, mental health and substance abuse treatment. Given such
demonstrated need:

a. Please provide the Committee with a detailed explanation
of any joint efforts by both departments to collect data on
suicides or to do a comprehensive study on suicides. If there
have not been any efforts, please explain the lack of such
efforts.

2. What is being done to address the unique mental health care
needs of recently returning servicemembers?
3. What can be done to improve outreach to servicemembers and
veterans needing mental health care services, especially those veterans
most at-risk?
4. What are your thoughts on the Military Officers Association of
America's recommendation to: Require VA-DoD to establish a single
strategy and a joint Suicide Prevention Office that reports directly to
the Department Secretaries through the Senior Oversight Committee
(SOC)?
5. Many of the experts have stated that early intervention is
critical in the prevention and treatment of mental health conditions
such as Post-Traumatic Stress Disorder. What programs do the
Departments have in place to flag, intervene and monitor at risk
servicemembers who are transitioning to VA? Is there a ``warm hand-
off''?
6. At the September 9, 2011, House Committee on Armed Services
hearing on suicide prevention programs in the military, Dr. Jonathan
Woodson, Assistant Secretary of Defense for Health Affairs at DoD,
mentioned the DoD/VA Integrated Mental Health Strategy (IMHS) that they
have been working to put in place over the last 10 months.

a. Can you comment further on what was recommended? Of the
numerous action items outlined in this strategy, what pieces
are still outstanding?

7. The Maine National Guard submitted testimony for the record in
which they outline their Resiliency, Risk Reduction and Suicide
Prevention Campaign Plan. What sort of resiliency training is DoD
incorporating in its prevention efforts?
8. How many more mental health providers are needed to meet
demand?
9. What do you need from us to assist you in addressing the mental
health issues of today?

Response from Col Carl Castro, Ph.D., Director, Military Operational
Medicine Research Program Research Area Directorate III, U.S. Army
Medical Research & Material Command, U.S. Department of Defense, to
Hon. Michael H. Michaud, Ranking Democratic Member, Subcommittee on
Health, Committee on Veterans' Affairs
Member: Congressman Michaud
Witness: USA COL Castro
Question: #1
Question: It has been clearly demonstrated that DoD and VA must
work together to address issues that face both departments,
particularly suicide, mental health and substance abuse treatment.
Given such demonstrated need: (a) Please provide the Committee with a
detailed explanation of any joint efforts by both departments to
collect data on suicides or to do a comprehensive study on suicides. If
there have not been any efforts, please explain the lack of such
efforts.

Answer: The DoD and the VA have been working together for some time
to address the issue of suicide prevention, as well as those associated
high risk behaviors that surround both fatal and non-fatal suicide
events. The DoD and VA currently share data in multiple instances. In
particular, the DoD/VA Suicide Nomenclature and Data Working Group has
developed an action plan to create a joint DoD/VA Suicide Data
Repository that will merge existing data from multiple sources to
create common identifiers and data elements, fill gaps in knowledge,
identify common risk factors, and present a longitudinal view across
the active and veteran populations. This effort will result in a single
source for all suicide events and self-directed violence across the
Departments as well as help inform programs and policies related to
suicide prevention in the future.

Question: #2
Question: What is being done to address the unique mental health
care needs of recently returning servicemembers?

Answer: The Department of Defense (DoD) has revised its deployment
mental health assessment process to provide comprehensive person-to-
person mental health assessments at pre-deployment and within 6 months,
1 year, and 2 years after return from deployment. These procedures
comply with requirements in the National Defense Authorization Act
(NDAA) for Fiscal Year 2012 (Section 702). The three post-deployment
mental health assessments must be performed either by licensed mental
health professionals or by designated personnel trained and certified
to perform the assessments. These mental health assessments include an
analysis of self-reported responses to mental health questions on
symptoms of depression, posttraumatic stress disorder (PTSD), and
alcohol misuse; detailed follow-up on positive responses to previous
mental health diagnoses and medication use; and exploration of other
reported emotional, life stress, or mental health concerns. During a
confidential dialog with the Servicemember, the provider would conduct
an assessment of the risk for suicide or violence, offer education on
relevant mental health topics, administer brief interventions, and make
recommendations for follow-up assessment and care, when indicated.
After returning home from deployment, help for any mental health
issues, including depression and PTSD, is available through the
Military Health System for active duty and retired Servicemembers, or
through the Department of Veterans Affairs (VA) for non-retired
veterans. Active duty, National Guard, and Reserve Servicemembers who
separate and who served in support of a contingency operation are
eligible for TRICARE's Transitional Assistance Management Program
(TAMP), which provides health benefits for 180-days to assist
Servicemembers and their families with the transition to civilian life.
Partnerships with the VA exist, such as the Recovery Coordination
Program, where Recovery Care Coordinators assist with Servicemember
transition from DoD to VA care, treatment, and rehabilitation. The DoD
inTransition program is a free, voluntary, and confidential coaching
and assistance program that provides a bridge of support for
Servicemembers while they are transitioning between health care systems
or providers.
Each Service has a comprehensive program to address the
reintegration needs of wounded, ill, and injured Servicemembers,
including the Army Wounded Warrior Program, the Marine Wounded Warrior
Regiment, Navy's Safe Harbor Program, and the Air Force Wounded Warrior
Program. Across DoD, the Military Family Life Consultants program helps
prevent family distress by providing education and information on
family dynamics, parent education, available support services, and the
effects of stress and positive coping mechanisms. Military OneSource
has counselors standing ready 24/7 by phone and email and are available
for face-to-face counseling. The DoD Yellow Ribbon Reintegration
Program was established to address the needs of National Guard and
Reserve Servicemembers and their families by facilitating access to
support and reintegration services. The Defense Centers of Excellence
for Psychological Health and Traumatic Brain Injury (DCoE) has a number
of education and outreach programs, to include DCoE's Outreach Center,
``24/7 Help,'' which provides information and resources on
psychological health and traumatic brain injury, and the
Afterdeployment.org Web site that assists Servicemembers and their
families in managing post-deployment challenges.
The Services have each developed garrison and training programs to
mitigate the effects of combat-related stress. The Army implemented the
Comprehensive Soldier Fitness Program Army-wide; the Air Force uses the
Landing Gear program; the Navy has an Operational Stress Control
program; and, the Marine Corps uses a program called Operational Stress
Control and Readiness, or ``OSCAR.'' Each of these programs seeks to
prepare Servicemembers to better cope with combat and deployment stress
before, during, and after deployment. On a more holistic level, the
Office of the Chairman of the Joint Chiefs of Staff has promoted the
Total Force Fitness model to address the need for a synchronized, DoD-
wide approach to strengthen resilience and maintain optimal military
force readiness. This model advocates that leadership at all levels of
DoD take steps to strengthen the comprehensive health of Servicemembers
across eight domains (Behavioral, Social, Physical, Environmental,
Medical, Spiritual, Nutritional, and Psychological) and to subsequently
establish holistic fitness programs within their commands and
organizations.

Question: #3
Question: What can be done to improve outreach to servicemembers
and veterans needing mental health care services, especially those
veterans most at-risk?

Answer: In order to facilitate early identification of and referral
for mental health concerns, DoD employs a robust, prospective, person-
to-person mental health surveillance program. VA and DoD are jointly
reviewing mental health screening policies and procedures with the end
goal of tracking and optimizing follow-up on positive screens for
posttraumatic stress disorder (PTSD), suicidal and homicidal ideation,
alcohol abuse and dependence, and depression. Enhanced case management
and follow-on support of Servicemembers will serve to eliminate gaps in
care between DoD and civilian medical facilities.
In addition, DoD provides many outreach and early intervention
programs to ensure continuity of care, to raise awareness among
Servicemembers, to train civilians treating Servicemembers, and to
increase leadership involvement in behavioral health efforts. Examples
of these programs include:

inTransition: A voluntary program supporting
Servicemembers moving between health care systems or providers while
receiving behavioral health care. inTransition offers information, non-
medical counseling, education, and advice services for eligible
beneficiaries, encouraging them to make use of available behavioral
health services. The program employs a ``warm hand-off'' technique in
referring and following up with Servicemembers and Veterans.
Yellow Ribbon Reintegration Program (YRRP) is a program
that assists Guard and Reserve Servicemembers and their families to
connect with local resources before, during, and after deployments,
especially during the reintegration phase. Yellow Ribbon events (the
Returning Warrior Workshops developed by the Navy Reserve) typically
take place in non-military venues. Local VA facilities have a strong
presence at these events, often enrolling Servicemembers in VA health
care and scheduling appointments when needed.
The Real Warriors Campaign (http://www.realwarriors.net/)
is a public education campaign that reinforces the notion that seeking
help is a sign of strength. It was launched by DCoE to combat stigma
related to seeking mental health treatment in the military.
Afterdeployment.org (www.afterdeployment.org) was
developed by DCoE, with an emphasis on `normalizing' post-deployment
adjustment problems, and encouraging help-seeking behavior among
servicemembers and veterans with invisible wounds.
VA launched a mental health outreach campaign called Make
the Connection (http://www.maketheconnection.net/) which was designed
to increase awareness and trust in VA's mental health services and aims
to reduce stigma about seeking mental health services.
VA's Readjustment Counseling Service (RCS) Mobile Vet
Center program is another initiative to help meet this commitment. As a
successful, long-running behavioral health support program, Mobile Vet
Centers provided outreach and readjustment counseling services at 1,800
events in FY 2010 and 3,600 events in FY 2011. The events were
national, State, or locally organized events, including demobilization
events for Active duty servicemembers. DoD and VA are working together
to expand the program to increase the mental health services available
to servicemembers and Veterans, especially those in rural areas. RCS
put an additional 20 Mobile Vet Centers (MVCs) into service.

A recently completed Report to Congress entitled ``A Study of
Treatment of Active and Reserve Components for Post-Traumatic Stress
Disorder'' noted several areas where outreach for Servicemembers can be
further strengthened, including:

Expanding existing programs that provide for early
identification and treatment, such as the Re-Engineering Healthcare In
Primary Care Program (REHIP) which enables DoD primary care providers
to screen and treat health-seeking patients in primary care clinics for
PTSD, suicidal ideation, and depression while integrating behavioral
health care providers into routine medical care.
Embed mental health providers into line units alongside
leaders to facilitate communication between line leaders and PH
resources.
Increase awareness, via targeted outreach, about the
impact of mental health diagnoses on one's career. Barriers to seeking
treatment may be reduced by educating Servicemembers that a mental
health diagnosis does not always equate to medical retirement or
separation from the military.

Finally, to advance the integration of mental health services into
primary care, DoD and VA held a joint conference titled, ``Behavioral
Health/Mental Health Services Roll Out in the Medical Home: Clinical,
Administrative and Implementation Priorities and Best Practices.'' The
conference brought together 305 clinical, administrative and research
leaders from VA and DoD facilities across the country to share lessons
learned and to encourage growth of integrated care services in the VA
and DoD.

Question: #4
Question: What are your thoughts on the Military Officers
Association of America's recommendation to: Require VA-DoD to establish
a single strategy and a joint Suicide Prevention Office that reports
directly to the Department Secretaries through the Senior Oversight
Committee (SOC)?

Answer: We agree that the DoD and VA need to work closely together
to address the suicide issue, and have already organized to meet that
goal. The DoD and the VA have been working together for some time to
address the issue of suicide prevention, as well as those associated
high risk behaviors that surround both fatal and non-fatal suicide
events. The DoD established a Defense Suicide Prevention Office (DSPO)
to serve as a focal point for collaboration with the VA and provide
oversight for the strategic development, implementation,
standardization, and evaluation of DoD suicide programs, policies,
surveillance activities. The DSPO will also have a full time VA liaison
staff member embedded with the DoD team to assist in identifying and
addressing high risk transition population issues.
For example, the DoD and VA currently share data in multiple
instances. In particular, the DoD/VA Suicide Nomenclature and Data
Working Group has developed an action plan to create a joint DoD/VA
Suicide Data Repository that will merge existing data from multiple
sources to create common identifiers and data elements, fill gaps in
knowledge, identify common risk factors, and present a longitudinal
view across the active and veteran populations. This effort has been
briefed to the Senior Oversight Committee and its associated
Subcommittees. The objective is to provide a single source for all
suicide events and self-directed violence across the Departments as
well as help inform programs and policies related to suicide prevention
in the future.

Question: #5
Question: Many of the experts have stated that early intervention
is critical in the prevention and treatment of mental health conditions
such as Post-Traumatic Stress Disorder. What programs do the
Departments have in place to flag, intervene arid monitor at risk
servicemembers who are transitioning to VA? Is there a ``warm hand-
off''?

Answer: In order to facilitate early identification of and referral
for mental health concerns, the Department of Defense (DoD) employs a
robust, prospective, person-to person mental health surveillance
program. Mandatory mental health assessments are conducted before
deployment (Pre-Deployment Health Assessment or Pre-DHA), and after
deployment (Post Deployment Health Assessment or PDHA; Post Deployment
Health Reassessment or PDHRA; and one- and two-years post-deployment as
part of the Periodic Health Assessment or PHA). The Department of
Veterans Affairs (VA) and DoD is jointly reviewing mental health
screening policies and procedures, including the PDHA/PDHRA/PHA, with
the end goal of tracking and optimizing follow-up on positive findings.
DoD provides many outreach and early intervention programs to
ensure continuity of care, to raise awareness among Servicemembers, to
train civilians treating Servicemembers, and to increase leadership
involvement in behavioral health efforts. These programs include:

inTransition: Managed by the Defense Centers of
Excellence (DCoE) for Psychological Health and Traumatic Brain Injury,
inTransition is a voluntary program supporting Servicemembers moving
between health care systems or providers while receiving behavioral
health care. The program employs a ``warm hand-off'' technique in
referring and following up with Servicemembers and Veterans. Additional
Information can be found at: (http://www.health.mil/InTransition/
default.aspx).
Yellow Ribbon Reintegration Program (YRRP): Another
significant DoD/VA outreach and prevention program is the YRRP. The
YRRP is a program that assists Guard and Reserve Servicemembers and
their families to connect with local resources before, during, and
after deployments, especially during the reintegration phase. Yellow
Ribbon events (the Returning Warrior Workshops developed by the Navy
Reserve) typically take place in non-military venues. Local VA
facilities have a strong presence at these events, often enrolling
Servicemembers in VA health care and scheduling appointments when
needed.
VA Suicide Hotline: Veterans Crisis Line (started July
2007) and Chat Service (started July 2009) are intended to reach out to
all Veterans and Servicemembers, whether they are enrolled in VA health
care or not. The Crisis Line is staffed with mental health
professionals and support staff to provide 24-hours services. After
receiving a call, the responder conducts a phone interview to assess
psychological condition. The responder then determines whether the call
is emergent, urgent, routine, or informational. Calls requiring
emergency services necessitate keeping the caller safe; urgent care
requires same day services at a local VA facility; and routine calls
require a consultation by the local Suicide Prevention Coordinator
(SPC). The online version of the Crisis Line, the Veterans Chat
Service, enables Veterans, Servicemembers, 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 Crisis Line, where further
counseling and referral services can be provided and crisis
intervention steps can be taken.

Question: #6
Question: At the September 9, 2011, House Committee on Armed
Services hearing on suicide prevention programs in the military, Dr.
Jonathan Woodson, Assistant Secretary of Defense for Health Affairs at
DoD, mentioned the DoD/VA Integrated Mental Health Strategy (IMHS) that
they have been working to put in place over the last 10 months. (a) Can
you comment further on what was recommended? Of the numerous action
items outlined in this strategy, what pieces are still outstanding?

Answer: An important activity within the DoD/VA Integrated Mental
Health Strategy (IMHS) focuses on exploring methods to disseminate
knowledge of suicide risk and prevention practices through prevention
programs, coordinated training and collaboration with entities outside
of DoD and VA.
The following activities have been completed thus far:

To assist in the dissemination of suicide prevention
practices, programs, and tools, the DoD Suicide Prevention and Risk
Reduction Committee (SPARRC) Web site
was launched in October 2010. The Web site streamlines suicide
prevention resources for easy access to a clearinghouse of information.
It serves as a comprehensive resource with access to hotlines,
treatments, programs, forums and multimedia tools designed to support
all Servicemembers, Veterans, families and health professionals.
Additionally, the Web site includes links to Service-specific suicide
prevention resources, as well as reliable and accurate information on a
range of suicide prevention related topics.
The 2011 DoD/VA Annual Suicide Prevention Conference was
held in Boston, Massachusetts on March 13-17, 2011. The theme of this
conference was ``All the Way Home: Preventing Suicide among
Servicemembers and Veterans.'' The conference provided an opportunity
to disseminate practical tools and innovative research in the area of
suicide. In addition, it educated representatives from across DoD and
VA on the current practices and studies related to suicide prevention.
Four tracks were offered to focus on practical applications and
innovations: clinical, multi-disciplinary, family/peer to peer, and
research.

The 2012 DoD/VA Annual Suicide Prevention Conference will be held
in Washington DC on June 20-22, 2012. The theme of this conference will
be ``Back to Basics: Enhancing the Well-Being for our Servicemembers,
Veterans, and their Families''. Three tracks will be offered: clinical,
research, and practical applications.
Suicide prevention related activities that are in progress include:

Dissemination of a toolkit intended to provide DoD/VA
program managers with the tools to empower family members to play a
more significant role in the DoD/VA suicide prevention effort. The
toolkit includes an inventory and evaluation of current suicide
prevention communications to families, and highlights key programs that
are effective in providing information to this target audience. It also
provides a variety of approaches for DoD, the Services, and VA to
optimize the communication to families of Servicemembers and Veterans
about the warning signs of suicidal behavior and the range of resources
families have at their disposal to obtain the help they need.
Data will be collected in February and March 2012 to
inventory and review National Guard and Reserve suicide prevention,
intervention, and post-vention programs. The data will be used to
populate a resiliency and prevention program database intended to avoid
duplication of effort, permit ease of reporting to leadership and
facilitate their expanded implementation should that be indicated.

Question: #7
Question: The Maine National Guard submitted testimony for the
record in which they outline their Resiliency, Risk Reduction and
Suicide Prevention Campaign Plan. What sort of resiliency training is
DoD incorporating in its prevention efforts?

Answer: The Chairman of the Joint Chiefs of Staff has issued
guidance that institutes ``The Total Force Fitness (TFF)'' framework as
the over-arching DoD wellness and resiliency training model. The TFF
framework is the methodology for understanding, assessing, and
maintaining the fitness of the Armed Forces. The TFF framework consists
of eight domains and five guiding tenets. The TFF domains include
Physical, Environmental, Medical and Dental Fitness, Nutritional,
Spiritual, Psychological, Behavioral and Social Fitness. The tenets
include the belief that fitness should strengthen resilience in
families, communities and organizations. The TFF framework and its
tenets are designed to keep Servicemembers resilient and flourishing in
the current environment of sustained deployment and combat operations
as serves as a basis for resiliency training across the Department.
Resiliency training currently includes the Army's Comprehensive
Soldier Fitness (CSF) Program, the Navy's Total Family Fitness and the
Combat Operational Stress Program, the Air Force's Total Airman
Comprehensive Fitness Program, and the Army National Guard Resiliency,
Risk Reduction and Suicide Prevention (R3SP) program. The Defense
Centers of Excellence for Psychological Health and Traumatic Brain
Injury (DCoE) has also played an active role in shaping the
Department's suicide prevention and resiliency training efforts, and
holds a yearly Warrior Resilience Conference targeted for the senior
NCO cadre.

Question: #8
Question: How many more mental health providers are needed to meet
demand?

Answer: The Military Health System (MHS) Chief Human Capital Office
has established a methodology to determine the gap differential in
Mental Health Provider staffing. This methodology establishes a
standardized means of comparing the differences between the manpower
positions authorized and assigned (positions filled) in occupations
which include: Psychologists, psychiatrists, social workers, mental
health nurses, mental health nurse practitioners, tech/counselors, and
other mental health providers.
Within the DoD, we review the status on a quarterly basis and this
review includes Army, Navy, Air Force, and JTF-CAPMED military,
civilian, and contractors staffing. The latest update which reflects
status as of 4Q11 (as of September 30, 2011) is shown. Our gap is
determined by comparing the authorized numbers with the assigned
numbers. The Services then develop an action plan to close the gap.

Percent
MHS-WIDE Needs Assigned filled

Psychologist 1726.5 2063 119.5%
Psychiatrist 823.5 771 93.6%
Social Worker 2547 2349 92.2%
Mental Health Nurse 600 618 103.0%
Mental Health Nurse 92 59 64.1%
Practitioner
Other Licensed MH Provider 59 64.5 109.3%
Tech/Counselor 3372 2959 87.8%
Total 9220 8884 96.3%

Within the MHS, a 3 year review of mental health provider staffing
reveals a 34.8 percent increase from FY 2009 through FY 2011. We
anticipate a growing need for additional mental health provider
staffing due to emerging requirements.

2009 2010 2011

Psychologist 1,520 1,815 2,063
Psychiatrist 652 758 771
Social Worker 1,789 2,082 2,349
Nursing (including NP) 570 580 677
Other Licensed MH Provider 97 66 65
Tech Counselor 1,962 2,199 2,959
GRAND TOTAL 6,590 7,500 8,884

From FY 2009 through FY 2011 +34.8 percent increase.

Whether more authorized mental health billets are needed to meet
demand can only be answered by each military Service. As they make
those decisions, the Services have access to the Psychological Health
Risk-Adjusted Model for Staffing (PHRAMS), an application developed to
forecast psychological health staffing requirements/needs in the
Military Health System.
The PHRAMS application and user guide were first released to the
Services in January 2010 for use in planning for future psychological
health staffing needs. Updates to PHRAMS have been ongoing, with
version 4 estimated for release to the Services in August 2012.
July 2010, GAO Report 10-696 ``Enhanced Collaboration and Process
Improvements Needed for Determining Military Treatment Facility Medical
Personnel Requirements'' cited PHRAMS as representing ``the culmination
of a collaborative manpower requirements effort to develop a
standardized, more consistent approach across the Services for
determining mental health personnel requirements.'' The report also
stated ``Key organizational issues, like strategic workforce planning,
are most likely to succeed if, at their outset, top program and human
capital leaders set the direction, pace, and tone and provide a clear,
consistent rationale for the transformation.

Question: #9
Question: What do you need from us to assist you in addressing the
mental health issues of today?

Answer: Recent advances in the study of suicide and its treatment
in Veterans and Active Duty Servicemembers, which stem from the
assiduous support of Congress and the American people, may herald a
turning point in the management of this longstanding public health
problem. The assistance of the House Veterans Affairs Committee has
been instrumental in this effort. Ongoing attention to this matter will
be essential to maintaining the momentum our labors have fostered to
date.
We are learning that military members represent a unique cohort
with respect to suicide. Military suicide rates have been far more
variable than age-adjusted civilian rates. On balance, military rates
have been consistently lower than civilian rates since collection of
these data was initiated. This regular finding was attributed to a
``warrior effect,'' that embraces discipline, fidelity to peers,
resilience, rigorous accession standards, and pursuit of an honorable
mission. However, the excursions of Army suicides to rates above the
civilian rate, and military suicides exceeding combat deaths, raise
important questions for military and civilian leaders.
Editorials by well-regarded researchers in top psychiatric
publications, including the Journal of the American Psychiatric
Association and the Journal of the American Academy of Child and
Adolescent Psychiatry, express a view that suicide may be the next
public health menace needing to be systematically categorized and
managed. Leaders in many fields have come to realize that suicide is a
multifactorial problem that cuts across disciplines. Optimization of
personnel policy, attunement to unit cohesion, resilience and personal
accountability for behavior, intrepid leadership, and focused evidence-
based medical interventions, based on real-time data, will all be part
of a solution.
The fruits of our initial data collection will enlighten our
intervention programs to prevent suicide. DoD/VA efforts, which have
been fostered by the abiding support of your committee, are leading the
way on research fronts. The DoD's Military Suicide Prevention Research
Program ($110 million investment since 2008), Army Study to Assess Risk
and Resilience ($50 million from Army and $15 million from NIMH) have
already added to an exponentially growing body of knowledge in
suicidology.
Ongoing DoD/VA efforts in suicide research and treatment, which
will include validated suicide screening and assessment tools and
treatments that can be shown to save lives, will be vital to
consolidating our nascent gains. Answers will not be simple, nor will
they be related to a stunning innovation. However, DoD will continue to
seek a measured and multidisciplinary solution, which should be defined
as a sustained decrease in current rates to a level well below the
civilian norms.