[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
STOPPING SUICIDES:
MENTAL HEALTH CHALLENGES WITHIN
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
DECEMBER 12, 2007
__________
Serial No. 110-61
__________
Printed for the use of the Committee on Veterans' Affairs
----------
U.S. GOVERNMENT PRINTING OFFICE
39-647 PDF WASHINGTON : 2008
For sale by the Superintendent of Documents, U.S. Government Printing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
Washington, DC 20402-0001
COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
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 12, 2007
Page
Stopping Suicides: Mental Health Challenges Within the U.S.
Department of Veterans Affairs................................. 1
OPENING STATEMENTS
Chairman Bob Filner.............................................. 1
Prepared statement of Chairman Filner........................ 66
Hon. Steve Buyer, Ranking Republican Member...................... 3
Hon. Stephanie Herseth Sandlin, prepared statement of............ 66
Hon. Harry E. Mitchell, prepared statement of.................... 67
Hon. Cliff Stearns, prepared statement of........................ 67
Hon. Leonard L. Boswell.......................................... 5
Hon. Donald A. Manzullo.......................................... 6
WITNESSES
U.S. Department of Veterans Affairs, Ira Katz, M.D., Ph.D.,
Deputy Chief Patient Care Services Officer for Mental Health,
Veterans Health Administration................................. 48
Prepared statement of Dr. Katz............................... 84
______
Bowman, Mike and Kim, Forreston, IL.............................. 6
Prepared statement of Mike and Kim Bowman.................... 68
Coleman, Penny, Rosendale, NY, Author, Flashback: Posttraumatic
Stress Disorder, Suicide, and the Lessons of War............... 33
Prepared statement of Ms. Coleman............................ 69
Meagher, Ilona, Caledonia, IL, Author, Moving a Nation to Care:
Post-Traumatic Stress Disorder and America's Returning Troops.. 35
Prepared statement of Ms. Meagher............................ 76
Zivin, Kara, Ph.D., Research Health Scientist, Health Services
Research and Development, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 54
Prepared statement of Dr. Zivin.............................. 86
SUBMISSIONS FOR THE RECORD
U.S. Department of Veterans Affairs, Michael Shepherd, M.D.,
Physician, Office of Healthcare Inspections, Office of
Inspector General, statement................................... 87
______
American Legion, Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission, statement............... 91
Disabled American Veterans, Joy J. Ilem, Assistant National
Legislative Director, statement................................ 93
Iraq and Afghanistan Veterans of America, Todd Bowers, Director
of Government Relations, statement............................. 98
National Coalition for Homeless Veterans, statement.............. 99
Vietnam Veterans of America, Richard F. Weidman, Executive
Director for Policy and Government Affairs, statement.......... 103
MATERIAL SUBMITTED FOR THE RECORD
Additional Hearing Material:
Hon. Michael J. Kussman, M.D., M.S., MACP, Under Secretary
for Health, U.S. Department of Veterans Affairs, sample of
letter sent to veterans, informing veterans of the National
Suicide Prevention toll-free hotline number, 1-800-273-TALK
(8255), and pocket-sized card with VA Suicide Crisis
Hotline phone number/information, as well as a Crisis
Response Plan.............................................. 107
U.S. Department of Veterans Affairs Pamphlet, entitled
``Suicide Prevention, Men and Women Veterans, Knowing the
Warning Signs of Suicide,'' dated September 2007........... 108
Post-Hearing Questions and Responses for the Record:
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to
Hon. Gordon H. Mansfield, Acting Secretary, U.S. Department
of Veterans Affairs, letter dated December 14, 2007, and VA
responses.................................................. 110
Hon. Harry E. Mitchell, Member of Congress, U.S. House of
Representatives, to Hon. James B. Peake, M.D., Secretary,
U.S. Department of Veterans Affairs, letter dated February
8, 2008, and response letter dated February 27, 2008,
following up to request additional information not supplied
in earlier VA responses to questions for the record........ 115
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to
John D. Daigh, Jr., M.D., CPA, Assistant Inspector General,
Office of Healthcare Inspections, U.S. Department of
Veterans Affairs, letter dated December 14, 2007, and
response letter dated January 24, 2008..................... 117
Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking
Republican Member, Committee on Veterans' Affairs, to Hon.
James B. Peake, M.D., Secretary, U.S. Department of
Veterans Affairs, letter dated December 21, 2007, and
response letter dated February 5, 2008, requesting
additional data on suicide rates among veterans............ 121
Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking
Republican Member, Committee on Veterans' Affairs, to Rick
Kaplan, Executive Producer, CBS Evening News With Katie
Couric, letter dated December 21, 2007, and response letter
dated May 16, 2008, from Linda Mason, Senior Vice
President, Standards and Special Projects, CBS News........ 128
STOPPING SUICIDES:
MENTAL HEALTH CHALLENGES WITHIN
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
----------
WEDNESDAY, DECEMBER 12, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:10 a.m., in
Room 345, Cannon House Office Building, Hon. Bob Filner
[Chairman of the Committee] presiding.
Present: Representatives Filner, Snyder, Michaud, Herseth
Sand- lin, Mitchell, Hall,
Hare, Berkley, Rodriguez, McNerney, Space, Walz, Buyer,
Stearns, Boozman, Brown-Waite, Bilirakis, and Buchanan.
Also Present: Representatives Boswell, Manzullo, and
Kennedy.
OPENING STATEMENT OF CHAIRMAN FILNER
The Chairman. This meeting of the House Committee on
Veterans' Affairs is called to order.
I appreciate your attendance, and I appreciate your
interest in this very important issue of mental illness,
particularly of the suicides that have occurred in our
veterans' population, especially those involved in combat
situations.
So this is going to be a very tough hearing, an emotional
hearing. It is an issue the military, the U.S. Department of
Veterans Affairs (VA) and the American public does not like to
talk about. Yet, we owe it to our fighting men and women. We
owe it to their families. We owe it to our future mental health
as a Nation to explore this issue in as much depth as possible.
This year, as we try to deal with the influx of veterans
who are coming from Iraq and Afghanistan, plus the needs of our
older veterans, which continue, it has been a great challenge
for this Committee and for this Congress and for this Nation.
Earlier in the year, and in a series of articles since, The
Washington Post reporters dealt with the terrible scandal at
Walter Reed which had the effect, as other local newspapers
around the country did stories on their military and veterans'
hospitals, of a wake-up call for all of America. Their
veterans, their troops coming back from the current war were
not getting the treatment, the care, the respect, the honor and
the dignity that Americans thought they deserved.
Because of that awareness that really spread throughout
America, this Congress was able to add almost $13 billion of
new money for healthcare for veterans, an unprecedented
increase of 30 percent or more, based on the public perception
that we had to do more.
The injuries that come from this war are very great, both
physically and mentally, and yet, America has not really come
to grips with it.
One of the television networks, ABC, whose reporter Bob
Woodruff had suffered a blast injury and traumatic brain injury
(TBI) in Iraq, opened up that subject to millions of Americans.
And we know more now about TBI and how to treat it.
Recently, the CBS network opened up again to millions of
Americans the issue of suicides amongst our veterans. They had
a great deal of difficulty getting information from the
authorities or from the U.S. Department of Defense (DoD) or
from the Department of Veterans Affairs. That is one of the
issues we are going to explore today, the issue of information
and the tracking of these issues. But they had to spend 5 or 6
months tracking down statistics in different States because
nobody seemed to be interested in Washington, of understanding
the statistics.
Their report of several weeks ago again opened the eyes of
millions of Americans to statistics, which went way beyond what
people had thought or imagined as to the number of suicides,
not only amongst our returning vets but amongst veterans from
previous wars. I think it is now recognized that as many
Vietnam veterans have now committed suicide as had died in the
original war. That is a terrible, terrible statistic and says
we have to do more.
So what we are going to do today is try to open up this
subject which is very difficult for the families involved and
for our government. We want to talk about the statistics. Why
doesn't the VA do more about trying to understand the nature of
the issue? We leave it to citizens like Ilona Meagher, who will
be testifying later, to keep a Website for tracking suicides,
of which she is one person with limited resources. This is what
our government should be doing.
We want to talk about the stigma of mental illness and how
we try to deal with this as a Nation. We want to talk about the
apparent inability of the military to look at mental illness
and people's honest attempts to deal with it as something to be
recognized, promoted, encouraged. It is denied. Anybody who
admits mental illness is threatened with no promotions or no
jobs in law enforcement when they leave the military.
It is an issue for all of us in America but particularly
for those in the military, and we have to face it honestly and
come to grips with it. That is what we hope to do today.
We have a brave mother and father who have decided that
their son's suicide must be talked about and understood to help
others, and other families, prevent that. We have citizens,
authors who have dealt very directly with this issue and, of
course, the professionals within the VA system and those in the
veterans service organizations (VSOs) who try to help their
members deal with these issues.
So we will have a very tough hearing, as I said earlier,
but it is an important hearing. America must look at these
issues. We have to decide that we have to deal with them in a
far more open and dedicated manner, and that is our objective
today.
I would yield for an opening statement of the Ranking
Member, Mr. Buyer.
[The prepared statement of Chairman Filner appears on p.
66.]
OPENING STATEMENT OF HON. STEVE BUYER
Mr. Buyer. Thank you, Mr. Chairman.
Some in this room today, including several of our
witnesses, have been personally devastated by the loss of a
loved one who has chosen to take their own life. Before I
begin, I want to personally thank you for testifying about your
extremely personal and painful experiences. While I know
nothing can compensate you for the loss of your loved ones, we
can hopefully find ways to help deter another soldier from
succumbing to such tragedy.
I hope that, as we delve into these sensitive matters, we
do not lose sight of the fact that every case that we will
discuss here today represents a human life, a veteran, a
family, and a tragedy. Discussing the tragic circumstances
surrounding a suicide of one who has worn the uniform should be
done with great respect and in recognizing also their service
to our country. We must search for answers and solutions to
veteran suicide.
As most of our witnesses will attest this morning, tracking
suicide rates nationwide is very difficult, and it is clear to
me that the data we currently have does not give us a
definitive understanding nor a scope of the problem. There
seems to be significant variations among the data provided by
CBS News, the VSOs, the DoD and the VA. These veterans' lives
were important, and it would be a dishonor to them and to their
service if information is not accurately portrayed. Accurate
information is crucial to identifying risk factors, to
providing better prevention and treatment protocols.
Therefore, it is imperative that the VA have a better
method to systematically collect and to track suicides so we
can get a true understanding and scope of our challenge. It is
my understanding that the VA is beginning to work with the DoD
to do this, and I applaud them. But, again, I cannot overstate
the urgent need to do it quickly. When decision makers do not
have accurate data, we must rely on anecdotal evidence. While
this can raise awareness, it does not help us make informed
decisions on how best to develop strategies to diminish the
risk and to prevent the events of suicide.
Notwithstanding the tragic stories that surround this
hearing, I believe we can point to the steps that the VA and
the DoD have taken to help veterans and servicemembers deal
with mental health challenges.
The VA has already formulated a comprehensive strategy for
suicide prevention, focusing on the needs of both new veterans
from Operation Iraqi Freedom (OIF) and Operation Enduring
Freedom (OEF) and on those of prior conflicts. The specific
program for suicide prevention is based on public health and
clinical models and activities both within the VA facilities
and the civilian medical community.
The cornerstone of this program is the VA's new 24-hour
veteran suicide prevention hotline, which opened its lines in
July of 2007. Since its inception, the VA reports that they
have made more than 1,300 referrals to suicide prevention
coordinators and have rescued 317 veteran callers. Veterans
experiencing thoughts of suicide can call 1-800-273-TALK for
help.
We have seen clearly that early intervention and treatment
has a significant and demonstrated impact and is crucial to
preventing suicide. It is important to recognize the warning
signs and to ensure that servicemembers receive the treatment
they need right away.
This starts with DoD. I am very encouraged that a new
training program called BattleMind, developed at the Walter
Reed Army Institute of Research, is being developed and is
working to help soldiers transition from the combat zone to the
home front.
Mr. Chairman, I would sum this up with this. VA and DoD
have made strides in the treatment of mental health disorders
that can lead to suicide. However, until families like the
Bowmans no longer bear such pain, not enough is being done. I
welcome their testimony here today, and I hope this hearing can
help us gain a better understanding of how to offer more
effective and timely assistance for those troubled
servicemembers to prevent them from turning to such a tragic
option.
On a personal note, as I see the parents sitting in front
of me, your quest for answers will never end, and probably on
your last breath there will still be the thoughts of your son.
At the age of 16, my best friend committed suicide. His
baseball cap sits in my office. I think people walk in, and
they think it is my baseball cap, but it is that of a very dear
friend. I constantly search for answers because none of us
knew, even as close as we were to him. And, of course, the
parents would drill us all the time about the signs. What were
they? And there were no signs. There were no risk factors. It
was just one of these bizarre strikes of the mind that just--I
do not have an answer. I just want you to know I carry the pain
of suicide, and I am in constant search of answers. And I am
haunted, haunted by suicide. Even among my colleagues--if you
want to talk about something that is not discussed, in the 15
years I have been in Congress, it is the number of suicides of
sons and daughters of Members of the Senate or of the House,
and it is not discussed--or the attempts. It is that dark side.
So you know what? It is not just us, and it is not just
those in the military. You can touch any sector of our society.
So, as we delve into this issue, we have to also be very
sensitive, because I recognize there are anti-war advocates who
also want to say that these individuals who then commit suicide
and who have worn the uniform are somehow victims, and that is
not right either, as we are trying to find out actually how can
we prevent and how can we be helpful to someone who thinks that
suicide is some form of option that can help them.
So, on a personal note, I thank you for your bravery to
come here and to talk about your son, and I know you are doing
this because you absolutely believe that your testimony here
today can help someone else.
Thank you. I yield back.
The Chairman. Thank you, Mr. Buyer.
Our first panel will be Mr. and Mrs. Mike Bowman, whose
son, Tim, an Army specialist in the Illinois National Guard
from Bravo Troop, 106th Cavalry, committed suicide.
Before that, if you will allow me, Mr. and Mrs. Bowman, to
ask our colleague Mr. Boswell if he would just step forward for
2 minutes. He is the author of Public Law 110-110, the Joshua
Omvig Veterans Suicide Prevention Act, named after a young man
in his own district, whose parents have now become friends with
the Bowmans.
The Bowmans are being introduced by our other colleague
from Illinois, Mr. Manzullo.
Mr. Boswell, please.
OPENING STATEMENT OF HON. LEONARD L. BOSWELL
Mr. Boswell. Thank you, Mr. Chairman, Ranking Member Buyer
and Members of the Committee. I appreciate your holding this
hearing and your leadership on this issue.
To Mike and Kim, we extend our hand in friendship, our
concern and sympathy for the loss of your son, Tim, and we
pledge to do our best to stop this.
As we all know, suicide is sweeping through our veteran
population, and the Committee has shown leadership in
addressing the issues our veterans face today. I want to thank
you again for allowing me to speak on this important issue.
Suicide is an epidemic which is encompassing much of our
veteran population. For too long, suicide among veterans has
been ignored, and now is the time to act. We can no longer be
afraid to look at the facts, and the sad fact is we are missing
adequate information on the number of veterans who commit
suicide each year.
I was shocked, and I am sure all were, when we saw the CBS
Evening News report focusing on veteran suicides. They found
that in 2005, over 6,200 veterans committed suicide--120 per
week. The report also found that veterans were twice as likely
to commit suicide as nonveterans. These statistics are
devastating.
As a result of this report, I immediately introduced H.R.
4204, the ``Veterans Suicide Study Act,'' which several Members
of the Committee have co-sponsored. If time had permitted,
there would be many, many more, because no one--no one--who I
approached chose not to sign on.
This legislation will direct the VA to conduct a study to
get the real facts on the rate of suicide among veterans. It is
just one step that we must do to ensure that we have adequate
information so we can treat our veterans as they return from
combat.
I would also like to personally thank the Chairman and the
Ranking Member of the full Committee for their action in
support of the Joshua Omvig Veterans Suicide Prevention Act
earlier this year. Now that this crucial piece of legislation
has been signed into law, I am confident our veterans will
begin to receive more of the vital care they need.
While the Joshua Omvig bill puts in place a comprehensive
approach in treating high-risk veterans, we still need to know
the facts. So I implore the Committee, and the Congress, to act
swiftly on H.R. 4204 so we can ensure we have the data we need
to treat our Nation's heroes. Our veterans have dedicated their
lives to keep our great Nation safe, and it is now our duty and
our time to protect them.
So I want to thank you again for allowing me to share this
time with you, Mr. Chairman, and I am sorry I have to go to a
markup. Thank you very much.
The Chairman. Thank you, Mr. Boswell, for your leadership
on this issue.
Mr. Manzullo, if you want to introduce your constituents.
Thank you for being here with us.
OPENING STATEMENT OF HON. DONALD A. MANZULLO
Mr. Manzullo. Thank you, Mr. Chairman. I have the honor
today of introducing, three constituents who are testifying
before the Committee today.
In inverse order, on the second panel is Ilona Meagher.
Ilona's father was a Hungarian freedom fighter and also became
a member of the United States Armed Forces, so he is a veteran
of both the Hungarian and the American Armed Forces. Ilona is a
tremendous campaigner, a seeker of truth, and she wrote this
book, ``Moving a Nation to Care,'' about the very subject of
which we are discussing this morning.
The other two constituents really exemplify the people
about whom Ilona Meagher is concerned, and they are the Bowmans
from Forreston, Illinois. Kim and Mike live about 10 miles from
my farm in the same county in northern Illinois. Their
testimony is nothing less than startling and compelling. They
would rather be anywhere in the world than here today to talk
about what happened in their lives and to their precious son.
I encourage the Members of this Committee to continue their
leadership, to draft legislation or whatever is necessary, in
order to make sure that the Bowman's testimony is not in vain
and that their son's life is not in vain and that the lives of
other young men and women who have taken their lives, will be
used in order to prevent those situations from occurring in the
future.
The Chairman. Thank you, Mr. Manzullo.
Mr. and Mrs. Bowman, you are recognized for your testimony.
I had a chance to talk to you yesterday and to understand a
little bit more about Tim, about the incredible job he was
doing overseas, about the soldier that he was, about the close
relationship you had with him, about your patriotism and his.
So, again, I cannot say I am looking forward to your testimony,
but I just thank you for having the courage to be here and for
making sure that Tim's life and death will be used to help
other people.
Please, Mr. Bowman.
STATEMENTS OF MIKE AND KIM BOWMAN, FORRESTON, IL (PARENTS OF
SPECIALIST TIM BOWMAN, U.S. ARMY, ILLINOIS NATIONAL GUARD,
BRAVO TROOP, 106TH CAVALRY)
Mr. Bowman. Mr. Chairman and Members of the Committee, my
wife and I are honored to be speaking before you today, repre-
senting just one of the families who lost a veteran to suicide i
n 2005.
As my family was preparing for our 2005 Thanksgiving meal,
our son Timothy was lying on the floor of my shop office,
slowly bleeding to death from a self-inflicted gunshot wound.
His war was now over; his demons were gone. Tim was laid to
rest in a combination military-firefighter funeral that was a
tribute to the man that he was.
Tim was a life-of-the-party, happy-go-lucky, young man who
joined the National Guard in 2003 to earn money for college and
to get a little structure in his life. On March 19th of 2005,
when Specialist Timothy Noble Bowman got off the bus with the
other National Guard soldiers of Foxtrot 202 who were returning
from Iraq, he was a different man. He had a glaze in his eyes
and a 1,000-yard stare, always looking for an insurgent.
Family members of F202 were given a 10-minute briefing on
post traumatic stress disorder (PTSD) before the soldiers
returned, and the soldiers were given even less. The commander
of F202 had asked the Illinois Guard Command to change their
demobilization practices to be more like the regular Army, only
to have his questions rebuffed. He knew that our boys had been
shot up, had been blown up by improvised explosive devices, had
extinguished fires on soldiers so their parents would have
something to bury, and had extinguished fires on their own to
save their lives. They were hardened combat veterans now, but
were being treated like they had been at an extended training
mission.
You see, our National Guardsmen from the F202 were not
filling sandbags. They departed in October of 2003 for 6 months
of training at Fort Hood and Fort Polk. On Tim's 22nd birthday,
March 4th of 2004, Foxtrot left for Iraq, where they were
stationed at Camp Victory. Their tour took them directly into
combat, including 4 months on the most dangerous road in the
world, the highway from the airport to the Green Zone in
Baghdad, where Tim was a top gunner in a Humvee. Tim, as well
as many other soldiers at F202, earned their Purple Hearts on
that stretch of road known as ``Route Irish.'' We are still
waiting for Tim's Purple Heart from various military paperwork
shuffles.
My wife and I are not here today as anti-war protesters,
and let me make that very clear. Our son truly believed that
what his unit did in Iraq helped that country and helped many
people that they dealt with on a daily basis. Because of his
beliefs, I have to believe in the cause that he fought and died
for. That does not mean I do not feel that we lost track of our
overall mission in Iraq.
When CBS News broke the story about veterans suicides, the
VA took the approach of criticizing the way the numbers were
created instead of embracing it and using it to help increase
mental healthcare within their system. Regardless of how
perfectly accurate the numbers are, they obviously show a trend
that desperately needs attention.
CBS News did what no Government agency would do. They
tabulated the veterans suicide numbers to shed light on this
hidden epidemic and to make the American people aware of this
situation. The VA should have taken those numbers to Capitol
Hill, asking for more people, funding and anything else they
need to combat this epidemic. They should embrace this study,
as it reveals the scope of a huge problem, rather than complain
about its accuracy.
If all that is going to be done with the study is to argue
about how the numbers were compiled, then an average of 120
veterans will die every week by their own hand until the VA
recognizes this fact and does something about it. The VA mental
health system is broken in function and understaffed in
operation. There are many cases of soldiers coming to the VA
for help and being turned away or misdiagnosed for PTSD and
then losing their battle with their demons.
Those soldiers, as well as our son Timothy, can never be
brought back. No one can change that fact. But you can change
the system
so that this trend can be slowed down dramatically or even stopp
ed.
Our son was just one of thousands of veterans that this
country has lost to suicide. I see every day the pain and grief
that our family and extended family go through in trying to
deal with his loss. Every one of those at-risk veterans also
has a family that will suffer if that soldier finds the only
way to take battlefield pain away is by taking his or her own
life.
Their ravished and broken spirits are then passed on to
their families as they try to justify what has happened. I now
suffer from the same mental illness that claimed my son's
life--PTSD from the images and sounds of finding him and
hearing his life fade away, and depression from a loss that I
would not wish on anyone.
If the veterans suicide rate is not classified as an
epidemic that needs immediate and drastic attention, then the
American fighting soldier needs someone in Washington who
thinks it is. I challenge you to do for the American soldier
what that soldier did for each of you and for his country: take
care of them and help preserve their American dream as they did
yours. To quote President Calvin Coolidge, ``The Nation which
forgets its defenders will itself be forgotten.''
Today, you are going to hear a lot of statistical
information about suicides, veterans and the VA, but keep one
thing in mind. Our son, Specialist Timothy Noble Bowman, was
not counted in any VA statistic of any kind. Let me repeat
that. Our son is not included in any VA count. Now, why, you
ask? He had not made it into the VA system because of the
stigma of reporting mental problems. He was National Guard, and
he was not on a drill weekend when he took his life. Therefore,
he was not counted as active duty. The only statistical study
that he was counted in was the CBS News study. And there are
many more just like him. We call them KBAs, killed because of
action, the unknown fallen.
I challenge you to make the VA an organization to be proud
of instead of the last place that a veteran wants to go for
help. It is the obligation of each and every one of you and all
Americans to channel the energies, the resources and the
intelligence and wisdom of this Nation's best and brightest to
create the most effective, efficient and meaningful healthcare
system for our men and women who have served.
We must all remove the stigma that goes with the soldier's
admitting that he or she has a mental issue. Let those soldiers
know that admitting they have a problem with doing the most
unnatural thing that a human being can do is all right. Mental
health issues from combat are a natural part of the process of
war and have been around for thousands of years, but we
categorize that as a problem.
Take that soldier who admits a head and mental health
injury from combat and embrace him as a model for others to
look up to. Let the rank-and-file know by example that it is
okay to work through your issues instead of burying them until
it is too late. Grab that soldier and thank him for saying, ``I
am not okay,'' and promote him. A soldier who admits a mental
injury should be the first guy you want to have in your unit,
because he may be the only one who really has a grasp on
reality. But instead, he is punished and shunned, and by that
example, he has become the model for PTSD and suicide.
While we are at it, why do we call it a disorder? That
title, in itself, implies ramifications that last forever. It
is an injury, a combat injury, just like getting shot. And with
proper care and treatment, soldiers can heal from this injury
and can be as productive and as healthy as before.
We, as a country, have the technology to create the most
highly advanced military system in the world, but when these
veterans come home, they find an understaffed, underfunded,
underequipped VA mental health system that has so many
challenges to get through it that many just give up trying. The
result is the current suicide epidemic among our Nation's
defenders, one of which was our son, Specialist Timothy Noble
Bowman, a 23-year-old soldier and our hero. Our veterans should
and must not be left behind in the ravished, horrific
battlefields of their broken spirits and minds. Our veterans
deserve better.
Thank you, Mr. Chairman.
[Applause.]
[The prepared statement of Mr. and Mrs. Bowman appears on
p. 68.]
The Chairman. Mrs. Bowman, do you have anything to add?
Thank you for being here with Mike. And, again, thank you for
your courage in being here.
Mr. Michaud, you are recognized.
Mr. Michaud. Thank you very much, Mr. Chairman and Mr.
Ranking Member, for having this very important and timely
hearing today.
And it is going to be a tough day going through all of the
testimonies, but I appreciate your remarks, Mr. Bowman.
Thank you, Mrs. Bowman, for coming.
Our soldiers, as you know, put their lives in harm's way to
protect our country. Not all wounds are physical. The memories
of the war do not disappear when they take off the uniform. A
lot of us have seen the casualties of war. Maine recently lost
one of its sons to suicide. Kyle Curtis, who served in Iraq,
took his own life, like your son.
My question is: When your son came back, did he try to get
some assistance from the VA? Did either one of you notice any
changes in the way your son was acting? Did you try to see or
to encourage him to get help?
Mr. Bowman. Timothy was a very smart kid, for one thing,
and that gave him the ability to--as soon as he would start to
open up in a situation where he thought his anger or his
drinking problem or any sign that he was having trouble was
going to be visible by us, he would immediately change the
subject, or if we were sitting around our patio, he would go
home. He would find a way to leave that situation that was
putting him in that position, so that he could close that door
in the back of his mind again and go on to something else.
He had shown us small signs but not enough to trigger
anything, because we did not know what we were looking for. And
we, as National Guard families, are never educated on what to
look for, because it is volunteer. You know, you show up at a
readiness group meeting, and there is somebody there who gives
us a 10-minute briefing. That was 2 months before the guys got
home. Then you go through the process of the homecoming, and
you realize that they are going to be changed when they come
out of combat. That is fact. So then they hit your back door,
and sure, there are some issues that you see, yet they think it
is normal, and they portray it as being normal, and they tell
you that it is normal. ``This is just the way I am now.''
Now, he showed us one little sign. He showed certain
friends other little signs. If we had all gotten together, we
would have seen a larger picture, and we would have known he
was in more trouble. But he was so good at hiding that that
nobody knew for sure.
And he was a model employee. He worked for me in the family
business. We have an electrical contracting business. He would
have been the third generation in 40 years. He was an absolute
model employee. He went to work every morning regardless of
what happened the night before or anything else. So, you know,
you would discount any problem he was having at night because
he did such a good job during the day.
So trying to read the picture was very, very tough for him,
especially with our not being educated on what the signs should
be.
Mr. Michaud. Not knowing where you live in relationship to
the VA hospital, other than providing resources to the VA so
they can hire staff to take care of the need that is out there,
as well as to provide additional resources so if you live in a
rural area, they could contract with providers in a rural area,
do you think it would be helpful if the VA established a
program for those individuals who might not want to go to the
VA facility to have counseling online, on a computer?
With technology today, a lot of individuals, particularly
our younger individuals, are on the computer all of the time.
Do you think it would be helpful if the VA established a
program where someone could actually access help from home,
whether it is to a clinic or to the VA hospital?
Mr. Bowman. I would say, yes, definitely. As in the case
with Tim and with a lot of his unit buddies, they are very
well-computer-connected. They stay connected with us now via e-
mail and by all kinds of ways through the computer.
I would think that would be an easy way, especially as long
as they can enter it anonymously, because you have the stigma
of, if you walk into a VA clinic, somehow that information is
going to get back to your commanding officer. And until that
stigma is removed, that you have just admitted to having a
mental health issue, they have to be able to find help in some
way so it is not going to come back to haunt them in their
careers.
A lot of these guys who come home from Iraq, a lot of the
guys in Tim's unit are 10-years-plus in the National Guard.
They want to get to their 20 years. They do not want to get
out. So they do not want to have a problem with their careers
down the road, which means they also do not want to have a
problem with promotions. And it is a known fact that if you
voluntarily admit that you have a mental health issue that your
chance of progression in the military ranks at that point is
pretty well shot.
So, with the computer, it is if you can make it anonymous
and can make it helpful. By ``helpful,'' I mean it is peer-to-
peer counseling.
We had a discussion this morning about this very issue. The
Vet Centers were a wonderful idea, but then all of a sudden,
the VA comes along and they decide they have to have a guy with
a title and a suit as a counselor at the Vet Center. Now, what
did that do? That took that soldier who was walking in with
that issue and made him on the defensive right off the bat. He
was not talking to his peer anymore. He was talking to somebody
who was sitting at another level above him.
If you take a Vet Center and you make it a room with a
couch and a pop machine and you put guys in there who are not
in uniform and who are not in a suit or anything else and they
just sit and talk, you will have veterans opening up. But if
you take a guy with PTSD and you shove him in a room with a
doctor in a suit, he is going to shut that door.
Mr. Michaud. Thank you very much. It has been very helpful.
Once again, I am sorry for the loss of your son, but I
really appreciate both of you and your willingness to come
forward to talk about your tragedy in order to help others who
have not taken their lives. Hopefully, we will be able to move
forward in a positive, productive manner.
So, once again, thank you very much for coming here today.
Mrs. Bowman. Thank you.
Mr. Michaud. Thank you, Mr. Chairman.
The Chairman. Ms. Brown-Waite, you are recognized.
Ms. Brown-Waite. Thank you very much, Mr. Chairman.
Mr. and Mrs. Bowman, all of us here who are parents can
only imagine what it is like to lose a child. It is the
toughest thing that a parent ever does.
One of the questions that I was just asking counsel was--I
do not believe, in many of the Community-Based Outpatient
Clinics (CBOCs) where they offer mental healthcare, that that
information gets back to the commanding officer. And I think we
need to look at that. I know the CBOCs in my district consider
anyone who seeks mental health or any kind of care as a VA
case, and it is not reported to the National Guard commanding
officer or to the Reserves or even if the person is ready
reserve call-up.
Tell me why you believe that--tell me why veterans who have
served believe that the information gets back to the commanding
officer.
Mr. Bowman. The 118 soldiers who were in F202 have
basically all--they have all adopted us. We are their adoptive
parents now, and they are all our adopted sons. I talk with
these boys all the time, and they open up to me because they
know that I will understand about their mental status. They ask
me questions about Tim.
I have a list as long as my arm of soldiers in that unit
who are all seeking counseling of some form or another
privately, all away from the military, away from the VA, some
as far as 100 miles away from home, to make sure that that
information does not get back to their unit.
Now, you say that that information should be kept
anonymously by the VA and should never make it back. If that is
true, then you are not--I am sorry, not ``you''--then they are
not educating the rank-and-file soldiers to let them know that
it is safe to go to the VA. You have to change that stigma.
And I know for a fact that I can call four or five guys
right now who will tell you the same thing. They are all
active-duty National Guard. They will not go to a VA center for
this because they are going back. My son's unit is going to
Afghanistan in the spring, and they do not want to risk a
redeployment opportunity by having a mental health issue all of
a sudden show up on their records.
Ms. Brown-Waite. Please do not misunderstand me. I am not
questioning it. I am just saying what I believe is the policy.
I will certainly check on that, as to if someone goes to a VA
hospital or to a CBOC, that that information is kept private.
Certainly, under Health Insurance Portability and
Accountability Act (HIPAA), for example, which covers the
privacy of medical records, that would be absolutely prohibited
unless the patient releases any information.
So what I am saying is, believe me, I do not think there is
a person on this panel on either side of the aisle who would
ever stand for, if that is the policy, its continuing. If it is
not the policy, I agree with you, it needs to be out there loud
and clear, absolutely loud and clear, to our military.
The last casualty in my district happened to have been
someone who was active-duty who committed suicide. I do not
believe that the people who are active-duty even are properly
informed. In this case, the young man was crying, and one of
his buddies came up to him and said, ``Can I help you? Do you
need to talk to someone?'' He said, ``Yes.'' So the buddy left
to go get the chaplain, and in the meantime, this young soldier
committed suicide. What should have happened was, if it were
just the two of them, he should have stayed there with him and
should have gotten, called, you know, just perhaps gone outside
the door and called for help. So there are certainly ways that
we could do a better job at suicide prevention.
Again, thank you very much for coming and for sharing your
story. And I will follow up on that issue.
Mrs. Bowman. Thank you.
Ms. Brown-Waite. Thank you.
The Chairman. Thank you, Ms. Brown-Waite.
By the way, I would not just concentrate on the official
records, on whether they are sealed or not. It is the knowledge
of when someone walks into a clinic. People talk; their buddies
talk. The information is there even if the exact record may not
be held. It is that information and that sense that seeking
help is itself the problem for the military.
So, you know, when you are in a small community like this,
everybody knows what everybody is doing. I would think that
that is more of the sense than someone's individual record
being given.
Would you agree, Mr. Bowman?
Mr. Bowman. Yes, it very true, especially in a National
Guard unit because, traditionally, those men are closer than a
regular military unit because they all live in the same
neighborhood also.
The Chairman. Mr. Hare, I know the Bowmans live near your
district.
Mr. Hare. Thank you, Mr. Chairman.
I want to thank the Bowmans for their courage in coming
today and for telling the story, the chilling story, about your
son, Tim. I had the opportunity to sit with both of you this
morning with my friend, Representative Manzullo. I cannot begin
to express my sorrow for your loss. My son is about the age of
your son.
I find it appalling that you have not received the Purple
Heart for your son, and I want you to know, this morning,
Representative Manzullo and I will work very hard, and we
promise you that we will get this situation taken care of
quickly. I cannot imagine that that is something that has not
already been done, but we will work on that.
Your son was a brave young man. He served this country
honorably. We talked a lot about some of the things, about
Iraqi veterans and Afghanistan veterans coming back. One of the
things that you talked about, Mr. Bowman, too, was about how on
a Monday you are in Iraq and on a Thursday you are home. You
may be playing soccer or watching your kid's soccer game or
doing things, but it
is a very different war, and it has put tremendous stress upon p
eople.
I just want to ask a couple of things of both of you. We
talked about this this morning, but I think, for the record, it
is important.
You know, the Chairman has a wonderful idea, and that is to
screen every person who comes back for PTSD. You know,
Representative Murtha said if you are in combat for more than 6
months you are a prime candidate. For those particularly in the
Guard and in the Reserves who have to come out and say, ``Hey,
I think I have a problem here,'' they are really setting
themselves up, as you said, for a possible loss of employment,
a possible loss of being redeployed again in their units. So I
wonder if you think that makes sense, from a perspective of
testing everybody.
But also, I was amazed when you said you only had a 10-
minute briefing prior to your son's coming home. A lot of
parents--I know Mrs. Bowman this morning was obviously very
upset. You do not know what to look for. This is not just an
individual problem. It seems to me, Mr. Chairman, this is a
problem that affects the entire family. How do you know what to
look for if you do not know what to look for or know what the
signs are?
So it puts you at a handicap, and then the parents and the
family end up feeling like somehow they could have intervened
or should have intervened, but if you do not know what you are
looking for, you are relying upon bits and pieces. Like you
said, Mr. Bowman, different groups of people had to come up and
say, hey, Tim said this or Tim said that.
So I don't know. If you would spend maybe just a couple of
minutes talking about the need--and I thoroughly agree with the
Chairman that every person coming back should be screened. I
think we should look farther down the road, because it does not
necessarily manifest itself within 30 days of coming home. It
could be 4 or 5 years. We have seen this.
Then also, maybe, just how little knowledge you had or the
families had before your sons and daughters were coming back
from this war to know even what to look for.
Mr. Bowman. The redeployment process, basically
reintegrating back into society--we were talking with Chairman
Filner last night about the unboot camp, the reverse boot camp.
It is something that we have lobbied with the Illinois National
Guard for a long time.
You cannot just educate the soldier; you have to educate the fam
ily.
Now, obviously, I am speaking from the standpoint of a
National Guard parent, but Army Reserves and Marine Reserves
would pretty well fall into the same category. I have a young
Marine Reservist who lives right up the road from me who is
going through the same type of scenario right now.
You cannot make it optional. Our education meeting from the
State Family Readiness Group was optional. You did not have to
be there as a family member. So, out of 118 families, we might
have had half of them there, so there were 50 families who were
there. The meeting was about an hour long.
We spent, I would say, about 10 minutes with a brochure on
PTSD, and then the rest of the time dealt with the health
insurance, because, see, a lot of these guys have families.
They need to know when the health insurance runs out, their
last check. They need to know all of the financial aspects.
When does my husband have to go back to work? When does my son
come off of Federal title and go back onto State title?
It is all of these questions because, at that point, those
are much higher on the priority list than PTSD. So you start
out the meeting talking about health issues, and that gets
shoved off to the side. Then they hand you a magnet with a
bunch of phone numbers on it that says, ``Here is where you
call for help.''
It does not work because the excitement of the moment, the
excitement of the homecoming overtakes everything. So you have
to come back to the issue after they are home. There is a 2-
week period of coming home. Let them be with their families for
a couple of weeks, and then bring them back. It has been a
long-talked-about idea through a lot of families. Bring the
families with them, and do not make it optional. Yes, you are
going to have to pay for it because a lot of these guys have
kids, but what would you rather pay for, a couple of weeks in a
camp where you can educate the family and the soldier or
looking at another statistic and another news report where you
have lost another veteran to suicide who took his own life?
You have to make it appealing to people. You cannot make it
something that is so absurd or grueling that nobody is going to
pay any attention.
Mrs. Bowman. It is one more battle.
Mr. Bowman. Yes, it suddenly becomes another battle,
exactly.
There are ways to do that. You know, you get the right
people involved in the situation. You look at how you can
educate kids with cartoons and video games and how they excel
with that type of training because they relate to it. And that
is the kind of re-education that not only the soldier needs but
the families need and all of the family.
Mr. Hare. Just one final thing. I know I am out of time.
With regard to the price, the price that your family has
had to pay, and particularly for those people who have lost
their lives because they did not know where to go, I do not
think we even ought to be quibbling over whether or not we can
afford to do this. This is something that I think we have a
moral obligation to do for the men and women who serve this
country.
So, with that, I yield back.
The Chairman. Thank you, Mr. Hare.
Mr. Stearns.
Mr. Stearns. Thank you, Mr. Chairman. Thank you for holding
this hearing.
Let me echo sincerely the comments of my colleagues, in
which we are very sorry for this tragedy. Having three boys, I
think anybody who has children certainly identifies with the
grief that you are going through.
But I would say to you, in all candidness, that your coming
here is good for us, but it is probably good for you to talk
about it and to tell us, in the ways that you are doing, so
that we better understand. As to the actual telling of it to us
by you, I think and hope and pray that it helps you too, as you
mentioned that you have post traumatic stress symptoms
yourself. Obviously, every death is a tragedy, but losing those
who fought so bravely to protect us in this room, and in this
country, is something that we cannot discount and that we
cannot brush aside.
In hearing from your testimony that he was one of those who
spent 4 months on the most dangerous road in Iraq, going from
the airport to the Green Zone, Members of Congress go to Iraq,
but we fly by helicopters from the airport to the Green Zone,
so we are not in that dangerous zone.
I read also that you indicated that his Purple Heart has
still not arrived. Is that true?
Mr. Bowman. That is correct.
Mr. Stearns. That is something that we will look into, too.
The thing that struck me about this is--and Members will
talk about this. Mrs. Bowman, is it possible I could ask you a
question and get your feeling too? I notice your husband is
doing all of the talking.
When you look back at it, do you think the Veterans
Administration, if they sent people to your home--I know I
asked the staff here, does the Veterans Administration have
counseling? It says they provide readjustment counseling and
outreach services to all veterans who serve in any combat zone.
Services are also available for their family members for
military-related issues. Veterans have earned these benefits,
and these services are provided to them, but, I mean, that
means you have to go to the Vet Center to get it.
So, Mrs. Bowman, in retrospect, is there something that the
Veterans Administration could have told you or something that
you could have done, where you felt that you just did not have
the psychological skills or that you did not have the
education? I mean, is there a void there that we, as Members of
Congress, could legislate and could tell the Veterans
Administration that we are not going to wait for the families
to come to the Vet Centers and that we are going to send the
people to you once we identify those individuals coming back?
Mrs. Bowman. Right. It is just like my husband said. If we
would have been included with Tim in some kind of a program
where we had to report back to someone, where we had some kind
of screening or a one-on-one with all three of us or with the
two of us, as far as what we have seen or have not seen, and
Tim on his own, so that we could, you know, get together and
realize there is an issue here and that they could now help us
deal with this and give us the tools to do that.
Mr. Stearns. I have been in hearings for something like
this, and I chaired a Subcommittee on Commerce, Consumer
Protection and Trade, and we dealt with families who had
children who took steroids and who committed suicide. So I have
looked at this.
What I found is that, if there is employment for the
individual, that is a big step--but Timothy had employment--and
if he is adequately compensated and has enough cash flow or
something so that he at least is not on the edge there.
Secondly, it is that he has significant counseling by folks,
and if necessary, he is provided medication.
Was he provided medication?
Mrs. Bowman. He did not ask for medication.
Mr. Stearns. He did not ask. Is there a reason why he did
not ask?
Mrs. Bowman. He did not realize he had the problem he did.
Mr. Stearns. So he did not even realize that this post
traumatic stress disorder was affecting him, and he was not
receptive to counseling or to the medication?
Mrs. Bowman. No.
Mr. Stearns. Okay. Then the last thing I found was some
kind of education. Did he have a high school degree?
Mrs. Bowman. Yes.
Mr. Stearns. He did. Okay.
So, once those three are in place, then the building of the
self-esteem is the key. And the parents somehow have to
convince him or her that everything is going to be all right;
we are going to work through it. In this case, it did not
happen, and it is so tragic and sad.
I think, as legislators, we can direct the Department of
Veterans Affairs to not only brief you but to come into your
house and set up perhaps a casual type of counseling where the
veterans themselves, who are back and who are, shall we say,
aware of this problem, can sit down with Timothy and say,
``Okay, let's shoot the breeze here and talk about it. What is
happening in life? Who are you dating?'' and things like that.
So, I mean, that is what you are telling me would have been a
big step.
My last thought here is that both of you feel that you
were--or were not--adequately briefed enough to know how to
help Timothy. Can you just elaborate on that a little bit?
Mr. Bowman. No, we were not briefed on what direction to
send him. The only information we got was, like, of a mandatory
nature. Before you could do anything, as far as getting him
help, you had to get him registered with the VA. He had to go
to the VA office with his DD-214 and get registered there, and
then you could start the process.
He came home with a battlefield injury that was going to be
with him for the rest of his life, a broken hand that was a
little bit handicapped after combat. So he needed to go to the
VA because there was some follow-up surgery that was going to
need to be done in a couple of years. In order to do that, you
have to register. Well, he finally did that, but he was home
for about 7 months before he registered.
A lot of the guys who came out of combat were like that.
They would not take that step to go get registered at the VA.
It was almost kind of a mental block that they just kind of did
not want to do it. Then one of the guys in the unit started
working at the VA office, and then all of a sudden they all
started rolling in, because everybody started pushing them.
Tim had an appointment with the VA that was actually
scheduled for a couple of weeks after he died. We got a
reminder letter in the mail that, you know, gave me the
appointment time and stuff. And I stopped up at the clinic in
Freeport to see what it was about, and of course, they couldn't
tell me because of HIPAA, so we don't know if that was about
his hand. It would have been his first appointment. We don't
know if that was his hand or what it might be.
As long as we have brought the VA registration issue up,
one of the things that has always kind of bugged me about this
is that a veteran has to go to the VA office with his DD-214.
Why isn't the VA sitting there when they get off the bus when
they are coming home from Iraq? There are 118 guys coming off
of three buses at a National Guard armory. Why don't they have
somebody at that armory with a computer and a desk, registering
them before they can go home?
They are coming out of combat. You know that they are going
to need help. Sign them up right there. That way, you know
where they are, you know who they are, and they are in the VA
system right away. Don't make it so that the soldier has to go
to the VA. Make the VA go to the soldier.
[Applause.]
Mr. Stearns. Thank you, Mr. Chairman.
Just a point in passing for Members. There are tests,
written tests, that soldiers can take when they get out that,
once you take these tests--it is just a question and answer
over a period--they take this test, it will tell them of their
post traumatic stress disorder, tell them of their depression
and their emotional disability. And once they know that I would
think that would be a step, too.
The Chairman. But, Mr. Stearns, we have lots of evidence
that those are not, one, filled out accurately. Because, again,
the soldier knows if he checks anything he is going to have to
stay and not get home; two, his deployment is threatened; and,
three, commanding officers have called in soldiers who have
made the wrong check on those questionnaires and said you are
going to have problems unless you change that. So, as I said in
my opening statement, the whole culture of the military is set
against him. He is not encouraged nor shown the importance of
talking about this and getting help.
Mr. Stearns. Thank you, Mr. Chairman.
The Chairman. Mr. Rodriguez, who in his former life was a
professional mental health worker, so we thank you, Mr.
Rodriguez, for your involvement on this.
Mr. Rodriguez. Mr. and Mrs. Bowman, first of all, thank you
very much for your testimony. I know that it is difficult, and
it is also hard to hear these types of tragedies. But it is
something that we have to dialogue about and hear about in
order for us to start doing something about it, and I want to
thank you for coming forward.
I have had a situation in Eagle Pass, Texas, where one of
my soldiers had communicated with his family and seemed in good
spirits and then the next day committed suicide. And he was a
soldier. So when you commit suicide and you are in the
military, that person's body was brought back and was treated
in a very different way. Here is a soldier who committed
suicide while in duty.
And I just had another request from another community on a
soldier whose parents noticed--this was going to be either the
third or fourth time they were going to go to Iraq--noticed
that there was something very different about their son. And I
made some calls, and I had difficulty trying to see if we can
just get some treatment for this soldier prior to getting sent
to Iraq again. And I know the family, so there was no issue as
it dealt with the courage that was needed in order to go there
or anything like that. It had to do with some mental health
problems that they had encountered. And so, somehow, that issue
of stigma has to be something that we need to work on.
And as indicated earlier, I know our Chairman, Bob Filner,
has talked about providing treatment for every single soldier;
and that way that stigma would not be there for a period of
time. And sometimes you are not able to pick up on that
diagnosis initially until much later, and so we have to be able
to come back a year later.
And I just wanted to see if you might have any reflections
on that? How long before you witnessed anything or you were
able to pick up on something from the very beginning and how
long was he out from the military before.
Mr. Bowman. He came home in March of 2005, March 29----
Mrs. Bowman. Nineteenth.
Mr. Bowman. Okay--and he died on November 24th of 2005. So
he was only home for 8 months before his demons took him over.
And, like I said before, his symptoms, he concealed them so
well that we could see that there were maybe some problems, but
you couldn't identify--you couldn't put the pieces together to
make the picture clear enough to be able to push him toward a
certain area, certain direction.
The check-ups--the after-action check-ups when they come
home, we feel, are extremely important. When they get off the
bus, get them in the system, get them home for a couple of
weeks, bring them and the family back, go through the
demobilization, unboot-camp process with everybody, however
long that takes.
But then bring them back in 90 days. Bring them back in for
1 day, a Saturday, a Sunday, then wait another 90 days, and
then maybe you stretch it out to 6 months the next time. But
don't just come to a point and stop and then throw them away.
We can track a cow with mad cow disease to the middle of a
pasture in Montana. You have got to be able to track these
veterans.
And you don't make it optional, which means you have to pay
them for it. It goes back to the price, but the price is small
compared to what the veteran will pay and his family. Bring him
back in. The symptoms of PTSD will manifest themselves anywhere
from 30 days to 5 years. So you have got to know what you are
looking at, and you have to be able to see down the road, and
the evaluations have to mean something. They can't be that
four-page test that Tim took when he was at Fort Carson. I have
got that test. It is a joke.
Mr. Rodriguez. Let me also thank you for your testimony and
also indicate--and I want to take this privilege to recognize
Umberto Aguirre from Del Rio, who is here, and the GI Forum.
Will the members of the GI Forum please stand?
I want to personally thank them, because they have been
working with our veterans. I know we have some homeless
shelters throughout the country and some training programs and
these veterans have continued to reach out to a lot of the
veterans out there. And I want to personally thank the GI
Forum. Thank you for being there and all the leadership of the
GI Forum and thank you very much for your testimony.
The Chairman. Thank you, Mr. Rodriguez.
Mr. Boozman.
Mr. Boozman. Thank you, Mr. Chairman.
I just want to thank you for your testimony. It was very
helpful. We certainly appreciate the sacrifice of your son and
sacrifice of your family. My dad did 20 years in the Air Force.
And, again, it is a matter of resources. We need to put a
lot more resources in the area. Your son, you know, we can talk
about, oh, not reporting for a variety of different reasons;
and, you know, I didn't have the privilege of knowing him. But
sometimes it is that you are afraid of it being a stigma on
your report for future promotion or whatever.
And then a lot of times with guys--and a lot of my friends
were this way--it is also an admission of a personal weakness
perhaps that you didn't think you ought to be having. I don't
mean that as a personal weakness, but the connotation, you
know, I am having these feelings that I shouldn't have, and I
am a tough guy and you don't--you know, like I say, tough guys
are like that.
So we just need to get it figured out. We need to put a lot
more resources. Some States are doing a much better job than
other States right now. We need to look at the States who are
doing a really good job. And then, again, when it comes down to
it, require a very high level of care, a very high level of how
we attack this problem, and then just mandate that we get it
done and provide the funding.
So, again, thank you very much for being here. It was very,
very helpful.
Mrs. Bowman. Thank you.
The Chairman. I just want to ask unanimous consent that our
colleague from Rhode Island, Mr. Kennedy, who is the author of
the Mental Health Parity Act, be allowed to join us, at the
dais for the Committee hearing today. Hearing no objection, it
is so ordered.
I now recognize Mr. Mitchell, who is Chairman of our
Oversight and Investigations Subcommittee, and was the first
one to make sure that we followed up on that CBS News report
with this hearing, thank you. Mr. Mitchell.
Mr. Mitchell. Thank you, Mr. Chairman.
First, Mr. and Mrs. Bowman, I want to offer my condolences.
I want to thank you for having the courage to come forward
today and share your son's story.
You spoke in your testimony about the VA's reaction to the
CBS News investigation about veteran suicides, and I guess I
would like to know this. How did you feel when you heard the
VA's reaction and did it make you feel like the VA was working
to help families like yours?
Mrs. Bowman. No.
Mr. Bowman. My wife can attest to the fact that when I saw
Dr. Katz's reaction on the TV, the first thing I wanted to do
was reach through the screen and choke him. That as a family
member was my reaction to their response to that number. Why
not take that number and say, you know, oh, my God, we have got
a problem here. Let us do something about it. This is obviously
an issue. But instead it is, let us pick on the guy who put the
number together.
You know, I don't get it. As a family member, I was
appalled. I was absolutely appalled. It is just one more case
where the VA let the veteran down.
Mr. Mitchell. Thank you.
The Chairman. Thank you, Mr. Mitchell.
Ms. Berkley. Again, thank you for your leadership in this
area.
Ms. Berkley. Thank you, Mr. Chairman. I appreciate the fact
that you have scheduled this hearing, and I appreciate Mr. and
Mrs. Bowman for being here. I know it can't be an easy thing
for you, but we appreciate it very much.
When somebody dies from my home State of Nevada in the line
of duty, I call the family, and it doesn't matter whether they
live in my district or not. I think it is the only right thing
to do, to offer my condolences, not only as a congresswoman but
as a parent and a mother who has sons of her own.
Earlier this year, I had the occasion of calling a
grandmother who raised her grandson. He had served one tour of
duty in Iraq; and he had come home to Pahrump, Nevada, which is
a very small bedroom community outside of Las Vegas, and was
emotionally a mess. And he told his grandmother he cannot go
back. He cannot go back. He doesn't care if goes to jail. He
doesn't care if this happens, if that happens.
Now, the military's response to him was to give him Valium
and send him back. He was back for 24 hours, and he blew his
brains out. It was in this context that I spoke to his
grandmother to offer my condolences. Now, I could talk to this
woman for the rest of her life and I could never heal the hole
in her heart that she will have for the rest of her life.
There are so many statistics. I have got pages of them in
front of me now, and you are living this. And it is important
for us to recognize, and I think just by holding this hearing
and bringing this to the attention not only of the American
people, but of Members of Congress, we are making a giant leap
forward. Because a generation ago, even a decade ago, this
conversation could not have taken place.
Mr. Bowman. You are right there.
Ms. Berkley. I came from the Vietnam era. That was my war.
I was in college. Now, I meet with my Vietnam vets all the time
back in Las Vegas. Most of my homeless in Las Vegas are
Vietnam-era vets. I talk to them. I have normal conversations
with them as if I was sitting there talking to you.
But they came back messed up, and we didn't recognize that
there is a mental health price to pay for service to our
country. You can recognize a wound and treat it, but we were so
ignorant of the fact that people, men and women, are coming
back with wounds that we cannot see.
Taking care of these veterans, taking care of our National
Guard members, taking care of our military is the cost of
waging war; and this is not an area that can be short-changed.
It should not be short-changed.
Now, I had another constituent, Lance Corporal Justin
Bailey. He returned from Iraq with PTSD. He developed a
substance abuse problem. And he came from a nice middle-class
family. His father is a teacher in my district. They are
normal, average, good Americans that believe in this country,
believe in the cause and believe that their son was serving his
country.
He came back with undiagnosed PTSD. They know it now. He
developed a serious substance abuse disorder. They begged him
to get help through the VA. He didn't want to go. They
convinced him to go. He went. Now, he was on five different
substances when he checked himself into the VA. The VA gave him
two more medications, and 24 hours later he was dead at the VA.
I tell you this because if we don't have--we can pass every
law in the world here, but if we don't have adequate education,
if we don't have adequate training, if we don't have adequate
personnel that can recognize the problem when they see it and
confront it, nothing we are doing here is going to make much of
a difference. So I have introduced a Mental Health Improvement
Act which aims to improve the treatment and services provided
by the VA to veterans with PTSD and substance abuse disorders;
and I am hoping that my colleagues, particularly here on the
Veterans' Affairs Committee, will join me in co-sponsoring this
legislation.
It isn't enough to recognize the problem, although we are
moving forward in that direction, and I think it is good. It is
not enough to pass legislation. We have to ensure that once
these young men and women get into the system that the system
knows what to do with them, and this legislation I hope will
help that.
I want to thank you again for being here and hope that your
tragedy will kick-start this legislative process so that we can
protect our men and women in the military when they come home
from their service. Let us eliminate the stigma attached to
mental health problems and mental health issues.
And you are so right, and so many of my colleagues that
have mentioned this, you are right in saying the VA and the
Department of Defense need to go to our fighting men and women,
not the other way around. We will save countless numbers of
lives and improve the quality of their lives for the rest of
their lives. And I thank you very much.
Mrs. Bowman. Thank you.
Mr. Bowman. Thank you.
The Chairman. Thank you.
Mr. McNerney.
Mr. McNerney. Thank you, Mr. Chairman.
I don't have any questions, really. I just want to thank
the Bowmans for your courage in coming today, and I think it
reflects honor upon your son. Now it is our duty to learn from
your experience and see that some of these changes are
implemented that will make a difference in people's lives,
particularly your observation that help should be anonymous and
helpful, as well as your suggestion that post-deployment
treatment be mandatory. We will be taking a look at those.
Thank you for your courage.
That is all.
Mrs. Bowman. Thank you.
Mr. Bowman. Thank you.
The Chairman. Thank you.
Mr. Walz, who, I just want to tell the Bowmans, is the
highest enlisted man ever to be elected to Congress and has
lots of experience, decades with the Minnesota National Guard.
And also, they have a program that he might want to describe,
the Yellow Ribbon Campaign, which tries to deal with the
returning servicemembers in a way that at least starts on the
path that you have suggested.
Mr. Walz, thank you for your efforts.
Mr. Walz. Thank you, Mr. Chairman; and thank you, Mr. and
Mrs. Bowman, for being here. There are no words that are going
to be said here that are going to ease the pain of your loss,
and we clearly understand that. I have to say, though,
especially Mrs. Bowman, you occupy one of the highest and most
respected positions in this society as a Gold Star mother. And
I have to tell you as a Member of Congress and as a veteran and
a retired sergeant major and a citizen, I am ashamed that you
have to come here today, that the idea that you would have to
come here and ask this Congress to do the right thing for your
son is absolutely appalling.
And with all due respect to our news organizations, while I
am happy they broke that story, there is not a single person in
this room that doesn't know this was an issue. There are
Members, there are people sitting behind you, veterans and
advocates that have fought decades on this very issue; and I
have worked with them. They have advocated for this, they have
spoken about it, and we have seen year after year after year
not addressing this in a real comprehensive manner. And that is
simply appalling, and it is a shame.
And I can tell you there is not a Member up here
especially, and there is not a Member in Congress, that hasn't
stood in front of soldiers, talked about them, talked about how
great they are, but time and time and time again this Congress,
and all of us are guilty of this, have simply failed to move
things forward that make a difference. And that is an absolute
shame.
And I have said that there is no one in this country again
that should ever allow anyone to stand in front of a soldier if
they are not going to stand behind him and move this, never. We
have seen those yellow ribbons. Many of them are very faded
now, and you can barely read them, and the fact of the matter
is we haven't done what they said. We haven't addressed these
issues. We haven't taken this in.
Senator Dole occupied the same position of both of you, and
Ms. Shalala, and they sat here and addressed the issue at
Walter Reed. And Senator Dole was very clear in what he said.
He said, you spent billions putting them in harm's way. Spend
billions in whatever it takes to get them out. And that is very
clear to us what we need to do. So there are things here. And
Mr. Kennedy is going to speak in a little bit, and I think this
is an very important piece of this puzzle.
And both of you with your keen understanding of how this
works, especially from National Guard families, I can tell you
this. Having been one of those that came back--we were in
support of OEF, but sitting there with OEF/OIF veterans when we
came back, they showed us the Horse Whisperer and told us to be
nice when we went home, and that was the extent of it. That was
in 2004.
Now I am proud to say that, because of the people sitting
in here and people who came before me, things have changed over
the last 4 years. They have not changed enough. But Mr. Kennedy
is following and moving something forward that the late Senator
from Minnesota, Senator Welch, advocated so clearly, mental
health parity and this issue of understanding and
destigmatizing mental health.
And I being in there and knowing as a first sergeant knows
exactly what you are saying and watching as people aren't
trained on this, that there is a discrimination that goes
against a soldier who has the courage, the fortitude and, as
you said, the insight to admit this.
So there are a couple things I want to ask you, because I
think you do have a keen understanding on this. We started
noticing this in Minnesota; and the State of Minnesota, under
the Adjutant General and the Governor, did something that
actually I guess in letter of the law violated VA
recommendations. We set up a program that said, do you know
what? This hands-off policy, it is what soldiers think they
want. The last thing you want when you come home is to set
meetings and things like that or to talk to anybody.
What we found was and what the research shows is that most
of these patterns of behavior and most of this PTSD gets worse
in the first 90 days. If you can address it early on, while it
is fresh, in an environment that is nonthreatening and
everybody is in it together--we have what we call Beyond the
Yellow Ribbon Campaign, and we bring them back right away, and
we reevaluate them, and we do something this Congress is going
to do now to put forward. We make sure we are testing them for
traumatic brain injury.
As many of us know--it was the Blind Veterans of America
that brought it to our attention earlier--we are starting to
see a lot of veterans with eye troubles that were actually mild
traumatic brain injury and those types of things. So we are
starting to screen them early, we are starting to put them in
front of the right people, and we are starting to bring their
families in to understand.
As you said so clearly, many of us were much older and we
had children at home. Many of these Guardsmen have not only
small children, they have teenage children that clearly
understand what is going on.
What we are trying to do and will vote on this later today
is to get the money to do a pilot program to take this thing
nationwide. My question to you is, do you think this is the way
to go? Is this the way to address it?
Mrs. Bowman. Absolutely.
Mr. Bowman. And you need to bring all the soldiers in. One
of the stigmas that has always been held up, especially with
National Guard, is they will bring a chaplain or a counselor in
for drill weekend. And anybody who wants to see the chaplain,
he is over in room 105. And everybody looks at who is going to
walk in that door. They know who is going in that door. And the
Guard says, you know, they have to come to us. So our thought
from the very beginning is bring them all in. Everybody gets a
screening. You don't single out the guy who has a problem. You
screen everybody. Because half the people who don't walk in the
door have the biggest problems, and you have to screen
everybody. That way there is no stigma among the unit.
Everybody walked through that door and saw that counselor.
Mr. Walz. Well, once again, thank you. And, again, this
group behind you, this group sitting out here, they are the
ones that are going to assure accountability on this. I think
the time of lip service has pretty much run its course, and
there is going to be a day of reckoning if we get this thing
right or we get it wrong. Because we can't continue on like
this. Especially, as I said, everyone in this room knows it is
an issue. Now let us fix it.
I yield back, Mr. Chairman.
The Chairman. Thank you, Mr. Walz.
Mr. Hall.
Mr. Hall. Thank you, Mr. Chairman; and thank you both, Mr.
and Mrs. Bowman, for coming here. My condolences for your loss,
and my thanks to your son for his service to our country. My
apologies, as my colleague, Mr. Walz, said, that you should
have to be in this position.
All of us who represent the different districts around the
country have veterans come to us, I am sure, with all kinds of
problems and especially with PTSD; and no small number of those
are either suicidal impulses or other clearly identified PTSD
symptoms.
I have a friend who is a Vietnam vet who was diagnosed with
post traumatic stress syndrome. At the time, it was called
PTSS. And you said, Mr. Bowman, you thought that the term
``disorder,'' it was counterproductive because it seemed to
describe it as something being wrong with a person, as a
malady, and it should be more treated as an injury of war so
that it wouldn't carry the stigma.
So I am wondering if perhaps a wording change like that,
that we do--because words do matter. And what the government
calls things, the labels we put on them as a society or as a
branch of government or the VA, for instance, or the medical
community can stigmatize more or less. So I am curious if you
would think that something like post traumatic stress syndrome
would be better than, say, disorder.
Mr. Bowman. I think anything that makes the term something
that is not permanent. The term ``disorder'' applies to
muscular dystrophy, multiple sclerosis, something like that, a
debilitating disease that once you get it, you have got it for
the rest of your life. Now that doesn't mean that PTSD goes
away. But it is an injury that, if it is dealt with in the
first 90 days, again, if you can combat it early enough, you
can reduce its impact to the point where you have got a
healthy, fully functioning soldier who is actually better off
now than he was when he went to combat because he has gone
through the battlefield, he has gone through the mental anguish
of war, and now he has found a way to deal with it.
Mr. Hall. Thank you.
And I think it is important that, until we are able to do
that, we not redeploy combat soldiers who have PTSD. So it is
doubly important that we identify all of them, which would
reinforce the concept that you have both spoken to, and
Congressman Walz and others have spoken to, of bringing all
soldiers in for screening, rather than just say ``go to door
number five,'' or whatever it is, so that they are watched and
identified.
I don't really have more questions for you. I just thank
you for being here.
And I want to say that in my short time in office, my staff
has helped servicemembers, veterans, ranging from 84 years old,
a World War II veteran, within the last couple of weeks who we
got 100 percent clarification for PTSD for a soldier who had
two ships sunk out from under him in the Pacific Ocean in World
War II and twice found himself floating in the ocean with body
parts and sharks and other comrades around him and so on and
was rescued twice. Until 2 weeks ago, having tried repeatedly
since the 1970s with his friends and with people who were
trying to help him, and it was just this year that he finally
was classified.
On down through Vietnam-era veterans right up to a 25-year-
old, twice-deployed soldier who came back from Iraq and spent 2
years looking for a PTSD classification. He had all the classic
symptoms: an exaggerated startle reflex, suicidal tendencies,
couldn't go to sleep without seeing in his mind's eye the
picture of his fellow soldiers being killed or of an innocent
Iraqi girl who was caught in the crossfire in Fallujah and
other things. They are images that are hard to get out of one's
mind once you have been through that experience. And we were
able to get him--because he came forward to us, we were able to
get him the classification, 100 percent PTSD classification.
But it is the ones who, because they are trying to be
strong and because they can hide it, as you said, are hard to
identify; and that is why I think it is critical that we screen
everybody. The percentages are running so high that I think
that is really the only way to be safe and to make sure that we
don't let soldiers like Timothy slip through the cracks.
And, once again, thank you for being here; and, Mr.
Chairman, thank you for holding this hearing.
I yield back.
The Chairman. Thank you.
Mr. Snyder.
Mr. Snyder. Thank you, Mr. Chairman and Mr. Buyer, for this
discussion today.
And I want to thank the both of you, as others have, for
being part of this national discussion. I hope you are pleased
with the kind of comments and discussions that you have
triggered here today.
I did not know your son. My guess is that he would be
proud, as a 23-year-old, of what you are doing today. Because
you are not doing it for him. You are doing it for the sons and
daughters of everyone else around the country.
I also appreciate the context that you have put this in,
which is the absolute finality of devastation of suicide is
terrible for that person and for the family and friends of that
person. But in your very last line you say, ``Our veterans
should and must not be left behind in the ravished, horrific
battlefields of their broken spirits and minds.''
Because somebody does not commit suicide does not mean they
are out of the ravished, horrific battlefields of their broken
spirits and minds. And there is a lot of human misery that is
out there, and we know it is out there. I suspect there is some
in this room or has been some in this room.
We don't do the thing saying, will everybody who needs
mental health counseling right now or in the last year please
stand up and go to the door if you would like to be
interviewed. Because we all have our private moments of
devastation. But for some of us human beings that becomes
something that just eats at you hour after hour, day after day,
week after week, month after month, year after year and,
unfortunately, tragically results in suicide in some. But it is
also tragic if it is untreated for those months and years and
decades, as you have pointed out in your statement.
Mr. Kennedy, who I hope we will be hearing from here
shortly, has recognized through his work for some years now
that in the private sector, the nonmilitary, nongovernment part
of our lives, we have not solved this issue of how to deal with
mental health challenges. A lot of insurance doesn't cover it.
We have a lot of human misery out there that goes untreated
because people don't know how to get it and pay for it, and
that is a problem that we have in this country.
But thank you for your service and being part of this
national discussion and debate.
Mrs. Bowman. Thank you.
The Chairman. Thank you.
Mr. Kennedy, thank you for your work on mental health
parity. You and I have talked about these issues for a long
time, and I will recognize you for any statement or for
questions.
Mr. Kennedy. Thank you, Mr. Chairman.
I also want to join my colleagues in offering my
condolences to you for your terrible loss and say that it is
this personal story that you have offered that I think is going
to be the catalyst for the change. Tragically, in this country,
the statistics don't move people, but a personal story like
yours does.
The statistics in this country, suicide is twice the rate
of homicide in this country. We read about murders every day,
but we don't read about suicides every day. It is the silent
killer in this country. It is epidemic. But your story here
today is helping to highlight something that is an untold story
that is too often the case for so many families and now,
especially, amongst our returning veterans.
So you are, as my colleagues have said, really profiles of
courage in really sharing your story to benefit other families
from having to go through what you have been through. So I
really salute you and thank you for your son's service.
My colleagues have referenced the mental health parity bill
that Senator Paul Wellstone originally introduced that is now
actually in the midst of being considered between the Senate
and the House. And it has a lot to do with your story because
many of these returning veterans, they are all going to be
returning to the private work force. And, as you know, the
stigma continues. And this Committee has set up what are known
as Vet Centers because of the stigma, because they know many
veterans won't go to the VA for their mental health services
because they are afraid it will show up on their record, and so
they set up Vet Centers for that purpose.
Because of that, you can understand that many veterans may
not even choose to avail themselves of anything having to do
with the VA when it comes to mental health; and they may, as
now private sector employees, choose to get their mental health
services through the private sector.
That is why it is even more important that we pass mental
health parity legislation. Because all these returning veterans
will need to be covered as private-sector employees, and we
have a chance now to pass this sweeping parity bill that
basically says mental health should be treated like every other
part of your healthcare in a holistic way.
And it is so very important because of the facts that I
have just stated, but I wanted to ask you, with respect to
families, veterans' families, do you think the VA is doing
enough to address the families' mental health needs as a means
to address the veterans themselves, mental health needs? In
other words, one of the ways that veterans suffer so greatly is
when they return their families are suffering themselves,
having had a very difficult time themselves being away from
their loved one.
And what ways do you think, also--do you think that peer-
to-peer programs like the vet-to-vet support groups are
effective? And do you think that the VA ought to be taking
these programs to scale? Meaning do you think that we ought to
really ramp them up so that they are not just here and there,
but they ought to be national, and so that every veteran
returning gets to talk to another vet, and that we in the
Congress support these veteran-to-veteran peer support
programs?
If you could comment on those?
Mr. Bowman. As far as the VA help for the families, I have
never seen a VA person approach me in my entire life. Nobody
even came to us after Tim died. Nobody offered us family
counseling. His battalion commander was checking to find out if
we qualified for family counseling after he died, and there is
nothing out there for us, even though he gave his--as I feel he
gave his life for his country.
So I can't comment on what the VA is doing for families,
because I have never seen it. And as being in the National
Guard array with a lot of the kids that I know, they haven't
seen it either, because they are stretched out. Out of 118
soldiers in my son's unit, there were from 78 or 79 different
towns spread across Illinois, Iowa, some small towns, some big
towns. But nobody has ever jumped up and said, hey, somebody
came to me with some support information. And we know these
families because we have stayed in touch with them. So that to
me is a gray area.
Mr. Kennedy. And you think the families could be a big help
to the returning veteran. If they knew in advance when their
loved one was returning more about mental health because they
had received some preparation and had gotten some support, they
might be the greatest resource in that regard.
Mr. Bowman. Yes. Especially with Guard and Reserve.
Because, as I said, and we saw it with Tim and I have seen it
with other Guardsmen. They can suck it up for a weekend drill.
And they will go in and spend a weekend drill and they will
look like the most normal human being you ever find. Well, who
has them for the other 28 days out of the month? The family.
That is when you are going to see the breakdowns, the
nightmares, the night terrors, the sweats, the screams, the
swinging in the middle of the night, sleeping in the closet
with a 9mm. All those signs are going to be seen by somebody
other than Guard people.
So if you educate the family on those signs then at least
they have a chance to locate some help for them before it turns
into a disaster.
Mrs. Bowman. And we ourselves chose to go on our own and
get counseling. We have been in grief counseling for a year,
both of us now, as well as our daughter. And it has made a huge
difference for us.
Mr. Bowman. And mental healthcare for--well, we discussed
this earlier. I went to our local mental health association,
which has offices all over our area. They are supposed to be
the place to go. And by the time I got done with their initial
screening paperwork, the financial paperwork, the pre-interview
with the caseworker and all the other stuff--and I told him
right up front, I don't qualify for any financial assistance
whatsoever. I am going to pay for this visit. Just walk me into
a counselor. And by the time I got all done and I did get to
the counselor I was so mad at the system of trying to get there
I told her if I was standing on a ledge right now I would have
already taken the step because I can't believe what you just
put me through. And that is what I am supposed to go to as a
citizen in my own neighborhood.
Then I go off the grid and find somebody that is a licensed
private counselor, and she won't work in that system because of
all that paperwork, and she has got all kinds of patients that
she sees, and she has been very successful. It is frustrating
just in the mental health aspect of it.
Mr. Kennedy. Well, you just made a great case for mental
health parity; and we will work on that, too.
The Chairman. Thank you, Mr. Kennedy.
Mr. Buchanan, do you have any questions?
Mr. Buchanan. No.
The Chairman. Mr. Buyer.
Mr. Buyer. Thank you very much.
And once again, Mr. and Mrs. Bowman, thank you very much
for being here.
I would like to make an association toward the comment of
Dr. Snyder. And you are absolutely correct. We as a country do
not do well in not only a tracking system with regard to
suicides but on the issue on prevention, identifying risk
factors and things. So, as a country, I agree with you we don't
do well; and it is a subject matter that we also don't discuss
much.
So, as I look at the Center for Disease Control, they put
out their study, the National Violent Death Reporting System.
So, as you look into this--now, this is using their reports and
status from 2001, their latest numbers, among Americans ages 15
to 24, homicide is the second leading cause of death; homicide
was contributing, an average, of 14 deaths per day in this age
group of 15 to 24. Suicide was the third leading cause of
death; and, on average, we have 10 deaths per day in this age
group of 15 to 24 for suicides as a country.
Then when you look at the propensities--I continue on--the
males take their own lives at nearly four times the rate of
females. So 78.8 percent of all U.S. suicides are males. Now,
of all males, suicide is the eighth leading cause of death, and
it is the sixteenth leading cause of death for females.
Now when you look at these statistics--and what is kind of
interesting about statistics and numbers and how you analyze
these things, you also have to look at this a little bit
further. Males, when they have made this compulsive decision to
commit suicide, are more effective. Why? Because they use guns.
Women don't use guns. Women use pills. And they aren't as
successful at this compulsive decision to end their life. And
then it reinforces the other statistic that shows that women
have a higher statistical average to repeat an attempt on
suicide.
So it is interesting when you start reading these
statistics, yes, they begin to tell a story, but it is not a
whole story because we don't have a very good tracking system.
We don't do very good statistics. As a matter of fact, when I
looked at this national reporting system, really not many
States report. You can see that.
So that is why I agree and associate myself with Dr.
Snyder. He is absolutely correct. We, as a country, on this
particular issue are not doing well.
So in your statement when you said when CBS News broke the
story about veteran suicide, the VA took the approach of
criticizing the way the numbers where created instead of
embracing it, well, I just want you to also know that CBS
News--there are other writings out there that have highly
criticized CBS News and their story and the way they came up
with their own statistics. My gosh, you have the New York Post.
Their headline is--they called it bogus. I mean, they went
after the way CBS News came up with statistics.
What I enjoyed about your testimony today is that,
regardless of statistics and the war of statistics and how you
come up with them, there is a challenge in front of us.
I loved your use of the word ``injury.'' And I have heard
Bob Filner also talk about if you use the word ``disorder''
there is a stigma that is attached with it and we have to come
up with a better language. And he is absolutely correct. That
needs to be done. And we are going to need to work with the
great minds of mental health to come up with the right
language.
And to my good friend, the Sergeant Major, this is an issue
that didn't happen just because CBS News broke the story in
November. We are going to have the testimony coming up here by
the Inspector General (IG), and the IG is going to talk about
their report on implementing VHA's mental health strategic plan
initiative for suicide prevention.
Sergeant Major, this was started in the year 2004. And I
would agree with you, Sergeant Major, that the VA was very slow
in getting this on the ground. And so there I would agree with
you. We are going to have some testimony coming up on these
initiatives, and I welcome your participation in that panel.
I yield back. Thank you.
The Chairman. Thank you, Mr. Buyer.
I would offer, since the television program CSI is so
successful, stress injury is pretty descriptive, but it is hard
to change such a thing.
Mr. Bowman. Again, all you have to do to change that term
is do it right now.
The Chairman. All right. We will talk about CSI, combat
stress injury. I think the next panel may be a--have a----
Mr. Hare. Mr. Chairman, would you indulge me for just 1
second here?
Let me just say this to all of you, and I appreciate the
Ranking Member, but your figures on pieces of paper do not
reflect people. And, ultimately, just listening to this
testimony today, families are not brought into this loop when
it comes to their servicemember having problems. The
servicemember is not screened when they come back. There is a
stigma attached to all of this.
I agree with my friend from Minnesota. What we have to do
at the end of the day is to say, ``this is enough.'' We have
hit the wall with this issue here, and we have to look at what
we are doing. The VA has to be much more proactive than they
are. These are great cards, but if they don't work they don't
work, and we have to figure out what does work.
So I would just again say to you I want to thank you so
much. I am so sorry about what happened to you. But we have, as
I said to you in my office, a moral obligation to try
everything we can possibly try to make this better. And if it
costs us a few more bucks, so be it. But, ultimately, at the
end of the day, our job as I see it is to make sure other
families like yourself don't have to go through the pain that
you have had to go through. And I think, to be honest, the VA
has a whole lot of work they could do in educating the parents
and making sure our troops are not singled out.
So I just want to thank you so much for coming today, and
we will get this done one way or another. We will get it done.
The Chairman. Again, you all have obviously thought a lot
about this since Timothy's death. You are very articulate, and
you have helped us all understand this issue.
Two major things strike me, in conclusion, about your
recommendations. Number one, I think the President and the
Administration have been dead wrong in trying to wall off this
war from public consciousness. They are so afraid of opposition
that they don't want to educate people as to what is going on.
If all of us--parents, teachers, ministers, employers--know
what PTSD is, know what TBI is, traumatic brain injury, we can
all help Timothy; and that is a public education campaign.
People all over the country want to help. I sat down with
the Outdoor Advertising Association of America. If they were
asked, their billboards would be useful for getting people to
understand what PTSD is, just knowing where to turn to get
information. That is a public education campaign that I think
we have to do. And if the President just called any of these
people in his office they would do it for free as a service to
their Nation and to Timothy and his comrades.
In addition--and I have been trying to get this into this
year's budget--it is clear from what you say and everything we
have learned that it should be a part of active duty on either
return from combat or separation from service--and it has to be
not only active duty but the Guard and Reserves--go through a
process. I have called it a ``deboot'' camp. I have called it
basic untraining, decompression. I am now focused on a heroes
homecoming camp. That as part of your active duty, for whatever
number of weeks we can get the VA and DoD to agree to, that
every soldier with his or her unit, with his or her family,
gets diagnosed for both PTSD and traumatic brain injury.
Because, as policymakers, I think we have to assume that
everybody has it unless we find out they don't, as opposed to
you prove to us that you have it and then we set up all kinds
of things. You don't have PTSD, you have personality disorder
and get rid of you that way. So it has to be mandatory; and
that allows early treatment, which is absolutely necessary.
In addition, if you had this heroes homecoming camp, you
could do job counseling and credentialing and educational
counseling. All the spouses would be together for mutual
support. All the soldiers would be together for that kind of
comradeship, which was so important for them in combat.
And I think we just have to do this. We expect kids, as you
said, to be in Baghdad 1 day and taking their kids to soccer 2
days later. It is absolutely contrary to anything that the
brain can accomplish.
So I hope that we can move in those areas. We have to
change a culture.
But Dr. Martin Luther King once said, you can't make a man
love me, but you sure as hell--I don't think he said ``sure as
hell''--but you sure can make him stop lynching me. That if we
have certain laws and behaviors, that will contribute to the
change of the culture.
I think your testimony has brought us a long way. You have
a chance for any last-minute statement. You have been here for
almost 2 hours. That is a long time for congressmen and women
to stay and talk to you, but it shows how powerful your
testimony has been. And any last statement we would welcome.
Mr. Bowman. Just a couple of things.
One, I truly--we truly are honored to be here today. We
decided after Tim died that his death was not going to be for
nothing, that good would come of his death. It is the only way
that we can deal with his death.
This has been therapeutical for us. There is no doubt about
it. Because we know that his name has meant something. We know
that he has already saved lives.
On another note, I am an Assistant Illinois State Captain
for Patriot Guard Riders. If you are familiar with that
organization, we are the people who stand between funerals and
protesters. That is my therapy that I have taken on so that I
can survive day in and day out.
We have done two funerals in Illinois that were soldiers
that took their own lives, and I have never been so embarrassed
by the military in my life as to see the way that those
families were treated--no honor guard, no flag folders, no pall
bearers, nothing. Patriot Guard Riders folded the flags. We
carried the casket.
There is no reason that every person who served a day in
the military in this country should not be accorded the
military funeral rights that every soldier should be given, and
that includes the most honor you can hand them. Because that
honor at graveside is what that family will remember. And if
you want to help that family heal, the country has to remember
that they need to thank that family for that soldier, and they
have to thank that soldier. And the only way you have to do
that is at the graveside and at the funeral.
And I implore anybody who can work on anything to do that,
is to make that happen. Because a suicide carries a bad enough
stigma with it as it is. I was told after our son died, before
his funeral, do everything you can for him now, and we did. And
his unit was home. So all of his unit buddies were there. He
was also a member of the fire department. Between the two of
them, they coordinated everything and made it just an
absolutely beautiful service for 2 days.
But not everybody is that lucky, and I am asking you to
help those that don't have those connections.
Thank you.
The Chairman. Thank you. You have honored your son and your
family, and we thank you so much.
We will ask the second panel to come forward.
Again, thank you, Mr. and Mrs. Bowman. We thank both of you
for joining us.
The Chairman. Again, I must introduce you with a personal
thank you as you all have educated me with your books about
combat stress injury and suicide.
Penny Coleman, whose husband, a Vietnam vet, committed
suicide, is the author of Flashback: Posttraumatic Stress
Disorder, Suicide and the Lessons of War.
Ilona Meagher is the author of Moving a Nation to Care:
Posttraumatic Stress Disorder and America's Returning Troops
and has taken upon herself to have Web sites which track
suicides because her government does not.
The Chairman. With that, you have the floor, which--I don't
know how you arranged which to go first, but please, Ms.
Coleman, you are next.
STATEMENTS OF PENNY COLEMAN, ROSENDALE, NY, AUTHOR, FLASHBACK:
POSTTRAUMATIC STRESS DISORDER, SUICIDE, AND THE LESSONS OF WAR;
AND ILONA MEAGHER, CALEDONIA, NY, AUTHOR, MOVING A NATION TO
CARE: POST-TRAUMATIC STRESS DISORDER AND AMERICA'S RETURNING
TROOPS
OPENING STATEMENT OF PENNY COLEMAN
Ms. Coleman. Mr. Chairman, Members of the Committee, fellow
panelists, good afternoon.
I am the widow of Daniel O'Donnell, a Vietnam veteran who
came home from his war 38 years ago with what is now known as
PTSD and subsequently took his own life.
I use the term PTSD grudgingly, like Mike Bowman. It is the
official term, but it is deeply problematic. My husband did not
have a disorder. He had an injury that was a direct result of
his combat experience in Vietnam. Calling it a disorder is
dangerous. It reinforces the idea that a traumatically injured
soldier is defective, and that idea is precisely what keeps
soldiers from asking for the help they need.
I met Daniel 6 months after he returned from Vietnam, and I
married him a year later. The man I fell in love with was
gentle and playful and very funny on good days. But there were
other days when he would fly into rages over trifles and more
than a few nights when he would wake up screaming and sweating
and fighting something terrible that wasn't there. Or he would
take to his bed with the blinds drawn sometimes for days, and
all he would tell me was that he didn't want to live.
I thought that if I loved him enough I could fix him. I was
wrong. I had no idea what I was up against. After Daniel died,
I tried to blame him, but I ended up blaming myself.
For my book Flashback, I interviewed other women who lost
loved ones to suicide in the wake of Vietnam. In addition to
their grief, these women, like me, lived with guilt and shame
and isolation. I now believe that our isolation was exploited
to help camouflage a terrible tragedy.
Unlike Agent Orange vets or Gulf War vets, who have never
stopped demanding that the VA take responsibility for their
illnesses, in the case of veteran suicides the most logical
advocates were dead. We, their widows, did not become
advocates. We believed their deaths were our fault, and we each
thought we were the only one.
It is more than 30 years since the war in Vietnam ended,
and still no one has any idea how many Vietnam veterans have
taken their own lives because no one has ever tried to track or
count them. The 1990 National Vietnam Veterans Readjustment
Study mandated by Congress and government funded, the study
that proved the syndrome now called PTSD, never even mentioned
suicide, in spite of the fact that suicide was central to every
study that preceded it, including those on which it was based.
No data, no proof; no proof, no problem.
The United States invaded Iraq----
Mr. Kennedy. Would you repeat that again?
Ms. Coleman. Which piece? The last paragraph?
Mr. Kennedy. What was left out. What was that study?
Ms. Coleman. The National Vietnam Veterans Readjustment
Study, which claimed to be the biggest study that had ever been
done on any demographic group and claimed to address all of the
issues, the healthcare issues of Vietnam veterans, never
mentioned suicide or suicidal ideation.
Mr. Kennedy. Wow.
Ms. Coleman. It is an astonishing omission.
The Chairman. And what year was that?
Ms. Coleman. Nineteen-ninety it was published. The research
was done between 1986 and 1988, I believe.
The Chairman. Thank you.
Ms. Coleman. The United States invaded Iraq in March of
2003, and by August, so many American soldiers had killed
themselves that the Army sent a mental health advisory team to
investigate. Their report confirmed a suicide rate three times
what the military considers statistically normal. It also
acknowledged that one-third of the veterans who are being--of
the psychiatric casualties who are being evacuated had suicide-
related behaviors as part of their clinical presentation.
Nonetheless, the team's conclusion was that soldiers were
killing themselves for the same reasons that soldiers, quote,
typically kill themselves, personal problems.
A supplement to the report listed things that soldiers most
often identified as stressors--seeing dead bodies, human
remains, being attacked, losing a friend. But the report itself
only mentions marital problems, financial problems, legal
problems, what they call underdeveloped life coping skills.
Translation, soldiers are dying because they are managing their
lives and their affairs badly.
Every year since 2003, the suicide rate in the military has
increased; and another team of military psychiatrists have been
dispatched. Their conclusions are always the same: insufficient
life coping skills.
As recently as August, Elspeth Ritchie of the Army Surgeon
General's Office insisted that, in spite of the suicide rate
that had reached a 26-year record high, Pentagon studies still
haven't found the connection between soldier suicides and war.
There are various possible explanations for the Pentagon's
refusal to accept that connection, but one of the most
compelling is certainly budgetary.
To cite just two examples, soldiers often resort to self-
medication when they are denied or discouraged from treatment,
and that is commonly used to justify a dishonorable discharge,
and that means that a soldier will be deprived of healthcare
benefits. Or VA claims that somehow more than 22,000 soldiers,
most of whom had already been diagnosed with a post traumatic
stress injury or a traumatic brain injury, have been dismissed
from the service with a diagnosis of personality disorder which
is considered a preexisting condition, which also therefore
absolves the VA of any responsibility for their future care.
Such cynical cost-saving measures are devastating to the lives
of soldiers and their families.
There is currently no cure for post traumatic stress
injuries. Though many learn to manage their symptoms, far too
many will suffer the effect of their combat experience for the
rest of their lives. They will continue to have nightmares and
flashbacks. Many will continue to be hypervigilant, have
startle responses that are often violent. Many will have
trouble managing their anger and their relationships for the
rest of their lives. Many will try to self-medicate to help
them forget. And far too many will die by their own hands.
But that sad truth cannot be used as an excuse for
inaction. Our soldiers and our veterans need all the help they
can get as soon as possible. Their psychic injuries may not be
curable, but they are treatable. Their lives and the lives of
their families can be made infinitely less difficult if they
are given the care and support they have earned.
They can be assured that their suffering is a normal
response to an abnormal situation. They can talk to other
veterans and practice compassion for themselves by feeling it
for others. They can be taught proven techniques for managing
their stress and their anxiety. And they can be relieved of the
added burden of financial worry, all of which may help dissuade
them from suicide.
This is a public health issue of monstrous proportion, and
I am here to bear witness to the fact that military suicides
are not a new phenomenon. They are old news. This has happened
before, and it should never have been left to citizens to sound
the alarm.
The disingenuous surprise and denial from official sources
is simply unacceptable. I am deeply concerned that the issue is
being politicized, that sides are being taken, lines drawn that
make it appear as though there are two sides to this issue.
There are not. There can't be. These are our soldiers, our
veterans. They are also our husbands, our wives, our parents
and our children; and they are dying by the thousands.
I am grateful to CBS News that they have finally given us
some solid numbers. Six-thousand two-hundred fifty-six veteran
suicides in 1 year. Those numbers are astonishing. They cannot
be justified or ignored. Our soldiers and our veterans are not
disposable, and yet that is how they are being treated. More
than 6,256 veteran suicides a year, and each one of those
numbers represents an individual beloved face and a life-
shattering experience.
I know that Daniel came back from Vietnam with an injury
that finally and directly caused his death. I believe that he
decided that he deserved to die because he had suffered too
little or that he wanted to die because he had suffered too
much. We call his death a suicide, but I have come to believe
it was either an execution or euthanasia or some tragic
combination of the two, and that continues to break my heart.
I am grateful to this Committee for holding these hearings.
May only good come from your efforts. Thank you.
[The prepared statement of Ms. Coleman appears on p. 69.]
The Chairman. Thank you.
Ms. Meagher.
OPENING STATEMENT OF ILONA MEAGHER
Ms. Meagher. Thank you, Chairman Filner, Ranking Member
Buyer and other distinguished Members of the Committee. I thank
you for the opportunity to appear before you today.
To open, I would like to briefly share my thoughts on why I
think I am before you.
I am not only someone who spent 2 years researching and
writing about post traumatic stress and our returning troops. I
am also a veteran's daughter. My father was born in Hungary,
served 2 years in an antitank artillery of a Hungarian
conscript, fought against the Soviet Union on the streets of
Budapest during the 1956 Hungarian Revolution, later fled to
America and in 1958 again became a soldier, this time wearing a
United States Army uniform and serving as a combat engineer in
Germany.
My father's unique experience of having served on both
sides, both East and West, in such differing armies during the
Cold War gave him a unique perspective on military life. And so
growing up, my sisters and I often heard my father say you can
always tell how a government feels about its people by taking a
look at how they treat their troops. Looking at our returning
soldiers and their widely reported struggles with the military
and with the VA healthcare systems they rely on, of being
stigmatized from seeking care or of being placed on lengthy VA
waiting lists when they need immediate help, some even
committing suicide before their appointment dates arrive, has
raised this citizen's alarm bells.
For years, we have had a ``see no evil, hear no evil''
approach to examining post-deployment psychological
reintegration issues, which includes suicide. After all we have
learned from the struggles of the Vietnam War generation and
the ensuing controversy over how many of these veterans had or
had not committed suicide in its wake, why is there today no
known registry where Afghanistan and Iraq veterans' suicide
data is being collected? How can we ascertain reintegration
problems, if any exist, if we are not proactive in seeking them
out?
As late as May 2007, the Department of Veterans Affairs
spokeswoman Karen Fedele told The Washington Post that there
was no attempt to gather Afghanistan and Iraq veteran suicide
incidents. Quote, ``We do not keep that data,'' she said. ``I
am told that somebody here is going to do an analysis, but
there just is nothing right now.'' That was in May 2007.
Meanwhile, the Army reported that its suicide rate in 2006
rose to its highest level in 26 years of keeping such records.
Last month, at long last, the Associated Press revealed that
the VA is finally conducting preliminary research. They have
tracked at least 283 OEF/OIF veteran suicides through the end
of 2005. I have a note here. I have seen that the VA testimony
may include a different figure than this, so we are already
disputing this figure. The Associated Press reported 283 OEF/
OIF veteran suicides in the VA system. That figure was nearly
double the rate of the additional 147 suicides reported by the
DoD's Defense Manpower Data Center.
Looking only at these two suicide figures from the VA,
283--and from the DoD, 147--there have been at least 430
Afghanistan and Iraq veteran suicides that have occurred either
in the combat zone or stateside following their deployments.
Lost in the VA and DoD counts, as the Bowmans discussed, are
those veterans who have returned from their deployments, who
are still in the military and who are not yet in the VA system.
The DoD says they do not track those incidents, and I assume
neither does the VA.
Many of the 430 confirmed suicides that we now know about
are as a result of our wars in Afghanistan and in Iraq. They
should, but will not, be listed with the DoD's official OEF/OIF
death toll, which, yesterday, stood at 4,351. If they are 430
confirmed OEF/OIF suicides, that translates to an additional 10
percent of the overall fatal casualty count of these wars that
are due to suicides, 10 percent. Therefore, dismissing the
issue of veterans' suicides in the face of this data is
negligent and does nothing to honor the service and sacrifice
of our veterans and families and communities that literally are
tasked with supporting them once they return.
Yet, prior to last month's CBS News investigation, which we
have heard about, one additional note in that CBS News
investigation noted that 20- to 24-year-old Afghanistan and
Iraq veterans are two to four times more likely to commit
suicide. They are not the only ones who have talked about its
being double the rate of suicide for our veterans. There was a
June 2007 study as well--we could talk about that--that showed
that the veterans' suicide rate is double the rate of the
civilian population.
In my written testimony, I have included 75 suicides that I
and other citizen journalist colleagues have been tracking
since September 2005 and which, today, reside in the ePluribus
Media PTSD Timeline. They offer only a small and incomplete
sliver of insight into how some of our returning troops are
faring on the home front, especially in light of the fact that
at least another 355 incidents could be added among them
according to the VA and the DoD. I believe they collectively,
though, tell an even greater tale about the failure of us as
individuals and as a society to ensure that our returning
warriors are cleansed completely from the psychological wounds
of war. They also reflect the failure of our government
institutions to protect those who protect us.
While I realize that these distressing stories are the
exception and not the rule, to our exceptional military family
members and their having to deal with the deterioration of a
loved one they thought had safely returned from combat, they
are the rule. In 1956, the same year that my parents fled to
this incredible country, the 84th Congress in this very House
that we sit in today had this to say in a presidential
commission report on veterans' benefits: ``The government's
obligation is to help veterans overcome special, significant
handicaps incurred as a consequence of their military service.
The objective should be to return veterans as nearly as
possible to the status they would have achieved had they not
been in military service, and maintaining them and their
survivors in circumstances as favorable as those of the rest of
the people. War sacrifices should be distributed as equally as
possible within our society. That is the basic function of our
veterans' programs.''
Finally, I am not a pedigreed expert or a government
official. I am shaking in my seat. I am not seasoned in
testifying before Congress, so I do appreciate the opportunity
to stand in for the civilian population and to represent them,
but those who are the professionals and the seasoned, pedigreed
officials from the U.S. General Accountability Office, the
Congressional Research Service and even to the Veterans
Administration have sat in this very seat over these past
years, and they have told you that we are falling far short in
providing the resources and programs that our returning
veterans need and military families need to successfully return
to their personal lives following their service to this Nation.
To those who resist hearing the cold, hard truth of where
we are today, I have only one thing to say: The time is here to
stop fighting the data. Let us, please, start fighting for our
troops. This is America. We can do better. We must do better.
Thank you.
[The prepared statement of Ms. Meagher appears on p. 76.]
The Chairman. Thank you both very much.
Dr. Snyder, do you have any questions?
Mr. Snyder. I was browsing through your book. I wanted to
ask: Is it May-ger?
Ms. Meagher. Mee-ger.
Mr. Snyder. Meagher. I am sorry.
Ms. Meagher. That is fine.
Mr. Snyder. You gave a series in your statement here of
very specific things. I appreciate what you say, by the way,
about shaking in your boots. We do that quite a bit here
because sometimes we are not sure what way to go either with
some of these things. But one of the issues, in fact, was
referred to earlier by Representative Kennedy here. You talked
about outside community-based resources that are available, and
I recognize that there--I think there are a lot of communities
that are trying to step forward right now to help families the
best they can. I think about what happens as the years go by.
Sooner or later, the war in Afghanistan and Iraq will be a
historic event, and years will go by, but we know these
problems that you all are dealing with and talking about, both
of you, do not go away.
So we come back to this issue of having services available,
not just for the individual veteran but also for that veteran's
family. It may be issues of marital difficulties, of substance
abuse, of anger management, of the fact that the veteran still
does not realize that what is haunting him is what happened
before, and so we still come back to this issue of the
inadequacy of our mental healthcare system in the United
States.
If both of you want to discuss that broader issue, it is
that which is not just for the veteran, himself, and that we
expect to give the highest care to the veterans' healthcare
system or to the military retiree system of healthcare, but it
is for our system nationwide. I have directed this to Ms.
Meagher, but I would like you to comment also on it if you
would, Ms. Coleman.
Ms. Meagher. I do have some comments because I approach
this from--of course, I am a veteran's daughter, as I said, but
I am a concerned citizen, so I am not a journalist. I did what
is called ``citizen journalism'' because I saw a problem. And
the problem that I saw was that we were not, first of all, in
our Nation, called up to pay attention to the issue. Our
soldiers are returning, and there are no victory gardens being
planted. There are no war bonds funding drives. There is no
indication that we are at war. That translates into the same
things that are happening in communities. While there are
incredible organizations and people in pockets all across the
country whom I met while I was on my book tour and learned a
lot from who are ready and willing to do something, they do not
have the ability to tap into who the veterans who are in the
community. So I heard over and over from these incredible
people doing incredible things that we are ready and waiting,
but they are not coming in.
Now, nobody asked them to do these things, and it is
unfortunate that our leadership did not ask because it would
have made for a stronger country. I believe that many of the
things that I comment on cannot be legislated, and I cannot, I
think, say----
Mr. Snyder. Did you say ``cannot be''?
Ms. Meagher. We need to move our society forward and ask
them to pay attention to this issue and to take it seriously.
Mr. Snyder. I agree with that. I think of things, though,
like--you mentioned your father today. My father died, who was
one of Patton's guys, and he got involved, and he would talk to
me sometimes. Like after I went into the Marine Corps, we would
talk about some of this stuff--about the burial details he got
involved in. He just felt that, someday, one of those guys
might be him. He would go down into these burned-out tanks and
would have to bring out these bodies of Americans, and it would
just haunt him. He could never watch any show on television but
a game show--no cop shows, no crime shows, no westerns, no war
movies. It was only game shows because they had no violence in
them.
Well, I do not think he knew what was going on, but I think
it was you, Ms. Coleman, who talked about the person who sleeps
in his closet or maybe it was the Bowmans or both of you. Okay.
Well, I also think that there are going to be children in those
households who are around this stuff, and there are these
veterans who know that they are having problems that may be
impacting negatively on those children. Well, we do not have a
system where the children could go down to the VA hospital
where they could get good quality mental health counseling for
a 5-year-old or for a 9-year-old or for a 12-year-old or for a
15-year-old. Again, we get back to Mr. Kennedy's work here.
So that is what I was getting at, the community-based
resources. Even now, you are talking about our not really being
called forward as a country, but think of where we will be 5
and 10 and 15 and 20 years from now when memories will have
faded about our responsibilities, and we are still going to
have families from these folks who are going to have these
needs.
I think it is on the second page where the two of you
recommend and you talk about complimentary counseling to all
immediate family members. That is what triggered my thought
because we need to have a system in this country of providing
better mental health coverage because that need is going to be
there for a lot of years for these families, and it may be
generational. And I think that we are going to be grappling
with it on this Committee, but we need to be grappling with it
in our entire healthcare system.
Ms. Meagher. I do have one suggestion that could be easily
done, and I would have done it myself if I only had the
opportunity.
Mr. Snyder. Yes.
Ms. Meagher. I think it could be easily done.
All of these resources that are out there--now, I am from
Illinois, and the Bowmans are as well. We have National Guard
troops. They come from the community.
Mr. Snyder. Right.
Ms. Meagher. So they know the community. The community
knows them. And there are resources available to them, but
there is not a database. There is nothing where somebody who is
sitting in Texas or in Illinois can simply just go to a
database to see ``what is available in my community.'' The
military is not giving the information to the soldiers, and the
soldiers do not know where to go often. They do not know that
there are psychologists who are at the ready to donate their
services. There are programs. There are all types of programs.
So there could be a database. There could be something that is
put together that has resources for people.
Mr. Snyder. In fact, the problem that we run into with our
Reserve component--and Arkansas has had a lot of Reserve
component troops, both Guard and Reserve. What they run into is
they may come from communities where, in fact, the healthcare
providers there are not part of the military healthcare system
because they have not had to be. Nobody has come in and said,
``Do you accept TRICARE?'' Now they are going through, ``What
is TRICARE? Why is that important to us?'' ``Well, it is,
because we have been mobilized as a family, and that is now our
healthcare system because my husband or wife is not on their
work-related healthcare system anymore. This is our healthcare
system. If you do not take it, it means I cannot get
healthcare, and I am going to have to go someplace that takes
my insurance.'' So we run into those kinds of issues.
My time is up, Ms. Coleman, but I wanted to give you a
chance to comment.
Ms. Coleman. I think that one of the saddest things about
these wars has been the fact that we have been invited not to
participate.
Mr. Snyder. I am sorry. I could not hear you.
Ms. Coleman. I think one of the saddest things about these
wars has been that we have been asked not to participate, that
we have been deprived of the image of funerals and of coffins
and of tears and of wounds even. I think that has deprived us
of the opportunity to check in with our consciences, and I
think it has deprived us of the opportunity to help those who
have been wounded to carry the burden of their pain. And I
think it has not contributed to a reinforcement of our social
fabric, and I think that is too bad.
Mr. Snyder. Thank you both for being here.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Ms. Herseth Sandlin.
Ms. Herseth Sandlin. Well, thank you to both of you.
I was going to pose a question or two with regard to what
you two have seen or as to, in your conversations with others,
whether or not there is a difference either in the experience
or in the numbers of active duty versus the National Guard and
Reserve. We have done a lot of work on this Committee over the
last couple of years in examining that question in a lot of
different contexts.
On the one hand, you could say, well, perhaps it is our
national Guardsmen and Reserves because the community itself,
the entire community, is affected by that or a set of
communities is by a particular unit's being deployed, and so
that support network is particularly strong among the families
during deployment and when those men and women return home, and
there would be a greater likelihood that they would be somehow
finding or maneuvering through the community, given the support
of that community, to find resources to meet their needs. At
the same time, I hear you saying that there are some
communities, particularly larger ones, perhaps, and they are
unlike those that I represent in South Dakota or perhaps some
in Arkansas, where the unit is from five or six different very
small communities versus a larger community or a community
where there is a larger base.
Have you noticed a difference? How do we best address that
situation? Perhaps a database is good in terms of the resources
that are available in a community for National Guardsmen and
women, but what other issues do we have to get over for active
duty in response to--of course, we have talked about the stigma
in the past and the concern that these men and women have as it
relates to seeking those resources and a fear about how it
affects their military careers.
So can either of you talk about the differences that you
think exist? Are there numbers broken down to suggest that we
have higher rates of suicide among active duty versus National
Guard and Reserve, or is it exactly the opposite?
Are there other hurdles that we can help address based on
the constituencies that we all represent here and the different
constituencies that we represent back in our districts to help
you and to, again, be part of that network within a community
to facilitate information and to reach out and to know who
these people are and to make them aware of the services that
are available to them?
Ms. Coleman. The information that has been available since
the beginning of these wars about active duty troops has been
very hard to get a hold of. Newspaper reporters have had to
file Freedom of Information Act (FOIA) requests to find out
what was happening in terms of suicides among active duty
troops.
When The Hartford Current did a series of articles in May
of 2006, by submitting FOIA requests, they got information
about several suicides. I think when CBS News was trying to
initiate their report, they also submitted a FOIA request to
the Department of Defense. And the Department of Defense gave
them some number of active duty troops, but told them that
veteran suicides were just something that they were not keeping
track of. I do not know.
Ms. Meagher. There are some stats and some specific changes
and differences as far as Guard and Reserve troops, how their
experience unfolds.
According to the DoD, they did a Pentagon task force study
on the troops in the summer of 2007, and they reported that 38
percent of soldiers--31 percent of Marines--showed symptoms of
PTSD, psychological problems. Meanwhile, 49 percent of the
National Guard and 43 percent of the Reserves did.
Now, as to some of the reasons that I have seen in the data
that I have read, there are a few things that are happening
there. When Reserves are called up, they may have their own
businesses. Those businesses may go under if they have been
deployed two or three times. Although the Bowmans spoke about
their own family support since they are in the same community,
it is not like a base. There are not specific places where the
family members can go to get support. So some do not come in
like that half of the base that did not come in that the
Bowmans mentioned, and some might come in for these little
impromptu gatherings, but there is not one
area where everybody can support each other. So that is signific
ant.
There are also differences in--I have seen in reports of
National Guard troops that they may deploy all as one unit, but
often, especially with individual ready Reserves that are
activated, they are used as fillers, and so they are going with
people who they might not have trained with. There are also a
lot of other issues that revolve around insurance issues, but
worries about financial--if you have lost your business, that
is an added stress. It is not PTSD per se, but it is an added,
additional stressor. There are worries about their families at
home, and many of them have kids that some of the younger
active troops do not have.
Ms. Coleman. One other thing, suicide statistics are
renowned for being difficult to gather. The Center for Disease
Control and Prevention (CDC) says that they expect that it is
somewhere between 10 and 50 percent underreported. If a veteran
drives the family car into a tree or overdoses or gets into a
confrontation with a policeman, those are not necessarily going
to be recorded as suicides, and they are what Mike Bowman
called a ``killed by'' service. I think that it is very
difficult to actually get a handle on the number of suicides.
When CBS News asked State governments to give them the
number of suicides that they had recorded, those were the
suicides that family members chose to acknowledge, and a lot of
States do not consider something as suicide unless there is a
note that has been left. I think that the numbers that we do
have are as good as we can get.
Ms. Herseth Sandlin. Thank you both.
Thank you, Mr. Chairman.
The Chairman. Mr. Kennedy.
Mr. Kennedy. Thank you.
I just want to follow up on my initial point, when we were
speaking with the Bowmans, and it was with regard to the family
issues, the thought that the Bowmans were paying out of pocket
right now for counseling was really troublesome to me. You
know, here they are trying to get counseling for the loss of
their son who suffered as a result of his service, and they are
paying for it personally rather than the United States paying
for it. I mean, I think that we owe it to the families to be
paying for their mental health counseling as a result of the
loss that they suffer when they lose a father, a spouse, a
loved one in the line of service. In the case of a suicide,
certainly, this ought to be extended to families as well, and
it is just absolutely incredible to me that we do not have this
extended to family members.
I would like to ask you to comment on--you know, the Kaiser
Foundation just completed a study of adverse childhood
experiences. In California, they have measured the trauma dose,
basically, of children who come from families where they have
high doses of Cortisol. Basically, it is a child who comes from
a family where there is domestic violence. You know, the fight-
or-flight instinct in a human being means you have high doses
of Cortisol if one is threatened. For children, if they hear
loud screaming, if they see violence, Cortisol is released in
the brain just as it would be for any one of us and just as it
would be for a veteran or for anybody in a situation where it
is fight or flight. This creates changes in the brain.
In any event, they have measured this in families where
children come from homes where there is domestic violence,
where there is drug or alcoholism, where there are these kinds
of high-risk situations. These children are at much higher risk
for suicide themselves, for drug abuse, for a whole list of
things down the road, and this has been borne out by evidence
now.
So what strikes me is not only are we going to see a wave
of challenges with veterans down the road, but we are going to
see a wave of challenges with their families. We are talking
now about a registry for trying to track veterans' suicides. It
would seem to me we ought to be getting a registry of tracking
the children of these veterans. Can you comment on that? I
mean, we have got a whole generation of the children of these
veterans, and they have been seeing their parents go off for
two or three tours of duty.
In dealing with that kind of trauma, what do you think we
are going to deal with with these kids down the road with their
parents' coming back and having suffered all that they have
suffered and the impact on them?
Ms. Coleman. After the war in Vietnam, 20 years after the
war in Vietnam, the Australians created what they called a
``nominal role.'' They got in touch with all of their Vietnam
veterans, the ones who were still alive, and they have yearly
contact with them, and they keep track of what is happening not
only with them but what is happening with their children. And
one of the things that they found was that those children were
three times more likely to kill themselves than their peers,
which was an eye opener and a tragedy.
Ms. Meagher. That is one of the things, the secondary PTSD
of the family members. After reading an article about a cluster
of suicides and of murder-suicides that had taken place at Fort
Lewis in 2005, that is what brought me into the issue. I read
in that article that the reporter had listed how many other
family members--how many wives, how many children--were
affected, and that is when it really clicked with me that this
is a larger issue than just the mere data, than just the mere
stats of the individual people.
What makes military suicides different than any other
suicide that might be in the general population is that we have
a responsibility for these family members. If a person--and I
have a sister who committed suicide, so I know that that is
another additional reason why I was emotionally very attached
to the families who were dealing with this issue, because I
knew the stigma that our family had to go through. While my
sister was not a veteran, she was a private citizen, and there
is no obligation for the government to do anything. There is no
obligation for the community to care--my family cared--but for
our soldiers and for our military family members, we have an
obligation to them. So that is what makes it different.
As far as things that you could legislate, we have not
really talked much about what we can do to prevent and to
protect and to shore up our veterans for this new type of
warfare that they are in. I know that there is a Psychological
Kevlar Act. There are only, I believe, ten co-signers. Phil
Hare, Representative Hare, is one of them, and I am proud to be
from his State.
I think we need to look into proactive measures to be able
to help our troops from basic training onward. We need to push
the military culture to change and to grow in their idea of
what it means to prepare a soldier for battle. It is not just
to pull the trigger. It is also to be able to live with that,
that work.
Mr. Kennedy. I appreciate your mentioning the Psychological
Kevlar Act. That is my bill.
It seems to me, if we put our soldiers through strenuous
boot camp, that ought to be not only for the physical but for
the psychological nature. They ought to be prepared for what
they are going into, and we ought to have mental health
literacy as well as physical literacy when we go in.
I was really struck, Ms. Coleman, by the fact that children
of veterans of Vietnam in Australia were three times more
likely to commit suicide than their counterparts. That is
pretty----
Ms. Coleman. We do not have those same statistics.
Mr. Kennedy. We do not have the same statistics here, but
that is in Australia. Whether this is a question of our
Veterans Affairs Department, it seems to me it is a question of
our national interests. It is properly, maybe, an issue that
has to do more with our U.S. Department of Health and Human
Services--another area of our governmental policy--but it is an
issue that we have to address as a Nation and that we should
address as a Nation.
Ms. Coleman. Coming off of what Ilona said about it's being
really important that we focus on preventative care, it seems
to me--think about this. What if we immediately granted full
disability to all combat veterans who submit a claim through an
appropriate VA representative? Those benefits would continue
until the VA succeeds in denying the claim after all of the
appeals have been resolved. The VA would then have an incentive
to streamline their process, but it would also put the emphasis
on prevention as opposed to diagnostic and curative, which is
public health. I know that the flagship suicide prevention
hospital in the VA is the Canandaigua Center for Excellence,
and all of their literature emphasizes public health outreach.
It seems to me, if there were not an adversarial relationship
between veterans and the VA, that that would make it much
easier for them to get the care they need, and that would
probably make it much less expensive to take care of them over
the long run.
The Chairman. Thank you, Mr. Kennedy.
Mr. Buyer.
Mr. Buyer. Ms. Coleman, I would like for you to know that
information that we obtained to help prepare for this hearing
we got readily available off the Web, so we contacted the
Defense Manpower Data Center. Anyone in the country can get on
the Web, and they can pull down the statistics. So, in your
testimony to us that they are hiding this information, I just
want you to know that it is readily available to people.
Secondly, I would like to add, Ms. Meagher, that I want to
thank you for your contribution. I think it was therapeutic to
you, as this experience had to be. Now, as a policy maker, the
challenge is the many types of disease groups that we deal
with. Name a disease, and then we have to do this analytical
overview of populations and their propensities to have come
down with, say, cancer even if they had not been in the
military, because then we try to examine, if it was something
caused by military service, and the causal connection, the
link, because then there are dollars attached to those kinds of
things. So we study all of these things.
On this issue, with regard to suicide, we recognize that as
a society. I will go back to Dr. Snyder's comment as being
absolutely correct that, as a society, we have a challenge, and
it is the propensity of these young adults, 15- to 24-year-old
males, to committing suicide in our society, and when it is one
of the top ten killers, we have a problem in our society.
Then you do the overlay of obligation. I agree with you.
When you put on the uniform and we do the inculcation and the
matriculation process, our obligations to care for them will
continue. The overlay on what we have just discussed and what
makes it really challenging is what I brought up earlier: There
are individuals who want to use that data for their own causes
and antiwar themes. What happens is that we then get away from
what we really want: What do I want for my comrades?
What I want for my comrades is I want them to be able to go
obtain their mental health without a stigma, and that is why I
really dislike the word ``disorder.'' There is this whole
balance that we have to go through between the military. Dr.
Snyder has to struggle with this being on the Armed Services
Committee. You have got a responsibility here as commanders to
develop military cohesion that will be effective on the
battlefield right? If you are effective and you have got the
cohesion, you are also saving lives because buddies look after
buddies. Balance that with the privacy then of a soldier. Now,
commanders also have played an integral role. Because they are
responsible for military cohesion, they need to know about the
mental status of their soldiers so they can define the cohesion
to be successful. So somewhere in here is this challenge of
providing mental health services so that the commanders can
also have a comfort zone. It is not only the commanders. It is
the buddies, the man to their right and left; are they okay to
carry a weapon? You know, this is very challenging, and I think
the military is doing a better job today than what they have
done in the past on their abilities to have soldiers talk about
their experience when they debrief. It used to be John Wayne.
You know John Wayne. ``I went in. I did bad things. I feel
good. I am fine. I am going back to my job.'' No. It is okay to
talk about it.
In listening to the professionals--the psychiatrists, the
psychologists and the counselors--they talk about early
intervention is, in fact, the best. The reason it is the best
is that, as to these risk factors that we all are in search of,
not everybody shows it, and that is what is so hard. You have
done that through your own life in struggling with, ``What
could I have seen about my sister?'' I do that about my friend.
What was there? You know, my brother and I have these
conversations. We did not know. We did not see. We were with
him. I never saw it until he did something impulsive.
So I think the Chairman is on the right track here in
trying to come up with some form of a classification where
soldiers and our veterans when they return home--our Guardsmen,
Reservists--have a comfort zone where it is okay to obtain
mental health counseling; at the same time, our commanders are
in a comfort zone that the individual is not imbalanced--do you
know what I mean, that he is okay? It was okay to talk about,
when I went into the room, bad things that happened.
``Oh, bad things happened? No. What exactly happened?''
``I shot and killed two.''
``How did you feel about it?''
``I did not like it. It was my job. It was my duty. I had
to do it, but I keep thinking about it.''
``Well, what do you keep thinking about?''
So you are forced to talk that thing through, and that is
helpful, and commanders are trying to do that kind of thing.
The more we move to that prevention aspect of it, I think the
better off we are going to be in the end.
So I compliment you, Mr. Chairman. I yield back.
The Chairman. Thank you.
I wish all commanders were as open as you suggest.
Mr. Kennedy.
Mr. Kennedy. Yes. We are working on a network of care--an
Internet-based, comprehensive resource--for those who can
access it both for providers and for those trying to get help,
and that is going to be available, hopefully, throughout the VA
system. We are working on that. That is a very good suggestion.
The Chairman. I want to give you both a chance to comment
on the data question that Mr. Buyer raised.
It has been my experience that this data is not available.
We have asked people sitting in your chairs for data. They have
not provided it from the VA and from the DoD.
When I read your Web site, Ilona, it brought to mind, you
know, what if the Pentagon had to raise its money through bake
sales? You know, you are trying to do something that the
government should do, and your resources are very limited to do
that, but the government is not doing it, and it seems
absolutely necessary that they do. They do not want to know, it
looks to me. I mean, this could be tracked. We can do this. We
do not want to know the answer as far as I can tell.
Would you comment on the availability of data, both of you?
Ms.
Meagher. Well, I can say this, that I am just a private citizen
who, in 2005, was interested in the topic and thought to
myself, Well, there is this cluster of suicides and murder-
suicides, and some of them were highly decorated in Fort Lewis
in Seattle. I wanted to see, is it just happening there, or is
it happening elsewhere?
So I used simple search engine technology. I just started
Googling, and I started to find different incidents all across
the country reported in local media. Now, large Web sites like
The New York Times and The Washington Post, they are able to
archive all of their incidents. Small, local communities do
not. So, a couple of months later, maybe that police standoff--
we are not just talking suicide here. Of course, we are for
this hearing, but there are a lot of things that are going on,
and we try to track them all, and it is not meant to
stigmatize. Obviously, there is a larger portion of troops who
have the support services that they need, who have the family
in place to help them, to make the right decisions, to make the
right calls, but for those families who are having these
problems--the suicides, the police standoffs, the drunk driving
incidents, the domestic violence and on and on--those things
need to be tracked and preserved, not to point a finger but
just so that we can have some data for them to do some research
on, have the people who know how to do this research do it, and
if it is lost, then it is lost, and we lose an opportunity to
preserve that.
Mr. Kennedy. So we should track it within the corrections
system, too?
Ms. Meagher. Yes.
Mr. Kennedy. And we are not.
Ms. Meagher. If I can make one more point about law
enforcement, there are a lot of things the communities can do,
and I have already seen them happen. In my area in Dixon, the
Mayor has tried to be proactive by bringing in law enforcement
and educational institutions and churches and healthcare
organizations. Law enforcement needs to be, in many ways even,
a safe haven. We need to have military families be able to pick
up the phone--be it to law enforcement or to their healthcare
providers--and not have to fear that, if they do pick up the
phone again, there is the stigma.
If I pick up the phone and if one is having a PTSD episode,
if a loved one is having an episode, one should not be
penalized for having to pick up the phone before it gets to
this pancaking of, you know, one incident after another, and
then we have a bad record, and then we have lots of problems.
That just increases stress. We need to think about ways to
prevent that.
Mr. Kennedy. In my State, my municipal police academies
have gotten together and have put their own debriefing and
program together at their own expense because so many of the
Guard and Reservists are, obviously, first responders. When
they come back, if the VA is not doing it, they are going to do
it themselves to help reintegrate these Guard and Reservists
back into the first responder community. Of course, the issue
of those ending up Guard and Reservists and others ending up in
prison is also something we are doing as a State initiative. We
are trying to track those who are ending up in our corrections
system because of the issue of reacting badly because of the
problems that they are facing emotionally and psychologically.
Ms. Coleman. In August of 2007, the Army released a 165-
page suicide event report for the year 2006, and that was
described in all of the reports that I read as a first time
ever public analysis of what the Army called ``confidential
data'' submitted by units from across the Army over the past 2
years. I think it included previously unreleased statistics on
attempted suicides, and it found hundreds of attempted
suicides, particularly among active duty soldiers who had
returned from the war, and an increase in the number of soldier
suicides in Iraq from the previous year. I do not think those
figures had been available before.
The Department of Defense's Web site, up until very
recently, had two, three, four acknowledged suicides among
active duty troops, and there were a lot of noncombat
accidental deaths but almost no suicides. This is a very
different picture of what has been happening within the
service.
The Chairman. We thank you for your testimony. There is a
lot of movement here because we have votes over on the floor
for which we have to take about a 30- to 35-minute recess. We
will decide how we are going to conclude the hearing when we
get back.
Both of you have done tremendous work in trying to have
this Nation understand these issues, in trying to get a sense
of both raising the consciousness about the issue and speaking
to our consciences to respond to it. These are our young men
and women, and we have an obligation to them, and we have to
understand the extent of the problem and face it squarely and
then figure out what we are going to do about solving it. So
you have done a great service to the Nation with your books,
with your articles, with your Web sites. We look forward to
working with you when we have any needed legislation that we
are going to do here. Thank you so much.
We are going to recess for 35 minutes.
[Recess.]
The Chairman. Again, I apologize to our witnesses for the
recess. And also we tried to, I think, do too much in one day.
So I think, with the agreement of all the participants, we are
going to move on to panel five for the Department of Veterans
Affairs to present its testimony. And then early next year we
will hold another hearing for other testimony to continue.
I think the morning testimony was very compelling and took
a longer time than we had imagined. We thank you for waiting
this long.
Dr. Katz, Deputy Chief, Patient Care Services, Office of
Mental Health in the Department of Veterans Affairs; and Dr.
Kara Zivin, Research Health Scientist with the Health Services
Research and Development of the Department of Veterans Affairs.
You are recognized, Dr. Katz.
STATEMENTS OF IRA KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT CARE
SERVICES OFFICER FOR MENTAL HEALTH, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY ROBERT ROSEN- HECK, M.D.,
DIRECTOR, DIVISION OF MENTAL HEALTH SERV- ICE AND OUTCOMES
RESEARCH, VETERANS HEALTH ADMINISTRATION; LAWRENCE ADLER, M.D.,
DIRECTOR, MENTAL ILLNESS RESEARCH EDUCATION CLINICAL CENTER,
VETERANS INTEGRATED SERVICES NETWORK 19, VETERANS HEALTH
ADMINISTRATION; AND FREDERICK C. BLOW, PH.D., DIRECTOR, SERIOUS
MENTAL ILLNESS TREATMENT RESEARCH AND EVALUATION CENTER, ANN
ARBOR VETERANS AFFAIRS CENTER FOR CLINICAL MANAGEMENT RESEARCH,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; AND KARA ZIVIN, PH.D., RESEARCH HEALTH SCIENTIST,
HEALTH SERVICES RESEARCH AND DEVELOPMENT, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS (ON HER OWN
BEHALF)
OPENING STATEMENT OF IRA KATZ, M.D., PH.D.
Dr. Katz. Thank you, Mr. Chairman and Members of the
Committee.
I want to begin by expressing my most profound condolences
to Mr. and Mrs. Bowman and to Ms. Coleman. What they have
spoken of is important to me personally and to all of my
colleagues. I want to assure them that we have taken their
words to heart, and so has the Department of Veterans Affairs.
I want to thank you, Mr. Filner, for holding this hearing.
The discussion represents an important day for mental health in
America.
I want to go over my prepared oral testimony, but to say
that, especially after the discussion this morning, it is only
a fraction of what I am personally feeling, and it is also only
a fraction of what VA is doing.
There is no question, suicide among veterans is a tragedy.
The Department of Veterans Affairs recognizes our obligation to
work to prevent suicide, both in individual patients and in the
entire veteran population. We are concerned about epidemiology.
We are more concerned about people and the tragedies that they
represent. But we focus on epidemiology because findings in
this area can guide prevention.
VA has a long track record of research and publication in
this area. One of our leaders is Dr. Han Kang, who is here.
Others are on this panel with me.
One peer-reviewed publication from a long-term, 20-year
follow-up of Vietnam-era veterans reported that the rate of
suicide among veterans who were deployed to Southeast Asia did
not differ statistically from veterans of the same era who were
not deployed. Another published study of veterans from the
first Gulf War provided similar findings.
VA and Dr. Kang have just completed a preliminary
evaluation of suicide rates among veterans returning from Iraq
and Afghanistan. From the beginning of the war through the end
of 2005, there were 144 known suicides among these new
veterans. This number translates into a rate that is not
statistically different from the rate for age-, sex- and race-
matched individuals from the general population.
However, suicide rates among veterans are too high. The
population receiving care from the Veterans Health
Administration has more risk factors for suicide than the
general population. Most veterans are male, and men have higher
suicide rates. Those who come to the VA for care tend to be
older, less well-off and more likely to have a mental health
condition or another chronic illness. Those with the greatest
need for care are those who are most likely to come to VA. And
this increased need is associated with increased risks of
suicide.
The Chairman. I am sorry to interrupt, Dr. Katz. I just
don't understand that conclusion, that those with the greatest
need are those who are most likely to come.
We have talked for 3 hours about the reasons why people
don't come. And I could make the same case, since you are
making a hypothesis here, that there is no real data that the
people most in need don't come. I could make the very same
argument.
So, why do you think that? I don't understand it at all.
You don't know who is coming or why those who are not coming
aren't coming. You don't know that.
Dr. Katz. I will take the question for the record and get
back to you, post hearing.
The Chairman. I am just asking. You drew a conclusion which
I think is wrong, and you can't argue for it? I mean----
Dr. Katz. Well, those who come--for example, there are the
demographic issues--age, sex and all. But, most significantly,
those who come to VA for care are more likely to have mental
health conditions than others.
The Chairman. But you are not giving me any basis for
making that statement. I don't know why that is the case.
Again, those who have been subject to arguments that, you can't
come if you are weak and they accept that, no matter how
difficult--I mean, the suicides we heard about in the morning
session, they never got in touch with the VA, and they had
pretty difficult situations. So I just don't know why you would
just make that assumption.
Dr. Katz. Well, it is not just an assumption. There is no
question that there are many people in need who don't come to
VA for care. That is a problem, and it is a problem that we
have to solve. But, on a statistical basis, those who do come
to us have major care needs and, with those major care needs,
increased risks for suicide.
The Chairman. But those who don't come could even be in
greater need. You say the reverse here, and I don't know on
what basis you are doing that.
Especially, in light of the little bit of data here, 144
known suicides. We have heard arguments all morning that your
data is probably incomplete. There is unreported stuff. There
is underreported stuff. There is not tracking. I mean, you are
not anxious, it doesn't seem to me, to go after this stuff. So
you are basing your conclusions on very suspect data to begin
with.
Dr. Katz. Mr. Filner, I would like to get back to you about
your concerns. But I want to stress that the issue is
prevention. Arguing about rates isn't the issue. The issue is--
--
The Chairman. You are the one that is arguing the rates.
Every one of your paragraphs ends with a thing about the
rates--every one of them. You are not talking about prevention
here at all. I read your whole thing, and I couldn't figure out
what you were doing to stop suicides, frankly.
Dr. Katz. Well, I will tell you, our suicide-prevention
activities are based on the principle that decreasing suicide
requires both enhancing overall mental healthcare and programs
specifically designed to prevent suicide.
Part of the training for all staff has been to teach that
even strong and resilient people can develop mental health
conditions. We also teach, both within our facilities and in
the community, that care for these conditions is available and
must be provided quickly. We also teach that treatment works.
The VA Suicide Prevention Program includes two centers that
conduct research and provide technical assistance. It also
includes a suicide-prevention call center and suicide-
prevention coordinators located in each of VA's 153 hospitals.
All together, 200 staff members, 200 mental health
professionals in VA, have suicide prevention as their major
responsibility.
The Department is partnered with the Lifeline Program of
the Substance Abuse and Mental Health Services Administration
to develop a suicide hotline for VA as part of the national 1-
800-273-TALK system. Since it began, there have been more than
6,000 calls from veterans, 1,300 referrals to suicide-
prevention coordinators, and more than 300 rescues where police
or ambulances were called, any one of which may have been life-
saving.
The Chairman. Any suicides amongst those?
Dr. Katz. In our current follow-up, we haven't seen any.
The Chairman. I am sorry?
Dr. Katz. We haven't seen any.
The Chairman. You have 6,000 calls and you are giving me
all this data of 1,300 referrals, 300 rescues. But you haven't
seen or you don't know if there are any suicides?
Dr. Katz. We are doing follow-up of those who have called,
and have been referred to VA facilities and the results from
the follow-up will be available soon.
The Chairman. These are obvious questions. I don't know why
you don't have them before you come in. You give us all this
data, which is a lot of activity, but I don't know about any
results. I can't tell from your report that we have any results
here. You are giving me a whole bunch of numbers, and usually
that is a reason why you don't----
Dr. Katz. Mr. Filner, with permission, I could send to you
the stories of a number of people who have called the hotline,
so you could see the dedication and skill of VA professionals
in action.
The Chairman. I am not arguing that at all. The people who
are doing this are wonderful people. They are dedicated. They
are doing their job.
We heard testimony that something like 6,000 veterans have
committed suicide last year, or 2005, the year that CBS News
was doing it. What about that? I mean, there is nothing in here
that talks about that statistic. I mean, I don't even care if
it is right. It is somewhere close to the truth. What about
that? You say you saved 300, but what about the 6,000?
Dr. Katz. Mr. Filner, VA has a major suicide-prevention
program, the most comprehensive in the Nation. The numbers,
frankly, aren't the issue.
The Chairman. What if it was 3,000? What if it was 1,000?
What is the difference?
Dr. Katz. If the number were 300, we would still be doing
everything possible.
The Chairman. But you are not referring to why. Why do
those 6,000 exist, with all this work you are doing? What is
the measure of your effectiveness if all these people didn't
know the hotline number, they didn't call the hotline----
Dr. Katz. Sir, the 6,000 exists because mental illness is a
real illness, and mental health conditions can be fatal.
The Chairman. I understand. But to have credibility for
what you are all doing professionally, you have to address
these issues, and you are just ignoring them. You don't have a
word in here about that. I mean, it takes away the sense of
credibility that you are trying to raise here that you are
doing all this, because we have both anecdotal evidence and now
we have more statistical data that we are failing as a Nation.
Not you individually, not anybody who is on a hotline with
anybody, but as a Nation we are failing. And you are acting as
if everything is goodness and light in this effort.
Dr. Katz. Sir, Patrick Kennedy talked about mental health
in America, and he is right. VA, in suicide prevention, is
ahead of the rest of America, as we should be.
The Chairman. I will accept that. What happens to the 6,000
veterans who committed suicide last year, the 6,000 who
committed suicide the year before and the 6,000 the year before
that? What is going on with them, if we are so successful?
Dr. Katz. That is why we have the foremost researchers in
America working on this problem. That is why our mental health
budget has increased 60 percent since the beginning of the war.
The Chairman. I understand, but when you ignore these
issues in a report that is supposed to talk about what you are
doing, you damage your credibility, you damage whatever we are
trying to do. Because I have to say, you are ignoring the whole
problem here with this report. You are using activity as a
substitute for effectiveness. Just because all these people are
working doesn't mean they are effective.
Again, I don't know. We have a National Guard, which you
are not even discussing here. We have all the people who are
not enrolled in the VA, which we are not discussing here.
Mr. Bowman is still here. He made a really interesting
suggestion: Go meet these kids at the bus when they come off.
That is what I want to talk about. You heard their testimony.
Throw this prepared testimony away and talk to the Bowmans,
talk to Ms. Coleman, talk to Ms. Meagher, and say what we are
going to do about these issues. You are not doing that. I mean,
you had the advantage of listening to them. Respond to them.
You are reading this report, which, you know, had so many
questions to begin with, but I still don't know what you are
doing for those people, I still don't understand it.
You have a National Guard parent whose whole unit has never
heard anything about how to help address possible suicide. So
what are we doing about that? If you say, ``Well, we are VA; we
can't help the National Guard,'' then say that, and then I will
be happy to figure out legislation that says, you know, how you
can do that.
Mr. Buyer. Sir, can we have regular order and permit the
witnesses to testify, please?
The Chairman. If they had regular order about how to write
their reports, we would be okay. I mean, it is not helpful, the
way you are doing this.
You can complete your testimony.
Dr. Katz. Mr. Filner, with your permission, could I yield
time to Dr. Rosenheck?
Mr. Buyer. Dr. Katz, would you finish your statement,
please?
Dr. Katz. Sure.
I was talking about the major programs for suicide
prevention that VA is conducting complementing our major
expansion of our general mental health programs.
We have held two VA suicide-prevention awareness days for
required education for all employees. The first focused on
enhancing awareness of the issue; the second, training staff on
how to work with available prevention resources, including the
hotline and coordinators.
The coordinators get calls and referrals from the suicide
hotline, as well as from providers. They educate their
colleagues. Then----
The Chairman. Dr. Katz, did you study the well-publicized
incidents when Marines or soldiers walked into a VA hospital
saying they thought they had this PTSD thing, which they didn't
understand, and were having suicidal thoughts? They were told
that there was nobody available, or an appointment would not be
available for a month, and they went home and killed
themselves. Have you addressed that in here?
I mean, you are telling me about in-service training. That
is great. What happened about that training when these kids
came into the hospital and then went out and killed themselves?
Do you address that?
Dr. Katz. In this document, no. In fact, the VA has----
The Chairman. Why not? Well, you are telling me about in-
service training. There are well-publicized incidents when that
either failed or had not occurred yet. Tell us what happened in
those cases.
Dr. Katz. I will send you the case reports from the
hotline. They are incredible human stories.
I also want to talk about policy, how, beginning this
summer, we established a policy that any new request or any new
referral for a mental health appointment has to have an
evaluation within 24 hours to determine the urgency. If there
is an urgent need, care must be provided immediately. If not,
the patient has to be seen within 2 weeks.
The Chairman. Did this happen after these incidents? One in
Minnesota, one in Florida, and, I think, there was another
State. And 2 weeks wouldn't have saved them anyway. I mean, was
this in response to that, so it wouldn't happen again?
Dr. Katz. These policy advances were in response to new
patients from Iraq and the needs of established veterans.
The Chairman. Okay. I will let you continue, but, look, if
you don't deal with these stories and this evidence where we
have failed our patients, then your credibility of what you are
doing is zero. It looks like you are just shoving them under
the rug, you don't want to talk about them, you don't want to
deal with them, and so you avoid them. Some of us have memories
about these things, and some of us have policy issues. You
don't enhance your credibility when you avoid them.
Finish your testimony, please.
Dr. Katz. Well, Mr. Filner, you are being somewhat
dismissive of a major public health effort in suicide
prevention that VA is doing.
The Chairman. I am not dismissing the effort. I am
dismissing the way you are talking about it, as if everything
is goodness and light, we have no problems, everybody is being
helped, we saved all these lives. We just had 3 hours of
testimony that this is not true. Respond to that.
Dr. Katz. I was profoundly affected by what I heard.
The Chairman. But you are reading the whole report that you
wrote before you heard them, as if they didn't testify.
Dr. Katz. My reaction is thank God we are doing what we are
doing. I truly believe we are saving lives.
The Chairman. I don't disagree with that. I want to know,
what about the lives we are not saving too?
Dr. Katz. They affect all of us.
The Chairman. Well, tell us about them. That is all.
Enhance your credibility by dealing with all of them.
You may finish.
Dr. Katz. I do want to end by mentioning that we applaud
Congress for passing the Joshua Omvig Prevention Bill, recently
signed by President Bush. We have implemented essentially all
of the provisions of the bill already, and, in fact, we did so
before it was passed.
We continue to do research to develop and implement new
strategies to improve our ability to save lives by preventing
suicide. We believe our healthcare system can and must serve as
a national model for mental healthcare and suicide prevention
now and in the future.
Thank you.
[The prepared statement of Dr. Katz appears on p. 84.]
The Chairman. Dr. Zivin.
OPENING STATEMENT OF KARA ZIVIN, PH.D.
Dr. Zivin. Good afternoon, Mr. Chairman.
I would like to take this opportunity to express my
condolences to all the families who have lost a loved one to
suicide.
I am honored to provide testimony to the Committee about
suicide among veterans treated for depression in the VA health
system. I come before this Committee as a mental health
services researcher who has conducted research on this topic.
The views and opinions are expressed on my own and do not
necessarily represent those of my current employer, the
Department of Veteran Affairs, or the views of the VA research
community.
I am here today to report on findings from a study that I
conducted, along with my colleagues at the Department of
Veterans Affairs, National Serious Mental Illness Treatment
Research and Evaluation Center, SMITREC, and the VA's Health
Services Research and Development Center of Excellence in Ann
Arbor, Michigan, where I am a research investigator, as well as
an assistant professor of psychiatry at the University of
Michigan Medical School.
We recently published a paper in the American Journal of
Public Health examining suicide rates using data from the VA's
National Registry for Depression for 807,694 veterans of all
ages diagnosed with depression and treated at any Veteran
Affairs facility between 1999 and 2004. In all, 1,683 veterans
in VA depression treatment died by suicide during the studied
observation period, representing 0.21 percent of this treatment
population.
When we calculated the overall suicide rate in this
population over the 5\1/2\-year study period, it was 88.3 per
100,000 person years, which is approximately seven to eight
times greater than the suicide rate in the general adult U.S.
population.
A higher suicide rate would be expected among a population
of patients in treatment for depression than the general U.S.
population, given that depression is a potent risk factor for
suicide.
Because most healthcare systems lack the capability of
assessing suicide rates among their treatment populations,
there are few points of comparison with nonveteran treatment
populations. However, at least one prior study reports a
suicide rate for men receiving depression treatment in managed-
care settings between 1992 to 1994 of 118 per 100,000 person
years, a suicide rate which is somewhat higher than that
observed in this veteran depression treatment population.
In our study, we observed that the predictors of suicide
among veterans in depression treatment differed in several ways
from those observed in the general U.S. population. Typically,
people in the general population who die by suicide are older,
male and white and have depression and medical or substance
abuse issues. In this study, we, too, found that depressed
veterans who had substance abuse problems or psychiatric
hospitalization in the year prior to their index depression
diagnosis had higher suicide rates.
However, when we divided the depressed veterans into three
age groups--18 to 44 years, 45 to 64 years, and 65 years or
older--we found that the younger veterans were at the highest
risk for suicide. Differences in rates among depressed veterans
of different age groups were striking: 18- to 44-year-olds
completing suicide at a rate of 95 suicides per 100,000 person
years, compared with 77.9 per 100,000 person years for the
middle-age group and 90.1 per 100,000 person years for the
oldest age group.
We did not assess whether individuals had served in combat
during a particular conflict, although the existence of a
military service-connected disability was considered.
In this VA treatment population, men veterans were more
likely to commit suicide than women veterans. Suicide rates
were 89.5 per 100,000 person years for depressed veteran men
and 28.9 per 100,000 person years for veteran women. However,
the differential in rates between men and women in this
population of three to one was smaller than that which has been
observed in the general population of four to one.
We found higher suicide rates for white depressed veterans,
95 per 100,000 person years, than for African Americans of 27.1
per 100,000 person years and for veterans of other races, 56.1
per 100,000 person years. Veterans of Hispanic origin had a
lower rate, 46.3 per 100,000 person years, of suicide than
those not of Hispanic origin, 86.8 per 100,000 person years.
Adjusted hazard ratios also reflected these differences.
Surprisingly, our findings revealed a lower suicide rate
among depressed veterans who also had a diagnosis of post
traumatic stress disorder, PTSD, compared to depressed veterans
without this disorder. Depressed veterans with a concurrent
diagnosis of PTSD had a suicide rate of 68.2 per 100,000 person
years compared to a rate of 90.7 per 100,000 person years for
depressed veterans who did not also have a PTSD diagnosis.
We investigated further to examine whether specific
subgroups of depressed veterans with PTSD had higher or lower
suicide risks. We found that concurrent PTSD was more closely
associated with lower suicide rates among older veterans than
among younger veterans. This study does not reveal a reason for
this lower suicide rate, but we hypothesize that it might be
due to a high level of attention paid to PTSD treatment in the
VA system and the greater likelihood that patients with both
depression and PTSD will receive psychotherapy and more
intensive visits. In general, individuals with depression and
PTSD diagnoses have higher levels of VA mental health services
use than individuals with depression without PTSD.
Interestingly, depressed veterans who did not have a
service-connected disability were more likely to commit suicide
than those with a service-connected disability. This may be due
to greater access to treatments among service-connected
veterans or more stable incomes due to compensation payments.
We hope that our findings will help inform clinical
treatment and policy initiatives to reduce suicide mortality
among veterans with depression.
I thank you for this opportunity to testify and will be
pleased to answer any questions that you have.
[The prepared statement of Ms. Zivin appears on p. 86.]
The Chairman. Mr. Mitchell.
Mr. Mitchell. This question is for Dr. Katz.
And I have read your testimony. I didn't hear your
testimony, but I read your testimony. And one of the things I
am concerned about is, throughout your testimony, you are
talking about those programs you have in place, which is good,
and that you are effective for those you have in place.
But what bothers me is, this morning we heard testimony
from the parents of Timothy Bowman, whose numbers will not be
in your figures. He committed suicide. He will not be part of
the DoD or the VA's numbers. And my concern is, unless somebody
comes and registers with you, what outreach do you have?
You know, this is a very serious problem, those who do not
register. All you have are figures of those who came in and
registered with the VA. Even in Arizona, this is a growing
concern. Veteran suicide rates in Arizona have risen 39 percent
since 2003, and one-quarter of all suicides in Arizona are with
veterans. This is, I think, an epidemic.
And I know what you are saying with all of those figures
that you have there, but my concern is, do you really have
enough resources to go after the veterans who do not show up
and are not on your figures, the figures either from DoD or the
VA? Because I think it is important that we go out and try to
get the correct figures.
Am I understanding that you have not really collected
figures, total figures, on all those returning from Afghanistan
or Iraq?
Dr. Katz. Well, I want to begin by--actually it is very
ironic. We know that Tim Bowman was a person and that his loss
is terrible, and, as a Nation, we have to mourn him. The
question is, is he a statistic? Is he counted in VA research?
And the answer is yes. Dr. Kang's research counts all veterans,
whether or not they have come to VA for care.
This raises questions about, the people who don't come to
VA for care, how are we reaching out to them? Our Vet Centers
have hired over one hundred peer counselors, ex-vets who go out
to post-deployment health reassessment, who go to Guard and
Reserve meetings, and who speak in community centers and
related venues. There are more than 90 returning veterans
outreach teams in our medical centers and clinics. We really
have extensive outreach.
Is it enough to enroll every veteran? No. Is it enough to
prevent every suicide? Apparently not.
We have, thanks to you, considerable funds. And our goal,
our mission and our challenge is to use these funds
effectively. We really have to go reaching out to people and
providing services, where mental healthcare has never gone
before. We have intensive research going on, and VA has, by
necessity, become more adept at translating research into
clinical and public health action than anyone else. Are we
there yet? Of course not. Have you given us enough resources?
Yes. Our challenge is to use them to improve lives and save
lives.
Mr. Mitchell. So, Dr. Katz, you are telling me that you
have enough resources to do the job that is necessary to find
these veterans and to treat these veterans. You have enough
resources.
Dr. Katz. Yes, sir.
Mr. Mitchell. Thank you.
The Chairman. Mr. Buyer.
Mr. Buyer. You know, sometimes, Mr. Mitchell, it is not
just a matter of resources, it is what are you going to do with
them.
Mr. Mitchell. Yes.
Mr. Buyer. When you look back, 3 years ago we gave them
$300 million, and they couldn't even spend $100 million of it.
Dr. Katz. Can I comment about that, sir?
Mr. Buyer. You may.
Dr. Katz. A year ago, the Committee raised concerns that
there was underexecution of mental health enhancement funding.
I guess that is bureaucratic talk for under-spending of the
resources.
This past year, there were $306 million allocated for
mental health enhancements in VA. The actual spending was $325
million. We overspent and, to be honest, we were congratulated
by senior leadership for overspending, because nothing is more
important than mental health.
Mr. Buyer. I hate to get into the numbers and statistics,
but I am going to do that for just a second, because, really,
it is all sort of disturbing to me.
I look at the Inspector General's (IG) report, and the IG
says, all right, out of the 25 million veterans in the United
States, they estimate as many as around 5,000 veterans per year
are turning to suicide, of the 25 million. Then CBS News, they
throw out a number of 6,256 in 2005. I mean, since this report
came out, I mean, there is a difference of 1,200. That is still
a big number to me.
But I am curious, do you know how CBS News came up with
that number if the IG or the VA comes up with a different
number? Are you familiar with how they--has CBS News shared
with you the methodology of how they came up with their number?
Dr. Katz. They shared their algebra but not their raw data.
We want the numbers. It could help to guide and fine tune our
prevention efforts. They handed me the numbers when I was
interviewed, and then they took it back. We requested it from
the producers. The Inspector General requested it from the
producers. They are not forthcoming about the numbers. I would
think that, as a matter of citizenship, CBS News should be
required to provide these numbers, so VA can translate them
into prevention.
Mr. Buyer. Well, the numbers are important in how we get to
them.
Let me ask Dr. Zivin, is it important for us to understand
the gender distribution in these numbers?
Dr. Zivin. The gender distribution, was that your question,
sir?
Mr. Buyer. Yes. Is that important for us to know as
policymakers.
Dr. Zivin. It is important for us to know all
characteristics associated with suicide and how those may be
similar or different in the VA or among all veterans than the
general population. And that is something we are studying. We
have both VA- and NIH-funded research to examine all
characteristics associated with suicide.
Mr. Buyer. Have you seen the CBS News report?
Dr. Zivin. I have seen it, yes, sir.
Mr. Buyer. And what is your opinion regarding the fact that
gender distribution would have been left out of their numbers?
What does that tell you?
Dr. Zivin. Sir, I would like to ask the members of this
panel if they would like to comment on this, or perhaps we
could get back to you about this.
Mr. Buyer. Well, if anyone here on the panel has an opinion
on it, please let us know. Because I think it is rather
bothersome that they would leave out gender distribution. Does
anyone have an opinion with regard to that?
Dr. Katz. They controlled for gender but did so in a very
strange way. Their number for veteran suicides is not, in fact,
an accurate reflection of the rates of suicide.
Dr. Rosenheck, you wanted to comment?
Dr. Rosenheck. Well, actually, I wanted to shift gears a lit
tle bit.
Mr. Buyer. No.
Dr. Rosenheck. Okay.
Mr. Buyer. I get to shift gears.
Dr. Rosenheck. In direct response, none of us feel we have
seen a complete report of this data so that we, as professors,
can judge the validity of the conclusions.
Mr. Buyer. All right. I am not going to challenge the
intent of CBS News, because I am hopeful that their intent and
motivation was pure. And if it was pure, they have nothing to
hide and should be willing to work with you, with regard to the
numbers.
Let me ask this question. The Canadian Government uses the
term ``operational stress injury''--they don't use PTSD to
describe their diagnosis. Would that be useful and helpful to
us, if we would turn to ``operational stress injury'' so we can
maintain PTSD but come up with another type of description
whereby it encourages soldiers and veterans to come in to
discuss this without stigma? Do you have an opinion with regard
to that?
Dr. Katz. Well, I think we heard from the world's experts
about what we call it. And in terms of what it is called and
how people react to that, the world's experts are the consumers
and the families. If they want to change the name, we should
change the name.
Mr. Buyer. Mr. Chairman, with latitude, I have one last ques
tion.
One of the concerns is being able to provide mental health
services to members of the National Guard and the Reserve
components when they return from their overseas deployments. In
Indiana, on January 2nd, I will stand with the 76th Brigade. We
are going to send an entire brigade to war. Not since World War
II.
So what outreach programs do you, the VA, have in place for
the National Guard and the Reserve?
Dr. Katz. There are peer counselors from the Vet Centers
who should be there, as should returning veterans outreach
people from our medical centers and clinics.
Mr. Buyer. How do we prepare the families while the
soldiers are gone? What do we do that is proactive?
I think that is what the Chairman--my interpretation is,
what are you doing on the prevention side? Let's not just wait
until they come home. What are we doing to help prepare the
families?
We do a lot with the families, not only their care
packages, and they have their own support groups. But what do
we do, in being off our heels and on our toes, to be proactive
on what they should look for? What should they be doing to be
helpful to them while they are deployed? Are we doing anything?
Dr. Katz. Vet Centers are authorized to provide outreach
and education for families under specified circumstances while
the veteran is deployed. VA is not authorized by law to do so.
Mr. Buyer. Under specified circumstance. That is telling me
that is some sort of limited service.
Dr. Katz. I am actually confessing my personal lack of
knowledge about the specifics. I am embarrassed. I apologize
for it. We will have to get back to you.
Mr. Buyer. I understand that these men and women are
activated so now they are part of DoD.
Dr. Katz. Yes.
Mr. Buyer. But we deal with the consequences of war, the
consequences. And it is easy to take care of them when we see
the physical wound, so it is the mental wound that is our
challenge.
So this leads to the whole path of how we work
cooperatively with DoD in trying to get bi-directional, on-
time, real-time mental health data. That is a real challenge.
But here is what I want to do. I want to do this with you.
We now know we have a brigade that is going. I am going to work
with you. I want you to work with myself and the Chairman of
this Committee, as we also work with DoD, and you tell us what
we can do that is proactive with regard to this brigade as it
goes, and what authorities do you need, what do you need from
us. You probably don't need much authority. A lot of things you
can do. But tell me what you can't do, and we can break down
these barriers.
Will you take that on with us?
Dr. Katz. Absolutely, with pleasure and with honor.
Mr. Buyer. All right. Thank you.
I yield back.
The Chairman. And I give the same answer, with pleasure and
with honor.
Mr. Buyer. All right. Thank you.
The Chairman. Let me just say a few words.
Mr. Buyer mentioned that CBS News had 6,000 and IG had
5,000. That is a big difference. Both of those are a big
difference, from what I see in this. It is a different
universe, Iraqi and Afghanistan, since 2005--144. I mean, this
is a purposeful putting forth the lowest figure that you could
possibly get to.
Dr. Katz. No, sir. Those are the full count of suicides in
returning veterans.
The Chairman. But you chose a universe on purpose that
never would touch--how about 5,000 or 6,000? That would get
people annoyed. 144? Oh, I can live with that. You are giving
numbers here that do not reflect reality in terms of the
problem that we have to face and you have to face as
policymakers.
And, frankly, your statement, Dr. Katz, that ``CBS News
should be required to give the statistics''----
Dr. Katz. Yes.
The Chairman [continuing]. That is disgraceful from an
organization, that they have to FOIA, we have to FOIA, a parent
has to FOIA, to get any information on this.
I have, from this chair to that seat--and maybe you were
one who was there, I can't recall now--at least three or four
different times in the last 7 or 8 months, asked for data on
suicides from the VA. They always said they will get back to
me. They have never gotten back to me. You try to get data, you
get all kinds of different numbers from different universes.
And besides, the data you use, as we have heard this
morning, is all slanted anyway. I mean, it is a very specific
definition of a suicide that you are using that is way
underreported from the reality.
CBS News tried to get the data. They didn't want to spend 6
months going to States and do this thing. They couldn't get the
data from you because you don't track this stuff. You simply
don't track it. You don't want to know about it.
And I had a whole report from Dr. Zivin, who--I never, by
the way, ever heard somebody on the panel say they are not
speaking for the Department of Veteran Affairs when you are
here. I mean, they must have approved this, but you are not
speaking for them. I don't know, that is strange.
But you give four or five pages of data. I don't see
anybody on this panel, in prepared testimony, say what you are
going to do. How does this inform your treatment? What
prevention are you doing to do based on this?
This is a bunch of numbers that is meaningless in the
context that we are working in today. That is, you had time to
give this data to somebody to say, ``What are we doing about
using this data for actual clinical or preventive operations?''
And there is nothing. It is just a case of--of ``analysis
paralysis.'' It is just a bunch of statistics that you are
going to throw out to us here and say that you have done your
duty. You guys have not done your duty. You have not given us
adequate numbers or even an explanation of the problem in
getting those numbers.
We haven't talked about, if there are 5,000 or 6,000 or
2,000 veterans that are dying every year, how are we going to
get to them? You tell me what you are doing, but you are not
telling me about the evidence that we have that we are not
being effective. How are you dealing with that? You have not
done the job.
We are going to have another hearing on this.
[Applause.]
And I want you to come back with a better report. This is
not very useful. Again, all you do is compare some things in a
strange universe that does not come to grips with the issue.
Dr. Katz. Mr. Filner?
The Chairman. Mr. and Mrs. Bowman this morning, and the
other testimony, were crying out for help. I responded to say,
here is what I am thinking about to respond. I don't know if it
is good or bad. I said we have to have a public education
program. I said we have to have mandatory diagnosis of PTSD and
brain injury. I said we have to do that in a unit with family
there.
You didn't come up with anything. You didn't even respond
to my meager suggestions.
Dr. Katz. Mr. Filner, I really need to respond to one specif
ic issue.
The Chairman. Respond to them all. I don't care.
Dr. Katz. Well, we can provide additional numbers.
The Chairman. You always say that, and we never get
anything.
Dr. Katz. We can provide additional----
The Chairman. I have done this for at least several years.
Dr. Katz. You are delivering the message to America that
there are major problems in VA treatment. I want to deliver the
message that care is available and that treatment works. We
have programs in place that can help people.
The Chairman. How would you have helped Timothy Bowman or
the Timothy Bowman that is coming tomorrow? Nobody has talked
to them, nobody has done anything, nobody has counseled them,
nobody made Timothy aware of anything, and nobody is making the
Timothys of tomorrow aware. So how are you responding to their
cry for help?
Dr. Katz. It is tragic that----
The Chairman. But what are you doing about it?
Dr. Katz. We are doing the----
The Chairman. But it didn't reach these people.
Dr. Katz. That is tragic.
The Chairman. Well, then find a more effective way. Don't
keep telling us you are doing things when they are not
effective. It is proven not effective. You reach a very small
percentage of those who need help. Why?
Dr. Katz. Sir, I really think we want to emphasize the
message that treatment is available and treatment works.
Because that message is a matter of public health, and that
message can be life-saving.
The Chairman. Well, let me tell you the message that I want
to send, that we have an epidemic, as has been said before, we
have a public health crisis. And no matter how hard you are
working now, we are not doing the job. We need to do more.
And you need to tell us, rather than how much stuff you are
doing, what we need to do to be effective. You answered Mr.
Mitchell that you had sufficient resources. You don't have
anybody to call up Mr. Bowman to even offer condolences, let
alone help his counseling. So, I mean, surely some more
resources would be nice.
Mr. Mitchell, you have a question?
Mr. Mitchell. Yes. I would like to follow up on that with
Dr. Zivin.
According to your testimony, your study was based on
veterans who had been diagnosed with depression and were
treated at VA hospitals or VA facilities.
What I would like to know is, what about veterans who don't
fall in either of these categories? What about the veterans who
have not been diagnosed with depression or who have not been
treated at VA facilities? What about the veterans who are
suffering from post traumatic stress disorder or haven't
visited a VA facility?
Could you shed any light on the scope of the problem facing
these and other categories of veterans?
Dr. Zivin. It is true that we focus in this study
specifically on depressed veterans treated in the VA
population, and that represents only a fraction of all veterans
who either have depression or PTSD or both. And one of the
things that we are doing as part of our ongoing research and
what Dr. Katz was just alluding to is that we are now
collecting and having data on all veterans, with or without
depression, and rates of suicide.
One of the other things to mention is that the VA has
developed a comprehensive strategic plan which is specifically
focused on treatment for PTSD, suicide prevention and a number
of other initiatives specifically targeting at-risk veterans.
And I will ask my colleagues here to comment further, if
you have other questions.
Mr. Mitchell. Just one comment to add to that. There are
some people who come back who don't believe that they have a
problem, and therefore, they don't register. Maybe they don't
fill out the forms or tests that I understand are necessary,
yet they have it. Is there any outreach?
I understand, Dr. Katz, you said you have programs, but
there are only programs if somebody comes in. What about the
people who have not been diagnosed yet who end up with this
disorder months, maybe years, later? What about those who have
not registered with the VA?
What kind of programs do you have in place, not just to
reach those who have registered and who have been diagnosed,
what kind of programs do you have in place to go beyond that?
Dr. Katz. We are in agreement that a major challenge for us
is reaching more people. We have talked about what we do for
those who enter our doors, either the Vet Centers or medical
centers and clinics. We have talked about the outreach that we
are doing. How do we effectively reach the rest of the
community?
Dr. Kussman is writing a letter that should go out this
week or next to all veterans, raising these issues. Other
strategies are being developed including additional follow-up
to the post-deployment health reassessment. We recognize the
need to do more to reach more people, yet we are working
intensively--and we are working intensively on how to do it.
Dr. Rosenheck reminded me of a fact from Dr. Han Kang's
work that makes this issue very poignant. Among returning
veterans, among OIF/OEF veterans, the rates of suicide among
those who come to us don't differ from the age-, sex- and race-
matched individuals, but the rates of suicide among those who
don't come to us are higher. It is reassuring about what we are
doing and a clear message about what we should be doing next.
Mr. Mitchell. Absolutely.
And one last question, real quickly. Do you believe that
there is a suicide epidemic?
Dr. Katz. There is a suicide epidemic in America.
Mr. Mitchell. Among veterans?
Dr. Katz. The numbers--what are the numbers? About 18
veterans kill themselves each day in America. That is too many.
About four or five----
Mr. Mitchell. According to CBS News, it was 120 a week.
Dr. Katz. About the same.
Mr. Mitchell. That is not higher than the general
population?
Dr. Katz. Rates among veterans are somewhat higher than the
general population because of demographics and increased in
risk factors for depression, related conditions.
Mr. Mitchell. I think one way we can find out about that is
if you have the data. And I think that is--you know, one of the
people were arguing about earlier was the methodology data that
CBS News had. And if we had the data, we could certainly refute
or agree that there is or is not an epidemic and it is more so
among veterans. I think that is what we have been trying to
find out.
Dr. Katz. Some of the Nation's foremost investigators in
this area are before you.
Dr. Blow, could you talk about some of the data?
Dr. Blow. Sure. Among veterans receiving services in VHA,
so those actually touching the VHA, the rates are about 1\1/2\
times age- and sex-adjusted population rates. The rates for
women are about two times that of that U.S. population overall
rates for women. So it is much higher for women than for men.
Mr. Mitchell. Again, these are people in your system.
Dr. Blow. That is exactly right, the 5.5 million veterans
who actually we serve.
Mr. Mitchell. We already heard about someone not in the
system. That is the purpose of what we are trying to find,
people who are not in the system being treated.
The Chairman. Mr. Mitchell, this room has been reserved for
another Committee, so we have to adjourn this.
I have one last--you have a last statement.
Mr. Buyer. Dr. Katz, I want you to go back from here and
talk with your chief and your team, and I want you to be ahead
of us. Work with your counterpart in DoD between their
BattleMind Training initiative that they have, along with your
initiatives, and we will use that brigade as a cohort. And we
are going to circle back here next week, okay? But get ahead of
us. All right.
Dr. Katz. Thank you.
The Chairman. Thank you, Mr. Buyer.
And let me again--I mean, I am very disappointed with the
testimony. When Mr. Mitchell gave you a chance just to talk
about outreach, you said that the Deputy Secretary is writing a
letter. That doesn't do it.
Look, I will just comment on one thing. We know, we
absolutely know as a fact--I don't care what any researcher
tells me--that the images of war in Iraq trigger PTSD reactions
in people from earlier wars. I could figure out a hundred ways
for you to go out to those people now. Just take the Vietnam
vets. Go out, find them and say, ``We are going to help you.''
You have all this great stuff you are telling me about. We
know Iraq is going to trigger this from Vietnam vets. Go find
them. Go to the Vet Centers, go to the Vietnam Veterans of
America, go to the VSOs who are here. Go to the major cities.
Set up a place where you can screen people more. Go out to
communities.
You are doing this research which doesn't tell us anything,
and you are not reaching the people who need the help. We said
it many times this morning. We have an obligation. You are not
meeting that obligation. You are doing stuff and you are
spending a lot of money and you have all these professors, but
we are not meeting the needs. And until we do that, we are not
going to be satisfied here.
We are going to take this up early next year. We will
continue the hearing we started today. But we are going to talk
to the new Secretary, General Peake, and let him know how
disappointed we are in this, and hopefully we can move to do
our veterans a greater service. We are not doing the job now.
Mr. Kennedy.
Mr. Kennedy. I would just like to ask that you apply the
bottom line to the families of veterans so that they can better
identify these symptoms amongst their own family members.
Right now they are not given the tools, so to speak, of being
able to act as the identifier and supporter of their own loved
one when they come home.
Am I right?
Dr. Katz. You are right. Vet Centers, as well as DoD, can
begin on it. For medical center and clinic staff to do that
would take an act of Congress.
Mr. Kennedy. But family members are the ones who spend the
most time with their loved one. They ought to be brought in and
made a better and bigger part of this whole process.
Dr. Katz. Absolutely.
The Chairman. And acts of Congress is what we do, so just
tell us what we need to do.
Mr. Buyer. Mr. Kennedy, that is exactly what we are going
to try to do.
Mr. Kennedy. And finally are we tracking--as you said,
women are twice as likely to have suicide rates within the VA
as men. Are we tracking women veterans within the VA separately
from men and their issues, because I understand they have very
specific and unique issues as to men veterans when they are in
the VA system.
Are we doing----
Dr. Blow. There are many initiatives in the VA to enhance
services for women veterans with their special needs and
especially with the special needs that they encounter because
of their combat exposure.
Mr. Kennedy. Yes, but are we tracking their women-specific
issues, around their specific issues, mental health needs,
issues?
Dr. Blow. Yes, absolutely. We have many different women's
mental health initiatives trying to find out what happens to
them over time, and we try to address their specific needs in
treatment.
Dr. Katz. A minor correction. The twofold is women in the
VA relative to women in the general population. It is still a
lower rate than men.
Dr. Rosenheck.
Dr. Rosenheck. I did want to talk to the Bowmans because I
am the son of a veteran who committed suicide, and I have been
now in the VA and have been a psychiatrist and have been a
professor of psychiatry and epidemiology for almost 40 years,
and my work is animated every day by the fact that my father
was a veteran who had committed suicide. I want to tell you
that my colleagues in the VA come to this work with a personal
sense of mission. All of us, many of us--more than in any other
group--are veterans, and more than any other group, we know and
have been touched by mental illness and by all kinds of
illness. People do not come to the VA as a simple, professional
job. People who work in the VA are driven by a sense of mission
and of caring, and I want to say, in shifting back to my
capacity as program evaluator and as a scholar--well, I am
staying with the personal--I started with the VA in 1973. I was
a first-year resident at the VA in Connecticut, and I was
seeing veterans coming back from Vietnam. I have worked at the
VA for my whole career since then, and the change from 1973 to
now is so astonishing. When I was a first-year resident, I had
no language. I had no culture. I had no background to
understand the young men who were coming and sitting in front
of me right off the battlefield. We had no terms.
Now, whether you talk about PTSD or PTSI, we have a
language, and the whole country knows it. I get called by
reporters, ``Can you get PTSD from watching the war on TV?''
Everybody knows about this syndrome, and they know about it
because of the gift of the Vietnam veterans. Every year, we are
seeing more and more--I have been tracking it for 10 years, and
the progress we are making in terms of the numbers of veterans
we are seeing is astonishing, and the commitment of the
organization from the bottom to the top to serving veterans who
served in combat, I can just----
The Chairman. We thank you for that.
Mr. Kennedy. I understand that we do not on the women's
side----
The Chairman. Mr. Kennedy, we have to end this.
Mr. Kennedy. We are not tracking women-specific issues from
the general veterans' population, and I hope that we do a
better job of doing that.
The Chairman. Let me just say in conclusion, Dr. Katz and
your colleagues, nobody is disputing your personal commitment
or your effectiveness in dealing with veterans. What we are
saying is how much of a--possibility exists in this country to
deal with these issues. That is the great disappointment to me.
We have the ability to do the job for everybody. Although we
have made progress and we have all of these dedicated people,
we have not done the job. And until we do the job, we are going
to keep up the oversight that we have to do.
This hearing is adjourned.
[Whereupon, at 2:35 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Bob Filner,
Chairman, Full Committee on Veterans' Affairs
Good morning and welcome to the House Veterans' Affairs Committee
hearing on Stopping Suicides: Mental Health Challenges within the
Department of Veterans Affairs.
Mental health issues have been a focus of this Committee all year
long and will continue to be at the forefront of our agenda. Public Law
110-110, the Joshua Omvig Veterans Suicide Prevention Act, was enacted
in November of this year.
The House has also passed H.R. 2199, the ``Traumatic Brain Injury
Health Enhancement and Long-Term Support Act of 2007,'' H.R. 2874, the
``Veterans' Health Care Improvement Act of 2007,'' and H.R. 612, the
``Returning Servicemember VA Healthcare Insurance Act of 2007.'' Each
of these pieces of legislation addresses mental health issues in some
aspect concerning the well-being of veterans.
The demands confronting VA today are complex and sometimes
overwhelming. VA must find a way to ensure quality and efficiency do
not suffer as they move forward, continuing to treat veterans from past
wars while adapting to the unique needs of the younger veterans of
modern warfare who are entering the system for the first time.
We know that OEF/OIF servicemembers are subject to repeated
deployments, an intense level of close combat, extended deployment
lengths and repeated family separations.
VA has reported that of the 263, 909 separated OEF/OIF veterans who
have obtained VA healthcare since FY 2002, 38 percent have received a
diagnosis of a possible mental disorder. Of that population, 48 percent
have a possible diagnosis of PTSD. The prevalence of mental health
problems among returning servicemembers is troublesome and should be of
concern to everyone.
Recent events have been brought to the attention of this Committee
through a CBS report on the rising suicide rates among veterans. We
also know that male veterans are at elevated risk of suicide relative
to nonveterans. In fact, they are twice as likely to die of suicide
compared to male nonveterans in the general population.
Of great concern to the Committee is the recent VA Inspector
General report that found that nearly 1,000 veterans who receive VA
care commit suicide every year, and as many as 5,000 a year are
committed among all living veterans.
Today we will take a hard look at programs the VA has implemented
to address the challenges of suicide.
I look forward to the upcoming testimony.
Prepared Statement of Hon. Stephanie Herseth Sandlin
Thank you to everyone for being here. I congratulate Chairman
Filner and Ranking Member Buyer for holding today's hearing to examine
and identify mental health challenges within the Department of Veterans
Affairs healthcare system.
As the wars in Iraq and Afghanistan continue to produce a new
generation of veterans, it is important that Congress evaluate the
impact of these conflicts on the mental well-being of returning
servicemembers. We must closely evaluate the ability of the VA to meet
the mental healthcare demands placed upon it.
While I am pleased that the VA offers a wide array of mental health
programs, there continues to be room for improvement. In particular, I
believe we must do more to meet the mental healthcare needs of our
rural veterans--who often must travel long distances to reach VA
healthcare services.
I am pleased that we have the opportunity to hear from today's
panelists and am grateful to have the opportunity to hear their
suggestions and answers to the critical issues involved. I look forward
to hearing their testimonies.
Again, I want to thank everyone for taking the time to be here and
discuss these important matters.
Prepared Statement of Hon. Harry E. Mitchell
Thank you, Mr. Chairman. And thank you for holding today's hearing.
Last month, CBS News brought some shocking, and critically
important information to light. Not just that those who served in the
military were more than twice as likely to take their own life in 2005
than Americans who never served or that veterans aged 20 to 24 were
killing themselves when they returned home at rates between two-and-a-
half to four times higher than nonvets the same age, but that the
Department of Veterans' Affairs wasn't keeping track of veteran
suicides nationwide.
The VA is one of the best healthcare systems in the country, with
literally thousands of professionals working to help veterans with
mental health needs.
But with all due respect, if the VA doesn't know the size and the
scope of the problem, how can we know if they're adequately addressing
our veterans' mental health needs?
As disturbed as I was by the CBS' report, I was even more disturbed
by the VA's response. Instead of reviewing the information and thinking
critically about whether the VA might need to take some additional
measures, they immediately attacked the messenger, calling CBS News'
analysis a ``questionable journalistic tactic.''
Obviously it would be great to compare CBS' numbers to those kept
by the VA, but that's precisely the point; the VA hasn't been keeping
them.
I think this kind of defensiveness is a disservice to veterans, and
to all the hardworking employees of the VA who are doing their best to
help our wounded warriors.
So, as we begin today's hearing, I just want to say that I hope we
can get past the name-calling, and hurt feelings and gotcha-fights
about methodology and do what the American people expect us to do: work
together to prevent more of these unspeakable tragedies and, if at all
possible, try to bring some small measure of comfort to those who
mourn.
I yield back.
Prepared Statement of Hon. Cliff Stearns
Mr. Chairman,
Thank you for holding this important hearing today. The statistics
regarding the rate of suicides among veterans is beyond alarming, it is
catastrophic. These young men and women are heroes--each and every one
of them. Veterans returning from war frequently become valued neighbors
and leaders in their community, giving of their time and themselves to
help others at home as they did abroad. Their presence reminds us of
the high cost of our freedom, and inspires us to act for others rather
than just ourselves. These young men and women who have served our
Nation in such extreme circumstances--enduring unbelievable amounts of
the stress of war so that those of us who remain at home can live in
the peace they protect, deserve the utmost respect--and the utmost care
that we can provide.
It is appropriate today that we remember that the problem of the
traumatic effects of war upon our veterans has been grappled with for
decades. In fact, only about two hours away lies the battlefield of
Antietam--the bloodiest single day battle in all of American history
with almost 23,000 casualties. Many of those that survived left the
field with more hidden wounds that bandages could not bind. Back then,
it was called by other names like ``war sickness.'' In World War II it
was ``shell-shock'' or ``battle fatigue,'' through the years until now
we refer to it as ``Post Traumatic Stress Disorder.'' From the very
first shots fired for our independence, those who fought to maintain
that independence have suffered under the traumatic stress.
Throughout our battle history, we have learned more and more
regarding best treatments for this condition, yet more needs to be
done. I would be interested in statistics that could show clearly the
leading factors to suicide attempts. Are most veterans who commit
suicide suffering from PTSD, or from other complicating reasons such as
substance abuse, or other mental conditions? The better we can identify
the key indicators and symptoms leading toward suicide attempts, the
better we can develop and provide treatments. As a co-sponsor of H.R.
327, the Joshua Omvig Veterans Suicide Prevention Act, I was proud when
it was signed into law on November 5, 2007. I believe that this is a
key step toward attacking this problem. I also understand that the VA
is improving its screening processes, hiring more counselors, and
developing more ``best practices'' to combat this growing problem.
However, the clock is ticking, and we need to move quickly to prevent
the loss of more of our wounded warriors. I look forward to hearing
from our panel of experts more about this dreadful problem and how we
are going to work together to prevent the loss of more of our Nation's
heroes.
Prepared Statement of Mike and Kim Bowman, Forreston, IL
(Parents of Specialist Tim Bowman, U.S. Army, Illinois National Guard,
Bravo Troop, 106th Cavalry)
Mr. Chairman, members of the committee, my wife and I are honored
to be speaking before you today representing just one of the families
that lost a veteran to suicide in 2005.
As my family was preparing for our 2005 Thanksgiving meal, our son
Timothy was lying on the floor of my shop office, slowly bleeding to
death from a self-inflicted gunshot wound. His war was now over, his
demons were gone. Tim was laid to rest in a combination military,
firefighter funeral that was a tribute to the man he was.
Tim was the life-of-a-party, happy-go-lucky young man that joined
the National Guard in 2003 to earn money for college and get a little
structure in his life. On March 19th of 2005 when Specialist Timothy
Noble Bowman got off the bus with the other National Guard soldiers of
Foxtrot 202 that were returning from Iraq he was a different man. He
had a glaze in his eyes and a 1,000-yard stare, always looking for an
insurgent.
Family members of F202 were given a 10-minute briefing on PTSD
(Post Traumatic Stress Disorder) before the soldiers returned and the
soldiers were given even less. The commander of F202 had asked the
Illinois Guard Command to change their demobilization practices to be
more like the regular Army, only to have his questions rebuffed. He
knew that our boys had been shot up, blown up by IED's (Improvised
Explosive Device), extinguished fires on soldiers so their parents
would have something to bury, and extinguished fires on their own to
save lives. They were hardened combat veterans now, but were being
treated like they had been at an extended training mission.
You see, our National Guardsmen from F202 were not out filling
sandbags. They departed in October of 2003 for 6 months of training at
Forts Hood and Polk. On Tim's 22nd birthday, March 4, 2004, Foxtrot
left for Iraq where they were stationed at Camp Victory. Their tour
took them directly into combat including 4 months on ``the most
dangerous road in the world,'' the highway from the airport to the
Green Zone in Baghdad where Tim was a top gunner in a Humvee. Tim as
well as many other soldiers in F202 earned their Purple Hearts on that
stretch of road known as Route Irish. We are STILL waiting for Tim's
Purple Heart from various military paperwork shuffles. My wife and I
are not here today as anti-war protesters. Our son truly believed that
what his unit did in Iraq helped that country and helped many people
that they dealt with on a daily basis. Because of his beliefs, I have
to believe in the cause that he fought and died for. That doesn't mean
that I don't feel that we lost track of the overall mission in Iraq.
When CBS News broke the story about veterans suicides, the VA took
the approach of criticizing the way that the numbers were created
instead of embracing it and using it to help increase mental healthcare
within their system. Regardless of how perfectly accurate the numbers
are, they obviously show a trend that desperately needs attention. CBS
did what NO government agency would do; they tabulated the veteran
suicide numbers to shed light on this hidden epidemic and make the
American people aware of this situation. The VA should have taken those
numbers to Capitol Hill asking for more people, funding, and anything
else they need to combat this epidemic. They should embrace this study
as it reveals the scope of a huge problem, rather than complaining
about its accuracy. If all that is going to be done with the study is
argue about how the numbers were compiled, then an average of 120
veterans will die every week by their own hand until the VA recognizes
this fact, and does something about it.
The VA mental health system is broken in function, and understaffed
in operation. There are many cases of soldiers coming to the VA for
help and being turned away or misdiagnosed for PTSD and then losing
their battle with their demons. Those soldiers, as well as our son
Timothy, can never be brought back. No one can change that fact. But
you can change the system so this trend can be slowed down dramatically
or even stopped.
Our son was just one of thousands of veterans that this country has
lost to suicide. I see every day the pain and grief that our family and
extended family goes through in trying to deal with this loss. Every
one of those at-risk veterans also has a family that will suffer if
that soldier finds the only way to take the battlefield pain away is by
taking his or her own life. Their ravished and broken spirits are then
passed on to their families as they try to justify what has happened. I
now suffer from the same mental illnesses that claimed my son's life,
PTSD, from the images and sounds of finding him and hearing his life
fade away, and depression from a loss that I would not wish on anyone.
If the veteran suicide rate is not classified as an epidemic that
needs immediate and drastic attention, then the American fighting
soldier needs someone in Washington who thinks it is. I challenge you
to do for the American soldier what that soldier did for each of you
and for his country: Take care of them and help preserve their American
dream as they did yours. To quote President Calvin Coolidge, ``The
Nation which forgets its defenders will be itself forgotten.''
Today, you are going to hear a lot of statistical information about
suicide, veterans, and the VA. But keep one thing in mind, our son,
Specialist Timothy Noble Bowman, was not counted in any VA statistics
of any kind. He had not made it into the VA system because of the
stigma of reporting mental problems. He was National Guard, and he was
not on a drill weekend when he took his life. The only statistical
study that he was counted in was the CBS News study. And there are many
more just like him. We call them KBA's, killed because of action, the
unknown fallen.
I challenge you to make the VA an organization to be proud of
instead of the last place that a veteran wants to go. It is the
obligation of each and every one of you and all Americans to channel
the energies, resources, and the intelligence and wisdom of this
Nation's best and brightest to create the most effective, efficient and
meaningful healthcare system for our men and women who have served. We
must all remove the stigma that goes with a soldier admitting that he
or she has a mental issue. Let those soldiers know that admitting they
have a problem with doing the most unnatural thing that a human being
can do is all right. Mental health issues from combat are a natural
part of the process of war and have been around for thousands of years,
but we categorize that as a problem. Take that soldier that admits a
mental health injury from combat and embrace him as a model for others
to look up to. Let the rank-and-file know by example that it's okay to
work through your issues instead of burying them until it's too late.
Grab that soldier and thank him for saying, ``I'm not okay,'' and
promote him. A soldier that admits a mental injury should be the first
guy you want to have in your unit, because he may be the only one that
really has a grasp on reality. But instead, he is punished and shunned
and by that example, he has become the model for PTSD and suicide. And
while we are at it, why do we call it a disorder? That title, in
itself, implies ramifications that last forever. It is an injury, a
combat injury, just like getting shot. With proper care and treatment
soldiers can heal from this injury and be as productive and healthy as
before.
We as a country have the technology to create the most highly
advanced military system in the world, but when these veterans come
home, they find an understaffed, underfunded, and underequipped VA
mental health system that has so many challenges to get through it that
many just give up trying. The result is the current suicide epidemic
among our Nation's defenders, one of which was Specialist Timothy Noble
Bowman, our 23-year-old son, a soldier, and our hero.
Our veterans should and must not be left behind in the ravished,
horrific battlefields of their broken spirits and minds. Our veterans
deserve better!!
Mr. Chairman, this concludes my testimony. Thank you.
Prepared Statement of Penny Coleman, Rosendale, NY, Author
Flashback: Posttraumatic Stress Disorder, Suicide, and the Lessons of
War
INTRODUCTION
The Roman poet Horace said that it is a sweet and fitting thing to
die for one's country. That sentiment has been offered as comfort to
widows and orphans for more than 2,000 years. However hollow and
inadequate it might seem to those who are left only with memories and a
folded flag, it remains central to the allure and romance of military
culture. But I have never heard it suggested that there is anything
sweet or fitting about being a psychiatric casualty for one's country,
though surely soldiers and veterans who were injured in their minds
pledged the same and risked as much as their fallen comrades.
My husband, Daniel O'Donnell, came home from Vietnam in 1969, 11
years before Post Traumatic Stress Disorder (PTSD) became an official
diagnostic category. Like most veterans, he simply refused to talk
about his war experiences, so I had no way of knowing what he had
experienced or what was going on in his head. In retrospect, I imagine
he just thought he was going crazy. It must have been terrifying. I can
only image his despair.
After Daniel died, it never occurred to me to blame the war for
what had happened to us. I tried to blame him, but ended up blaming
myself. If only I had been kinder, more patient, more understanding,
quicker to notice and identify trouble. I can find more compassion for
us both from this distance. I can see now that he was just a kid who
had tried to stay alive in a situation that exploded all the rules he
had ever lived by, and that he was too sorry and too ashamed to start
over. And I can see now that I, too, was in over my head in a situation
I neither understood nor controlled. But at the time, and for decades
after, I believed his death was my fault, and I crept into a psychic
lair to hide my shame and lick my wounds in private. I married again
and had two children, but it was an awful way to live, tip-toeing
around everybody I loved, trying not to kill one of them by mistake. It
was a long time before I could find some compassion and forgiveness for
that young woman who had no idea what she was up against.
The research I did for my book, Flashback: Posttraumatic Stress
Disorder, Suicide, and the Lessons of War \1\ included interviews with
16 widows, mothers, and daughters whose loved ones also took their own
lives after serving in Vietnam. The story I have just told is only my
version of a litany that ran through every interview.
---------------------------------------------------------------------------
\1\ Penny Coleman, Flashback: Posttraumatic Stress Disorder,
Suicide, and the Lessons of War (Boston, MA: Beacon, 2006).
---------------------------------------------------------------------------
POST TRAUMATIC STRESS DISORDER AND MODERN WARFARE
Every war in historical memory has produced psychiatric casualties.
In fact, in every war American soldiers have fought in the past
century, the chances of becoming a psychiatric casualty were greater
than the chances of being killed by enemy fire.\2\ So surprise is at
best a disingenuous response to what is happening yet again. At the
same time, several issues have emerged that have affected rates of post
traumatic stress injuries in modern warfare; these include the
intensity and time a soldier is exposed to combat; unit cohesion, that
is, the extent to which soldiers have been given a chance to know and
trust those with whom they are fighting; and the nature of contemporary
military training.
---------------------------------------------------------------------------
\2\ Lieutenant Colonel David Grossman, On Killing (New York: Little
Brown, 1996).
---------------------------------------------------------------------------
Length of exposure versus unit cohesion: There were two central
lessons that military psychiatrists took from the wars of the 20th
century. The first is that soldiers fight for love--not hate. And not
love of country. They're fighting for the soldier next to them, the one
they can trust to take their back. The interpersonal bonding that
happens when soldiers get to know and trust each other is what the
military calls unit cohesion, and it is known to be one of the most
effective protections against traumatic stress injuries.\3\ The second
lesson is that if it is bad enough for long enough, anyone will fall
apart. Anyone. It's not about how strong you are or how brave you are--
how truly manly you are. There is no such thing as a bullet-proof
mind.\4\
---------------------------------------------------------------------------
\3\ Jonathan Shay, Achilles in Vietnam (New York: Touchstone,
1995).
\4\ Ibid.
---------------------------------------------------------------------------
During the Vietnam era, the military took the second of these two
lessons seriously. The DEROS policy (Date of Expected Return from Over
Seas) let every soldier know they would be leaving Vietnam exactly one
year after they arrived. They hoped that a year would be a manageable
time for a soldier to withstand the stress of the combat environment.
And indeed, the limited amount of time spent in the combat zone may
have been the reason that only about 1% of soldiers were evacuated for
psychiatric reasons, compared to World War II.\5\ At the same time, in
the interest of efficiency, the military ignored the first rule, about
the importance of personal loyalty and unit cohesion. After basic
training, soldiers were inserted individually into the war machine
according to some bureaucratically efficient system. They were cut off
from the friendships they had established during training. They were
sent into terrifying situations surrounded by strangers who they didn't
know or have any reason to trust. Furthermore, their officers were also
rotated, serving for only six months with a unit. It has now been
established that the ways in which DEROS undermined unit cohesion were
a major contributor to the psychic injuries of the Vietnam war.\6\
---------------------------------------------------------------------------
\5\ Ibid.
\6\ Ibid.
---------------------------------------------------------------------------
Current military policy has turned that on its head. Now, the
military keeps units together, but ignores the time/intensity rule.
Soldiers are repeatedly deployed, spending far more time in combat than
even the generous limits the Army considers safe.\7\ Some units have
been deployed three or four times in as many years, and it is becoming
ominously clear that the psychic resources of our soldiers has been
exhausted.
---------------------------------------------------------------------------
\7\ Davis H. Marlowe, Psychological and Psychosocial Consequences
of Combat and Deployment: With Special Emphasis on the Gulf War (Santa
Monica, California: Rand, 2001).
---------------------------------------------------------------------------
In 2004, the release of the Abu Grahib photographs broke the
unforgivable silence in the mainstream press about atrocities committed
by American soldiers in Iraq. Haditha followed, then Mahmoudiyah,
Ishaqi, and at this writing, multiple other instances of savage,
homicidal violence directed against civilians have been reported. More
recently, there have been the reports of veterans involved in violent
incidents after coming home.\8\ These acts are being committed by
American soldiers who are predictably out of control. They are the
inevitable result of pushing our soldiers way beyond their limits. They
are not the result of a few bad apples run amok.
---------------------------------------------------------------------------
\8\ http://timelines.epluribusmedia.org/timelines/
index.php?&mjre=PTSD&table_name=tl_ptsd
&function=search&order=date&order_type=ASC.
---------------------------------------------------------------------------
I'm not suggesting that American soldiers take no responsibility
for their actions. I would argue that we must balance outrage at
criminal and sadistic acts with the insistence that this new generation
of soldiers and veterans not be asked to take responsibility for the
terrible and tragic circumstances that led to those acts. Individual
soldiers cannot be the only ones taking the blame.
The nature of contemporary military training: Military training has
been part of the experience of millions of young American men since the
Revolutionary War. Prior to the Vietnam era, however, that training
consisted largely of practicing military skills and learning to manage
military equipment. It is only in the last half century that training
has evolved into an entirely new phenomenon that makes use of the
principles of operant conditioning to overcome what studies done over
the last century have consistently demonstrated, namely, that healthy
human beings have an inherent aversion to killing others of their own
species.\9\
---------------------------------------------------------------------------
\9\ S.L.A. Marshall, Men Against Fire: The Problem of Battle
Command in Future Wars (Gloucester, MA: Peter Smith, 1978).
---------------------------------------------------------------------------
War Psychiatry, the army's textbook on combat trauma, notes that
``pseudospeciation, the ability of humans and some other primates to
classify certain members of their own species as `other,' can
neutralize the threshold of inhibition so they can kill conspecifics.''
\10\ Modern military training has developed carefully sequenced and
choreographed elements to disconnect recruits from their civilian
identities. The values, standards and behaviors they have absorbed over
a lifetime from their families, schools, religions and communities are
scorned and punished. Using cruelty, humiliation, degradation and
cognitive disorientation, recruits are reprogrammed with an entirely
new set of learned responses. Every aspect of combat behavior is
rehearsed until response becomes reflexive. Operant conditioning has
vastly improved the efficacy of American soldiers, at least by military
standards. It has proven to be a reliable way to turn off the switch
that controls a soldier's inherent aversion to killing. American
soldiers do kill more often and more efficiently. Lt. Col. Dave
Grossman, author of On Killing, calls this form of training
``psychological warfare, [but] psychological warfare conducted not upon
the enemy, but upon one's own troops.'' \11\
---------------------------------------------------------------------------
\10\ Coleman, Flashback, 73-4.
\11\ Grossman, On Killing, 251.
---------------------------------------------------------------------------
There are any number of ways that modern training methods both
support violence, aggression and obedience and help to disconnect a
reflex action from its moral, ethical, spiritual, or social
implications. Drill instructors rely on sexist and homophobic labels
like ``girl,'' ``pussy,'' ``lady'' or ``fairy'' to humiliate, degrade
and ultimately exact conformity. Recruits are drilled with marching
chants that privilege their relationships with their weapons over their
relationships with women (``You used to be my beauty queen. Now I love
my M-16''), overtly conflate sex and violence (``This is my rifle, this
is my gun. This is for fighting; this is for fun.''), and treat the
killing of civilians as humorous (``Throw some candy to the children.
Wait till they all gather round. Then you take your M-16 now, and mow
the little * * * * * * * down.'') \12\ Aside from teaching these young
soldiers to quash their innate feelings about killing in general, they
are being programmed with a distorted version, not only of what it
means to be a man, but of what it means to be a citizen.
---------------------------------------------------------------------------
\12\ Carol Burke, Camp All-American, Hanoi Jane, and the High-and-
Tight. (Boston, MA: Beacon, 2005).
---------------------------------------------------------------------------
Thankfully, the brainwashing has not yet been developed that will
override the humanity of most American soldiers. As multiple
deployments become the norm, however, and as more scrambled psyches are
sent back into combat instead of into treatment, it is frightening to
consider that the brainwashing may yet prevail. Given the training to
which these soldiers have been subjected and the chaotic conditions in
which they find themselves, it is inevitable that more will succumb to
fear and rage and frustration. They will inevitably be overwhelmed by
cumulative doses of horror and they will lose control of their judgment
and their compassion. It is a credit to their humanity, not a sign of
their weakness, that these men and women find it hard to live afterward
with what they have seen and, in some cases, done. The soldiers who,
following orders, have run over children in the road rather than slow
down their convoy will never be the same again.\13\ Nor will the
soldiers manning checkpoints who shoot, as ordered, and kill entire
families who failed to stop, only to learn later that no one had
bothered to share with them that the American signal to stop--a hand
held up, palm toward the oncoming vehicle--to an Iraqi means, ``Hello,
come here.'' \14\
---------------------------------------------------------------------------
\13\ Mark Benjamin, ``Military Injustice,'' Salon.com, June 7,
2005. http://archive.salon.com/news/feature/2005/06/07/whistleblower/.
\14\ Deborah Scranton, Dir. The War Tapes (Sen Art Films, 2007).
---------------------------------------------------------------------------
This generation of soldiers wants to tell their stories because
they want to believe that Americans want to know.\15\ They are not
looking for absolution, but they want the architects of current policy
to accept their share of the blame. They have already carried home the
psychic wounds and the dangerous reflexive habits of violence that will
always diminish their lives and their relationships. In return, they
are hoping we will listen to them this time when they ask us to look a
little harder, dig a little deeper, use a little more discernment.
---------------------------------------------------------------------------
\15\ http://www.ivaw.org/wintersoldier.
---------------------------------------------------------------------------
In addition, a number of aspects of deployment and treatment in the
current situation are directly responsible for adding to the problem of
PTSD and suicide. These include the failure to screen sufficiently for
mental health problems, the inappropriate use of drugs, and the re-
triggering of PTSD symptoms among Vietnam veterans.
Failure to screen: In May, the Hartford Courant ran a series of
articles exposing the common practice in this army of deploying
soldiers in spite of serious, documented mental health histories,
including severe depression, bi-polarity, even autism. On their pre-
deployment health forms, there's a box a recruit can check if they've
had any kind of mental health issues in the past year. Of the 3% who
checked the box, 1 in 300 was given any kind of follow-up assessment.
Some were already on anti-depressants when they were recruited.\16\ The
use of waivers has meant that individuals with histories of emotional
problems, problems that have involved them in felonious activities,
including drug abuse and sale, domestic violence and other violent
crimes, individuals who would never have been previously accepted into
the military, are now being enlisted and deployed.\17\
---------------------------------------------------------------------------
\16\ Lisa Chedekel and Matthew Kauffman, ``Mentally Unfit, Forced
to Fight,'' The Hartford Courant, May 14, 2006.
\17\ Mark Benjamin, Out of jail, into the Army. Salon.com, February
2, 2006. http://www.salon
.com/news/feature/2006/02/02/waivers/.
---------------------------------------------------------------------------
The inappropriate use of drugs: Self-medication with marijuana and
heroin by soldiers in Vietnam is legendary; what is less well know is
that, for the first time, the military made aggressive use of powerful
tranquilizers and anti-anxiety drugs.\18\ In the short run, those drugs
were effective, if the definition of effectiveness was boots on the
ground, but in the long run, they were the moral equivalent of giving a
soldier a local anesthetic for a gunshot wound and sending him back
into combat.
---------------------------------------------------------------------------
\18\ Grossman, On Killing.
---------------------------------------------------------------------------
It may be that the doctors prescribing in the Vietnam era did not
realize the effects of those drugs over time, but today's military
doctors have the benefit of ample evidence.\19\ When soldiers are given
those kinds of drugs while they are still experiencing the stressor,
the drugs interrupt the development of normal coping mechanisms--and
the long-term effects of the trauma are worse. Still, anti-depressants
that come with warning labels about side effects that include suicide
are being given to active-duty soldiers with little or no supervision,
a practice that is virtually playing Russian roulette with their lives.
---------------------------------------------------------------------------
\19\ Ibid.
---------------------------------------------------------------------------
The re-triggering of symptoms among Vietnam veterans: Contemporary
warfare not only creates its own emotional casualties, but reignites
the symptoms of veterans of previous wars. The Washington Post reported
a year ago that ``Vietnam veterans are the vast majority of VA's PTSD
disability cases--more than 73 percent.'' These included ten thousand
new claims filed by veterans who were entering the system for the first
time, more than 30 years after their war came to an end.\20\
---------------------------------------------------------------------------
\20\ Donna St. George, ``Iraq War May Add Stress for Past Vets:
Trauma Disorder Claims at New High,'' Washington Post, June 20, 2006,
A01 http://www.washingtonpost.com/wp-dyn/content/article/2006/06/19/
AR2006061901400_pf.html.
---------------------------------------------------------------------------
Apologists such as American Enterprise Institute scholar Sally
Satel have accused veterans of memorizing the diagnostic criteria for
PTSD before going to see a VA doctor. They have accused the VA doctors
of over-diagnosing and thereby making their patients believe they are
sick, and the particularly cynical accusation that Vietnam vets who are
getting close to retirement are angling for ways to pad their old age
with inflated disability checks.\21\
---------------------------------------------------------------------------
\21\ Sally Satel, ``Stressed Out Vets: Believing the worst about
post-traumatic stress disorder,'' The Weekly Standard, August 21, 2006.
---------------------------------------------------------------------------
Veterans, however, claim that the cause of their applications for
benefits, far from being fraud, is the daily onslaught of horrific
images and stories coming out of Iraq and Afghanistan that have
triggered their flashbacks and reactivated intolerable symptoms. One of
those is former senator Max Cleland, a triple amputee from the war in
Vietnam, who was compelled to re-enter therapy at Walter Reed for PTSD
symptoms that have flared up since the war in Iraq began. Cleland
recounts that he cannot read newspapers or watch television now because
both are triggers for PTSD, something that he claims is happening to
Vietnam veterans all over America.\22\
---------------------------------------------------------------------------
\22\ http://www.wsbtv.com/news/9747929/detail.html.
---------------------------------------------------------------------------
FACTORS IN THE CURRENT POLICIES THAT ARE TRAGICALLY INCREASING THE
INCIDENTS OF SUICIDE
In November 2007, CBS News released the results of their
investigation into veteran suicides. Using the clout that only major
broadcast networks seem capable of mustering, CBS News contacted the
governments of all 50 States requesting their official records of death
by suicide going back 12 years. They heard back from 45 of the 50
States. From the mountains of gathered information, they sifted out the
suicides of those Americans who had served in the armed forces. What
they discovered is that in 2005 alone--and remember, this is just in 45
States--there were at least 6,256 veteran suicides, 120 every week for
a year and an average of 17 every day.\23\
---------------------------------------------------------------------------
\23\ http://www.cbsnews.com/stories/2007/11/13/
cbsnews_investigates/main3496471.shtml.
---------------------------------------------------------------------------
I am grateful to CBS News for undertaking this long overdue
investigation. And though I am also heartbroken that the numbers are so
astonishingly high, I am tentatively optimistic that perhaps now that
there are hard numbers to attest to the magnitude of the problem, it
will finally be taken seriously.
Part of taking that seriously will be to acknowledge the ways in
which the current spate of suicides is being exacerbated by government
and military policy. In the above section, I presented a number of the
major factors in the high incidence of PTSD among American soldiers and
veterans. In this section, I will point to additional factors that
explain why PTSD so often leads to suicide. A few examples include the
redeployment of psychically injured soldiers, a lack of sufficient
medical care professionals, lengthy waits for treatment, complex
bureaucratic red tape, and a variety of justifications for dishonorably
discharging traumatized veterans, thus rendering them ineligible for VA
psychiatric care. It is difficult not to connect all of these factors
to a tragic prioritizing of budgetary considerations at the expense of
the lives of soldiers and veterans.
Redeployment of psychically wounded soldiers: In November 2006, the
Pentagon released guidelines that allow commanders to redeploy soldiers
suffering from traumatic stress disorders. Service members with ``a
psychiatric disorder in remission, or whose residual symptoms do not
impair duty performance'' may be considered for duty downrange. It
lists post traumatic stress disorder as a ``treatable'' problem and
sets out a long list of conditions when a soldier can, and cannot be
returned for an additional tour in Iraq.\24\ Post traumatic stress
injuries, under the best of circumstances, are treatable, but not
curable. Sending soldiers back into the situation that triggered their
injury in the first place is taking undue, I would say cruel, license
with their mental health.
---------------------------------------------------------------------------
\24\ Aaron Glantz, ``Iraq Vets Left in Physical and Mental Agony,''
Inter Press Service, January 4, 2007.
---------------------------------------------------------------------------
Lack of sufficient medical care professionals/Lengthy waits for
treatment: The Defense Health Board's Task Force on Mental Health has
reported that there is a shortage of active duty mental health
professionals. According to the report, ``DoD has already dramatically
reduced its number of active duty mental health professionals and there
are proposals to further reduce active duty staffing.'' \25\ As a
result, according to other researchers, ``doctor-to-patient ratios are
climbing, waiting periods to see specialists are growing, and the time
that psychiatrists spend with the most troubled patients--those with
post traumatic stress disorder, or PTSD--is shrinking.'' \26\ In
September 2007 a Congressionally mandated report by the nonpartisan
Government Accountability Office found the Pentagon and VA care for
service members suffering from PTSD and Traumatic Brain Injury was
``inadequate'' with ``significant shortfalls'' of doctors, nurses and
other caregivers necessary to treat wounded soldiers.\27\ The result is
that soldiers and veterans requesting treatment for PTSD still
typically are put on waiting lists and wait six months to a year.
---------------------------------------------------------------------------
\25\ http://www.usmedicine.com/
article.cfm?articleID=1610&issueID=102.
\26\ Anne C. Mulkern, Denver Post, July 05, 2005.
\27\ ``Vets Healthcare Not Meeting Standards: Army Has Yet To Fully
Staff New Units Created To Fix Problems At Walter Reed'' (GAO:
Washington, DC, Sept. 26, 2007). http://www.cbsnews.com/stories/2007/
09/26/national/main3300260.shtml.
---------------------------------------------------------------------------
Complex bureaucratic red tape: Since the start of the Iraq war, the
back-log of unanswered disability claims has grown from 325,000 to more
than 600,000, with 800,000 new claims expected in each of the next two
years.\28\ On average, a veteran must wait almost six months to have a
claim heard. If a veteran loses and appeals a case, it usually takes
almost two years to resolve.\29\ The number of claims adjusters at the
VA likewise dropped. It is worth noting that if a service member or
veteran dies while an appeal is pending, the appeal dies as well.\30\
---------------------------------------------------------------------------
\28\ Brian Friel, ``Hurry Up And Wait,'' Government Executive, May
1, 2007. http://www.govexec.com/features/0507-01/0507-01s4.htm.
\29\ Chris Adams, VA's ability to provide benefits worsens,
December 1, 2006. http://www.mcclatchydc.com/staff/chris_adams/story/
15238.html.
\30\ St. George, ``Iraq War May Add Stress.''
---------------------------------------------------------------------------
Moreover, a veteran applying for compensation for Post Traumatic
Stress Disorder must submit a 26 page form, the key to which is a
detailed essay on the specific moments when he or she experienced a
terrifying event or series of incidents that caused mental illness to
develop. This is not easy because one of the symptoms of PTSD is for a
person to try to block out any memory of that event. According to the
psychiatric guide DSM IV, a person with PTSD often displays a
``persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness.'' \31\ In other words, the last
thing a person experiencing PTSD wants to do is sit down and write an
essay on why, and exactly how, they've become mentally ill. A veteran
must also back that claim up with hard evidence that their PTSD is
indeed ``service connected''--in essence proving he or she was indeed
in the place they said they were and that the terrifying incident did
indeed occur. If the veteran received a medal during the incident the
job is easier. If not, the vet must track down their service records to
see if any paperwork was generated as a result of the incident that
caused the development of their injury. DoD paperwork is notoriously
difficult to track down, if it exists in the first place. I applaud the
efforts of Representatives Donnelly and Upton for introducing H.R.
1490, The Fairness in Veterans Disability Benefits Act, which aims to
simplify the process for new veterans as they transition out of the
military and try to provide for their families. It is certainly a step
in the right direction, but $400 per month is not going to pay the rent
anywhere in this country.
---------------------------------------------------------------------------
\31\ Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
(DSM-IV) (Washington D.C.: American Psychiatric Association, 1994),
available online at www.psychologynet.org/dsm.html.
---------------------------------------------------------------------------
Ineligibility for medical benefits: A variety of patterns related
to PTSD are currently leading to a denial of medical benefits. In some
cases, soldiers and veterans who have applied for help with PTSD
symptoms try to manage terrifying symptoms by self-medicating with
drugs or alcohol; this substance abuse, itself a complication of PTSD,
is then used to justify a dishonorable discharge, even in cases in
which a soldier has repeatedly asked for treatment.\32\ In other cases,
diagnoses such as ``pre-existing conditions'' are used by the military
to deny its responsibility for treating soldiers suffering emotional
trauma.\33\
---------------------------------------------------------------------------
\32\ Daniel Zwerdling, ``Soldiers Say Army Ignores, Punishes Mental
Anguish,'' ``All Things Considered,'' National Public Radio, December
4, 2006. http://www.npr.org/templates/story/story.php?storyId=6576505.
\33\ Joshua Kors, ``How Specialist Town Lost His Benefits,'' The
Nation, April 9, 2007. http://www.thenation.com/doc/20070409/kors.
---------------------------------------------------------------------------
One of the saddest consequences of the Bush administration's
failure to anticipate and plan for an extended conflict in Iraq is the
billions of additional dollars the VA has discovered it needs to cover
the shortfall in its healthcare budgets for the past three years.
Administration apologists such as Sally Satel have kept up a steady
stream of accusation and innuendo in the media ever since it became
clear that their new war was going to suck in, chew up and spit out
devastated soldiers every bit as reliably--and expensively--as the war
in Vietnam did.\34\ It is worth recalling that, prior to the scandal
concerning conditions at Walter Reed, President Bush's appointees at
the Pentagon had strenuously lobbied Congress against funding military
pensions, health insurance and benefits for widows of retirees. Their
argument: that money spent on caring for wounded soldiers and their
families could be better spent on new state-of-the-art military
hardware or enticing new recruits to join the force. In January 2005,
Bush's Undersecretary of Defense for Personnel and Readiness David Chu,
the official in charge of such things, went so far as to tell the Wall
Street Journal that veterans' medical care and disability benefits
``are hurtful'' and ``are taking away from the Nation's ability to
defend itself.'' \35\
---------------------------------------------------------------------------
\34\ http://www.sallysatelmd.com.
\35\ Jaffe, Greg. ``Balancing Act: As Benefits for Veterans climb,
military spending feels squeeze.'' Wall Street Journal, Jan. 25, 2005,
pA1.
---------------------------------------------------------------------------
Indeed, what we have seen in the past four years are frantic and
often tragic attempts to save money, all at the expense of the
veterans. The military tried charging wounded soldiers at Walter Reed
for their lunches. Congress made them take that back. They tried
spinning PTSD as veteran fraud and insisted that 72,000 100% disabled
vets get themselves recertified. 100% disabled vets are the most
fragile and the most likely to be further traumatized by a complicated
bureaucratic process. Congress made them take that back as well, but
not before at least one overwhelmed veteran took his own life with his
recertification request papers on his chest.\36\
---------------------------------------------------------------------------
\36\ Mark Benjamin, ``The VA's Bad Review,'' Salon.com, October 26,
2005. http://archive .salon.com/news/feature/2005/10/26/suicide/
index.html.
---------------------------------------------------------------------------
A new study by Columbia University economist Joseph E. Stiglitz,
who won the Nobel Prize in economics in 2001, and Harvard lecturer
Linda Bilmes concludes that the war is costing $720 million a day or
$500,000 a minute.\37\ This total, which is far above the
administration's prewar projections, attempt to take into account the
long term healthcare costs for the U.S. soldiers injured in Iraq so
far. Veterans groups joke the Bush Administration has instituted a
policy of ``don't look, don't find,'' in order to absolve themselves of
criminal, financial, and medical liability for their treatment of
veterans.
---------------------------------------------------------------------------
\37\ Kari Lydersen, ``War Costing $720 Million Each Day, Group
Says,'' Washington Post, September 22, 2007. http://
www.washingtonpost.com/wp-dyn/content/article/2007/09/21/AR2007
092102074.html.
---------------------------------------------------------------------------
RECOMMENDATIONS
The basis for addressing the virtual epidemic of death that
constitutes suicide among soldiers and veterans much be first to
acknowledge the problem. While Americans may disagree about current
American policy in Iraq, surely we can all agree with the motto of the
VA, ``To care for him [and now her] who shall have borne the battle and
for his widow and orphan.''
In August of 2006, Fox News proposed that Congress provide that
certain types of military service--such as any service in theaters of
combat, not just actual combat experience, and other forms of hazardous
duty--automatically qualify veterans for lifetime health benefits.
There is much to be said for that proposal. Among other things, it
would eliminate the motivation for unjust dishonorable discharges and
alternative diagnoses. It would also mean that scientific research
involving combat veterans might be less politicized and less likely to
be skewed.\38\
---------------------------------------------------------------------------
\38\ Steven Milloy ``Politicized Science Produces Bad Public
Policy,'' August 17, 2006. https://www.foxnews.com/story/
0,2933,209078,00.html.
---------------------------------------------------------------------------
Less extreme but still vitally needed specific steps include:
Attack stigma: The ``D'' in PTSD should immediately be
dropped. To call the psychic injuries of soldiers a disorder reinforces
the misperception that there is something inherently wrong with the
soldier. The prejudice that reinforces, in soldiers, veterans,
caregivers and military officers alike, is in many ways responsible for
the resistance of sufferers to ask for the help they so desperately
need. Military personnel at all levels must be educated to understand
that PTSD is not a sign of weakness or cowardice. Soldiers and veterans
must be debriefed to help individuals understand and cope with the
stress that is a normal response to an overwhelming situation.
Treatment for emotional injuries must be given parity with treatments
for more visible physical wounds. For example, promoting the
elimination of stigmatizing questions on security clearance
questionnaires can set the precedent for culture change within the
Department of Defense and model similar changes in procedure for other
employment categories, thus eliminating the risks to future employment
for individuals in need of treatment for PTSD.\39\
---------------------------------------------------------------------------
\39\ ``The War inside; troops are returning from the battlefield
with psychological wounds, but the mental-health system that serves
them makes healing difficult,'' The Washington Post, June 17, 2007.
---------------------------------------------------------------------------
Multiply the caregivers: The military's cadre of mental-
health workers is ``woefully inadequate to meet their needs.'' The
current decline in military mental health professionals must be
reversed as quickly as possible.
Provide mandatory and adequate screenings for all
enlistees and for all returning soldiers: In the first instance, this
will help to stop the practice of deploying soldiers who are already
emotionally fragile. It will also serve to create a medical history
enabling a veteran to later prove service-connection in the event of
emotional trauma. Finally, because everyone participates, such a
screening policy would eliminate the shame and stigma.
Stop redeploying psychically injured soldiers.
Create a structure for screening soldiers and veterans
outside of the chain of command.
Eliminate the wait for soldiers and veterans reporting
symptoms and requesting treatment and ensure that sufficient emergency
contacts and treatment options are available.
Hire and train additional Veteran Service Representatives
and Veteran Service officers to help veterans navigate the system.
Streamline application and benefit procedures and make
them more `vet-friendly.'
Increase the number and size of Vet Centers, which
provide flexible and easily accessed programs and resources, and create
procedures for collaboration between Vet Centers and demobilizing
troops.
Hold follow-up interviews with demobilized troops at 30,
60, and 90 day intervals and then periodically for several years.
CONCLUSION
I will never know if any or all of the above recommendations, if
implemented, would have saved my husband Daniel's life. I do know that
they would have given both of us a better chance. I believe as well
that, had deaths such as Daniel's been officially acknowledged,
studied, and counted, not only would our lives as survivors been very
different, but it would be far more difficult for officials now with
any credibility deny a connection between combat-related PTSD and
suicide.
I find hope in the fact that public attention and better knowledge
of mental health issues have helped legitimize the psychiatric injuries
soldiers sustain in every war. Though government apologists still
shamefully spin and distort the numbers, and though military culture
still encourages stigmatization, and even punishment, for what they
insist on calling weakness or malingering, there is still far more
information about posttraumatic stress injuries available, and that
makes it less likely that this generation of soldiers and their
families will experience the same degree of isolation on top of their
grief that we felt. The difference is that we are talking about it now.
Prepared Statement of Ilona Meagher, Caledonia, IL, Author
Moving a Nation to Care: Post-Traumatic Stress Disorder and America's
Returning Troops
Chairman Filner, Ranking Member Buyer, and other distinguished
members of the Committee, I thank you for the opportunity to appear
before you today.
To open, I'd like to briefly share my thoughts on why it is that I
believe I'm here.
I am not only someone who's spent the past two years researching
and writing about post traumatic stress in our returning troops, I'm
also a veteran's daughter. My father was born in Hungary, served two
years in antitank artillery as a Hungarian Army conscript, fought
against the Soviet Union on the streets of Budapest during the 1956
Hungarian Revolution, and later fled to America where, in 1958, he
again became a soldier, this time wearing a United States Army uniform,
and serving as a combat engineer stationed in Germany.
My father's unique experience of having served on both sides--East
and West--in such differing armies during the Cold war, gave him a
unique perspective on military life.
And so, growing up, my sisters and I often heard my father say,
``You can always tell how a government feels about its people by
looking at how it treats its soldiers.''
Looking at our returning soldiers and their widely reported
struggles with the military and VA healthcare systems they rely on, of
being stigmatized from seeking care or of being placed on lengthy VA
waiting lists when they need immediate help--some even committing
suicide before their appointment dates arrive--have raised this
citizen's alarm bells.
We have had a ``see no evil, hear no evil'' approach to examining
post-deployment psychological reintegration issues such as suicide.
After all we have learned from the struggles of the Vietnam War
generation--and the ensuing controversy over how many of its veterans
did or did not commit suicide in its wake--why is there today no known
national registry where Afghanistan and Iraq veteran suicide data is
being collected? How can we ascertain reintegration problems--if any
exist--if we are not proactive in seeking them out?
As late as May 2007, Department of Veterans Affairs spokeswoman
Karen Fedele told the Washington Post that there was no attempt to
gather Afghanistan and Iraq veteran suicide incidents. ``We don't keep
that data,'' she said. ``I'm told that somebody here is going to do an
analysis, but there just is nothing right now.'' \1\
---------------------------------------------------------------------------
\1\ ``Veterans' Group Emphasizes Suicide Risks,'' Jennifer C. Kerr,
Associated Press, May 28, 2007.
---------------------------------------------------------------------------
Meanwhile, the Army reported its suicide rate in 2006 rose to 17.3
per 100,000 troops, the highest in 26 years of keeping such records. At
long last, the Associated Press revealed that the VA is finally
conducting preliminary research. They've tracked at least 283 OEF/OIF
veteran suicides through the end of 2005, nearly double the rate of the
additional 147 suicides reported by the DoD's Defense Manpower Data
Center.
Looking only at the these suicide figures from the VA (283) and the
DoD (147), there have been at least 430 Afghanistan and Iraq veteran
suicides that have occurred either in the combat zone or stateside
following combat deployment. Lost in the VA and DoD counts are those
veterans who have returned from their deployments, are still in the
military and not yet in the VA system. The DoD says they do not track
those incidents, and I assume neither does the VA because these
veterans are not yet on their radar.
Yet, even with this omission, many of these 430 confirmed suicides
are a result of our wars in Afghanistan and Iraq and should--but
won't--be listed with the DoD's official OEF/OIF death toll of 4,351.
It bears mentioning: Currently 10 percent of the overall fatal casualty
count of these wars is due to suicide.
Dismissing the issue of veteran suicide in the face of this data is
negligent and does nothing to honor the service and sacrifice of our
veterans and the families and communities that literally are tasked
with supporting them once they return.
Yet, prior to last month's CBS News investigation, which revealed
that 120 veterans of all wars committed suicide every week in 2005 and
that 20-24-year-old Afghanistan and Iraq veterans are two to four times
more likely to commit suicide than their civilian counterparts, the
scope of the problem has been largely unknown because no one with
proper resources and access to do the compiling of data came forward to
do so.
In my written testimony, I've included 75 suicides that I and other
citizen journalist colleagues have been tracking since September 2005
and which today reside in the ePluribus Media PTSD Timeline.
Offering only a small and incomplete sliver of insight into how
some of our returning troops are faring on the home front--especially
in light of the fact that at least another 355 incidents could be added
among them according to the VA and DoD--I believe that they
collectively tell an even greater tale about the failure of us as
individuals and as a society to ensure that our returning warriors are
cleansed completely from the psychological wounds of war.
They also reflect the failure of our government institutions to
protect those who protect us.
While I realize that these distressing stories are the exception
and not the rule, to our exceptional military families having to deal
with the deterioration of a loved one they thought had safely returned
from combat, they are the rule. In 1956, the same year that my parents
fled to this incredible country, the 84th Congress--in the very House
that we sit in today--had this to say in a Presidential commission
report on veterans' benefits:
``The Government's obligation is to help veterans overcome
special, significant handicaps incurred as a consequence of
their military service. The objective should be to return
veterans as nearly as possible to the status they would have
achieved had they not been in military service . . . and
maintaining them and their survivors in circumstances as
favorable as those of the rest of the people. . . . War
sacrifices should be distributed as equally as possible within
our society. This is the basic function of our veterans'
programs.'' \2\
---------------------------------------------------------------------------
\2\ U.S. Congress. House, The President's Commission on Veterans'
Pensions. The historical development of veterans' benefits in the
United States: A report on veterans' benefits in the United States,
84th Cong., 2nd sess., May 9, 1956.
I am not a pedigreed expert or a government official seasoned in
testifying before you, but those who are from the GAO and the
Congressional Research Department and even the Veterans Administration
itself, have sat in this very seat over the years and told you we are
falling far short in providing the resources and programs our returning
troops and military families need to successfully return to their
personal lives following their service to the Nation.
To those who resist hearing the cold hard truth of where we are
today, I'd like to say: The time is here to stop fighting the data, and
to start fighting for our troops.
This is America. We can do better. We must do better.
Suggestions to ease the veteran suicide problem:
Offer all returning veterans immediate compensation and
treatment support the first six months after their return home.
Fostering positive coping skills (vs. negative coping skills of self-
medication or domestic violence) must be a key goal of our veterans'
reintegration programs; veterans forced to wait at least six months for
VA compensation and treatment benefits to kick in do not feel
supported, they feel under siege.
Increase 21st century asymmetrical warfare and
psychological injury understanding and preparation. The DoD should
continue to make adjustments in its training to give service members
the tools they need to counter the modern battlefield's unique
stressors. The Psychological Kevlar Act of 2007 would push the DoD to
provide proactive psychological training for veterans from boot camp
onward; more need to sign on to this legislation and it should be
passed into law.
Force the DOD and VA do a better job of communicating
with veterans on their rights and resources, and making outside
community-based resources known to them as well. Many vets are unsure
of what benefits they have earned and what rights they have to them.
Some are discouraged from using them. Many community programs and
groups are ready and waiting to assist returning veterans and military
families, but are unknown to the very people who might benefit from
them. While Secretary Robert Gates has said it may take up to three
years to fully implement the PTSD portion of the Dole-Shalala
recommendations, why are we not utilizing the resources that are
available in communities across the country?
Properly and fully fund the Veterans Administration.
Billions in underfunding translates to long waiting lines, lack of
funds for PTSD research, and not enough PTSD specialists at each VA
facility.
Reduce tour lengths, decrease overall number of combat
deployments, and increase dwell time between deployments by funding an
increase in forces. With each successive deployment, troops'
susceptibility to PTSD increases. Army Chief of Staff George W. Casey
Jr. testified last month before the Senate Armed Services Committee
saying that the military must be grown in order for dwell-time to be
increased, etc.
Restrict the ability to redeploy troops diagnosed with
PTSD. No PTSD-diagnosed troops should be redeployed into a combat zone,
and troops should not be deployed taking psychotropic drugs such as
Paxil or Zoloft, that have been shown by the FDA to increase suicide
risk.
Improve post-deployment assessments. Move away from
relying on questionnaires and make physicals and one-on-one demob
consultations mandatory. In February 2006, the VA contracted the
Institute of Medicine to do a thorough review of scientific and medical
literature related to the diagnosis and assessment of PTSD; the
Committee strongly concluded that the best way to determine whether a
person is suffering from PTSD is with a ``thorough, face-to-face
interview by a health professional trained in diagnosing psychiatric
disorders.'' The DoD should follow the same rule.
Invest more in counseling and support. Rather than
relying on quick-fix medications to solve returning psychological
problems, invest time and resources in holistic wellness programs to
help veterans and their families recover from the experience of war.
Remove stigma/punishment for those seeking help. One of
the easiest ways to do this would be to operate under the assumption
that everyone will need some form of support following combat. Move
away from a system where those struggling most must somehow find the
strength to conspicuously come forward on their own.
Require completion of a `boot camp in reverse'
transitional training program. Military families who have lost loved
ones to suicide consistently say there should be a more formal reentry
program following return from combat, weekly meetings/classes lasting
from 2 to 3 months. The program should be as required to attend and
complete by all service members as boot camp.
Pay special attention in supporting National Guard and
Reserve forces. Not being a part of a cohesive unit, they are
especially susceptible to PTSD.
Stop closing VA Hospitals and Vet Centers. We should be
providing more opportunities for veterans scattered across the country,
especially in rural areas, to have access to healthcare benefits.
Increase funding to community service boards. Many
troops--especially those with the National Guard and Reserve or in
rural areas--do not have easy access to health services. Make sure they
have alternatives to getting the care they need, or fully reimburse
their private healthcare bills.
Increase Vet Center program offerings. Offer more
complimentary group and individual classes for troops and military
families that explain what PTSD is, how it can be treated and how one
can forge the tools necessary to move their lives beyond it.
Provide complimentary counseling to all immediate family
members. If the service member refuses to seek help, the spouse and
children should have access to counseling service to help them through
their loved one's reintegration process.
Increase personal data security and treatment anonymity.
Many will not come forward to get the help they need because they worry
it may come back to haunt them when they're up for a promotion, being
considered for a mission, or when looking for civilian employment.
Family members, however, should not be kept in the dark, especially if
veteran is prescribed psychotropic medication.
Selection of OEF/OIF Veteran Suicides
The ePluribus Media PTSD Timeline, is a collection of press-
reported cases of post-combat related possible, probable, self-reported
and/or confirmed incidents of PTSD or broader reintegration
difficulties. The work is meant to preserve incidents that are at risk
of being lost to us with the forward movement of time, as small town
news websites do not archive many of their reports.
Additional reasons for the existence of the PTSD Timeline include:
Allowing for ease of study of PTSD and related
reintegration issues by researchers, reporters, educational and
government institutions.
Fostering further discussion and exploration of post-
combat reintegration issues.
Validating to military family members that we are paying
attention to their experiences.
What follows is a brief glimpse at the personal post-war landscape
for our military families revealed through suicide incidents tracked by
me and other citizen journalists in the PTSD Timeline since September
of 2005.
Legend: /ss/=stateside suicide /oif/=OIF combat zone suicide /oef/=OEF
combat zone suicide
2002
Following the terrorist attacks of September 11th, Operation
Enduring Freedom commenced with the invasion of Afghanistan on October
7, 2001. Fort Bragg, N.C., home of the Army Special Operations Command,
was the first to experience a cluster of post-deployment reintegration
issues when three military wives were murdered by their recently
returned husbands within a span of five weeks. (One additional wife was
murdered during this same timeframe, but the husband had not deployed
to OEF).
On June 11, 2002 /ss/, Rigoberto Nieves (32-year-old Special Forces
sergeant) fatally shot his wife and then himself in an off-base murder/
suicide after having returned home from Afghanistan in mid-March. On
July 19, 2002 /ss/, Brandon Floyd (30-year-old Special Ops soldier)
shot his wife and then himself in an off-base murder/suicide after
having returned home in January.
CNN reported at the time: ``Fort Bragg garrison commander, Army
Col. Tad Davis, is reviewing counseling and stress-management programs
available at the base. A spokesman said the Army wants to see if there
is something it could do better. But one military official who had
previously served at Fort Bragg pointed out that Special Operations
soldiers may be reluctant to seek help.'' \3\
---------------------------------------------------------------------------
\3\ ``Fort Bragg killings raise alarm about stress,'' Barbara
Starr, CNN, July 27, 2002.
---------------------------------------------------------------------------
2003
On March 19, 2003, Operation Iraqi Freedom commenced.
Joseph Suell (24-year-old veteran and father of two who'd served in
South Korea, Kuwait and Iraq) intentionally overdosed on June 16, 2003
/oif/, the day after Father's Day. Corey Small (20-year-old Ft. Polk,
La., army private) shot himself in front of others after making a phone
call home on July 3, 2003 /oif/.
The following day, on July 4, 2003 /oif/, James Curtis Coons (36-
year-old army master sergeant with 17 years of military service, OIF
Bronze Star) hanged himself with a bed sheet at Walter Reed Army
Medical Center; he had been evacuated from Kuwait two weeks earlier
following an overdose.
Alyssa Peterson (27-year-old Arabic-speaking interpreter with the
311th Military Intelligence BN, 101st Airborne), who reportedly
disagreed with interrogation techniques being used at Tal-Afar prison,
shot herself on September 12, 2003 /oif/. On October 1, 2003 /ss/, Kyle
Edward Williams (21-year-old soldier with a clean record who'd served
in Iraq with the 507th Maintenance Company) shot and killed an Arizona
man who'd broken into his car and later shot himself.
Thomas J. Sweet II (23-year-old Ft. Riley, Kan., 5th Field
Artillery Regiment, 1st Infantry Division sergeant) shot himself on
November 27, 2003 /oif/, the very day he received word of his
promotion. Jeffrey Braun (19-year-old 82nd Airborne Division
paratrooper) shot himself on December 1, 2003 /oif/.
2004
Alexis Soto-Ramirez (43-year-old 544th Military Police Company
specialist), who'd been evacuated a month earlier from Iraq due to back
pain, hanged himself with his bathrobe sash at Walter Reed Army Medical
Center on January 12, 2004/ss/.
Five days later, on January 17, 2004 /ss/, Jeremy Seeley (28-year-old
101st Airborne specialist) walked off Fort Campbell, Ky., checked into
a hotel, and overdosed on household poison.
Boyd Wicks, Jr. (Marine infantry sergeant) returned from Iraq in
June 2003 and was discharged in October; he committed suicide on
February 1, 2004 /ss/, his father saying of PTSD. On March 7, 2004 /
oif/, Matthew Milczark (18-year-old Marine) shot himself in a Kuwaiti
military chapel. One week later, on March 14, 2004 /ss/, William Howell
(36-year-old Ft. Carson, Colo., Special Forces chief warrant officer
with 17 years of military service as a Green Beret) threatened his wife
with a gun, and then shot himself as police officers moved in on him;
he'd returned from Iraq a mere three weeks earlier.
Four days later, on March 18, 2004 /ss/, Brandon Ratliff (6-times
decorated Army Reserve's 909th Forward Surgical Team executive
officer), shot himself after writing The Columbus Dispatch, ``I didn't
think I'd have to fight over there and have to fight these guys, too.''
He'd lost a promised promotion and raise following his tour in
Afghanistan saving injured soldiers on the frontline.
On March 21, 2004 /ss/, Ken Dennis (22-year-old Marine corporal and
combat rifleman who'd served in Pakistan, Afghanistan, Somalia,
Djibouti and Iraq) hanged himself with his belt in his Renton, Wash.,
apartment eight months after returning from Iraq. He'd confessed to his
father, ``You know, Dad, it's really hard--very, very hard--to see a
man's face and kill him.''
Jeffrey Lucey (23-year-old Marine Reserve) hanged himself in his
basement on June 22, 2004 /ss/, after his parents had involuntarily
committed him to the local VA; he was released three days later and
told to stop drinking before they could assess him for PTSD.
Also on June 22, 2004 /ss/, Adam Kelley (36-year-old Gulf War
combat veteran) ended his 13-year struggle with PTSD and shot himself
in his car while sitting in his truck behind a Las Vegas sandwich shop.
His mother blamed long VA waits, shuffling from one doctor to another,
prescribing medications that did more harm than good and monthly
appointments with a physician's assistant rather than weekly
appointments with a physician's aide as contributing factors.
Andre Ventura McDaniel (40-year-old Ft. Carson, Colo., Special
Forces soldier) shot himself six weeks after returning from Iraq, on
August 28, 2004 /ss/. On September 24, 2004 /ss/, Michael Torok (23-
year-old Ft. Bragg, N.C., communications specialist) stabbed himself in
the heart in his car parked alongside a rural Illinois cornfield. He
had visited the Hines VAMC for various ailments following his
Afghanistan service, but Hines was not screening all returning veterans
for PTSD at the time. The next day, he told his parents he was going to
visit a friend and was never seen or heard from again.
On October 9, 2004 /ss/, Brian McKeehan (37-year-old Fort Euliss,
Va., soldier) hanged himself with a bed sheet in the Virginia Peninsula
Regional Jail, one month after returning from Iraq and 12 hours after
being arrested for assaulting his wife. In the four weeks he was home,
local police had responded to six domestic violence complaints. Michael
Jon Pelkey (29-year-old Fort Sill, Ok., captain) shot himself on
November 5, 2004 /ss/ a year after returning from Iraq. He had received
a private diagnosis of PTSD, but was told of months-long waits for
mental healthcare appointments on base.
Curtis Greene (25-year-old Ft. Riley, Kan., soldier) abruptly went
AWOL, saying he did not want to return to Iraq; after his wife begged
him to return, he hanged himself in his barracks on December 6, 2004 /
ss/. Police had previously responded to two domestic violence calls and
he was being treated for PTSD.
2005
Andres Raya (19-year-old Camp Pendleton, Calif., Marine) committed
suicide-by-cop on January 9, 2005 /ss/ four months after taking part in
the invasion of Fallujah. After telling his family he did not want to
return to Iraq, he fired on Modesto police in an apparent premeditated
3-hour ambush in which one police officer was killed and another
critically injured. Mark C. Warren (44-year-old 116th Armor Cavalry
Regiment Oregon Army National Guardsman) shot himself in Kirkuk on
January 31, 2005 /oif/.
John Ruocco (40-year-old Marine cobra helicopter pilot from
Newbury, Mass.) hanged himself in February 2005 /ss/, three months
after returning home from Iraq and a few weeks before he was to
redeploy. His wife said he worried about the ramifications of seeking
help, personally and professionally.
On February 3, 2005 /ss/, Richard T. Corcoran (34-year-old Ft.
Bragg, N.C. Special Forces soldier who'd served in Afghanistan) shot
his ex-wife and her boyfriend, and then shot himself.
Alan McClean (62-year-old decorated Vietnam Purple Heart/Bronze
Star veteran and minister who'd lost both legs to a landmine) shot
himself in his Washington State church office on February 11, 2005 /
ss/. Formerly supportive of the war effort, but deeply affected by the
rising casualty counts, he wrote, ``35 Marines died today in Iraq, only
slightly more noticed than my legs.'' His daughter said later, ``I
underestimated the power of the war to take his life and I really feel
that though my dad's been in Wenatchee, the war in Iraq killed him.''
Steven Michael Logan (26-year-old Marine intelligence clerk),
personally reenlisted by Secretary of the Navy Gordon R. England at the
peak of Mount Suribachi above Iowa Jima a year earlier, shot himself on
February 28, 2005 /ss/. Samuel Lee (19-year-old 2nd Infantry Division
soldier) serving in Ramadi shot himself on March 28, 2005 /oif/ and
Dominic Campisi (30-year-old Delaware Air National Guardsman), who'd
served in both Afghanistan and Iraq, killed himself on April 17, 2005 /
ss/ only days after returning from Uzbekistan.
On May 23, 2005 /oef/, Kyle Hemauer (21-year-old 29th Infantry
Division Virginia National Guard specialist) shot himself in
Afghanistan. And in Iraq on June 4, 2005 /oif/, the highest-ranking OIF
death at the time, Ted S. Westhusing (44-year-old colonel and leading
scholar of military ethics) shot himself in his base trailer. In emails
to family, he seemed especially upset that traditional military values
such as duty, honor and country had been replaced by profit motives in
Iraq.
Justin ``Paul'' Byers (19-year-old Iowa Army National Guardsman)
stepped in front of highway pickup truck on June 20, 2005 /ss/ after
hearing of his 22-year-old brother's death in Iraq. On July 9, 2005 /
ss/, Jeremy Wilson (23-year-old Ft. Carson, Colo., 10th Special Forces
Group soldier) hanged himself in his barracks a month after returning
from Iraq. Jason Cooper (23-year-old Mt. Pleasant, Iowa, 308th
Quartermaster Army Reserve specialist) hanged himself in his basement
four months after his Iraq tour on July 14, 2005 /ss/.
Eleven days after being pinned by then Army Chief of Staff Peter
Schoomaker himself with the Army's new Combat Action Badge, Leslie
Frederick, Jr. (23-year-old Purple Heart and Bronze Star Ft. Lewis,
Wash., specialist) shot himself in his Tacoma apartment on July 26,
2005 /ss/.
Two days later, on July 28, 2005 /ss/, Saxxon Rech (20-year-old
Camp Lejeune, N.C., Marine) shot his girlfriend and himself in
Washington; he had been mysteriously discharged in February. Two days
later, Robert Decouteaux (24-year-old Ft. Hood, Tx., soldier) shot
himself on July 30, 2005 /ss/, and another two days later, on August 1,
2005 /ss/, Robert Hunt (22-year-old Ft. Hood, Tx. 1st Cavalry Division
radio operator-maintainer) was found dead in his apartment; both
Decouteaux and Hunt had served in Iraq for a year and were scheduled to
return in the fall.
Another two days later, on August 3, 2005 /ss/, Stephen Sherwood
(35-year-old Ft. Carson, Colo., 2nd Brigade Combat Team soldier) shot
his wife and then himself nine days after returning home from a year's
deployment in Iraq. He enlisted in January 2004 to have health benefits
because his wife was pregnant.
Bernardo C. Negrete (53-year-old retired brigadier general who'd
served in Grenada, Panama and Iraq) shot himself on September 16, 2005
/ss/ after his wife complained that he stop drinking and come to bed.
Phillip Kent (26-year-old Fort Hood, Texas, 720th Military Police
Battalion 2nd lieutenant/platoon leader during the hunt for Saddam
Hussein in Tikrit), after being hospitalized for PTSD following his
return home and being discharged early, committed suicide on September
28, 2005 /ss/.
On October 8, 2005 /ss/, Greg Morris (57-year-old 4th Infantry
Division Vietnam veteran diagnosed with PTSD) shot himself; by his side
were his gun, Purple Heart, and a folder of information on how the VA
planned to review veterans PTSD cases [a plan that was halted following
public outcry].
On November 8, 2005 /ss/, Chris Forcum (20-year-old Marine lance
corporal) killed himself in Oregon six weeks after returning from Iraq.
His father said at the time that ``they teach soldiers how to fight,
but they don't teach them how to live when they come home.'' Timothy
Bowman (24-year-old Illinois National Guard specialist) had joined the
military after 9/11; he shot himself on Thanksgiving morning, November
24, 2005 /ss/, eight months after coming home from Iraq.
Jeffrey Lehner (42-year-old Marine Aerial Refueler Transport
Squadron sergeant) shot his father and then himself on December 7, 2005
/ss/, after calling his VA counselor in distress saying he would not be
coming in the next day. After serving in Afghanistan, the Gulf War
veteran had returned home at the end of 2004 in need of help, admitting
himself to a VA hospital for intensive PTSD treatment. Instead, he was
placed with bipolar and schizophrenic patients because the PTSD ward
was full. On December 22, 2005 /ss/, Joshua Omvig (22-year-old Iowa
Army Reverse soldier) shot himself a year after returning from Iraq.
2006
On January 16, 2006 /ss/, Douglas Barber (37-year-old National
Guards supply convoy driver), following a two-year struggle with the VA
over receiving treatment for his PTSD, changed his answering machine
message to say he was checking out of this world, telephoned police and
waited for them on his porch; when they would not shoot him, he shot
himself.
Chuck Call (30-year Army gunner who'd volunteered to go to Iraq
with another unit when his was not called up) committed suicide three
months after returning on February 3, 2006 /ss/. Haunted by nightmares
and anxiety, he sought VA benefits only to be told he did not qualify
for them due to his income. On February 20, 2006 /ss/, Jon Trevino (36-
year-old Scott AFB 375th Aeromedical Evacuation Squadron tech sergeant
who served in both Afghanistan and Iraq) shot his wife and himself.
In Iraq, Tina Priest (21-year-old Fort Hood, Texas, 4th Infantry
Division soldier) shot herself on March 1, 2006 /oif/, two weeks after
saying she was raped by a fellow soldier and days after being diagnosed
and treated for Acute Stress Disorder consistent with Rape Trauma
Syndrome.
Two days later, Donald Woodward (23-year-old army soldier) shot
himself on his favorite Pennsylvania hiking trail on March 3, 2006 /
ss/. He'd tried killing himself once before by lighting his truck on
fire and getting inside; his wife pulled him out; afterward, he finally
agreed to get some help from the VA, which gave him antidepressants and
scheduled a counseling appointment a month later. He committed suicide
before the appointment date arrived.
Three days later, Greg Braun (26-year-old Army Ranger sniper with
the 128th Infantry of Wisconsin National Guard) shot himself in his
basement four months after returning home from Iraq on March 6, 2006 /
ss/. He had served in Kosovo as well as tours in Iraq, and was a
Milwaukee policeman. Eric Ryan Grossman (22-year-old Marine) ran into
California interstate traffic killing himself when a minivan hit him on
April 6, 2006 /ss/, only five days after returning from a seven-month
tour in Iraq.
James Gallagher (Camp Pendleton, Calif., Marine gunnery sergeant)
committed suicide eight months after returning from Iraq on May 1, 2006
/ss/. On July 25, 2006 /oef/, Andrew Velez (22-year-old Army
specialist) shot himself in Sharona, Afghanistan. Two years earlier his
brother had died in Iraq and he was said to have ``locked up'' after
identifying his remains. He suffered flashbacks and held his wife
hostage between tours.
At home following a near-suicide attempt in Iraq in which he sought
the help of his commanding officer, David Ramsey (27-year-old Ft.
Lewis, Wash., 47th Combat Support Hospital critical care nurse
specialist) slipped through the cracks stateside as Madigan AMC
released him from their care, unaware of his near suicide attempt in
Iraq due to a lack of access to electronic records. Missing his follow-
up appointment, he shot himself on September 7, 2006 /ss/.
On October 17, 2006 /ss/, Zachary Bowen (28-year-old Army MP who'd
served in Kosovo and Iraq) strangled and dismembered his girlfriend and
11 days later threw himself off of the ledge of the Omni Royal New
Orleans hotel with a suicide note in his pocket. A day later, on
October 18, 2006 /ss/, Jeanne ``Linda'' Michel (33-year-old Camp Bucca
Navy medic) shot herself two weeks after returning to her husband and
three kids. While overseas, she was prescribed Paxil for depression
without family notification, and taken off the antidepressant, again
without family notification, when she returned home.
James E. Dean (29-year-old corporal) killed himself via suicide-by-
cop shortly after learning he was to be redeployed to Iraq. The
Afghanistan veteran diagnosed with PTSD barricaded himself at his
father's farm on Christmas Day; a Maryland State Police sharpshooter
killed him 15 hours later, on December 26, 2006 /ss/.
2007
On January 16, 2007 /ss/, Jonathan Schulze (25-year-old Marine
machine gunner) hanged himself following two attempts to get help from
the Minnesota VA system, once in Minneapolis/St. Paul, the other in St.
Cloud. He was given a waiting list number of 26 for a counseling
appointment, but was dead before the date arrived. The following day,
on January 17, 2007 /ss/, Michael Bramer (23-year-old Fort Bragg, N.C.,
82nd Airborne Division Special Forces Unit paratrooper who'd served in
Afghanistan and Iraq) shot himself in his home.
Justin Bailey (27-year-old Marine rifleman), among the first wave
of the Iraq invasion and diagnosed with PTSD since returning, checked
himself into a Los Angeles VAMC needing immediate help for prescription
drug addiction. Yet, the day before his death, he received
prescriptions for five medications, including a two-week supply of the
potent painkiller methadone; he overdosed in his VAMC room on January
26, 2007 /ss/.
Jessica Rich (24-year-old Fort Carson, Colo., 52nd Engineering
Battalion Army Reserve heavy equipment operator) drove directly into
oncoming interstate traffic on February 8, 2007 /ss/; medically
evacuated from Iraq due to lower back pain and PTSD, she was on a
waiting list for a specialized PTSD treatment program.
On February 20, 2007 /ss/, Brian Jason Rand (26-year-old Ft.
Campbell, Ky., 30th Infantry Regiment sergeant) shot himself at a local
park seven weeks after returning home to Clarksville, Tenn. He answered
`yes' to PTSD to the identifiers on his post-deployment questionnaire
following his second tour; yet, two days after being diagnosed with
PTSD he was redeployed to Iraq for a third and final time.
Chris Dana (23-year-old 163rd Infantry Battalion Montana National
Guardsman) shot himself on March 4, 2007 /ss/ after having canceled his
appointment for PTSD. His brother said after returning in November 2005
he seemed to be melting from the inside; his father said his eyes had
lost their shine, the joy of living.
Stephen Edward Colley (22-year-old Ft. Hood, Texas, helicopter
mechanic) committed suicide on May 16, 2007 /ss/. Returning from Iraq 6
months earlier, his father said he felt he could not get the
psychological help he needed from the military for fear it would
jeopardize his future career. On May 27, 2007 /ss/, Brian William Skold
(28-year-old 151st Field Artillery Minnesota National Guardsman) died
via suicide-by-cop.
The ninth Ft. Campbell, Ky., soldier to commit suicide in 2007,
Derek Henderson (27-year-old Afghanistan and Iraq veteran) jumped to
his death from a bridge over the Ohio River on June 21, 2007 /ss/. He
had begun carrying a 12" knife and wanted a gun to ``fight the enemy,''
his medical records indicating PTSD five times. On July 25, 2007 /ss/,
Noah Charles Pierce (23-year-old 3rd Infantry Division soldier) shot
himself in rural Minnesota. The soldier who had signed up for the
military after 9/11 wrote in his suicide note that he had killed people
and now it was time to kill himself.
On August 29, 2007 /ss/, John R. Fish II (19-year-old Ft. Hood,
Texas, 41st Fire Brigade ammunitions specialist) shot himself. He had
returned from a long Iraq deployment in November 2006. Steven D. Lopez
(23-year-old Ft. Bragg, N.C., Afghanistan and Iraq veteran) shot his
wife and then himself on November 5, 2007/ss/;
he had sought help from base doctors and was prescribed Paxil.
On November 20, 2007 /ss/, Joseph Colin Russell (25-year-old two
tour Ft. Hood, Texas, 1st Cavalry Division, 2nd Brigade soldier) shot
himself at a friend's house. He was homeless and accused of being
responsible for the death of another vet following a fight at a
nightclub.
Two days later, on November 22, 2007 /ss/--Thanksgiving Day--Tyler
Curtis (25-year-old two tour Iraq veteran) committed suicide three
months after returning to Maine following his 2006 discharge from the
Army. He was torn by grief for the families of those he may have
killed.
Prepared Statement of Ira Katz, M.D., Ph.D.,
Deputy Chief Patient Care Services Officer for Mental Health,
Veterans Health Administration, U.S. Department of Veterans Affairs
Mr. Chairman and members of the Committee, thank you for the
invitation to appear before you today to discuss the Department of
Veterans Affairs (VA), Veterans Health Administration (VHA) Mental
Health program and suicide prevention. Accompanying me today are Dr.
Robert Rosenheck, Director of the Division of Mental Health Services
and Outcomes Research; Dr. Lawrence Adler, Director of the Mental
Illness Research, Education and Clinical Center (MIRECC) in Veterans
Integrated Service Network (VISN) 19; and Dr. Frederick Blow, Director
of the Serious Mental Illness Treatment Research and Evaluation Center
(SMITREC) at the Ann Arbor VA Center for Clinical Management Research.
Mental illness is a serious disease, affecting not only the
individual who has the problem, but also his or her family; and the
community in which he or she lives. The symptoms that characterize
mental illnesses can cause profound suffering for the patient and for
others. Moderate levels of the illness are strongly associated with
problems at work and at home; severe manifestations can lead to
devastating outcomes such as suicide. While relatively few people with
mental illnesses die from suicide, the fact that it occurs is a
constant reminder that these illnesses are real, and that they can be
fatal.
The Department of Veterans Affairs is determined to implement the
findings of the President's New Freedom Commission on Mental Health,
which require all mental health providers to offer Americans with
mental health needs world-class treatment focused on early intervention
and recovery. Our comprehensive Mental Health Strategic Plan, completed
in 2004, provided a blueprint for us to expand our outreach to veterans
and to enhance the capacity and quality of our mental health services.
To implement this plan, we have increased our expenditures for mental
health services from $2 billion in 2001 to $3 billion in the current
fiscal year. In addition, we have added more than 3600 new mental
health staff members to our facilities since 2005, bringing the total
number of VA employees working in this area to more than 10,000.
While a significant number of veterans of the conflicts in Iraq and
Afghanistan have required treatment for mental health conditions on
their return home, the number is well within our capabilities for
providing treatment. Approximately 100,500 of the 750,000 veterans of
this conflict have come to VA with a mental health condition since the
beginning of the war. This represents only about 10 percent of the
total number of veterans with mental health issues VA sees in any one
year. Just less than half (48,559) of those veterans received at least
a preliminary diagnosis of Post Traumatic Stress Disorder or PTSD.
The 10-percent increase in patients with mental health conditions
since 2002 should be balanced against the 50-percent increases in
expenditures and mental health staffing in VA since 2001. Our new
resources are adequate for us to address the mental health needs of
returning veterans, and to enhance our mental health services for
veterans of all eras. In terms of their suffering and need for
effective treatment, the number of returning veterans with mental
health issues is very significant; but our Department is able to meet
their needs.
SUICIDE PREVENTION
Suicide among veterans is a tragedy. The Department of Veterans
Affairs believes that it is our obligation to work to prevent suicide
both in individual patients and in the entire veteran population. Our
suicide prevention activities are based on the principle that in order
to decrease rates of suicide, we must provide enhanced access to high
quality mental healthcare, and to develop programs specifically
designed to help prevent suicide. We have trained all VA employees
about the risk factors and warning signs of suicide, and have offered
them strategies to help them deal with veterans who may be at risk of
taking their own lives.
VA employees have been given the message that even strong and
resilient people can develop mental health conditions. Care for those
mental health conditions is readily available and should be timely
provided. We know that treatment can work.
VA's suicide prevention program includes two centers that conduct
research and provide technical assistance in this area to all our
locations of care. One is our new Mental Health Center of Excellence in
Canandaigua, New York, which focuses in developing and testing clinical
and public health intervention. The other is the VISN 19 Mental Illness
Research Education and Clinical Center in Denver, which focuses on
research in the clinical and neurobiological sciences. Our system of
care also includes a suicide prevention call center, also in
Canandaigua with suicide prevention coordinators located in each of
VA's 153 hospitals. Altogether, VA has more than 200 mental health
providers whose jobs are specifically devoted to preventing suicide
among veterans.
The Department has partnered with the Lifeline Program of the
Substance Abuse and Mental Health Services Administration to develop a
VA suicide prevention hotline. Those who call 1-800-273-TALK are asked
to press ``1'' if they are a veteran, or are calling about a veteran.
When they do so, they are connected directly to VA's hotline call
center, where they speak to a VA mental health professional with real-
time access to the veteran's medical records. In emergencies, the
hotline contacts local emergency resources such as police or ambulance
services to ensure an immediate response. In other cases, after
providing support and counseling, the hotline transfers care to the
suicide prevention coordinator at the nearest VA facility to ensure
that follow-up is prompt and appropriate.
In the five weeks from October 7 to November 10, 2007, 1,636
veterans and 311 family members or friends called the hotline number.
These calls led to 363 referrals to suicide prevention coordinators and
93 rescues involving emergency services. Since the hotline began in
July, there have been more than 6,000 calls from veterans or families,
more than 1,300 referrals to Suicide Prevention Coordinators in VA
medical centers, and more than 300 rescues, any one of which may have
been life-saving.
Suicide prevention coordinators receive referrals of those at risk
for suicide from both the hotline and from providers in their
facilities, and ensure that care for those at risk addresses their high
risk status. Coordinators educate their colleagues, veterans and
families about risks for suicide, provide enhanced treatment monitoring
for veterans at risk and ensure that any missed appointments are
followed up on. The coordinators work with the entire staff of their
medical centers to maintain awareness of those who have previously
attempted suicide, and ensure that their care is enhanced.
Prevention coordinators also work with patient safety officers to
conduct quarterly safety inspections of inpatient psychiatry units, and
to coordinate staff education programs about suicide prevention. These
coordinators are in the process of organizing a system of flags in the
electronic medical record to alert providers about those at high risk,
and are conducting training for community members who have frequent
contact with veterans to help them recognize those at risk and
encourage them to seek treatment.
Finally, VA has held two National VA Suicide Prevention Awareness
Days throughout our system to focus all of our 200,000 healthcare
employees on this issue. The first event focused on enhancing overall
awareness of the issue, and the second trained all VA staff on how to
work with available prevention resources, including the hotline and the
suicide prevention coordinators.
VA is very much concerned about the epidemiology of suicide among
veterans, and has used findings in this area to guide our prevention
programs. As new data on suicide rates, risk factors for suicide and
regional variations become available, we will use that data to refine
our programs, and to better evaluate their level of success. In all of
this epidemiological work, VA uses information from the Centers for
Disease Control and Prevention's (CDC) National Death Index currently
available through the end of calendar year 2005.
VA's Epidemiology Service has published findings from a long-term,
20-year follow-up on the health of Vietnam-era veterans. The peer-
reviewed, published study reported that rates of suicide among veterans
who were deployed to Southeast Asia did not differ statistically from
veterans of the same era who were not deployed. A published study of
veterans from the first Gulf War provided a similar finding.
VA has now completed a preliminary evaluation of suicide rates
among veterans returning from Iraq and Afghanistan. From the beginning
of the war through the end of 2005 there were 144 known suicides among
these new veterans. This number translates into a rate that is not
statistically different from the rate for age, sex, and race matched
individuals from the general population.
Taken together, the population of veterans who receive care from
the Veterans Health Administration have more risk factors for suicide
than the general population. Although there are increasing numbers of
female veterans, most veterans are male. Those who come to the VA for
care tend to be older, less socio-economically well off, and more
likely to have a mental health condition or another chronic illness. It
is, therefore, by no means surprising that those receiving care from VA
have higher suicide rates than those in the general population. Those
with the greatest need for care are those who are most likely to come
to VA. This increased need can be associated with increased risks.
This, in fact, was one of the major factors leading to VA's focus on
suicide prevention.
Because of new enrollment criteria for veterans of the Global War
on Terror, the characteristics of Iraq and Afghanistan veterans coming
to VA today are different from those for veterans from prior eras. As a
result, early data being evaluated by VA, suggests that while rates
among OIF/OEF veterans who come to VHA for care are not different from
the general population, rates among those veterans who do not come to
VA appear to be higher. One possible explanation for this finding is
that VA mental healthcare is effective, and that it can be lifesaving.
Further research in this area is underway.
VA's latest data do not demonstrate an increased risk of suicide
among OEF/OIF veterans compared to the age and gender matched American
population as a whole. Nevertheless, one suicide among those who have
served their country is too much. Available information on suicide
rates and risk factors among veterans are reinforcing the importance of
the work VA has done to enhance its mental health services since 2001;
and the usefulness of our comprehensive program for suicide prevention.
VA has already implemented the key provisions of the Joshua Omvig
Veterans Suicide Prevention Bill, which was recently signed by
President Bush, and we continue to do research to develop and implement
new strategies that will improve our ability to save lives by
preventing suicide. VA believes that our healthcare system can and must
serve a national model for suicide prevention, now and in the future.
Thank you for the opportunity to address the Committee. At this
time, I would be pleased to answer your questions.
Prepared Statement of Kara Zivin, Ph.D.,
Research Health Scientist, Health Services Research and Development
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning, Mr. Chairman, I am honored to provide testimony to
the Committee about suicide among veterans treated for depression in
the VA Health System. I come before this Committee as a mental health
services researcher who has conducted research on this topic. The views
and opinions expressed are my own, and do not necessarily represent
those of my current employer, the Department of Veterans Affairs, or
the views of the VA research community.
I am here today to report on findings from a study that I conducted
along with my colleagues at the Department of Veterans Affairs'
National Serious Mental Illness Treatment Research and Evaluation
Center (SMITREC) and the VA's Health Services Research and Development
Center of Excellence in Ann Arbor, Michigan. We recently published a
paper in the American Journal of Public Health examining suicide rates
using data from the VA's National Registry for Depression for 807,694
veterans of all ages diagnosed with depression and treated at any
Veterans Affairs facility between 1999 and 2004.
In all, 1,683 veterans in VA depression treatment died by suicide
during the study observation period, representing 0.21 percent of this
treatment population. When we calculated the overall suicide rate in
this population over the 5.5-year observation period, it was 88.3 per
100,000 person-years (PY), approximately 7-8 times greater than the
suicide rate in the general adult U.S. population. A higher suicide
rate would be expected among a population of patients in treatment for
depression than the general U.S. population, given that depression is a
potent risk factor for suicide. Because most healthcare systems lack
the capability of assessing suicide rates among their treatment
populations, there are few points of comparisons with nonveteran
treatment populations. However, at least one prior study reports a
suicide rate for men receiving depression treatment in managed care
settings between 1992-1994 of 118 per 100,000 PY, a suicide rate which
is somewhat higher than that observed in this veteran depression
treatment population.\1\
---------------------------------------------------------------------------
\1\ Simon GE, VonKorff M. Suicide mortality among patients treated
for depression in an insured population. American Journal of
Epidemiology. Jan. 15, 1998;147(2):155-160.
---------------------------------------------------------------------------
In our study, we observed that the predictors of suicide among
veterans in depression treatment differed in several ways from those
observed in the general U.S. population. Typically, people in the
general population who die by suicide are older, male, and white, and
have depression and medical or substance abuse issues. In this study,
we too found that depressed veterans who had substance abuse problems
or a psychiatric hospitalization in the year prior to their index
depression diagnosis had higher suicide rates.
However, when we divided depressed veterans into three age groups:
18 to 44 years, 45 to 64 years, and 65 years or older, we found that
the younger veterans were at the highest risk for suicide. Differences
in rates among depressed veterans of different age groups were
striking; 18 44-year-olds completing suicide at a rate of 95.0 suicides
per 100,000 PY, compared with 77.9 per 100,000 PY for the middle-age
group, and 90.1 per 100,000 PY for the oldest age group. We did not
assess whether individuals had served in combat during a particular
conflict, although the existence of a military service-connected
disability was considered.
In this VA treatment population, men veterans were more likely to
complete suicide than women veterans. Suicide rates were 89.5 per
100,000 PY for depressed veteran men and 28.9 per 100,000 PY for
veteran women. However, the differential in rates between men and women
(3 : 1) was smaller than has been observed in the general population (4
: 1).
We found higher suicide rates for white depressed veterans (95.0
per 100,000 PY) than for African Americans (27.1 per 100,000 PY) and
for veterans of other races (56.1 per 100,000 PY). Veterans of Hispanic
origin had a lower rate (46.3 per 100,000 PY) of suicide than those not
of Hispanic origin (86.8 per 100,000 PY). Adjusted hazard ratios also
reflected these differences.
Surprisingly, our initial findings revealed a lower suicide rate
among depressed veterans who also had a diagnosis of post-traumatic
stress disorder (PTSD) compared to depressed veterans without this
disorder. Depressed veterans with a concurrent diagnosis of PTSD had a
suicide rate of 68.2 per 100,000 PY compared to a rate of 90.7 per
100,000 PY for depressed veterans who did not also have a PTSD
diagnosis. We investigated further to examine whether specific
subgroups of depressed veterans with PTSD had higher or lower suicide
risks. We found that concurrent PTSD was more closely associated with
lower suicide rates among older veterans rather than among younger
veterans. This study does not reveal a reason for this lower suicide
rate, but we hypothesize that it may be due to the high level of
attention paid to PTSD treatment in the VA system, and the greater
likelihood that patients with both depression and PTSD will receive
psychotherapy and more intensive visits. In general, individuals with
depression and PTSD diagnoses have higher levels of VA mental health
services use than individuals with depression without PTSD.
Interestingly, depressed veterans who did not have a service-
connected disability were more likely to complete suicide than those
with a service-connected disability. This may be due to greater access
to treatments among service-connected veterans, or more stable incomes
due to compensation payments.
We hope our findings will help inform clinical treatment and policy
initiatives to reduce suicide mortality among veterans with depression.
Thank you for this opportunity to testify. I will be pleased to
answer any questions you may have.
Statement of Michael Shepherd, M.D.,
Physician, Office of Healthcare Inspections,
Office of Inspector General, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee, thank you for the
opportunity to testify today on suicide prevention and the Office of
Inspector General (OIG) report, Implementing VHA's Mental Health
Strategic Plan Initiatives for Suicide Prevention.
Background
In 2004, suicide ranked as the 11th leading cause of death with a
rate of 11.1 per 100,000 in the general U.S. population and the 3rd
leading cause of death within the 15-24 age range. It is estimated that
each suicide intimately affects the lives of at least six other people.
In any particular suicide, individual and collective proclivities
tend to combine. Consequently, the attempt to make sense of the
multiple potential contributions from identifiable psychiatric
disorder(s), co-morbid medical illness and functional impairments,
specific personal events, and sociocultural factors has been the work
of and an ongoing challenge to mental health professionals,
sociologists, and epidemiologists. This effort has increased knowledge
about suicidal patients and provided information for utilization in
their treatment. However, there has been little reduction in overall
rates through the years, indicating there is more to learn.
Suicidologists have struggled with standardization issues for many
years. While it has long been held that the pursuit of valid and
reliable suicide statistics is important to public health policy,
establishing the validity and reliability of suicide rates has been a
notable source of concern. In the U.S. it is widely assumed by mental
health professionals that the actual suicide rate is higher than
officially reported. Establishing the validity and reliability of
suicide rates is complicated by stigma. Other sources of variability
include limitations of death certificates, variability in the training
of those tasked with certifying cause of death, use of differing
guidelines for suicide determination, and the presence of equivocal
causes such as single car accidents and drug overdoses.
The 2001 Surgeon General's National Strategy for Suicide Prevention
identifies steps in a public health model for suicide prevention.
Collecting data on rates of suicide and suicidal behavior is typically
referred to as medical surveillance. Data may include information on
how suicide rates vary by time, geography, age or special populations.
In addition, data collection may include information on characteristics
of individuals who suicide, circumstances surrounding suicide events,
the presence and absence of possible precipitants, and the adequacy or
accessibility of supportive factors and health services.
For example, the National Violent Death Reporting System is a
Centers for Disease Control and Prevention (CDC) effort to develop a
nationwide, state-based monitoring system for violent deaths. State and
local agencies use this system to input data from medical examiners,
coroners, death certificates, police reports, toxicology studies, and
other sources. At present 17 States are designated to participate in
the system. Veteran status is one of several uniform data elements
recorded for input into the system. The data is pooled with the hope
that it can ultimately be used to answer fundamental questions about
suicide and to aid participant States in the design and implementation
of tailored suicide prevention and intervention efforts.
Suicide is not a single illness with one true cause; it is a final
common outcome with multiple potential antecedents, precipitants, and
underlying causes. Interventions that may be more effective for one set
of patients may differ from those of greatest benefit for a different
set of patients. Comprehensive suicide prevention programs, those
employing a portfolio of intervention elements, and particularly those
that incorporate a range of services and providers, are thought to have
a greater likelihood of reducing suicide rates. Selecting which
interventions to implement includes consideration of the needs and
characteristics of the target population, ways to integrate
interventions into existing programs, efforts to strengthen
collaboration, and an analysis weighing the resource requirements
versus the potential effectiveness of individual interventions.
Veterans Health Administration's Mental Health Strategic Plan
In 2003, a VA mental health workgroup was asked to review the
President's New Freedom Commission on Mental Health's 2002 report, to
determine the relevance to veteran mental health programs of the
Commission's goals and recommendations, and to develop an action plan
tailored to the special needs of the enrolled veteran population. A 5-
year action plan with more than 200 initiatives was ultimately
developed and finalized in November 2004. Among the action items were a
number specifically aimed at the prevention of suicide. In addition,
endorsement and implementation of the goals from the Surgeon General's
2001 National Strategy for Suicide Prevention, and recommendations from
the Institute of Medicine's 2002 report Reducing Suicide: A National
Imperative, were incorporated into the VA Mental Health Strategic Plan
(MHSP).
OIG Report on VHA's Implementation of Suicide Prevention Initiatives
In response to a request from this Committee, the OIG undertook an
assessment of VHA progress in implementing initiatives for suicide
prevention from the MHSP. In our May 2007 report, individual MHSP
initiatives for suicide prevention were categorized and consolidated
into the following domains:
Crisis Availability and Outreach.
Screening and Referral.
Tracking and Assessment of Veterans at Risk.
Emerging Best Practice Interventions and Research.
Development of an Electronic Suicide Prevention Database.
Education.
We recommended that:
VHA make arrangements for 24-hour crisis and mental
healthcare availability, either in person, or via a crisis line, and
that at each facility an on-call mental health specialist should be
available to crisis staff either in person or by phone.
All nonclinical staff who interact with veterans receive
mandatory training about responding to crisis situations involving at-
risk veterans inclusive of suicide protocols for first contact
personnel.
Healthcare providers receive mandatory education about
suicide risks and ways to address these risks.
The requirement of sustained sobriety should not be a
barrier to treatment in specialized mental health programs for
returning combat veterans.
VHA should facilitate bi-directional information exchange
between VA and DoD for patients with mental illness coming into VHA
healthcare and/or leaving VHA healthcare for re-deployment to active
duty status.
VHA should establish a centralized mechanism to review
ongoing suicide prevention strategies, to select among available
emerging best practices for screening, assessment, and treatment, and
to facilitate systemwide implementation, in order to ensure a single
VHA standard.
Crisis Availability
Although we found that most facilities reported availability of 24-
hour mental healthcare either through the emergency room, a walk-in
clinic, or a crisis hotline, this initiative had not achieved
systemwide implementation and a coordinated toll free hotline was not
in place at the time of our report. On July 25, 2007, the Department of
Veterans Affairs subsequently began operation of a 24-hour national
suicide prevention hotline for veterans. The hotline has reportedly
received greater than 9,000 calls. Callers include veterans who
previously would have called a non-VA suicide hotline, veterans who
would not have utilized a non-VA hotline, family members and friends of
veterans, and other distressed nonveterans. Several of the veteran
calls have resulted in 911 emergency rescues and admission to VA
hospitals. Hotline personnel facilitate referral of distressed
nonveterans to a non-VA suicide prevention hotline through a
partnership with the Substance Abuse and Mental Health Services
Administration.
I recently visited the hotline, located at the Veterans Integrated
Service Networks (VISN) 2--Center of Excellence at Canandaigua, New
York, on less than 24 hours notice. During my visit with hotline staff,
the phone lines were in use throughout the duration. I observed a call
from a young veteran who told the hotline clinician that she planned to
take the bottle of pills that she had next to her. After assessment and
a lengthy discussion with the caller, the hotline line clinician
arranged for an emergency rescue. I also observed a call from a
discouraged Vietnam era veteran who had recently become homeless and
was calling from his car in which he was living. Hotline staff arranged
for him to be met by the suicide prevention coordinator at the local VA
facility.
Suicide Prevention Coordinators
The VA Office of Mental Health Services has been in the process of
implementing suicide prevention coordinators at all VA medical centers.
At present, dedicated staff are reportedly in place at approximately 85
percent of facilities and ``acting'' suicide prevention coordinators
are in place at remaining sites. Hotline clinical staff told me that
after requesting a consult for a caller at a VA facility, they contact
the facility suicide prevention coordinator electronically and/or by
phone. If they do not hear back within 24 hours, they contact the
coordinator again. Within 48 hours of the call to the hotline, an
update on the patient's disposition is to be reported by the suicide
prevention coordinator to hotline staff. At 2 weeks post call, hotline
staff contact the suicide prevention coordinator for an update as to
whether the caller has remained engaged in follow-up in the VA system.
Education and Training of VA Personnel
In terms of initiatives for education on suicide prevention, at the
time of our May report, we found that only 50 to 60 percent of
facilities provided programs to train first contact nonclinical
personnel about crisis situations involving veterans at risk for
suicide. Only one-fifth of these programs included mandatory
presentation of suicide response protocols. Almost all facilities
provide education to health providers on suicide risks, ways to address
these risks and best practices for suicide prevention. However, at only
a small percentage of facilities were these programs mandatory. Since
that time, the VISN 2 Canandaigua Center of Excellence has developed a
CD and guide for training VA nonclinical personnel and a second CD and
guidebook for community-based training. The training, titled Operation
S.A.V.E. (Signs of suicidal thinking; Ask questions; Validate the
veteran's experience; Encourage treatment and Expedite referral) will
reportedly be carried out by the facility suicide prevention
coordinators. A copy of the CDs and guide were provided to me on my
recent visit. The VISN 2 Center of Excellence leadership report plans
to subsequently develop a guide and CD for VA clinicians.
Treatment for Co-Morbid Mental Health and Substance Use Disorders
In terms of eliminating sustained sobriety as a barrier to
treatment in specialized mental health programs for returning combat
veterans, on November 23, 2007, the Deputy Under Secretary for Health
for Operations and Management issued a memorandum to Network Directors
that states that ``VHA facilities and providers must never take the
position that a patient is untreatable because substance use or
dependence precludes treating mental health conditions while mental
illness makes it impossible to treat abuse or dependence. Instead,
services must be designed and available to provide care for veterans
with substance use disorders and mental health conditions, alone or
together, regardless of acuity or chronicity.''
Facilitation of Emerging Best Practice Implementation
The OIG report recommended that VHA facilitate establishment of a
centralized mechanism to select among emerging best practices for
suicide prevention, the VISN 2 Center of Excellence has subsequently
been organized into a clinical core, an education and training core, a
VACO initiatives core, and a research core. The clinical core group is
responsible for the organized development of pilot and demonstration
projects. The initiative core is responsible for implementation of VA
Central Office suicide prevention initiatives. The research core is
focused on performing program evaluation, health services research, and
intervention effectiveness research in order to expedite the
dissemination of promising approaches throughout VA.
Bi-Directional Exchange of Health Information
Bi-directional information exchange between VA and DoD which
includes patients with mental illness coming into VHA healthcare and/or
leaving VHA healthcare for re-deployment is an ongoing issue that has
been discussed at other hearings.
VHA Development of a Veteran Suicide Database
At the time of our inspection, researchers at the VHA Serious
Mental Illness Treatment Research and Evaluation Center (SMITREC) in a
joint effort with researchers at the University of Michigan School of
Public Health in Ann Arbor, Michigan, had been developing a methodology
by which to create a database of veterans who had utilized VHA care in
an index year and then stopped utilizing VHA care in subsequent years.
This database would then be matched with data from the CDC National
Death Index (NDI), to determine which of these veterans were deceased.
This data would then be matched with an enhanced version of the
National Death Index to determine which veterans no longer accessing
VHA care had died from suicide. In early October, SMITREC researchers
reported that they have subsequently calculated suicide rates for 2001
and 2002 among veterans who obtain care in VHA. In recent weeks, they
reported working on data received from the NDI for calculation of rates
from 2003-2005.
At the time of the May OIG report, a template of data elements
pertaining to suicides and suicide attempts had been piloted in Rocky
Mountain Network (VISN 19) facilities. In the past few months, VHA has
reportedly been expanding use of the template to VHA facilities
nationwide. Clinical providers at VHA facilities nationwide have been
asked to input data regarding attempts or completed suicides by their
patients using a template which contains prompts for data elements
including age, gender, diagnosis, date of attempt, method used,
outcome, date last seen at VA prior to attempt, among others. The
facility suicide prevention coordinator is responsible for receiving
and collating data inputted into the template by clinical providers and
submitting a spreadsheet to the Center of Excellence at the Canandaigua
VAMC on the 10th of each month. October was the first month for which
data was submitted to the Canandaigua Center of Excellence. Most but
not all VHA facilities submitted data and the extent of provider
compliance with filling out the templates is presently unclear.
Since October 2003, the Department of Defense (DoD) Defense
Manpower Data Center has sent the VA Environmental Epidemiology Service
a periodically updated personnel roster of troops who participated in
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), and
who had separated from active duty and become eligible for VA benefits.
This data however does not include recently discharged or retired
veterans who were not deployed in support of OEF/OIF or veterans who
have served in other eras.
The OIG LC Database
During the past year, colleagues at the OIG Office of Healthcare
Inspections have diligently pursued creation of a database to
quantitatively characterize the care transition process from DoD to
VHA. A September 2007, OIG Informational Report entitled Quantitative
Assessment of Care Transition: The Population-Based LC Database,
describes the creation of an analytical database derived from more than
30 data files acquired from VA and DoD that incorporates details about
all service members discharged from July 1, 2005 to September 30, 2006.
The database includes veterans who were deployed, those who were not
deployed, members of the Reserves and National Guard, those who have
accessed care in VHA and those who have not. The paper discusses the
methodology used to create the database, data confidentiality issues,
its limitations, and analytic potential for research and other
applications. This unique database may provide background for
understanding and interpreting ongoing and planned studies pertaining
to select medical conditions, causes of mortality, and/or healthcare
access.
Conclusion
Suicide is an unequivocally tragic and often incomprehensible
event. Preventing suicide is a complex, multifaceted challenge to which
there is not one best practice but several promising but not proven
approaches and methods. Since 2004, progress had been made toward
implementation of the MHSP initiatives for suicide prevention. Progress
has continued with greater integration and at an accelerated pace since
the time of the OIG report in May and the enactment of the Joshua Omvig
Suicide Prevention Act. The full array of suicide prevention
initiatives has not yet attained systemwide implementation. It is
therefore incumbent upon VA to continue moving forward toward full
deployment of suicide prevention strategies for our Nation's veterans.
Mr. Chairman, thank you again for this opportunity to testify on
this important issue. I would be pleased to answer any questions that
you or other members of the Committee may have.
Statement of Joseph L. Wilson, Deputy Director
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
views on Stopping Suicides: Mental Health Challenges within the
Department of Veterans Affairs (VA). The VA has the Nation's largest
mental health program, which is continually implementing various
programs to accommodate the growing demand for mental health services
to all veterans.
Unfortunately, during a time which greatly warrants the development
of such programs, the increased scrutiny of VA's mental health services
and budget exist due to the increased demand for mental health services
from veterans returning from combat in Iraq and Afghanistan, as well as
veterans from previous eras.
Mental Health Strategic Plan, Initiatives, and Other Recommendations
Upon the completion of its Comprehensive Mental Health Strategic
Plan (MHSP), the VA began implementation of mental health initiatives
in 2005. The Mental Health Initiative (MHI) was instituted to provide
funding to support the implementation of the MHSP outside of the
Veterans Equitable Resource Allocation (VERA) model.
To effectively plan the funding for the MHI, the MHSP was divided
into four main areas to include: enhancing capacity and access for
mental health services; integrating mental health and primary care;
transforming mental health specialty care to emphasize recovery and
rehabilitation; and implementation of evidence-based care. Under these
key categories are multiple funded programs, which are also currently
attempting to accommodate increasing issues, to include suicide,
amongst our Nation's veterans.
One of many indicators of increase in suicides is evident in
recommendations made to VA by the Joint Commission on the Accreditation
of Healthcare Organizations (JCAHO), an organization formed in 1951
with a mission to maintain and elevate the standards of healthcare
delivery through evaluation and accreditation of healthcare
organizations, and its National Patient Safety Goal (NPSG). Implemented
on January 1, 2007, JCAHO advised that all VA facilities take the
following steps to comply with the NPSG:
Develop and implement strategies to properly assess,
treat, and manage patients identified at risk for suicide.
Document the relevant risk factors for suicide in each
patient's medical record.
Document treatment and the treatment setting in a manner
that addresses the presence of (or absence of) relevant risk factors
that increase risk for suicide and features that may decrease risk for
suicide.
Provide the appropriate telephone number(s) for telephone
calls during working hours and other times, in writing, to at-risk
patients and/or significant others.
Instruct patients and their significant others to call
the facility's Emergency Department or Urgent Care Center if they have
a crisis situation.
Ensure that the local or regional mental health hotline
knows about VA as a resource in case a veteran should contact them.
Ensure that the safety concerns in the design of the
inpatient mental health unit (and its furnishings) are addressed.
Establish and implement a policy stating who is
responsible for identifying and working with local agencies so that VA
patients receive emergency support and referral to the VA as soon as
possible.
The American Legion supports directives established by the Mental
Health Strategic Plan and JCAHO, and their intentions to prevent
tragedies such as suicide. However, there are concerns of adequacy of
funding for these programs, as well as accommodation, across the board,
for veterans of previous eras and the ever-increasing number of
veterans who are returning from Iraq and Afghanistan. The American
Legion continues to urge the Congress to annually appropriate the
necessary funds for the Department of Veterans Affairs to ensure
comprehensive mental health services are available to veterans.
Suicide
The VA estimates that more than 5,000 veterans take their lives
each year. Suicide rates are 35 percent higher for Iraq veterans than
for the general population. Thirty-six percent of the 250,000 Iraq and
Afghanistan veterans who have sought care in the VA system were treated
for mental health problems.
According to research, 283 Afghanistan veterans between 2001 and
2005 have taken their own lives. It was also reported that awareness
was intensified nationwide when the United States Army reported the
increase of its 2006 suicide rate, which rose to 17.3 per 100,000
troops. Within the past year the Army reported 23 soldiers, then
currently in Iraq and Afghanistan committed suicide with at least seven
Iraq and Afghanistan veterans committing suicide since returning home.
In July 2007, VA opened a 24-hour National Suicide Prevention
hotline for veterans. Recently, the VA submitted an informative letter
to veterans disclosing the National Suicide Prevention toll-free
hotline number included with definitive/probable suicide warning signs.
The passing of H.R. 327, also titled the Joshua Omvig Veterans Suicide
Prevention Act, which requires VA to develop and implement more
programs, such as outreach and education, more than suggests an
impending crisis amongst the Nation's veterans. During the development
and implementation of mental health programs, there also arises the
question of effectiveness.
Signs of increase is also evident at VA's National Suicide hotline
center based in Canandaigua, N.Y., in which counselors have taken more
than 9,000 calls since its inception this year. In addition, the VA
recently announced plans to provide suicide prevention coordinators at
each of its 153 medical centers.
In 2004, VA completed a five-year action plan that included
implementation of goals from the Surgeon General's 2001 National
Strategy for Suicide Prevention and recommendations from the Institute
of Medicine's (IOM) 2002 report ``Reducing Suicide--A National
Imperative.'' Afterward, the aforementioned were incorporated into the
VA Mental Health Strategic Plan (MHSP).
In addition, individual MHSP initiatives for suicide prevention
were categorized and consolidated, to include:
Crisis availability and outreach; screening and referral.
Tracking and assessment of veterans at risk.
Emerging best practice interventions and research.
Development of an electronic suicide prevention database.
Education.
The warranted emergence of such programs to prevent this dreadful
tragedy is indicative of a more imminent crisis becoming worse, absent
effective means of curtailment. The American Legion agrees these
initiatives are steps in the right direction and continues to remain
incessant on monitoring the efficiency and effectiveness of programs
implemented in the MHSP. We also implore the Congress to mirror our
sentiment as well.
Conclusion
In response to a call for help from this Nation's veterans,
programs related to crises such as suicide are continuously being
implemented. However, in accordance with a 2006 Government
Accountability Office (GAO) report, there are issues of adequacy and
accountability in the areas of funding and assessment, which in turn
leave gaps in this system, therefore allowing veterans in need to fall
through the cracks.
It is the insistence of The American Legion that a proactive effort
be implemented with continuous oversight to ensure complete access is
available to avert suicides amongst our Nation's veterans. The American
Legion also urges the Congress to provide annual oversight of VA's
mental health services to augment deterrence of such tragedies as the
above mentioned.
Mr. Chairman and members of the Committee, The American Legion
sincerely appreciates the opportunity to submit testimony and looks
forward to working with you and your colleagues to resolve this
critical issue. Thank you for your continued leadership on behalf of
America's veterans.
Statement of Joy J. Ilem,
Assistant National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Committee:
Thank you for inviting the Disabled American Veterans (DAV) to
provide testimony at this important hearing focused on preventing
suicides and meeting other mental health challenges of veterans who
receive their care from the Department of Veterans Affairs (VA). This
hearing is especially timely given the series of disturbing reports
that have appeared recently on these important issues.
The Department of Defense (DoD) and VA share a unique obligation to
meet the healthcare and rehabilitative needs of veterans who have been
wounded during military service or who suffer from readjustment
difficulties and other consequences of combat deployments. VA recently
announced it has made suicide prevention a priority and has developed a
focused program based on increasing suicide awareness, prevention, and
training to improve the recognition of suicide risk by healthcare
staff. A national suicide prevention hotline has been established and
suicide prevention coordinators have been hired in each VA medical
center. DAV welcomes these efforts but we believe they will be
fruitless if VA fails to improve the effectiveness of treatment for
post traumatic stress disorder (PTSD), depression, substance abuse and
other mental health disorders--which together appear to create the
greatest threat to rising suicide rates in veterans.
Suicide is a significant public health problem and should be
addressed by aggressive efforts in the veteran population. In the
December issue of the American Journal of Public Health,\1\ VA
investigators reported the results of their longitudinal study carried
out from 1999-2004 using nationally representative data to determine
suicide rates among veterans treated by VA for depression. Of the over
800,000 veterans studied, 1,683 or 0.21 percent committed suicide.
Overall, the rates of suicide among depressed veterans were 7-8 times
higher than the rate for the general population. However, suicide rates
in depressed veterans were similar to rates found in men receiving care
for depression in managed care systems. Unlike other studies that
report higher rates in older adults, this VA study found that depressed
veterans who were younger were at the greatest risk. One of the
findings of the study confirmed that veterans with co-morbid depression
and substance abuse are at very high risk for suicide. Veterans from
the northeast and central U.S. had lower suicide rates than veterans
from the south and west. This is consistent with the geographic and
regional suicide rate variations.
---------------------------------------------------------------------------
\1\ Suicide Mortality Among Individuals Receiving Treatment for
Depression in the Veterans Affairs Health System: Associations with
Patient and Treatment Setting Characteristics. Zivin K, Kim M, McCarthy
JF, Austin KL, Hoggat KL, Walters H, Valenstein, M. AJPH (2007)
97(12):2193-2198.
---------------------------------------------------------------------------
The findings of this study give clinicians important clues to
characteristics that produce higher suicide risk in veterans suffering
from depression. Youth, incidence of substance use and geographic
location are all associated with suicide risk. DAV hopes that further
studies of suicide risk can increase our understanding and reduce the
impact on veterans who fought in Afghanistan, Iraq and previous
conflicts.
Research demonstrates a clear association between deployment to a
combat zone and subsequent mental health problems, substance abuse, and
psychosocial problems such as marital conflict and incarceration. Key
to our discussion today is the recognition that combat service is
associated with higher rates of suicide in the early post-deployment
period. This information is summarized in a report from the Institute
of Medicine (IOM) entitled Gulf War and Health: Volume 6 Physiologic,
Psychologic, and Psychosocial Effects of Deployment Related Stress,
published in November 2007.\2\ The IOM committee studied literature
covering all deployments in the 20th and 21st centuries including World
War II, the Korean War, the Vietnam War, the 1991 Persian Gulf War, and
Operations Iraqi and Enduring Freedom (OIF/OEF). This eminent group of
experts reviewed the scientific evidence and determined that the
evidence is sufficient to conclude that there is an association between
deployment to a war zone and PTSD, other anxiety disorders, depression,
alcohol abuse, suicide and accidental death in early years after
deployment, and marriage and family conflict. In addition, the
committee found that there was suggestive evidence of an association
between deployment stress and drug abuse, chronic fatigue syndrome,
fibromyalgia and other pain syndromes, gastrointestinal symptoms, skin
disorders, increased symptom reporting and unexplained conditions and--
and incarceration. The committee noted that there was insufficient
investigation by VA and DoD to allow the Committee to draw cause-and-
effect conclusions regarding deployment stress and later physiological,
psychological and psychosocial conditions. The IOM report states very
clearly that veterans, young and old, are at increased risk of suicide
because of their presence in combat.
---------------------------------------------------------------------------
\2\ Gulf War Health: Volume 6. Physiologic, Psychologic, and
Psychosocial Effects of Deployment-Related Stress. The National Academy
Press, Washington DC, 2007.
---------------------------------------------------------------------------
Military deployments in Iraq and Afghanistan are among the most
demanding since the Vietnam War over four decades ago. These
deployments are causing heavy casualties in what are considered the
``invisible'' wounds of war: PTSD, depression, family dislocations and
other distress, and a number of other social and emotional consequences
for those who have served in OIF/OEF. VA reports that OIF/OEF veterans
have sought care for a wide array of co-morbid medical and
psychological conditions, including adjustment disorder, anxiety,
depression, PTSD, and the effects of substance use. Through October
2007, VA reported that, of the 263,909 separated OIF/OEF veterans who
have sought VA healthcare since the beginning of those hostilities, a
total of 100,580 unique patients had received a diagnosis of a possible
mental health disorder. More than 48,000 enrolled OIF/OEF veterans had
a probable diagnosis of PTSD; almost 33,000 have been diagnosed with
depression; and, more than 40,000 reported nondependent abuse of
drugs.\3\
---------------------------------------------------------------------------
\3\ Department of Veterans Affairs, VHA Office of Public Health and
Environmental Hazards, ``Analysis of VA Healthcare Utilization Among
U.S. Global War on Terrorism (GWOT) Veterans: Operation Enduring
Freedom, Operation Iraqi Freedom,'' October 2007.
---------------------------------------------------------------------------
According to the recent report of the DoD Mental Health Task Force
(Task Force), suicide rates have risen among OIF/OEF active duty
members.\4\ In a finding that is key to this hearing, the Task Force
also concluded that alcohol abuse contributed in 65 percent of the
instances of suicidal behavior in military servicemembers. Depression
and marital and relationship difficulties were seen as additional key
contributors to suicidal ideology. After receiving these reports, DoD
is beginning to reinforce suicide prevention efforts, and VA is
targeting suicidal behavior in the veteran population, including
establishing a veteran-specific referral procedure when veterans call
800-273-TALK, the National Suicide Prevention Hotline sponsored by the
Substance Abuse and Mental Health Services Administration of the
Department of Health and Human Services. Experts assert that any
effective suicide prevention effort must offer ready access to robust
mental health and substance abuse treatment programs, including
components related to outreach, prevention, stigma reduction, improved
screenings and early interventions. DAV concurs that these components,
with the resources to fully support them, are critical to success of
this prevention effort.
---------------------------------------------------------------------------
\4\ An Achievable Vision: The Report of the Department of Defense
Mental Health Task Force, June 15, 2007.
---------------------------------------------------------------------------
In a study of 315 homeless male veterans and 310 homeless female
veterans, VA researchers found that 27 percent and 37 percent,
respectively, reported they had attempted suicide in the past 5 years,
and an additional 44 percent and 49 percent, respectively, reported
they had contemplated suicide. The study also found over 80 percent of
homeless veterans had mental disorders, prominently among them
substance abuse, and that its degree of severity was a strong predictor
of suicidality. In men, combat exposure and PTSD were predictive, and
in women, recent sexual or physical trauma correlated positively with
suicidality.\5\
---------------------------------------------------------------------------
\5\ Brenda, BB. Gender Differences in Predictors of Suicidal
Thoughts and Attempts Among Homeless Veterans That Abuse Substances.
Suicide and Life Threatening Behavior, 35, (2005) 106-116.
---------------------------------------------------------------------------
The link between substance abuse and other mental disorders and
suicide is strong. Earlier this year in a study of over 8,000 veterans
who received substance abuse treatment, VA researchers found that nine
percent had attempted suicide in the year prior to VA treatment, but
only four percent had made suicide attempts in the year following
treatment.\6\ This would seem to validate the premise that effective
substance abuse treatment leads to reduction in suicide attempts. A 25-
year study of 641 Vietnam veterans also found that over time, there was
a strong correlation between suicidality, PTSD and substance abuse.\7\
Both these VA studies dealt predominantly with older veterans, but
experts believe it would be reasonable to expect that similar studies
focused on younger veteran cohorts, including OIF/OEF veterans, would
show results consistent with these findings.
---------------------------------------------------------------------------
\6\ Ilgen, MA; Harris, A; Moos, R; et al. Predictors of Suicide
Attempt One Year After Entry Into Substance Abuse Disorder Treatment.
Alcoholism, Clinical and Experimental Research, 31, (2007) 635-642. And
Ilgen, MA; Jain, A; Lucas, E; Moos, R. Substance Use Disorder Treatment
and a Decline in Attempted Suicide During and After Treatment. J Stud
Alcohol and Drugs, 68, (2007) 503-509.
\7\ Price, RK; Risk, NK; Haden, AH, et al. Post Traumatic Stress
Disorder, Drug Dependence and Suicidality Among Male Veterans. Drug and
Alcohol Dependence, 76S, (2004) S31-43.
---------------------------------------------------------------------------
Mr. Chairman, there are rising indications that the misuse of
substances will continue to be a significant problem for OIF/OEF
service members and veterans. In a recent study, VA New Jersey-based
researchers examined substance abuse and mental health problems in
returning Iraq veterans.\8\ These researchers noted that although
increasing attention is being paid to combat stress disorders in
veterans, little systemic focus has been made on substance abuse
problems affecting this population. In the group studied (292 New
Jersey National Guard members who had returned from Iraq within 12
months of data collection) nearly 47 percent of participants reported a
mental health and/or substance abuse problem. Substance abuse problems
were found to be higher among veterans with other mental health
problems. Access to substance abuse treatment both during and after
deployment was especially low for those needing it (among veterans with
dual disorders, 41 percent received mental health treatment but only
nine percent received treatment for substance abuse). Similarly, a
study of returning Maine National Guard members found substance abuse
problems in 24 percent of the troops surveyed.\9\ In the most recent
DoD anonymous Survey of Health Related Behaviors Among Active Duty
Personnel, 23 percent of the respondents acknowledged a significant
alcohol problem.\10\
---------------------------------------------------------------------------
\8\ Kline, A., Falca-Dodson, M., Substance Abuse and Mental Health
Problems in Returning Iraqi Veterans. VA New Jersey Healthcare System,
New Jersey Department of Military and Veterans Affairs 2007,
(unpublished).
\9\ Wheeler, E. Self Reported Mental Health Status and Needs of
Iraq Veterans in the Maine Army National Guard. Community Counseling
Center, 2007 (unpublished).
\10\ Bray, R., Hourani, L., Olmstead, K., Witt, M., Brown, J.,
Pemberton, M., Marsden, M., Marriott, B., Scheffler, S., Vandermaas-
Peeler, R., Weimer, B., Calvin, S., Bradshaw, M., Close, K., & Hayden,
D. (2006, August). 2005 Department of Defense Survey of Health Related
Behaviors Among Active Duty Military Personnel: A Component of the
Defense Lifestyle Assessment Program (DLAP). Prepared for the Assistant
Secretary of Defense for Health Affairs, U.S. Department of Defense,
Cooperative Agreement RTI/7841/006-FR). Research Triangle Park, NC:
Research Triangle Institute.
---------------------------------------------------------------------------
Substance abuse--common as a secondary diagnosis among newly
injured veterans and others with chronic long-term illness or injury--
can often be overshadowed by more compelling acute care needs. Mental
health experts agree that untreated substance abuse can result in a
variety of negative health consequences for the veteran with marked
increases in healthcare expenditures, as well as social costs due to
additional stresses on families from loss of employment and legal
costs. In both the VA and DoD healthcare systems, current evidence-
based treatment guidelines for substance use disorders confirm the
substantial body of research supporting the effectiveness of a variety
of treatments for these problems. VA must continue to educate its
primary care providers about these proven techniques, including better
detection of substance use disorders, to ensure that these problems are
identified early and treated.
We urge VA to provide a full continuum of care for mental health
and substance use disorders including more consistent, universal
periodic screening of OIF/OEF combat veterans in all its healthcare
facilities and programs--especially in primary care. Outpatient mental
health counseling and pharmacotherapy should be made available at all
larger VA community-based outpatient clinics. Also, short-term
outpatient counseling including motivational interventions; intensive
outpatient treatment; residential care for those most severely
disabled; detoxification services; ongoing aftercare and relapse
prevention; self help groups; and, opiate substitution therapies and
newer drugs to reduce craving, should be included in VA's substance
abuse and prevention services program. We believe further investment in
a comprehensive package of substance-use services will help younger
veterans during an often difficult readjustment period following combat
deployments. Hopefully, VA can use preventive approaches that will help
restore these veterans and to prevent chronic long-term mental health
consequences that attend drug and alcohol addictions, and thereby also
lower risks for suicide. These types of VA services could also be
beneficial to older veterans struggling with chronic addictions.
Mr. Chairman, war also places great stress on family and social
relationships. Active duty service members currently are called on to
make frequent deployments of long duration, in dangerous combat
assignments. Time at home between these deployments is marked by
intensive training in garrison and continuous preparations for
redeployment. Active reservists and National Guard members face
unanticipated redeployments that disrupt their families and strain
their financial and employment security.
We have substantial data and reports that document the strain the
wars are putting on combat veterans' mental health and their
relationships with spouses and families. Interpersonal conflict is
clearly increasing, and recent data suggest that the problems grow
rather than diminish in the months after service members return home.
Soldiers also reported more mental health problems and were referred at
higher rates for mental health services. Of special concern are the
high rates of alcohol use being reported by soldiers. DAV is very
concerned about all these reports, and note that these findings do not
even reflect the full impact of extended deployments, the third, fourth
or even fifth deployments for some individuals, or the impact of
redeployed service members who already may be actively suffering from
untreated PTSD.
We understand that VA medical centers and their community-based
outpatient clinics do not routinely provide marital and family
counseling services. VA's Readjustment Counseling Service, through its
community-based Vet Center program, is the only major source of marital
and family counseling services in the VA healthcare system. Vet Centers
are user-friendly and have high veteran satisfaction, but these vital
services should be made more generally available at VA's major medical
facilities to increase access to these important services. Congress
should ensure that marital and family counseling services are offered
as a part of the healthcare benefits package, when needed in
relationship to combat readjustment issues for veterans under care at
VA.
In addition to marriage and family counseling services, VA needs to
improve it's substance use treatment programs. Since the late 1990s, VA
has seen unparalleled growth in veterans' use of its healthcare system
however, according to VA mental health staff, the number of veterans
who received specialized substance abuse treatment services has
declined since 1998 despite increasing demand from veterans with these
problems. At a time when substance abuse care needs appear to be rising
and suicide risk among OIF/OEF veterans is high and so troubling, we
urge VA to ensure these programs are available to veterans who need
them.
These healthcare and psychosocial issues are complex. Therefore,
VA's approach must be comprehensive and involve long-term structural
improvements in the care provided to these veterans. We see the need
for the following actions by VA:
VA should immediately improve access to substance abuse
treatment services, particularly early interventions for OIF/OEF
veterans that are designed to prevent chronic conditions and more
serious problems.
DoD and VA must eliminate the stigma attached to service
members and veterans seeking care for mental illness and substance
abuse with the same urgency and sincerity that we give to ``medical''
illnesses. Otherwise, some veterans will not seek help and may fall
into despair and be at risk for suicide.
VA must provide access for OIF/OEF veterans and their
spouses to marital and family counseling, to help restore relationships
that deteriorate as a consequence of military deployment and
separation, and to strengthen the social support system these veterans
need as they reintegrate into their homes and communities.
VA must assure that access to comprehensive age-
appropriate mental health services is available to all OIF/OEF
veterans, and develop services targeted to the new needs of the
increasing cohort of women veterans who have been exposed to combat
stress. VA must continue to enhance access to mental health, PTSD and
readjustment counseling services for all veterans. Enhancements in
these programs have been initiated, but we should remain vigilant to
ensure that they are sustained and that state-of-the-art, quality
healthcare services are delivered, irrespective of a veteran's gender
or geographic location.
VA should provide Congress its strategic plan, through
its Office of Rural Health for OIF/OEF veterans living in rural areas
far from VA facilities and essentially without access to any form of
direct VA service in mental health and otherwise. We urge VA and this
Committee to find acceptable ways for these veterans (many of whom
served as called-up National Guard members) to gain access to the full
continuum of healthcare services offered by VA, to address their mental
health and readjustment needs, and help them restore their marital and
family relationships after serving.
Mr. Chairman, we bring to the Committee's attention an issue that
we believe is of great importance and directly affects veterans'
suicide risk. Earlier in this testimony, I indicated that a recent IOM
report had shown that combat service was associated with veterans'
later incarcerations. Incarceration presents a life-altering
consequence. There appears to be a link between combat and
incarceration, mental health decline, substance abuse and elevated
suicide risk for some veterans.
The Committee may be aware of a recent front page article in the
Washington Post concerning the pending prosecution under the Uniform
Code of Military Justice (UCMJ) of Army Lt. Elizabeth Whiteside. As
indicated in a Post editorial following publication of the original
story, ``the 25-year-old Army reservist had a stellar record of service
but had a breakdown, possibly caused by her service in war-torn
Baghdad. After a series of stressful incidents, she shot herself in the
stomach. Despite the unequivocal judgment of psychiatrists that she
suffers from significant mental illness, her commanders pressed
criminal charges against her, and she's now waiting to hear whether the
Army will court-martial her.'' We believe Lt. Whiteside's case
resonates with the rest of our testimony, and the challenges we face as
a Nation in dealing with the mental health consequences of war.
Earlier this year, the Department of Justice's (DOJ) Bureau of
Justice Statistics issued a report indicating that, while veterans are
not disproportionately represented in Federal and State prison
populations compared to nonveterans, OIF/OEF veterans do constitute
nearly five percent of the total population of incarcerated
veterans.\11\ Since 2002 approximately 5,000 former military members
who served in our ongoing wars, individuals who participated at some
level in U.S. efforts to restore the freedoms of the Iraqi and Afghani
peoples, have subsequently lost their own personal freedom after
returning home.
---------------------------------------------------------------------------
\11\ Noonan, ME; Mumola, CJ. U.S. Dept. of Justice, Office of
Justice Programs, Bureau of Justice Statistics, ``Veterans in State and
Federal Prison, 2004,'' May 2007.
---------------------------------------------------------------------------
Depression, substance use disorders and other mental health issues
are common in prison. Each of those imprisoned individuals' stories
deals with unique circumstances and convicted criminal behavior. In
some instances, sadly, individual failures to readjust and to gain
access to effective care and services spirals down into impulsiveness,
emotional breakdown, loss of control, loss of employment, and even
homelessness and criminal behavior.
Mr. Chairman, there is another ``hidden'' veteran population, in
prison and out, that is currently beyond reach of any VA program: these
are veterans whose behavior while in service led to entanglement in the
UCMJ, resulting in both imprisonment and/or so-called ``bad paper''
discharges. Veterans with less than honorable discharges are not
defined as ``veterans'' under title 38, United States Code. Thus, they
are ineligible for any service or benefit from VA. The DOJ report noted
that 31 percent of veterans in Federal and State prisons have
dishonorable discharges from military service.
The DOJ report also indicated that more than 2,000 active duty
personnel are currently imprisoned in military penal facilities. Once
their sentences are served, most of them will be issued discharges
under less than honorable conditions, or they will receive dishonorable
discharges. In general these persons will not be able to avail
themselves of federal benefits including VA's programs for PTSD, mental
health and other readjustment services.
We believe these subjects should be added to the Committee's
concerns about mental health and suicide. At this juncture DAV offers
no specific recommendations for legislation; however, we believe that
DoD and VA share a responsibility to ensure that war-traumatized
service personnel and veterans should not be criminalized before an
effort is made to intervene with therapeutic remedies. We ask the
Committee to investigate the circumstances of both military and
civilian justice systems, and to work with your colleagues on the
Committee on Armed Services, to determine whether DoD and VA are using
all the tools at their disposal to divert military personnel and
veterans in trouble to therapeutic solutions rather than allow them to
be criminalized.
In summary, many of our active duty service members, veterans and
their families are experiencing the stressors we have noted in this
testimony and are experiencing real emotional hardship in their lives.
To address these challenges, DoD, VA and Congress need to work
together--and the time to cooperate is now. For a small number of
veterans, these stressors are having devastating consequences,
including increased risk of suicide. Taking action now--before their
problems become more complicated and severe, is in their best interests
and in the best interest of the Nation. The resources we spend today,
and the programs that Congress authorizes to promote better mental
health, will have long term positive benefits for veterans and will
reduce financial and social costs to the Nation. We owe them nothing
less.
Mr. Chairman, thank you for this opportunity for DAV to offer its
views on these matters. I will be pleased to address your questions, or
those from other Members of the Committee.
Statement of Todd Bowers, Director of Government Relations,
Iraq and Afghanistan Veterans of America
Mr. Chairman and members of the Committee, thank you for hearing me
speak today. On behalf of Iraq and Afghanistan Veterans of America, I
would like to thank you all for your unwavering commitment to our
Nation's veterans. The Committee originally invited our Executive
Director, Paul Rieckhoff, to testify today. Unfortunately, Mr.
Rieckhoff had a prior engagement that he could not reschedule and so he
asked me to be here today on his behalf. I will do my best to fill his
boots this morning.
I would like to begin by thanking the Committee for the outstanding
leadership you provided to ensure that legislation combating suicide
among veterans made its way into law. Specifically, I would like to
thank you for your efforts to pass the Joshua Omvig Suicide Prevention
Act. IAVA wholeheartedly endorsed this groundbreaking legislation and
we are excited about the positive impact it will have on all veterans.
I was very excited to hear about the nomination of General Peake to
be the new secretary of the Veterans Administration. General Peake is a
combat veteran who holds dear the Army's ``Warrior Ethos.'' The Warrior
Ethos states that ``I will always place the mission first, I will never
accept defeat, I will never quit, I will never leave a fallen
comrade.'' I believe we can apply the lessons of combat, and the
Warrior ethos, to improving suicide prevention at the VA.
On my second combat tour in Fallujah, Iraq, I was on a patrol with
my team of six Marines. As we moved through the city we made our way to
Jolan Park, located in the northwestern portion of the city, to link up
with our battalion's Executive Officer. Once we arrived at the park we
found ourselves alone. There were no other Marines in sight. As we
surveyed the area, I noticed a group of Marines four blocks away waving
their arms and jumping up and down. By the time I was able to figure
out that they were telling us we were in danger, it was too late. I
turned to inform my Captain and, just as I opened my mouth, the
building next to us exploded. The blast was so strong that it threw me
backward. Once the dust settled and the ringing in our ears subsided,
the Marines who were waving at us from down the street made their way
over to our vehicle. ``What the hell is wrong with you guys!?'' a Major
screamed at us. Apparently they were utilizing a controlled blast to
destroy a massive weapons cache used by the insurgents and had called
in the grid coordinates over the radio to warn all Marines to stay
clear of the area. We did not get the communication. Our radio had lost
its encryption.
The failure to communicate that day in Fallujah nearly killed me
and six of my fellow Marines.
I believe communication is also key to success in suicide
prevention.
The Army's Field Manual 6-22.5, ``A Leader's Guide to Combat and
Operational Stress,'' states that ensuring ``communication lines are
open'' is one of the most ``potent countermeasures to confront combat
stress and to reduce psychological breakdown. . . .''
Recently, the VA had made great strides to improve communications
lines by creating a Nation-wide Suicide Prevention hotline. This
hotline is available to veterans and their families 24 hours a day,
seven days a week. This new program has had amazing results. The VA has
highlighted many stories of veterans who have used the hotline to get
the help they need. But after talking to many IAVA's members, including
those in the National Guard and Reserves, we have found that they do
not know that this service is available. Better outreach is the only
way to ensure that these new programs are available to all who need
them.
But outreach is a difficult task if you do not know where your
targets are. A national registry of veterans would solve this gap in
communication.
The Gulf War Registry was established to inform veterans of changes
in policy regarding issues specific to the war in the Gulf such as
exposure to burning oil wells and Gulf War syndrome. Although this
registry is newly available to Iraq veterans, its potential is still
limited. Right now, the registry is not open to Afghanistan veterans,
and is only made available to those who are in the VA system. Only
about one-third of Iraq and Afghanistan veterans eligible for VA care
have sought care, so the vast majority of veterans are not eligible for
inclusion.
We at IAVA believe that all veterans should be included in a
registry upon discharge from the military. Currently the tracking
system for veterans is almost non-existent. Registering veterans, along
with their deployments to specific conflicts, would help the VA reach
out to veterans and family members who will benefit from their
outstanding initiatives and programs, including the suicide hotline.
Much of the work of suicide prevention, however, must occur much
earlier in the process. IAVA has strongly endorsed the mandatory pre-
and post-deployment mental health screening of our service members by
mental health professionals. This will produce a more accurate
assessment of the impact that combat has on a service member's mental
health. Making screening mandatory will reduce the stigma related to
seeking mental health treatment. I would compare this to the mandatory
drug testing that the Department of Defense conducts for all service
members. If all are required to take part, then it becomes a part of
daily routine and no longer singles individuals out.
In addition to universal screening, a coherent national anti-stigma
campaign will help ease the barriers keeping troops from early
treatment. I am very pleased to announce that IAVA has partnered with
the Ad Council for the next three years to implement a ``Stigma
Reducing'' national ad campaign. This campaign will be in print, on
television and radio and online, and will convey to the American public
and our Nation's veterans that treating mental health injuries is a
routine step in reintegration.
I'd like to close with another personal story of a family in
Northern Virginia who have experienced first-hand the effects of
suicide among the veterans' community. They have become my friends and
are almost like family to me. A few years ago, the father of the
family, who served in the Army, took his own life. He left behind three
children. Years later, his family still carries the tremendous
emotional burden of unanswered and unanswerable questions. What more
could have been done to save him?
I ask you, today, to consider that question. What could have been
done? Would a hotline have been enough? A flier in the mail about the
signs of suicide? A call from his local Vet Center?
My friend's family will never know the answer. If we act now, we
can implement measures that will be a crucial step in reducing suicide
amongst veterans.
On the battlefield, casualties are often unavoidable. What is
avoidable is suicide. If we take the proper steps to combat suicide
among the veterans community, we can and will win this battle. Thank
you.
Statement of National Coalition for Homeless Veterans
Mr. Chairman and Members of the Committee:
We are assembled here to talk about the mental healthcare available
to, and the reported increase in suicide among, this Nation's
veterans--and specifically, how the Department of Veterans Affairs (VA)
is addressing these critical concerns.
The National Coalition for Homeless Veterans (NCHV) is honored to
participate in this hearing for several reasons. NCHV, perhaps more
than any other organization, recognizes the tremendous contributions
this Committee has made in serving America's former guardians in their
greatest hour of need. We know that what our member organizations have
accomplished on behalf of veterans in crisis--men and women who have
lost everything but life itself--would not have been possible without
this Committee's guidance, support and courage to act.
Most importantly, NCHV is proud to stand with you during what we
believe is a defining moment in the history of this great Nation.
Never before has the U.S. Congress, and the people it represents,
been better prepared to address the future needs of America's armed
forces during a time of war. This Committee knows all too well that the
cost of our freedom and prosperity necessarily includes tending to the
wounds of the veterans who sacrifice some measure of their lives to
preserve it. We understand the Committee's purpose is to serve all
veterans, but this dialogue most certainly embraces the men and women
who have served in Iraq and Afghanistan, and all who will follow them.
The Nation's foremost authorities on mental health--the National
Institute of Mental Health, National Alliance on Mental Illness and
Mental Health America (formerly the Mental Health Association), agree
that the warning signs of increased risk of suicide include histories
of mental illness, extreme mood swings, changes in personality,
withdrawal from family members and friends, feelings of hopelessness,
and depression. Depending on the severity of a person's health and
economic hardships, self medication on alcohol or drugs increases the
likelihood of suicide by 30 to 70 percent.\1\
---------------------------------------------------------------------------
\1\ National Institute of Mental Health, Washington, D.C.
---------------------------------------------------------------------------
These behaviors, mental health issues, and emotional torments
characterize the great majority of the clients NCHV organizations
serve. Approximately 76% of the veterans we treat have histories of
substance abuse and diagnosed mental health challenges; more than 90%
of both male and female clients are unemployed. All of them are
homeless. More than half of the calls we receive on our toll-free help
line (1-800-VET-HELP) are from veterans who are sick, scared, socially
isolated, or economically disadvantaged--or from family members asking
how they can help their loved ones.
Suicide, a tragic and irreversible act, can most simply be defined
as the absolute absence of hope.
The act of willfully ending one's life is most often the result of
prolonged and deepening mental and emotional stresses, the erosion of
social supports such as friends and family ties, and the loss of
intimate relationships.\2\ Veterans--particularly combat veterans--are
called upon to endure all of these as necessary occupational hazards.
---------------------------------------------------------------------------
\2\ National Strategy for Suicide Prevention (NSSP), Office of the
Surgeon General, 2001.
---------------------------------------------------------------------------
War is arguably the most dehumanizing experience a person will ever
encounter. Every action tears at the tenets of civilized society; and
those who serve in a combat unit must disregard the most basic instinct
of all--self preservation. But the intensity of military training,
separation from one's social supports, and the inescapable anxiety of
knowing what their training is preparing them for can potentially be
just as burdensome to those who serve, whether or not they ever engage
in combat operations.
The prospect of multiple deployments, their effect on personal
finances, and repeated separation from one's family now gripping half
of the Reservists and National Guard troops serving in the War on
Terror can only magnify the impact of these pressures.
The overwhelming majority of America's veterans who have answered
the call to serve in the military return home to become successful
business executives, community leaders, captains of industry, public
servants, and even presidents.
However, unlike other veteran policy advocates, NCHV is singularly
concerned about those who do not--our sole purpose is to support the
men and women who proudly serve but then find themselves unable to
effectively cope with the challenges life throws at them without regard
to social standing, economic status, ethnic heritage or personal
conviction.
Every day, at more than 280 service organizations across the
country, we provide services to those who would have no hope were it
not for the support of Congress, the federal agencies charged with
helping our most disadvantaged citizens, and the multitude of community
and faith-based organizations that transform policy into life-saving
interventions and life-sustaining programs.
VA Mental Health Care
NCHV is, therefore, well qualified to comment on the availability
of mental health services through the Department of Veterans Affairs.
The partnership between service providers that help veterans in crisis
and the VA is vital to our mission to increase the capacity of service
providers and to promote effective and cost-efficient collaboration in
local integrated service networks. This partnership has been credited
with decreasing the number of homeless veterans on the streets of
America each night by more than 20% in the last five years.\3\
---------------------------------------------------------------------------
\3\ VA CHALENG Reports 2003-2006.
---------------------------------------------------------------------------
Virtually every community-based organization that provides
assistance to veterans in crisis depends on the VA for access to
comprehensive health services, and without exception their clients
receive mental health screenings, counseling and necessary treatment as
a matter of course. These services are well documented, and case
managers report this information to the VA as prescribed in their grant
reports. Follow-up services--counseling, substance abuse treatments,
outpatient therapies, medication histories and family support
initiatives--are also monitored closely and reported in client case
files.
Despite significant challenges and budgetary strains, the VA has
quadrupled the capacity of community-based service providers to serve
veterans in crisis since 2002, a noteworthy and commendable expansion
that includes, at its very core, access to mental health services and
suicide prevention.
The development of the VA Mental Health Strategic Plan from 2003
through November 2004, and its implementation over the last three years
with additional funding this Committee fought for, has increased the
number of clinical psychologists and other mental health professionals
within the VA healthcare system by nearly 1,000 positions. The
additional clinical staff have been noted at VA medical centers,
community-based outpatient clinics (CBOCs) and VA Readjustment
Counseling Centers (Vet Centers).\4\
---------------------------------------------------------------------------
\4\ Implementing VHA's Mental Health Strategic Plan Initiatives for
Suicide Prevention, Office of the Inspector General, Department of
Veterans Affairs, May 10, 2007.
---------------------------------------------------------------------------
Media attention to the fact that the VA did not expend the full
amount of funding authorized to achieve the Mental Health Strategic
Plan's goals in 2006 did not fairly report that program expansion of
this magnitude takes time to implement, with respect to both logistical
and personnel matters.
Veterans now have access to initial healthcare assessments and
referrals to VA services through a network that includes 153 medical
centers, nearly 900 VA community health clinics, 207 VA Readjustment
Counseling Centers, and about 280 community and faith-based veteran
assistance programs nationwide--a network that did not exist at the
close of the Vietnam War. Many of these points of access to mental
health services have opened within just the last 10 to 15 years. From
information in our database, we estimate there are more than 3,000
other organizations--both private and government agencies--that provide
various services to veterans in need.
The development of an interagency Suicide Prevention Hotline in May
2007, a collaboration between the Departments of Health and Human
Services and Veterans Affairs and staffed by trained counselors on a
24/7 basis, is a valuable resource for both veterans in crisis and
family members who are often the ones who call for help.
The ongoing development of peer counseling initiatives at many VA
facilities is a replication of successful interventions that have been
utilized at many community organizations for decades. Plans to provide
training for VA and community-based organization staffs on effective
mental health support procedures and suicide prevention beginning in
early 2008 are another testament to the agency's commitment to ensure
effective early mental health assessment and intervention strategies
for veterans of Operation Iraqi Freedom and Enduring Freedom (OIF/OEF).
VA officials publicly admit there is still considerable work to
do.\5\ And no one who is professionally invested in this work would
refute that point. NCHV has been a vocal advocate for enhanced VA
mental health services for homeless, low-income and recent combat
veterans since 2001. But a random survey of directors of several of our
larger member organizations in preparation for this hearing produced
three significant, and unanimous, conclusions:
---------------------------------------------------------------------------
\5\ ibid.
1. The incidence of suicide among veterans in a community-based
program in partnership with the VA is ``extremely rare,'' even though
these clients on admission are often regarded as among the highest risk
segment of the population.
2. Because these programs immediately address a wide range of
needs, and clients are more likely to receive proper mental health
treatment, case management and follow-up, the sense of hopelessness and
low self esteem often associated with suicide quickly subsides.
3. Were it not for VA's partnership with community and faith-based
organizations--and specifically the availability of VA mental health
services for their clients--the incidence of suicide among veterans
would likely be much higher.
Recommendations:
1. Ensure full implementation of the VA Mental Health Strategic
Plan--Specific recommendations of the Office of the Inspector General
include:
24-hour crisis and mental healthcare availability at
all VHA facilities, either in person or through a manned suicide/crisis
hotline.
24/7 availability of on-call mental health specialists
for crisis intervention staff.
Systemwide co-location of mental health services at
primary care facilities to reduce the stigma associated with seeking
mental health supports and to enhance service delivery.
Improve information sharing between the VA and
Department of Defense for all personnel entering the VA healthcare
system or leaving it to return to active duty.
Ensure adequate funding for VA mental health
professionals to provide training to VA and community-based
organization staffs on proper mental health supports and suicide
prevention strategies. This training is critical for all persons
associated with at-risk veteran populations--clerical staff, intake
counselors, case managers, peer counselors, and clinical staff.
2. Continue this Committee's leadership role in support of, and
authorize funding to the maximum extent possible for, the VA Grant and
Per Diem Program. These community-based therapeutic programs, in
partnership with the VA, provide a wide range of services that greatly
reduce the risk of suicide among veterans with extreme mental, social
and economic challenges. Most community-based organizations provide
follow-up counseling long after clients successfully complete their
recovery programs. This is widely viewed as a critical component of an
effective suicide prevention strategy.\6\
---------------------------------------------------------------------------
\6\ National Strategy for Suicide Prevention (NSSP), 2001.
---------------------------------------------------------------------------
3. Simplify and expand access to community mental health clinics
for OIF/OEF veterans in communities not well served by VA facilities.
While current practice allows a veteran to apply for a VA ``Fee Basis''
card to access services at non-VA facilities, the process is often
frustrating and problematic, particularly for a veteran in crisis.
Protocols should be developed to allow VA and community clinics to
process a veteran's request for assistance directly and immediately
without requiring the patient to first go to a VA medical facility.
4. Extend the period of eligibility for VA medical services for
Reservists and National Guard troops who serve in Operations Iraqi
Freedom and Enduring Freedom (OIF/OEF) from two years to a minimum of
five years. Research indicates, and VA Grant and Per Diem client case
files over the last 18 years prove, that many emotional and mental
health challenges emerge or worsen over time. This extension would also
allow for more precise diagnoses and more effective treatment regimens
for combat veterans.
5. Establish an interactive, 24/7, information and service
referral website for military members, veterans and their families; and
ensure that new recruits, Reservists and National Guard troops are
advised of the site as part of their induction into active duty. This
would virtually eliminate the problem of not knowing where to ask for
help regardless of when a service member or veteran becomes aware that
he or she may need assistance.
Conclusion
By any accounting, the work of the House Veterans Affairs Committee
on behalf of this Nation's most vulnerable former service men and women
over the last two decades has inspired the development and expansion of
a service provider network that performs miracles every day. Most of
the accomplishments reflected in this report have occurred in just the
last five to six years.
Rekindling hope in those who have no hope is the surest safeguard
against suicide. NCHV staff and program directors can personally attest
to this Committee's role in helping transform hopelessness into the
will to live and prosper for hundreds of thousands of our fellow combat
veterans. We believe the same can be said of the Department of Veterans
Affairs.
On behalf of the veterans we all serve, we implore you to claim
this moment in American history and make it part of your commendable
legacy. No veteran should have to lose everything he or she has before
we, as a nation, offer them a helping hand. Your leadership can make
sure that doesn't happen to the men and women who serve in Iraq and
Afghanistan.
Statement of Richard F. Weidman,
Executive Director for Policy and Government Affairs
Vietnam Veterans of America
Chairman Filner, Ranking Member Buyer, and other distinguished
members of this committee, Vietnam Veterans of America (VVA) thanks you
for the opportunity to present our views on suicide and PTSD among our
Nation's military personnel and veterans. We also want to thank you for
your consistent concern about the mental health care of our troops and
our veterans. I should note that Dr. Thomas Berger, Chair of VVA's
National PTSD & Substance Abuse Committee made substantial
contributions to this statement, as did Ms. Marsha Four, Chair of VVA's
National Committee on Women Veterans.
The subject of suicide is extremely difficult to discuss. It is a
topic that most of us would prefer to avoid. Accurate statistics on
deaths by suicide are not readily available because many are not
reported or are misreported for insurance reasons as well as the desire
of local officials to avoid the ``stigma'' of suicide in a family. Many
of us, as veterans of the Vietnam War and as comrades and caregivers to
our brother and sister veterans, have known someone who has committed
suicide and others who have attempted to take their life. Unfortunately
I have personally known many Vietnam veterans who were overtaken by
despair induced by their deep and intractable neuron-psychiatric wounds
from the war.
But as uncomfortable as this subject may be to discuss, it must be
confronted. It is a very real public health concern in our military and
veteran communities. A 12-year study published in the June 2007 issue
of the journal Epidemiology and Health clearly demonstrates that the
risk of suicide among male U.S. veterans is more than two times greater
than that of the general population after adjusting for a host of
potentially compounding factors, including age, time of service, and
health status. A report released this past May by the VA Inspector
General noted that ``veterans returning from Iraq and Afghanistan are
at increased risk for suicide because not all VA clinics have 24-hour
mental care available . . . and many lack properly trained workers.''
Media reports of suicide deaths and suicide attempts among active
duty OEF and OIF soldiers and veterans began to surface back in 2003
after a spate of suicides in Iraq during the first months of the war.
Since then, both the military and the VA have stumbled and fumbled in
their attempts to answer questions about the severity of this malady.
For example, while all the military services maintain suicide
prevention programs, the Army in its August 2007 Army Suicide Event
Report acknowledged that soldiers committed suicide last year at the
highest rate in 26 years, and more than a quarter did so while serving
in Iraq and Afghanistan. The report noted ``a significant relationship
between suicide attempts and number of days deployed in Iraq,
Afghanistan or nearby countries where troops are participating in the
war effort.'' The report added that there also ``was limited evidence
to support the view that multiple deployments are a risk factor for
suicide behaviors.'' It might be noted here that this report which was
released only after a FOIA request.
VVA believes that these deaths are among the most extreme failures
by the U.S. military to properly screen, treat, and evacuate mentally
unfit troops. Even a report by the Army released this past October
suggests that the quality of care, as much as the number of providers,
is a factor in the rising incidence of suicide among active-duty
service members. This report notes that more than half the 948 soldiers
who attempted suicide in 2006 had been seen by mental health providers
before their attempt--36 percent within just 30 days of the event. Of
those who committed suicide in 2006, a third had an outpatient mental
health visit within three months of killing themselves, and 42 percent
had been seen at a military medical facility within three months. Among
soldiers who were deployed to Iraq or Afghanistan when they attempted
suicide in 2005 and 2006, 60 percent had been seen by outpatient mental
health workers before the attempts. Forty-three percent of the deployed
troops who attempted suicide had been prescribed psychotropic
medications.
The report offered no details on the type or duration of mental
health care that troops received before they tried to kill themselves.
A June 2007 Pentagon task force on mental health report, however,
specifically notes the issue of quality of care, recommending that the
military develop core training for all medical staff in recognizing and
responding to service members ``in distress.'' This task force also
concluded that mental health providers needed additional training in
treating depression and combat stress.
To its discredit, the Department of Defense has managed to keep
what has clearly become what CBS News called a ``hidden epidemic''
under the radar of public awareness by concealing statistics about
soldier suicides. They have done everything from burying suicides on
official casualty lists as ``accidental non-combat deaths'' to outright
lying to the parents of dead soldiers. Meanwhile the Army officially
insists that they have yet to find a connection between PTSD, between
the stresses of combat and the type of combat waged in Iraq and
suicide.
It may be true that, as Will Rogers once said, there are lies,
there are damn lies, and there are statistics. But even the statistics
the Pentagon admits to are telling. Unfortunately what is told is a
grim story indeed, one of willful ignorance and recalcitrance to the
point of malfeasance on the part of senior officials who do not move to
correct these problems in both access to mental health care and quality
of care when access is gained.
Much of the problem that the VA will in fact be inheriting is
caused by the failure of the Army Medical Department and the Navy
Medical Department to properly address neuron-psychiatric wounds of
war. More than four years into this war, one may well ask ``how can
this be?''
Part of the problem with the military is lack of organizational
capacity caused by the questionable decision to downsize the military
medical departments as we were going to war. The former Secretary who
had overall responsibility is now gone, and the Assistant Secretary for
Health brought in because his entire experience was cutting costs by
reducing services for HMOs and insurance companies, and who actually
did the dirty work is also gone. However, the real architect of this
outrageous and irresponsible policy that has cost soldiers their lives
and/or their health continues on in his job as Under Secretary of
Defense. VVA was asked if we hold LTG James Peake accountable for
creating the situation of too many grievously injured soldiers needs
chasing too few clinicians and case managers, and we said no, because
we do not know how hard he fought on the inside. VVA continued in its
communication with the White House that we do question why David Chu
still has a job, after all of his public utterances of disdain for
injured soldiers, survivors of KIA, and more importantly the total
failure of his policies.
While VVA now understands that as of early this calendar year the
Army was given 3,000 additional persons/slots in the Army Medical
Department, it takes a long time to ``ramp up'' and we wonder how
successful this all will be as long as David Chu is driving this train,
aided by his top consultants at the unit of Rand Corporation led by
Bernard Rostker, who has already done so much damage to Gulf War I
veterans.
There is a solution. It requires data collection, training,
leadership and a cultural mind shift from the military, as well as the
network of consultants and hangers on that surround the civilian
officials who are at the head of DOD. Military leaders at all levels,
beginning with basic trainees, should be taught what their roles and
responsibilities are when warriors come home. This training should be
as structured and well thought out as fielding a new weapons system.
This includes Field manuals, training circulars, incorporation of
training into Common Test Training (CTT) and Mission Essential Task
Listings (METL).
If we change the culture in the military to deal openly and
honestly about the rigors of war when service members come home, then
we can begin to mitigate the suicide issue. We don't have a lot of
time. The longer we delay the worse the problem gets, and it becomes
more devastating to the all-volunteer military.
We've got the training for war part down cold. The missing
component is training to come home. If we do it right, retention and
recruiting will be high. Soldiers and families will grow and become
stronger from their experiences.
However, if we don't put as much emphasis on coming home as we do
in going to war the implications will be felt for the next 20 to 40
years. We can't continue to try and force the warriors to figure this
out on their own, with no help from the command structure and a
``grateful Nation.'' They have no reference point at which to begin
recovery and become strong.
When we begin teaching them how to come home it will become as
ingrained as field stripping an M4. It will become reflexive instead of
reactive; it will become proactive instead of passive. It will be
something that a war fighter has to do as a natural part of going into
and returning from battle. This will truly begin to remove the stigma
in the military that has led to situations like that experienced by Lt.
Elizabeth Whiteside, where the Army is still contemplating whether to
court martial her for attempting suicide after 10 months in Iraq
treating grievously injured soldiers, and rendering exemplary service,
when it all came crashing in on her. Her command structure in Iraq
created a hostile work environment as opposed to trying to be
supportive, and getting her counseling help. Compounding this is the
Command here in the Military District of Washington who even as we
speak today is still contemplating whether to be vindictive and try to
punish this fine young soldier by means of a court martial, possible
jail time, and stripping her of all Army and VA benefits, instead of
helping her to receive proper treatment. This case exposes just how far
we have to go to change the military culture in order to stop the
punishing of war fighters for experiencing psychiatric wounds.
Words alone won't fix this problem. There is lots of hard work
ahead. VVA asks that this distinguished panel partner with the
Committee on Armed Services and others in the House to please convince
someone in the Pentagon to start listening.
The Service Chiefs need to launch a Nationwide Anti-Stigma
Campaign, for starters.
Active-duty soldiers, however, are only part of the story. One of
the well-known characteristics of PTSD is that the onset of symptoms is
often delayed, sometimes for decades. Vietnam veterans are still taking
their own lives because new PTSD symptoms have been triggered, or old
ones retriggered, by stories and images from these new wars. Their
deaths, like the deaths of more recent veterans, are written up in
hometown newspapers; they are locally mourned, but officially ignored
because the VA does not track or count them unless they are part of the
VA registry. Both the VA and the Pentagon deny that the problem exists
and sanctimoniously point to a lack of evidence they have refused to
gather.
In yet another example of dancing around the issue, the VA
announced last spring that it was setting up a ``suicide prevention
hotline'' for veterans. This program is headquartered in Canandaigua,
New York, in cooperation with the National Suicide Prevention Resource
Center and the Substance Abuse and Mental Health Services
Administration. As part of its anti-suicide effort, the VA announced
that it was going to hire ``suicide counselors'' at each of its 153
medical centers. According to VA hotline administrators, as of late
November 2007, 92 percent of the now-titled suicide coordinator
positions had been filled and the national hotline center had handled
more than 15,000 calls between July 1 and November 17--while also
admitting that the tracking of calls is voluntary. The VA noted that
4,900 callers self-identified as veterans, 164 as active-duty military;
and that 600 calls came from concerned family and friends. Some 1,600
referrals were made to VA facilities, 100 referrals to Vet Centers.
At first glance, the call data are impressive and the VA is to be
congratulated in this endeavor. Yet real questions remain: How many
suicides have been prevented through this intervention, particularly in
light of the fact that the hotline call tracking is voluntary? And is
suicide prevention intervention and care available 24/7 across the VA
system, including both community outpatient clinics and medical
centers?
Finally, much has been made of the recent CBS News investigative
report on suicides of veterans, especially of the data collection and
analyses. VVA's concern is not that the reported figures are too high
or too low. VVA's position on suicide, however, is clear: one soldier/
veteran suicide is one too many, and there have been far too many.
Let's not quibble about how accurate the numbers are; rather, let's
focus on the issues of why veterans take their lives and what we,
collectively, can do to get more veterans into the counseling that
might save their lives.
Congress recently passed, and the President signed, the ``Joshua
Omvig Veterans Suicide Prevention Act,'' which mandates better suicide
prevention training for VA staff, a referral system to make sure that
vets at risk receive care, and the opening of a 24-hour veterans'
suicide hotline. While VVA lauds this bi-partisan effort, we implore
you to revisit the situation with regularity, and ask hard questions
that must be answered. With the exception of the creation of the
suicide hotline, how are the other mandates being translated into
suicide prevention programs, services, and training? What agency or
entity is accountable for them? And can DOD and the VA be directed to
provide truthful, accurate suicide statistics?
The faceless IED-fueled sniping that is killing and maiming scores
of our troops, is part of the root cause of the severe psychological
wounds that grips too many of our troops and veterans. Further, far
from being nothing like the Vietnam war as alleged by some officials
who were too busy with other pursuits to join the rest of us who went
to Southeast Asia, the Iraq war is, as one of our longtime members who
served as an infantry platoon leader with the 199th Brigade ``Red
Catchers'' in Vietnam: ``Iraq is Vietnam without water.'' You cannot
tell who the enemy is in most instances without an electric scoreboard,
and then only after a particular action is finished. This uncertainty
and constant pervasive danger causes deep and often chronic stress and
often leads to Post Traumatic Stress Disorder later on. It is up to all
of us, with your leadership, to do the very best that we can to
mitigate the horrors of combat by providing enough help and guidance to
the men and women who need it most. It is our obligation to continue to
search for answers, and not utter the empty claims that combat has
little or nothing to do with the suicides of troops who have
experienced it.
The Nation now clearly understands the gaps in care as outlined by
multiple military commissions. The service chiefs have ensured that our
service members were taught how to go to war and with the right
equipment. What remains missing and what we are identifying as a
fundamental gap in suicide prevention and all reintegration training is
teaching the force the fundamental skills of ``how to come home.''
To truly address suicides we must change the way our Nation and the
Military respond to the trauma of war and the complexities of
deployment. Moreover, we need to evaluate the way we define and
understand stress and trauma large scale.
No veteran should ever feel so left behind that suicide feels like
a viable option. We owe them so much more than rhetoric. Let's start by
training them to come home. Then they will be resourced to seek out
existing service and programs and the stigma of seeking help will be
minimized.
The Army's Creed, the Warrior Ethos, and even VVA's motto of
``Never again shall one generation of American veterans abandon another
generation''--are meaningless without the doing. And the doing requires
that we live by and die by our beliefs and the only thing we hold on to
is the knowledge that our country will be there for us if we need them.
The Warrior Ethos: written in Soldiers Magazine, July 2006, by
Peter J. Schoomaker talks about the common thread that has tied us all
together throughout 230 years of service to our Nation. Since 1775,
American Soldiers have answered the call to duty. From Valley Forge to
the battlefields of Gettysburg; from the Argonne Forest to the shores
of Normandy; from the rice paddies of Korea and Vietnam to the
mountains of Afghanistan and the streets of Baghdad; our military
history is rich with the willingness of generation after generation to
live by the Warrior Ethos. Service members will continue to live by
these creeds, the question is does the creed extend to them when they
come home, after the war.
We thank you for the opportunity to speak to this issue on behalf
of America's veterans, and we will work with you to find answers that
our mentally wounded warriors desperately need. I would be pleased to
answer any questions you may have.
MATERIAL SUBMITTED FOR THE RECORD
Department of Veterans Affairs
Under Secretary for Health
Washington, DC.
In Reply Refer To:
Dear Veteran,
If you're experiencing an emotional crisis and need to talk with a
trained VA professional, the National Suicide Prevention toll-free
hotline number, 1-800-273-TALK (8255), is now available 24 hours a day,
seven days a week. You will be immediately connected with a qualified
and caring provider who can help.
Here are some suicide warning signs:
1. Threatening to hurt or kill yourself.
2. Looking for ways to kill yourself.
3. Seeking access to pills, weapons or other self destructive
behavior.
4. Talking about death, dying or suicide.
The presence of these signs requires immediate attention. If you or
a veteran you care about has been showing any of these signs, do not
hesitate to call and ask for help!
Additional warning signs may include:
1. Hopelessness.
2. Rage, anger, seeking revenge.
3. Acting reckless or engaging in risky activities, seemingly
without thinking.
4. Increasing alcohol or drug abuse.
5. Feeling trapped--like there's no way out.
6. Withdrawing from friends and family.
7. Anxiety, agitation, inability to sleep--or, excessive
sleepiness.
8. Dramatic mood swings.
9. Feeling there is no reason for living, no sense of purpose in
life.
Please call the toll-free hotline number, 1-800-273-TALK (8255) if
you experience any of these warning signs. We'll get you the help and
assistance you need right away!
Sincerely yours,
Michael J. Kussman, M.D., M.S., MACP
__________
VA Suicide Crisis Hotline (1-800-273-TALK)
Who Should Call?
Anyone, but especially those who feel sad, hopeless, or
suicidal.
Family and friends who are concerned about a loved one
who may be having these feelings.
Anyone interested in suicide prevention, treatment and
service.
1-800-273-TALK
The service is free and confidential.
The hotline is staffed by trained counselors.
We are available 24 hours a day, 7 days a week.
We have information about support services that can help
you.
Crisis Response Plan
When thinking about suicide, I agree to do the following:
Step 1: Try to identify my thoughts and specifically what's
upsetting me.
Step 2: Write out and review more reasonable responses to my
suicidal thoughts.
Step 3: Do things that help me feel better for about 30 min (e.g.,
taking a bath, listening to music, going for a walk).
Step 4: If your suicidal thoughts persist, call 1-800-273-TALK
Step 5: If the thoughts continue, get specific, and I find myself
preparing to do something, call 911.
Step 6: If I'm still feeling suicidal and don't feel like I can
control my behavior, I go to the emergency room.
REMEMBER: The VA Suicide Hot Line is 1-800-273-TALK.
Get Mental Health Follow-up 1-202-745-8267 for an APPOINTMENT.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Washington, DC.
December 14, 2007
Honorable Gordon H. Mansfield
Acting Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Secretary:
In reference to our Full Committee hearing on ``Stopping Suicides:
Mental Health Challenges Within the Department of Veterans Affairs'' on
December 12, 2007, I would appreciate it if you could answer the
enclosed hearing questions by the close of business on January 28,
2008.
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
Debbie Smith by fax at 202-225-2034. If you have any questions, please
call 202-225-9756.
Sincerely,
BOB FILNER
Chairman
__________
Questions for the Record
The Honorable Bob Filner, Chairman
House Veterans' Affairs Committee
December 12, 2007
Stopping Suicides: Mental Health Challenges
Within the Department of Veterans Affairs
For Ira Katz, M.D., Ph.D.
Question 1: The Walter Reed Institute of Research recently
published a study assessing mental health problems among veterans
returning from Iraq, which found that 42.4 percent of National Guard
and Reserve-component soldiers screened by the Department of Defense
required mental health treatment. Given the very real risk of chronic
health problems and even suicide among this population, we cannot
afford a business-as-usual approach. What has VA done to provide needed
mental health treatment to these servicemembers?
Response: The Department of Veterans Affairs (VA) has expanded its
mental health programs dramatically since the start of the current
conflicts. Mental health expenditures in medical centers and clinics
increased from approximately $2 billion in fiscal year (FY) 2001 to
over $3 billion in FY 2007. The Veterans Health Administration (VHA)
developed its Comprehensive Mental Health Strategic Plan in 2004, and,
by the end of FY 2008, it will have spent over $1 billion in its
implementation, including hiring over 3,600 new staff to support
specific programs. VA has established over 90 Operation Enduring
Freedom/Operation Iraqi Freedom (OEF/OIF) teams to establish post-
deployment clinics in medical centers and to provide outreach and
education in the community.
In addition to the OEF/OIF teams, new initiatives have included
improvements in access and capacity for mental health services
throughout our system, integration of mental health services with
primary care in over 100 facilities, transformation of specialty mental
health services to focus on rehabilitation and recovery, implementation
of evidence-based practices focused on specific psychotherapies, and
establishment of a comprehensive national program for suicide
prevention.
In addition, VA has hired 100 peer staff for its Readjustment
Counseling Service (Vet Centers) to provide outreach to returning
veterans, and is in the process of expanding their staff and increasing
the number of Vet Centers from 209 to 232.
For returning veterans, VA provides outreach by sending staff to
all post deployment health reassessments (PDHRA) and by providing
education in Guard, Reserve, and community settings. We aggressively
encourage enrollment through the five-year post discharge period of
enhanced enrollment opportunity for all returning veterans who served
in the theater of operations whether or not these veterans require
medical services at the time. Once veterans are enrolled, we provide
screening for post traumatic stress disorder (PTSD), depression,
problem drinking, and traumatic brain injury (TBI), and clinical
evaluations of those who screen positive to support diagnosis and
treatment planning.
Question 2: What additional authority do you need from us to assist
you in addressing the mental health issues of today?
Response: VA strongly supported an extension to the post two-year
enhanced enrollment opportunity for returning veterans who have service
in the theater of operations. We are most pleased that the recently
passed National Defense Authorization Act of Fiscal Year 2008 provided
this by extending the enrollment timeframe to five years post
discharge.
Public information campaigns can serve a number of goals including
increasing awareness of the symptoms of warning signs of mental health
problems, destigmatizing mental health concerns and help-seeking, and
providing information about the availability and effectiveness of
mental health services in VA medical centers, clinics, and Vet Centers.
The tools available to VA in public information campaigns include press
releases, public service announcements, and outreach through community
events. These effective mechanisms can all be continued, and, in fact,
extended within existing statutory authority.
Question 3: What is VA currently doing and what more could they be
doing to reach out to veterans who are at risk for suicide and are not
currently being seen within the VA healthcare system?
Response: VA provides outreach to returning veterans through
participation in PDHRA events, through activities of 100 OEF/OIF peer
support specialists hired by Vet Centers, and through community-based
outreach activities of staff from both Vet Centers and medical centers
or clinics. One important type of outreach is through publicity for the
1-800-273-TALK hotline. Through this program, a number of veterans have
been referred to local facilities where suicide prevention coordinators
have helped them enroll in VHA. Another type of outreach is ``guide''
training from suicide prevention coordinators in medical centers.
Through this program, the coordinators educate members of the community
who have contact with veterans about symptoms of mental health
conditions, warning signs and risk factors for suicide, and procedures
for guiding veterans toward care.
An important additional activity that is currently under
development is collaboration with the Department of Defense (DoD) on
follow-up for those who screen positive on post deployment health
assessments (PDHA) or PDHRA assessments. There is, by now, good
evidence that these programs allow the identification of returning
veterans with symptoms of mental health conditions, and that they
support referrals for those with mental health problems. However, it
would be helpful to provide further follow-up to ensure that those
veterans most in need were, in fact, receiving care. Providing follow-
up to those who report symptoms could help to ensure that they receive
effective treatment.
Question 4: VA has recently expanded their suicide prevention
activities to include suicide prevention coordinators at each facility
as well as a 1-800 hotline. Could you give us a brief assessment on the
effectiveness of the program? How are you tracking the effectiveness of
the program?
Response: VA's comprehensive program for suicide prevention
includes increased public awareness of the importance of mental health
conditions, and both the availability and effectiveness of treatment;
overall enhancements in the capacity and scope of mental health
service; centers of excellence for research and technical assistance;
and a specific prevention system including both the 1-800-273-TALK
hotline, and suicide prevention coordinators in each medical center.
The most significant way to evaluate the effectiveness of the
program will be to follow suicide rates among veterans receiving VA
healthcare, the entire Nation's veteran population, and the population
at large. Rates are currently being evaluated and will continue to be
monitored in the future. Data on mortality and causes of death for
veterans using medical centers and clinics are available by merging VA
clinical and administrative records with data obtained from the Center
for Disease Control and Prevention's (CDC) National Death Index; on
suicide rates in the entire veteran population in a subset of States
are available through the CDC's National Violent Death Reporting
System; and data on suicide rates for the U.S. population are available
through the National Center for Health Statistics. Although no ``gold
standard'' is available for evaluating the effectiveness of a suicide
prevention program, the Air Force's program may serve as a benchmark.
It was viewed as successful when several years of operation led to a
reduction in suicide rates by one-third.
There are also a number of methods that we are using to evaluate
the prevention system made up of the hotline and the suicide prevention
coordinators. These include tracking the calls to the hotline,
referrals to the coordinators, and subsequent care. In addition, VA has
developed procedures that allow the coordinators to identify
individuals at high risk for suicide and to track suicide attempts.
Therefore, other ways to evaluate the impact of further developments in
our system would be to follow rates of suicide attempts and deaths from
suicide among high risk patients.
Question 5: VA recently put out a press release stating that it is
``accelerating its own research to prevent these tragedies.'' Could you
tell us what these activities involve?
Response: VA has a significant infrastructure for the conduct of
research on mental disorders and their treatment. This includes 10
mental illness research, education, and clinical centers (MIRECCs), the
seven divisions of the National Center for PTSD, a Center of Excellence
of Integrated Care and three on mental illness and PTSD, two centers of
excellence on substance abuse treatment and education, and two quality
enhancement research initiatives, one on mental health, and one on
substance use disorders, as well as a robust program supporting
investigator initiated research. The MIRECC at Denver and the Center of
Excellence in Mental Health and PTSD at Canandaigua, New York, focus
specifically on suicide prevention.
Ongoing studies are addressing suicide risk factors, validation of
suicide ideation screening instruments, structure/quality of mental
healthcare and its relationship to suicide prevention, and risk factors
for suicide as it relates to depression. Findings from two major
studies were presented at the House Veterans' Affairs Committee hearing
on December 12, 2007. One, conducted by VA's Office of Environmental
Epidemiology, is an investigation of mortality and causes of death in
returning OEF/OIF veterans. Another, conducted by VA's Serious Mental
Illness Research Education and Clinical Center, is studying rates of
suicide, risk factors, and local variability throughout the system.
Research under development by the Center of Excellence at Canandaigua
include clinical trials on the effectiveness of peer support for
suicide prevention, and psychological autopsy studies involving
linkages of VA medical centers with local coroners or medical
examiners.
VA plans to support several additional research programs and
activities aimed at reducing and preventing suicide, including new
research solicitations and a periodic update of a literature synthesis
of best practices for suicide prevention.
A new research solicitation will be issued shortly seeking studies
to validate screening instruments and to identify successful strategies
and interventions for suicide prevention. Of special interest in this
solicitation are efforts to: improve the continuum of care for
substance use disorders, improve earlier identification and treatment
of post-traumatic stress disorders, and implement recovery-oriented
treatment approaches, particularly evidence-based programs and peer
support services.
Examples of specific future research topics include:
Evaluating strategies to improve earlier identification
and treatment of PTSD and related mental health disorders (e.g.,
substance use and depression), especially in returning OEF/OIF
veterans.
Identifying risk factors and accuracy of assessment of
suicidality and evaluating best practices for suicide prevention.
Research on these topics will consider the suicide risks of veterans
who are experiencing PTSD, especially among OEF/OIF and elderly
veterans.
Investigating the effectiveness of evidence-based
recovery-oriented approaches to mental health treatment, such as
cognitive-behavioral treatments, family psycho-education, supported
employment, and social skills training.
Assessing symptomatic as well as functional changes in
patients.
Evaluating evidence-based treatment strategies within the
context of co-morbid social and medical issues.
Comparing strategies used in mental health services for
implementing recovery-oriented treatment programs.
Assessing outcomes at the patient, provider, and system
levels.
Assessing the effectiveness of peer-support programs in
supporting recovery and community reintegration in veterans with mental
illness.
Determining the appropriate mix and organization of
services (e.g., detoxification, inpatient, residential, intensive
outpatient, outpatient, psychosocial, and pharmacological) that will
ensure access to the full continuum of care for patients with substance
use disorders and varying life circumstances and co-occurring
conditions.
Evaluating methods of enhancing the integration and
coordination of mental health services with substance abuse or medical
(primary care and specialty) services, including the organization and
management of services for patients with these co-morbid conditions.
Improving the effectiveness and efficiency of behavioral
health screens in VA's healthcare system.
Question 6: Research has shown that the family is instrumental in
the recovery of veterans with mental health concerns. Family members
are affected by the mental health issues, as you heard in previous
testimony from Mr. Bowman. Currently, VA's authority to provide mental
health services to veterans receiving readjustment counseling services
under section 1712 A of Title 38, United States Code, is limited to
mental health services that are necessary to facilitate the successful
readjustment of a veteran to civilian life and limited to the provision
of counseling, training, and mental health services described in 38 USC
1782 and 1783 (bereavement counseling) for the veterans immediate
family. If eligibility to receive services were expanded for family
members, what, in your professional opinion, would be the proper scope
of these services?
Response: Vet Centers are authorized to include families in
readjustment counseling for combat veterans, and to provide bereavement
counseling for families of fallen warriors. Family members also receive
the services described in section 1782 (i.e., counseling, training, and
certain mental health services) when needed for the effective
readjustment of the veteran. Those same services are available to
immediate family members of veterans receiving VA medical treatment
when needed in connection with the veteran's treatment. Under current
authorization, these services can begin at any time for veterans being
treated for a service-connected disability, but it can begin only
during an inpatient hospitalization for others (i.e., for treatment of
a nonservice-connected disability). Both Vet Centers and medical
facilities can include families in outreach and education, including
education programs for veterans with serious mental illness. One modest
extension to current authorization, included in S. 2162 and H.R. 4053,
would be to allow the inclusion of families in care for veterans to
begin whenever it is clinically appropriate, both for veterans with
service-connected disability and others.
Further consideration of caregiver support demonstrates a problem
in defining an appropriate scope for the services that can be provided
to families. For veterans with significant impairments in day-to-day
functioning, family caregivers are often essential. Providing family
members with caregiver effectiveness training, or counseling to reduce
burn-out are appropriate services, with clear benefits for the veteran.
Treating caregiver depression could also benefit the veteran, allowing
a family caregiver to providing more effective support. However, this
is not currently authorized. It is possible to view psychotherapy for
depression as similar to counseling for burnout, and to make the case
that it should be allowable. However, it is less clear if prescribing
antidepressant medication should be allowable, or blood tests for
thyroid disease to determine if there were medical causes for the
depression, or changing medications for other conditions to reduce
depression as a possible drug side-effect, or . . . The point is that
there may be no obvious boundary between support for the family as part
of care for the veteran, limited care for a caregiver, and overall
healthcare for family members. VA is currently addressing this issue
through workgroups and funding of pilot studies on caregiver support.
There is, however, one area in which additional authorization may
help VA provide more effective outreach to returning veterans by
working with their families. There are cases, like the Omvig's, where
families may be concerned about mental health problems, but where the
veteran may not be willing to seek an evaluation or care. In these
cases, it may be useful for VA to be able to meet with families to
evaluate the situation and determine whether there is likely to be a
mental disorder that requires treatment, to provide education and
coaching to the family about how to manage problem behaviors, and to
work with the family to develop a strategy to encourage the veteran to
seek care. Much of this is being accomplished through programs for
education and outreach using existing legislative authority. However,
additional authorization may allow more intensive interactions between
VA staff and families.
For Kara Zivin, Ph.D.
Question 1: In your testimony, you talked a lot about research that
VA is currently doing on mental illness and suicide. In your
professional opinion, what are the gaps in the current research in
these areas, particularly in how they relate to veterans? What more
research should VA be doing in these areas?
Response: VA has the unique opportunity not only to attempt to
reduce suicide rates among veterans, but also to learn what suicide
prevention strategies are effective, so that effective rather than
ineffective strategies can use used for veterans and the U.S.
population, and by doing so has the potential to advance the science of
suicide prevention. VA is the only healthcare organization that
regularly tracks suicide rates, is highly organized, and treats a large
enough population so the effectiveness of prevention strategies can be
determined.
VA is currently making a tremendous effort to prevent suicide.
There are new and ongoing programs such as those located at the
Veterans Integrated Service Networks (VISN) 2 Center of Excellence in
Canandaigua, New York, which encompasses the national VA hotline/crisis
line active monitoring of suicide prevention initiatives (SPI) and
extensions of suicide research and education. Research is being
implemented to examine the hotline's suicide outcomes and the health
impact including treatment engagement and healthcare utilization. The
SPI relate to a series of efforts that are unfolding, such as
implementing suicide prevention coordinators at all VA medical centers,
cognitive behavioral therapy among high risk inpatients, screening
efforts pre- and post-deployment, among others. Finally, the
Canandaigua Center of Excellence is designed to develop new knowledge
regarding suicide prevention, and is currently focusing on older
adults, women, people with alcohol problems, and now developing new
efforts to engage returning OEF/OIF veterans.
In addition to specific initiatives, the VA's Serious Mental
Illness Treatment Research and Evaluation Center (SMITREC) in Ann
Arbor, Michigan, is pursuing major research program and planning around
suicide prevention. Research and research infrastructure are needed
across the board, and VA's efforts to promote collaboration across VISN
boundaries in a coordinated way, and capitalizing on expertise in its
centers of excellence and MIRECCs is well conceived. It is important
for VA to conduct ongoing evaluations of these suicide prevention
programs to refine and improve their effectiveness.
In particular, we need to learn more about good surveillance tools
to track changes over time in suicide attempt rates, or hot spots for
intervention. We need to be able to identify risk factors, regional
variation, differences in rates and characteristics associated with
suicide between veterans treated in VA and veterans treated outside VA,
as well as understanding more about veteran engagement in mental
healthcare. Continued efforts are essential to educate veterans and
their families about warning signs for suicide and educate providers on
suicide prevention and assessment. We need to learn more about how to
improve the means of suicide prevention as well as best practices
following suicide attempts. VA is assessing the relative impact of
specific treatment practices on suicide risks and relative risk periods
for suicide deaths. VA should also evaluate the effectiveness of
screening tools, treatment guidelines, incentives, and collaborative
care models. Ideally VA researchers would assess the unique risk and
protective factors of the cohort of interest and test interventions.
With newer cohorts of OEF and OIF veterans, studies of smaller
groups of veterans could include the National Guard and as well as
enlisted personnel to better understand their most vulnerable periods,
key risk factors, and what treatments seem most effective. Families
should be involved in this research to understand their perceptions of
risk and how they can be of most support. Evaluation of family and
patient satisfaction with VA care should be included in this research.
These efforts should be made in conjunction with VA's research
program and other well known suicide prevention researchers, so that
serious efforts to reduce suicide can be accompanied by solid research
that allows Congress and the U.S. public to determine and use the most
effective approaches.
These research efforts originating in VA will benefit both veterans
and the general U.S. population, because there are few systematic
studies of any U.S. individuals at risk for suicide over a period of
time. Such research will help identify periods of vulnerability and
helpful treatments that prevent suicide deaths or attempts,
particularly among those who have experienced trauma. We know that
restricted access to lethal means and physician education are effective
treatments, as well as psychotherapy and medications for mental
disorders such as depression and bipolar disorder.
Because the existing published research on suicide fatalities is
limited, and conducting this form of research is difficult, VA is
uniquely positioned to conduct this research and improve our
understanding of how to best help veterans at risk for suicide.
The Honorable Harry E. Mitchell
For Ira Katz, M.D., Ph.D.
Question 1: All documents which contain, refer, or relate to
requests by any providers of mental health services for veterans,
including, but not limited to requests by providers in the Veterans
Integrated Service Network (VISN) to the Veterans Health Administration
(VHA) for additional resources which were denied, or responded to with
less than the amount of resources requested, where such resources would
have been used for any of the following:
1. The collection of information relating to veterans at risk for
suicide;
2. The tracking of suicides committed by veterans, including, but
not limited to veterans who have sought assistance from VA;
3. Outreach to veterans who are or may be at risk of suicide;
4. Outreach to families of veterans relating to suicide prevention
and/or benefits for families of veterans who have committed suicide;
and
5. Research into the causes of suicide and/or treatment for
depression, post-traumatic stress disorder or any other diagnosable
condition which may increase the risk of suicide among veterans.
Response: During FY 2007, $306 million was allocated to the Mental
Health Enhancement Initiative administered by Office of Mental Health
Services to fund specific programs designed to advance the
implementation of the Mental Health Strategic Plan and to respond to
the needs of returning veterans. By the end of the year, substantially
over $320 million was, in fact awarded. At the beginning of FY 2007,
overall mental health expenditures for the year were estimated to be
over $2.8 billion. By the end of the year, over $3.2 billion was spent.
For FY 2008, approximately $370 million was allocated for the Mental
Health Enhancement Initiative. All of this was committed for
continuation of programs initiated in prior years. Based on current
projections, a substantial increase in enhancement funding is
anticipated for next year. The Office of Mental Health Services is
currently developing plans for use of these funds to establish a
uniform services package for mental health. Last year, $120 million was
appropriated in emergency supplemental funding for mental health and
substance abuse. These funds are still being allocated and a number of
requests for funding are under consideration at this time.
In general, requests for funding may come from providers or
investigators to medical centers, centers of excellence, VISNs, or any
of a number of offices in VA Central Office. Most of VA's research on
mental disorders and their treatment is funded through investigator
initiated grant proposals submitted to the Office of Research and
Development. I am not personally aware of all requests to entities and
offices other than the Office of Mental Health Services. But as Deputy
Chief Patient Care Services Officer for Mental Health and Director of
the Office of Mental Health Services, I am not aware of any proposals
for programs in any of the above categories for which funding was
denied.
Congress of the United States
U.S. House of Representatives
Washington, DC.
February 8, 2008
The Honorable James Peake, M.D.
Secretary
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Secretary:
I am seriously concerned about the response I received today, more
than a week after it was due, to my document request relating to the
House Veterans' Affairs Committee's hearing on December 12, 2007.
I asked for documents referring or relating to any requests for
additional resources to track veteran suicides and/or provide mental
health services for veterans at risk for suicide.
Instead of documents, I received a response from Deputy Chief of
Patient Care Services for Mental Health Ira Katz stating that he was
``not aware'' of ``proposals for any new programs . . . for which
funding was denied.''
I specifically asked for documents relating to ``requests . . . for
additional resources,'' not just ``proposals for new programs,'' nor
did I request a recap of how much funding Congress appropriated to the
Mental Health Enhancement Initiative in FY 2007.
I believe the response I received is incomplete.
If, for example, Dr. Katz is aware of any requests for additional
mental health counselors, facilities or equipment, I would like to
know. I would also appreciate an opportunity to review any related
documentation.
I have an obligation as a member of the Committee on Veterans'
Affairs, and the Chairman of its Subcommittee on Oversight and
Investigations, to help ensure that the Department of Veterans Affairs
has the resources it needs to help veterans at risk for suicide.
I hope the urgency with which the VA has treated my request is not
a reflection of the priority the VA assigns to this issue.
Enclosed are a copy of my request as well as the response I
received.
I look forward to a complete response as soon as possible. If you
have any questions, or require further clarification, please do not
hesitate to contact me.
Thank you for your assistance.
Sincerely,
Harry E. Mitchell
Member of Congress
Enclosure (1)
Cc: The Honorable Bob Filner, Chairman, House Veterans' Affairs
Committee
David Tucker, Chief Counsel, House Veterans' Affairs Committee
__________
The Honorable Harry E. Mitchell
For Ira Katz, M.D., Ph.D.
Question 1: All documents which contain, refer, or relate to
requests by any providers of mental health services for veterans,
including, but not limited to requests by providers in the veteran
Integrated Service Network to the Veterans' Health Administration (VHA)
for additional resources which were denied, or responded to with less
than the amount of resources requested, where such resources would have
been used for any of the following:
1. The collection of information relating to veterans at risk for
suicide;
2. The tracking of suicides committed by veterans, including, but
not limited to veterans who have sought assistance from VA;
3. Outreach to veterans who are or may be at risk of suicide;
4. Outreach to families of veterans relating to suicide prevention
and/or benefits for families of veterans who have committed suicide;
and
5. Research into the causes of suicide and/or treatment for
depression, post traumatic stress disorder or any other diagnosable
condition which may increase the risk of suicide among veterans.
Response: During FY 2007, $306 million was allocated to the Mental
Health Enhancement Initiative administered by Office of Mental Health
Services to fund specific programs designed to advance the
implementation of the Mental Health Strategic Plan and to respond to
the needs of returning veterans. By the end of the year, substantially
over $320 million was, in fact awarded. At the beginning of FY 2007,
overall mental health expenditures for the year were estimated to be
over $2.8 billion. By the end of the year, over $3.2 billion was spent.
For FY 2008, approximately $370 million was allocated for the Mental
Health Enhancement Initiative. All of this was committed for
continuation of programs initiated in prior years. Based on current
projections, a substantial increase in enhancement funding is
anticipated for next year. The Office of Mental Health Services is
currently developing plans for use of these funds to establish a
uniform services package for mental health. Last year, $120 million was
appropriated in emergency supplemental funding for mental health and
substance abuse. These funds are still being allocated and a number of
requests for funding are under consideration at this time.
In general, requests for funding may come from providers or
investigators to medical centers, centers of excellence, VISNs, or any
of a number of offices in VA Central Office. Most of VA's research on
mental disorders and their treatment is funded through investigator
initiated grant proposals submitted to the Office of Research and
Development. I am not personally aware of all requests to entities and
offices other than the Office of Mental Health Services. But as Deputy
Chief Patient Care Services Officer for Mental Health and Director of
the Office of Mental Health Services, I am not aware of any proposals
for programs in any of the above categories for which funding was
denied.
__________
U.S. Department of Veterans Affairs
Washington, DC.
February 27, 2008
The Honorable Harry E. Mitchell
U.S. House of Representatives
Washington, DC 20515
Dear Congressman Mitchell:
This is in response to your recent letter asking for more
information about requests for additional resources relating to veteran
suicides. This question has been reviewed once more, and no unfunded
requests from Department of Veterans Affairs (VA) facilities or staff
for resources directly related to suicide prevention were identified.
Your more recent request for information about requests from the
field for additional mental health counselors, facilities, or equipment
beyond those specifically related to suicide prevention is more
complex. In fiscal years 2005 through 2007, the Office of Mental Health
Services issued a number of requests for proposals to enhance mental
health programs. These proposals were competitively reviewed, and
funding decisions were made at times on the basis of need, and at other
times, on the basis of merit. The office also solicited requests for
nonrecurring, maintenance funds for space-related needs that are being
considered at this time.
As part of its ongoing activities, VA's Office of Research and
Development regularly receives applications for research awards in
mental health as well as other areas; these may include requests for
mental health counselors or equipment to support specific research
activities.
Finally, there are mental health components included in a number of
ongoing evaluations about major renovations and construction for
facilities. I would appreciate it if you could provide additional
details about the type of information you require to guide us in
preparing documents for your review.
I have been advised that my staff has contacted members of your
staff to arrange a meeting to respond to any remaining questions or
concerns. Thank you for your continued interest in our Nation's
veterans.
Sincerely yours,
James B. Peake, M.D.
Secretary
Committee on Veterans' Affairs
Washington, DC.
December 14, 2007
John D. Daigh, Jr., M.D., CPA
Assistant Inspector General
Office of Healthcare Inspections
U.S. Department of Veterans Affairs
Washington, DC 20420
Dear John:
In reference to our Full Committee hearing on ``Stopping Suicides:
Mental Health Challenges Within the Department of Veterans Affairs'' on
December 12, 2007, I would appreciate it if you could answer the
enclosed hearing questions by the close of business on January 28,
2008.
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
Debbie Smith by fax at 202-225-2034. If you have any questions, please
call 202-225-9756.
Sincerely,
BOB FILNER
Chairman
__________
U.S. Department of Veterans Affairs
Office of Inspector General
Washington, DC.
January 24, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
United States House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
Enclosed are responses to questions from the December 12, 2007,
hearing before the Committee on ``Stopping Suicides: Mental Health
Challenges Within the Department of Veterans Affairs.''
Thank you for your interest in the Department of Veterans Affairs.
Sincerely,
JOHN D. DAIGH, JR., M.D.
Assistant Inspector General for Healthcare Inspections
Enclosure
__________
Questions from the Honorable Bob Filner
For Michael Shepherd, M.D.
Physician, Office of Healthcare Inspections
Office of Inspector General, U.S. Department of Veterans Affairs
Before the Committee on Veterans' Affairs Hearing
``Stopping Suicides: Mental Health Challenges
Within the Department of Veterans Affairs''
December 12, 2007
1. In your testimony you stress the need for a comprehensive suicide
prevention program.
What is your assessment of the VA's suicide prevention
program?
In our report, Implementing VHA's Mental Health Strategic Plan
(MHSP) Initiatives for Suicide Prevention, the extent of implementation
was assessed along a spectrum of five stages: no action; in planning;
evidence of ongoing or completed pilot or demonstration projects;
implemented throughout an entire Veteran Integrated Service Network
(VISN) or multiple facilities in multiple VISNs (VISN-wide); and
systemwide implementation.
Our findings can be summarized as follows: In terms of crisis
availability and outreach, we found VISN-wide but not systemwide
implementation. Initiatives related to referral and tracking of at-risk
veterans were also at a VISN-wide stage. Those related to screening,
assessment of at-risk veterans, emerging best practice interventions,
education, and development of an electronic suicide surveillance system
were at a pilot stage. Because the VISN 19 Mental Illness, Education,
Clinical Center (MIRECC) is operational and has evidenced significant
collaboration with other MIRECC's, the MHSP initiative pertaining to
research (support for a MIRECC focused on suicide prevention) was
assessed as having achieved a systemwide level of implementation.
In your estimation, what changes does VA need to make in
ensuring an effective suicide prevention program as well as a
comprehensive one?
Whereas a public health approach has been applied to prevention of
coronary artery disease (lowering cholesterol, aerobic exercise) or
certain forms of cancer (smoking cessation) for more than a quarter
century, approaching suicide prevention from a public health paradigm
is a relatively recent development. Just as strategies to prevent lung
cancer may differ from strategies to prevent cervical cancer,
interventions that target a depressed elderly man with early cognitive
impairment may differ from interventions that target a young returning
veteran with post traumatic stress disorder (PTSD) and co-morbid
alcohol use. Suicide prevention is thought to require integrated
strategies, coordinated effort, and steadfast commitment to forward
progress. In terms of changes VA could make, we would offer the
following observations:
Community-Based Outreach--In our report, we noted that while
several facilities had implemented innovative community-based suicide
prevention outreach programs, (e.g., facility presentations to New York
Police Department officers who are Operation Iraqi Freedom/Operation
Enduring Freedom (OIF/OEF) veterans, participation by mental health
staff in local Spanish radio and television shows) the majority of
facilities did not report community-based linkages and outreach aimed
at suicide prevention. In addition, less than 20 percent of facilities
reported utilizing the Chaplain Service for liaison and outreach to
faith-based organizations in the community (e.g., inviting faith-based
organizations in the area to a community meeting at the VA Medical
Center (VAMC) to explain Veteran Health Administration (VHA) services
available, having a VA Chaplain accompany the OIF/OEF coordinator to
post-deployment events in the community). Although facilities would
need to tailor strategies to consider local demographics and resources,
a systemwide effort at community-based outreach appears prudent.
Timeliness from Referral to Mental Health Evaluation--In our report
we noted that while most facilities self-reported that three-fourths or
more of those patients with a moderate level of depression or PTSD who
are referred by primary care providers are seen within 2 weeks of
referral, approximately 5 percent reported a significant 4-8 week wait.
These patients are at risk for progression of symptom severity and
possible development of suicidal ideation. VISN leadership should work
with facility directors to ensure that once referred, patients with a
moderate level of depression or PTSD symptoms are seen in a timely
manner at any VAMC and Community-Based Outpatient Clinic (CBOC) where
significant waits are an issue.
Coordination between VHA and Non-VHA Providers--When patients
receive mental health treatment at both VHA and non-VHA providers and
facilities, seamless communication becomes an increasingly complex
challenge. This fragmentation of care is particularly worrisome in
periods of patient destabilization or following discharge from a
hospital or residential mental health program. The Office of Mental
Health Services should consider development of innovative methods,
procedures, or agreements, that improve flow of information for
patients receiving simultaneous treatment at VA and non-VA sector but
adhere to relevant privacy statutes. In addition, the Readjustment
Counseling Service and Office of Patient Care Service should pursue
further efforts to heighten communication and record sharing for
patients receiving both counseling at Vet Centers and treatment at
VAMCs and/or affiliated CBOCs.
Co-Occurring Combat Stress Related Illness and Substance Use--
Alcohol may contribute to the severity of a concurrent or underlying
mental health condition such as major depression. In addition, the
presence of alcohol may cause or exacerbate impulsivity and
disinhibited behavior. Acute alcohol use is associated with suicide and
suicide completers have high rates of elevated blood alcohol. A recent
study published in the Journal of the American Medical Association
(JAMA), Longitudinal Assessment of Mental Health Problems Among Active
and Reserve Component Soldiers Returning from the Iraq War, in which
Milliken et al., found that soldiers frequently reported alcohol
concerns on the Post Deployment Health Assessment and Reassessments
(PDHA and PDHRA) ``yet very few were referred to alcohol treatment.''
Alcohol misuse has been a common factor in OIF/OEF suicide cases that
we have reviewed.
Regardless of why a patient begins to abuse alcohol, physiologic
and psychologic drives become entrained with frequent and/or excessive
use, until the alcohol misuse ultimately takes on a life of its own
that is independent of patient history and circumstance. Functional
ability and quality of life become dually impacted by both underlying
anxiety and depressive symptoms and co-morbid substance use issues. For
patients with concurrent conditions, an effective treatment paradigm
may entail addressing the primacy of not only anxiety/depressive
conditions but also of co-morbid substance use disorders. Augmenting
services that address substance use disorders co-morbid with combat
stress related illness should therefore be given due consideration for
inclusion in a program aimed at suicide prevention.
2. In your professional opinion, does VA have the resources to
implement an effective program?
The Office of Inspector General has not reviewed VHA's resources
and we cannot offer an opinion.
3. In your report you made a number of recommendations about steps
that VHA should undertake.
Are there any that you believe VHA has not yet
undertaken?
While the VA has begun action on the recommendations in our report,
the following have not been completed:
Education of Nonclinical Staff--Subsequent to the OIG report, the
VAMC Canandaigua Center of Excellence has developed a CD and guide for
mandatory training of all VA nonclinical staff who interact with
veterans about responding to crisis situations involving at-risk
veterans. However, the process of actually disseminating training to
first line nonclinical personnel is only just beginning.
Education for Healthcare Providers--Implementation of a mandatory
education program for healthcare providers about suicide risks and ways
to address these risks is reportedly in the planning stages but has not
yet been developed.
Bi-Directional Information Exchange--Bi-directional exchange of
health information between VA and the Department of Defense (DoD),
which includes patients with mental health issues coming into VHA care
from DoD and/or those leaving VHA care for re-deployment, is an
unresolved issue that has been discussed at previous hearings including
the House Committee on Veteran's Affairs October 24, 2007, hearing
``Sharing of Electronic Medical Records between Department of Defense
and Department of Veterans Affairs.''
Establishing a Coordinated Mechanism for Implementing Emerging Best
Practices--We recommended that VHA should establish a centralized
mechanism to review ongoing suicide prevention strategies, to select
among available emerging best practices for screening, assessment,
treatment, and to facilitate systemwide implementation, in order to
ensure a single VHA standard. The VA Center of Excellence's structural
and philosophic organization aligns with the intent of this
recommendation. The center's capacity, in actual practice, to evaluate,
select, and facilitate systemwide implementation of emerging best
practices will only become discernible over time.
4. I know you are aware of the report by CBS that the rate of suicide
among veterans aged 20 to 24 is several times the rate among the same
age group in the general population.
Do you know whether CBS's numbers are accurate?
In the absence of underlying data from CBS, which we were unable to
obtain, we cannot reliably comment on the accuracy of CBS's numbers.
5. Have you been able to obtain the underlying data from CBS so you
can determine whether CBS's numbers are correct? If not, why not?
We requested the underlying data but were not able to obtain it.
CBS informed us that they could not provide the data to us because of
contractual arrangements and privacy protection agreements that CBS had
made with various State vital statistic offices from which it had
received the data.
6. What are the data that one would need to determine the rate of
suicide among veterans as compared to the general population?
One would need to reliably determine who died by suicide, who is a
U.S. veteran, and the number of general population at risk. If an
electronic death certificate system were created that had a field for
inputting cause of death; fields for salient epidemiologic factors;
allowed for input from multiple sources including medical examiners, a
decedent's physician, police reports, etc.; and was standardized across
States, one might ascertain more accurate and timely data regarding who
and how many have died by suicide. In addition, from a public health
perspective, an electronic death certificate system could enhance
epidemiologic analysis of other causes of mortality. This data could be
matched to existing data bases of qualified U.S. veterans to determine
a rate of suicide among more recent veterans. We are not aware of the
existence of a reliable electronic database that would include
qualified U.S. veterans who separated prior to 1973-74. Determining the
number of veterans who separated before the mid-1970's and also the
total number of veterans in the U.S. would therefore require merging of
various databases combined with the use of estimative models.
7. Do you know whether the VA in fact collects the necessary data to
be able to determine suicide rates among veterans and to compare those
rates to the general population?
VHA does not collect data that would enable calculation of a
suicide rate for all U.S. veterans or that would enable comparison to
nonveterans on a national basis. VHA collects data to determine suicide
rates among veterans who receive healthcare at VHA facilities, a
population that can be accurately quantified using VHA databases.
For 12 of the 17 States that participate in the National Violent
Death Reporting System, VHA reported having indirectly calculated
suicide rates among nonveterans in these States by subtracting veteran
suicide rates from the rates for the general population. The derived
nature of this calculation imposes limitations on the reliability of
this measurement.
Committee on Veterans' Affairs
Washington, DC.
December 21, 2007
The Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake:
On December 12, 2007, the House Committee on Veterans' Affairs held
a hearing to assess the programs that the Department of Veterans
Affairs (VA) provides for veterans who are at risk for suicide. This
hearing raised concerns regarding the discrepancy between the numbers
of veteran suicides reported by VA as compared to those reported by CBS
News on November 13, 2007.
Accurate data is crucial in identifying risk factors and providing
better treatment and suicide prevention programs. For this reason, we
respectfully request that the Department of Veterans Affairs share
their data on suicide among veterans with the Committee.
Specifically, we request to have the number of veteran suicides for
each year from 1995 through 2006, reported by year of death, age, race,
gender and manner of suicide. Additionally, we ask for the methodology
the Department uses to collect data on veteran suicides.
Undoubtedly, you share our desire to ensure that every measure is
taken to prevent our Nation's veterans from committing suicide. We
would greatly appreciate your willingness to share any information you
may have regarding this issue with the Committee.
Thank you for your prompt consideration and attention to this
request. Should you have any questions, please feel free to contact
either Committee Staff Director, Malcom Shorter, at 202-225-9756 or
Republican Staff Director, Jim Lariviere, at 202-225-3527.
Sincerely,
Bob Filner
Steve Buyer
Chairman
Ranking Member
__________
The Secretary of Veterans Affairs
Washington, DC.
February 5, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
This is in response to your letter requesting data on suicide rates
among veterans and the methodologies used by the Department of Veterans
Affairs (VA) to collect data on veteran suicides.
The enclosed information and worksheet contains data on veteran
suicides from two separate projects. One is an ongoing study of
mortality in Operation Enduring Freedom and Operation Iraqi Freedom
(OEF/OIF) veterans being conducted by VA's Office of Environmental
Epidemiology. Identification of veterans is based on information from
the Department of Defense and includes all OEF/OIF servicemembers who
were separated from active duty including National Guard and Reserve
personnel. The second project is an ongoing study of suicide in
veterans who have used Veterans Health Administration services from
2000 onward and who were alive at the start of 2001. The study includes
veterans of all eras.
For both projects, information about the time and causes of death
was derived from the National Death Index. Information contained in
data files on causes of death from the National Death Index is only
available through the end of 2005. I have also enclosed the methodology
used for both projects.
Your interest in our Nation's veterans is appreciated. A similar
letter is being sent to Congressman Steve Buyer.
Sincerely yours,
James B. Peake, M.D.
Enclosures
__________
Study of Operation Enduring Freedom/Operation Iraqi Freedom Veterans
Methodology
Population: As part of our mortality study of veterans who served
in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF),
the Department of Veterans Affairs (VA) obtained the identities of
490,346 OEF/OIF veterans who served as part of either OEF or OIF and
were separated or deactivated from military service between October
2001 and December 2005. This study will assess both overall mortality
risk as well as cause-specific mortality risk. Among the cause specific
mortality of particular interest are deaths due to motor vehicle
accidents and suicides.
Data Sources: The identities of the 490,346 OEF/OIF veterans,
military service characteristics, and various demographic data were
provided to VA by the Department of Defense Manpower Data Center. Vital
statistics data pertaining to OEF/OIF veterans was determined by using
VA's database, Beneficiary Identification and Records Locator
Subsystem, and deaths reported to the Social Security Administration
Death Master File. The Beneficiary Identification and Records Locator
Subsystem file has the identities of all veterans who have applied for
VA benefits (including death benefits), and the Social Security
Administration Death Master File includes all deaths reported to that
agency. All veterans were matched against the Beneficiary
Identification and Records Locator Subsystem and Social Security
Administration files using Social Security numbers. Cause of death data
was obtained from the National Death Index. Since 1979, the Office of
Vital Statistics in each State has reported deaths, including cause of
death data to the National Center for Health Statistics, where the
National Death Index is compiled. Causes of death were recorded using
International Classification of Diseases codes 10th Revision (ICD-10).
For traumatic deaths, including suicide, part of the ICD-10 codes
records the method of injury. For suicides, the ICD-10 codes report the
method of suicide. At the time this study began, the National Death
Index had cause of death data through December 31, 2005. Using the
aforementioned databases, VA identified a total of 818 deaths to
include 144 suicides.
The attached table has demographic and military service
characteristics as well as death certificate data and method of suicide
for the 144 suicides identified in this study.
CHARACTERISTICS OF 144 SUICIDES AMONG OEF/OIF * VETERANS THROUGH 2005
------------------------------------------------------------------------
Characteristic Frequency Percentage
------------------------------------------------------------------------
Age at death
------------------------------------------------------------------------
20-29 78 54.1
------------------------------------------------------------------------
30-39 39 27.1
------------------------------------------------------------------------
40-49 14 9.7
------------------------------------------------------------------------
50-59 13 9.1
------------------------------------------------------------------------
Year of death
------------------------------------------------------------------------
2002 7 4.9
------------------------------------------------------------------------
2003 21 14.6
------------------------------------------------------------------------
2004 48 33.3
------------------------------------------------------------------------
2005 68 47.2
------------------------------------------------------------------------
Method of suicide
------------------------------------------------------------------------
Poisoning 7 4.9
------------------------------------------------------------------------
Hanging 30 20.8
------------------------------------------------------------------------
Firearm 105 72.9
------------------------------------------------------------------------
Jumping 1 .7
------------------------------------------------------------------------
Sharp Object 1 .7
------------------------------------------------------------------------
Sex
------------------------------------------------------------------------
Male 141 97.9
------------------------------------------------------------------------
Female 3 2.1
------------------------------------------------------------------------
Race
------------------------------------------------------------------------
White 118 81.9
------------------------------------------------------------------------
Non-White 26 18.1
------------------------------------------------------------------------
Ever seen at VAMC
------------------------------------------------------------------------
Yes 33 22.9
------------------------------------------------------------------------
Branch of service
------------------------------------------------------------------------
Army 73 50.7
------------------------------------------------------------------------
Marines 15 10.4
------------------------------------------------------------------------
Air Force 33 22.9
------------------------------------------------------------------------
Navy 23 16.0
------------------------------------------------------------------------
Rank
------------------------------------------------------------------------
Officer 8 5.6
------------------------------------------------------------------------
Warrant Officer 1 0.7
------------------------------------------------------------------------
Enlisted 135 93.7
------------------------------------------------------------------------
Unit component
------------------------------------------------------------------------
Active 68 47.2
------------------------------------------------------------------------
Reserve 35 24.3
------------------------------------------------------------------------
National Guard 41 28.5
------------------------------------------------------------------------
* These suicides were identified among a cohort of 490,346 OEF/OIF
veterans selected for mortality follow-up through 2005.
Study of Veterans Using Veterans Health Administration
Methodology
Population: The Veterans Health Administration defined the
population of VA patients at risk for suicide in each fiscal year as
those who were alive at the start of the year, and who had received VA
services during either that year or the prior one. This approach to
identifying VA's patient population was developed in consultation with
VA mental health leadership and assumes that patients seen in VA
settings in the prior year would still be considered to be in active VA
care and part of the at-risk patient population in the following year.
Data Sources: This study used data from VA's National Patient Care
Database to identify all veterans with inpatient or outpatient services
utilization in any VA facility during the relevant years. Measures of
vital status and cause of death were based on information from the
National Death Index. The National Death Index is considered the ``gold
standard'' for mortality assessment information and includes national
data regarding dates and causes of death for all U.S. residents. This
information is derived from death certificates filed in the Office of
Vital Statistics for each State. National Death Index searches were
performed for cohorts of VA patients who received any VA services
during the relevant years, and who had no subsequent VA services
through June 2006. This cost-efficient method for conducting National
Death Index searches enables comprehensive assessment of vital
statistics and cause of death among all veterans in the VA patient
population. The National Death Index data request included Social
Security number, last name, first name, middle initial, date of birth,
race and ethnicity, sex, and State of residence. National Death Index
search results often include multiple records that are potential
matches. ``True matches'' were identified based on established
procedures.
Veterans' age and gender were identified from VA administrative
files included in the National Patient Care Database. Age at the start
of Fiscal Year 2001 was categorized as being either less than 30, 30 to
39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, or greater than or equal to
80 years. Information regarding race and ethnicity was not consistently
available in the National Patient Care Database for all VA patients. VA
identified dates and causes of death using National Death Index data.
Suicide deaths were identified using International Classification of
Diseases codes X60 through X84, and Y87.0 (World Health Organization
2004).
VA is conducting a comprehensive program for preventing veteran
suicides, and is conducting ongoing research to guide its prevention
strategies. The VA Office of Mental Health staff is available to
provide additional briefings to the Committee on rates, risks factors
and strategies.
Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
Characteristic ------------------------------------------------------------------------------------
N % N % N % N % N %
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total * 1403 100 1737 100.0 1600 100.0 1702 100.0 1784 100.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total, age 20 1401 100 1734 100.0 1598 100.0 1701 100.0 1781 100.0
and over
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sex
--------------------------------------------------------------------------------------------------------------------------------------------------------
Male 1360 97.1 1682 97.0 1559 97.6 1647 96.8 1720 96.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Female 41 2.9 52 3.0 39 2.4 54 3.2 61 3.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
Age Group
--------------------------------------------------------------------------------------------------------------------------------------------------------
20-29 yrs 26 1.9 44 2.5 38 2.4 50 2.9 38 2.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
30-39 yrs 108 7.7 119 6.9 111 6.9 105 6.2 105 5.9
--------------------------------------------------------------------------------------------------------------------------------------------------------
40-49 yrs 240 17.1 283 16.3 272 17.0 256 15.0 254 14.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
50-59 yrs 359 25.6 437 25.2 407 25.5 424 24.9 470 26.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
60-69 yrs 202 14.4 261 15.1 264 16.5 272 16.0 291 16.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
70-79 yrs 320 22.8 393 22.7 345 21.6 381 22.4 380 21.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
80+ yrs 146 10.4 197 11.4 161 10.1 213 12.5 243 13.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Race
--------------------------------------------------------------------------------------------------------------------------------------------------------
White Hispanic 30 2.1 25 1.4 32 2.0 24 1.4 29 1.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Black Hispanic 2 0.1 1 0.1 1 0.1 2 0.1 2 0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Native 2 0.1 6 0.3 3 0.2 2 0.1 7 0.4
American
--------------------------------------------------------------------------------------------------------------------------------------------------------
African 55 3.9 80 4.6 47 2.9 62 3.6 78 4.4
American
--------------------------------------------------------------------------------------------------------------------------------------------------------
Asian/Pacific 0 0.0 4 0.2 2 0.1 3 0.2 16 0.9
Islander
--------------------------------------------------------------------------------------------------------------------------------------------------------
Caucasian 895 63.9 1078 62.2 894 55.9 814 47.9 1142 64.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Unknown 417 29.8 540 31.1 619 38.7 794 46.7 507 28.5
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Includes age <20 years old.
Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
Characteristic ------------------------------------------------------------------------------------
N % N % N % N % N %
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total * 1403 100.0 1737 100.0 1600 100.0 1702 100.0 1784 100.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total, age 20 and over 1401 100.0 1734 100.0 1598 100.0 1701 100.0 1781 100.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mechanism of Suicide
--------------------------------------------------------------------------------------------------------------------------------------------------------
X60 Intentional self-poisoning (suicide) by and exposure to non-opioid 5 0.4 4 0.2 8 0.5 5 0.3 12 0.7
analgesics, anti-pyretics, and anti-rheumatics
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X61 Intentional self-poisoning (suicide) by and exposure to antiepileptic, 39 2.8 49 2.8 38 2.4 43 2.5 53 3.0
sedative-hypnotic anti-parkinsonism, and psychotropic drugs, not elsewhere
classified
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X62 Intentional self-poisoning (suicide) by and exposure to narcotics and 26 1.9 42 2.4 30 1.9 27 1.6 48 2.7
psychodysleptics (hallucinogens), not elsewhere classified
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X63 Intentional self-poisoning (suicide) by and exposure to other drugs acting 1 0.1 3 0.2 1 0.1 0 0.0 2 0.1
on the autonomic nervous system
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X64 Intentional self-poisoning (suicide) by and exposure to other and 100 7.1 97 5.6 103 6.4 112 6.6 102 5.7
unspecified drugs, medicaments, and biological substances
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X65 Intentional self-poisoning (suicide) by and exposure to alcohol. 2 0.1 2 0.1 5 0.3 0 0.0 1 0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X66 Intentional self-poisoning (suicide) by and exposure to organic solvents 2 0.1 3 0.2 1 0.1 6 0.4 3 0.2
and halogenated hydrocarbons and their vapors
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X67 Intentional self-poisoning (suicide) by and exposure to other gases and 34 2.4 62 3.6 35 2.2 59 3.5 50 2.8
vapors
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X68 Intentional self-poisoning (suicide) by and exposure to pesticides. 1 0.1 1 0.1 1 0.1 0 0.0 0 0.0
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X69 Intentional self-poisoning (suicide) by and exposure to other and 3 0.2 6 0.3 4 0.3 3 0.2 4 0.2
unspecified chemicals and noxious substances
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X70 Intentional self harm (suicide) by hanging, strangulation, and 163 11.6 214 12.3 189 11.8 207 12.2 189 10.6
suffocation.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X71 Intentional self harm (suicide) by drowning and submersion. 17 1.2 19 1.1 12 0.8 10 0.6 15 0.8
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X72 Intentional self harm (suicide) by handgun discharge. 192 13.7 248 14.3 255 16.0 227 13.3 277 15.6
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X73 Intentional self harm (suicide) by rifle, shotgun, and larger firearm 145 10.3 174 10.0 150 9.4 171 10.1 170 9.5
discharge.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X74 Intentional self harm (suicide) by other and unspecified firearm 566 40.4 726 41.9 675 42.2 728 42.8 758 42.6
discharge.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X75 Intentional self harm (suicide) by explosive material. 0 0.0 0 0.0 0 0.0 0 0.0 2 0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X76 Intentional self harm (suicide) by smoke, fire, and flames. 6 0.4 4 0.2 6 0.4 14 0.8 12 0.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X77 Intentional self harm (suicide) by steam, hot vapors, and hot objects. 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X78 Intentional self harm (suicide) by sharp object. 34 2.4 33 1.9 33 2.1 35 2.1 28 1.6
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X79 Intentional self harm (suicide) by blunt object. 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X80 Intentional self harm (suicide) by jumping from a high place. 31 2.2 18 1.0 30 1.9 27 1.6 22 1.2
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X81 Intentional self harm (suicide) by jumping or lying before moving object. 14 1.0 10 0.6 7 0.4 12 0.7 8 0.4
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X82 Intentional self harm (suicide) by crashing of motor vehicle. 1 0.1 4 0.2 5 0.3 4 0.2 7 0.4
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X83 Intentional self harm (suicide) by other specified means. 7 0.5 6 0.3 3 0.2 4 0.2 2 0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X84 Intentional self harm (suicide) by unspecified means. 5 0.4 6 0.3 4 0.3 4 0.2 11 0.6
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V87 Sequelae of intentional self harm. 7 0.5 3 0.2 3 0.2 3 0.2 5 0.3
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Includes age <20 years old.
Committee on Veterans' Affairs
Washington, DC.
December 21, 2007
Mr. Rick Kaplan
Executive Producer
CBS Evening News With Katie Couric
524 West 57th Street
New York, NY 10019
Dear Mr. Kaplan:
On December 12, 2007, the House Committee on Veterans' Affairs held
a hearing to assess the programs that the Department of Veterans
Affairs (VA) provides for veterans who are at risk for suicide. This
hearing raised concerns regarding the discrepancy between the numbers
of veteran suicides reported by VA as compared to those reported by CBS
News on November 13, 2007.
Accurate data is crucial in identifying risk factors and providing
better treatment and suicide prevention programs. For this reason, we
respectfully request that CBS News share their data on suicide among
veterans with the Committee.
Specifically, we request data on the number of veteran and
nonveteran suicides for each year from 1995 through 2005 reported by
State with year of death, age, race, gender and manner of suicide.
Additionally, request the data that CBS News used to define the at-risk
populations (e.g., veterans/nonveterans, men/women) by age group.
Undoubtedly, you and the entire CBS Evening News staff, share our
desire to ensure that every possible measure is taken to prevent those
who have worn the uniform from succumbing to the tragedy of suicide. As
such, we would greatly appreciate your willingness to share the
information you have accumulated with the Committee.
Thank you for your prompt consideration and attention to this
request. Should you have any questions, please feel free to contact
either Committee Staff Director, Malcom Shorter, at 202-225-9756 or
Republican Staff Director, Jim Lariviere, at 202-225-3527.
Sincerely,
Bob Filner
Steve Buyer
Chairman
Ranking Member
__________
CBS News
New York, NY.
May 16, 2008
The Honorable Bob Filner, Chairman
Committee on Veterans' Affairs
United States House of Representatives
One Hundred Tenth Congress
335 Cannon House Office Building
Washington, DC 20515
Dear Congressman Filner:
This is in reply to your letter of last December to Rick Kaplan,
Executive Producer of the CBS Evening News. It appears that your letter
was originally lost within CBS and only came to light when a copy of it
was given to Armen Keteyian, CBS News' Chief Investigative
Correspondent, at last week's hearing of the House Committee on
Veterans' Affairs. I apologize for the delay.
In your letter you request that CBS News provide ``data on numbers
the veteran and nonveteran suicides for each year from 1995 through
2005 reported by . . . [and] data that CBS News used to define the at-
risk populations (e.g., veterans/nonveterans, men/women) by age
group.''
You are quite right, Congressmen, in stating that we at CBS News
share your desire to ensure that every possible measure is taken to
prevent veteran suicide. We believe, however, that the respect in which
we are best able to serve the interests of veterans and of all other
segments of the American public is to preserve our ability to do
effective news reporting; and that to be effective reporters, we must
maintain our journalistic independence. For that reason we must
respectfully decline to provide the data you request.
Insofar as the Committee's request derives from its need for the
raw data on which CBS News based its reporting, that data is readily
available to the Committee from State agencies, which are public. If
the Committee's goal is to review the editorial process by which we
arrived at our reports' content, we respectfully urge that it would be
quite wrong of CBS News to submit voluntarily to such governmental
oversight. Indeed, doing so would fundamentally compromise the
editorial independence on which we and all news organizations depend.
I should also point out that obtaining suicide data from the
various States involved more than just a basic public records request.
Initially, several States refused to provide their data to CBS News out
of a concern for the privacy of the veterans involved and their
families. These States believed that the suicide numbers in some
categories are small enough so that individuals could be identified and
their privacy compromised. In order to obtain the data, CBS News had to
give these States our assurance that we would keep the raw data
confidential. Some States insisted upon written agreements to this
effect. Accordingly, we are constrained not only by principle, but by
these specific undertakings, from providing the Committee with the data
you have requested.
I hope you will appreciate Congressmen, that we take the work of
the House Committee on Veterans' Affairs very seriously and that we
withhold our cooperation only out of deference to our own
responsibilities as journalists.
Respectfully,
Linda Mason
Senior Vice President
Standards and Special Projects
cc Rick Kaplan
Armen Keteyian