[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]



 
                   THE TRUTH ABOUT VETERANS' SUICIDES

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


                                HEARING

                               before the

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

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 6, 2008

                               __________

                           Serial No. 110-86

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     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     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois                  GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania       MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada              BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado            DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas             GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana                VERN BUCHANAN, Florida
JERRY McNERNEY, California           VACANT
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

                               __________

                              May 6, 2008

                                                                   Page
The Truth About Veterans' Suicides...............................     1

                           OPENING STATEMENTS

Chairman Bob Filner..............................................     1
    Prepared statement of Chairman Filner........................    77
Hon. Steve Buyer, Ranking Republican Member......................     5
    Prepared statement of Congressman Buyer......................    78
Hon. John J. Hall................................................     7
Hon. Phil Hare...................................................     9
Hon. Ciro D. Rodriguez...........................................    10
Hon. Harry E. Mitchell...........................................    11
    Prepared statement of Congressman Mitchell...................    79
Hon. James P. Moran..............................................    12
    Prepared statement of Congressman Moran......................    82
Hon. John T. Salazar.............................................    14
Hon. Jerry McNerney..............................................    14
Hon. Corrine Brown...............................................    15
Hon. Stephanie Herseth Sandlin, prepared statement of............    80
Hon. Shelley Berkley, prepared statement of......................    80
Hon. Jeff Miller, prepared statement of..........................    80
Hon. Ginny Brown-Waite, prepared statement of....................    81
Hon. Timothy J. Walz, prepared statement of......................    81

                               WITNESSES

U.S. Department of Veterans Affairs:
    Hon. James B. Peake, M.D., Secretary.........................    15
        Prepared statement of Secretary Peake....................    83
    Michael Shepherd, M.D., Senior Physician, Office of 
      Healthcare Inspections, Office of Inspector General........    69
        Prepared statement of Dr. Shepherd.......................   107

                                 ______

Maris, Ronald William, Ph.D., Distinguished Professor Emeritus, 
  Past Director of Suicide Center, Adjunct Professor of 
  Psychiatry, and Adjunct Professor of Family Medicine, 
  University of South Carolina, School of Medicine, Columbia, SC.    53
    Prepared statement of Dr. Maris..............................    96
Rathbun, Stephen L., Ph.D., Interim Head and Associate Professor 
  of Biostatistics, Department of Epidemiology and Biostatistics, 
  University of Georgia, Athens, GA..............................    55
    Prepared statement of Dr. Rathbun............................   102
Rudd, M. David, Ph.D., ABPP, Professor and Chair, Department of 
  Psychology, Texas Tech University, Lubbock, TX.................    57
    Prepared statement of Dr. Rudd...............................   105

                   MATERIAL SUBMITTED FOR THE RECORD

Video Transcriptions:
    Transcription of CBS News Video entitled, ``Suicide Epidemic 
      Among Veterans,'' aired November 13, 2007..................   109
    Transcription of CBS News Video entitled, ``VA Hid Suicide 
      Risk, Internal E-Mails Show,'' aired April 21, 2008........   110

Reports:
    CRS Report for Congress entitled, ``Suicide Prevention Among 
      Veterans,'' May 5, 2008, Order Code RL34471, by Ramya 
      Sundararaman, Sidath Viranga Panangala, and Sarah A. 
      Lister, Domestic Social Policy Division, Congressional 
      Research Service...........................................   111

Background Materials:
    U.S. Department of Veterans Affairs Pamphlet entitled, 
      ``Suicide Prevention, Men and Women Veterans, Knowing the 
      Warning Signs of Suicide,'' dated September 2007...........   120
    U.S. Department of Veterans Affairs Pamphlet for VA Employees 
      entitled, ``Suicide Risk Assessment Guide,'' Issued by the 
      U.S. Department of Veterans Affairs, Employee Education 
      System.....................................................   121

Letters:
    Hon. Michael J. Kussman, M.D., M.S., MACP, Under Secretary 
      for Health, U.S. Department of Veterans Affairs, sample of 
      outreach 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.......................................   122
    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........   123
    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............   124
    Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking 
      Republican Member, Committee on Veterans' Affairs, to Hon. 
      Robert M. Gates, Secretary, U.S. Department of Defense, 
      letter dated December 21, 2007, requesting the number of 
      active-duty suicides for each year from 1995 to 2006; Hon. 
      Robert M. Gates, Secretary, U.S. Department of Defense, to 
      Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, 
      providing preliminary response designating David Chu, Under 
      Secretary of Defense for Personnel and Readiness, to 
      address the matter, letter dated January 17, 2008; Followup 
      request letters from Chairman Filner, dated May 6 and 21, 
      2008, requesting DoD to provide response to original letter 
      dated December 21, 2007; Response letter from Secretary 
      Gates, designating David Chu, Under Secretary of Defense 
      for Personnel and Readiness, to address the matter, letter 
      dated June 3, 2008; and Followup request letter from 
      Chairman Filner, dated June 5, 2008, requesting DoD to 
      provide response to original letter dated December 21, 
      2007. [AS OF SEPTEMBER 25, 2008, THE U.S. DEPARTMENT OF 
      DEFENSE HAS REFUSED TO RESPOND TO THE COMMITTEE'S REQUEST 
      FOR INFORMATION REGARDING THE NUMBER OF ACTIVE-DUTY 
      SUICIDES FOR EACH YEAR FROM 1995 TO 2006.].................   132

Materials Due from the U.S. Department of Veterans Affairs 
    Requested During the Hearing:
    Hon. Michael J. Kussman, M.D., MS, MACP, Under Secretary for 
      Health, U.S. Department of Veterans Affairs, to Hon. James 
      B. Peake, Secretary, U.S. Department of Veterans Affairs, 
      Memorandum dated May 5, 2008, Regarding Blue Ribbon Work 
      Group on Suicide Prevention in the Veteran Population......   134
    Table entitled, ``Rates and Risk of Suicide and Other 
      Suicidal Behaviors Among U.S. Veterans,'' Updated April 30, 
      2008, Prepared by Joseph Francis, M.D., MPH, Acting Deputy 
      Chief Quality and Performance Officer, Office of Quality 
      and Performance, U.S. Department of Veterans Affairs.......   137
    ``The Comprehensive Veterans Health Administration Mental 
      Health Strategic Plan,'' (A Comprehensive VHA Strategic 
      Plan of Mental Health Services), dated July 2004...........   142
    Table entitled, ``Crosswalking between the U.S. National 
      Strategy for Suicide Prevention, the VHA Comprehensive 
      Mental Health Strategic Plan and VHA's Suicide Prevention 
      Actions''..................................................   188
    Information Provided by the U.S. Department of Veterans 
      Affairs from Discussion with Secretary Peake during Post-
      Hearing Meeting............................................   189

Post-Hearing Questions and Responses for the Record:
    Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to 
      Hon. James B. Peake, M.D., Secretary, U.S. Department of 
      Veterans Affairs, letter dated May 21, 2008, and VA 
      Responses..................................................   208
    Attachments to Chairman Filner's Post-Hearing Questions and 
      Responses for the Record Retained in the Committee files 
      include the following: The Medical Inspector Final Report 
      #2008-D-654, entitled ``Quality of Care Review, Veterans 
      Affairs Medical Center (VAMC) Dallas, Texas, Veterans 
      Integrated Service Network 17,'' dated May 20, 2008; the 
      Course Script entitled, ``VA National Rules of Behavior,'' 
      Developed by the U.S. Department of Veterans Affairs, 
      Office of Information and Technology, Cyber Security 
      Service; and Presentation entitled, ``VHA Privacy Policy 
      Training, FY 2008''
    Hon. Stephanie Herseth Sandlin, Committee on Veterans' 
      Affairs, as forwarded by Hon. Bob Filner, Chairman, 
      Committee on Veterans' Affairs, to Hon. James B. Peake, 
      M.D., Secretary, U.S. Department of Veterans Affairs, and 
      VA Responses...............................................   236
    Hon. John J. Hall, Committee on Veterans' Affairs, as 
      forwarded by Hon. Bob Filner, Chairman, Committee on 
      Veterans' Affairs, to Hon. James B. Peake, M.D., Secretary, 
      U.S. Department of Veterans Affairs, and VA Responses......   238
    Hon. Shelley Berkley, Committee on Veterans' Affairs, as 
      forwarded by Hon. Bob Filner, Chairman, Committee on 
      Veterans' Affairs, to Hon. James B. Peake, M.D., Secretary, 
      U.S. Department of Veterans Affairs, and VA Responses......   240
    Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to 
      Michael Shepherd, M.D., Physician, Office of Healthcare 
      Inspections, Office of Inspector General, U.S. Department 
      of Veterans Affairs, letter dated May 21, 2008, forwarding 
      questions from Hon. Stephanie Herseth Sandlin, and response 
      letter dated July 2, 2008..................................   245

                   THE TRUTH ABOUT VETERANS' SUICIDES

                              ----------                              


                          TUESDAY, MAY 6, 2008

                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 10:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Bob Filner 
[Chairman of the Committee] presiding.

    Present: Representatives Filner, Brown of Florida, Snyder, 
Michaud, Herseth Sandlin, Mitchell, Hall, Hare, Berkley, 
Salazar, Rodriguez, McNerney, Space, Walz, Buyer, Stearns, 
Moran of Kansas, Brown of South Carolina, Miller, Boozman, 
Brown-Waite, Turner, Lamborn, and Buchanan.

    Also Present: Representatives Kennedy and Moran of 
Virginia.

              OPENING STATEMENT OF CHAIRMAN FILNER

    The Chairman. Good morning. This meeting of the Committee 
on Veterans' Affairs of the House of Representatives is now 
called to order.
    I ask unanimous consent that two of our colleagues, Mr. 
Kennedy and Mr. Moran, be allowed to sit with us at the dais. 
They have a longstanding interest in the issues that we will be 
discussing today. Any objection?
    Mr. Buyer. I have no objection. We should follow protocols 
of the Committee.
    The Chairman. Thank you, Mr. Buyer.
    The hearing today is entitled, ``The Truth about Veterans' 
Suicides.'' I hope we can get to that truth.
    A few months ago, on December 12, 2007, this Committee held 
a hearing that we entitled: ``Stopping Suicides: Mental Health 
Challenges within the U.S. Department of Veterans Affairs 
(VA).'' Nearly 5 months later, we are holding another hearing 
on this tragic issue and what the VA is doing. But it is 
brought to us because of data within the VA that seems to 
dispute what we were told in a hearing in December.
    Much of this was occasioned because last year, in November, 
CBS News aired a story called ``Suicide Epidemic Among 
Veterans,'' and recently, another story called ``VA Hid Suicide 
Risk, Internal E-Mails Show.''
    I want to just make sure everybody understands what we are 
dealing with, and I would like to play two brief segments of 
those newscasts on our new video system.
    [Videos played.]

    The Chairman. Mr. Buyer raised an interesting point now of 
how we are going to refer to this in the record--a tape. We 
have not exactly figured it out yet. We may have a transcript 
or referral to a Web site. But before the transcript of this 
hearing is done, we will work with you to figure out a way to 
do this.
    Mr. Buyer. Members, this is relatively new. Often we ask 
unanimous consent to place letters in the record. This is a 
first, that we actually watch a news program.
    I am willing to work with the Chairman to do something new. 
Either we refer to a Web site, whereby individuals could pull 
that down from a record, actually view the video, because that 
was how it was viewed in the Committee; or do we transcribe 
what was just put in there and put that in the record?
    We are going to work with the Chairman to figure out how we 
handle this.
    The Chairman. This is a 21st century problem.
    Mr. Buyer. We will work through it.
    Sorry, Mr. Secretary. Housekeeping.
    [A transcription of both the November 2007 and April 2008 
CBS News videos appear on pages 109 and 110. In addition, the 
videos may be viewed at http://veteransaffairs.edgeboss.net/
wmedia/veteransaffairs/videos/cbs_suicide_part_1.wvx (November 
2007) and http://veteransaffairs.edgeboss.net/wmedia/
veteransaffairs/videos/cbs_suicide_part_2.wvx (April 2008).]
    The Chairman. I think we all know that the first step in 
addressing a problem is to understand its full scope and 
extent. In the case of the VA and the epidemic of veteran 
suicides, either the VA has not adequately attempted to 
determine the scope of the problem, which I think is an 
indictment of the competence of the VA; or the VA knows the 
extent of the problem, but has attempted to obfuscate and 
minimize the problem to veterans, Congress, and the American 
people. This is an indictment, I think you would all agree, of 
the leadership of the entire Department.
    In December, Dr. Katz' testimony before this Committee 
stressed a low rate of veteran suicides, stating that: ``From 
the beginning of the war through the end of 2005, there were 
144 known suicides amongst these new veterans.'' In responding 
to the figures that CBS News researched, Dr. Katz stated that: 
``Their number for veteran suicides is not, in fact, an 
accurate reflection of the rates of suicide.''
    Either Dr. Katz knew that the CBS News figures were indeed 
an accurate reflection of the rates of suicides at that hearing 
or he had a sudden epiphany just 3 days later.
    In an internal e-mail dated December 15, 2007, Dr. Kussman, 
Under Secretary for Health in the Department, referred to a 
newspaper article and wrote that: ``Eighteen veterans kill 
themselves every day, and this is confirmed by the VA's own 
statistics. Is that true? Sounds awful, but if one is 
considering 24 million veterans.''
    That same day, Dr. Katz responds, ``There are about 18 
suicides a day among America's 25 million veterans. This 
follows from CDC (Centers for Disease Control and Prevention) 
findings that 20 percent of suicides are among veterans, and it 
is supported by CBS numbers.''
    Just this past February, Dr. Katz sends another e-mail that 
starts with, ``S-h-h. Our suicide prevention coordinators are 
identifying about 1,000 suicide attempts per month among the 
veterans we see in our medical facilities. Is this something we 
should carefully address ourselves in some sort of release 
before someone stumbles on it?''
    There was silence from the VA.
    As you saw on the viedo, the chief investigative reporter 
for CBS News, Armen Keteyian, characterized the VA's internal 
e-mails as a ``paper trail of denial and deceit, a disservice 
to all veterans and their families that has rightfully been 
exposed.''
    In April of this year, a Dallas Morning News editorial 
describing a ``recent spike in suicides among the psychiatric 
patients treated at the Dallas VA hospital,'' stated that 
``descriptions of how four veterans committed suicide in 4 
months, prompting the psychiatric ward to close, suggests that 
patients went to conspicuous and time-consuming lengths to end 
their own lives. There seemed to be ample time for staffers to 
stop them, had they been doing their jobs better.''
    The RAND Corporation, in a recently published study 
entitled, ``Invisible Wounds of War,'' found that since October 
of 2001, approximately 1.6 million U.S. troops have been 
deployed, and more than a quarter of them have mental health 
conditions.
    I think it is higher than that. The study estimated that 
approximately 300,000 of those deployed suffer from post 
traumatic stress disorder (PTSD) or major depression. Among 
those with PTSD or major depression, only half had seen a 
mental health provider or physician to seek help in the past 12 
months, and among those who sought help, just over half 
received ``minimally adequate treatment.''
    We saw a recent New York Times article that said up to one-
third of those diagnosed with PTSD of recent veterans had 
committed felonies, of which 200 had been homicides, mainly 
members of their own families.
    Something is going on in America. The study that RAND did 
found minimally adequate exposure to psychotherapy as 
consisting of at least eight visits with a mental health 
professional, such as a psychiatrist, psychologist, or 
counselor in the past 12 months, with visits averaging at least 
30 minutes.
    I would like to know, how does the VA mental healthcare 
treatment stack up against this definition of minimally 
adequate care?
    The RAND study also found that the VA faces challenges in 
providing access to Operation Enduring Freedom/Operation Iraqi 
Freedom (OEF/OIF) veterans, many of whom have difficulty 
securing appointments, particularly in facilities that have 
been resourced primarily to meet the new demands of older 
veterans. Better projections of the amount and type of demand 
among new veterans are needed to ensure the VA has the 
appropriate resources to meet the potential demand. ``New 
approaches of outreach would make facilities more acceptable to 
OEF/OIF veterans,'' so says the RAND study.
    I think many of us believe that the VA healthcare system 
has been pushed to the edge in dealing with mental healthcare 
needs of our veterans. I believe we are witnessing either an 
inability to address this problem or a purposeful attempt to 
minimize the problems faced by veterans and the VA, and sweep 
this epidemic of suicides under the rug.
    This morning we are going to attempt to get a better idea 
of the scope of this epidemic and what the VA is doing to 
respond to it. What specific steps has the VA taken since 
December, steps not previously planned, to get a better idea of 
the scope of what problem; and what has it done to begin to 
address the problem?
    Finally, I think we must seek real accountability from the 
VA.
    Mr. Secretary, we are looking to you to provide that.
    [The prepared statement of Chairman Filner appears on p. 
77.]
    The Chairman. Let me just say, for the record, that was my 
prepared, controlled statement. My uncontrolled statement goes 
something like this, Mr. Secretary:
    We should all be angry at what has gone on here, at what 
looks like posturing before this Committee by not telling us 
the truth and talking about how to deal with statistics without 
informing this Committee. Our oversight function has to work, 
and can only work, with mutual respect for each other. We both, 
presumably, want to do the best job we can for veterans. We 
have to have mutual respect for each other, and the facts; and, 
I believe your staff exhibited neither.
    If the testimony that Dr. Katz gave was wrong, being 
questioned 3 days after we went through a back-and-forth that 
was very difficult to do for both of us, why weren't we 
notified? Why didn't you say, ``we found new statistics and 
we're checking them out?'' You never told us anything after 
your chief doctor in charge of mental health testified 
differently.
    What we see is a pattern, Mr. Secretary, a pattern that we 
have seen going back to the days of atomic testing, through the 
Agent Orange controversies of Vietnam, depleted uranium, and 
more recently, Persian Gulf War Illness, PTSD, traumatic brain 
injury (TBI), suicides, and homelessness. The same pattern that 
really reveals a culture of a bureaucracy.
    The pattern is deny, deny, deny. Then, when facts seemingly 
come to disagree with a denial, you cover up, cover up, cover 
up. When the cover-up falls apart, you admit a little bit of a 
problem and underplay it: It's only a few people, only 1,000 
veterans got exposed to that gas; Agent Orange didn't affect 
very many; atomic testing, well, nobody knew what was going on.
    Then, finally, maybe you admit it's a problem and then, way 
after the fact, try to come to grips with it.
    We have seen it again and again and again. It is not just 
dealing with numbers, as your whole testimony does, Mr. 
Secretary. You are talking about numbers as if that is all it 
is. It is a bureaucratic situation.
    This is not a bureaucratic situation with just numbers. 
This is a matter of life and death for the veterans that we are 
responsible for.
    I think there is criminal negligence in the way this was 
handled. If we do not admit, if we do not assume there are 
problems, if we do not know what the problem is, then the 
problem will continue, and people will die. If that is not 
criminal negligence, I don't know what is.
    Mr. Secretary, we had a discussion right after you were 
confirmed. I came up to see you to congratulate you on your new 
role as Secretary. I asked you a question. I said, Are you 
going to just be a caretaker for the last year of this 
administration, or are you going to do something real and have 
a legacy? I said, I hope it is the latter, and I will help you 
do that.
    I will tell you how you deal with this issue will determine 
how we see your role. There is clear evidence of a bureaucratic 
cover-up here.
    One of the people in the e-mails is Dr. Kussman and I don't 
even see him here. I guess he had a previous engagement. He 
ought to be here. I also don't see the public relations guy 
that was one of the people in the other e-mail. They should be 
here to talk about what happened.
    I want to know, since I don't see it in your testimony and 
I see only vague references to the e-mail, how are you going to 
ensure accountability? Are you going to ask for the 
resignations of Dr. Kussman, Dr. Katz, and anyone else who 
participated in the cover-up of the data?
    I want to know if you are going to really take your role 
seriously and if there is going to be accountability for what 
has gone on here. This is not just an abstract discussion, this 
is not just a hearing to say, ``We got you.'' This is about our 
veterans and whether they have a life ahead of them or not.
    I will tell you I have talked to the Members of this 
Committee and they are pretty angry with what is going on. I 
think you need a better answer than your prepared statement, 
which just goes into bureaucratic details.
    Now, we will have opening statements.
    Mr. Buyer, you are recognized.

             OPENING STATEMENT OF HON. STEVE BUYER

    Mr. Buyer. Thank you, Mr. Chairman. I think those of us who 
have friends or family members that have committed suicide, 
number one, are haunted by that experience because we then look 
at that individual, and we reflect upon what could we have done 
to have prevented it. What did we miss? What were those risk 
factors?
    And sometimes they are noticeable. Sometimes when they are 
a friend and they are closest to you, you might be providing 
counsel to them, you think it is a moment of just being a good 
friend. Then, when they commit a foolish act and take their own 
life, you are tortured for the rest of your life.
    So this is a pretty powerful issue. Especially, it cuts 
across the sections of our population, when you think of 
suicide being the 11th leading cause of death in our society. 
So it is just not within the veteran population, it is within 
our population as a whole. When we don't have a national 
surveillance system, it is very difficult for us to even gain a 
better understanding.
    But we do have defined abilities to come up with the proper 
cohorts not only within U.S. Department of Defense (DoD), but 
also in the VA, so we can better understand, and identify those 
risk factors.
    I think, Mr. Secretary, by looking at how many Members have 
come here today, it sends a signal to you that the loss of a 
single veteran is a tragedy to us. I am sure that every Member 
of this Committee, in earnest, seeks to help you to identify 
contributing factors and to do anything we possibly can to 
prevent servicemembers or veterans from taking their own lives.
    We recognize that many of the veterans that do take their 
own lives, in fact, are inpatients and in psychiatric care. So 
even though we can provide in a controlled environment and we 
do everything we can, half of them that are inpatients are 
committing suicide.
    So it is one of those things where, even in a controlled 
environment, we can come up with identifying factors and still 
can't prevent someone from committing what we view as a very 
foolish act.
    So the challenge that you have is real.
    I want to thank the Chairman for continuing these hearings 
to discuss this important issue and to help those at risk. A 
number of questions were raised during our hearing last 
December regarding the validity of data on the number of 
veteran suicides. Such information is vital to understanding 
the scope of the problem, as well as identifying risk factors 
and providing better prevention and treatment protocols.
    Chairman Filner joined me in a letter I wrote to you, Mr. 
Secretary--and to DoD and CBS News--requesting their respective 
data on how it was formulated. For the record, CBS News failed 
to respond to Mr. Filner's and my letter. DoD only acknowledged 
the letter, and we are still waiting on their reply.
    Mr. Secretary, you were the only one to respond to Mr. 
Filner's and my letter. That letter included information and 
worksheets on two separate studies that the VA is conducting. 
So I appreciate the timeliness with which you responded to this 
Committee's concerns.
    These studies may provide some useful information, but they 
are limited to data on suicide rates among veterans in the VA 
healthcare system. VA must have a better method for the 
systematic collection and tracking of veteran suicide data. It 
is also important to find ways to reduce the stigma associated 
with mental healthcare and encourage more servicemembers to 
seek treatment when it is needed.
    During our last hearing, I asked the VA to be proactive and 
to reach out to soldiers and their families during 
premobilization, and to start with the 76th Indiana Brigade 
Combat Team as it prepared to deploy. Mr. Filner and I agreed 
that we would proceed with that.
    I want to thank you, Mr. Secretary. I am very pleased that 
the VA came, as requested, and participated in such an 
outreach.
    I also recognize that you are operating outside the lines 
of your jurisdiction. But you didn't say that. You didn't say, 
``That is outside my jurisdiction; I am now dancing on DoD 
turf.'' You said, ``I am going to embrace the counsel of the 
Committee and we are going to see if we can follow this group. 
We will identify ourselves with the family members. They are 
the ones who are the closest to being able to identify 
individual risk factors or if there is a change in my husband, 
my brother, my loved one, that we could see.''
    I stood with 3,400 Indiana soldiers, with Joe Donnelly at 
the RCA Dome on January 2, for the formal send-off ceremony. 
Along with about 20,000 friends and family members was VA staff 
from the Indianapolis VA Medical Center, the regional office, 
and the Vet Center. The VA reported about 1,700 families 
received information regarding VA benefits and services, 
including mental health services, Mr. Chairman, and information 
on post traumatic stress disorder and suicide prevention.
    The VA also followed up with subsequent briefings while the 
brigade was at Fort Stewart, Georgia, for training. As the 
brigade marched off to war, I believe they left with a clear 
impression that the VA was available to provide support and 
assistance to their families during their deployment, and that 
you will be there when they return from Iraq.
    There was very positive feedback regarding the VA's 
presence at these events; so I want to thank you, Mr. 
Secretary, for working with the Committee to be proactive and 
to do something outside the norm.
    Mr. Secretary, you have taken decisive action to meet these 
increased needs. This month, for example, the VA contacted 
nearly 570,000 recent combat veterans about VA medical care and 
benefits. These veterans were either injured in Iraq or 
Afghanistan or discharged from active duty but had yet been 
contacted by the VA. So I want to thank you for your outreach. 
It is something that Mr. Filner had also been expressing, and 
had expressed that to you.
    So, Mr. Chairman, I think we need to acknowledge when the 
Secretary acts on something that you ask for, we need to 
compliment him for it. The Secretary has also directed the 
creation of an independent working group to assess VA's suicide 
prevention programs.
    I want to thank Secretary Peake and other witnesses for 
their participation today, and I look forward to their 
testimony. In the end, I hope this hearing will drive home the 
message to our Nation's men and women who serve, and to their 
families, that if you need help, care is available and 
treatment works, and there is a road to recovery.
    I yield back.
    [The prepared statement of Congressman Buyer appears on
p. 78.]
    The Chairman. Before the Secretary testifies, are there 
opening remarks of any Members? I will call Members in the 
order that we have.
    Mr. Hall.

             OPENING STATEMENT OF HON. JOHN J. HALL

    Mr. Hall. Thank you, Mr. Chairman.
    Just briefly, I would say that if we can prevent any single 
suicide among our veterans, it is worth going to great lengths 
to do that. I would ask you--I know you are wearing two 
conflicting--and, sometimes--hats that are at cross-purposes 
with the ``Honorable Secretary'' before your name and the 
initials ``M.D.'' after it, and most of my questions will be 
addressed toward the M.D. part of it.
    It strikes me that minimally adequate treatment, as 
described in our documents we have before us, of at least eight 
visits in 1 year to a counselor, psychiatrist, or psychologist; 
and we understand from testimony before this Committee that 
that is not necessarily the same psychiatrist, psychologist or 
counselor. It is hard for an individual servicemember or 
veteran to strike up enough of a rapport with a doctor or 
counselor who is treating them, if they are seeing somebody 
different every time they go in and they have to kind of start 
from scratch. We have heard that that is a problem.
    Thirty minutes, anybody in this room who has been to 
therapy for any kind of marital counseling or depression or 
whatever can tell you that 30 minutes is just about enough to 
get started and say goodbye and book the next visit. So I would 
at least say that the definition of ``minimally adequate 
treatment'' is not adequate.
    I would also say that with the rates of bankruptcy and 
divorce that we are seeing, which are records, we are told are 
records among our veterans, that those two things--each of them 
alone, not to mention bankruptcy and divorce taken together--
are enough to drive people, servicemembers or regular 
civilians, to suicide. There are many stories during the Great 
Depression of people jumping off of buildings because their 
material wealth was gone, and they saw no hope.
    So some of this is rocket science in the mental health 
world; some of it is really just nuts and bolts and simple 
common sense in taking care of our veterans.
    I think that we should be as adaptable. Just as our 
military adapts their strategy in combat, we have had to change 
the course. For instance, in the war in Iraq we have had to 
change our strategy several times, and the insurgents have 
changed their strategy several times in response. They make a 
bigger bomb, we make a more armored vehicle, et cetera. We need 
to do the same thing, I think, on the VA side and constantly be 
ready to change our strategy.
    Lastly, we had a pair of parents before, I forget whether 
it was the full Committee or Subcommittee on Disability 
Assistance and Memorial Affairs, but two parents who were 
courageous enough to come in, whose son had taken his own life. 
They asked us for universal screening for PTSD for all veterans 
so they don't have to self-identify.
    I think that that is maybe one of the answers, because men 
or women who are taught to be tough and are taught to handle 
situations, and who also want to just get back to their 
families and not be held over for extra questioning and not 
have something on their record that might be a stigma in the 
future for employment or for being able to be in law 
enforcement or advance themselves in the Guard or Reserve or 
what have you.
    Their son, this couple's son, had not shown a sign that 
they, the parents, saw that would tip them off that he was so 
distressed that he was going to take his own life. So if 
parents, people that are close to an individual, don't see the 
change, and can't see it, I think we need the professionals to 
be right on top of the case. That would probably call for 
universal screening at some point after separation.
    With that, I look forward to your testimony. Thank you very 
much.
    I yield back, Mr. Chairman.
    The Chairman. Mr. Miller. Mr. Brown. Ms. Brown-Waite. Mr. 
Turner.
    Mr. Hare.

              OPENING STATEMENT OF HON. PHIL HARE

    Mr. Hare. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for appearing before the 
Committee today. It is nice to see you again.
    While I appreciate the amount of time and the effort and 
thought the VA has put into veteran suicide prevention, which I 
honestly believe has saved some lives, I have to say I was 
shocked and very disturbed after reading the e-mails.
    But this isn't about numbers or formulas or programming. 
This is about people; this is about families, wives, husbands, 
sons, daughters. This is about honoring those who serve this 
country.
    A few weeks ago I sat and talked with Mike and Kim Bowman 
of Illinois, whose son, Tim, committed suicide. Tim was an 
incredible young man who bravely served in Iraq and came home a 
changed man, suffering from PTSD. His parents did their best to 
try to help him, but they didn't know what signs to look for 
and how to reach out to help him. They are rightly angry and 
frustrated that, from their perspective, the VA didn't do more 
to reach out to help their son.
    I believe the first step in solving any problem is 
admitting that you have one. If the VA, for some reason, isn't 
being honest about the number of veterans committing suicide, 
then that is stopping us or preventing us from giving you the 
resources that you need to prevent them.
    I have said many times at hearings, and I will continue to 
say as long as I serve on this Committee, the question isn't, 
``Can we afford to give the necessary funds out to help our 
veterans?'' The question should be--the statement should be, 
``We simply can't afford not to give you the funds we need.'' 
But we have to know how severe the problem is in order to be 
able to help you on that.
    I think, to be honest, this is more than a problem; I think 
it is an epidemic among veterans if these numbers are remotely 
close, to what is happening and I believe they are.
    But we are all here today for the same reason, to find 
solutions to stopping veteran suicides so that no family like 
the Bowmans have to go through this. The RAND report found that 
300,000 military servicemembers who have returned from Iraq and 
Afghanistan report symptoms of PTSD or major depression, but 
only slightly more than half have sought treatment for their 
conditions.
    Let me just echo the sentiments of my friend from New York, 
Mr. Hall, when he said that screening all the veterans when 
they come back is something that we need to do. It is something 
that I think--clearly, they may not know that they have the 
problem, their families don't know; then we need to monitor 
them for some period of time down the road to make sure that if 
there is a problem, we can bring them in and be able to help 
them.
    With mental health disorder being a significant precursor 
to suicidal thoughts, it is clear to me that the VA has to do 
more to proactively reach out to veterans.
    As you know, Mr. Secretary, when we met--you know I come 
from a rural district, and I am also interested--one of my 
questions to you during the question period is going to be, How 
do we reach out to those rural veterans that come back where 
there may not be a VA hospital close to them? How do we get 
them in quickly and timely in order to prevent what happened to 
Mr. Bowman?
    So I thank you for coming today.
    I would yield back my time. Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Rodriguez.

          OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ

    Mr. Rodriguez. Thank you, Mr. Chairman.
    Let me, first of all, thank you, Mr. Secretary, for being 
here today. And let me just add that some of us have extremely 
high expectations for you--and I know that you are uniquely 
situated because you served not only in our military as a 
soldier, but also in the DoD--in terms of service there and the 
VA, and the difficulty that we have had as a Committee in the 
past to try to get both the DoD and the VA to work together.
    With this situation, also I think that we are talking right 
now about veterans committing suicide, but we have had a lot of 
active-duty soldiers also committing suicide. Nothing is worse 
than a soldier committing suicide in terms of how badly they 
and their families are treated when they come home, even by 
other veterans. They are treated as if they were cowards and 
those kind of things. Those are the numbers that we also need 
to seek out and get the right information for us to be able to 
do the right thing. I think you can be helpful there.
    Let me just add to what Chairman Bob Filner has said, we 
are coming from a perspective, when I got on this Committee 
some 12 years ago, I heard about Project 112, Project SHAD, 
where the DoD was denying that it even existed. Later on, as 
time went on--and 20 years have passed since the inception of 
those projects--we identified some 35 projects that were out 
there, that we did experimental things with our soldiers. Then 
we found it was not 30, it was 40; then it went to 50. I think 
the latest numbers were something like 60, where we 
experimented with our own soldiers.
    But it took us prying and pushing and tugging to be able to 
get that information, when we really need to work together to 
see how we can help address some of these situations--and 
hopefully that is what we will do--to move quickly to try to 
meet the needs of our soldiers and our families out there.
    I want to also lay down the groundwork for that in terms of 
how important it is, what do we do from now? We know we have a 
serious situation in the VA. And I know we have a serious 
situation in the DoD also, which I know you don't oversee, but 
that is also another area that we need to deal with.
    We have situations where--I just did an interview in San 
Antonio regarding a VA patient that died; the accusations are 
basically that he was killed because of presumed negligence on 
the part of the doctors--and the importance of peer review in 
the military, I mean in the VA, as it deals with doctors' 
recommendations and those kinds of things.
    So there are other areas that are very serious, and I am 
hoping that we can make some inroads in those areas. As we move 
forward on this testimony, I am hoping that we can come up with 
some recommendations, and if you have recommendations for us as 
to what you need to get it done.
    And, I know that for the longest time we didn't provide the 
resources that were needed, and we have a responsibility there. 
But we also ask that we be given the information and the data 
that is needed for us to be able to do that, and hopefully we 
can respond to some of those needs.
    Thank you very much. Thank you for being here, Mr. 
Secretary.
    [The following was subsequently received from the VA:]

      1. Update on Dallas (not requested during hearing)
      2. Noted patient died in San Antonio may be related to 
negligence--importance of peer review--provide updates.

    Response: The Office of Medical Inspector (OMI) conducted a site 
visit to the Dallas VA Medical Center (VAMC) on April 16 through April 
17, 2008. Its findings were presented to the Dallas VAMC leadership at 
the conclusion of the site visit and to the Veterans Health 
Administration (VHA) leadership on the OMI's return. The OMI identified 
a number of environmental issues that needed to be addressed. The 
Dallas VAMC reports that action to address environmental issues such as 
removal of metal holders for linen hampers, geriatric chairs in the 
showers, and replacement of unit doors that did not lock automatically 
were completed by April 30, 2008.
    The OMI recommendations currently under assessment or in progress 
include increasing the amount of therapeutic patient activity, 
replacing the suicide risk assessment tool, and changing the current 
continuity of care model to an inpatient model of care. The Dallas VAMC 
is addressing these issues.
    On April 22, 2008, a team from VA's Office of Mental Health 
Services visited the facility to evaluate the safety of its mental 
health program. It identified additional environmental, organizational, 
and programmatic issues that can improve the delivery of mental 
healthcare. Actions on many of these environmental issues, such as 
additional housekeeping staff, painting and repairs, installation of 
new doors, and moving cameras and monitors have been completed or will 
be in the near future. In addition to the actions noted, the Dallas 
VAMC is reassessing the mixing of acuities on the Mental Health unit.
    The report has not been cleared by OMI and is in the pre-decisional 
stage. It is anticipated that it will be ready by the end of May.
    San Antonio--An external Peer Review was completed in the second 
quarter FY 2008. South Texas is in the process of reviewing the results 
and developing professional practice evaluations.

    The Chairman. Thank you.
    Mr. Mitchell.

          OPENING STATEMENT OF HON. HARRY E. MITCHELL

    Mr. Mitchell. Thank you, Mr. Chairman.
    In November, 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 nonveterans the same age, but that the Department 
of Veterans Affairs wasn't keeping track of veteran suicides 
nationwide.
    In December we had a hearing to find out why.
    Mr. Chairman, I don't know if there is anyone here who 
attended that hearing who will ever forget it. Mr. Hare 
mentioned that we heard from Mike and Kim Bowman, whose 23-
year-old son, Tim, survived a year of duty in Iraq, only to 
come home and take his own life. Mr. Bowman warned us that our 
troops were coming home to an underfunded, understaffed, 
underequipped VA mental health system that imposes so many 
challenges that many are just giving up.
    So when Dr. Katz insisted at that hearing, repeatedly, that 
the VA had all the necessary resources to reach all veterans at 
risk for suicide and make special treatment available to them, 
I was skeptical. How could Dr. Katz be so sure that there 
weren't any requests for additional resources sitting somewhere 
within the vast VA system that have gone unfulfilled? Was he 
absolutely certain that there were no pending requests for an 
additional mental health counselor, for extra gas money to 
enable a VA employee to drive somewhere to contact an outreach?
    As Chairman of the Subcommittee on Oversight and 
Investigations, I felt I had a responsibility to make sure, so 
I asked the VA to double-check. I asked them to take a look at 
their records and send us any documents relating to any request 
for additional resources that had gone unfulfilled or 
underfilled. My thought was, if we could find out what the VA 
needs are to address this problem, we could get to work and 
make sure they got it.
    More than four months later, however, all I have gotten are 
excuses, complaints, and most recently, a suggestion that I, 
``Go file a Freedom of Information Act request.'' That is not 
just an insult to me, it is an insult to this Committee and to 
our veterans.
    I have tried to be reasonable. I have tried to work with 
Secretary Peake's office. But, Mr. Chairman, my patience is at 
an end.
    I have given the Department until Friday to finally produce 
the documents I requested. If they do not, Mr. Chairman, I want 
you to know that I will be asking you to pursue a subpoena.
    I yield back.
    [The prepared statement of Congressman Mitchell appears on
p. 79.]
    The Chairman. Thank you, Mr. Mitchell.
    Mr. Moran, we thank you for your interest. You have been 
interested in this issue and have been a leader for many years, 
and we thank you.

              OPENING STATEMENT OF HON. JIM MORAN

    Mr. Moran of Virginia. Thank you very much, Mr. Chairman 
and Ranking Member Buyer and my friends and colleagues.
    I want to mention, incidentally, with regard to the 
recommendation for individual screening, in the Defense 
Appropriations bill, when we put $900 million in for PTSD and 
traumatic brain injury, we did require that everyone get an 
individual face-to-face screening by the Pentagon. But the 
problem is, that is when all they can think about is getting 
home to their families, and it is oftentimes only after they 
get home that evidence of emotional problems, whether it comes 
out in domestic abuse or inability to hold on to a job and so 
on, manifests itself.
    The fact that 20 percent of our veterans from Iraq and 
Afghanistan show signs and symptoms of PTSD, depression, and 
anxiety is a compelling statistic. But even more so is the fact 
that that number increases to 50 percent for soldiers with 
multiple tours and inadequate time between deployments; and in 
fact, that is becoming more and more the case.
    One of the measures that I would suggest that this 
Committee might consider is to create a stand-alone, 24-hour, 
national, toll-free hotline to assist our veterans in times of 
intense crisis. The key is that this hotline would be staffed 
by veterans trained to appropriately and responsibly answer 
calls from other veterans.
    I understand that the Department of Veterans Affairs has 
developed a veterans option off of the National Suicide 
Hotline. While I applaud your effort to address this problem, I 
believe that there are about three deficiencies in this 
approach. First, oftentimes a veteran doesn't want to talk to a 
doctor; he or she wants to talk to someone who has got a real-
life perspective on what is going on in their mind--cultural 
competency, if you will. That is a term that has been used to 
express that a fellow veteran can provide a real difference in 
crisis counseling because they can better relate.
    Secondly, soldiers with mental illnesses face social stigma 
that is identified with seeking care through the VA. Research 
from the Air Force's Suicide Prevention efforts suggests that 
fear of the system, of an unfriendly mental health 
establishment, and of potential job-related consequences do 
keep many active-duty soldiers and recent veterans from seeking 
the care that they need.
    Thirdly, the VHA is already overburdened by a great many 
healthcare responsibilities; and as a result, I think it is 
ever more difficult to provide a topnotch hotline effort. 
Stretched budgets, staffing shortages, they may not be able to 
meet the challenges of so many returning veterans when our 
Nation redeploys from Iraq in the future.
    A nonprofit organization dedicated to suicide prevention 
might be better able to provide focus, stability, and 
commitment that the VA is particularly challenged in being able 
to achieve.
    So to conclude, our vets deserve as much support when they 
return from combat as they receive while in battle, and I know 
that this Committee is acutely aware of that fact. But too many 
of our veterans are struggling to make the difficult adjustment 
back to society, and they desperately need someone that they 
can talk to, that they can relate to, someone that has walked a 
mile in their shoes. So that is why I have offered legislation 
that would do that.
    I very respectfully suggest that this Committee consider 
that legislation. I certainly applaud this Committee for your 
efforts on behalf of veterans.
    Mr. Buyer. Would the gentleman yield?
    Mr. Moran of Virginia. I would be happy to.
    Mr. Buyer. Mr. Moran, I want to thank you for your 
leadership over the years. Your care and sincerity, it is real 
and very evident to me, having known you over the years. So I 
want to thank you for your leadership.
    We debated your bill; and I like the idea of having 
veterans, but not all veterans are trained in mental health. I 
know that is your aspiration. But you have a good idea, and we 
want to work through that.
    We did have a conversation, Mr. Chairman, and I want to 
caution my friends in the fourth branch of government who may 
be covering this hearing, please do not refer to suicide as an 
epidemic without saying that treatment is available. Because if 
you say or you put on the air that suicide is an epidemic in 
America, you are exacerbating the problem and you could 
actually be moving people to suicide. So, please, if you write 
that, say that treatment and care are available.
    Thank you for your leadership.
    Mr. Moran of Virginia. Thank you, Mr. Buyer.
    If I could quickly respond, what we are suggesting is that 
a nonprofit organization that would be available for veterans, 
that would spread the word within the network of veterans and 
give them training simply to be able to react to people on the 
other side of the line. They don't need to be trained in mental 
health counseling, just be able to know how to listen and to 
talk and to calm down someone that is in a time of crisis. That 
is what we are talking about.
    It is just that sometimes when you have very large 
institutions, it is difficult to accomplish what a nonprofit 
group that is particularly committed and understanding of the 
problem sometimes is able to provide with a lot less money. 
That is all I am suggesting.
    I thank you for your comments, Mr. Buyer.
    And thank you very much, Mr. Chairman, for giving me this 
opportunity.
    [The prepared statement of Congressman Moran appears on
p. 82.]
    The Chairman. Thank you, Mr. Moran. We will be looking 
again at that legislation.
    Mr. Salazar, any opening remarks?

           OPENING STATEMENT OF HON. JOHN T. SALAZAR

    Mr. Salazar. Mr. Chairman, I want to thank you for having 
this important hearing. I agree with my colleagues, but the one 
thing that I think we have to be very, very adamant about is 
finding out whether there was a cover-up by the VA to push 
these things under the carpet or was it something that they 
need additional tools for. We are here to help. That is what we 
are here for.
    So with that, thank you, Mr. Chairman.
    The Chairman. Ms. Berkley.
    Ms. Berkley. I would like to submit my opening statement 
for the record, if I may, so we can get to the witnesses.
    [The prepared statement of Ms. Berkley appears on p. 79.]
    The Chairman. So ordered. I would ask unanimous consent 
that all Members can submit their statements for the record. 
Hearing no objection, so ordered.
    The Chairman. Mr. McNerney, any quick opening?

            OPENING STATEMENT OF HON. JERRY McNERNEY

    Mr. McNerney. Thank you, Mr. Chairman. It is clear that all 
Members of the Committee are sincere in wanting to find the 
bottom of this.
    There is nothing that is more tragic than suicide. As Mr. 
Buyer pointed out, it is a situation that haunts the family and 
friends for years and years, especially when young men and 
women who have served our country and have looked to this 
country to help them when they have needs and, it appears, that 
that may not have been followed through.
    So it is our solemn responsibility to get to the bottom of 
this and to find ways to move forward that will prevent this in 
the future.
    Thank you.
    The Chairman. Ms. Brown.

            OPENING STATEMENT OF HON. CORRINE BROWN

    Ms. Brown of Florida. Thank you, Mr. Chairman, and I want 
to thank you for holding this hearing today.
    First of all, let me say, it is not just the veterans; it 
is the veterans and their families that are faced with this 
situation. I am looking forward to hearing from the Secretary 
and also from Dr. Katz on how he came up with this analysis and 
what can we do together to change this situation, because this 
is a serious problem.
    I have been on this Committee for 16 years, and this is a 
serious situation. We have passed the largest VA budget in the 
history of the United States, and I want to make sure that we 
are properly funding that healthcare issue, and the money is 
going where it needs to go.
    So, thank you, Mr. Chairman, for holding this hearing.
    The Chairman. Thank you.
    Mr. Secretary, I appreciate you being here. I was hoping 
that everybody who was associated with these e-mails would be 
with you but since they are not, I hope you can speak to those 
issues that we have raised.
    You are recognized, sir, for your statement.

    STATEMENT OF HON. JAMES B. PEAKE, M.D., SECRETARY, U.S. 
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY GERALD M. CROSS, 
   M.D., FAAFP, PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
 AFFAIRS; AND IRA KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT CARE 
      SERVICES OFFICER FOR MENTAL HEALTH, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Secretary Peake. Mr. Chairman, with your permission, I 
would like to provide a written statement for the record.
    The Chairman. So ordered.
    Secretary Peake. Mr. Chairman, Congressman Buyer, Members 
of this Committee, thank you for the opportunity to discuss the 
issues of veteran suicides. I really do appreciate your holding 
this hearing. It is a very important subject.
    We will be talking quite a bit about the numbers in this 
discussion. I will tell you, quite frankly, to me personally 
the most important thing is that each suicide number represents 
a soldier, a sailor, an airman, a Marine, a veteran who has 
served this country in uniform; and each individually is a 
tragedy and each deserves all that we can do to try to prevent 
that tragedy.
    While it is appropriate--and frankly, it is necessary--to 
try to measure and understand variances from the norm in 
trending and statistical significance, I want to assure you and 
this Committee and, frankly, the American people that we are 
not waiting on these numbers to focus the VA on addressing this 
very important issue.
    The title of today's hearing is, ``The Truth about Veteran 
Suicides.'' My objective is to tell you as clearly as I can 
what we do know about veteran suicides and the sources of the 
information. Also, I will tell you what we don't know and what 
I intend to do about that. I also will take this opportunity to 
tell you what we have been doing to address the issue of 
suicide directly, from a clinical perspective, and expanding 
our outreach even as we seek better ways to measure.
    First, to compare veterans with nonveterans, the gold 
standard and source of the database is the National Death 
Index. It is a product of the National Center for Health 
Statistics, a U.S. Department of Health and Human Services 
(HHS) function. The most current complete data set is from 
2005. 2006 data should be released, we are told, sometime soon.
    Looking at 2005 and back to 2001, the overall rate of 
suicide was 14.1 per 100,000 in the general population. That is 
not a percent; that is per 100,000. It is important to separate 
the rate of men and women. Men have a higher rate of suicide 
than women, and that is statistically significant. We must 
separate by age group because there are significant differences 
by age groupings.
    The National Death Index does not identify those who are 
veterans. To compare all veterans, not just those seen in the 
VA system, would require matching the full list of all 24 
million veterans against the National Death Index to see how 
many of them had committed suicide. We do not have the 
identifying information for all veterans to do this analysis. 
We would love to be able to do it; we don't have that 
information.
    The VA does have the ability to compare veteran suicide 
rates with the national average for groups of veterans who have 
used the VA health system. We have matched that group against 
the National Death Index by name to know the number of those 
veterans who have used the VA, who have committed a suicide. 
With that data, we can calculate a rate.
    The National Death Index data that we have broken that data 
into--first, men and women; let me just show you this is the 
population, 2005. Men make up about 20 percent of the 
population. Men veterans make up about 20 percent of the 
overall population. Women veterans make up only about 1 percent 
of the overall population, just to give you the perspective.
    What this chart is showing is for 2005. The numbers in red 
represent the numbers that are statistically higher than the 
general population. This is for women. This is for men. You can 
see that for 2005, in the older, but not in the younger, age 
groups for veterans who use the VA health system, just those 
veterans, the suicide rate was higher than the general 
population.
    Looking at this for each, from 2002, will give a more 
complete picture. But here, just to say this is the general 
suicide rate, this is the veterans'--again, those who have only 
been seen in our system because we don't have all the 
veterans--you can see that it is a bit higher than the general 
population, and it is statistically significant.
    Now, to show you the trending, this is the summary of data 
from 2002, 2003, 2004, 2005, and you can see that the red is 
the veteran population, again for age group 18 to 29, age group 
30 to 64, and then the older age group. What you see, the 
national population figure is here in terms of rates per 
100,000.
    The rates for veterans who are users of the VA, again, just 
users of VA, have also been relatively stable over this period. 
You can see that it is, again, stable. This is women, the 
smaller group; and it is--what we are showing with these 
brackets here are the statistical significance. So that this is 
clearly statistically significant.
    Looking at the veterans who have used the VA in this 
period, male veterans commit suicide at a somewhat higher rate, 
but with varying statistical significance by age over different 
years. You can see that in the charts.
    Within the group of male veterans there are differences in 
age of suicide compared to what is seen in the general 
population with a statistically higher middle-age group. So 
statistically you can see this age group is generally higher 
for veterans--above the national average.
    Male veterans commit suicide at a higher rate than female 
veterans. Within the group of female veterans--and that is what 
this slide shows--by age group, there is nearly a twofold 
increase over women in the general population. That is, again, 
variably, statistically significant over years and by age. So 
in this older age group in 2002, it was above the national 
average statistically. Here, it was about the same, and here it 
has bounced up again. I don't know what 2006 will show, but we 
need to follow that and find out.
    In 2002, to better understand the nature of violent deaths, 
the CDC Violent National Death Reporting System was established 
and gradually implemented, first in six States, then expanded 
to 16 by 2005, to collect data on violent deaths, including 
suicides. It gets information from a variety of sources, 
including death certificates, police reports, medical 
examiners, coroners, crime laboratories; and unlike the 
National Death Index, coroner-reported veteran status is 
included in the database. VA can get, at least for these 16 
States, information on overall suicide rates among all 
veterans.
    This chart summarizes the 2005 data. What you see of note 
is that, at least in these 16 States, there is a significantly 
higher rate of suicide in the younger age group of veterans 
compared to the general population. This is similar in both 
veterans seen in the VA system and those who do not use the VA 
system. This is for veterans who are really all veterans, and 
these are veterans who actually use the VA system. You can see 
these are relatively the same, but they are higher than the 
national averages.
    We intend to trend this information over each year of the 
available data, going back as far as we can go to 2002. We 
believe that some of these veterans' deaths in this data set 
represent servicemembers who were actually on active duty when 
they committed suicide. We will work with CDC and DoD to 
understand this group, particularly, obviously, wanting to know 
whether this represents OIF or OEF returnees.
    Clearly, OIF and OEF returning servicemen and women 
represent a group of particular interest to us today. We have a 
sense of urgency to understand and intervene to prevent even a 
single suicide. To better understand suicide in this particular 
cohort, Dr. Kang, of the VA, conducted a study, which matched 
servicemembers who had served in OIF and OEF theater and 
separated between 2002 and 2005 against the National Death 
Index. He found--just looking only at that group, he found that 
144 out of 490,346 separated OIF and OEF servicemembers 
committed suicide during that time, for an overall rate of 21.9 
per 100,000.
    Because there was some initial confusion around this study, 
I want to clarify that these, unlike our concerns about the 
last data that I presented, are deaths only of men and women 
who had separated from the military and do not include any 
deaths while a servicemember was on active duty.
    To compare to other national norms, we looked at this 
cohort against the national averages that I discussed earlier. 
For OIF/OEF veterans who had deployed and separated from 2002 
to 2005, the suicide rate was slightly higher than would be 
expected in an age-, gender-, race-matched general population, 
but the difference was not statistically significant except in 
the young non-VA user age group. So these are folks that were 
not seen in the VA, and again, it was only significant in the 
age group of 18 to 29.
    We have also examined this data for differences in suicide 
rates between those who use the VA and those who have not used 
the VA. We found that 17 per 100,000 OIF/OEF veterans who used 
the VA for care took their own lives, compared to 24 of 100,000 
OIF/OEF veterans who did not use the VA for care. Again, this 
apparent advantage to VA care, though encouraging, is not 
statistically significant. In this group, a slight but not 
improved rate is also true for those who visited our Vet 
Centers. There were only three women among the 144. So no 
conclusions can really be drawn from that group.
    Our medical statisticians have plumbed this data in 
anticipation of follow-on studies when the updated National 
Death Index information is available. Some of the insights that 
we have taken from this look include that there is little 
variation in suicide by branch of service. We also found that a 
diagnosis of a mental disorder predicted a nearly 1.8 times 
higher suicide risk than the general population. This is 
consistent with what has been published regarding people in 
general with mental health diagnoses, but emphasizes the 
absolute importance of our mental health efforts.
    Likewise, the use of firearms as a means of suicide in this 
group is consistent with the higher rate of this modality of 
suicide in all veterans compared to the general population.
    I would reiterate that all of this data comes from national 
data for suicide run against those who we know from our data 
sources and DoD are veterans. We must use these national 
numbers, because our clinical records do not capture in any 
reliable or complete way such events as suicides or suicide 
attempts. This national roll-up of information from the 
coroners through the States offers the most complete 
compilation of deaths and its causes, since we may well not 
know of a death even if it occurs locally.
    The information on deaths continues to be updated as the 
reports come in over time, so our confidence in the 
completeness of those numbers comes only after several years of 
data collection. We are awaiting now, again, the release of the 
National Death Index compilation for the year 2006 for further 
analysis, and we will dig into that very deeply as soon as we 
get it.
    For this reason, and not satisfied with that data lag, Dr. 
Katz, who led in the institution of a VA-wide system of 153 
suicide-prevention coordinators whose prime function was 
clinical in nature--taking care of patients, identifying and 
closely following high-risk patients, educating staff on 
suicide issues--he directed them, beginning in October of 2007, 
to report specifically on suicide attempts.
    This entailed getting a clear definition and reporting 
standards for suicide attempts. When is a suicide attempt an 
attempt? Does a cry for help with an overdose of a non-
threatening medication ingestion or a cut on the wrist so 
slight as to not really risk serious injury, is that really an 
attempt? Those are the kind of questions that we have to get 
standardized across 153 different reporting entities.
    On February 13, 2008, an internal e-mail from Dr. Katz 
discussed what was the first 3 months of this reported 
information. In his e-mail, he suggested that a thousand 
veterans a month under VA care were being reported as 
attempting suicide, and appropriately was concerned about 
releasing information that was not validated and was so very 
preliminary.
    The data was clearly not accurate. Our suicide prevention 
coordinators were new to their jobs. There was a great deal of 
uncertainty over borderline calls, and many of them were just 
beginning to make the community contacts that are essential in 
making an accurate count of the number of suicides and suicide 
attempts.
    A number of States had suspiciously low reporting rates. We 
are still not satisfied with the consistency of the reporting, 
its accuracy or its completeness.
    Let me show you this chart. And what this is is month by 
month, facility by facility, and what you can just see is how 
erratic the reporting is even now. The VA is addressing the 
problem through regular review, educating coordinators with 
questionable data, collaborating with our coordinators on 
difficult calls, and encouraging them to meet the right people 
in their communities to obtain additional data.
    To be clear, VA had not reported on suicide attempts 
previously, either to Congress or to the media. Though perhaps 
we should have been looking at it earlier, we were not. The 
number, 790 a year, was a CBS News number that they derived 
from a Freedom of Information data request looking at clinical 
records coding. I now understand, I think, the places in the 
spreadsheets that they got under the Freedom of Information and 
added together to get this number.
    But for all the reasons noted earlier, this source of data 
should not have been considered at all reliable if the purpose 
of the count was to determine the total number of suicides and 
attempts among veterans under our care. Some people who attempt 
suicide, but do not die, go elsewhere for care. Others do not 
admit that their injuries were due to suicide attempts, and may 
not, even when a counselor discusses a situation with them. CBS 
News' number, while arithmetically correct, is in actuality 
misleading.
    I can appreciate that the number of a thousand suicide 
attempts a month might be shocking. But in a system as large as 
ours, and with the numbers I have shown you nationally on 
suicides, and consistent with the literature, we might well 
expect a larger number of attempts than that because it's 
somewhere between 8 and 25 attempts per suicide completed in 
the national literature.
    But what is really important is to identify them, because 
people who attempt suicide are more likely to commit suicide 
and are so, therefore, such an important target for our 
interventions.
    There's a large body of scientific literature on suicides, 
and the VA has over the years, been a prime contributor to that 
knowledge. In fact, I can submit this binder full of peer-
reviewed articles for the record.
    It is where we have the basis for conclusions that target 
our efforts, conclusions such as: Among veterans receiving care 
from VA who died from suicide, almost 60 percent of those aged 
under 65 have a mental health or substance abuse diagnosis, but 
only 24 percent of those aged 65 and over have such a 
diagnosis.
    There is significant variability in suicide rates 
geographically. In general, the rates are lowest in the 
Northeast and highest in the West. I don't know exactly why. 
For veterans who died from suicide, firearms are the most 
common means, accounting for almost two-thirds of the deaths.
    Among Vietnam veterans, there appears to have been an 
increase in suicide rates in the first few years after veterans 
returned home; however, after a few years, those rates became 
comparable to the general population. There was no increase in 
suicide rates among veterans who returned from the first Gulf 
War. And those wounded, hospitalized and multiple wounds, have 
had a higher risk of suicide.
    You know, I have focused a lot on the numbers and what we 
know and don't know. And while I am pushing our VA team to 
explore these numbers in greater depth and expand our 
understanding of them, I want to emphasize that we are not 
waiting for perfect numbers to appreciate the importance of 
extending our intervention and outreach. Whether veterans 
suicides are at or above or below some national average, any 
suicide--any suicide--in our view, is a tragic loss.
    There is probably no system focusing on suicide and mental 
health issues in as a comprehensive and far-reaching way as 
your VA. And Dr. Katz here has been a key leader in that 
effort.
    Recognition of the problem by all who serve veterans is 
important. So we have had two national VA Suicide Prevention 
Awareness Days throughout our system to focus 200,000 
healthcare employees on this issue. We have trained VA staff on 
prevention resources, including the hotline and the roll of 
suicide-prevention coordinators. We are incorporating special 
training in suicide prevention for our case managers.
    Two of our mental health education and research centers 
focus on technical assistance across the VA for suicide 
prevention. One is our Mental Health Center of Excellence in 
Canandaigua, New York, with expertise in testing clinical and 
public health intervention; the other in Denver with clinical 
and neurobiological sciences, emphasizing suicide risk.
    In July of 2007, a suicide hotline center was established 
at Canandaigua. In the subsequent 10 months, the hotline has 
fielded more than 37,000 calls, more than 16,000 from veterans. 
Nearly 500 from active-duty servicemembers, and more than 2,000 
from family members or friends, just as you all have pointed 
out. These calls have led to more than 3,000 referrals to 
suicide-prevention coordinators and 885 rescues involving 
emergency services.
    Let me introduce Dr. Jan Kemp, who is with us today, who 
leads this effort on the ground up there in Canandaigua.
    Jan, stand up. Thanks.
    VA's hotline is staffed solely by mental health 
professionals, 24/7/365. They are trained in crisis 
intervention and issues such as traumatic brain injury and post 
traumatic stress disorder. In emergencies, they contact local 
emergency resources, police or ambulances. They can use the 
veteran's electronic medical record during the call and link 
directly with the medical center if they are one of our 
patients. And they work with the local suicide-prevention 
coordinators directly.
    Cards, pamphlets, refrigerator magnets--I provided samples 
that I believe are at your desks--are widely distributed. And 
our suicide-prevention coordinators ensure at-risk veterans and 
their family members get them.
    [Samples of cards and pamphlets appear on pages 120 and 
121. The refrigerator magnet will be retained in the Committee 
files.]
    This was pulled out by one of our veterans service 
organizations (VSOs) who said, boy, we're using this all over 
the place. Posters and hotline information such as these are 
located throughout VA medical centers, clinics and Vet Centers. 
Hotline stickers are on phones and by the doors in our 
residential programs.
    Far from hiding this issue, we are more public about it 
than any organization that I know. I've mentioned the suicide-
prevention coordinators before. Their main function is 
clinical, to educate staff and the veterans and the family 
members and to carefully monitor those at higher risk. So they 
maintain everyone's higher state of awareness and alertness to 
suicide issues, as well as dealing with individual patients.
    It was not primarily for epidemiologic purposes that they 
were identifying suicide attempts, but rather because we know 
that those who have attempted suicide are at the highest risk. 
Under Dr. Katz's leadership and with the help of Congress, we 
have grown our mental health program in a number of ways: more 
than 3,800 new mental health employees hired in the past 3 
years; incorporating mental health into primary care in our 
medical centers and in our Community-Based Outpatient Clinics 
(CBOCs); growing the number of both CBOCs and Vet Centers; 
expanding our hours of operation for mental health clinics 
beyond normal business hours; using telemental health to reach 
more remote veterans; providing separate access for women 
veterans with mental health, primary care and gynecologic care. 
It recognizes their increasing proportion of the force and 
their special needs and special desires for privacy. We are 
doing this in each of our hospitals.
    The standard for mental health access was tightened so that 
patients with mental health issues are screened within 24 
hours, provide urgent care immediately when needed--and if we 
don't have it in our house, we will buy it--or provided a full 
evaluation and a treatment plan within 14 days for those non-
emergent patients.
    I have spoken to you before on our outreach efforts with 
letters and participation in transition briefings for active 
and reserved demobilization at both deployment health 
reassessment sites and on bases and in military hospitals.
    [A sample of an outreach letter to veterans from Hon. 
Michael Kussman, M.D., MS, MACP, Under Secretary for Health, 
U.S. Department of Veterans Affairs, appears on p. 122.]
    On May 2nd, we began an outreach call center program to 
contact nearly 570,000 combat veterans of the war on terror to 
ensure that they know about our ability to provide them care. 
Now we can do that up to 5 years after separation and to 
provide them information on other benefits. The first of those 
calls are going to veterans who were sick or injured while 
serving in Iraq or Afghanistan. And if any of those 17,000 or 
so veterans do not have a care manager, we will offer to 
appoint them one.
    All of these efforts support not only our general concerns 
for our men and women veterans but to also directly address the 
issue of suicide concern about which we are here today.
    I am impressed by the quality of my people and the 
dedication to this work, but I also appreciate the value of an 
outside look. I have directed the creation of a blue-ribbon 
work group of experts in suicide and its prevention to look at 
all of our data, consult with our team and advise me on 
different looks at our own data or new lines of inquiry that 
they might recommend. The members will come from DoD, other 
government agencies, and other nationally recognized treatment 
research and public health experts on suicide and its 
prevention, all from outside the VA. They will be given all of 
the data that we have and access to all of our experts. I have 
asked for a report 15 days from the completion of their meeting 
to tell me how I can better approach suicide prevention and 
suicide research.
    You know, there is nothing more tragic than the loss of 
even one of these great men and women who have served this 
Nation. The VA is committed to doing all that we can to serve 
the individual while we continue to try to understand a very 
complicated problem that is also a national problem. We owe 
this Committee, and the Nation, accurate information and 
carefully studied, thoughtful conclusions while we provide the 
best care anywhere to our veterans, and that's exactly what I 
intend us to do.
    Again, Mr. Chairman, I do appreciate you holding this 
hearing, and I look forward to your questions.
    [The prepared statement and slide presentation of Secretary 
Peake appear on p. 83.]
    The Chairman. Thank you, Mr. Secretary.
    I don't doubt your commitment, but I will tell you, if 
there is a book on how a bureaucratic response should be given 
to an emotional problem, there should be a chapter in there 
with your testimony. Because what you have done is make us all 
look at these charts, which are almost impossible to read, and 
all the things you're doing and, of course, the icing on the 
cake, a blue-ribbon commission--it's always done to avoid an 
issue--without us understanding what you need in terms of 
resources from us and what we are missing. It sounds to me, 
``Everything is fine, we have it under control, we are going to 
study our data, we dug up all this data, but it is under 
control.'' You don't ask for any additional resources, you 
don't say what you could do, you don't say what mistakes you 
have made; everything is fine.
    [The following was subsequently received from VA:]

    The Blue Ribbon Work Group on Suicide Prevention in the Veteran 
Population provides advice and consultation to the Secretary on various 
matters relating to research, education and program improvements 
relevant to the prevention of suicide in the veteran population. The 
Blue Ribbon Work Group on Suicide Prevention in the Veteran Population 
will create a report, within 15 days of the completion of its meeting 
with recommendations for improvements in VA's programs related to 
suicide prevention, research, and education.
    Recommendations will be directly related to the primary objective 
of reducing risk of suicide in the veteran population. The attached 
Memorandum from Hon. Michael J. Kussman, M.D., MS, MACP, Under 
Secretary for Health, U.S. Department of Veterans Affairs, to Hon. 
James B. Peake, Secretary, U.S. Department of Veterans Affairs, dated 
May 5, 2008, Regarding Blue Ribbon Work Group on Suicide Prevention in 
the Veteran Population, appears on p. 134.

    The Chairman. And that is a standard answer to everything 
we have done for years and years in this Committee. That is why 
we are upset and impatient, because you are not focusing on 
what we can do together to make sure that all the mental 
illness issues that have been associated with combat: PTSD, 
domestic violence, homelessness and suicides--we are not doing 
the job. I don't care what your figures show. We have tens of 
thousands of young people getting out of the military or the 
Guard who have not been adequately diagnosed for either PTSD or 
brain injury.
    Every one of your statistics says, ``those who have come to 
us,'' which is, you know, a small fraction of who is out there. 
So we are not doing the job. And we can't do our job if you are 
not honest with us.
    And as I said before in my opening statement, we only came 
into possession of certain e-mails--I don't know how many there 
are out there, but we only have a few--brought to the public by 
discovery in a legal case out on the West Coast.
    So 3 days after the hearing in which we asked directly--and 
Mr. Mitchell just said this--Dr. Katz, ``Do you need any help 
from us? What resources do you need?'' And he said, ``No, we 
have it taken care of, and here are our statistics, CBS News 
was wrong, and you guys shouldn't worry about this.''
    Three days after that, Dr. Kussman writes to Dr. Katz and 
others that--I don't know if the e-mail is from home or work, 
but the fact that you are all working Saturday, is good--18 
veterans kill themselves every day. That is what the CBS News 
report said. ``Sounds awful, but let's not worry too much if 
you are considering 24 million veterans.''
    Even in the first e-mail that we have--and I don't know 
what else there is--nobody is saying, ``We are not doing the 
job here.'' They are saying, ``Does this sound good? Does this 
sound bad?'' And Dr. Katz says, yes, there are 18 suicides. 
This is supported by the CBS News numbers.
    Now, Dr. Katz, this contradicts what you told us in the 
hearing 3 days earlier. Why didn't you just call us up or ask 
for another hearing and say, ``You know, we are looking at 
things differently. I misspoke. I want to talk to you some more 
about the statistics.'' This looks like a cover-up, because you 
didn't tell us anything. And this is contradictory to what you 
said to our Committee in December.
    Why shouldn't you go to court for perjury or resign because 
you didn't tell us the truth?
    Dr. Katz, I am asking you. You keep looking at the 
Secretary, but I am asking you.
    Dr. Katz. Thank you for asking.
    In response to a question from Mr. Mitchell in the December 
12th hearing, I and my colleague, Dr. Fred Blow, who 
accompanied me to the hearing, did mention the 18-a-day for 
suicides among all veterans. We mentioned the four to five a 
day for suicides among those we cared for in VHA healthcare 
services.
    When I asked him to, Dr. Blow mentioned the fact that, 
overall, veterans had a rate of suicide about 1.5 times that of 
age- and sex-matched individuals from the general population. 
And he mentioned the fact that, among women, the ratio of 
suicides among veterans in our system to the general population 
was about two.
    That was mentioned in the hearing on December 12th. There 
was no cover-up. This was mentioned.
    The Chairman. Did you not say--and we saw the clips. Did 
you not say that the CBS News data was wrong?
    Dr. Katz. I was not referring to the entire data, but the 
subset of data dealing with the youngest of veterans.
    The Chairman. So the ``Mission accomplished'' should have 
said, ``Mission accomplished only by those sailors who were 
aboard this ship on those 2 days.'' We didn't see the fine 
print.
    We asked you several times, and you said several times that 
the CBS News data was wrong. You never made any qualification 
of that as far as I can remember. Your story was that they were 
wrong, and you didn't need any help to deal with this issue. Is 
that right? You were fine?
    Why do you keep looking at the Secretary? I am asking you, 
Dr. Katz.
    Dr. Katz. Sir, I did speak about the suicide rates among 
veterans on December 12th, and I continue to have concerns 
about the CBS News reports about rates and standard mortality 
ratios or ratios among the youngest veterans. I wish they would 
present their data so we could review it.
    The Chairman. Yes, but you are in charge. They are just 
reporting. They asked for all this data, and you never gave it 
to them, so they spent 6 months trying to find stuff that, Dr. 
Peake said the VA didn't have. Well, they went out and found 
it. So I assume somebody can go out and find it if you think 
it's important enough.
    Secretary Peake. Mr. Chairman, if I may, I don't disagree 
with your premise that somebody should be able to go out and 
find it. They did not provide it to us, even though we asked. 
And so we have now gone out and asked for the same information. 
I am very anxious to see what actually came back.
    As I tried to explain, we are using the data from the 
national sources, which is the gold standard that any 
responsible statistician would be able to use for this.
    I will tell you, I am worried that suicide in general in 
this Nation is underreported, not just in the military, not 
just in the VA.
    The Chairman. But don't start that red herring. We are 
talking about veterans right now. So don't tell me, ``Well, the 
whole society is screwed up.'' We are going to do our job for 
veterans.
    So on the December 12th data, you don't see any difference, 
Dr. Katz, between what you told us then and what you said a few 
days later. You say you are consistent.
    Dr. Katz. Again, the issue is the 18-a-day, the 4-to-5 a 
day, the ratios of 1.5 and 2.0. And those were provided at the 
December 12th hearing in response to a question from Mr. 
Mitchell.
    The Chairman. Now, on one, the February 13th e-mails you 
said, ``Shh!'' what did you mean by that?
    Dr. Katz. That was very unfortunate. I think the e-mail has 
to be divided into the subject line and the content. I deeply 
regret the subject line. It was an error, and I apologize for 
it.
    However, the content of the e-mail, the body of the e-mail 
reflects an appropriate and healthy dialogue among members of 
VA staff about when it is appropriate to disclose and make 
public information early in the process of developing----
    The Chairman. No. An appropriate e-mail would say, ``We are 
not sure of this data. We will study it further. Maybe we 
should inform the Committee.'' But what you said is, ``This is 
something we should carefully address ourselves before someone 
stumbles on it.''
    I mean, that is what you are concerned about, not the 
suicides, but somebody stumbling on this data.
    Dr. Katz. No, sir, I am concerned about saving lives.
    The Chairman. Well, but that is not what you suggest here.
    Dr. Katz. Sir, that e-mail was in poor tone, but the 
content was a dialogue about what we should do with new 
information.
    The Chairman. And did you tell Secretary Peake about all 
this, about the new data or these thousand attempts per month?
    Dr. Katz. The purpose of that e-mail was to open extensive 
dialogue within VHA about this emerging data.
    The Chairman. Did you tell Secretary Peake about that, that 
you were showing a thousand suicide attempts per month?
    Dr. Katz. I reported it to VHA's senior leadership.
    The Chairman. That is not what we have in the e-mails. We 
just have you talking to the PR guy.
    Dr. Katz. We were opening a dialogue about what to do with 
the new information.
    The Chairman. Yes, and the first thing you do is talk to 
your public relations guy instead of somebody who might know 
how to treat suicide. It seems to me that what you were trying 
to do was manage the data, not deal with the data.
    Dr. Katz. Sir, there has been extensive conversation about 
this with other suicide and mental health people.
    The Chairman. I'm sorry? I didn't----
    Dr. Katz. There was extensive conversation about the 
thousand a month with other people----
    The Chairman. Yes, but not in the information we have.
    Dr. Katz. Not in that e-mail, no.
    The Chairman. I would think that you would tell us about it 
since we have a concern about the issue and we are the ones who 
can help get you the money to deal with the issue.
    All I have is what you provided to the court by discovery 
motions, which I assume is as complete as you want it to be. If 
you have more complete information, then you probably didn't 
give enough information to the original requests. It appears to 
me that your interest is in managing the data as opposed to 
helping the veteran.
    Dr. Katz. Sir, earlier at that same court, in a hearing, I 
testified under oath to the thousand a month and talked about 
how knowing about that number was so very important, because it 
pointed to a thousand people a month where we really could do 
something to dramatically decrease suicide risks.
    The Chairman. Why didn't you just write us a letter, or set 
up a meeting, or brief us? I mean, instead of managing the 
data, why didn't you just talk to us about it and say, ``We are 
on it, we are serious, we care about it, we want you to know 
about it, and we need this much more money or not to do 
something?''
    Dr. Katz. Dr. Peake spoke to the fact that this wasn't data 
yet. These were observations and measurements very much in the 
state of development.
    The Chairman. When do you expect that to be real data? 
Another year, after your term is over?
    It looks like this would never have come to our attention 
unless there was the court case with discovery. You never had 
any intention of talking to us, dealing with the data in an 
open way, but you were trying to manage it from the inside. And 
who knows when we would have heard about it.
    Both the court case that got the data and the news media 
that has been looking at this issue have done a far better job 
than you have in keeping us informed.
    Mr. Buyer, I took too much time. I apologize.
    Mr. Buyer. I am trying to follow this. I was present at the 
December 12th hearing. And I know we have ongoing litigation, 
so I recognize, Mr. Secretary, you have to be careful if you 
have ongoing litigation, yet we are also asking you questions 
about data.
    And it appears that, when this e-mail is released in 
discovery in litigation, CBS News has created an impression now 
in our country by their report that no one knew about this 18 
per day until it was in discovery.
    Now, when I look at the report on the December 12th 
hearing--and I want to compliment my colleague, Mr. Mitchell. 
You did a very good job here, when you look at the transcript. 
I mean, you went right in on Dr. Katz, and you asked the 
specific question to him.
    You asked this: ``One last question really quick. Do you 
believe that suicide is an epidemic?'' Dr. Katz: ``There is a 
suicide epidemic in America.'' Mr. Mitchell then says, ``Among 
veterans?'' Dr. Katz says, ``The number''--then parentheses, 
(inaudible) end parens--``about 18 veterans kill themselves 
each day in America. That is too many,'' Dr. Katz says. And Mr. 
Mitchell then says, ``And?'' Dr. Katz's response is, ``About 
four or five.'' There is cross-talk, inaudible. Mr. Mitchell 
then: ``According to CBS News, it was 120 a week.'' Dr. Katz 
says, ``About the same.'' Mr. Mitchell then says: ``That is not 
higher than the general population?'' Dr. Katz says, ``It is 
somewhat higher than the general population among veterans 
because of demographics and risk factors.''
    Mr. Mitchell, then you asked a really good question. You 
said, ``I think one way we can find out about that is if you 
have the data. I think that is one thing that people were 
arguing about earlier, was the methodology of data that CBS 
had.''
    Now, see, when you asked that question, I homed right in on 
it. And that is the reason that I wrote the letter, and that is 
the reason Bob Filner joined me. And we sent this letter, with 
regard to methodology and data, not only to the Secretary but 
also to DoD and CBS News. CBS News has yet to share this with 
us. So if you can get it, Mr. Mitchell, I hope you can.
    But from what I recall from the hearing, Mr. Chairman, Dr. 
Katz, this was in response to Mr. Mitchell's questions.
    I have other questions for you, Mr. Secretary.
    You have much in your toolbox. When you think about the 
access that you have to great intellect in your research and 
development and your abilities to study and define cohorts, I 
would like to know, is there any epidemiological resource 
analysis that is being done for the, quote, ``at-risk,'' end 
quote, veterans from either Vietnam or the first Gulf War, 
specifically looking at the mortality rates for in-theater 
versus non-theater, veterans versus general population?
    Obviously, we are trying to home in on, then, those who are 
most susceptible, and so obviously you want to look at--and I 
just mentioned this to the Chairman--those who may already show 
trends in mental health, depression, PTSD, wounds or 
disabilities, whether they occur in-theater or non-theater.
    With that, I yield to you for a response.
    Secretary Peake. Well, sir, in this gathering of documents 
here that have been published on the Vietnam and Gulf Wars, it 
addresses some of those specific issues in terms of the 
epidemiology of suicide in those groups.
    It is very clear that those with mental health disorders, 
in some of our published literature just in the general veteran 
population, those with depression have a higher suicide attempt 
rate when you look at that as a group. And that gets better, 
that rate gets smaller if they are on medications. At least one 
of our studies has proved that.
    So it starts to give us the opportunity to target the 
individual groups. Those with suicide attempts clearly have a 
higher rate. So, again, we are trying to target the individual 
specific groups based on the science behind it in terms of what 
we are actually finding as you really understand what groups 
are at risk--those with wounds; we are looking at the TBI group 
as a potential for specific intervention.
    One of the reasons why I tried to emphasize in this call 
center outreach is to make sure that we are going after those 
who have returned who were injured, specifically to try to get 
them into care management, and why we are training the care 
managers on suicide intervention, because of just exactly that 
nexus. So that is exactly the direction that we are trying to 
go.
    Mr. Buyer. Mr. Chairman, I think what would be helpful for 
the Committee, the Secretary keeps referring to a binder that I 
can see is pretty thick, and he refers to, quote, ``peer-
reviewed articles.''
    I think it would be helpful to the Committee, Mr. 
Secretary, if you would provide the Committee with and would 
submit for the record a page of references----
    Secretary Peake. Absolutely.
    Mr. Buyer [continuing]. That would list the title, the 
author, the publisher, dates, and/or if there are Web sites, 
okay?
    Secretary Peake. Very well. We will provide that for the 
record.
    Mr. Buyer. Thank you very much.
    The Chairman. Mr. Michaud.
    Mr. Buyer. Mr. Chairman, and we are doing this for the 
record, it is being submitted for the record, their references 
would be submitted for the record.
    The Chairman. Yes, that is a fine idea, so ordered.
    [The following was subsequently received from VA:]

    In reference to the binder at the hearing, attached are research 
articles published in peer-reviewed medical journals that have 
relevance to the question of the rates and risk factors for suicide 
among veterans. All demonstrate VA's investment in research and 
epidemiology in providing scientifically evidenced understanding in 
mental health conditions that impact veterans.
    Articles are separated by whether the population studied was 
population based (ie., representing the full spectrum of all veterans) 
or a clinical cohort (ie., representing a sample of only those veterans 
who sought care in VA). In cases where websites are available they are 
cited.
Clinical cohorts cannot be used to estimate population-based rates and 
        risks.
    Patients who seek and receive medical care differ from the general 
population. For instance, they may be sicker, leading to higher 
expected rates of death. Also, they may travel far from home to get 
medical care, in which case it may be hard to calculate the 
``denominator'' (see below) of total patients at risk.
    Reported suicide rates in clinical cohorts are usually higher than 
that of the general population. Therefore, for determining the rates 
and risk factors for suicides among veterans overall, population-based 
studies assume a higher priority. Insights from clinical cohorts, 
however, are valuable for suggesting more effective ways to deliver 
clinical care to veterans who use the VHA healthcare system.
References
      Cypel Y, Kang H. Mortality patterns among women Vietnam-
era veterans: Results of a retrospective cohort study. Ann Epidemiol 
2008; 18:244-252.
      Herrell, R, Goldberg J., True, WR, Ramakrislman, V., 
Lyons, M., Eisen, S., Tsuang, MT. Sexual Orientation and Suicidality. 
Arch General Psychiatry 1999; 56: 867-874.
      Bullman TA, Kang HK. Risk of suicide among wounded 
Vietnam veterans. Am J Public Health 1996;86:662-667.
      Bullman TA, Mahan CM, Kang HK, Page WF. Mortality in U.S. 
Army Gulf War veterans exposed to 1991 Khamisiyah chemical munitions 
destruction. Am J Public Health 2005; 95:1382-1388.
      Kang HK, Bullman TA. Mortality among U.S. veterans of the 
Gulf War: 7-year follow up. Am J Epidemiol 2001; 154: 399-405.
      Kang HK, Bullman TA. Mortality among U.S. veterans of the 
Persian Gulf War. NEngl J Med 1996; 335:1498-1504.
      Zivin, K., Kim, M., McCarthy, JF., Austin, KL., Hoggatt, 
KJ., Walters, H., Valenstein, M. Suicide Mortality Among Individuals 
Receiving Treatment for Depression in the Veterans Affairs Health 
System: Associations with Patient and Treatment Setting 
Characteristics. American Journal of Public Health 2007; 97 (12): 2193-
2198.
      Desai, MM., Rosenbeck, RA., Desai, RA. Time Trends and 
Predictors of Suicide Among Mental Health Outpatients in the Department 
Veterans Affairs. Journal of Behavioral Health Services and Research 
2007.
      Gibbons, RD., Brown, CH., Hur, K., Marcus, SM., Bhaumik, 
DK., Mann, JJ. Relationship Between Antidepressants and Suicide 
Attempts: An Analysis of the Veterans Health Administration Data Sets. 
American Journal Psychiatry 2007; 164:7: 1044-1049.
      Tiet, QQ., Finney, JW., Moos, RH. Recent Sexual Abuse, 
Physical Abuse, and Suicide Attempts Among Male Veterans Seeking 
Psychiatric Treatment. Psychiatric Services 2006; 57(1): 107-113.
      Desai, RA., Dausey, DJ., Rosenbeck, RA. Mental Health 
Service Delivery and Suicide Risk: The Role of Individual Patient and 
Facility Factors. American Journal of Psychiatry 2005; 162: 311-318.
      Kausch, O. Suicide Attempts Among Veterans Seeking 
Treatment for Pathological Gambling. Journal of Clinical Psychiatry 
2003; 64(9): 1031-1038.
      Desai, RA., Lui-Mares, W., Dausey, DJ., Rosenbeck, RA. 
Suicidal Ideation and Suicide Attempts in a Sample of Homeless People 
with Mental Illness. Journal of Nervous and Mental Disease 2003; 
109(6): 365-371.
      Thompson, R., Katz, I., Kane, V., Sayers, SL. Cause of 
Death in Veterans Receiving General Medical and Mental Health Care. 
Journal of Nervous and Mental Disease 2002; 190(11): 789-792.
      Kausch, O, McCormick, RA. Suicide Prevalence in Chemical 
Dependency Programs: Preliminary Data from a National Sample, and an 
Examination of Risk Factors. Journal of Substance Abuse Treatment 2001; 
22: 97-102.
      Sernyak, MJ., Desai, R., Stolar, M., Rosenheck, R. Impact 
of Clozapine on Completed Suicide. American Journal of Psychiatry 2001; 
158(6): 931-937.

    The attached table entitled, ``Rates and Risk of Suicide and Other 
Suicidal Behaviors Among U.S. Veterans,'' Updated April 30, 2008, 
Prepared by Joseph Francis, MD, MPH, Acting Deputy Chief Quality and 
Performance Officer, Office of Quality and Performance, U.S. Department 
of Veterans Affairs, appears on p. 137.

    Mr. Michaud. Thank you, Mr. Chairman, Mr. Ranking Member, 
for having this hearing today.
    Mr. Secretary, just looking at some information--and, 
actually, one of the panelists that is coming up, Dr. Stephen 
Rathbun, who will be testifying later on today. CBS News 
actually asked him to run a detailed analysis on the 
information, the raw data that he obtained from the States.
    In that raw data, it shows that, according to the doctor, 
that it found that veterans are more than twice as likely to 
commit suicide in 2005 than non-veterans. But it also goes on 
to say that, between the age group of 20 and 24, that veterans 
are two-to-four times higher likely to commit suicide than non-
veterans.
    I don't know if you had a chance to look at that or if Dr. 
Katz has. Is that analysis correct?
    Secretary Peake. Sir, we have not seen that data.
    But I would like to, if I could, and with your permission, 
Mr. Chairman, put up that slide again on the 16 State material, 
and it is on your screen now actually. This study of these 
States under the National Violent Death Registry does give 
coroners information to say if this person is or is not a 
veteran. We understand it may also include active-duty people. 
But you can see that the numbers there suggest that there is a 
higher rate statistically in the younger servicemember--I'm 
sorry, veteran or potential servicemember, both in those who 
have been seen in the VA and those who are not.
    So at least in these 16 States, which is not necessarily 
representative of all of our States, it does give us that kind 
of inference here. And we see that both in men and in women.
    And so we take that very seriously, and that is why we are 
pushing so hard and why I want this outreach. Because I believe 
if you get these people in and get them into some kind of care, 
if they are depressed and get on treatment, there is evidence 
that we can mitigate some of this tragic loss in terms of 
death.
    So I can't speak to what was presented on data we haven't 
seen, but this is data that is available, and we have run it 
against what data we know for VA users, so we are comfortable 
or confident in that data.
    Mr. Michaud. And what role has the VA found that substance 
abuse and the lack of treatment has played in a veteran's 
suicide?
    Secretary Peake. Sir, it is one of the clearly linked 
conditions for suicide. Depression and the co-morbid conditions 
do relate to an increased suicide risk.
    Mr. Michaud. And you had mentioned outreach. And that is 
one of the whole ideas behind the CARES process, is to get more 
access points throughout the country for our veterans. And that 
is probably part of the reason that we are seeing some of the 
problems, particularly in rural areas.
    You mentioned a lot of the programs that the VA is doing to 
help our veterans deal with this problem that is out there. A 
couple of years ago, when the Congress actually provided the VA 
with about $300 million to take care of mental health needs, a 
GAO report--came back and said that only about $100 million to 
$150 million was used, and, out of that amount, they really 
couldn't tell what it was used for. It was supposed to be used 
specifically for mental health.
    So my question to you, Mr. Secretary, is, number one, how 
do you know that the money and the programs you are doing are 
going to directly benefit our veterans?
    And the second question is, have you seen a decrease in the 
number of suicides since these programs and outreach have been 
implemented?
    Secretary Peake. Well, sir, first, I will tell you that--
and as we have talked about here--for 2009, we expect to 
increase our expenditure on mental health to $3.9 billion. We 
have hired 3,800 new mental health workers--we have about 
17,000 mental health folks working in mental health across our 
system.
    Going to Mr. Moran's point, we have OEF and OIF people that 
we have hired specifically to do the peer review and reach into 
from our Vet Centers.
    And so I do know that there is a history of the inability 
to expend the money. And that is part of the difficulty of 
hiring people and the slowness of it. I think we are up to 
speed in terms of moving forward on that. And we will monitor 
that very carefully to make sure that we are putting everything 
that we need and that we have been given to use for mental 
health into that process.
    Mr. Michaud. The second question that I asked is, has there 
been a decrease?
    Secretary Peake. Sir, let me ask Dr. Katz.
    As I look at these numbers, you know, I can see a decrease. 
It is hard to say, well, that is the cause and effect. If you 
can put up that other slide, you can see that, at least in the 
one male in the slide that is up on the board now, in the 
younger age group, there in 2005, at least. But this is old 
data. And so the problem, sir, is being able to really get 
accurate data to be able to give you an honest answer on that. 
We are absolutely trying to plumb it and dig into it, but we 
don't have perfect knowledge about that.
    So that is part of why we are very interested in getting 
our suicide coordinators out there, up to speed, in terms of 
giving us as accurate a report as we can, not because that 
number is exactly important, but because we want to be able to 
intervene for those people.
    And so I don't think I can actually give you an honest 
answer about if we have seen a decrease in response to those 
specific interventions.
    And I would ask Dr. Katz, if you have any more comments on 
that.
    Dr. Katz. 2005 is the most recent year for which 
information is available from the National Death Index. It is 
just too early to evaluate the outcomes of the Mental Health 
Strategic Plan (MHSP), whose implementation began in the 
beginning of 2005.
    We are looking toward this data with incredible intensity. 
Just yesterday, I received data from the National Violent Death 
Reporting System about early data from 2006 veteran deaths. It 
is complex data; data like this always is.
    The best way to summarize it is that, at this point, the 
early data does not seem to show an increase in veteran suicide 
rates from 2005 to 2006. This is very important, but it is very 
early data. The numbers may change as late reports from State 
medical examiners, and county coroners come in. It has to be 
viewed as an evolving story.
    The Chairman. Mr. Hall, you are recognized.
    Mr. Hall. Thank you, Mr. Chairman.
    And in my short 5 minutes, I just want to ask a couple of 
practical questions.
    Dr. Peake, if I may call you by that title, there is a 
problem--currently, as I understand it, when a veteran gets a 
prescription or has to order a refill, there is no way for a 
doctor to expedite the delivery of the medication, which can 
take 10 days sometimes. For a veteran needing an antianxiety or 
antidepressant medication, it seems that he or she should be 
able to get that refill sent quicker by allowing the doctor to 
request overnight delivery.
    Is that something you can do by rule or that you think that 
is a problem that----
    Secretary Peake. I would think that would be within my 
purview. That has not been up to me, but I would be delighted 
to look at it.
    Mr. Hall. Well, it has now, and I just am asking you, if 
you can, to make a ruling and send it down to all of the staff. 
Because it is a drop--that is one of the ways in the general 
population, as well as the veterans population, if you are on 
an antianxiety/antidepressant drugs and you go off of them for 
a period of days, it is not a good thing; ask any doctor.
    Dr. Cross, you were going to say something?
    Dr. Cross. There are some other options, as well. Many of 
our facilities have pharmacies, like our medical centers, and 
they can make an arrangement with the local commercial 
pharmacy, if necessary, or they can pick it up there.
    And I don't think it really takes ten days for the CBOC to 
get the medicine out, but you raised an interesting issue. And 
I agree with you, that continuity of providing that medication 
is absolutely vital. And so I would like to look into that for 
you.
    [The information from VA was provided in response to Mr. 
Hall's Post-Hearing Questions for the Record, which appears on 
p. 238.]
    Mr. Hall. Thank you.
    And also, Dr. Peake, as far as your blue-ribbon Committee, 
would you consider, or have you already, appointed any 
representatives of veterans service organizations?
    Secretary Peake. Sir, I will tell you, what I am going 
after are people that have actually published and that are 
recognized experts. I am not looking--I am trying to get at our 
data. I mean, our veracity has been questioned. I think it is 
reasonable to be questioned. We are America's VA, and we ought 
to be transparent. What I want to get is some outside look at 
it and see from a scientific clinical research and public 
health perspective. And that is the kind of folks I am looking 
at here.
    Mr. Hall. I was concerned about, on one of your slides 
here, the one showing--by the way, if you could provide the 
Committee which 16 States you were looking at in the study, 
that would be great.
    Secretary Peake. Sir, this is the National Violent Death 
Reporting, and it is on the bottom of the slide there.
    [The information from VA was subsequently received:]

    Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, 
North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, 
Virginia, Wisconsin, Kentucky, New Mexico, Utah and 4 counties in 
California.

    Mr. Hall. Oh, good. Okay, I'll find that. But, anyway, it 
seems to show that the user-veteran suicide rate is higher than 
the all-veteran suicide rate, which would indicate that the 
VA's involvement may not actually be positive in these cases. 
Am I reading that correctly?
    Secretary Peake. Actually, what it shows is they are about 
the same, because the comparison for statistical significance 
is between the general population. So it is both the user and 
the non-user that are in that younger age group, particularly 
that are different from the general population. Between the 
two, there is not a statistical significance--it is the same 
whether you are in a VA or not in a VA.
    Mr. Hall. So a four-point difference is not considered 
statistically significant?
    Secretary Peake. In that test, in this case, it is not.
    Ira.
    Dr. Katz. It really depends on the particular statistical 
test that one does. We are dealing with a counterbalancing of 
two complex effects----
    Mr. Hall. Okay, thank you, Doctor. I have less than a 
minute left. If I may, I appreciate your explanation, but I 
wanted to ask two more questions.
    One is, on the following slide, the non-user, 18- to 29-
year-old rate of 3.4, which you have illuminated in red, is of 
concern. And that would seem to indicate a need for greater 
outreach, and refrigerator magnets and handout cards may not be 
doing it. I am curious, first of all, what you would propose?
    Let me just ask a second question, and then you can answer 
them both, if you will.
    There are fewer females serving than men serving, as you 
point out. However, the rate of suicide among female veterans 
is approximately twice the rate of male veterans in your 
testimony, if I am reading it correctly.
    And I am curious if you think that is related to sexual 
harassment or sexual abuse, which unfortunately occurs in our 
bases as well as our academies, military academies, and it is a 
problem that we are trying to deal with, I know at West Point, 
in particular, where I serve on the board of visitors. And/or 
is it due to a difference in the way women process their 
experiences in battle and these things they have seen and 
witnessed, do they have a different emotional reaction to it?
    So those are a couple of questions, if you would.
    Secretary Peake. Sir, first, the outreach. I agree with 
you, we are looking for whatever way of outreach that we can 
do. That is why I put this call center, outreaching call center 
into effect, to try to get at those who haven't used us, those 
who may finally be at a point where they had the teachable 
moment to realize that we are there for them and to establish 
that relationship. We have talked about putting signs on buses 
and things like that, even, to try to do outreach.
    In relation to women, sir, I would just like to correct, if 
I misspoke before. The women's rate is higher than the national 
average. Women, both veterans and non-veterans, are lower than 
males across the board. But our women veterans are higher than 
the general population.
    And I think then it is fair to try to understand why. They 
are about 14 percent of the DoD population now; they are about 
14 percent of the force. And so an increasing number are 
becoming veterans, and why we are pushing so hard to put 
women's programs into a system that, really, for years, was 
mostly an older men's service organization.
    So we really are trying to address that and to try to 
understand those issues of military sexual trauma. We are 
seeing that. When I talk to our Vet Centers, they say that is 
an issue that is very important. And so we are targeting that 
group to try to make sure they get the counseling that they 
need. We train our people specifically in that.
    Mr. Hall. Thank you.
    I yield back, Mr. Chairman.
    The Chairman. Thank you, Mr. Hall.
    Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman.
    Mr. Secretary, I only have 5 minutes, so I will give you 
the three questions and then--and, again, thank you for being 
here today.
    Why is there not more coordination between the DoD and the 
VA with soldiers separated or discharged with either TBI or 
PTSD? It would seem to me that more effort needs to be done to 
reach out to veterans to bring them into the system rather than 
wait for them to come to us.
    The other question I have--and, again, it goes back to what 
I think we talked about last week, with the rural areas--and 
how do we, for veterans in rural areas who call the hotline--do 
the suicide-prevention coordinator set them up with 
appointments at the nearest clinic, VA clinic or hospital? 
Because, you know, I've talked to veterans, and then asking 
them to ride for a few hours in a van ride, a lot of times they 
are just not going to do it. They just feel very uncomfortable 
doing that.
    And then my last question to you--it is probably and, I 
understand, very broad-based--but what can we do from your 
perspective for this Committee to be able to--is it, you know, 
more money, which is something I think we can look at, or what 
is it that we can do to help you with whatever we need to do on 
our end? If you were to say to us, ``Listen, this is what I 
need from you folks, to help me move down the road with this 
and to be able to bring more people in,'' is it hiring more 
people? Is it a combination of a number of things?
    And so, I hate to load you with three like that, but with 
only 5 minutes I thought I would try to get all three in.
    Secretary Peake. Sir, let me start first at the top, with 
DoD coordination. There is a general roster steering Committee 
on the 15th of May. We have been invited to be a part of that. 
Dr. Katz works closely with DoD. I spoke to the DoD psych 
consultant this morning, who used to work for me. So I think we 
have good relationships going on. We have a VA deputy now for 
General Sutton who is going to be running that PTSD/TBI effort 
for DoD to make sure that we are linked.
    I think the issue of outreach is important. So we do go to 
the Post Deployment Health Reassessments (PDHRAs), we do do the 
Transition Assistance Program (TAP) debriefings, to try to get 
that message out, as Mr. Hall was talking about, to make sure 
people, wherever we can get them--part of it is trying to get 
them when they are really ready to listen finally--the hotline.
    If you have an emergency, we go to the police, we go to the 
fire station, we go to whoever can make the intervention. And 
we have had 885 rescues. We follow up a week later or 24--I 
guess 48 hours a week and then 2 weeks later to track them 
down. We work directly with the treating facility. If they are 
active-duty--and we have had nearly 500 active-duty people call 
our hotline--we have the relationships with DoD to get them 
back in the DoD system, if that is what they need.
    So, you know, I think we are very pleased, and we continue 
to monitor and learn from it.
    What can we do? You know, the Chairman brought up the issue 
of family members. I think we need to do a better job of being 
able to reach family members. They can be the canary in the 
cage, if you will, when you have a servicemember or a veteran 
who isn't just quite acting right and may not even recognize 
it.
    I do appreciate the issue of stigma, and we need to 
continue to fight that down. I was very pleased to see what 
Secretary Gates did this last week about taking, you know, that 
question off the security questionnaires and so forth. I mean, 
it is those kinds of things that will help us down the road.
    But it is more than stigma, I think, that keeps people from 
coming to us. I think some of these folks, it is a lack of 
realization that something is wrong, that they are not quite 
right. They just don't appreciate it until, sometimes, it is 
too late. And if we can get family members and employers to 
really understand that this is treatable, if you get them in, 
we can help them, it will make a difference.
    And so for helping us to find ways and the authorities to 
reach out and do that would be something that would be 
positive.
    Mr. Hare. Thank you, Mr. Secretary.
    Just one last thing on the rural areas. In terms of, if 
somebody calls, a veteran who lives in a rural community, and 
they call the hotline, do you try to get them into the VA 
hospital?
    Secretary Peake. Sir, we will get them wherever the care is 
required and where we can get it. Unfortunately, some rural 
areas, it is a long way, whether you are a veteran or not. And 
that is a different kind of issue, but it is, again, part of 
that national issue that we were talking about before. But it 
is not, well, if you can't get to the VA, we are not going to 
take care of you.
    Mr. Buyer. Will the gentleman yield?
    Mr. Hare. I certainly will be happy to.
    Mr. Buyer. You just asked a very insightful question.
    So say, for example, you have Montana or Kansas, and they 
are not close to a Vet Center or an outpatient clinic. Do you 
contract care, or how do you fill the gap, Mr. Secretary?
    I think that is what the gentleman is trying to ask.
    Secretary Peake. Sir, in Montana, we do contract with 
centers around Montana. I have had a chance to visit both 
Billings and Helena, because I am concerned about rural America 
and access to care for our veterans that live in those areas.
    But the fact is we do fee-based care, as you know, sir, and 
we are willing to go out and we do go out and purchase the care 
if it is not available and it is needed.
    Mr. Buyer. Mr. Secretary, I would just ask you to work with 
Mr. Hare. He's got a rural district in Illinois, and he has a 
gap in coverage. Please work with him to make sure that gets 
covered.
    Secretary Peake. I absolutely will.
    Mr. Hare. Thank you, sir.
    The Chairman. Mr. Rodriguez.
    Mr. Rodriguez. Thank you, Mr. Chairman. And, once again, 
thank you for holding and conducting this hearing.
    Good seeing you again, Mr. Secretary.
    You know, I indicated earlier I think you are ideally 
situated, because we have been working for the longest time to 
try to establish a seamless transition from DoD to the VA. And 
I wanted to ask you, and I know there has been some questions 
on that, if we have made any gains in terms of where we are at 
on that, of trying to transition that soldier to the VA.
    Because there are going to be more soldiers coming in, and 
there are going to be some that are really going to be hurting, 
and the numbers might go up you know before they go down. And I 
understand that. And so I wanted for you to respond to that.
    Secondly, based on the Congressional Research Service (CRS) 
report that we have and you have also and Dr. Katz has 
mentioned it, that we don't have a hold on the actual suicides 
and attempts. We don't have a good hold on that.
    [The CRS Report entitled, ``Suicide Prevention Among 
Veterans,'' May 5, 2008, appears on p. 111.]
    Mr. Rodriguez. What else do we need to do besides possible 
recommendations later on where we can start getting and 
compiling that data in a way that makes sense where we will be 
able to see if we can make any inroads there?
    And thirdly, what do we do now, and maybe Dr. Katz can help 
on this, what do we do now to provide the services that are 
needed that we are not doing in reaching out?
    And I know that people are hurting out there. They are 
probably not the ones that will come out. And I know Mr. Moran 
had some recommendation in terms of utilizing some of those 
veterans organizations to reach out for those veterans that 
find themselves underneath the bridges throughout our country 
and those individuals out there.
    So if you might respond to those three questions.
    Secretary Peake. Yes, sir. First, on the issue of 
transition, I've been talking lately about the notion that 
there is ``transition'' with a big T and ``transition'' with a 
little T, if you will; that, you know, for these servicemembers 
that are coming out of our military treatment facilities and so 
forth that are wounded and injured, with the Federal recovery 
coordinators that we are starting to get into place and 
expanding that program, I think that will go a long way to 
helping them for a long-term transition.
    And that really is important, because these are folks that 
are wounded and, therefore, you know, appropriate to our 
discussion today, have a higher risk for suicide. So having a 
care manager is important.
    What we are in the process right now--and on the 15th of 
May, I should get my next report on it--is going back and re-
reviewing every soldier that we know that has been in our 
system to understand, okay, what is their current status on 
case management, who has been in touch with them recently, and 
to ensure that we have the follow-up that I believe we owe 
them. And so we are pushing very hard on that.
    Then there is the other issue of the transition. Sir, there 
has been a million and a half people who have deployed, a 
little bit more now. About 800,000 have separated from the 
service. About 300,000, a little more now, have come in to VHA 
for care. When they come into care, they do get screened for 
PTSD and TBI and suicidal tendencies. And so, you know, we have 
that relationship with them.
    Is it perfect? No. In fact, the people that--the national 
preventive task force basically says there is no real good 
evidence to prove about screening. We believe in it, though. 
And so we are doing it every single time.
    There is that other group out there, however, that 500,000 
that haven't come to see us, that we will be part of this big 
outreach effort that we are doing now to try to help them if 
they need that help in transition. So we just want to make sure 
they have that relationship with the VA, that they know that we 
are there for them.
    I will tell you, I know that trying to get at the data is 
hard. The military is looking at how to really study every 
single suicide. We get an in-depth review of any suicide that 
we know of from one of our patients, because we can try to 
plumb it to understand what the factors are, so that we can 
learn from it. So it really becomes an individual case study 
for each one of these, as well.
    The problem is, as I say, sometimes we don't know if one of 
our veterans has gone out somewhere else and it has not been 
reported to us. And so we do want to stay in touch with the 
national data.
    Mr. Rodriguez. I would hope that we would establish and 
start looking at some system that would give us information, 
not only from the 16 States, but all of them as much as 
possible.
    And then, finally, the last recommendation in terms of what 
do we do now, even if it is an initial phase to try to reach 
out there, and maybe even utilizing existing veterans 
organizations to work with some of our veterans. And I know 
they are not trained in this area, but they are definitely 
trained at reaching out and dialogueuing with them and maybe 
getting them to come back in.
    Secretary Peake. You know, I, kind of, made the point that 
when I was talking--I meet with the veterans service 
organizations regularly. And when I was talking to them, they 
pulled it out and said, ``Oh, look, this is a great tool.'' 
This is what they are using to pass out; it is a VA product.
    And so we are linked with the veterans service 
organizations. We agree with you, sir, that they are an 
important ally and an important partner. And we share the same 
concerns with them about trying to do this kind of outreach.
    Mr. Rodriguez. And before I know I ran out of time, and I 
don't know how I can overemphasize it, let us know if we need 
do more--but when it comes to these issues in terms of working 
with a family. Because I know the VA, for a long time--you 
know, only in certain situations have they worked with the 
family. But I think when it comes to these situations, we need 
to really stress that and the importance of that and how we do 
that in different ways.
    Secretary Peake. Thank you, sir.
    The Chairman. Thank you.
    Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for being here. I truly 
appreciate what you do and appreciate your service. And as the 
members of the military medical community say, you are one of 
them, and that is a very important thing.
    And you and I have talked. You know as well as I do all of 
us are here to serve our veterans, first and foremost. I have 
been your strongest supporter in whatever we can do for the VA, 
but because of that commitment I am also the biggest critic.
    And, Dr. Katz, I will have to say, your term--using 
``unfortunate'' for that e-mail--that is very correct. And I 
say this, I am not a judge of your medical professionalism, I 
am not a judge on the things you are doing there. What I am a 
judge on is oversight, and perception of our veterans, and they 
are losing faith in the system because of instances like this. 
So it is very unfortunate, because they believe the system will 
fail them. And that is something we are fighting hard to 
overcome. I believe we have made great progress. And those 
types of unfortunate slip-ups or whatever or these beliefs are 
very, very damaging to what we are going to do.
    So I am deeply sorry that this incident happened. But I can 
tell you, today's tone is much different than when you came in 
December. And that troubles me, in terms of restoring that 
faith.
    The one thing I would say, my ultimate goal--and I was just 
speaking with the Ranking Member--is how do we implement this 
plan to make sure that it is successful. I know that gathering 
this data is very difficult. But I know some of the new data we 
are seeing from the CDC, is actually--I think, Dr. Katz, when 
you get a chance to look at it, and we looked at it this 
morning, tables 5 and 6 show a fairly significant increase in 
18- to 29-year-old males. And I think we are going to see 
somewhat of a trend.
    The problem here was we didn't start looking at this until 
2005. We didn't have an Inspector General (IG) report and 
recommendations on this until May of 2007, and here we sit in 
2008. This should have been planned for, and prepared for, when 
we went into these conflicts. The VA knew these types of 
situations arose after Vietnam, and yet we weren't prepared to 
deal with them. That is very troubling to me.
    So when those of us try and gather data or try and 
implement this, I can tell you, I went to the Veterans 
Integrated Services Network (VISN) 23, asked for data on 
Minnesota, they promptly replied--I was speaking with them, and 
they said they sent it through your office, and your office, 
Mr. Secretary, delivered it to me 1 hour before this hearing.
    I have nothing but the best interests of the VA at heart. I 
wanted to have this data so I could ask the appropriate 
questions as it deals with my constituents. And I have to 
believe--why was that held up?
    And I hear a Subcommittee Chairman say he has to use the 
Freedom of Information Act to get information from the VA? His 
concerns is for the veterans. He is on the Oversight and 
Investigation Committee. Why does he have to use the Freedom of 
Information Act? And why am I waiting until the hour before the 
hearing?
    Those types of things trouble me, because the issue here--
and I think all of us understand--the key is identifying and 
preventing suicides. That is the ultimate key. The key to doing 
that is making sure these people see the proper people.
    Now, I had a proposal that I sent over, and I discussed it 
with you personally, Mr. Secretary, about this inability when a 
person transitions from the DoD to get his DD-214 into the 
hands of people who can help him.
    We, in Minnesota, have County Veterans Service Officers in 
all of our counties. Those County Veterans Service Officers are 
veterans who are professionals in navigating the system. 
Because of the support of our Governor, the Director of 
Veterans Affairs in Minnesota, all of the veterans service 
organizations, and our nationally recognized Beyond the Yellow 
Ribbon campaign, our National Guard members, 99-plus percent of 
them are enrolled in the VA system; 36 percent are regular 
soldiers.
    As one young veteran told me as he came back, ``We come 
back in ones and twos and fall between the cracks,'' as he sat 
beside his father who lost his leg in Vietnam.
    When we have asked, I get put off and, quite honestly, get 
the run around from the VA. ``It can't happen because we can't 
trust the County Veterans Service Officers because they are not 
employees of the VA.'' That's what they tell me. They may lose 
data. I asked them to provide me a single case of a County 
Veterans Service Officers breaching confidentiality, and they 
couldn't do it. I need not remind you who lost the 26 million 
names.
    This issue of not wanting to cooperate on the State level, 
of not trying to get it on the front end--if we had every DD-
214 assigned and put out, you would have a success rate like we 
have in Minnesota of 99 percent compliance, and you would have 
them identified. Maybe we wouldn't need bus stickers as much. 
Maybe we wouldn't need those types of things. We would have 
them identified, we would know who they are.
    My County Veterans Service Officers tell me this, and I 
tell you today--and I am going to find out, because I am not 
loose with facts, as you well know, Mr. Secretary. The front 
page of my hometown newspaper in Mankato today says, ``Standoff 
and Tragedy Averted; Iraqi War Veteran Takes Hostages.'' His 
complaint was he couldn't access the system.
    Now, I don't know if that is true or not. I don't know if 
he is even an Iraqi veteran. And I don't know if he tried to 
access the system, because wild claims have been made in the 
past that were not true about that.
    The VA does a wonderful job. They do a great job of caring 
for our veterans. We simply have improvements to be made.
    So my question is, why the resistance on allowing us to 
register the DD-214s? Why not allow us to make the necessary 
changes? I understand privacy, I understand the HIPAA 
regulations. But why, in this case, when the least we could do 
is at least say, you have a veteran living here and you need to 
at least make contact with him.
    I would like to see, and I will find out, if this young man 
was ever talked to, or why he slipped through the cracks.
    [The following was subsequently received from VA:]

    DoD controls form DD-214, Certificate of Release or Discharge from 
Active Duty. The military service mails Copy 3 of the DD-214 to VA. If 
a military member elects to do so and specifies a State, Copy 6 of the 
DD-2314 is sent to the State Director of Veterans Affairs. We have 
provided your staff with a point of contact at DoD (Lori Howes, 703-
697-4491; [email protected]).
    State Benefits Seamless Transition Program (for seriously injured): 
Currently forty-three states, including Minnesota, participate in the 
State Benefits Seamless Transition Program. To date, 350 veterans have 
signed the consent form authorizing VA to notify their local State 
Department of Veterans Affairs of their return to their home state.
    The initiative involves VA staff located at the following 
Department of Defense medical facilities:

      Walter Reed Army Medical Center, Washington DC
      National Naval Medical Center, Bethesda
      Brooke Army Medical Center, San Antonio, TX
      Darnall Army Medical Center, Ft. Hood, TX
      Madigan Army Medical Center, Puget Sounds, WA
      Eisenhower Army Medical Center, Augusta, GA
      Evans Army Community Hospital, Ft. Carson, CO
      Naval Medical Center, San Diego, CA
      Womack Army Medical Center, Ft. Bragg, NC
      Naval Hospital, Camp Pendleton, CA
      Naval Hospital, Camp Lejeune, NC

    Under the program, wounded veterans returning to their home States 
can elect to be contacted by their local State Department of Veterans 
Affairs about State benefits available to them and their families. VHA 
Liaisons for Healthcare identify injured military members who will be 
transferred to VA facilities, inform them about the program, and obtain 
a signed consent form from veterans electing to participate. The State 
offices, in turn, contact the veterans to inform them of available 
State benefits.
    In order to participate in the program, State Departments of 
Veterans Affairs must provide a point of contact and dedicate a fax 
machine in a private, locked office to receive the release of 
information forms. VA asked States to participate in the program in 
February 2007 when it was expanded beyond the Florida pilot program.
    Transition for non-seriously injured: In order to ensure that OIF/
OEF combat veterans receive high quality healthcare and coordinated VA 
services and benefits as they transition from the DoD system to VA, VA 
and the National Guard developed a creative partnership. Late in 2005, 
following the signing of a MOU between the National Guard and VA, the 
National Guard (NG) hired 54 (now 60) National Guard Transition 
Assistance Advisors (TAAs) to serve as VA/NG Liaisons in the field at 
the State level to assist NG servicemembers and their families and 
provide access to VA benefits and services. In February 2006, the newly 
hired National Guard/VA TAAs were trained by VA faculty experts about 
VA benefits and services at the VBA Academy in Baltimore. The purpose 
of the training was to enhance the outreach skills of the TAAs by 
learning about VA benefits and services and to connect them with VA 
resources and staff members in the field at the VA Medical Center 
(VAMC) and the Regional Office (RO). This new knowledge assisted them 
to help Guard members to access VA medical and benefits and address 
access issues in the 54 States and territories for returning Guard/
Reserve members. Annual refresher training was held in January 2007 and 
2008 in conjunction with the National Guard Family Program Conference. 
The TAAs have been the critical link in facilitating access to VA by 
National Guard/Reserves returning combat troops in each of the 50 
States and 4 territories of Puerto Rico, Virgin Islands, Guam and 
District of Columbia and providing VA with critical information on 
numbers of returning troops, location, homecoming and reintegration 
events. TAAs also facilitate enrollment into VHA care for returning 
troops and families.
    The TAA program continues to be a funded National Guard Program and 
is presently expanding this program with a goal of 2 TAAs per each 
State with large number of deployed troops. VHA OEF/OIF Outreach Office 
staff continues to be linked with the 60 TAAs by providing access and 
collaboration at monthly teleconferences, quarterly newsletters, and 
monthly identification of success stories and best practices in the 
States. Outreach staff work with VA experts at annual training events 
to ensure they are updated on changes in VA services/benefits. TAAs 
facilitate the development and maintenance of State coalitions 
utilizing the State Triad Leadership of the Adjutant General, State 
Director of Veterans Affairs (DVA) and VA leadership to integrate and 
coordinate the delivery of VA services and benefits to those Guard and 
Reservists in each State when providing needed outreach programs. Over 
47 States have developed State Memorandum of Understandings (MOUs) 
through the Leadership Triad of the State Director VA, Adjutant General 
and VA Leadership from the VISN, VAMC and RO. These State partnerships 
are the foundation for State coalitions with participation by community 
and State organizations to address the coming home needs of the Guard 
and the Reserve members.
    Outreach: On May 2, 2008, VA began contacting nearly 570,000 combat 
veterans of the Global War on Terror to ensure they know about VA 
medical services and other benefits. The Department will reach out and 
touch every veteran of the war to let them know it is here for them. 
The first of those calls are going to an estimated 17,000 veterans who 
were sick or injured while serving in Iraq or Afghanistan. If any of 
these 17,000 veterans do not now have a care manager to work with them 
to ensure they get appropriate healthcare, VA will offer to appoint one 
for them.

    Mr. Buyer. Will the gentleman yield?
    Mr. Walz. Yes.
    Mr. Buyer. Mr. Walz, when you referred to ``the plan,'' 
``why aren't you implementing the plan,'' were you referring to 
the Mental Health Strategic Plan?
    Mr. Walz. Yes. And the Ranking Member has brought up a 
great point on this. In the IG's report of May 2007, we have 
never heard where you are at on that or what the timeline is or 
where you are going with that. And, as I referenced earlier, I 
would like to have seen that put into place before our troops 
landed in Iraq. But that being the case, I am most concerned 
that it actually gets done now, and I am wondering where it is 
at.
    So I thank you.
    Secretary Peake. I think that it is absolutely the right 
thing to ask for both things, in terms of getting our returning 
servicemembers into our system is what we want to get done. And 
I will circle back and work with you.
    I would like to apologize to you and to Mr. Mitchell for 
what may seem like recalcitrance. I have seen your letter, sir. 
I tried to call you last night, actually, because I wanted to 
get some clarification. I think I have some things for you. But 
I am interested in increasing the transparency of the VA. And, 
as I said, we are America's VA, and our intent is to be 
forthcoming. If we have something to hide, we shouldn't be 
hiding it, we should be doing something about it. So I will 
just put that on the table.
    In terms of the Mental Health Strategic Plan, actually, 
when I looked at the IG report, it looks like we are moving 
ahead. I mean, it is a complicated and a big plan. And maybe I 
can come back, for the record, to give you the specific metrics 
about each one of the milestones. But I do know that we are 
moving forward on it. And, as I say, the complexity of it is 
such that I can't give you a clear summary of it right now. But 
I have looked at it. I have had that same discussion with Dr. 
Kussman and Dr. Katz. It was one of the first things that I 
asked him to brief me on, was the strategic plan.
    It has lots of pieces. I will tell you that, like any plan, 
it never survives first contact with the enemy. So we don't 
want to be just resting on our laurels that we have a plan and 
that it is moving along, but that it is continuing to be 
relevant to the needs of our servicemen and women that are 
returning as veterans. And that includes finding these issues, 
if you have a younger group that we need to refocus some of our 
efforts and our resources on.
    And I will just tell you that we will continue to be 
vigilant and look for the issues so that we become more 
proactive rather than just reactive.
    Mr. Buyer. Will the gentleman yield?
    When the Secretary answers that question--Mr. Secretary, I 
think you will be helpful to us if you will also take the plan 
and compare to it HHS, and the National Strategy for Suicide 
Prevention. So when you do the comparability between the two 
agencies, it will become helpful to us.
    Mr. Walz, you asked a great question. And I yield back.
    [The following was subsequently received from the VA:]

    The Comprehensive VHA Mental Health Strategic Plan, which describes 
initiatives and current status, appears on p. 142. A crosswalk between 
the U.S. National Strategy for Suicide Prevention, the VHA 
Comprehensive Mental Health Strategic Plan and VHA's Suicide Prevention 
Actions comparing the three programs, also appears on p. 188.

[GRAPHIC] [TIFF OMITTED] 43052A.001

    Mr. Walz. Well, I thank you, Mr. Secretary. And I think 
today, again, we can't make it any clearer that this Committee 
is here to serve our veterans. And I represent the Mayo Clinic 
area, and their mantra is: What is good for the patient is 
good. What is good for our veterans is good. And whatever we 
can do to deliver that, we are here as partners for that.
    I know it is a difficult job you have taken. I know much of 
this has happened before you were at the helm. Many of us are 
very, very optimistic that you are the man to do it. Anything 
unfortunate needs to be swept and cleaned and put out in the 
public eye and let sunshine heal it and get moving forward.
    So, thank you.
    The Chairman. Mr. Mitchell.
    Mr. Mitchell. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being here.
    I mentioned in my opening statement about the testimony at 
the December hearing of Mr. and Mrs. Bowman, Mike and Kim 
Bowman, who lost their son to suicide. Mr. Bowman, at that 
hearing, warned us--and I want to quote this--that, ``Our 
troops are coming home to an understaffed, underfunded, 
underequipped VA mental health system.''
    So, as a result of that, I asked the question to Dr. Katz, 
do we have the resources necessary to find these veterans and 
to treat these veterans, and the answer was yes. I said, do you 
have, again, enough resources, and the answer was yes.
    As you know, I have been trying to assess what kind of 
additional resources your Department may need in order to make 
sure that we can provide these resources. We need to make sure 
that we conduct an outreach to veterans who are at risk of 
suicide, to treat veterans who are at risk of suicide, to track 
veterans who commit suicide. We need that information.
    In light of what CBS News reported--in fact, it is 
important that in Arizona--and I don't know if Arizona is one 
of the 16 States listed on this chart that you had, but the 
suicide rates among veterans in Arizona has increased 39 
percent since 2003. They make up nearly a quarter of all 
suicides in the State. So I thought I had a responsibility to 
go and double-check to see if you do have all the resources 
necessary.
    In my last letter that was sent to your office on April 
24th I asked, ``To review documents relating to requests for 
additional resources within the Department that were denied, 
unanswered or responded to with less than the amount of 
additional resources requested.''
    I think it is important that we know if you are being 
provided with enough resources to make sure that the VA is not 
understaffed, not underfunded, not underequipped. That is what 
our goal is here.
    So I want to ask you three questions in response to this.
    First of all, do you feel that, ``Go file a Freedom of 
Information Act,'' is an appropriate response to a Member of 
this Committee seeking additional information about testimony 
offered by the VA at one of our hearings?
    The next question, do you think there is something 
inappropriate about the Chairman of the Oversight and 
Investigations Subcommittee to ask to review records kept by 
the Department about an issue that has been the subject of one 
of our hearings?
    And, finally, will you be producing the documents I 
requested by Friday?
    Secretary Peake. First, I am saddened to hear that somebody 
would tell you to go file a Freedom of Information Act. I don't 
know where that came from. I will tell you that I don't think 
it is appropriate. The issue is--actually, you could file that. 
I mean, this is information you would be given.
    If there is a concern about or a question about what you 
are asking for, I owe you a phone call, which is what I tried 
to do last night, to say I am not sure what you are really 
after and I want to make sure we have it. I think we ought to 
give you that information, because I agree with you that we 
share the same goal, in terms of helping veterans.
    So, as I say, I will close the loop back with you before 
Friday to give you what I think that you are asking for.
    Mr. Mitchell. Well, and let me just repeat, Mr. Secretary. 
I asked for any documents relating to a request for additional 
resources within the Department that were denied, unanswered, 
or responded to with less than the amount of additional 
resources requested.
    What we are trying to find out is, you know, we want to 
make sure that you are funded right, you are staffed right, you 
have the equipment. We can't do that unless--and there may be 
somebody, and I want you to be absolutely certain, that, yes, 
there was somebody in Montana, or wherever they may be, who 
asked for something and we said we didn't have the resources or 
we gave them less than they needed.
    We just need to know what it is that we can do to make sure 
that our veterans are coming back and getting everything that 
they deserve and were promised.
    Thank you.
    [Congressman Mitchell received the information.]
    Secretary Peake. Thank you, sir.
    The Chairman. Dr. Snyder.
    Dr. Snyder. Thank you, Mr. Chairman.
    Good to see you again, General Peake. I appreciate you 
being here.
    Dr. Katz, I want to be a bit of an advocate for you, at 
least a little bit, because I want to be sure I understand. In 
the first--well, Mr. Chairman, I think Mr. Buyer brought this 
out, too--that one point of attack on you has been today that, 
in this exchange of e-mails in which Dr. Kussman sends you an 
e-mail back in December that says, the McClatchy newspaper 
article says these statistics, and you confirm those 
statistics. But, in fact, two or three days before, you had 
given those same numbers here. I mean, it is in the transcript.
    So, while there are a lot of reasons to be critical, I 
think, of those e-mails referring to ``Shh,'' you know, that 
kind of business, that was not what happened back in December. 
Is that correct? I mean, you gave those exact same numbers that 
you confirmed to Dr. Kussman. You did it here at the hearing, 
and then you did it--it was in response to Mr. Mitchell's 
question.
    Dr. Katz. Yes, sir.
    Dr. Snyder. The second thing is, with regard to the facts 
in the second set of e-mails, the one that you have apologized 
for in terms of the subject line, in fact, you instigated an e-
mail going to your communications person that says, we are now 
identifying 1,000 suicide attempts per month, and you're asking 
the question, essentially, ``Is this something we need to 
release after we sort it out?''
    But what you all are saying, I think, today, if I am 
hearing you right, is you think that 1,000 number is a pretty 
loosey-goosey number. There is a lot of variation of reporting 
that you are trying to nail down.
    Is that a fair statement, Secretary Peake.
    Secretary Peake. Yes, sir, I do. And we are concerned that 
it is underreporting, probably.
    Dr. Snyder. Maybe underreporting.
    So your conversation, there, Dr. Katz, is an effort to say, 
we have some new information but it may not be accurate yet. 
But you are, in fact, instigating an inquiry about, should we 
be releasing this. And I can understand that.
    Where I would part company, I think, with you on this, Dr. 
Katz, is--and, Secretary Peake, you may want to address this, 
because, in response to somebody's question, you talked about 
how you want to have increased transparency. I have never 
trusted the press operations coming out of, I guess I have to 
say, this administration. And it appears to me you got bad 
advice. Here you, Dr. Katz, are saying, ``We have new 
information. We think it needs to get out there.'' You didn't 
write it very artfully. ``We think it needs to get out there, 
because this is a small town and people have a way of stumbling 
on stuff.'' And your press office comes back and says, ``Oh, 
no, let's figure out how to spin it.'' I mean, that is what 
that response is. Is this the fact--we are stopping them. 
Somebody is trying to get you to spin it. In fact, what you are 
trying to do is, ``We have new information; let's get it out 
there.''
    And my advice is you have a communications department. You 
ought to figure out what you want to communicate, and then 
communicate it. Tell them, ``Here, get this information out 
there.'' But don't let people tell you how to spin information 
that you think is new. I don't think you are well-served.
    Dr. Katz. Sir, could I respond?
    Dr. Snyder. Go ahead and respond.
    Dr. Katz. The e-mail was only part of the communication.
    Dr. Snyder. Oh, I am sure that is right. Every one of us 
have bad e-mails----
    Dr. Katz. The other part of the communication from VHA's 
senior leadership was, make sure everything is done to address 
the increased risk in these thousand people a month.
    The Chairman. Was that response in writing?
    Dr. Katz. No, it was in conversation.
    Dr. Snyder. A specific question I wanted to ask, Secretary 
Peake, is one of the folks on the second panel suggests that, 
because of the way some of the CBOCs are set up, that people 
who are coming in for treatment may be getting psychotherapy 
and counseling but not an appropriate level of antidepressants 
and pharmacological therapy.
    Do you agree with that? Is that a concern that you have 
had?
    Secretary Peake. I really don't have data to address that, 
but I would take a look at it.
    [The following was subsequently received from the VA:]

    No. To promote a consistent and portable prescription benefit, VA 
uses a single National Formulary (VANF) at all points of service, 
including CBOCs. The VANF provides access to a very broad array of 
medications used to treat mental health conditions and with few 
exceptions, these medications are available to CBOC mental health 
providers. If a CBOC mental health provider is not licensed to 
prescribe medications (ie., Licensed Clinical Social Worker or 
Psychologist), the CBOC primary care provider can prescribe them and if 
necessary, he or she has remote access to a VA Psychiatrist for mental 
health medication consultation.
    At present, of CBOCs serving more than 1,500 unique patients, 452 
(97%) have a meaningful mental health presence as defined by having at 
least 10% of the total number of visits coded as mental health visits.
    For those serving less than 1500 unique veterans, mental health 
visits represent at least 10% of the total visits in 109 (58%) CBOCs.* 
In other facilities, mental health services are provided by primary 
care clinicians, or they are available by referral. The major 
difference between mental health services in medical centers or CBOCs 
is not the presence or absence of general mental healthcare, but 
difficulties in making specialty mental health services available in 
CBOCs, especially smaller and more rural ones. Historically, VA's 
approach to this has been to refer patients when necessary to specialty 
mental health programs in VA or non-VA sites. However, over the past 
few years, there has been increasing use of telemental health 
technologies to provide these services. Currently, telemental health is 
available in 196 (40%) of CBOCs serving more than 1,500 unique veterans 
and in 48 (21%) of smaller ones.**
    Vet Centers will refer veterans to the local VAMC for medical care 
and follow up of prescriptions if needed. In the mental health mental 
status evaluation, any indicators of need for medical psychiatric or 
primary care are automatically referred to the medical center. If 
veterans are on medications and have challenges in getting 
prescriptions filled, they are referred to the local VAMC or CBOC.

    *Data source is adapted from VSSC website, Past Performance 
Measures, Mental Health at CBOCs Performance Measure, FY 2008, Quarter 
1.
    **Telemental health data is from the Office of Care Coordination, 
March 08. All Telemental health visits are coded as MH visits and are 
not separated in the data base summary. These data include specific fee 
basis visits at some sites.

    Dr. Snyder. When you talk about the issue of trying to sort 
out veterans from active component--you may have addressed this 
with Mr. Walz--how are Reserve component members who come back 
from active duty and entitled to come to the VA for a period of 
time--are they counted as a veteran or an active component?
    Secretary Peake. Sir, we count them as veterans.
    Dr. Snyder. As veterans.
    Secretary Peake. Yes, sir. They do have DD-214s that they 
have then demobilized.
    Dr. Snyder. Well, I appreciate you being here.
    I think a lot of this could have been avoided, Dr. Katz, 
by, as you pointed out, some more artfully written e-mails. 
Because we are all here in the spirit of trying to solve these 
problems. And unfortunately, you take snippets of this, and it 
does not provide a very good picture of what was going on at 
the time. It appears to be a department under siege.
    And I don't think that has ever been your style 
professionally, Secretary Peake. I think you are one of the 
ones to solve problems. You may want to address that with your 
communications department and let them work for you rather than 
vice versa.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Snyder.
    Mr. McNerney, any questions?
    Mr. McNerney. Thank you, Mr. Chairman.
    Dr. Katz, last November you attacked a CBS News report 
which claimed that there were 6,200 suicides in 2005 among 
those who had served in the U.S. military, by saying, and I 
quote, ``Their number is not, in fact, an accurate reflection 
of the rate.'' But then, just 3 days later, you wrote an e-mail 
admitting there were about 18 suicides per day among America's 
25 million veterans. That is about 6,570 a year.
    Did you intentionally withhold information from CBS News?
    Dr. Katz. From CBS News?
    Mr. McNerney. Well, you attacked the CBS News report, and 
then you admitted that their numbers were not only right but 
they were low. And then you didn't----
    Dr. Katz. I was concerned about their findings with respect 
to very young veterans, not the entire veteran population.
    Mr. McNerney. So was information withheld at that point?
    Dr. Katz. Sir, I was not asked for information from CBS 
News. I was merely asked to react to their information. I was 
given a piece of paper, and it had ratios of veteran and non-
veteran suicides, and asked if I was shocked by that. I was not 
shocked by the overall number of veteran suicides, and I think 
their four-to-one ratio for the youngest of veterans may not 
hold up. You saw a different ratio earlier.
    If you are interested in whether there is an epidemic 
related to the war, you would also want to see what the rates 
were before the war. CBS News never addressed that. I have 
concerns about the CBS News report. Those concerns were what I 
have been referring to. I have never had concern about their 
overall estimate for numbers of veteran suicides.
    Mr. McNerney. After the VA provided CBS News with the 790 
number as the annual number of veteran suicide attempts, you 
wrote an e-mail to your media advisor again, because you were 
concerned that there might be as high as 12,000 per year, is 
that correct?
    Dr. Katz. Sir, it may be even higher than that, in terms of 
suicide attempts. And we could speak to that.
    As I recall, the number 790 came from information sent to 
CBS News when they asked for information about attempts or 
completed suicides from the medical records. And from that 
information, they extracted the number 790 as the count of 
attempted suicides or deaths from suicide in 2005.
    The estimate of a thousand a month came from the 
tabulations done by the suicide-prevention coordinators, which, 
because it was information and methods under development, were 
not yet in the medical records.
    Mr. McNerney. Well, in the same e-mail, you question 
whether or not you should release the information before 
someone else stumbles upon it. So it seems to me that 
information on suicide statistics was either withheld or wrong 
numbers were released.
    My real concern here is that that would have prevented 
procedures that could have saved precious lives, lives of young 
soldiers who served our country and depended on us to help them 
when they needed it.
    How can you assure this Committee that that behavior 
doesn't constitute wanton disregard of your duties and 
responsibilities and that that will change and that we will see 
procedures put in place that will prevent this?
    Secretary Peake. Sir, let me try to address that.
    First of all, I would tell you, as I tried to comment in my 
opening remarks, that the numbers are important for trending 
and all of those kinds of things. What is important is making 
sure that we are doing the kinds of things that we are doing to 
try to intervene in this, what we know, is a high risk group, 
those with suicide attempts, to intervene with that younger age 
group that we demonstrated have a higher level of suicide risk. 
And, you know, that is full bore out, to try to work those 
issues.
    Trying to get the right numbers and making sure that we 
give valid numbers is important, and I think that we owe 
appropriate, validated numbers to this Committee and to people 
that ask for that information.
    So I can't tell you more, except to say that we are 
absolutely committed to trying to do the right thing by all of 
our servicemembers, our veterans, and not worry as much about 
whether this is a little above or a little below some national 
average, but to focus on doing the clinical right thing.
    Mr. McNerney. Mr. Secretary, the Joshua Omvig Suicide 
Prevention Act requires that you submit recommendations for 
further legislation and administrative action that the 
Secretary considers appropriate to improve suicide-prevention 
programs within the Department of the Veterans Affairs.
    Do you have recommendations for us today, or do you have 
recommendations in general to meet the requirements of that 
act?
    Secretary Peake. Sir, I don't have those to present to you 
today. But, as that may be required by the act, I will provide 
those.
    [The following was subsequently received from the VA:]

    The Comprehensive Program for Suicide Prevention Among Veterans 
report for P.L. 110-110 was submitted to Congress in February 2008 and 
is attached for your review. In the report we stated that we are able 
to monitor risk and needs and respond to them under existing legal 
authority. VA did not recommend further legislative action and remains 
with this position. Since the report was released, VA has the following 
updated information:
    Requirement: Designation of Suicide Prevention Counselors--To 
support the identification of patients at high risk, the Suicide 
Prevention Coordinators have been integrating information from 
providers, other staff, and community contacts about veterans who have 
survived suicide attempts. In preliminary findings, we have identified 
approximately a thousand attempts per month. To address the increased 
needs for these vulnerable veterans, VA has implemented standardized 
approaches to enhancing care while, at the same time, encouraging 
innovation and creativity.
    Further developments in process at this time include tests of the 
Coordinators inter-rater reliability and their sensitivity in the 
identification of suicide attempts. Both will be necessary before the 
number of attempts (or reattempts) in a facility can be used as a 
measure for epidemiological or quality improvement purposes.
    Requirement: Hotline--From the time the veterans' Hotline was 
established in July, 2007 until the end of April, 2008, we received 
43,294 calls. From the start of 2008 until the end of April we received 
33,915 calls, with 16,414 confirmed as coming from veterans and 2,125 
from family members or friends. These led to 2,725 referrals to the 
Suicide Prevention Coordinators at VA facilities and 746 ``rescues'' 
requiring emergency services.
    The ``Report to Congress for Public Law 110-110, Comprehensive 
Program for Suicide Prevention Among Veterans,'' dated February 2008, 
appears as an attachment to the response to Ms. Berkley's Post-Hearing 
Questions for the Record, which appears on p. 240.

    Mr. McNerney. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Ms. Brown.
    Ms. Brown of Florida. Thank you.
    Mr. Secretary, a couple of quick questions.
    One, we have talked a lot today about the veterans. And I 
mentioned the families earlier. What are we doing to work with 
the families, the outreach to prevent suicide?
    Secretary Peake. Well, first of all, within our Vet 
Centers, they can do family counseling, and we really encourage 
that. When a servicemember is within our care, providing 
counseling to the family member is deemed part of that care, 
that we can provide that kind of counseling as well.
    As I was talking with Mr. Hare, one of the things I would 
like to find a way to do is to reach out and touch family 
members in a more specific way. So, as we go to the TAP 
briefings, you know, it is possible to have family members 
there, but, in all honesty, we are not seeing them available.
    I think that what the Ranking Member brought up, in terms 
of being able to participate in those kinds of events, are 
things that we need to expand on. But I think it is an area 
that we need to come up with an action plan. And I will be 
happy to do that and report back to this Committee on that 
action plan.
    [The following was subsequently received from VA:]

    The Secretary has asked that assistance to families be a VA 
priority. Since 1979, the Vet Center program has been authorized to 
provide family services as it relates to the readjustment of the 
veteran. When an individual is reactivated, they shift from veteran 
status to active military status. The servicemember and dependents then 
revert to Department of Defense protocol. Once they complete their tour 
and demobilize, they are once again veterans and they and their family 
members are eligible for Vet Center services.
    In FY 2007, Readjustment Counseling Service provided 1,055,186 
visits to 164,228 total veterans. Cumulatively since the beginning of 
the War, Readjustment Counseling Service has provided services to 
288,594 OEF/OIF veterans (through 1st Quarter FY 2008). 216,172 were 
provided outreach services and 72,422 received readjustment counseling 
in the Vet Center.
    Cumulatively, since 2003, (bereavement counseling authorization) 
Readjustment Counseling Service has provided bereavement services to 
the families of 1,238 fallen servicemembers, 876 of which were in 
theater casualties in Iraq and Afghanistan.

    Ms. Brown of Florida. The other thing is the women--I am 
very concerned that women veterans are one of the fastest-
growing groups and one of the most underserved groups. Have you 
thought about having a task force just for women vets and 
trying to come up with how we can be more supportive and what 
we can do just targeting that group?
    Not to take anything away from veterans in general, but I 
think women are unique and they have unique needs. And in a lot 
of our VA centers, their needs have not been addressed.
    Secretary Peake. You know, ma'am, I have not only a Federal 
Advisory Committee Act (FACA) that looks at those kind of 
issues for women, but also an office that focuses on women's 
issues, with Dr. Irene Trowell-Harris as my lead.
    We continue to ask this issue every time we get into it: 
Now, are we taking care of the women veterans? Because, in 
fact, we have been historically a male service organization, in 
a way.
    Ms. Brown of Florida. It still is, sir.
    Secretary Peake. And I have been traveling a lot and, every 
time, have asked to see the women's health unit. I have been 
impressed with some of the things we are doing.
    But it is very important to understand that they want to be 
able to have a single portal where they can go in and get 
women's healthcare, primary care, and mental healthcare without 
being labeled. And so we are making sure that that is in there.
    But I think we must continue to monitor very closely and 
make sure that we have consistency across the whole VA when we 
do those kinds of programs.
    Ms. Brown of Florida. What can the Committee do 
legislatively to assist, to widen your scope?
    Secretary Peake. As we look at being able to provide access 
and assistance to a family member, there may be ways that we 
need to work together to find a road ahead there.
    If a spouse, as an example, is depressed with their 
servicemember or veteran spouse who may have a physical 
disability or mental disability or TBI or something like that, 
it would be nice to be able to ensure that they have the care 
to include medications, if that is necessary, to help them 
through that, even if for the short term. And so we are looking 
at ways to try to get that kind of an authority.
    Ms. Brown of Florida. You mentioned the Vet Centers, and I 
do think it is a great delivery service. But, in some cases, 
they have been cut or underfunded. Maybe we can think about how 
we can rev up those Centers. Because it is going to be 
comprehensive. It is going to be jobs, it is going to be 
healthcare, it is a whole list of things. A lot of these 
veterans come back, their jobs are no longer there. So it is 
comprehensive.
    Secretary Peake. Yes, ma'am. To my knowledge, we have not 
had--I mean, I have asked specifically, and I am told that we 
have not cut Vet Centers, and we are funding them as they have 
requested. I will go back and check on that.
    I do agree with you about the jobs issue. And, frankly, you 
have young men and women who have gone overseas and have done 
something that they feel in their life is really meaningful, 
and they don't necessarily want to go back to that old job that 
they had before. We do need to increase our efforts in that 
regard, as well.
    [The following was subsequently received from VA:]

    Vet Centers are fully funded. Their funding levels:

      2004 $87 million (206 Vet Centers)
      2005 $94 million (207 Vet Centers)
      2006 $100 million (209 Vet Centers)
      2007 $113 million (215 Vet Centers)
      2008 $153 million (232 Vet Centers)

    The FY 2008 budget represents a 50% increase from 2006 through 
2008.
    Vet Centers provide individual and group counseling, marital and 
family counseling for combat service related issues, military sexual 
trauma counseling and referral, bereavement counseling for the families 
of fallen servicemembers who die while on active duty, demobilization 
outreach and direct service, substance abuse assessment and referral, 
employment services, Veterans Health Administration and Veterans 
Benefits Administration referral, and veteran community outreach and 
education.
    Twenty-two new Vet Centers have been approved.

    Ms. Brown of Florida. Well, thank you.
    And thank you, Mr. Chairman. I yield back the rest of my 
time.
    The Chairman. I am trying to decide if there are additional 
questions. Do you want the Secretary to be back, Mr. Boozman, 
Mr. Lamborn, Mr. Kennedy? We have three votes. Do you want to 
talk to the Secretary when we return?
    Mr. Lamborn. I don't need to.
    The Chairman. We will get to Mr. Kennedy when we return.
    And I hope you will respond to these general questions, 
Secretary Peake. A half-dozen Members of Congress asked you 
very specifically, what do you want us to do, how can we help? 
You didn't ask us for one thing, one piece of legislation, one 
dollar of funds. Who is better at outreach than we are? That is 
our job. Have you ever asked a Member of Congress to help on 
the outreach? Nobody has ever asked me.
    We know the people. We talk to the people. We are in touch 
with them every day. Otherwise, we wouldn't be here. Use us. 
But you never mentioned one thing you wanted us to do.
    Second, although I guess Dr. Katz is a doctor and not a 
lawyer, your rhetoric still bothers me, and I am not sure you 
are performing your job in an effective way, given the 
unfortunate e-mails.
    But in answer to one question, Dr. Katz, you said, ``CBS 
News asked me for medical records.'' Why don't you say, ``Here 
are the medical records.'' But if you really wanted to get that 
information, you should ask for the number of attempts that our 
coordinators are coming up with.
    You are not very helpful in transparency--you are not 
helping. You are supposed to be the expert. If we are not 
asking the right questions, if the press is not asking the 
right questions, help us ask the right questions. You are just 
sitting there with all this data, ``Well, he asked for this; I 
will give him this,'' or, ``I am not sure that is accurate, so 
we won't give him that.''
    The data is only important to reflect--it is a symptom of a 
major problem with our current veterans and previous veterans. 
The problem is inadequate mental health treatment. Suicide is 
the ultimate symptom--the tragic symptom--but PTSD is a 
symptom, homicides are a symptom, homelessness is a symptom, 
marital difficulties are a symptom, domestic violence is a 
symptom. We have to be focused on all the symptoms and we are 
not doing the job.
    I don't care what data you have, or what programs you are 
starting; if you have a thousand--and you said it could be more 
suicide attempts per month, we have some real difficult issues. 
And you never asked us for anything to help you deal with it. 
It is as if you have it under control. You don't have it under 
control.
    I talked to you, as I said, in our first conversation, 
Secretary Peake. I said the one thing that is the most 
important, that is missing from the mental health problem, is a 
mandatory evaluation by competent medical personnel. I said I 
had the concept of a Heroes Homecoming Camp that I thought we 
could use. It was never followed up on.
    We are letting tens of thousands of young men and women out 
of the service, out of the National Guard, without adequate 
diagnosis. You keep saying, well, everybody that comes to us, 
we screen.
    Is that screen, by the way, just a questionnaire, or is 
that an hour interview with a psychiatrist? How do you screen? 
You said it several times today. How do we screen?
    Secretary Peake. It is a reminder to the primary care 
physician to ask specific questions and to create the dialogue 
with the patient. It is not an hour-long diagnostic session 
with a psychiatrist.
    The Chairman. So we don't adequately diagnosis anybody, 
unless they ask for it? Then we have to make that mandatory for 
every young man and woman who leaves combat so there is no 
stigma. I suggest that you do it in cooperation as part of 
their active duty service with the Army, Marines, et cetera, 
with their family there, and with their company of soldiers 
there. Let's get everybody the support system they need and get 
that mandatory diagnosis.
    If they are coming in, psychiatrists tell me and people 
have testified to us, that you need competent medical 
personnel--and there is minimally adequate treatment here that 
the VA is not giving. We are not giving adequate diagnosis or 
treatment to these hundreds of thousands of young people who 
are getting out. That is the problem.
    Until you tell us what you need to solve the problem, all 
this data is meaningless. The data is only, as you said, a way 
to understand the issue. But we have to get to the issue.
    We have these kids in active duty. All I have to do is say, 
visit the psychiatrist. This is not a hard thing to do.
    Mr. Kennedy.
    Mr. Kennedy. The evidence is so clear, and adherence to 
medical advice averts hospitalizations over and over and over 
again. And the same thing adheres to behavioral medicine and 
mental health.
    If we had people who called back and stayed on top of these 
soldiers after they got out of the military and stayed in touch 
with them with care management--not just the ones that were 
grievously injured, as you pointed, that are at high risk for 
suicide, but all the soldiers. Because we want to stay in touch 
with the ones that are at modest risk, because we don't know 
which ones may have had an exposure to trauma. Or the trauma 
that they were exposed to they might not have the resiliency to 
that that other soldiers had.
    And so if we stayed in touch with all of them, and that is 
not a huge expense, because we don't want them to become the 
severe cases later on. So this is an investment in prevention 
for us. So if we stayed in touch with all of them, that is an 
investment in keeping them out of the hospital, and prevention.
    We can put this in place as a preventive measure and employ 
these new technologies in keeping in touch and preventive 
medicine. And I think that is one of the recommendations in 
prevention you ought to put forward.
    The Chairman. Mr. Kennedy, I thank you for your leadership 
and being a part of this.
    I will make it real simple, Secretary Peake. Get us a plan 
with the Secretary of Defense and the VA to evaluate--not 
screen, not quiz, not give self-questionnaires--to diagnosis 
with competent medical personnel for every soldier for brain 
injury and for PTSD. We will make it that simple. You will 
bring down every single one of these figures. You will not have 
to start with ``Shh,'' ``Shh,'' ``Shh.'' We will come to grips 
with this. Come back with a plan, which I already gave to you, 
in a week or two. I will bet you that every single issue we 
talked about today comes under control.
    Mr. Secretary, you have been generous with your time.
    We have three votes. We are going to come back in about 20 
minutes. The first panel is excused, and we will go to the 
second and third.
    [Recess.]
    The Chairman. Dr. Maris, thank you for joining us. The 
other Members of the Committee will be following.
    I know you have to catch a plane. I would like to introduce 
you as a Distinguished Professor Emeritus at the University of 
South Carolina, past director of the Suicide Center at the 
University of South Carolina, and you have an extensive 
background in research on suicidal behaviors.
    I believe you will testify as to the problem of suicide 
among veterans, whether or not it is an epidemic, and what you 
think the VA is doing about it.
    Let me thank you for taking the time to be here with us.

   STATEMENTS OF RONALD WILLIAM MARIS, PH.D., DISTINGUISHED 
 PROFESSOR EMERITUS, PAST DIRECTOR OF SUICIDE CENTER, ADJUNCT 
   PROFESSOR OF PSYCHIATRY, AND ADJUNCT PROFESSOR OF FAMILY 
  MEDICINE, UNIVERSITY OF SOUTH CAROLINA, SCHOOL OF MEDICINE, 
   COLUMBIA, SC; STEPHEN L. RATHBUN, PH.D., INTERIM HEAD AND 
      ASSOCIATE PROFESSOR OF BIOSTATISTICS, DEPARTMENT OF 
EPIDEMIOLOGY AND BIOSTATISTICS, UNIVERSITY OF GEORGIA, ATHENS, 
   GA; AND M. DAVID RUDD, PH.D., ABPP, PROFESSOR AND CHAIR, 
  DEPARTMENT OF PSYCHOLOGY, TEXAS TECH UNIVERSITY, LUBBOCK, TX

            STATEMENT OF RONALD WILLIAM MARIS, PH.D.

    Dr. Maris. Thank you, Mr. Chairman, Committee Members, 
ladies and gentlemen.
    Just for the record, I was a plaintiff expert in the Vets 
v. Peake trial in San Francisco. So I am coming at this partly 
with a plaintiff perspective.
    In my written report, I want to highlight that suicide is 
more than one outcome; it is a multidimensional outcome. And 
for the Committee's sake, I would hope they would look not just 
at completed suicides, but suicide attempts and other kinds of 
collateral damage, partially self-destructive behaviors, 
depression, alcohol, domestic violence, PTSD.
    Secondly, I have also identified some risk factors, and I 
list those in my written report, starting off, of course, with 
depression and affective disorders, alcohol and substance 
abuse. My point is that I think all these 15 risk factors that 
have been shown to be related to suicide outcomes ought to be 
asked of all vets. And I will come back to that in just a 
minute. What the VA does is they ask two simple questions; they 
don't ask all the risk factors for everybody.
    I was asked whether or not we could talk about what causes 
veteran suicide. And I want to say that part of the problem is 
the Department of Veterans Affairs has not provided me or the 
courts with crucial data that are needed. Every time there is a 
military death, suicide attempt or serious incident, the VA 
produces something called an incident brief, which summarily 
decides the suicide or suicide attempt. Then, about 45 days 
later, each incident goes through what is called a root-cause 
analysis, and a three-page report is generated.
    When I was an expert in San Francisco in the Vets v. Peake 
trial, I was given only 170 of the somewhat estimated 15,000 
incident briefs and none of the root-cause analyses. My point 
being that such crucial documents would help clarify how many 
vet suicides there are and what the VA itself thinks causes 
them.
    One of the documents in that trial was a document by 
William Feeley, a Deputy Under Secretary for Health Care. And 
he said in his deposition, I quote, ``Suicide occurs like 
cancer.'' That is wrong. We all have to die, some by cancer, 
some by heart disease, but no one needs to suicide. It seemed 
to me that that comment suggested that the VA seems to think 
there are a certain number of vet suicide deaths that are 
inevitable and there is not a lot we can do about them.
    The VA has a number of suicide coordinators. Interestingly, 
I think the Committee should remember none of these suicide 
coordinators are in what they call their CBOCs, their 875 
outpatient clinics. They are all at the VA medical centers. So 
the vast majority of treatment is at these outpatient clinics, 
which I understand do not have suicide coordinators and do not 
have people who can write prescriptions for antidepressant 
medications.
    When they measure suicide risk in the VA, they have 
something called the suicide template, and that just has two 
simple questions. Those questions have to do with whether or 
not the patient felt hopeless, whether or not they felt 
depressed, and whether or not they were thinking about suicide. 
If you answer ``no'' to either of those two questions on the 
so-called suicide template, you are not asked any more 
questions, even though there are a number of other risk factors 
that I have outlined in the first part of my written report and 
that the VA itself actually states in their suicide template 
the vets do not get asked those important questions.
    So they are simply asking about self-reports of suicide 
ideation and hopelessness or depression. They don't even 
measure depression and hopelessness using standardized clinical 
scales like the Beck or the Hamilton scales. So I have some 
problems with how they measure these important variables and 
the kinds of questions that they ask.
    There is surprisingly little in the VA healthcare policies 
about treating depressive disorders psychopharmacologically. 
One of the backbones of the standard of care for suicidal 
depression is to get somebody diagnosed appropriately and, if 
they need it, to put them on some sort of psychopharmacological 
treatment. I am not sure why this is not a major part of the 
documents that I have read.
    There are serious questions about these suicide 
coordinators: Who are they? What do they do? Are they really 
trained as well as they claim they are trained?
    And then, finally, there are some questions about delays in 
treatment. To even get mental health treatment for 2 years, a 
vet has to fill out a 23-page application, which can be hard to 
do if you have PTSD, and then receive a disability rating from 
zero to 100 percent from a compensation and pension 
examination. If the disability is denied or too low, found not 
to be related to military service, then the appeal process can 
be long and drawn out and sometimes----
    The Chairman. Dr. Maris, I hate to interrupt you, and I 
apologize. There is another procedural vote that was just 
called and I have to run over and vote. I apologize again.
    We will recess for a few minutes and hopefully return right 
away.
    [Recess.]
    Mr. Hall [presiding]. The hearing will resume and come to 
order. We do have a couple of Members here, so there is a 
quorum. And I will, at the request of Counsel, sit in as 
Chairman until Chairman Filner returns.
    And, Dr. Maris, you were testifying. If you would be so 
kind as to----
    Dr. Maris. Yes, I have one sentence left.
    Mr. Hall. Is that all? Well, feel free to add one or two 
more if you would like.
    Dr. Maris. Defense expert Alan Berman in the Peake v. Vets 
trial testified that it could take up to 10 years for the 2007 
MHSP plan to be implemented. One wonders how many vets are 
going to die in the interim due to lack of assessment and 
intervention.
    [The prepared statement of Dr. Maris appears on p. 96.]
    Mr. Hall. Thank you, Dr. Maris.
    Dr. Rathbun, your statement has been entered in full into 
the record, and you are recognized for 5 minutes.

             STATEMENT OF STEPHEN L. RATHBUN, PH.D.

    Dr. Rathbun. Thank you, Mr. Substitute Chairman, I guess. 
The Chairman is out. I have never done this before, so you will 
have to excuse me if I am not quite on protocol.
    I got involved in this when Pia Malbran from CBS News 
contacted me last fall. I believe it was some time in August.
    The Chairman [presiding]. I apologize again for----
    Dr. Rathbun. Sure.
    The Chairman. I wonder, Dr. Maris, for the people who 
weren't here, if you could repeat the two points you made on 
the 15 risk factors versus two questions and CBOCs without 
suicide coordinators.
    Dr. Maris. Sure. The VA suicide risk assessment has 
something called a suicide template. They ask two questions to 
vets at any particular time, either at deployment or clinic 
visits. Those questions are: In the last 2 weeks, have you felt 
hopeless or depressed? Number two, in the last 2 weeks, have 
you thought about harming yourself?
    If the vet answers no, actually, to the second question, 
they are asked no more risk factors. And my point is that is 
way below the standard, to leave it at that. There are many 
reasons why somebody would not answer yes to those questions, 
many of which have been discussed earlier today: fear of career 
advancement, you know, kind of, being a tough guy. So that you 
need to ask all of those risk factors on their template or my 
15 risk factors on my written report of all vets.
    The CBOC question is that there is 154 VA medical centers; 
that is where the suicide coordinators are located. They also 
have most of their service delivered by the CBOCs, community-
based outpatient clinics. None of the suicide coordinators are 
in those 875 outpatient clinics.
    As I understand it, most of those outpatient clinics do not 
have licensed physicians who are capable of prescribing 
antidepressants. So it concerns me that the vast majority 
structurally of the treatment is being given at the outpatient 
clinics and that the suicide coordinators actually aren't even 
there.
    The Chairman. Thank you. I think those are two very 
important points for us to keep in mind.
    Dr. Stephen Rathbun is the Interim Head and Associate 
Professor of Biostatistics at the Department of Epidemiology 
and Biostatistics at the University of Georgia. Dr. Rathbun has 
performed statistical analysis of veteran suicide data for the 
CBS News and will talk about that analysis.
    I, again, apologize for breaking in on you.
    Dr. Rathbun. Okay. No problem. I will just start all over.
    It wasn't really made clear exactly what I should be 
talking about today, but I think I can go over a little bit of 
the history of how I came to do the data analysis and some of 
the results that I found.
    I was approached originally back in August by Pia Malbran 
from CBS News to assist them with the analysis of veteran 
suicide data. After being approached, I agreed to do so, 
essentially as a statistical consultant. I am a biostatistician 
and not an expert on veteran suicides. I consulted with her on 
the format that the data needed to come in, and she eventually 
did provide the data in that format.
    One of the important things when analyzing data of an 
observational nature, as these data are--these are not the 
results of experimental manipulations of study subjects--the 
statistical protocol should be specified in advance. So, prior 
to actually receiving the data, I determined what type of 
analysis should be carried out on the data. And in the interest 
of keeping things simple, which is usually a good idea, I tried 
to keep it the most straightforward analysis, standard data 
analysis as possible.
    What Pia actually asked me to do was estimate rates of 
veteran and non-veteran suicides over the general population 
and broken down by gender and age, among other things. And when 
making these estimates, it is important to adjust for the fact 
that veterans are not representative of the general population. 
Veterans tend to be more male, and their representation in 
different age groups are different according to, I suppose, how 
many, you know--what the current state of the world affairs 
are. Certainly, in World War II, there were a lot higher 
percentage of veterans than there are currently.
    So I carried out the analysis using standard statistical 
methods, and those analyses were reported on CBS News on 
November 13. And the general findings were that veteran 
suicides were about roughly double of the non-veteran suicides.
    The comparisons I am making here are veterans versus non-
veterans. The results that you saw earlier were veterans versus 
the general population. Since the general population includes 
veterans, that can have an impact of reducing the magnitude of 
the effects somewhat. So that can explain some of the 
differences between my results and the results that the 
Veterans Administration might be presenting.
    But, in general, the veterans had about double, roughly 
double, the suicide rates as the non-veterans. If you break it 
down by gender, you find a similar pattern of higher rates 
among males than females. And within both genders, you also 
have higher rates of suicides among veterans than non-veterans, 
roughly about double the rates of non-veterans in both genders.
    One of the things I was asked to look at was the breakdown 
by age. And in our story, we broke it down by 5-year age 
classes: 20 to 24, 25 to 29, and so on. And when looking at 
those ages, in this case gender-adjusted rates for each of the 
ages, the thing that stood out to me the most was the higher 
relative rate of veteran suicides among the 20- to 24-year-
olds. Here those rates were estimated between about 24 to 36 
per 100,000 veterans compared to about eight per 100,000 
nonveterans.
    Higher rates also can be found among the 40-year-olds, but 
the non-veterans in that group also have higher rates, so it is 
not quite as striking there.
    In the interest of brevity, I guess I can leave it up for 
questions right now.
    [The prepared statement of Dr. Rathbun appears on p. 102.]
    The Chairman. Let me just make sure I understand what you 
said. The charts that we saw earlier included the veterans back 
into the general population?
    Dr. Rathbun. Yeah, the figures were general population 
numbers.
    The Chairman. So that is a real distorting aspect?
    Dr. Rathbun. I don't know how much a distortion it is. I 
would have to have the actual numbers on the numbers of 
veterans in each of the age groups to get some idea of exactly 
how big an effect.
    The Chairman. But it could be?
    Dr. Rathbun. Some. I think it is only just the relative 
magnitude that would be affected. The general story, I think, 
will be the same.
    You might not get--if you had different ages--if you have 
in different age groups of our population differential veteran 
representation, then that can cause some pattern in the 
relative rates when comparing veterans to non-veterans, if you 
were to do that direct comparison instead.
    To defend what they did, however, I think the records, the 
national death records were very readily obtained from the CDC, 
I think it is where they come from. And it is the viable thing 
to do, but you really have to understand what is going on with 
those numbers. And it can be a little bit misleading if you 
don't understand the numbers.
    The Chairman. You know, I see Dr. Katz is still here, but I 
don't see the expertise in the VA that you are showing here to 
analyze the data. So maybe we could talk about that again of 
who should be questioning whom.
    Dr. David Rudd is the Professor and Chairman of the 
Department of Psychology at Texas Tech University. He is a 
former Army psychologist with a background as a practicing 
psychologist in clinical research whose work focuses on the 
assessment, management and treatment of suicide. He will 
highlight the scope of the problem of suicide and some steps 
that might be taken by the VA.
    Thank you again for taking the time to be here with us.

               STATEMENT OF M. DAVID RUDD, PH.D.

    Dr. Rudd. Thank you, Mr. Chairman. You have my testimony, 
and it has been entered into the record. Rather than repeat 
much of what has been shared this morning and some of what Dr. 
Maris shared, I would like to highlight a couple of points that 
I think are important to consider when you look at the context 
for this problem.
    If you look at the issue of veterans being treated for 
depression, estimates are that the suicide rate is seven to 
eight times greater than the general adult population. In order 
to understand the context for that, it is important to look at 
comparable civilian data. And I have offered some of that in 
the written testimony, but I will highlight a few things for 
you along those lines.
    The suicide prevalence rate for major depression and 
affective disorders in general is actually lower than is 
oftentimes quoted, but seems to depend on the apparent severity 
of the illness, with the outpatient suicide prevalence rate 
being 2 percent in contrast to 6 percent for those previously 
hospitalized for suicidal symptoms and 4 percent for those 
hospitalized for other reasons. Basically, that is a function 
of severity. The more likely someone is to be hospitalized, the 
more severe the illness, and the higher the risk over the 
course of a lifetime.
    If you are looking at estimates in terms of suicide attempt 
rates, it is estimated that 24 percent of those suffering major 
depression make a suicide attempt during the course of the 
illness. It is estimated that up to 50 percent of individuals 
with bipolar disorder will make a suicide attempt, and up to 80 
percent will manifest suicidal symptoms of some sort during the 
course of the illness.
    Standardized mortality ratios for major depression and 
bipolar disorder paint a very stark picture. Those with major 
depression evidence a 20-fold increase for risk of death by 
suicide relative to the general population; and those with 
bipolar disorder, a 15-fold increase. There are data available 
for other disorders, but the take-home message is a simple one: 
that suicide risk is considerable for a number of mental 
illnesses, and ultimately the mental illness, untreated, 
unrecognized or undertreated, can be fatal.
    It is also important to consider the expected rates of 
adverse events during treatment. And this actually is something 
that gets very little attention in terms of the literature, 
particularly looking at suicide attempt rates. Data are now 
available from a number of randomized clinical trials. We 
actually have 53 randomized clinical trials that can be 
considered and reviewed. Estimates indicate that as many as 40 
to 47 percent of those in treatment, meaning psychotherapy and/
or medication, make a suicide attempt during the first year of 
treatment. Once they have made one suicide attempt, it is 
estimated that they will make an average of approximately 2.5 
during the course of treatment. I think it is important to 
consider that in terms of providing the context.
    Standardized mortality ratios for men and women recently 
discharged from the hospital for suicidal behavior range from 
100 to 350 across several studies. These are tragically high 
numbers. And what those numbers indicate is that the death rate 
is remarkably high for people that are discharged from a 
hospital. And the rate varies within the first week of 
discharge relative to the first month of discharge as well.
    I think you take those couple of points, in addition to 
what Dr. Maris shared, as well as what was shared this morning, 
and there are a number of possible conclusions.
    First, as was outlined nicely in the RAND study, there are 
high rates of psychiatric illness following combat exposure, 
and that includes both direct and vicarious exposure. Multiple 
deployments for Operation Iraqi Freedom and Operation Enduring 
Freedom likely compound the situation because of repeated 
combat exposure, sometimes after the initial emergence of 
symptoms. The VA is faced with assessing and treating very 
large numbers of seriously ill veterans.
    Second, the overall rates of both suicide and suicide 
attempts are tragic but consistent with the general trends for 
the types and observed rates of psychiatric illness that 
present.
    Third, an effective response requires effective resources.
    And, finally, there is an element of this problem that is 
likely to be enduring and potentially chronic in nature. And, 
actually, that is one of the things that I would emphasize, is 
my concern that this is going to be a chronic issue, much like 
we saw with some of the Vietnam veterans over time.
    If you look at the treatment literature in general, I would 
encourage you that, ultimately, the treatment literature says 
some very basic things about treating and addressing 
suicidality, that very simple things work. Making sure people 
have access to emergency services when they need them--that 
works; that will save lives. Making sure that somebody gets 
into the system quickly after the emergence of significant 
symptomatology works and can save lives. Very simple things 
like managing crises effectively, in terms of the removal of 
method or access to method, works and can save lives.
    So I think, ultimately, if you take the data that is 
available elsewhere, it provides considerable information that 
helps inform a response to this problem in terms of the 
veteran-specific population.
    Thank you, Mr. Chairman. I am happy to respond to any 
questions.
    [The prepared statement of Dr. Rudd appears on p. 105.]
    The Chairman. Thank you so much.
    Mr. Hall, do you have any questions for the panel?
    Mr. Hall. If the Ranking Member has none.
    The Chairman. No, I am just going to call them, and then we 
can conclude.
    Mr. Hall. Oh, okay.
    I would like to ask Dr. Rudd, in your written testimony, 
you state that, ``Delays in evaluating the escalating numbers 
of service-connected disability claims can be one of the 
barriers to effective care being provided.''
    And just to make a point that we voted out of this 
Committee a bill last week, which would help to remove some of 
those barriers and allow earlier decisions for service-
connected disability claims.
    And also to ask you--and I guess this would be to both you 
and Dr. Rathbun--about the standard for care of a minimum of 8 
at-least-30-minute sessions per year with either a psychiatrist 
or psychologist or a counselor, which does not have to be the 
same psychiatrist, psychologist or counselor.
    As a professional mental health expert, what is your 
opinion of that standard?
    Dr. Rudd. Well, I would think that it could be potentially 
problematic for a number of reasons. I think one of the things 
that we know from the treatment outcome literature is that 
there is a portion of this problem that will be enduring and 
chronic in nature. And that amount of care may not be adequate 
to address the problem. There will be some chronicity. It will 
take more visits and probably for a longer period of time than 
many people expect.
    Mr. Hall. And how much weight or how much credibility or 
belief should we put in treatment by medication versus 
treatment by psychotherapy?
    Dr. Rudd. Well, I think both have been proven very 
effective. It really depends on the nature of the disorder. But 
both have been proven very effective. And, for many disorders, 
doing both simultaneously has actually been evidenced to be the 
most effective intervention and the most effective treatment.
    Mr. Hall. I wanted to ask Dr. Rathbun about, under your 
statistical page here, you show what we saw earlier in the 
charts from the VA, that the younger veteran seems to be having 
a much harder time coping, and the suicide rates are higher 
among the 20-24-year old rate.
    Obviously, we know, as was testified to earlier, that there 
are more males than females serving, and young men are 
notoriously slower to mature than young women. I am a father of 
a daughter, so I have witnessed, you know, the other side of 
it.
    But I am wondering if maybe we shouldn't be trying to 
provide a slightly different type of treatment or screening for 
younger veterans who, for whatever reasons, are not either 
processing their experience in combat as well or are not 
reaching out for help as well.
    Dr. Rathbun. Well, I can only address the numbers 
themselves. I am not an expert on suicide and/or its treatment. 
I am a biostatistician, mainly trained in analysis of numerical 
data, numerical information. And I do have some background in 
other disciplines, but it is primarily ecology, the environment 
and environmental health, rather than the suicide issue. This 
is my first real exposure to suicide.
    Mr. Hall. Well, maybe we should ask Dr. Rudd then.
    Dr. Rathbun. I think his comments would have a little more 
knowledge than mine would.
    Dr. Rudd. Well, I would tell you that we do know 
scientifically that there are some treatments that work. We 
actually did a large-scale study with Army individuals on 
active duty a number of years ago, more than a decade ago, and 
had some efficacy in terms of response with those individuals 
that were all suicidal. That was one of the criteria to get 
into the study.
    I think that there are issues in terms of barriers that are 
critical. And this is just anecdotal; I can't give you 
scientific evidence for it. But having served as an Army 
psychologist, I can tell you there is great concern among young 
people about issues of confidentiality, about the impact of 
receiving mental health, psychiatric, psychological care on 
their future prospects for their employment either inside the 
military or outside the military. Much of that is myth. I think 
targeting that very specifically becomes critical, helping 
people understand the importance of care early in the cycle of 
the problem.
    Part of my personal concern about this is that you have 
young people who return from combat who have the emergence of 
symptoms and then are hesitant to get care because they worry 
about the impact on their status, the potential for promotion 
and success in the military, don't get care, symptoms become 
much more complicated, they develop comorbid disorders, in 
terms of substance abuse and other problems, which makes it 
much more difficult to treat later on.
    And so I think there is a piece of this that very much is a 
misunderstanding about the importance of getting care and that 
it is not going to impact your future, it is not going to 
impact your promotion and status in the military. There seems 
to be a considerable misunderstanding about that.
    Mr. Hall. Thank you.
    And I would just point out before I yield back, Mr. 
Chairman, that the parents of one of the veterans who took his 
own life who testified before us suggested that the name or the 
initials be changed from ``PTSD'' to ``post traumatic stress 
injury'' or ``syndrome'' or something else, because 
``disorder'' suggested a malady, like there is something wrong 
with you as a person, whereas what you are really having is a 
reaction to an experience that is not normal.
    Dr. Rudd. Absolutely.
    Mr. Hall. And that the stigma should be removed somehow. 
Whether a name change can do that alone, I doubt. But I 
appreciate your comments on removing the stigma and trying to 
reach our veterans as early as possible.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you.
    Mr. Rodriguez, any questions?
    Mr. Rodriguez. Let me just follow up on the same comments. 
Because I know we have struggled with trying to pick them up as 
quickly as possible and talked about maybe providing services 
to them automatically and maybe not to label them at that point 
in time. And I don't know if you might have some comments as it 
relates to that, because it would be just in terms of maybe for 
6 months or a year to provide services automatically. That way, 
every soldier that has gone into a combat would automatically 
go through that without the stigma of being labeled having one 
thing or another and getting some degree of access to some 
services beforehand.
    I was wondering if you want to make some comments on that.
    Dr. Rudd. Sure. I think it would be interesting to look at 
that as an option.
    I think you can look at other areas of the literature, and 
specifically you can look at suicide-prevention programs that 
have been in school systems, you can look at stress debriefings 
that have been done for firefighters and other individuals. And 
what that literature seems to suggest is that universal kinds 
of intervention usually don't work very well, that they don't 
tend to reach the people that are at highest risk. And I think 
that what they suggest is that we need to be more creative 
about what we do and how we reach individuals.
    When I think about that, I will tell you very simple things 
make a difference. Simply reminding people of the availability 
of a service actually has an impact on suicidality. There was a 
wonderful study done decades ago where they simply sent a 
reminder letter to people who were at suicide risk from the Los 
Angeles Suicide Prevention Resource Center. They sent them 
periodic reminders on an annual basis. And the people who got 
the letters actually committed suicide at markedly lower rates 
than those who did not get the letters. So just an expression 
of care and expression of concern to let someone know that you 
are available can go a long way.
    But I am not sure that universal intervention programs 
would be received well and work well, I think, just from an 
anecdotal experience when I was in the service.
    Mr. Rodriguez. Doctor, you also talked about the ones who 
were hospitalized and their health. I guess it jumped from 2 to 
4 to 6 percent in terms of actual suicide.
    Are there certain programs that could be triggered 
automatically because there are those stressors? Any thoughts 
on that?
    Dr. Rudd. I think speculation suggests that when somebody 
is hospitalized for an episode of suicidality and they are 
discharged, that one of the things that happens is they are 
returned to the environment that was stressful for them to 
begin with, and so risk is elevated.
    I think that data suggests very simple things need to be 
done. When somebody is discharged from the hospital, they need 
to follow up very quickly with an outpatient provider. That 
doesn't always happen. Sometimes that takes weeks for someone 
to follow up.
    Those sorts of interventions, I would hypothesize, would 
save lives. Making sure that somebody follows up within a day 
to 2 days after discharge from a hospital with an outpatient 
provider and make that something that is routine as a part of 
care. That is something that might well save lives.
    Mr. Rodriguez. And, Dr. Rathbun, your data basically, if I 
can summarize, let me know if I am--you indicated that veterans 
are twice as likely to commit suicide than the general public? 
Is that what it is?
    Dr. Rathbun. Yes, it is roughly about that. I can give you 
a little bit more precise ratios.
    Mr. Rodriguez. Okay. And on the data on the young soldier, 
that was a little higher?
    Dr. Rathbun. For the young veterans, the range that I gave 
in my report is on the order of about three to four times the 
non-veteran.
    Mr. Rodriguez. Okay. Thank you very much.
    Thank you.
    The Chairman. Mr. Buyer.
    Mr. Buyer. Mr. Rathbun, I want to focus on your--I want to 
become clear. Your testimony is that, based upon your 
statistical analysis of the data, that there is approximately a 
2-to-1 ratio of more veterans committing suicide than those in 
the general population?
    Dr. Rathbun. That is right.
    Mr. Buyer. Okay. Of the non-veterans, okay. So what that 
CBS News story, then, is attempting to do is challenge the 
credibility of the VA, right?
    Dr. Rathbun. No, that is not the intent here.
    Mr. Buyer. Pardon?
    Dr. Rathbun. My role in this was as a statistical 
consultant, just to provide the estimates that are given here.
    Mr. Buyer. All right. I understand. You are not a health 
clinician. You are a statistician.
    Dr. Rathbun. Yes, I am a statistician.
    Mr. Buyer. And what CBS News did with your analysis was 
their own business and how they used it and created a story 
with it, that is CBS News' business, correct?
    Dr. Rathbun. Well, I do care how they use the information.
    Mr. Buyer. Well, I not only care how it is used, I care 
about how you came to your conclusions.
    Dr. Rathbun. I didn't----
    Mr. Buyer. Wait a second.
    Dr. Rathbun. Okay, sure.
    Mr. Buyer. I care because the credibility of the VA, then, 
has been placed at stake with the American people.
    Now, I have a series of questions for you, okay?
    Dr. Rathbun. Okay.
    Mr. Buyer. One, I would like to know--first of all, I would 
ask unanimous consent that the letter that Chairman Filner and 
I sent to Rick Kaplan, the Executive Producer of CBS Evening 
News With Katie Couric, dated December 21, 2007, be entered 
into the record.
    The Chairman. Without objection.
    [The letter to Rick Kaplan, Executive Director, CBS Evening 
News With Katie Couric, dated December 21, 2007, and the 
response from Linda Mason, Senior Vice President, Standards and 
Special Projects, CBS News, dated May 16, 2008, appears on p. 
123.]
    Mr. Buyer. I would also ask that the letters that you and 
I, Mr. Chairman, had sent to Secretary Peake, along with his 
responses, be entered into the record.
    The Chairman. Without objection.
    [The letter 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, appears on p. 
122.]
    Mr. Buyer. I also ask that the responses from the 
Department of Defense regarding not only our letter to DoD and 
their response be entered into the record.
    The Chairman. Without objection.
    [Chairman Filner and Congressman Buyer wrote to Hon. Robert 
M. Gates, Secretary, U.S. Department of Defense, on December 
21, 2007, requesting the number of active-duty suicides for 
each year from 1995 to 2006. On January 17, 2008, Secretary 
Gates responded designating David Chu, Under Secretary of 
Defense for Personnel and Readiness to provide information to 
the Committee. Chairman Filner again wrote to Secretary Gates 
on May 6 and May 21, 2008, requesting the information. On June 
3, 2008, Secretary Gates again responded that he was 
designating David Chu, Under Secretary of Defense for Personnel 
and Readiness to provide information to the Committee. On June 
5, 2008, Chairman Filner again wrote Secretary Gates requesting 
the information. As of September 25, 2008, the U.S. Department 
of Defense has refused to respond to the Committee's request 
for information regarding the number of active-duty suicides 
for each year from 1995 to 2006. The referenced letters appear 
on p. 123.]
    Mr. Buyer. With letter that the Chairman and I had sent to 
CBS News, we had asked CBS News to share with us the data on 
suicide among veterans with the Committee.
    Given your written statement, obviously CBS News is unable 
to do that because you destroyed the data. Is that not correct?
    Dr. Rathbun. CBS News retains a copy of the data, I 
thought. I am not certain if they do or not. But they had asked 
me to not keep a copy. They were concerned about the 
confidentiality of some of the veterans, mainly in the smaller 
States.
    Mr. Buyer. So, is your belief that CBS News still has the 
data?
    Dr. Rathbun. I don't know one way or the other, actually.
    Mr. Buyer. But they had asked for you to destroy the data?
    Dr. Rathbun. Yes.
    Mr. Buyer. Okay. Did you conduct a blind analysis to 
improve the integrity of your tests?
    Dr. Rathbun. A blind analysis? You mean--I am not knowing 
what you are referring to. I am not an epidemiologist, so it 
is----
    Mr. Buyer. A blind analysis, meaning anybody else have an 
opportunity to look at the data? Is it peer-reviewed?
    Dr. Rathbun. No, this is not peer-reviewed.
    Mr. Buyer. It was not peer-reviewed and you destroyed the 
data?
    Dr. Rathbun. Yeah. That makes me feel----
    Mr. Buyer. Then thereby we are to embrace with great trust 
that what you did in your work was correct?
    Dr. Rathbun. I have to say that, for the record, I have 
been very uneasy about this aspect of it, given that this is 
going beyond the story.
    Mr. Buyer. I would think so. You are a professor?
    Dr. Rathbun. Yes, I am.
    Mr. Buyer. Would you advocate that of your students?
    Dr. Rathbun. Not at all.
    Mr. Buyer. As a methodology in normal business practice?
    Dr. Rathbun. That is why I have been very uneasy.
    Mr. Buyer. Sir, would you advocate that to your students?
    Dr. Rathbun. No, I would not.
    Mr. Buyer. No, you would not. Now, you said that you were 
not paid by CBS News; you got a baseball cap.
    Dr. Rathbun. I did get a baseball cap.
    Mr. Buyer. Do you know whether or not the parent company of 
CBS News made any forms of contribution to the University of 
Georgia?
    Dr. Rathbun. I have no information on that.
    Mr. Buyer. Viacom, is that who owns CBS News? You have no 
knowledge whether or not they made any contributions on 
research or anything?
    Dr. Rathbun. I am not aware of what the University receives 
in terms of those contributions.
    Mr. Buyer. Then let me ask this. If you are uncomfortable 
and you would never advise your students to destroy data and 
not permit a peer-review process with regard to the results, 
why?
    Dr. Rathbun. This was not intended as a scientific 
investigation. I was asked as a consultant to do a data 
analysis.
    What I am really uncomfortable with is having it gone 
beyond the story and being asked to testify in court about it 
and, actually, quite frankly, in this group, given that I no 
longer had the data to back up the numbers.
    Mr. Buyer. Yes, I think CBS News put you, as a 
professional, in a very, very uncomfortable position. I think 
the best thing, Professor, coming out of this that you can 
always do now is use this as an example for your students here 
and ever after as to why you should never do something like 
this. Because it is being used and manipulated and it brings 
things into question, and it makes it challenging for us.
    Dr. Rathbun. I am comfortable with the results that I 
found, but I am uncomfortable in presenting them beyond their 
original intent, which was just that story.
    Mr. Buyer. But, professionally, you would even be more 
comfortable if it were peer-reviewed and one of your peers 
objectively confirms your findings, would you not?
    Dr. Rathbun. Of course. Sure. I had never--since I do not 
do my work in suicide, my work is really far outside that 
discipline, I would have been unlikely to publish this kind of 
results anyway. It is just not my priority, at the moment.
    Mr. Buyer. Well, I want to thank you for coming. I want to 
thank you for being very honest and forward with us. Because we 
have a new Secretary in the VA, who is a doctor himself, who 
spent 40 years in the Army, and he cares a lot about the men 
and women who wear the uniform, and I think he embraces this 
issue with great sincerity.
    And I know the Chairman has challenged the Secretary here 
today and members of his staff. But when I am faced with a 
story that CBS News put out there, when, in fact, we can't gain 
access to the data, the data was destroyed, and a process that 
was not peer-reviewed, and the last thing, Mr. Chairman, I 
would like to conclude with is, when we look at the CRS Report 
for Congress, ``Suicide Prevention Among Veterans,'' the CRS 
report on page five said, quote, ``It is tempting to make 
comparisons between studies and with information about suicide 
in the general population. Such comparisons are often made, but 
they are not necessarily valid. Among other things, data about 
suicides in the general population includes suicides among 
veterans, information about suicides in groups that exclude 
veterans, is scant, and is information about the extent for 
which data for veterans may skew the data for the general 
population, if at all.''
    CRS, Mr. Chairman, did a pretty good report, they are 
pretty concerned, and they laid out that there is much work for 
us to do to build a database nationally for us to be able to 
track this kind of thing.
    But I do appreciate you coming here today.
    And I would note to the Secretary, your time is very 
valuable, sir, and I, with deep respect, appreciate you being 
here to listen to this. But I think we are going to have to 
place great trust and confidence in your analysis and what you 
are going to have to do, Mr. Secretary, if this is what has 
been done out in the population generally.
    I yield back.
    The Chairman. Thank you, Mr. Buyer.
    What we heard today is that the VA data basically confirms 
the CBS News data.
    Dr. Rathbun, when Dr. Katz was with us a few months ago, he 
said something about VA controlled for gender but in a strange 
way.
    Do you know what he is talking about? Or how did you 
control for gender?
    Dr. Rathbun. I have no idea about what that would mean.
    The Chairman. You don't know?
    Dr. Rathbun. I used, I think, very standard methodology 
adjusting for gender and age.
    The Chairman. Dr. Katz, you said something about your 
objection to the data for younger veterans. You clarified that 
today. What was your problem with the way the data dealt with 
younger veterans? Can you just repeat that for us?
    Dr. Katz. I was much less concerned with what Dr. Rathbun 
did to the data than the data that was given to Dr. Rathbun.
    Mr. Stearns. Point of order, Mr. Chairman.
    Dr. Katz. When the coroner----
    The Chairman. Can you just come to the microphone?
    Mr. Stearns. Point of order, Mr. Chairman. I think what you 
should do is bring this person up and identify who he is for 
the record, so we know.
    The Chairman. Dr. Katz, can you come forward, please?
    Dr. Katz testified earlier today.
    Mr. Stearns. Okay.
    The Chairman. I was trying to clarify what I took as your 
general condemnation of the CBS News data. Today, you clarified 
that you were concerned with younger veterans. If you want to 
make that more clear, you have the opportunity.
    Dr. Katz. Well, in the spirit of attribution and review, I 
want to acknowledge that it was Dr. Cross who pointed out this 
issue to me.
    When coroners and medical examiners check or don't check 
the veteran status box on a standardized death certificate, 
they don't distinguish between active duty and veterans. 
Someone may have died while in active duty in the community and 
be evaluated for cause of death by a coroner or medical 
examiner, and that coroner or medical examiner would check off 
``yes'' for a veteran, because that person was, in the past, a 
service man or woman.
    So that the States' death certificates tabulation of 
veteran status will include veterans as evaluated by the 
coroner or funeral director. It will also perhaps include some 
people who are active-duty personnel who took their lives while 
on active duty.
    The Chairman. But----
    Dr. Katz. So that the number of suicides tabulated will 
include both active duty and veterans.
    The denominator, the evaluation of the number of people at 
risk, given your data source, includes only veterans. An 
extended numerator with a focused denominator will lead to an 
inflated rate. That will be a greater problem in the younger 
veterans, for which the mathematical contribution from active-
duty personnel would be greater. And that is why I have 
concerns about the younger veterans.
    The Chairman. I understand your concern.
    Dr. Katz. Thank you.
    The Chairman. Thank you for coming back.
    Dr. Rathbun, do you have any response to that?
    Dr. Rathbun. Yes, I do have some response.
    CBS News, after the original taping and before they 
actually broadcast the story on November 13th, approached me 
with additional numbers which were active-duty suicide numbers, 
and asked me to subtract those from the data on the veteran 
suicides. And that is, actually, why the data on the veterans 
is given as a range rather than as a single number. It is 
really one--the lower number reflects the subtraction of those 
observations that were of some question. Pia Malbran expressed 
concern that some of the active duty may have been counted as 
veterans.
    The Chairman. So, I mean, this was figured out before any 
actual----
    Dr. Rathbun. I am not really certain where she came up with 
those numbers. I really can't talk to the quality of those 
particular numbers. We didn't discuss them at any great length.
    The Chairman. But the concept was understood?
    Dr. Rathbun. Yes.
    The Chairman. Dr. Rudd, I missed what you were saying. When 
a question was asked by Mr. Hall, you said universal prevention 
was problematical. Did I understand you correctly?
    You heard what I said earlier about universal diagnosis of 
everybody who is discharged or even after combat. That is a 
universal process that I believe can be done.
    Did you say that was not a good thing to do or wasn't 
effective?
    Dr. Rudd. No, no, that is not what I was saying. Actually, 
let me be a little more specific around that.
    Universal prevention programs where there is a targeted 
intervention for everyone, where everyone gets an intervention 
regardless of whether or not--and those are usually 
psychoeducational programs that have been done in the school 
system.
    The Chairman. But you wouldn't object to universal 
diagnosis?
    Dr. Rudd. No, not coming out of a combat zone.
    The Chairman. All right. Counsel wanted me to ask, again, 
it was along the same lines as Mr. Hall; the RAND report 
defined minimally adequate treatment, eight visits in the past 
12 months, averaging at least 30 minutes.
    I forget what Mr. Hall asked about that, but is that an 
adequate standard?
    Dr. Rudd. It won't be an adequate standard for a portion of 
those that are diagnosed and identified as ill.
    The Chairman. I remember now. Thank you. You clarified 
that.
    In looking back at this over the years, it seems to me 
that, a big problem is the vast number of both National Guard 
and active-duty troops who do not get adequately diagnosed.
    Everybody knows what they have to check on a form to get 
home quickly. We have had reports of commanding officers 
telling their troops, ``Don't check that box, because that will 
keep you here,'' or lead to further security problems, which 
has been clarified recently, or possible denial of law 
enforcement jobs. There is a self-denial. There is an ethos 
that says don't admit mental illness. And there may be a true 
lack of symptoms, which might not be seen right away.
    When that soldier returns to civilian society they don't 
always have the support mechanisms they had while on active 
duty. They are often without the understanding of their family, 
the community and their employer. By the way, I want to invite 
the VA--and I appreciate you staying here.
    Tomorrow at four o'clock, the Sesame Street people are 
going to roll out the DVD they just finished for young children 
under the age of five. There are more than a million children 
of those currently deployed in Iraq, those who have returned, 
or those who will be deployed. Sesame Street has done a DVD on 
how to deal with situations when Dad or Mom come back injured, 
or perhaps, with an amputation or PTSD. They rotate their 
puppets of Elmo and Rosita with real-life situations. For 
instance, they have a young child, four or five, bringing a 
prosthetic leg to Dad and making it look natural and that it is 
something not to fear.
    They are doing outreach, which I think is incredible. They 
are going to distribute this DVD free of charge to all the 
families who request it. That is the kind of knowledge 
everybody needs to have.
    If you let people out of the military without diagnosis or 
having that knowledge, it is going to be pretty hard to deal 
with, which is why we have the problem we have now.
    So, my plan is for soldiers to be given treatment while on 
active duty within a company-size of fellow soldiers to keep 
that camaraderie there, along with their families who help in 
both diagnosis and treatment. I call it a Heroes Homecoming 
Camp. It is like a ``de-boot camp'' or a boot camp just before 
discharge where you can decompress and get an understanding of 
what went on and then get an adequate diagnosis and early 
treatment.
    It seems to me that it would do a lot to remedying all the 
symptoms that we have seen in our society. You can't catch 
everybody, and you can't prevent every suicide. You would have 
to do followup at 3 months, 6 months or a year later. It seems 
to me we can help a lot of soliders before they are allowed out 
of active duty.
    And I don't know if you want to comment on that as a 
concept.
    Dr. Rudd. I think the one comment that I would offer is 
that the Air Force actually has had a model suicide-prevention 
program for a number of years and were able to significantly 
reduce suicide rates across several years.
    And a part of that program is very much similar to what you 
are talking about, which is a universal change in how we think 
about mental illness, how we think about suicide prevention, an 
acceptance of the risk of mental illness from the very top and 
changing the community psyche about how we think about issues 
of illness and getting treatment when it is needed.
    And that program could serve as a model and a very 
effective one.
    The Chairman. I hope that Secretary Peake heard that.
    Secretary Peake, you were the surgeon general of the Army. 
I just met with the current surgeon general and he was saying 
something about doing some education. I asked why he didn't 
promote or bring out in public the generals or colonels who 
have had PTSD and have dealt with it to show in a public way, 
that they can be promoted to general. Show that they have been 
successful in the military, even having dealt with PTSD. That 
would be the way to take away the stigma and to give soldiers 
the confidence that it is okay. I mean, I would call it combat 
stress injury and get the whole ``disorder'' out of the name.
    But that would be a real good example for soldiers, which 
would be faster than anything the Army or Marines are doing now 
to say, hey, it is okay because General X or General Petraeus 
says, ``I have had PTSD, and it is okay.''
    I assume that would be a good thing for soldiers to see?
    Dr. Rudd. Well, I think, actually, that is one of the 
things that the Air Force program did. They talked about these 
issues from the very top, about the importance and 
significance. It was emphasized from the top all the way 
through the system. And the focus shifted, and there is greater 
acceptability.
    And when you have that, you have people willing to talk 
about their own personal issues, I think, with greater 
frequency. And that, sort of, demystifies and, to some degree, 
helps destigmatize the problem.
    The Chairman. Thank you.
    I appreciate you all spending the time, Dr. Rathbun and Dr. 
Rudd. You have helped us understand this, and we appreciate it 
very much. Thank you so much.
    Our last panel is Dr. Michael Shepherd from the Office of 
Inspector General at the Department of Veterans Affairs. Dr. 
Shepherd is a physician with the Office of Health Care 
Inspections that will discuss the need for VA to continue 
moving forward with full implementation of the suicide-
prevention initiatives from the Mental Health Strategic Plan.
    Thank you, again, for taking the time.

 STATEMENT OF MICHAEL SHEPHERD, M.D., SENIOR PHYSICIAN, OFFICE 
 OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Shepherd. Mr. Chairman and Members of the Committee, 
thank you for the opportunity to testify on suicide prevention 
and the Office of the Inspector General report, ``Implementing 
VHA's Mental Health Strategic Plan Initiatives for Suicide 
Prevention.''
    My statement today is based on that report, as well as 
individual cases that the IG has reviewed and reported on 
involving veteran suicides and accompanying mental health 
issues.
    In the process of these inspections, clinicians in our 
office have had the opportunity to meet with and listen to the 
concerns of surviving family members and to witness the 
devastating impact that veteran mental health issues and 
suicide have had on their lives.
    In prior testimony, we have stressed the importance of the 
need for VA to continue moving forward toward full 
implementation of suicide-prevention initiatives from the 
strategic plan. In terms of some additional changes VA could 
make, we would offer the following observations.
    Number one, community-based outreach. In our report, we 
noted that, while several facilities had implemented 
innovative, community-based suicide-prevention outreach 
programs, the majority of facilities did not report community 
linkages aimed at suicide prevention. Although facilities would 
need to tailor strategies to consider local demographics and 
resources, a system-wide effort at community outreach appears 
prudent.
    Number two, timeliness from referral to mental health 
evaluation. In our report, we noted that, while most facilities 
reported at least three-fourths of those patients with moderate 
depression referred by primary care providers are seen within 2 
weeks of referral, approximately 5 percent reported a 4- to 8-
week wait. Because these patients are at risk of progression of 
symptom severity and development of suicidal ideation, VISN 
leadership should work with facility directors to ensure that, 
once referred, patients with moderate depression and those 
recently discharged from the hospital are seen in a timely 
manner at all VA medical centers.
    Number three, co-occurring combat stress-related illness 
and substance use. Substance use may contribute to the severity 
of a concurrent mental health condition, such as major 
depression. The presence of alcohol may exacerbate impulsivity, 
and acute alcohol use is associated with suicide. Quality of 
life becomes duly impacted by anxiety and depressive symptoms 
and comorbid substance use issues. Augmenting services to 
equally address combat stress and comorbid substance use 
should, therefore, be given due consideration for inclusion in 
a comprehensive program aimed at suicide prevention.
    Number four, enhanced access to mental healthcare. 
Treatments for mental health problems may necessitate multiple 
visits over time and may entail multiple modalities, including 
individual and group therapy, medication management and/or 
readjustment counseling. Therefore, efforts of enhanced patient 
access to appropriate treatment may help facilitate both 
patient engagement and the potential for treatment benefit.
    For example, improved availability of mental health 
services at CBOCs may help mitigate vocational and logistical 
challenges facing some veterans residing in rural areas who 
otherwise may have to travel longer distances to appointments. 
In certain locations, availability of care during off-tour 
hours may increase the ability for some transitioning veterans 
to access mental health treatment while minimizing interference 
with occupational and educational obligations, and would be 
consistent with the recovery model for mental health treatment, 
which emphasizes not only symptom reduction, but also 
restoration of function.
    Number five, facilitating early family involvement. Mental 
health symptoms can have a significant and disruptive impact on 
family and domestic relationships. Relational discord has been 
cited as one factor associated with suicide in active-duty 
military and returning veterans. The VA should consider efforts 
to bolster early family participation in patient treatment.
    Lastly, coordination between VHA and non-VA providers. When 
patients receive mental health treatment from both VA and non-
VHA providers, communication becomes an increasingly complex 
challenge. Fragmentation of care is particularly worrisome in 
periods of patient destabilization or following hospital 
discharge.
    The Office of Mental Health Services should consider 
development of innovative methods to facilitate flow of 
information for patients receiving simultaneous treatment from 
VA and non-VA providers within the constraints of relevant 
privacy statutes.
    In addition, the Readjustment Counseling Service and Office 
of Patient Care Services should pursue further efforts to 
foster communication for patients receiving treatment services 
at Vet Centers and VAMCs or CBOCs.
    Mr. Chairman, thank you again for the opportunity to 
testify. I would be pleased to answer any questions that you or 
other Members of the Committee may have.
    [The prepared statement of Dr. Shepherd appears on p. 107.]
    The Chairman. Thank you, Dr. Shepherd.
    Mr. Rodriguez, do you have any questions?
    Mr. Rodriguez. On those five recommendations that you have 
made, do you know how the VA ranks in those areas?
    Dr. Shepherd. Well, in terms of number one and number two--
--
    Mr. Rodriguez. Excuse me, six recommendations.
    Dr. Shepherd. You mean from this statement?
    Mr. Rodriguez. Yes, from the statement. You mentioned 
community-based outreach, also timely referrals, between 
referrals. You mentioned enhancing mental healthcare. You 
mentioned family involvement in the last one, in terms of 
coordination with others.
    Do you know how the VA might rank?
    Dr. Shepherd. Sure. In terms of community-based outreach in 
the Mental Health Strategic Plan implementation report, we 
found that a minority of facilities were engaged in community 
linkages or use of the chaplaincy for community-based outreach.
    In terms of timeliness from referral to mental health 
evaluation, rather than considering all waiting times, we 
focused on patients with moderate depression. Those with severe 
depression you would expect to be referred quickly. Those with 
minor, it would be debatable. And those with moderate 
depression or those who recently have been hospitalized and 
discharged, you would think of as a group that is an at-risk 
subpopulation that you would really want to hone in on. So we 
looked at their reporting on that, which showed that most did 
do a timely job in referring. But, in our view, even a small 
percent means there is more work to be done on that.
    In terms of the other items, those reflect our observations 
from a series of cases involving individual patients that we 
have looked at.
    Mr. Rodriguez. Okay. Thank you.
    The Chairman. Thank you.
    Mr. Stearns, any questions?
    Mr. Stearns. Thank you, Mr. Chairman.
    Dr. Shepherd, as mentioned, there are six recommendations 
here. So you say if these six recommendations were implemented, 
the problem would be totally solved, partially solved, would 
move to a better conclusion? What is your feeling?
    Dr. Shepherd. I am not saying the problem would be solved. 
I am saying that it is our feeling that these recommendations 
would help move the ball forward, in terms of additional 
considerations that may help with suicide prevention.
    Mr. Stearns. Additional considerations that would help with 
suicide prevention.
    Dr. Shepherd. Right.
    Mr. Stearns. Who asked you to do the survey? I wasn't 
clear.
    Dr. Shepherd. Originally, we were asked by this Committee. 
Specifically, we were asked by Congressman Michaud.
    Mr. Stearns. Okay. How long ago?
    Dr. Shepherd. The report came out in May 2007. The request 
was in the late fall of 2006.
    Mr. Stearns. 2006, okay. So it took you, what, 2 years to 
do this?
    Dr. Shepherd. No, about 6 months.
    Mr. Stearns. 6 months, okay. And were you the prime person, 
or were there other people?
    Dr. Shepherd. I was the prime person, and then there were a 
couple other people.
    Mr. Stearns. Did it ever occur to you while you were doing 
this that DoD has a component of this? That is, at the point 
the DoD has the soldier, if they don't do anything, and then 
the soldier comes to the VA, perhaps it might be too late, 
because the soldier will not be as obligatory as he was still 
in the Department of Defense and still in regular duty. Had 
that ever occurred to you during this study?
    Dr. Shepherd. Yes. And I would agree with that sentiment, 
we don't, obviously, provide oversight to the DoD, but 
maximizing intervention in both DoD and VA would be ideal.
    Mr. Stearns. I know you didn't look and you weren't 
requested to look at DoD. But if you did the study, you are 
saying when you came up with your six recommendations, it 
occurred to you that there is responsibility for the Department 
of Defense here?
    Dr. Shepherd. Yes. Again, I think that it is a joint 
effort.
    Mr. Stearns. It is a joint effort. And would you say that 
is 50/50 or maybe the predominance of this initial, shall we 
say, solution to the problem would be at the Department of 
Defense?
    Dr. Shepherd. I honestly don't know how I would partition 
that.
    Mr. Stearns. Dr. Shepherd, would you describe in detail the 
actions that the VA has taken to address the recommendations 
made by the May 10, 2007, IG report and perhaps what challenge 
exists?
    Dr. Shepherd. Sure.
    One of our recommendations in the original report was 
basically making arrangements for 24-hour crisis mental 
healthcare availability. And one of the responses to the 
report, VA did establish a suicide-prevention hotline based out 
of Canandaigua, New York. And I have visited that hotline in 
person and seen the folks working there in action, and have to 
applaud the work they are doing up there.
    We suggested that they needed to develop education for non-
clinical first-exposure personnel, such as clerks, on suicide 
prevention. VA subsequently developed a CD and training module, 
which they began, I believe, in December to disseminate.
    We asked them to develop a similar module for clinicians. 
My understanding is that module and development has not 
occurred yet.
    We had recommended that sustained sobriety should not be a 
barrier to treatment in specialized mental health programs for 
returning combat veterans. And subsequent to our report, the 
Deputy Under Secretary for Health Operations and Management did 
put out a directive basically stating--I am going to put this 
in my words--that substance use issues should not keep people 
from getting appropriate mental healthcare. Because, in the 
past, there were instances where people would say, well, 
someone needs to be completely sober before we can treat them. 
And so that directive did occur to address that.
    Mr. Stearns. So would you say four of the six have been 
implemented, it sounds like?
    Dr. Shepherd. Yes, four of the six have been implemented.
    Mr. Stearns. Okay. And have you seen any appreciable 
difference since that, or has there been any feedback to say, 
okay, these six recommendations, we have done four of them, 
which is four out of six, is two-thirds, 67 percent have been 
done, and we have noticed a dramatic difference? Have you heard 
anything?
    Dr. Shepherd. I haven't, but it is also too early a time 
horizon to tell. I think when you are----
    Mr. Stearns. Well, it has been a year.
    Dr. Shepherd. It has been a year. And we have heard, again, 
very good feedback about the number of veterans calling the 
suicide hotline.
    Mr. Stearns. So when you are making these recommendations, 
you put in place so that you get feedback and know how it is 
working on your recommendations?
    Dr. Shepherd. Yes. We have gotten feedback that a lot of 
the veterans are obviously calling the hotline and utilizing 
that as an outreach tool.
    In terms of ultimate impact, because of numbers in terms of 
suicide, really would take a longer time horizon to fully 
appreciate.
    Mr. Stearns. Well, I can just tell you, in the private 
sector, if recommendations came that we all agreed upon, they 
would be put in place about a year, and everybody would move on 
and have a measurement, a metric to determine how well they had 
been implemented.
    So the fact--you are saying that two of them have not been 
implemented, right?
    Dr. Shepherd. Right, and that is concerning to us. And as I 
have stated earlier, we continue and have continued to ask them 
to move forward.
    Mr. Stearns. Okay. My time has expired.
    Do you think it is because of lack of money, or why haven't 
these two been implemented?
    Dr. Shepherd. I am not sure why they haven't been 
implemented.
    Mr. Stearns. Do you want to venture a guess?
    Dr. Shepherd. It would be a pure guess.
    Mr. Stearns. No one has come back to you and said, this is 
a problem why haven't we done these?
    Dr. Shepherd. No.
    The Chairman. I am sorry, which two?
    Mr. Stearns. The last two.
    All right. Well, I think my time has expired, Mr. Chairman. 
But I think the point is, it has been a year since the 
recommendations. Two of them have not been implemented. We 
can't even find out whether it is because of money or because 
of personnel. Dr. Shepherd can't even give us an idea----
    The Chairman. What are you trying to get at? What is your 
conclusion?
    Mr. Stearns. Well, I am not a witness here today, Mr. 
Chairman, but I sure am here to try to find out. And I am just 
a little concerned, after a year, why these two haven't been 
implemented. And I would think that the IG could tell us that 
the feedback they get--they don't have the money, the 
personnel, or is it just a low priority?
    The Chairman. Let me ask you the procedure on these 
reports. Do you have to get another request to report on the 
follow-up?
    Dr. Shepherd. No. We----
    The Chairman. Or do you follow it up automatically? Is the 
VA given a certain amount of time to respond?
    Dr. Shepherd. The VA is given a certain amount of time to 
respond to the initial report. And then, subsequent to the 
response, I believe it is quarterly, we have an office within 
the IG that requests further follow-up. The next one is due 
mid-June. And then I look at the responses that are sent to 
that office, in terms of whether I think they are legitimate 
responses or not.
    In addition, since the issuance of this report, I have had 
subsequent conversations with various people, for instance, I 
met with someone from Ann Arbor about 2 months ago, wanting to 
know where things are at in terms of one of the initiatives 
they were working on. And I have visited Canandaigua.
    So, as a process, quarterly, we have an office that does do 
follow-up. And that is passed through me to make sure that if 
they say, we are going to do it and we are going to do it by 
blank, then I think that is reasonable, or I may say I don't 
think that is reasonable.
    [The following was subsequently received from VHA:]

    The Office of Inspector General re-opened the following 
recommendations:
    Recommendation 2: The Acting Under Secretary for Health should 
ensure that VISN directors ensure that facility directors ensure that 
all non-clinical staff who interact with veterans receive mandatory 
training about responding to crisis situations involving at-risk 
veterans; this should include suicide protocols for first contact 
personnel.
    VHA Update 8/2007: Planning for facility based training in suicide 
prevention for clinical and non-clinical staff is proceeding with full 
rollout anticipated for no later than October 31, 2007. Suicide 
Prevention Coordinators have been identified at each VA Medical Center 
to support the implementation of these educational efforts locally. In 
addition to monthly conference calls, these providers attended a 
special training conference August 21-23, 2007. This Conference 
included a protocol for Guide Training to assist nonclinical personnel 
in appropriate identification and management of veterans who present 
with suicidal ideation or behavior. VA will hold a national Suicide 
Prevention Awareness Week (September 9-15, 2007) that will feature 
educational presentations for clinical and non-clinical staff from VACO 
and the Canandaigua Center of Excellence in Suicide Prevention.
    Update 3/6/2008: The National Suicide Prevention Center of 
Excellence in Canandaigua has developed and distributed a standard 
suicide awareness training package to the field through the facility 
Suicide Prevention Coordinators. A memo from the Under Secretary for 
Health has been drafted, and is concurrent for release through the 
office of the Deputy Under Secretary for Health for Operations and 
Management, that will task each facility with developing their own 
ongoing training, awareness and communication plan that includes 
appropriate procedures/suicide protocols, and community resources for 
all first contact personnel in both clinical and non-clinical 
personnel. It is expected that all frontline staff complete the 
training by September 1, 2008. Facility Suicide Prevention Coordinators 
are required to report compliance with this training monthly to the 
National Suicide Prevention Coordinator.
    Update 5/9/2008: Mandatory training for non-clinical staff is in 
place. Monitoring of the training and documentation of compliance is 
currently through forwarding of sign-in sheets to the National Suicide 
Prevention Coordinator. Processes for use of the Learning Management 
System for documentation are being developed.
    Recommendation 3: The Acting Under Secretary for Health should 
ensure that VISN directors ensure that facility directors ensure that 
all healthcare providers receive mandatory education about suicide 
risks and ways to address these risks.
    VHA Update 8/2007: Educational protocols for clinicians as well as 
non-clinicians are under development for implementation no later than 
October 30, 2007, and full compliance by April 30, 2008. The facility 
Suicide Prevention Coordinators will be critical in ensuring 
implementation and compliance across the system.
    Update 3/6/2008: A ``State of the Art'' conference on Suicide 
Awareness and Intervention Training was held in Canandaigua on March 5 
and 6, 2008 to finalize the content used in development of a mandatory 
``Suicide Risk and Treatment'' training program for VHA clinicians. 
Final program content will be forwarded to the Employee Education 
System (EES) by April 1, 2008, who expect to complete development of 
the on-line standardized training program by September 30, 2008. Once 
the program has been fully implemented, clinicians will be given 120 
days to complete. Full compliance with the training requirement is 
expected to be completed by January 31, 2009.
    Update 5/9/08: Training activities are in place. The remaining 
issue is to ensure accountability of participation of all healthcare 
providers. A Directive to this effect is in the concurrence process; 
monitoring of completion will be accomplished through VA's Learning 
Management System (LMS).

    The Chairman. Thank you.
    The first thing you did mention was the National Call 
Center and the Secretary provided us with the pamphlet 
advertising this. It sounds like a lot of people are calling. I 
don't know if Mr. Stearns was here when Mr. Moran from Virginia 
was talking about the concern of many veterans dealing with the 
Federal Government.
    I know, Mr. Stearns, that you always say, ``Well, the 
Federal Government can't do this, and besides, people aren't 
worried about it.'' Mr. Moran made the point that many veterans 
may not want to interact with the Federal Government, as 
represented by the VA, and that this kind of advertisement may 
work with a certain percentage but it is probably also turning 
off a certain percentage.
    He was arguing--and I think we need to look at his bill--
for a hotline to be run by peers especially, but probably 
working with a nonprofit, for both privacy and the 
understanding that they don't want to deal with the Federal 
Government anymore. They don't trust them. I think there is a 
point there.
    I don't know if there is a way to even look at that. Have 
you been trying to make any study about people who would call 
the hotline center? Of course, you can't ask anybody who 
committed suicide, but maybe the veterans who have attempted 
suicide.
    Dr. Shepherd. No, I haven't looked at or studied who the 
callers are. I do think that Congressman Moran's suggestion and 
the existing hotline are not necessarily mutually exclusive, 
and maybe there could be a way to combine ideas.
    The Chairman. Exactly. I think you are right. Mr. Moran 
stimulated me to read this, and I know Mr. Stearns would use 
this in another context sometime, but, ``Pick up the phone if 
you are experiencing an emotional crisis and need to talk to a 
trained VA professional.''
    I mean, there are a lot of folks where that would be the 
last thing they would do. You are dealing with, again, a 
bureaucracy or the Government, and I don't think that kind of 
appeal would work.
    Dr. Shepherd. And, again, talking about combining ideas, I 
believe Morris Armstrong is a veteran who started the Vet-to-
Vet model in New Haven, which I believe is a program that 
follows a Vet-to-Vet model. But he does work with VAMCs and VA 
facilities. And so, following that model of a joint non-VA and 
VA venture, perhaps is a way to think about it.
    The Chairman. I think you are right; they are not mutually 
exclusive. I was hearing from the VA that this is their 
outreach; however, we need to look at it from the point of view 
of someone who, by their very problem, is suspicious of an 
organized bureaucracy.
    Dr. Shepherd. Sure. And that is why also as I said in my 
statement, we would encourage all forms of aggressive outreach, 
including, for instance, one center invites local clergy in and 
gives them information about the facility and what the services 
are, so that if a parishioner or relative comes up to the 
reverend and says, ``My son is having trouble,'' they know 
where to refer them or how to get them help. And I think 
innovative outreach ideas like that should continue to be 
pursued.
    The Chairman. Well, again, thank you very much.
    Remind me, on the quarterly reports, are they automatically 
sent to Congress?
    Dr. Shepherd. No, I don't believe they are. But that is a 
statement out of ignorance, so I will have to check on that.
    The Chairman. I hope they are. I think we have talked about 
this with the IG before, that the reports should come to us, we 
should not have to ask about what is going on.
    We thank you for your contribution, and we look forward to 
your continuing oversight.
    [The Chairman and the Ranking Member are provided quarterly 
updates on the status of open recommendations. The Committee 
receives copies of Office of Inspector General reports as they 
are released.]
    Dr. Shepherd. Thank you, Mr. Chairman.
    The Chairman. And unless there are further questions, this 
hearing is adjourned.
    [Whereupon, at 2:58 p.m., the Committee was adjourned.]

                            A P P E N D I X

                              ----------                              

              Prepared Statement of Honorable Bob Filner,
             Chairman, Full Committee on Veterans' Affairs
    Good morning and welcome to the Committee on Veterans' Affairs' 
hearing on ``The Truth about Veterans' Suicides.''
    On December 12, 2007, this Committee held a hearing entitled 
``Stopping Suicides: Mental Health Challenges within the Department of 
Veterans Affairs.'' Nearly five months later, we are again holding a 
hearing on the tragic issue of suicide among our veterans and what the 
VA is doing to address what is clearly an epidemic. In November of last 
year, CBS News aired a story entitled ``Suicide Epidemic Among 
Veterans.'' On April 21, 2008, CBS News aired a story ``VA Hid Suicide 
Risk, Internal E-Mails Show.''
    The first step in addressing a problem is to understand the scope 
and extent of the problem. In the case of the VA and the epidemic of 
veteran suicides, either the VA has not adequately attempted to 
determine the scope of the problem, which is an indictment of the VA's 
basic competence, or the VA knows the extent of the problem, but has 
attempted to obfuscate and minimize the problem to veterans, Congress, 
and the American people, which is an indictment of the leadership of 
the entire Department.
    In December, Dr. Katz, in testimony before this Committee, stressed 
a low-rate of veteran suicide, stating that ``from the beginning of the 
war through the end of 2005 there were 144 known suicides among these 
new veterans.'' In responding to the figures used by CBS, Dr. Katz 
stated that ``their number for veteran suicides is not, in fact, an 
accurate reflection of the rates of suicide.''
    Either Dr. Katz knew that the CBS figures were indeed an accurate 
reflection of the rates of suicide at that hearing or had a sudden 
epiphany only days later.
    In an internal email, Dr. Kussman, on December 15, 2007, referring 
to a newspaper article, writes that ``18 veterans kill themselves every 
day and this is confirmed by the VA's own statistics. Is that true? 
Sounds awful but if one is considering 24 million veterans.'' That same 
day, Dr. Katz responds: ``There are about 18 suicides per day among 
America's 25 million veterans. This follows from CDC findings that 20% 
of suicides are among veterans it is supported by CBS numbers.''
    In February of this year Dr. Katz sends an email stating ``Shh!--
Our suicide prevention coordinators are identifying about 1000 suicide 
attempts per month among the veterans we see in our medical facilities. 
Is this something we should (carefully) address ourselves in some sort 
of release before someone stumbles on it?''
    There was silence from the VA.
    Armen Keteyian, Chief Investigative Reporter for CBS News, 
characterized the VA's internal emails as ``a paper trail of denial and 
deceit--a disservice to all veterans and their families--[that] has 
rightfully been exposed.''
    In an April 24, 2008, newspaper article, a VA spokeswoman stated 
that ``there are an estimated 1,000 suicide attempts per month among 
the 7.8 million veterans treated by Veterans Affairs, she said.''
    The VA spokeswoman may have misspoke, or this could be yet another 
example of the VA's attempt to hide the true magnitude of the problem. 
In the VA's most recent budget submission, the VA claims it will treat 
5.2 million veterans this year, and 5.3 million next year--2.5 million 
fewer veterans than the 7.8 million quoted in the newspaper article.
    In April, a Dallas Morning News editorial, describing a ``recent 
spike in suicides among psychiatric patients treated at the Dallas VA 
hospital'' stated that ``descriptions of how four veterans committed 
suicide in four months--prompting the psychiatric ward to close--
suggest that patients went to conspicuous and time-consuming lengths to 
end their own lives. There seemed to be ample time for staffers to stop 
them had they been doing their jobs better.''
    The RAND Corporation, in a recently published study entitled the 
``Invisible Wounds of War,'' found that since October 2001, 
approximately 1.6 million U.S. troops have deployed, and that ``upward 
of 26 percent of returning troops may have mental health conditions.'' 
The study estimated that approximately 300,000 of those deployed suffer 
from PTSD or major depression. Among those with PTSD or major 
depression, only half had seen a mental health provider or physician to 
seek help in the past 12 months, and among those who had sought help, 
``just over half received minimally adequate treatment.''
    The study defined minimally adequate exposure to psychotherapy as 
consisting of at least eight visits with a mental health professional 
such as a psychiatrist, psychologist or counselor in the past 12 
months, with visits averaging at least 30 minutes. How does VA mental 
health care treatment stack up against this definition of minimally 
adequate care?
    The RAND study also found that ``the VA too faces challenges in 
providing access to OEF/OIF veterans, many of whom have difficulty 
securing appointments, particularly in facilities that have been 
resourced primarily to meet the demands of older veterans.
    ``Better projections of the amount and type of demand among newer 
veterans are needed to ensure that the VA has the appropriate resources 
to meet the potential demand. New approaches of outreach could make 
facilities more acceptable to OEF/OIF veterans.''
    I think many of us believe that the VA health care system has been 
pushed to the edge in dealing with the mental health care needs of our 
veterans. And, I believe that we are witnessing either an inability to 
address this problem, or a purposeful attempt to minimize the problems 
faced by veterans and the VA and sweep the epidemic of veteran 
suicides, and the mental health care needs of our returning 
servicemembers, under the rug.
    So this morning we are going to attempt to get a better idea of the 
scope of this epidemic, and what the VA is doing to respond to it. What 
specific steps has the VA taken since December, steps not previously 
planned before December, to get a better idea of the scope of the 
problem, and what has it done to begin to address the problem?
    Finally, I believe we must also seek real accountability from the 
VA, and, Mr. Secretary, we look to you to provide that accountability.

                                 
              Prepared Statement of Honorable Steve Buyer,
     Ranking Repubican Member, Full Committee on Veteran's Affairs
    Thank you Mr. Chairman.
    The loss of a single veteran to suicide is a tragedy.
    I am sure that like me, every member of this committee seeks to 
identify and eliminate contributing factors, and to prevent one more 
service-member or veteran from taking his or her own life. I want to 
thank Chairman Filner for continuing hearings to discuss this issue and 
to help those at risk.
    A number of questions were raised during our hearing last December 
regarding the validity of data on the number of veteran suicides. Such 
information is vital to understanding the scope of the problem, as well 
as identifying risk factors and providing better prevention and 
treatment protocols.
    Chairman Filner joined with me in a letter I wrote to VA, DoD, and 
CBS requesting their respective data and how it was formulated. CBS 
failed to respond.
    DoD acknowledged the letter, yet I am still awaiting a further 
reply.
    Secretary Peake was the only one to provide a thorough response, 
which was about two separate studies VA is conducting.
    These studies may provide some useful information, but they are 
limited to data on suicide rates among veterans in the VA health care 
system. VA must have a better method for the systematic collection and 
tracking of veteran suicide data. It is also important to find ways to 
reduce the stigma associated with mental health care and encourage more 
servicemembers to seek treatment when it is needed.
    During our last hearing, I asked VA to be proactive and reach out 
to soldiers and their families during pre-mobilization--and to start 
with the 76th Indiana Brigade Combat Team as it prepared to deploy to 
Iraq. I was very pleased that VA came as requested and participated in 
the outreach event.
    I stood with 3,400 Indiana soldiers at the RCA dome on January 2 
for the formal send-off ceremony. Along with about 20,000 friends and 
family members was VA staff from the Indianapolis VA Medical Center, 
Regional Office, and Vet Center.
    VA reported that about 1,700 families received information 
regarding VA benefits and services, including mental health services 
and Information on Post Traumatic Stress Disorder (PTSD) and Suicide 
Prevention.
    VA also followed-up with subsequent briefings while the Brigade was 
at Ft. Stewart, Georgia for training.
    As the Brigade marched to war, I believe they left with a clear 
impression that VA will be available to provide support and assistance 
to their family during their deployment and will be there when they 
return from Iraq. There was very positive feedback regarding the VA 
presence at these events.
    Secretary Peake has taken decisive actions to meet the increased 
needs for mental health services. For example, on May 1st, VA began 
contacting nearly 570,000 recent combat veterans about VA medical care 
and benefits.
    These veterans were either injured in Iraq or Afghanistan or 
discharged from active duty, but have not yet contacted VA.
    The Secretary has also directed the creation of an independent 
workgroup to assess VA's suicide prevention programs.
    I want to thank Secretary Peake and the other witnesses for their 
participation today and I look forward to their testimony.
    In the end, I hope that this hearing will drive home the message to 
our Nation's men and women who serve, and to their families, that if 
you are in need of help, care is available, treatment works and there 
is a road to recovery.

                                 
           Prepared Statement of Honorable Harry E. Mitchell
    Thank you Mr. Chairman.
    In November, 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 20-24 were 
killing themselves when they returned home at rates between two-and-a-
half to four times higher than non-vets the same age, but that the 
Department of Veterans Affairs wasn't keeping track of veteran suicides 
nationwide.
    In December, we held a hearing to find out why.
    And, Mr. Chairman, I don't think there is anyone who attended that 
hearing who will ever forget it.
    We heard from Mike and Kim Bowman, whose 23-year-old son, Tim, 
survived a year of duty in Iraq, only to come home and take his own 
life.
    Mr. Bowman warned us that our troops are coming home to an, 
``understaffed, under-funded, under-equipped VA mental health system'' 
that imposes so many challenges, many are just giving up.
    And so, when Dr. Katz insisted at that hearing, repeatedly, that 
the VA had all the necessary resources to reach all veterans at risk 
for suicide and make treatment available to them, I was skeptical.
    How could Dr. Katz be so sure that there weren't any requests for 
additional resources sitting somewhere, within the vast VA system, that 
had gone unfulfilled? Was he absolutely certain that there were no 
pending request for an additional mental health counselor? Or for extra 
gas money to enable a VA employee to drive somewhere to conduct 
outreach?
    As Chairman of the Subcommittee on Oversight and Investigations, I 
felt I had a responsibility to make sure.
    So I asked the VA to double-check.
    I asked them take a look at their records, and send us any 
documents relating to any requests for additional resources that had 
gone unfulfilled or under-fulfilled.
    My thought was, if we could find out what the VA needs to address 
this problem, we could get to work make sure they get it.
    More than 4 months later, however, all I've gotten are excuses, 
complaints, and, most recently, a suggestion that I, ``go file a 
Freedom of Information Act request.''
    That's not just an insult to me, it is an insult to this Committee, 
and to our veterans.
    I've tried to be reasonable. I've tried to work with Secretary 
Peake's office. But, Mr. Chairman, my patience is at an end.
    I've given the Department until Friday to finally produce the 
documents I requested. If they do not, Mr. Chairman, I want you to know 
that I will be asking you to pursue a subpoena.
    I yield back.

                                 
       Prepared Statement of Honorable 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 and the problem of suicides among veterans.
    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 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. Shelley Berkley
    Mr. Chairman,
    I am extremely discouraged that we are here today holding a hearing 
on the VA's cover-up of veterans' suicide attempts. I find it 
absolutely appalling that anyone would try to conceal these numbers--
preventing us from addressing the root of the issue of suicide among 
veterans. We must provide sufficient mental health services to our 
veterans in order to address the needs facing our servicemembers 
returning from Iraq and Afghanistan.
    Nationally, one in five veterans returning from Iraq and 
Afghanistan suffers from PTSD. Twenty-three percent of members of the 
Armed Forces on active duty acknowledge a significant problem with 
alcohol use. It is vital that our veterans receive the help they need 
to deal with these conditions.
    The effects of substance abuse are wide ranging, including 
significantly increased risk of suicide, exacerbation of mental and 
physical health disorders, breakdown of family support, and increased 
risk of unemployment and homelessness. Veterans suffering from a mental 
health issue are at an increased risk for developing a substance abuse 
disorder.
    As servicemembers return from combat, it becomes increasingly 
important to provide them with the mental health services they need to 
readjust to society and deal with the invisible wounds of war.
    A constituent of mine, Army Pfc. Travis Virgadamo returned home 
from Iraq on leave. During this trip, he told his family he had been so 
frightened, he had sought and received psychiatric counseling from the 
military in Iraq. He also received additional counseling during that 
trip home in late July. The Army's response was to treat him with 
Prozac. After returning to Iraq, Virgadamo was placed on suicide watch 
and the bolt from his rifle was taken away, making the weapon useless. 
He was also given a desk job. After Virgadamo was cleared for combat 
again, they gave him back the bolt to his rifle. Hours later, he killed 
himself.
    Even though he was still on active duty (placing him under DoD 
jurisdiction), this incident only reinforces the fact that we need to 
place more emphasis on mental health of servicemembers in or returning 
from combat.

                                 
              Prepared Statement of Honorable Jeff Miller
    Thank you, Mr. Chairman.
    There is no doubt that suicide under any condition is a tragedy. 
Suicide that could have been prevented is even more so, and we here on 
this Committee have a duty to provide the best services for a targeted 
group: our Nation's veterans. These brave men and women spend countless 
hours, days, and years defending liberty for us here at home, and it is 
imperative that we provide them the best services upon their return 
from combat.
    As we learn more each day about mental health, it is imperative 
that we apply these findings toward helping those who suffer, 
especially when it comes to preventing suicide. To be sure, veterans 
have a unique set of factors that may lead to an increased suicide 
rate. None of us here doubt the extreme rigors of combat and the toll 
it can take on a person. However, with no single factor causing 
suicide, it is a difficult and ongoing process to identify those most 
at risk and those most likely to attempt suicide.
    While this Committee cannot identify and eliminate every factor 
that may contribute to suicide risk, especially those arising from the 
civilian world, we certainly can work toward addressing those arising 
from service, including PTSD and substance abuse. I look forward to 
hearing what steps have been implemented by VA, what progress has been 
made, and what steps they will take in the future. Our soldiers gave 
too much to not receive the best treatment across all fronts upon their 
return home. A smooth transition to civilian life and easy access to 
care must be ensured for them, and this can be aided with a proactive 
approach by the VA to see that they have everything they need before it 
is too late.
    I yield back.

                                 
           Prepared Statement of Honorable Ginny Brown-Waite
    Thank you Mr. Chairman.
    It is no secret that the Department of Veterans Affairs is seeing 
an increase in cases of Traumatic Brain Injury and Post Traumatic 
Stress Disorder among OEF/OIF veterans. While these conditions may not 
be as visible as an amputated leg or gun shot wound, they can be just 
as debilitating. Left untreated, these conditions may lead to the 
veteran committing suicide.
    To address these growing concerns, this Committee approved and the 
President signed into law the Joshua Omvig Veterans Suicide Prevention 
Act. The act requires the VA to establish a comprehensive program for 
suicide prevention among veterans. Signed into law in November 2007, 
this act will dramatically affect the way the VA handles veterans with 
suicidal tendencies.
    Unfortunately, a majority of veterans with conditions that lead to 
suicide do not seek help for these conditions. That is why the outreach 
section of the Joshua Omvig Veterans Suicide Prevention Act is so 
important. The VA must reach out to veterans, their families and the 
organizations that help veterans to ensure this nation's veterans 
receive the care they deserve.
    I look forward to hearing from all of the witnesses here today 
about what is being done and what still needs to be done to minimize 
the number of veteran suicides. Specifically, I look forward to hearing 
from Secretary Peake as to the implementation of the programs contained 
in the Joshua Omvig Veterans Suicide Prevention Act and the impact they 
have made thus far.
    Thank you, Mr. Chairman.

                                 
            Prepared Statement of Honorable Timothy J. Walz
    Mr. Chairman, Ranking Member Buyer, Members of the Committee, thank 
you for the opportunity to speak. And thank you to the witnesses who 
are here today.
    I have been troubled by recent, credible allegations that the U.S. 
Department of Veterans Affairs has been withholding important 
information about the rates of suicides and suicide attempts among 
America's veterans. I wrote to Chairman Filner requesting a hearing, 
and I am very pleased that we are having one. We must reach out to our 
veterans--young and old--to make sure they know where they should go 
for help if they are feeling suicidal. The VA should get all of the 
resources and tools it needs to care for our veterans. The reason I 
called for an investigation is so that we can get our facts straight, 
and from there, we'll have a better sense of whether new legislation is 
needed to address this problem . . . or just new leadership on these 
issues. The VA must be forthcoming about what it knows about suicide 
attempts among veterans in the VA system and overall, as well as about 
suicides. Only if we have accurate information can we act decisively to 
address this troubling trend among veterans.
    I have been very pleased to work with the fine people at the VA in 
Minnesota to ensure that our veterans continue to receive world-class 
healthcare at VA facilities. When the latest information about the VA 
was disclosed, I wrote to the head of VISN 23 requesting information on 
mental healthcare for Minnesota's veterans and statistics on suicide 
and suicide attempts among them. He and his staff have worked 
diligently to gather the facts that I had requested, and I appreciate 
that. I have not yet seen the information, as it came back from VA in 
Washington only this morning, right before this hearing began, but I 
look forward to reviewing it carefully so the people of the First 
District and all of Minnesota can be sure that we are doing all we can 
to help Minnesota's veterans.
    I commend CBS News for bringing important facts to light, 
fulfilling the press' duty to the public and its right to know. 
Internal VA e-mails obtained by CBS show a concerted effort by Dr. Katz 
and others at the VA to minimize the extent to which the public would 
learn facts unflattering to the VA and its ability to serve veterans in 
need of mental health assistance. In February of this year, Dr. Katz 
sent an e-mail to Ev Chasen, VA's Chief Communications Officer, with 
the subject: ``Not for the CBS News Interview Request.'' In the e-mail 
exchange, Dr. Katz and Ev Chasen discussed how to deal with the VA's 
own data showing alarming rates of suicide attempts--1000 per month--
among veterans in the VA medical system itself. They were clearly 
trying to minimize the publicity the information might receive. The 
spirit of Dr. Katz's e-mail was characterized by its first line, 
stating, ``Shhh!''
    In December of 2007, the House Veterans' Affairs Committee held a 
hearing on the topic at which Dr. Katz testified. At that hearing, he 
at times sought to cast doubt on a recent CBS report about the numbers 
of suicides among veterans. At other times in the hearing, he appeared 
to confirm the numbers CBS was reporting, but did so in a way that was 
not clear, parsing words and numbers. In an e-mail just three days 
after that hearing, also published by CBS, Dr. Katz wrote an e-mail to 
a colleague at the VA which made clear that VA's own numbers on the 
rate of suicide among veterans were in line with the CBS report. 
Reviewing that transcript is a disturbing experience, because Dr. Katz 
and others seemed more interested in distracting from the issue at hand 
by bashing the news media, than in informing the Committee, the press 
and the public about this very important matter so that we can address 
it in as effective a way as possible.
    I am pleased that we are having this follow up hearing today, so 
that we may gain all the facts and thereby work to prevent suicide 
among our veterans.

                                 
            Prepared Statement of Honorable James P. Moran,
        a Representative in Congress from the State of Virginia

      Mr. Chairman, Members of the Committee, I thank you for 
holding this important hearing and I commend your work that you've 
already undertaken on behalf of our Nation's veterans.
      Most of us understand from the media reports and 
anecdotal accounts from our constituents that suicide among our 
veterans is one of the most pressing issues that we should address.
      We know that the new generation of returning soldiers is 
more vulnerable to the immediate psychological wounds of war that lead 
to suicide. 20 percent of our veterans from Iraq and Afghanistan show 
signs and symptoms of PTSD, depression and anxiety. This number 
increases to 50 percent for soldiers with multiple tours or inadequate 
time between deployments.
      One of the measures that we can take to prevent suicide 
is to provide a voice of understanding in their time of need. The 
``Veterans Suicide Prevention Hotline Act'' would create a stand-alone 
24-hour National toll-free hotline to assist our Nation's veterans in 
crisis.
      The key is that this hotline would be staffed by 
veterans, trained to appropriately and responsibly answer calls from 
other veterans. These volunteers would be trained in active listening 
and crisis de-escalation respond to a variety of crisis calls.
      I understand that the Department of Veterans' Affairs has 
developed a veterans' option off of the National Suicide Hotline. While 
I applaud their effort to finally address this problem, I believe that 
there are key differences in the approach.
      Sometimes a veteran doesn't want to talk to a doctor--he 
or she wants to talk to someone who's got a real-life perspective of 
what's happening. This ``cultural competency'' that a fellow veteran 
provides can make a real difference in crisis counseling.
      Moreover, soldiers with mental illnesses face societal 
stigma associated with seeking care through the VA. Research from the 
Air Force's suicide prevention efforts suggest that fear of ``the 
system'', of an unfriendly mental health establishment, and of 
potential job-related consequences keep many active duty soldiers and 
recent veterans from seeking the care they need.
      I am also concerned that the VHA is already overburdened 
by their many healthcare responsibilities to provide a top-notch 
hotline effort. Stretched budgets and staffing shortages may not be 
able to meet the challenges of many returning veterans as our Nation 
redeploys from Iraq in the future. A non-profit organization dedicated 
to suicide prevention would be able to provide focus, stability and 
commitment that the VA may not.
      To conclude, our vets deserve as much support when they 
return from combat as they receive while in battle. Too many of our 
veterans are struggling to make the difficult adjustment back to 
society and need someone they can talk to, someone who's walked a mile 
in their shoes. This legislation will offer that caring voice at the 
end of the line.
      I applaud the Committee for their work on this effort.

                                 
         Prepared Statement of Honorable James B. Peake, M.D.,
             Secretary, U.S. Department of Veterans Affairs
1. ISSUES RELATED TO COLLECTING SUICIDE DATA
    The purpose of this testimony is to provide information on the 
issues related to veterans suicide: what VA knows, including the 
sources of information we use; what we do not know, and what we intend 
to do about that problem; and what we have been doing to directly 
address the issues of suicide from a clinical perspective, and how we 
are expanding our outreach, even as we seek better ways to measure the 
problem.
    The language used to talk about suicide is complex. Suicidal 
behavior exists along a continuum; from thinking about ending one's 
life, to developing a plan to do so, to non-fatal suicidal behavior, to 
actually ending one's own life. The Centers for Disease Control (CDC) 
has come up with some definitions of suicidal behavior which the 
Department of Veterans Affairs (VA) has adopted.
    CDC has defined suicidal ideation as having thoughts of harming or 
killing oneself; a suicide attempt is a non-fatal, self-inflicted 
destructive act in which a person has either an explicit or an inferred 
intent to die; self-inflicted injuries are suicidal and non-suicidal 
behaviors such as self mutilation; and suicide itself refers to a fatal 
self-inflicted destructive act in which there is an explicit or an 
inferred intent to die.
    Suicide is a relatively infrequent act. Although suicide is the 
11th leading cause of death among Americans of all ages, 
when studying any group over short periods of time the number of actual 
suicides will be low. Only very large studies conducted over long 
periods of time allow the accumulation of enough observations to make 
meaningful comparisons.
    Suicide risks vary by age, gender and other factors. For Americans 
in general, the highest rates of suicide are among older men, but 
middle-aged veterans appear to take their own lives in greater 
proportions than their elders.
    Suicides often occur in close proximity, especially after media 
attention. This kind of behavior is called ``copycat behavior,'' or the 
``Werther effect,'' after a wave of suicides in 18th century 
Europe following the publication of a book by Goethe. It can be 
difficult to tell when a cluster represents a temporary trend, or a 
sustained trend.
    Official suicide rates based on death certificate data can be 
incomplete. There are regional differences in how suicides are defined; 
how ambiguous cases are classified; and how thoroughly coroners or 
medical examiners investigate causes of death. In some areas religious 
traditions, life insurance policies, or legal sanctions may lead to 
underreporting. The increased awareness of the relationship between 
mental illness and suicide may cause an apparent increase in the 
reported number of suicides--without the rates actually differing.
    And finally, reconstructing the events leading up to a death is 
difficult. Death certificates provide only a limited amount of 
information about actual causes of death, so researchers need to 
contact those closest to the victim to understand the true 
circumstances of death, and the factors that contributed to a death. 
Family members and others can often provide inaccurate or incomplete 
information.
    The way researchers determine incidences for suicide is to express 
the number of suicides in a population per hundred thousand people per 
year. Because suicide rates vary by age, with both older and younger 
people at higher risk, any rates that attempt to make comparisons 
across different populations by year must be adjusted to allow for 
accurate comparisons. One way to do so is to look at age specific rates 
of suicides and compare them to the U.S. population as distributed by 
age. CDC uses the U.S. population census figures for 2000 to do this.
    Another method of adjustment is called the standardized mortality 
ratio. This ratio compares the number of observed deaths in a defined 
group with the number of deaths that would be expected if that group 
had the same age-specific rates as a standard population.
    Finally, there are sophisticated statistical techniques which can 
be used to derive a relative risk that take into account multiple 
characteristics of individuals, such as gender, race and ethnicity, 
medical conditions and other factors.
    Each of these methods of adjustment has their strengths and their 
weaknesses. Each is potentially misleading when comparing populations 
with very different age or gender distributions. A careful analysis of 
suicide rates that is age and gender specific is both necessary and 
appropriate.
    Because of this, VA has long subjected its own data, that of the 
Department of Defense, and data from nationally accepted statistical 
sources to careful and painstaking analysis to obtain the truth about 
veterans' suicide.
    A suicide rate is normally calculated by describing the number of 
cases occurring in a defined group over a specific period of time. 
These are called incidences of suicide, and to avoid expressing 
incidences as very small fractions, suicide rate is typically expressed 
in terms of the number of suicides per 100,000 persons per year.
    To make accurate comparisons of suicide rates, such as trends over 
time or comparisons among veterans and non-veterans, three important 
elements are needed. First is an accurate count of events for both 
groups, called the numerator. Second is an accurate estimate of the 
total population at risk, called the denominator. And third, as already 
mentioned, there needs to be an adjustment for age and gender 
differences between populations.
2. HOW VA COLLECTS SUICIDE DATA
    VA relies on multiple sources of information to identify deaths 
that are potentially due to suicide. This includes VA's own Beneficiary 
Identification and Records Locator Subsystem, called BIRLS; records 
from the Social Security Administration; and data compiled by the 
National Center for Health Statistics in its National Death Index.
    This is a painstaking and difficult process for VA and for others, 
best illustrated by the fact that suicide data from the Centers for 
Disease Control and Prevention are available only through 2005. 
Calculating suicide rates specifically for veterans is made even more 
difficult by the fact that the National Death Index does not include 
information about whether a deceased individual is a veteran or not.
    The National Death Index is simply a central computerized index of 
death record information on file in the vital statistics offices of 
every state. The Index is compiled from computer files submitted by 
State vital statistics offices. Death records are added to the file 
annually, about twelve months after the end of a calendar year. CDC 
uses this data to compile its statistics on American death rates.
    Given that the NDI does not indicate veteran status, VA regularly 
submits requests for information to NDI. Because the system contains a 
list of all Americans who have died, and because of the capabilities of 
its Electronic Health Record system, VA is able to send NDI a list of 
all patients who have not been treated at any VA medical centers in the 
past twelve months and before, to see if they are still among the 
living.
    NDI checks this list against their records, and tells VA which 
veterans have died, and the cause of their death as listed on the 
veterans' death certificates. From this information, VA is able to 
learn the approximate number of veterans under its care who have died 
of suicide, and to use that information to make comparisons on rates of 
suicide among those veterans and all other Americans.
    This information tells VA about the suicide rates among veterans 
under its care, but says nothing about the rates of suicide among 
veterans who are not currently in the system. For those veterans, an 
even more complicated process has to be followed in order to estimate 
rates. VA obtains regular updates from the Department of Defense's 
Defense Manpower Data Center on soldiers separating from the military. 
Those new veterans immediately become part of total population and 
suicide calculations.
    In 2002, the CDC established the National Violent Death Reporting 
System, or NVDRS. NVDRS today is fully implemented in 16 states, and 
collects data on violent deaths, including suicides. NVDRS collects 
data on violent deaths from a variety of sources, including death 
certificates, police reports, medical examiner and coroner reports, and 
crime laboratories. Veteran status is included in the database.
    Together, these sources offer a comprehensive picture of the 
circumstances surrounding homicides and suicides. This, too, is a time-
consuming and difficult task, and standard reports from NVDRS are 
available only through 2005.
    Because NVDRS is a comprehensive source of data, and because it 
indicates whether or not a coroner has indicated that the deceased is a 
veteran, VA is able to obtain counts of the number of suicides among 
all veterans in the sixteen stats that have fully implemented this 
system, broken down by sex, age, race and state. To summarize, 
determining suicide rates among veterans is a challenging puzzle. 
Multiple data sources must be used, and data must be carefully checked 
and rechecked. Each system helps obtain a piece of the complicated 
puzzle that constitutes the process of accurately estimating rates of 
veteran suicides.
    These are time-consuming processes--but they are the best ways VA 
knows to obtain aggregate data on suicide. The weaknesses inherent in 
this method are clear.
    First, the CDC's manual for completion of death certificates states 
that the determination of whether or not someone is a veteran should 
usually be done by funeral directors. The information available to 
directors is limited, and their willingness to investigate the question 
of veteran status varies. Generally, these directors allow families to 
self-certify their response to the question of whether their loved one 
was a veteran; an approach fraught with pitfalls. In addition, funeral 
directors may not be clear on whether a young person died on active 
duty, or shortly after leaving the service.
    Second, the classification of a death as suicide is dependent on 
the work of coroner's offices throughout America. This paper has 
already discussed issues related to coroner determinations: regional 
differences in definitions; the manner in which ambiguous cases are 
classified; the level of investigative determination; religious 
traditions, and legal sanctions all create difficulties in data 
reliability.
    And third, data takes a very long time to assemble. Neither NDI nor 
NVDRS has released reports of data newer than 2005--and it is midway 
through 2008 at present.
    There are actions VA can take, and is taking, to improve the 
reliability and the speed of the data the Department is obtaining and 
providing to Congress. First, VA has begun negotiations with NVDRS 
staff that will provide information from all of NVDRS' sources (death 
certificates, police reports, medical examiner and coroner reports, and 
crime laboratories) on a monthly and quarterly basis, as they are 
received by NVDRS.
    VA will not be able to determine when there is sufficient 
information to provide full and publishable data--only NVDRS can do 
that--but will be able to examine and analyze these reports in a way 
that will allow the Department to spot suicide trends by age, sex and 
even region more quickly and to take action in those areas.
    The Department will also systematically assess its efforts to 
inform funeral directors about the importance of determining whether or 
not a person who has died of suicide is or is not a veteran, and what 
sorts of information to consider in making that determination.
    VA will also investigate working directly with state vital records 
offices, as the NDI does, to obtain information on veteran suicides 
directly from them.
    And finally, VA has a new way of obtaining information on both 
suicides and suicide attempts: the Department's suicide prevention 
coordinators.
    Until VA committed itself last year to providing full time suicide 
prevention coordinators at each of its 153 hospitals, it could provide 
no useful number of attempted suicides among patients. Last October, a 
standardized definition of suicide attempts was developed and 
coordinators were asked to begin to count the number of such attempts 
of which they were aware.
    VA's definition of a suicide attempt included any behaviors that 
might have potentially allowed veterans to injure themselves, when 
there was evidence that the veteran had the intent to kill himself or 
herself--whether or not he or she was actually injured. The definition 
also included events in which a veteran was rescued, an attempt 
thwarted, or a veteran changed his or her mind after taking an initial 
action.
    On February 13, 2008, an internal email from VA's Deputy Chief of 
Patient Care Services for Mental Health discussed the existence of this 
information. In this email, he suggested 1,000 veterans a month under 
VA care were being reported as attempting suicide, and was concerned 
about disclosing the information.
    The data was not sent to CBS because of his concerns.
    The number of attempts referenced was based on only three months 
worth of data, too short a time period to determine if it was reliable.
    The data was demonstrably not accurate. Even now, six months after 
collecting data began, the reports indicate that a number of states 
have suspiciously low reporting rates--and there is remarkable 
variability among individual VA facilities throughout the United 
States, due either to regional variability in suicide rates, 
differences in the manner in which individual suicide coordinators 
reported data, or both.
    VA's suicide prevention coordinators were new to their jobs, and 
new to their tasks. There was a great deal of uncertainty over 
``borderline calls,'' and many of them were just beginning to make the 
community and in-hospital contacts that are essential in making an 
accurate count of the number of suicide attempts among patients.
    VA is addressing the problem of the accuracy of suicide 
coordinators' data in a number of important ways; by regularly 
reviewing the data the Department receives, and educating coordinators 
on the proper way to collect and report this information;
    And VA is regularly reviewing difficult ``calls'' with its suicide 
coordinators--and encouraging them to meet the right people in their 
communities to obtain additional data.
    In the near future, the Department intends to ask suicide 
prevention coordinators for the names of all those in their facility 
who have attempted suicide. This will allow further refinement of this 
data by checking the electronic medical records of individual veterans 
whose names have been reported as having attempted suicide. VA will 
learn how this information has been entered into the health record, and 
how practitioners have incorporated this information into the treatment 
plan for the individual whose record is being reviewed--with important 
implications for preventing suicide throughout VA's system.
    VA's suicide coordinators are providing another important service; 
they are providing an additional source of data on the number of 
completed suicides at their facilities. This data, too, has significant 
problems: while VA can tell with considerable accuracy how many 
veterans commit suicide within its facilities, suicide coordinators 
have both limited time and contacts among coroners and funeral 
directors to provide accurate counts of the numbers who have died of 
suicide in the community.
    While coordinators will be encouraged to continue to make those 
contacts, and to attempt to refine the accuracy of the numbers of dead 
they submit, VA believes that the focus of suicide prevention 
coordinators must be on preventing suicide among the living. 
Epidemiologists and researchers, using the data sources described 
above, will be the ones to learn more from those who have been lost.
    Before turning to the actual data, here is a brief explanation of 
some data which has been widely attributed to VA, but which, in fact, 
is not the Department's. On March 20, 2008, CBS aired a story on 
veterans' suicide which included a statement in which the network said 
it had ``obtained from VA'' the information that there had been 790 
attempted suicides among veterans under the Department's care in all of 
2007.
    VA has since reviewed its records to try to understand where CBS 
might have gotten their information, and believes the number stemmed 
from a response to a Freedom of Information Act Request CBS made to the 
Veterans Health Administration's Freedom of Information Act Officer on 
December 20, 2007; a request that was subsequently modified on January 
29, 2008. VA provided CBS with the information they asked for--
information in the Department's National Patient Care Data base for the 
years 2000 through 2007, broken down by year, state, age group, gender 
and race.
    This data provides a breakdown of why veterans were seen in VA's 
hospitals and clinics by International Classification of Diseases code. 
Once such code is ``Suicide and other Self-Inflicted Injuries.'' CBS 
apparently counted the total number of veterans for whom that code was 
entered--and came up with 790 attempts for 2007.
    That number, unfortunately, is not at all useful if the purpose of 
the count is to determine the total number of suicides and attempts 
among veterans under VA's care. Some people who attempt suicide, but do 
not die, do not then present directly to VA for care. Others do not 
admit that their injuries were due to suicide attempts until a 
counselor discusses their situation with them. And still others treat 
their own wounds without seeing a clinician; the attempt is only 
revealed later, during counseling. CBS's number, while arithmetically 
correct, is actually misleading.
3. VA' S DATA ON SUICIDES AND ATTEMPTS
    To review what we do know specifically, let us compare veterans' 
rates of suicide to non-veterans rates. The source of the base data is 
the National Death Index, a product of the National Center for Health 
Statistics of the Department of Health and Human Services. The most 
current complete data in this area is from 2005; 2006 data should be 
released soon. The overall rates of suicide for men and women from 2001 
through 2005 are shown in Tables 1 and 2. It is important to separate 
the rates for men and women. By doing so, we see that men have a higher 
rate of suicide than women; a rate that is statistically significant. 
It is also important to separate these figures by age groupings, 
because there are significant differences in that area as well. These 
tables provide that information as well.

                  Table 1:  Suicide Rates Per 100,000 Male U.S. Citizens by Fiscal Year and Age
----------------------------------------------------------------------------------------------------------------
                                                                  2001      2002      2003      2004      2005
----------------------------------------------------------------------------------------------------------------
All men                                                           23.18     23.63     23.20     23.20     23.19
----------------------------------------------------------------------------------------------------------------
18-29                                                             20.14     20.08     19.38     20.21     19.35
----------------------------------------------------------------------------------------------------------------
30-64                                                             22.45     23.10     23.13     23.00     23.19
----------------------------------------------------------------------------------------------------------------
65+                                                               31.42     31.81     29.76     29.01     29.53
----------------------------------------------------------------------------------------------------------------


                 Table 2:  Suicide Rates Per 100,000 Female U.S. Citizens by Fiscal Year and Age
----------------------------------------------------------------------------------------------------------------
                                                                  2001      2002      2003      2004      2005
----------------------------------------------------------------------------------------------------------------
All women                                                          5.22      5.44      5.42      5.81      5.65
----------------------------------------------------------------------------------------------------------------
18-29                                                              3.40      3.67      3.56      3.91      3.90
----------------------------------------------------------------------------------------------------------------
30-64                                                              6.28      6.47      6.57      7.09      6.78
----------------------------------------------------------------------------------------------------------------
65+                                                                3.88      4.09      3.79      3.79      3.99
----------------------------------------------------------------------------------------------------------------
Source: CDC's WISQARS Injury Reporting System and CDC's National Center for Health Statistics' National Death
  Index


    Tables 3 and 4 provide overall rates of suicide for male and female 
Veteran VA users, broken down into three age groups: 18 to 29; 30 to 
64; and 65 and older.

                Table 3:  Suicide Rates Per 100,000 Male Veteran VA Users by Fiscal Year and Age
----------------------------------------------------------------------------------------------------------------
                                                                  2001      2002      2003      2004      2005
----------------------------------------------------------------------------------------------------------------
All Male VA users                                                 36.49     41.58     32.92     35.40     37.19
----------------------------------------------------------------------------------------------------------------
18-29                                                             27.75     36.54     35.64     42.54     26.94
----------------------------------------------------------------------------------------------------------------
30-64                                                             41.37     46.32     39.57     38.44     40.66
----------------------------------------------------------------------------------------------------------------
65+                                                               32.03     37.03     26.77     32.09     34.27
----------------------------------------------------------------------------------------------------------------


               Table 4:  Suicide Rates Per 100,000 Female Veteran VA Users by Fiscal Year and Age
----------------------------------------------------------------------------------------------------------------
                                                                  2001      2002      2003      2004      2005
----------------------------------------------------------------------------------------------------------------
All Female VA users                                                9.87     12.49      9.00     12.28     13.59
----------------------------------------------------------------------------------------------------------------
18-29                                                              2.12     15.75      5.93      7.41      7.81
----------------------------------------------------------------------------------------------------------------
30-64                                                             11.99     11.17     10.76     14.88     13.96
----------------------------------------------------------------------------------------------------------------
65+                                                                6.58     15.66      3.95      4.31     17.60
----------------------------------------------------------------------------------------------------------------
Source: CDC's National Center For Health Statistics' National Death Index


    These tables show that men, whether or not they are veterans, have 
a higher rate of suicide than women, in numbers that can be considered 
statistically significant. In addition, there are significant 
differences by age groupings. VA is able to make these comparisons, 
because it is able to match the names of veterans under our care whom 
we have not recently seen against the National Death Index. The Death 
Index then provides information on which of these men and women have 
died, and the cause of their death, including suicide.
    What cannot be learned from this table is how the rates of suicide 
compare among all veterans, not only those in the VA system, to the 
general population. Doing so would require matching the full list of 
24.5 million veterans against the National Death Index to see how many 
of them have committed suicide. That currently is not possible. 
However, VA has matched up general population rates of suicide in the 
sixteen states reporting to NVDRS in 2005 against the rate of veteran 
suicide in those states.

     Table 5:  Suicide Rates per 100,000 in 16 States Among General
            Population vs. Veteran Population (Males) in 2005
------------------------------------------------------------------------
                                              18-29     30-64      65+
------------------------------------------------------------------------
All male VA users                             53.18     36.85     36.00
------------------------------------------------------------------------
All male veterans                             44.99     25.60     31.52
------------------------------------------------------------------------
All men                                       20.36     23.28     30.51
------------------------------------------------------------------------


     Table 6:  Suicide Rates per 100,000 in 16 States Among General
            Population vs. Veteran Population (Women) in 2005
------------------------------------------------------------------------
                                              18-29     30-64      65+
------------------------------------------------------------------------
All female VA users                           25.02     15.81       ---
------------------------------------------------------------------------
All female veterans                           15.35     11.41      3.66
------------------------------------------------------------------------
All women                                      4.35      7.04      3.63
------------------------------------------------------------------------
Sources:
General Population: CDC's Web-based Injury Statistics Query and
  Reporting System
OEF/OIF: DoD's Defense Manpower Data Center
Suicide Data: CDC's National Center for Health Statistics National Death
  Index and CDC's National Violent Death Reporting System


    At this time, there is no firm explanation of the reason for the 
disparity in rates between VA's patients and other Americans. However, 
the veterans VA serves--as opposed to the overall population of 
American veterans--are older, sicker, and poorer than the general 
population of the United States. VA researchers believe this may 
account for at least some of the apparent differences.
    VA's summary of this data from 2001 through 2005 yields the 
following hypotheses:

      Male veterans commit suicide at a somewhat higher rate 
than other men, but with varying statistical significance by age and 
over different years.
      Within the group of male veterans there are differences 
in the age at which veterans die of suicide compared to what is seen in 
the general population--especially in the ages between 30 and 64, at 
which ages veterans have a statistically significant higher rate. This 
finding is reproducible over time.
      Male veterans commit suicide at a higher rate than female 
veterans.
      Within the group of female veterans, there is nearly a 
twofold increase over the rate of suicide for women in the general 
population, which is also variably statistically significant over the 
years and by age.

    Clearly, returning service men and women represent a group of 
particular interest to the Nation. VA has a particular sense of urgency 
to understand why these men and women might be taking their own lives--
and to intervene to prevent even a single suicide. To better understand 
suicide in this particular cohort, Dr. Han Kang of VA's Environmental 
Epidemiological Service conducted a study that matched those 
servicemembers who had served in the theater of operations, and who 
separated from service between 2002 and 2005 against the National Death 
Index.
    Using this method, Dr. Kang found that 144 out of 490,346 separated 
OEF/OIF servicemembers committed suicide during that time, for an 
overall rate of 21.9 per 100,000. These are deaths only of men and 
women who separated from the military, and the data does not include 
any suicides while a servicemember was on active duty.
    To compare this to other national norms, Dr. Kang looked at this 
cohort against the national averages discussed above. For OIF/OEF 
veterans who had deployed and separated from 2002-2005, the rate was 
slightly higher than would be expected in an age, gender and race 
matched general population, but not by a statistically significant 
amount. (Standardized mortality Ratio of 1.15 (p >.05.)
    Dr. Kang also examined this data for differences in suicide rates 
between those who have used VA for care and those who have not. He 
found that 17.0 of every 100,000 OEF/OIF veterans who use VA for care 
take their own lives, compared to 24.0 of every 100,000 OEF/OIF 
veterans who do not use VA for care. This apparent advantage of VA 
care, though encouraging, is not statistically significant. In this 
group, the same is true for vet center users.
    Male veterans 18-29 who used VA care took their own lives at a rate 
of 21.0 per 100,000, compared to veterans of that age who did not use 
VA for care, a group which died of suicide at a rate of 30.4 per 
100,000--a statistically significant difference. Male veterans aged 30-
64 who used VA for care died of suicide at a rate of 17.5 per 100,000, 
compared to a rate of 22.8 per 100,000 for their fellow veterans who 
did not use VA for care--not a statistically significant difference. 
Since only 3 women OEF/OIF veterans died of suicide through 2005, 
accurate rates within age groups cannot be calculated.
    VA statisticians have worked with this now-older data in 
anticipation of follow-on data when the updated National Death Index 
information is available. Some of the insights they have found include 
the knowledge that there appears to be little variation in suicide risk 
by branch of service. Statisticians also found that a diagnosis of a 
mental disorder predicted a nearly 1.8 times higher suicide risk than 
the general population. This is consistent with what has been published 
in research journals regarding the non-veteran population, and 
emphasizes the importance of the Department's mental health efforts.
    All of this data comes from national data for suicide against those 
who are known, from VA's data sources or from Department of Defense 
records, to be veterans. These national numbers must be used because 
VA's clinical records do not capture, in any reliable or complete way, 
such events as suicides or suicide attempts.
    The National Death Index, a national roll-up of information from 
coroners through the states, offers the most complete compilation of 
deaths among veterans and their causes--since VA may not know of a 
death even if it occurs in an area in which the Department has a 
facility. Because information on deaths continues to be updated as 
reports come in over time, confidence in the completeness of those 
numbers only comes after several years of data collection. VA is 
awaiting at this time the release of National Death Index compilations 
for 2006 for further analysis.
    Regarding inpatient deaths: from 2000 through 2007, exactly 50 VA 
inpatients took their own lives while under the Department's care, 
based on root cause analyses of the deaths received by VA's Office of 
Patient Safety. That number varies from a high of 14 such suicides in 
2002, to a low of 2 in 2007, when Veterans Health Administration 
officials demanded that all facilities pay special attention to 
improving their environment of care to reduce opportunities for 
suicide.
4. VA' S SUICIDE PREVENTION EFFORTS
    The steps VA is taking to prevent suicide among veterans are 
important and significant. All VA employees have been given the message 
that even strong and resilient people can develop mental health 
conditions; care for those conditions is readily available and should 
be immediately provided; and treatment works.
    VA has held two National VA Suicide Prevention Awareness Days 
throughout its system to focus all 200,000 health care employees on 
this issue. The first event focused on enhancing overall awareness of 
the issue. The second coincided with National Suicide Prevention 
Awareness Week. During that week, VA staff was trained on how to work 
with available prevention resources, including the hotline and the 
suicide prevention coordinators. VA will continue participating in 
Suicide Prevention Awareness Week activities every year, with a special 
focus on veterans and ways VA can continually improve its suicide 
prevention efforts.
    The Department is in the process of adding 23 new vet centers 
throughout the Nation to provide more individual, group and family 
counseling to veterans of all wars who have served in combat zones, 
bringing the total number of vet centers to 232.
    VA's suicide prevention program includes two centers that conduct 
research and provide technical assistance in this area to all locations 
of care. One is the Mental Health Center of Excellence in Canandaigua, 
New York, which focuses in developing and testing clinical and public 
health intervention related to suicide risk and prevention. 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 with special emphasis on issues related to suicide risk.
    VA's system of care also includes a suicide prevention call center, 
also located in Canandaigua, and the suicide prevention coordinators 
previously discussed, who are located at 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.
    To develop the suicide prevention call center, the Department has 
partnered with the Lifeline Program of the Substance Abuse and Mental 
Health Services Administration. Those who call 1-800-273-TALK are asked 
to press ``1'' if they are a veteran, or are calling about a veteran.
    Unlike other such hotlines, VA's hotline is staffed solely by 
mental health professionals--24 hours a day, seven days a week. Hotline 
staff is trained in both crisis intervention strategies, and in issues 
relating specifically to veterans, such as traumatic brain injury and 
post traumatic stress disorder. In emergencies, the hotline contacts 
local emergency resources such as police or ambulance services to 
ensure an immediate response.
    Cards, pamphlets and posters--even refrigerator magnets--bearing 
the number are distributed by suicide prevention coordinators to at-
risk veterans and their family members.
    In addition, posters with hotline information are located 
throughout VA medical centers and clinics, and in all residential 
rehabilitation programs there are stickers on phones and by doors with 
the hotline number. Vet Centers also make this information available.
    If the caller is a veteran enrolled with VA for care, the hotline 
staff is able to use the veteran's electronic medical record during the 
call, if the veteran is a VA patient and willing to identify himself or 
herself. These records provide information that is invaluable during a 
crisis, including information on medications; the patient's treatment 
plan; and who to contact during this emergency.
    Staff can talk directly to the facility that is treating the 
veteran. They can place consults in the patient's medical record, and 
are able to make arrangements to directly refer veterans to a Medical 
Center or Community-based outpatient clinic to be seen if that's 
appropriate.
    And hotline staff follows up on these referrals. They check 
patient's records to see if consultations were completed; actions are 
taken; and followups are ongoing. If the record does not show this 
information, the suicide prevention coordinator is called, ensuring 
that no referral is lost in the process.
    From its beginnings in July, 2007 through the end of April, 16, 414 
calls have come to the hotline from veterans and 2125 family members or 
friends have called. These calls have led to 3464 referrals to suicide 
prevention coordinators and 885 rescues involving emergency services. 
493 active duty servicemembers have also called.
    Besides keeping track of veterans who have tried to take their own 
lives, suicide prevention coordinators receive referrals of those at 
risk for suicide from both the hotline and from providers in their 
facilities. They also ensure that care for these veterans is 
appropriate for their situations.
    Coordinators educate their colleagues, veterans and families about 
risks for suicide. They 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 their care is enhanced to reduce the risk of 
renewed attempts.
    They also work with patient safety officers to conduct quarterly 
safety inspections of inpatient psychiatry units, and coordinate staff 
education programs about suicide prevention. These coordinators are in 
the process of organizing a system of flags in the electronic medical 
record system to alert providers about those at high risk. They are 
also conducting training for community members who have frequent 
contact with veterans to help them recognize those at risk and 
encourage them to seek treatment.
    There is a large body of scientific literature on suicide. Over the 
years, VA has been a prime contributor to the knowledge that has been 
developed in the scientific community on this issue. Our research has 
helped us target our efforts to reduce suicide. Some of the information 
our researchers have developed includes:

      Among veterans receiving care from VA who died from 
suicide, almost 60% of those under age 65 had a mental health or 
substance abuse diagnosis on their medical records--but only 24% of 
those 65 or over had such a diagnosis.
      There is significant variability in suicide rates among 
veterans by geography. In general, rates are lowest in the Northeast 
and highest in the West.
      Firearms are the most common means used by veterans who 
died of suicide, accounting for nearly two-thirds of all deaths.
      There appears to have been an increase in suicide rates 
among Vietnam veterans during the first two years after these veterans 
returned home. After a few years, however, Vietnam veterans' rates of 
suicide were comparable to those of the general population.
      There was no increase in suicide rates among veterans who 
returned from the first Gulf War.
      Those veterans who are wounded in combat are at higher 
risk of suicide.

    5. FUTURE ACTIVITIES
    In the near future, the Department will continue to educate its 
employees; through additional Suicide Prevention Days; through posters 
identifying the warning signs of suicide; and through its continuing 
Employee Education process to identify those at possible risk of 
suicide to ensure they get proper care. As new data on suicide rates, 
risk factors for suicide and regional variations become available, VA 
will use that data to refine its programs, and to better evaluate their 
level of success.
    VA will increasingly reach out to the newest generation of 
veterans, by using communications outlets familiar to them. VA now has 
a virtual office on ``Second Life;'' and recently collaborated with MTV 
on a video on readjustment issues for returning veterans that can be 
found on their Web site.
    VA will continue its efforts to meet the mandate of the President's 
New Freedom Commission to reduce the stigma that surrounds mental 
illness.
    VA will also continue the expansion of its mental health program 
that has enabled the Department to hire more than 3800 new mental 
health employees in the past three years, and expand hours of operation 
for mental health clinics beyond normal business hours. These efforts 
to better identify and treat mental illness will help prevent 
contemplation of suicide and suicide attempts--and will help ensure 
that veterans in crisis are already involved in VA's system and have 
somewhere to turn when they need help.
    The Department will aggressively follow up on patients in mental 
health and substance abuse programs who miss appointments to ensure 
they are not lost to follow up care. VA will also monitor the standards 
the Veterans Health Administration has set for itself: to provide 
initial evaluations of all patients with mental health issues within 24 
hours, provide urgent care immediately when that evaluation indicates 
it is needed, and to complete a full evaluation and initiate a 
treatment plan within 14 days for those not needing immediate crisis 
care.
    On May 2, VA began contacting nearly 570,000 combat veterans of the 
Global War on Terror to ensure they know about VA medical services and 
other benefits. The Department will reach out and touch every veteran 
of the war to let them know it is here for them. The first of those 
calls are going to an estimated 17,000 veterans who were sick or 
injured while serving in Iraq or Afghanistan. If any of these 17,000 
veterans do not now have a care manager to work with them to ensure 
they get appropriate healthcare, VA will offer to appoint one for them.
    All case managers for OEF/OIF veterans will be trained in suicide 
risk recognition and management for their patients, and encouraged to 
establish a personal relationship with those veterans to support their 
healthcare needs.
    I have also directed the creation of a work group on suicide 
prevention in the veteran population. This work group will look at all 
matters relating to VA's ability to prevent suicide among veterans. 
They will be given all the data VA has, and access to the best experts 
VA knows.
    The work group will be asked to provide a report within fifteen 
days of the completion of their meeting on how VA can better approach 
suicide prevention, suicide research, and suicide education.
    All work group members will come from outside the Department of 
Veterans Affairs. Some will be DoD specialists; others will be from 
other government agencies. Nationally recognized clinical treatment, 
research and public health experts on suicide and suicide prevention 
will augment them. The work group will provide an additional level of 
advice and oversight to all the issues described above.
    There is nothing more tragic than the loss of even one of those 
great men or women who have served this nation. The VA is committed to 
doing all that we can to serve the individual while we continue to try 
to understand a very complicated problem that is also a national 
problem. We owe this committee and the nation accurate information and 
carefully studied, thoughtful conclusions while we provide the ``best 
care anywhere'' to our Veterans.
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               Statement of Ronald William Maris, Ph.D.,
   Distinguished Professor Emeritus, Past Director of Suicide Center,
                    Adjunct Professor of Psychiatry,
               and Adjunct Professor of Family Medicine,
     University of South Carolina, School of Medicine, Columbia, SC
    What Causes Suicide? Suicide is not one thing, but is a 
multidimensional outcome (including a continuum of self-destruction 
from unintentional self-harm, partially self-destructive behaviors, 
ideas about suicide, plans to suicide, lethal and non-fatal suicide 
attempts, and finally, to suicide completions; which themselves can be 
escape, revenge, altruistic, and/or risk-taking) resulting from several 
risk factors interacting over time (what I call a ``suicidal career,'' 
Maris, 1981). Risk factors for suicide include relatively chronic 
vulnerabilities (like being an aging male, owning a gun, having a 
history of depressive disorder, being an alcoholic, etc.) and more 
acute stressors (like post-traumatic stress disorder, recent losses, 
pharmacological crises [such as serotonergic dysfunctions], inability 
to get effective healthcare, etc.).
    From my case-control surveys I have derived about 15 evidence-based 
risk factors for suicide outcomes (the following list includes 
statistically significant risk factors compared to controls of nonfatal 
suicide attempts and natural death in a random sample of 2,153 suicides 
(Maris, 1969 and 2002). There could be more than just fifteen risk 
factors for suicide (See Maris, 2000, Chapter 17) and the list below is 
not necessarily ranked (although factors 1 and 2 tend to be the most 
prevalent in suicides). The factors that cause most suicides are (See 
Maris et al., 2000:80; Maris, 2002; Maris, 2007):

      Depressive and affective disorders, schizophrenia
      Alcohol and substance abuse
      Suicide ideas, plans, preparations
      Prior suicide attempts (caveat: many white males die 
after one attempt)
      Available lethal methods (especially, firearms)
      Social isolation, loss of social support
      Hopelessness (Beck claims hopelessness is more predictive 
of a suicide outcome than depression is; See Maris et al., 1992)
      Being an older white male (generally the older, the more 
likely suicide is)
      History of suicide or mental disorder in one's first 
degree relatives
      Work problems, unemployment, lower SES, homelessness
      Marital problems & discord, separation, divorce, 
widowhood
      Stress, PTSD, negative life events, traumas
      Feelings of anger, aggression, impulsivity, serotonergic 
dysfunction
      Physical illnesses; like spinal cord, brain injury, 
epilepsy, arthritis, ulcers
      Repetition and co-morbidity of above risk factors; 
``suicidal careers''

    Obviously, what causes veteran suicides has both common and unique 
factors compared to the general population in the United States. Murphy 
and Robins (1970, 1981) found in St. Louis county that about 47% of all 
suicides had an affective disorder and 25% had alcohol problems. Rates 
of depression, alcohol abuse, having a firearm, isolation, marital 
disruption, and trained aggression are all more prevalent in veteran 
populations. Zivin (12/7/07 @ 2193) estimated that veteran depression 
symptoms are 2 to 5 times higher than those in the general population.
    Kang (12/11/07) states that as of 9/2007 among vets in healthcare 
at the VA, 40% had major depression diagnoses and 20% had diagnoses of 
PTSD (DSM IV code 309.81).
    Post-traumatic stress disorder is extremely important among combat 
veterans (about 33% of female veterans experience sexual trauma, which 
can also cause PTSD) because it is common (15 to 50% of vets have PTSD; 
See Vets for Common Sense et al. v. Peake et al. Complaint, 7/23/07 @ 
18-69) and it is interactively related to other suicide risk factors. 
CBS (11/13/07) reports that 28.3 percent of Iraq vets had mental health 
problems. Kang (12/11/07 @ 445) claims that of the approximately 1.6 
million troops deployed in Afghanistan and Iraq 3,444 (now over 4,000) 
have been killed and 90% have been ``traumatized.''
    PTSD was first stated as a psychiatric anxiety diagnosis in 1980 in 
the DSM-III (code 309.81). It involved the following symptoms or 
criteria:

      Being exposed to a traumatic event where death or serious 
injury occurs accompanied by feeling of intense fear and helplessness.
      The event is persistently re-experienced.
      The victim avoids trauma-associated stimuli.
      The victim experiences symptoms of increased arousal.
      The symptoms last one month or more (acute v. chronic) 
and are characterized by social and occupation dysfunction
    PTSD is one of the unique suicidogenic factors among veterans and 
interactively raises other suicide risk factors. Note, too that the 
percentage of all USA general population deaths that are suicides is 
2.1% (AAS, 1/24/08). But among 15 to 24 year-olds 12.3% of all death 
are by suicide. Kang reminds us that the median vet suicide age is 20 
to 29 (12/11/07 @ 441) and 18-24 year-old soldier suicides make up 26.3 
% of all suicide [about twice that of the non-soldier population]. 
Thus, obviously, the prompt and accurate diagnosis and treatment of vet 
PTSD (and related depressive and substance abuse disorders) is a major 
condition for veteran suicide prevention.
    One reason I cannot answer definitely about what causes veteran 
suicides is that the Office of Veteran Affairs has not provided me or 
the courts crucial data that are needed. For example, each time there 
is a military death, suicide attempt, or other serious incident, the VA 
produces a short ``incident brief'' which summarily describes the 
suicide or suicide attempt (Feeley, 4/9/08 @ 158). Then about 45 days 
later each incident undergoes what is called a ``root cause analysis'' 
and a 3-page report is generated (Feeley @ 160). On April 22, 2008, 
when I was an expert for the Plaintiff in the Veterans . . . v. Peake 
trial in San Francisco, I was given only 170 of the estimated 15,000 
incident briefs and none of the root cause analyses. Clearly these VA 
documents could go a long way in establishing what causes veteran 
suicides and whether or not there is an ``epidemic'' (Dr. Katz denies 
that there is an epidemic, 11/13/07). It seems that these personal, 
clinical documents could be redacted, with patients' names and other 
identifying information removed, and then supplied to independent 
scientific investigators, like myself. Clearly such crucial documents 
would help clarify how many vet suicides there are and what the VA 
thinks causes them (i.e., what are the root causes).
    How High is the Veteran Suicide Rate and Is It An ``Epidemic''? 
Virtually everyone agrees that the Iraq & Afghan vet suicide rates are 
higher than those of the general USA population. One problem in getting 
a consistent answer to our question is that there are shifting veteran 
populations (all vets, WWII, Korea, Viet Nam, Gulf War, Afghanistan, 
and Iraq), shifting times frames (e.g., yearly, 01-05, 06-08, etc.) and 
various samples based on different data sets (e.g., incident briefs, 
death certificates from the U.S. Department of Vital Statistics, 
Department of Defense data, etc. Consequently there is a very wide 
range of estimates of vet suicides.
    Nevertheless, there is consensus that the vet suicide rates 
(especially in OEF/OIF veterans; viz., Afghan and Iraq vets) are higher 
than those of the general population; high enough to constitute a 
serious national problem that demands resolution (Katz, 11/13/07).
    Some of the estimates of veteran suicides rates and how much higher 
they are than those of the general population are:

      Katz (VA Deputy Chief of Patient Care Services) (2/21/08) 
says 3.2 times higher (suicide rate of 34.6 /11, N = 8,218, VHA 
patients from 2001-2005).
      OIG Mental Health Strategic Plan for Suicide Prevention 
(5/10/07) says 7.5 times higher (viz., 83/100,000/11), page 8.
      Rathbun/CBS (2/28/08) says 1.8 to 2.3 times higher (6,256 
vets of any war surveyed in 45 states = about 120 vet suicides per 
week).
      Zivin (12/7/07 @ page 2194) says 1683 of 807,694 vets 
suicided = 208/100,000 or about 19 times higher than the general 
population.
      Katz (2/13/08 in an e-mail to Ev. Chasen) says that ``VA 
suicide prevention coordinators are identifying about 1,000 suicide 
attempts per month among vets seen in VA medical facilities (note: 
usually suicide attempts exceed completed suicides about ten to twenty-
five times [AAS, 1/24/08]).
      Katz (e-mail to Kussman [Under Secretary for Health] on 
12/15/07) reports 18 suicides per day out of 25,000,000 total vets.
      Kang (12/11/07) simply says ``the risk of death for vets 
from suicide and motor vehicle accidents is higher that for the general 
population'' (page 444, N = 144, 01-05, OIF/OEF vets only).

    How high is a high enough vet suicide rate to merit national 
concern? From one perspective even one suicide is too many, since 
suicide is one of the leading causes of unnecessary death (See Maris et 
al. 2000). William Feeley, Deputy Under Secretary for Health Care 
Operations at the VA, said in a deposition (4/9/08, p. 38): ``Suicide 
occurs like cancer occurs.'' Wrong! We all have to die (some by cancer, 
some by heart disease, etc.), but no one needs to suicide. The VA seems 
to think that a certain number of vet suicide deaths are inevitable and 
that there is not much we can do about them.
    When I consulted with Columbia University and the FDA to determine 
if 9 antidepressant medications caused child and adolescent suicide, 
the FDA decided that a relative risk of 2.1 or higher was sufficient to 
require a Black Box warning be put in the drug's package insert and in 
the Physician's Desk Reference. While there is no arbitrary bright line 
for danger, note that almost all of the relative risks for vet suicide 
are above 2.0.
    Webster says an ``epidemic'' means prevalent and spreading rapidly 
among many people in a community (like the U.S. military) at the same 
time.'' Although we often reserve the concept of epidemic for extreme 
cases like the plague, smallpox, influenza, polio, etc. It does seem 
that veteran suicides are the product of a disease process and are 
increasing. For example, Kang (12/11/07 @ 441) claims the following 
percentages for vet suicides (OIF/OEF) from 2002 to 2006:

    2002 = 7%
    2003 = 21%
    2004 = 48%
    2005 = 68%

    This looks a little like an epidemic to me (although one would need 
to control for the numbers of vets and calculate rates).
    The Office of the Inspector General's Mental Health Strategic Plan 
for Suicide Prevention (by John Daigh, Jr., M.D., Assistant Inspector 
General. 5/10/07). The purpose of this ambitious document is to assess 
implementation of action pertaining to suicide prevention in the VHA's 
mental health strategic plan (p. 1). Overall I found this plan to be a 
systematic, well-organized survey, but in fact it points out many of 
the VA's shortcomings in suicide assessment and prevention. For the 
record in the VA there are (1) 21 regions (``VISNs''), (2) 154 
hospitals or medical centers, (3) 875 outpatient clinics or ``CBOCs'', 
and (4) 136 nursing homes (Feeley, 4/9/08 @ 45).
    In the plan overview (@ iv) it indicates that ``at present the MHSP 
initiatives for suicide prevention are only partially implemented.'' 
For example, on page 21 there is a chart summarizing the findings for 
six major objectives:

              Areas:
                           Findings:                               
    A. Crisis intervention
                        24 hour mental health services in 94.5% of 
facilities
    B. Screening
                        98% screen for depression, major suicide risk 
factor
    C. Assessment
                        70% do not have tracking system
    D. Interventions
                        61.8% do not target special groups
    E. Databases
                        See SMITREC (data not available)
    F. Education
                         61.4% of facilities did not make information 
on suicide risks mandatory

    The document (Cf., ``Suicide Risk Assessment Guide, Reference 
Manual,'' VA 001510 in Vets . . . v. Peake, 5/21/08, p. 1, no date) 
argues that suicide attempts are a major risk factor for suicide in 
vets (p. 1). The problem with this finding is that about 90% of older 
white males only make one suicide attempt (usually because they shoot 
themselves in the head; See Maris, 1981). Thus, for most vet suicides, 
a prior suicide attempt cannot be used to prevent their suicides. It is 
too late already.
    Later (p. 16) the MHSP document argues that the ``VA strategy for 
suicide prevention should include universal screening designed to 
activate the system for suicide prevention.'' In fact (See ``Suicide 
Template,'' below) universal screening for vet suicide prevention 
includes asking only two questions (viz., ``Have you felt depressed or 
hopeless in the last two weeks?'', and ``Have you thought about 
hurting/harming yourself in the last two weeks?'' If the vet answers 
``No'' to question # two, no further suicide screening is done (Cf., 
Marcus Nemuth deposition, 3/25/08, VA staff psychiatrist in Seattle 
area). Asking one or two suicide questions, which could easily be 
denied, misunderstood, misrepresented, etc., is not a suicide screen up 
to the standard of care. Probably self-destruction is under-counted by 
the VA with such perfunctory screens.
    Importantly, when the VA measures the crucial suicide risk factors 
of depression and hopelessness, as far as I could determine, they just 
use self-reporting; not short, reliable and valid scales, like:

      The Hamilton Rating Scale for Depression (1960)
      The Beck Depression Inventory (1967; Cf., Maris et al., 
2000: 84)
      Beck Hopelessness Scale (1974; Maris et al., 2000, Figure 
3.5, p. 85)
      Beck Suicide Intent Scale (1990)

    All of these scales are relatively short (17-20 questions), have 
the advantage of indirection (i.e., the vet is not sure what they 
measure), have known validity and reliability, and could be done in 15 
to 30 minutes. Since hopelessness and depression are key suicide risk 
factors, they should be measured systematically, not by subjective 
self-reporting. Finally, some vets may not even know if they are 
depressed, hopeless, or suicidal.
    On page 36 of the MHSP we are told ``90.9% of the VA facilities do 
not have suicide case managers.'' Why identify vets with suicide risk, 
if no one follows them? Recently, I have been told that in fact there 
are ``suicide coordinators'' in all 21 VA VISNs in the 154 medical 
centers (but none at the 875 CBOCs). However, it is unclear (to me) who 
these people are, what their suicide prevention training is, what their 
exact job descriptions are, and how effective they are. There is also a 
question about the quality of staffing of CBOCs, most of which have 
LPNs, RNs, MSWs, and MA psychologists, and not psychiatrists.
    We know that two psychiatric drugs have proven very effective in 
reducing suicidality in patient populations. One of these medications 
is lithium (See Baldessarini in Simon and Hales, 2006) for depressed 
and bipolar I patients even get lithium (@ p. 41). Likewise with 
suicidal schizophrenic patients, the drug Clozaril has been shown to be 
effective in clinical trials in reducing the suicide rate (See MHSP @ 
42). In the vast majority of VA clinics (90.7%) fewer than 10% of their 
schizophrenic patients are on Clozaril.
    Thus, most of the MHSP initiatives are only partially implemented 
after several years (about four years) and some of the operational 
definitions of key risk factors are below the standard of care.
    Measuring Suicide Risk Factors and the Suicide Template. There is 
no reason why all veterans could not have all significant suicide risk 
factors measured at least at deployment, discharge, or at other crucial 
clinic visits (see my list of 15 suicide risk factors on page 1, 
above). The VA's ``Suicide Risk Screening and Comprehensive Suicide 
Risk Assessment'' form (aka ``Suicide Template'' or ``Suicide Risk 
Assessment Pocket Card'') is woefully inadequate to detect suicidality. 
As I said above, just asking if the vet felt (1) hopeless or depressed 
in the last two weeks or (2) thought about harming themselves in any 
way does not measure suicidality.
    The vet could easily deny depression or suicide ideation 
(especially if they thought it might affect their promotions or 
military career, or were ashamed of their mental health issues). When I 
worked for the U.S. Army in Berlin, Germany, doing suicide prevention 
training, the staff psychiatrist there told me he had little to do, 
because especially male soldiers would not admit to any mental health 
problems for various career reasons. Many males do not seek mental 
health treatment. Other soldiers may not even realize they are 
depressed or self-destructive.
    In short, all the questions on the suicide template need to be 
asked and answered and put in objective formats that do not make it 
obvious what is being measured. The suicide pocket assessment card has 
questions about (1) a suicide plan, (2) whether the plan includes 
firearms, (3) what psychiatric symptoms the vet is having, if any, (4) 
lack of social support, (5) the age, sex, race and family history of 
suicide of the vet, (6) whether or not there have been any prior 
suicide attempts, (7) levels of impulsivity, (8) past psychiatric 
diagnoses or treatment, (9) chronic pain, (10) protective factors like 
religion, (11) additional risk factors, (12) quantification of suicide 
risk level, and (13) immediate actions and treatment needed. Every vet 
should have every risk factor assessed, not just one or two of them, 
and asked in a manner that is effective.
Systematic Healthcare Deficiencies as Reflected in the VA Incident 
        Briefs.
    Although I was provided only 170 of the estimated 15,000 incident 
briefs in which VA patients' suicides and suicide attempts were 
described, nonetheless they provide a sample of suggested systematic 
healthcare and treatment deficiencies identified by the VA itself. 
Below are some of the highlighted treatment failures of the VA in 
assessing and managing suicidal veterans (all documents were provided 
in the Vets v. Peake trial in San Francisco, California and were Bates-
stamped for that trial; obviously, they have been redacted to protect 
individual patients; in each bullet item one could add ``and the vet 
suicided or attempted suicide,'' etc. Since these documents are 
``protected,'' I have removed the VA Bates-stamped numbers):

      Treatment was delayed.
      Patient with suicide ideation not evaluated for suicide 
risk (violates template, criterion # 2).
      No coordination of patient's care (even though there are 
s. coordinators).
      Vet should have been admitted but was not.
      Inadequate response to vet's expressed wish-to-die.
      VA needs a suicide hotline (Note: VA now has a hotline, 
but research shows that a very small percentage of suicides [perhaps < 
1%] even call the hotline; Feeley @ 51; I am not persuaded that male 
soldiers are likely to call a hotline).
      No referral for severe antisocial behavior of vet.
      No psychiatric evaluation of vet was done in the ER.
      Suicide assessment policies and procedures were not 
followed.
      Hopeless vet not identified as such.
      Vet not rescheduled for appointment within one week per 
policy.
      Suicide risk assessment was negative, but patient 
suicided anyway.
      Patient denied access to VA hospital and then suicided.
      Doctor at VA fired for inadequate treatment of soldier 
found dead.
      Inadequate healthcare for homeless vet with suicide 
ideation and threat.
      VA not meeting the needs of suicidal vet.
      Feeley says of this vet's suicide: ``VHA not meeting 
standard that we are after.''
      Vet actually shoots self on the grounds of the VA 
outpatient clinic.

    These bulleted items reflect the VA's own admissions of healthcare 
problems or failures in treating suicidal vets. One can only imagine 
how much more investigators could have learned about assessment and 
treatment failures of suicidal vets, had they been given all of the 
redacted incident briefs and root cause analyses. Since this hearing is 
entitled ``The Truth About Veterans' Suicides,'' it only makes sense 
that all incidents be made public, after removing references to 
individual vets.
    William Feeley, VA Deputy Under Secretary for Health Operations and 
Management (He reports to Dr. Kussman and Kussman reports to Secretary 
Peake; the following facts are reported in Mr. Feeley's deposition of 
April 9, 2008 in the Vets v. Peake legal suit). Feeley said that 
although he was 3rd in the chain of command, and when it came to vet 
healthcare, ``the buck stops here'' (although later on Feeley tried to 
pass the buck to Dr. Katz and others at the VA).

      Feeley said (@ 19) that the 21 VISN directors all report 
to him at least once a week, but when asked about vet suicide rates, he 
said he did not talk to directors about their suicide rates (why not, 
if this is a ``major problem''?). As Feeley put it (@ 35): ``Suicide 
rates are not a metric we are measuring.''
      When asked about implementing the MHS Plan of 7/2004, his 
reply was (@ 64): ``I did not read the plan from cover to cover.''
      When asked between 2004 and 2008 if there were a national 
systematic program for suicide prevention, Feeley answered ``No.''
      One of the policies that have been supposedly fully 
implemented in the MHSP of 2007 was 24-hour VA healthcare. @ 97 Feeley 
was asked to name that policy. His answer: ``I don't know that 
policy.''
      @ 100 Feeley was asked, (well) ``where are these 
policies?'' Answer: ``I don't know where they are.''
      Question @ 104: ``Has the idea of screening every service 
person coming back from Iraq or Afghanistan for PTSD been a subject of 
discussion?'' Answer: ``I really could not give you an answer on 
that.''
      Question @ 105: ``Is there a national screening program 
for every returning serviceman or woman to meet with a mental health 
professional?'' Answer: ``I don't know the answer to that.''
      The MHSP (7/20/04) @ A-14 says that every military person 
. . . will meet individually with a mental health professional as part 
of post-deployment and separation. Question: ``Has that happened?'' 
Answer: ``I don't believe it has.''
      Question @ 141-142: ``Have you read the national strategy 
for suicide prevention and the Institute of Medicine's report Reducing 
Suicide (2002)?'' Answer: ``No.''
      Question @ 147: ``What methods are there for tracking at-
risk (for suicide) veterans?'' Answer: `` I'm not sure, sorry.'' What 
are suicide coordinators for?
      Question @ 171: ``Is there any relationship between the 
number of times a vet is deployed and suicide?'' Answer: ``Don't 
know.''

    One could easily conclude that if the ``suicidal buck'' stops with 
Mr. Feeley, then the VA is in serious trouble when it comes to 
assessing and preventing veteran suicides. Mr. Feeley is singularly and 
dramatically uninformed about suicide. But maybe that is when Feeley 
passes the buck to Dr. Katz?
    Leftovers and Loose Ends. There are a few other important issues 
that at least deserve mention.
    First, it is possible that soldiers become suicidal in part due to 
conditions pre-dating their military recruitment. If so, their baseline 
vulnerabilities (See the concept of ``stress-diathesis'' in Maris et 
al., 1992, Chapter 27) may interact with the stressors of combat to 
exacerbate their suicidality. One example on this might be the DSM 
diagnosis of antisocial personality disorder among young males (@ least 
18 years old; DSM code 301.7). There is some evidence (See Vets v. 
Peake Complaint, 7/23/07 @ 8-24) that some soldiers may have been 
induced to accept a discharge diagnosis of antisocial personality 
disorder, rather than (say) PTSD. Importantly, a diagnosis of 
personality disorder precludes the veteran from receiving disability 
benefits, since the psychopathology was presumed to be present prior to 
the recruitment. Nevertheless, even if true, the Department of Defense 
needs to improve its recruitment screening procedures to keep such 
recruits out of the military in the first place.
    Second, there is surprisingly little mention in the VA mental 
healthcare policies and procedures documents about treating the 
depressive disorders psycho-pharmacologically. It is axiomatic in 
suicide prevention that much of the treatment of suicidality requires 
prompt and precise diagnosis of depressive disorders, followed by 
appropriate specific pharmacological treatment of the patient with one 
or more of the SSRI antidepressants (e.g., Lexapro, Prozac, Zoloft, 
Paxil, Louvox, Celexa, etc.), SNRIs (e.g., Cymbalta or Effexor, etc.), 
anxiolytics (such as the benzodiazepines like Xanax, Klonopin, Traxene, 
Ativan or non BZs, like Buspar, etc.), perhaps a major tranquilizer 
(like Risperdal or Zyprexa, etc.), and even electroconvulsive therapy 
in some cases. Note that many of the VA's 875 outpatient clinics or 
``CBOCs'' often do not even have a physician on staff, who can write 
critical prescriptions that suicidal vets may need. Since there are 875 
CBOCs but only 154 VA hospitals or medical centers, structurally (given 
the VA healthcare system) a depressed vet is likely to get only 
psychotherapy, rather than both pharmacotherapy and psychotherapy.
    Third, the VA takes pride that they now have ``suicide 
coordinators'' in their medical centers (See Feeley, 4/9/08 @ 88). 
However, serious questions remain about these suicide coordinators. 
Only the 154 medical center hospitals even have suicide coordinators; 
none of the 875 CBOCs do. Thus, the vast majority of VA facilities in 
fact do not have suicide coordinators. Several questions remain: (a) 
What do these coordinators do, exactly (job descriptions)? (b) How are 
they trained to do suicide assessment and prevention (Berman addressed 
this issue in Vets v. Peake)? (c) What are their professional 
credentials and licensing (LPN, RN, SW, MA psychologist, MH techs, 
etc)? (d) Who supervises these suicide coordinators? (e) Do suicide 
coordinators interact directly with suicidal vets in clinical care of 
the VA patients? (f) What exactly are they ``coordinating'' (data, 
people, policies and procedures, etc.)?
    Finally, there is a whole set of issues concerning diagnosis, 
treatment, and benefit delays in VA mental healthcare, which I have not 
yet commented on (See Vets v. Peake, 4/21/08, Federal trial in San 
Francisco). To even get mental health treatment for up to two years the 
veteran must fill out a 23-page application form (which can be very 
hard to do, if you in fact do have PTSD) and then receive a disability 
rate from 0 to 100% from a ``Compensation and Pension'' examination 
(Complaint, 25-98). If the disability is denied or too low, found not 
to be related to military service; then the appeal process can be long 
and drawn-out (some vets die during the appeal process), which can 
encourage a suicidal resolution of the vet's problems. Note, too, that 
most of the VA suicide prevention initiatives (See OIG, MHSP, 5/10/07) 
have only been partially implemented after four years. Defense expert 
Alan Berman in the Vets v. Peake trial, testified that it could take up 
to 10 years for the MHSP to be implemented. One wonders how many vets 
are going to die in the interim due to lack of assessment and 
treatment?
                               References
    American Association of Suicidology. 1/17/08. USA Suicide. 2005 
Official Final Data.
    American Psychiatric Association. 2000. DSM-IV-TR. Washington, DC: 
American Psychiatric Press.
    CBS/Stephen Rathbun. 1/19/08 & 2/22/08 Declaration.
    Beck, A.T. 1967. Depression. New York: Harper.
    Beck et al. 1974. The measurement of pessimism: the hopelessness 
scale. J. Consulting & Clinical Psychology 42: 861-865.
    Beck, A.T. 1990. Suicide intent scale in Blumenthal, S. & Kupfer, 
D. (eds.). Suicide over the Life-Cycle. Washington, DC: American 
Psychiatric Press.
    Beck, A.T. et al. 1999. Suicide ideation at its worst point. . . . 
Suicide and Life-threatening Behavior 29: 1-9.
    Feeley, William. 4/9/08 deposition in Vets. v. Peake trial in 
Federal court in San Francisco, 4/21/08.
    Goldsmith, S.K. et al. (eds) 2002. Reducing Suicide: a National 
Imperative. Washington, DC: National Academies Press.
    Hamilton, M. 1960. A rating scale for depression. Journal of 
Neurology, Neurosurgery, and Psychiatry 23:56-61.
    Hoge, C. W. et al. 2004. Combat duty in Iraq and Afghanistan, 
mental health problems, and barriers to care. The New England Journal 
of Medicine 351: 13-22.
    Kang, H.K. & Bullman, T.A. 12/11/07. The risk of suicide . . . 
among vets of OIF and OEF (unpublished).
    Katz, Ira. 2/21/08. Suicide study (unpublished).
    Maris, R.W. 1969. Social Forces in Urban Suicide. Homewood, IL: 
Dorsey Press.
    Maris, R.W. 1981. Pathways to Suicide. Baltimore: Johns Hopkins 
University Press.
    Maris, R.W. et al. 1992. Assessment and Prediction of Suicide. NY: 
Guilford Press.
    Maris, R.W. et al. 2000. Comprehensive Textbook of Suicidology. NY: 
Guilford Press.
    Maris, R.W. 2002. Suicide. The Lancet. Vol 360: 219-226.
    Maris, R.W. 2007. Foreword to Cutliffe & Stevenson. Care of the 
Suicidal Person. Edinburgh, Elsevier.
    Office of the Inspector General. 5/10/07. Mental Health Strategic 
Plan for Suicide Prevention. John Daigh, Jr. VA Office of the Inspector 
General. Pages 1071.
    Robins, E. (with Murphy, G.). 1981. The Final Months. NY: Oxford 
Press.
    Nemuth, M. 3/25/08. Deposition in Vets v. Peake.
    Simon, R.I & Hales, R.E. 2006. Textbook of Suicide Assessment and 
Management. Washington, DC: American Psychiatric Press.
    Veterans for Common Sense et al. v. Peake et al. Trial commencing 
4/21/08 in Federal Court, San Francisco, CA. Judge Samuel Conti.
    Zivin, K. et al. 2007. Suicide mortality among individuals 
receiving treatment for depression in the VA health system. American 
Journal of Public Health, 2193-2197.

                                 
            Prepared Statement of Stephen L. Rathbun, Ph.D.,
         Interim Head and Associate Professor of Biostatistics,
 Department of Epidemiology and Biostatistics, University of Georgia, 
                               Athens, GA
Summary
    In the fall of 2007, I was asked to perform a statistical analysis 
of veterans' suicide data collected by CBS News for a story that was 
broadcast on November 13, 2007. I agreed to do so, and was not 
compensated for my contributions. For 2004 and 2005, CBS provided data 
on numbers of veteran and non-veteran suicides and veteran and non-
veteran population sizes, cross-tabulated by state, gender and age 
class. Suicide data were obtained from state death records and 
population sizes from the U.S. Census. These data are the property of 
CBS News and were erased from my computer following the broadcast on 
November 13, 2007. To avoid investigator biases, methods of statistical 
analyses were specified prior to receiving the data. Standard 
statistical procedures were used to analyze the data; estimated suicide 
rates adjusted for age and gender. Veteran suicide rates were estimated 
to be approximately double those of non-veterans. This pattern of 
higher estimated veteran suicide risk was observed for both genders and 
all age classes. The most striking pattern was an especially high risk 
ratio for 20-24 year old veterans; in this age class, veteran suicide 
rates were estimated to be about 3 times those of non-veterans.
Introduction
    This statement concerns the analyses of veterans' suicide data 
conducted at the request of CBS News during the fall of 2007, the 
results of which were broadcast during CBS Evening News on November 13, 
2007. The following will describe my relationship with CBS News, the 
data that were analyzed, the method of statistical data analyses, and 
the results of those analyses.
    Before proceeding, please note the following:

    1.  I am an expert in biostatistics, but not an expert on veterans' 
suicides. Although I have a 18-year record of teaching and research in 
biostatistics, I have not had any prior experience with suicide data. 
While I can comment on the methods of data analyses, estimated suicide 
rates and limits of statistical inference regarding the data analysis, 
I cannot make expert comments regarding what causes the observed 
patterns of suicide rates.
    2.  The suicide data are a property of CBS News and at the request 
of CBS News, my copy was erased following the November 13, 2007 
broadcast. This was done to comply with agreements made between CBS 
News and States to ensure the confidentiality of sensitive human-
subjects data.
    3.  On March 4, 2008 I testified on behalf of the plaintiffs in the 
case of Veterans for Common Sense and Veterans United for Truth, Inc. 
vs. Gordon H. Mansfield, Acting Secretary of Veterans Affairs (U.S. 
District Court, Northern District of California, San Francisco 
Division, Case No. C-07-3758-SC). No compensation was received from the 
plaintiffs for this testimony. I had no prior relation with either 
party in this action.
Relationship with CBS News
    I had no prior relationship with CBS News before Pia Malbran, 
producer of the veterans' suicide news story, contacted me in August 
2007 asking me to analyze veterans' suicide data. Aside from the gift 
of a CBS News baseball cap (valued at less than 20), I was not paid by 
CBS News for the work that I have done. I understand from Pia Malbran, 
producer of the veterans' suicide news story, that I was contacted 
because I had no relationship with the Veterans Administration, 
veterans groups, or involvement with advocacy related to veterans' 
issues.
Data Collection
    During my initial consultations, Pia Malbran discussed the sources 
of the data, and I advised her regarding the format in which the data 
should be provided for data analysis. Ms. Malbran requested that 
suicide rates be adjusted for age, gender, and race. She obtained 
population totals from the U.S. Census, and population totals for 
veterans from the Veterans Administration. The states provided her 
information on the number of veteran suicides and total number of 
suicides. Veteran status was to be ascertained from state death records 
indicating that suicide was the cause of death, and including a check 
box indicating whether or not the subject was a veteran. In a few 
cases, veteran status was not available in the death records. Data were 
to be provided for 2004 and 2005. Death records after 2005 were not 
available at the time that the news story was prepared.
    In response to Pia Malbran's description of the available data, I 
indicated that an excel spreadsheet should be prepared including 
columns for state, age class, gender, race, number of veteran suicides, 
number of suicides with unknown veteran status, total number of 
suicides, number of veterans, and population total. Suicides with 
unknown veteran status were allocated to veterans and non-veterans in 
numbers proportional to the respective sizes of veteran and non-veteran 
populations. For example, if 10% of all 25-29 year old males in a given 
state were veterans, then 10% of the suicides of unknown veteran status 
in that group would be allocated to veterans, while the remaining 90% 
of suicides in that group would be allocated to non-veterans. This 
proportional allocation results in conservative estimates, under-
estimating the differences between veteran and non-veteran suicide 
rates.
    Preliminary data analysis indicated that states and the Veterans 
Administration had different definitions of race with respect to the 
classification of black Hispanic-Americans. So, race was dropped from 
the data collection efforts. Thus, the data can be cross-classified by 
state, age class, gender, veteran status, and population size for data 
analysis. A total of 45 states provided data for 2004 and 2005.
    For states with small populations of veterans, the cross 
classification of veterans by age, gender and suicide status may 
suffice to identify individual subjects. For that reason, CBS News had 
to agree that data be kept confidential before data were released to 
CBS News. To ensure this confidentiality, I was asked to erase the data 
immediately following the November 13, 2007 broadcast of the veterans' 
suicides news story. This was done as requested.
Data Analysis
    To avoid investigator bias, the methods of statistical data 
analyses were specified before data were received from CBS News. The 
specific choice of methods was based on the type of data collected, and 
the specific estimates that Pia Malbran requested in her memo of 
October 1, 2007:

    1.  What is the overall rate of suicide (per 100,000--age and 
gender adjusted) for veterans verses non-veterans nationwide?
    2.  What is rate (per 100,000--age and gender adjusted) of suicide 
for veterans verses non-veterans state by state ranked highest to 
lowest?
    3.  What is the overall rate of suicide (per 100,000) for veteran 
males (all ages) verses non-veteran males nationwide?
    4.  What is the rate of suicide (per 100,000) among male veterans, 
65 or older? And, how does that compare with male non-veterans, 65 or 
older?
    5  What is the rate of suicide (per 100,000) among veterans (both 
genders) aged 20 to 34?

    A logistic regression model was fit to the data from each year 
(2004 and 2005), including main effects for age-class, gender, and 
veteran status, as well as two-way interactions among pairs of these 
explanatory variables. Logistic regression is the standard statistical 
method for modeling binary responses such as suicide status; a person 
has either committed suicide or not committed suicide. The inclusion of 
interactions allows the effect of veteran status on suicide risk to 
depend on gender and age. As per the pre-specified protocol for data 
analysis, the three-way interaction among age, gender and veteran 
status was dropped from the model since it was not statistically 
significant.
    All estimated suicide rates were adjusted for the impact of age and 
gender. This was done because suicide rates depend on age and gender. 
For example, suicide rates are higher among males and than among 
females. Moreover, males are over-represented among veterans since 
males are more likely to serve in the military than females. Given the 
higher suicide rates among males, and the over-representation of males 
in veteran populations, failure to adjust for gender will result in 
over-estimates of veteran suicide rates. Similar arguments can be made 
for the impact of age.
    Initial data analysis was completed before my portion of the story 
was taped by CBS News on October 3, 2007. On October 16, Pia Malbran 
contacted me with data on the numbers of active-duty soldiers 
committing suicide in 2004 and 2005, cross-classified by age and 
gender. She expressed concern that some of these soldiers may have been 
mistakenly classified as veterans in the state death records, and asked 
me to re-analyze the data subtracting these cases from the veteran 
suicide counts. Thus, two estimates of veteran suicide rates will be 
presented. The higher estimate is based on the original analysis, while 
the lower estimate was obtained after these active-duty suicides were 
subtracted.
    All analyses were carried out using SAS. Analyses using this 
statistical software involve written code documenting exactly how the 
analyses are carried out. This is as opposed to other statistical 
software packages that rely on point-and-click menu-driving procedures 
for data analysis that leave no record documenting the method of 
analysis. SAS code used for my data analysis was provided to Ira Katz 
following the November 13 CBS News broadcast.
Results
    The estimated suicide risk is higher among veterans than non-
veterans. Table 1 presents the age- and gender-adjusted estimates of 
suicide rates by veteran status for each of the two years. The suicide 
risk among veterans was estimated to be 1.86-2.32 times the risk among 
non-veterans in 2004, and 2.10-2.34 times the risk among non-veterans 
in 2005. These risk ratios were computed by dividing the suicide rates 
among veterans by the suicide rates among non-veterans.

    Table 1.  Estimates of overall suicide rates adjusted for age and
   gender. All rates are expressed as numbers of suicides per 100,000
                                 people.
------------------------------------------------------------------------
            Veteran Status                    2004             2005
------------------------------------------------------------------------
Veterans                                     17.5-21.8        18.7-20.8
------------------------------------------------------------------------
Non-Veterans                                       9.4              8.9
------------------------------------------------------------------------

    Table 2 presents the age-adjusted estimates of suicide rates for 
males and females by veteran status for each of the two years. For both 
veterans and non-veterans, suicide rates were higher among males than 
among females. Among males, the suicide risk for veterans was estimated 
to be 1.67-2.09 times the risk among non-veterans in 2004, and 1.79-
2.01 times the risk among non-veterans in 2005. Among females, the 
suicide risk for veterans was estimated to be 2.08-2.60 times the risk 
among non-veterans, and 2.47-2.73 times the risk among non-veterans in 
2005.

 Table 2. Estimates of suicide rates by gender adjusted for age. All rates are expressed as numbers of suicides
                                               per 100,000 people.
----------------------------------------------------------------------------------------------------------------
                       Gender                           Veteran Status           2004                2005
----------------------------------------------------------------------------------------------------------------
Males                                                          Veterans           30.6-38.3           31.5-35.3
----------------------------------------------------------------------------------------------------------------
                                                           Non-Veterans                18.3                17.6
----------------------------------------------------------------------------------------------------------------
Females                                                        Veterans           10.0-12.5           11.1-12.3
----------------------------------------------------------------------------------------------------------------
                                                           Non-Veterans                14.8                 4.5
----------------------------------------------------------------------------------------------------------------

    Table 3 presents the gender-adjusted estimates of suicide rates for 
the various age-classes by veteran status. The most striking result is 
the high relative risk of suicide among 20-24 year old veterans when 
compared to non-veterans. For this group of young veterans, the suicide 
risk is estimated to be 2.81-4.31 times the risk among non-veterans in 
2004, and 2.75-3.84 times the risk among non-veterans in 2005. Veterans 
in their forties also had high estimated suicide rates, but the risk of 
suicide among non-veterans in their forties was also estimated to be 
high. Consequently, the risk ratio did not exceed 1.73 in this age 
group.

 Table 3.  Estimates of suicide rates by age adjusted for gender. All rates are expressed as numbers of suicides
                                               per 100,000 people.
----------------------------------------------------------------------------------------------------------------
                      Age Class                         Veteran Status           2004                2005
----------------------------------------------------------------------------------------------------------------
20-24                                                           Veteran           23.3-35.8           22.9-31.9
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                 8.3                 8.3
----------------------------------------------------------------------------------------------------------------
25-29                                                           Veteran           12.8-15.5           13.1-16.1
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                 9.0                 8.3
----------------------------------------------------------------------------------------------------------------
30-34                                                           Veteran           14.1-14.7           16.1-17.7
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                10.2                 9.9
----------------------------------------------------------------------------------------------------------------
35-39                                                           Veteran           16.4-17.8           16.1-16.5
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                11.4                10.5
----------------------------------------------------------------------------------------------------------------
40-44                                                           Veteran           20.4-20.6           19.4-19.7
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                13.4                12.6
----------------------------------------------------------------------------------------------------------------
45-49                                                           Veteran           22.4-22.5                23.4
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                14.4                13.5
----------------------------------------------------------------------------------------------------------------
50-54                                                           Veteran                20.3                21.0
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                13.4                12.9
----------------------------------------------------------------------------------------------------------------
55-59                                                           Veteran           15.3-15.4           16.0-16.1
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                11.4                11.0
----------------------------------------------------------------------------------------------------------------
60-64                                                           Veteran           14.3-14.4                13.6
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                10.3                10.5
----------------------------------------------------------------------------------------------------------------
65+                                                             Veteran                11.8           14.9-15.0
----------------------------------------------------------------------------------------------------------------
                                                            Non-Veteran                 9.6                 9.7
----------------------------------------------------------------------------------------------------------------


                                 
           Prepared Statement of M. David Rudd, Ph.D., ABPP,
             Professor and Chair, Department of Psychology,
                   Texas Tech University, Lubbock, TX
    Mr. Chairman and Members of the Committee, thank you for the 
invitation and opportunity to join you here today and discuss the 
tragic, but important problem of suicide among our Nation's veterans. I 
am honored to be here. My scientific and clinical opinions are 
influenced by a diverse background as a practicing psychologist, 
clinical researcher whose work focuses on the assessment, management 
and treatment of suicidality, along with the fact that I'm a veteran. 
Having served previously as an Army psychologist, I'm keenly aware of 
the complexity and challenge of clinical decisionmaking during wartime, 
the competing demands juggled by military mental health providers, and 
the arduous task of managing soldiers at risk for suicide both during 
active duty and after discharge. As a researcher, I understand suicide 
is most often the end outcome of a complex web of variables, several 
easily identified but not so easily treated. As a veteran, I have some 
understanding of what it means to serve our country, the personal and 
professional sacrifices that are made, and the potential consequences, 
but only a fraction compared to those that return from war struggling 
with injuries both visible and invisible.
    The tragic increase in both active duty and veteran suicide rates 
since the beginning of Operation Iraqi Freedom and Operation Enduring 
Freedom (OIF/OEF) underscore a seldom recognized but very real fact 
about mental illness; that it can be fatal. Data are now available from 
multiple sources, including the Department of Veterans Affairs (VA), 
the recently released RAND Corporation study, along with the existing 
literature indicating that anywhere from a quarter to a third of 
previously deployed veterans present with a mental health problem 
following discharge. Most prominent among the problems are major 
depression, post-traumatic stress disorder (PTSD), traumatic brain 
injury (TBI), and substance abuse. Data available prior to the most 
recent military conflicts (OIF/OEF) indicated heightened suicide risk 
among the general veteran population, with estimates indicating that 
veterans are twice as likely to die by suicide, regardless of whether 
or not they were affiliated with the VA. More recent data indicate a 
marked increase in suicide risk among veterans being treated for 
depression, with the risk being 7-8 times greater than that for the 
general adult population in the United States. Similarly, recent 
revelations about suicide and suicide attempt rates among veterans have 
been alarming, with estimates as high as 18 suicides a day. Recent data 
on TBI are also of concern, indicating suicide rates in the range of 3-
4 times the general population and lifetime suicide attempt rates of 
8%, along with significant rates of suicidal ideation (23%). At this 
point, the relationship between brain injury and suicidality is not 
well understood.
    An accurate and meaningful interpretation of these data requires a 
look at and consideration of comparable civilian data. Although it is 
certainly difficult to accurately estimate suicide rates for those in 
and out of treatment, there is some data for comparison. The suicide 
prevalence rate for major depression and affective disorders in general 
(i.e. major depression, bipolar disorder I and II and affective 
psychosis) is actually lower than often quoted. Rates differ depending 
on the apparent severity of the illness, with the outpatient suicide 
prevalence rate being 2%, in contrast to 6% for those previously 
hospitalized for suicidal symptoms and 4% for those hospitalized for 
other reasons. Rates of suicide attempts are much higher. It is 
estimated that as many 24% of those suffering major depression make a 
suicide attempt during the course of the illness. It is estimated that 
up to 50% of individuals with bipolar disorder will make a suicide 
attempt and up to 80% will manifest suicidal symptoms of some sort. 
Standardized mortality ratios (ratio of observed deaths to expected 
deaths) for major depression and bipolar disorder paint a stark 
picture; those with major depression evidence a twentyfold increased 
risk for death by suicide relative to the general population and those 
with bipolar disorder a fifteenfold increase in risk. There are data 
available regarding other disorders, but the take home message is that 
the risk for suicide is considerable for a number of mental illnesses. 
Mental illness can be fatal, particularly if unrecognized, untreated or 
under-treated.
    It is also important to consider the expected rates of adverse 
events during treatment, in particular, suicide attempt rates. Data are 
available from randomized clinical trials targeting suicidal behavior 
(irrespective of diagnosis). Estimates indicate that as many as 40-47% 
of those receiving treatment (psychotherapy and medications) make 
suicide attempts during the first year of treatment. If an attempt is 
made during the first year, the average is approximately 2.5 attempts. 
This is what routinely happens during treatment. We also know that an 
individual making multiple suicide attempts will likely struggle with 
suicidality for many years, if not a lifetime. These data, coupled with 
data about recent discharge from the hospital, indicate that risk for 
suicide (in the context of mental illness) is not only potent but 
enduring. Standardized mortality ratios (ratio of observed deaths to 
expected deaths) for men and women recently discharged from the 
hospital range from 100 to 350 across several studies. These are 
tragically high numbers. The VA experience is not markedly different 
than its civilian counterpart when it comes to the presentation of 
high-risk suicidal patients.
    There are several possible conclusions. First, as outlined nicely 
in the RAND study, there are high rates of psychiatric illness 
following combat exposure, including both direct and vicarious 
exposure. Multiple deployments for OIF/OEF likely compound the 
situation because of repeated combat exposure, sometimes after the 
initial emergence of symptoms. The VA is faced with assessing and 
treating large numbers of seriously ill veterans. Second, the overall 
rates of both suicide and suicide attempts are tragic but consistent 
with general trends for the types and observed rates of psychiatric 
illness. Third, an effective response requires effective resources. 
Finally, there is an element of this problem that is likely to be 
enduring and potentially chronic in nature.
    The VA has already moved toward increasing recognition and 
treatment of suicidal veterans, implementing a telephone hotline and 
making available training on recognizing and responding to suicide 
warning signs. Treatment outcome studies targeting suicidality have 
confirmed that simple things work and can save lives. Limiting and 
removing access to the suspected method can save lives. Removing 
barriers to emergency care can save lives. Patient tracking and 
effective followup for treatment non-compliance can save lives. 
Evidence-based treatments for depression, bipolar disorder, PTSD are 
effective and can save lives. Despite the fact that treatment is 
effective, it's estimated that only about half of those at risk pursue 
care.
    The military and VA system face unique barriers to providing 
effective care, including issues of confidentiality, delays in 
evaluating the escalating numbers of service-connected disability 
claims, and misconceptions about the nature and effectiveness of mental 
healthcare. The FDA warning label for antidepressants is but one 
example of how misunderstanding of the scientific data can lead to 
fewer people expressing a willingness to seek care, with potentially 
tragic results. Science, clinical experience, and common sense converge 
when it comes to suicidality. Improving our ability to both recognize 
and respond quickly to those at risk can save lives. Removing barriers 
to care, particularly emergency care, can and will save lives. Those 
that have served our Nation deserve no less. It is tragic and 
heartbreaking when a soldier that has survived the trauma of war 
returns home to die by his or her own hand, especially when treatment 
is an option.
    Thank you, I appreciate the opportunity to speak with you today and 
welcome the chance to respond to questions.

                                 
             Prepared Statement of Michael Shepherd, M.D.,
          Senior 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 the VHA's Mental Health 
Strategic Plan Initiatives for Suicide Prevention. My statement today 
is based on that report as well as individual cases that the OIG has 
reviewed and reported on involving veteran suicides and accompanying 
mental health issues. In the process of these inspections, clinicians 
in our office have had the opportunity to meet with and listen to the 
concerns of surviving family members, and to witness the devastating 
impact that veteran mental health issues and suicide have had on their 
lives.
    The May 2007 OIG report reviewed initiatives from the Veterans 
Health Administration's (VHA) mental health strategic plan pertaining 
to suicide prevention and assessed the extent to which these 
initiatives had been implemented. In prior testimony, we have stressed 
the importance of the need for VA to continue moving forward toward 
full implementation of suicide prevention initiatives from the mental 
health strategic plan. In terms of other 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 
City 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 a VA 
Medical Center (VAMC) to explain 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 system-wide 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 referred by 
primary care providers are seen within 2 weeks of referral, 
approximately 5 percent reported a significant 4-8 week wait. Because 
these patients are at risk for progression of symptom severity and 
possible development of suicidal ideation, Veterans Integrated Service 
Network leadership should work with facility directors to ensure that 
once referred, patients with a moderate level of depression and those 
recently discharged following hospitalization are seen in a timely 
manner at all VAMCs and Community Based Outpatient Clinics (CBOCs).
    Co-Occurring Combat Stress Related Illness and Substance Use--
Substance use may contribute to the severity of a concurrent or 
underlying mental health condition such as major depression. The 
presence of alcohol may cause or exacerbate impulsivity and acute 
alcohol use is associated with completed suicide. In 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, Milliken et 
al., found that soldiers frequently reported alcohol concerns on the 
Post Deployment Health Assessment and Reassessments ``yet very few were 
referred to alcohol treatment.''
    Regardless of why a patient begins to abuse alcohol, with frequent 
and/or excessive use, physiologic and psychologic drives develop until 
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 require 
addressing the primacy of not only anxiety/depressive conditions but 
also of co-morbid substance use disorders. VA should consider 
augmenting services that address substance use disorders co-morbid with 
combat stress related illness for inclusion in a comprehensive program 
aimed at suicide prevention.
    Enhanced Access to Mental Health Care--Treatments for mental health 
problems may take time to show effect. For example, antidepressant 
medication, when indicated, may take several weeks to several months to 
effect symptom reduction or remission. For some patients, treatment may 
necessitate multiple visits that occur consistently over time and may 
entail multiple modalities including individual and/or group evidence 
based psychotherapy, medication management, and/or readjustment 
counseling. Therefore, efforts that enhance patient access to 
appropriate treatment may help facilitate both patient engagement and 
the potential for treatment benefit.
    For example, ongoing enhancements in the availability of mental 
health services at CBOCs may help mitigate vocational and logistical 
challenges facing some veterans residing in more rural areas who 
otherwise may have to travel longer distances to appointments at the 
parent VAMC.
    In certain locations, the VA may want to consider expanding care 
during off-tour hours to increase the ability for some transitioning 
OIF/OEF veterans to access mental health treatment while minimizing 
interference with occupational, and/or educational obligations. This 
would be consistent with the recovery model for mental health treatment 
which emphasizes not only symptom reduction but also promotion and 
return to functional status.
    Facilitating Early Family Involvement--Mental health symptoms can 
have a significant and disruptive impact on family and domestic 
relationships. Relational discord has been cited as one factor 
associated with suicide in active duty military and returning veterans. 
In addition, some studies indicate that family involvement in a 
patient's treatment may enhance the ability for some patients to 
maintain treatment adherence. VA should consider efforts to bolster 
early family participation in patient treatment.
    Coordination between VHA and Non-VHA Providers--When patients 
receive mental health treatment from both VHA and non-VHA providers, 
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. VA's Office of Mental Health Services should 
consider development of innovative methods or procedures to facilitate 
flow of information for patients receiving simultaneous treatment from 
VA and non-VA providers while adhering to relevant privacy statutes. In 
addition, VA's Readjustment Counseling Service and VA's Office of 
Patient Care Services 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.
    Mr. Chairman, thank you again for this opportunity to testify. I 
would be pleased to answer any questions that you or other Members of 
the Committee may have.

                                 
                                CBS News
                    Suicide Epidemic Among Veterans
                        NEW YORK, Nov. 13, 2007
    (CBS) They are the casualties of wars you don't often hear about--
soldiers who die of self-inflicted wounds. Little is known about the 
true scope of suicides among those who have served in the military.
    But a 5-month CBS News investigation discovered data that shows a 
startling rate of suicide, what some call a hidden epidemic, Chief 
Investigative Reporter Armen Keteyian reports exclusively.
    ``I just felt like this silent scream inside of me,'' said Jessica 
Harrell, the sister of a soldier who took his own life.
    ``I opened up the door and there he was,'' recalled Mike Bowman, 
the father of an Army reservist.
    ``I saw the hose double looped around his neck,'' said Kevin Lucey, 
another military father.
    ``He was gone,'' said Mia Sagahon, whose soldier boyfriend 
committed suicide.
    Keteyian spoke with the families of five former soldiers who each 
served in Iraq--only to die battling an enemy they could not conquer. 
Their loved ones are now speaking out in their names.
    They survived the hell that's Iraq and then they come home only to 
lose their life.
    Twenty-three-year-old Marine Reservist Jeff Lucey hanged himself 
with a garden hose in the cellar of this parents' home--where his 
father, Kevin, found him.
    ``There's a crisis going on and people are just turning the other 
way,'' Kevin Lucey said.
    Kim and Mike Bowman's son Tim was an Army reservist who patrolled 
one of the most dangerous places in Baghdad, known as Airport Road.
    ``His eyes when he came back were just dead. The light wasn't there 
anymore,'' Kim Bowman said.
    Eight months later, on Thanksgiving Day, Tim shot himself. He was 
23.
    Diana Henderson's son, Derek, served three tours of duty in Iraq. 
He died jumping off a bridge at 27.
    ``Going to that morgue and seeing my baby . . . my life will never 
be the same,'' she said.
    Beyond the individual loss, it turns out little information exists 
about how widespread suicides are among these who have served in the 
military. There have been some studies, but no one has ever counted the 
numbers nationwide.
    ``Nobody wants to tally it up in the form of a government total,'' 
Bowman said.
    Why do the families think that is?
    ``Because they don't want the true numbers of casualties to really 
be known,'' Lucey said.
    Sen. Patty Murray, D-Wash., is a Member of the Veterans' Affairs 
Committee.
    ``If you're just looking at the overall number of veterans 
themselves who've committed suicide, we have not been able to get the 
numbers,'' Murray said.
    CBS News' investigative unit wanted the numbers, so it submitted a 
Freedom of Information Act request to the Department of Defense asking 
for the numbers of suicides among all servicemembers for the past 12 
years.
    Four months later, they sent CBS News a document, showing that 
between 1995 and 2007, there were almost 2,200 suicides. That's 188 
last year alone. But these numbers included only ``active duty'' 
soldiers.
    CBS News went to the Department of Veterans Affairs, where Dr. Ira 
Katz is head of mental health.
    ``There is no epidemic in suicide in the VA, but suicide is a major 
problem,'' he said.
    Why hasn't the VA done a national study seeking national data on 
how many veterans have committed suicide in this country?
    ``That research is ongoing,'' he said.
    So CBS News did an investigation--asking all 50 states for their 
suicide data, based on death records, for veterans and non-veterans, 
dating back to 1995. Forty-five states sent what turned out to be a 
mountain of information.
    And what it revealed was stunning.
    In 2005, for example, in just those 45 states, there were at least 
6,256 suicides among those who served in the armed forces. That's 120 
each and every week, in just one year.
    Dr. Steve Rathbun is the acting head of the Epidemiology and 
Biostatistics Department at the University of Georgia. CBS News asked 
him to run a detailed analysis of the raw numbers that we obtained from 
state authorities for 2004 and 2005.
    It found that veterans were more than twice as likely to commit 
suicide in 2005 than non-vets. (Veterans committed suicide at the rate 
of between 18.7 to 20.8 per 100,000, compared to other Americans, who 
did so at the rate of 8.9 per 100,000.)
    One age group stood out. Veterans aged 20 through 24, those who 
have served during the war on terror. They had the highest suicide rate 
among all veterans, estimated between two and four times higher than 
civilians the same age. (The suicide rate for non-veterans is 8.3 per 
100,000, while the rate for veterans was found to be between 22.9 and 
31.9 per 100,000.)
    ``Wow! Those are devastating,'' said Paul Sullivan, a former VA 
analyst who is now an advocate for veterans rights from the group 
Veterans For Common Sense.
    ``Those numbers clearly show an epidemic of mental health 
problems,'' he said.
    ``We are determined to decrease veteran suicides,'' Dr. Katz said.
    ``One hundred and twenty a week. Is that a problem?'' Keteyian 
asked.
    ``You bet it's a problem,'' he said.
    Is it an epidemic?
    ``Suicide in America is an epidemic, and that includes veterans,'' 
Katz said.
    Sen. Murray said the numbers CBS News uncovered are significant: 
``These statistics tell me we've really failed people that served our 
country.''
    Do these numbers serve as a wake-up call for this country?
    ``If these numbers don't wake up this country, nothing will,'' she 
said. ``We each have a responsibility to the men and women who serve us 
aren't lost when they come home.''

                                 
                                CBS News
               VA Hid Suicide Risk, Internal E-Mails Show
                             April 21, 2008
    (CBS) The Department of Veterans Affairs came under fire again 
Monday, this time in California Federal court where it's facing a 
national lawsuit by veterans rights groups accusing the agency of not 
doing enough to stem a looming mental health crisis among veterans. As 
part of the lawsuit, internal e-mails raise questions as to whether top 
officials deliberately deceived the American public about the number of 
veterans attempting and committing suicide. CBS News chief 
investigative correspondent Armen Keteyian reports.
    In San Francisco Federal court Monday, attorneys for veterans' 
rights groups accused the U.S. Department of Veteran's Affairs of 
nothing less than a cover-up--deliberately concealing the real risk of 
suicide among veterans.
    ``The system is in crisis and unfortunately the VA is in denial,'' 
said veterans rights attorney Gordon Erspamer.
    The charges were backed by internal e-mails written by Dr. Ira 
Katz, the VA's head of Mental Health.
    In the past, Katz has repeatedly insisted while the risk of suicide 
among veterans is serious, it's not outside the norm.
    ``There is no epidemic in suicide in VA,'' Katz told Keteyian in 
November.
    But in this e-mail to his top media adviser, written two months 
ago, Katz appears to be saying something very different, stating: ``Our 
suicide prevention coordinators are identifying about 1,000 suicide 
attempts per month among veterans we see in our medical facilities.''
    Katz's e-mail was written shortly after the VA provided CBS News 
data showing there were only 790 attempted suicides in all 2007--a 
fraction of Katz's estimate.
    ``This 12,000 attempted suicides per year shows clearly, without a 
doubt, that there is an epidemic of suicide among veterans,'' said Paul 
Sullivan of Veterans for Common Sense.
    And it appears that Katz went out of his way to conceal these 
numbers.
    First, he titled his e-mail: ``Not for the CBS News Interview 
Request.''
    He opened it with ``Shh!''--as in keep it quiet--before ending with 
``Is this something we should (carefully) address--before someone 
stumbles on it?''
    On Monday, CBS News showed the e-mail to Rep. Bob Filner, D-Calif., 
who chairs the House Committee on Veterans Affairs.
    ``This is disgraceful. This is a crime against our Nation, our 
Nation's veterans,'' Filner told CBS News. ``They do not want to come 
to grips with the reality, with the truth.''
    And that's not all.
    Last November when CBS News exposed an epidemic of more than 6,200 
suicides in 2005 among those who had served in the military, Katz 
attacked our report.
    ``Their number is not, in fact, an accurate reflection of the 
rate,'' he said last November.
    But it turns out they were, as Katz admitted in this e-mail, just 
three days later.
    He wrote: there ``are about 18 suicides per day among America's 25 
million veterans.''
    That works out to about 6,570 per year, which Katz admits in the 
same e-mail, ``is supported by the CBS numbers.''
    In an e-mail late Monday to CBS News, Katz wrote that the reason 
the numbers were not released was due to questions about the 
consistency and reliability of the findings--and that there was no 
public cover up involved.

                                 

                         CRS REPORT TO CONGRESS
                   Suicide Prevention Among Veterans
                              May 5, 2008
                           Order Code RL34471
         By Ramya Sundararaman, Sidath Viranga Panangala, and Sarah A. 
Lister
          Domestic Social Policy Division, Congressional Research 
Service
CONTENTS
      Summary
      Introduction
      Data and Data Systems for Tracking Suicide
      Suicide in the U.S. General Population
          Incidence of Suicide
          Risk and Protective Factors
      Suicide Among Veterans
          Incidence of Suicide
          Risk and Protective Factors
          The Effects of PTSD, TBI, and Depression on Suicide 
        Risk
      Congressional Action
      VA's Suicide Prevention Efforts
          Mental Health Strategic Plan
          Mental Health Research
          Suicide Awareness
          Screening
          Suicide Prevention Hotline
          Funding for Suicide Prevention
          Conclusion
List of Tables
      Table 1. U.S. Death Rates for Suicide, by Age, 2004
                                Summary
    Numerous news stories in the popular print and electronic media 
have documented suicides among servicemembers and veterans returning 
from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom 
(OEF). In the United States, there are more than 30,000 suicides 
annually. Suicides among veterans are included in this number, but it 
is not known in what proportion. There is no nationwide system for 
surveillance of suicide specifically among veterans. Recent data show 
that about 20% of suicide deaths nationwide could be among veterans. It 
is not known what proportion of these deaths are among OIF/OEF 
veterans.
    Veterans have a number of risk factors that increase their chance 
of attempting suicide. These risk factors include combat exposure, 
post-traumatic stress disorder (PTSD) and other mental health problems, 
traumatic brain injury (TBI), poor social support structures, and 
access to lethal means.
    Several bills addressing suicide in veterans have been introduced 
in the 110th Congress. On November 5, 2007, the Joshua Omvig Veterans 
Suicide Prevention Act (P.L. 110-110) was signed into law, requiring 
the Department of Veterans Affairs (VA) to establish a comprehensive 
program for suicide prevention among veterans. More recently, the 
Veterans Suicide Study Act (S. 2899) was introduced. This bill would 
require the VA to conduct a study, and report to Congress, regarding 
suicides among veterans since 1997.
    The VA has carried out a number of suicide prevention initiatives, 
including establishing a national suicide prevention hotline for 
veterans, conducting awareness events at VA medical centers, and 
screening and assessing veterans for suicide risk.
    This report discusses data sources and systems that can provide 
information about suicides in the general population and among 
veterans, and known risk and protective factors associated with suicide 
in each group. It also discusses suicide prevention efforts by the VA. 
It does not discuss Department of Defense (DoD) activities, or VA's 
treatment of risk factors for suicide, such as depression, PTSD, and 
substance abuse.
    This report will be updated when legislative activity warrants.

                               ----------
                              Introduction
    Considerable public attention has been drawn toward the mental 
healthcare needs of veterans, especially those returning from combat in 
Iraq and Afghanistan. Numerous news stories in the popular print and 
electronic media have documented suicides among servicemembers and 
veterans returning from Operation Iraqi Freedom (OIF) and Operation 
Enduring Freedom (OEF).\1\ Some veterans advocacy groups have filed a 
class-action lawsuit claiming that the Department of Veterans Affairs 
(VA) is not providing adequate and timely access to mental healthcare, 
and that this has led to an ``epidemic of suicides.'' \2\
---------------------------------------------------------------------------
    \1\ Ken Fuson and Jennifer Jacobs, ``Iowans Lauded for Anti-suicide 
Efforts,'' The Des Moines Register, January 26, 2008; Dana Priest, 
``Soldier Suicides at Record Level,'' Washington Post, January 31, 
2008, Page A01; ``Soldier, After Bipolar Treatment and Suicide 
Attempts, Sent Back to War Zone,'' Editor & Publisher, February 11, 
2008; ``Suicide Epidemic Among Veterans--A CBS News Investigation 
Uncovers a Suicide Rate for Veterans Twice That of Other Americans,'' 
aired November 13, 2007. OEF, which began in October 2001, conducts 
combat operations in Afghanistan and other locations. OIF, which began 
in March 2003, conducts combat operations in Iraq and other locations.
    \2\ Veterans for Common Sense and Veterans United for Truth, Inc., 
v. James B. Peake, Secretary of Veterans Affairs, et al., Plaintiffs 
Trial Brief, Case No. C-07-3758-SC, filed April 17, 2008.
---------------------------------------------------------------------------
    However, most often the data cited in these press reports do not 
differentiate between suicides among veterans and active duty 
servicemembers.\3\ It is important to make this distinction, because 
two separate healthcare systems--at the VA and the Department of 
Defense (DoD), respectively--are responsible for providing mental 
healthcare to these two distinct populations. This report explains the 
difficulties in determining the incidence of suicide among veterans, 
summarizes what is known about suicides in the general population and 
among veterans, and discusses known risk and protective factors 
associated with suicide in each group. It also discusses recent 
congressional action to address suicide among veterans, and suicide 
prevention efforts by the VA. The report does not discuss DoD 
activities, or VA's treatment of risk factors for suicide, such as 
depression, post-traumatic stress disorder (PTSD), and substance abuse.
---------------------------------------------------------------------------
    \3\ Within the context of the VA, a veteran is defined as a 
``person who served in the active military, naval, or air service, and 
who was discharged or released there from under conditions other than 
dishonorable.'' [38 USC Sec. 101(2); 38 CFR Sec. 3.1(d)]. The VA 
largely bases its determination of veteran status upon military 
department service records.
---------------------------------------------------------------------------
               Data and Data Systems for Tracking Suicide
    Suicide is the act of intentionally ending one's life, attempted 
suicide is an effort that does not have a fatal outcome, and suicidal 
ideation is thinking about or wanting to end one's life. Because 
completed (versus attempted) suicide results in death, national 
statistics on suicide come from death certificate data.\4\ These data 
are collected by state and territorial health officials, under their 
authority, and are voluntarily reported to the Centers for Disease 
Control and Prevention's (CDC's) National Vital Statistics System. The 
CDC analyzes the data and publishes information on numbers and rates of 
death, and important trends, in the United States.\5\ The CDC also 
publishes a U.S. standard death certificate, which states and 
territories can modify. Most U.S. deaths are not investigated by 
government officials. Possible suicides may be investigated, however, 
pursuant to state and territorial authorities. To the extent that a 
death is recognized as a suicide, the standard death certificate 
provides the means to report suicide as the manner of death, but it has 
limited options for noting other information that may be relevant to 
the suicide.
---------------------------------------------------------------------------
    \4\ In reference to fatal suicides, the public health community 
prefers to use the term ``completed,'' rather than ``committed'' or 
``successful,'' to recognize the frequent association of suicide with 
mental illness, and reduce the accompanying stigma.
    \5\ For more information, see Centers for Disease Control and 
Prevention (CDC), Mortality Data from the National Vital Statistics 
System, at http://www.cdc.gov/nchs/deaths.htm, visited May 2, 2008.
---------------------------------------------------------------------------
    In 2003, CDC launched the National Violent Death Reporting System 
(NVDRS), an active surveillance system that provides detailed 
information about the circumstances of violent deaths, including 
suicide.\6\ The NVDRS augments death certificate data by linking it to 
death investigation reports filed by coroners, medical examiners, and 
law enforcement officials. These added layers of information allow the 
NVDRS to identify suicide risk factors, such as depression; to gather 
additional information, such as toxicology results; and to more 
reliably capture information that could have been, but was not, 
completed on the standard death certificate. At this time, the NVDRS is 
not in operation nationwide, but only in 17 states, and NVDRS data 
might not be generalizable to the entire U.S. population. Also, because 
protocols for death investigation vary from one state to the next, 
NVDRS data might not be comparable between those states in which it is 
in operation. CDC's goal is to expand the system to all 50 states, all 
U.S. territories, and the District of Columbia, and to continue efforts 
to standardize data collection and analysis across states.
---------------------------------------------------------------------------
    \6\ See CDC, National Violent Death Reporting System, at http://
www.cdc.gov/ncipc/profiles/nvdrs/default.htm.
---------------------------------------------------------------------------
    At this time, there is no nationwide system for surveillance (i.e., 
tracking) of suicide among all veterans. As with all suicides in 
civilian jurisdiction, suicides among veterans may be investigated, and 
the death certificates completed, by state and territorial authorities. 
Unless a veteran's suicide occurs in a VA facility, opportunities for 
the VA to become aware of the incident may be limited. Three approaches 
are being used to track the incidence of suicide among veterans, though 
each of them has serious shortcomings.
    First, CDC's standard death certificate allows officials to note if 
a decedent has ever served \7\ in the U.S. Armed Forces. However, the 
fact that a decedent is a veteran is not always known when the 
certificate is completed. Although suicides among veterans are a part 
of total national suicide statistics, it is not known what proportion 
of that total is made up of veterans.
---------------------------------------------------------------------------
    \7\ This definition captures current and former U.S. military 
servicemembers.
---------------------------------------------------------------------------
    Second, VA data may be linked to CDC's vital statistics data 
through the National Death Index (NDI). This CDC data system allows 
authorized researchers to link national death data to other data 
systems, identifying the fact that an individual had died of suicide, 
and that a death certificate has been filed.\8\ This would allow the VA 
to identify suicide deaths among its enrollees. (Subsequent research 
steps are cumbersome. For example, researchers typically must contact 
state officials to access the actual death certificates.) The NDI is 
not an ongoing data linkage that would constitute surveillance for 
suicide. It can be used, however, to support special studies by linking 
specific data sets. For example, researchers from the VA and the 
University of Michigan conducted a study in which they linked data from 
VA's National Registry for Depression (NARDEP) to the NDI, allowing VA 
to match its patient registry to certified suicide deaths even when the 
decedent's veteran status had not been noted on the death 
certificate.\9\ However, because only about one-third of veterans 
receive their healthcare from the VA, using VA health systems data for 
linkage would not capture the complete experience of suicide among 
veterans.
---------------------------------------------------------------------------
    \8\ See CDC, National Death Index, at http://www.cdc.gov/nchs/
ndi.htm.
    \9\ Zivin et al., ``Suicide Mortality among Individuals Receiving 
Treatment for Depression in the Veterans Affairs Health System: 
Associations with Patient and Treatment Setting Characteristics,'' 
American Journal of Public Health, Vol. 97, No. 12, pp. 2193-8, 
December 2007, hereafter referred to as Zivin et al., study of 
depression and suicide in veterans.
---------------------------------------------------------------------------
    Third, the NVDRS resolves many of the problems discussed above. 
Through ongoing active surveillance, NVDRS substantially improves the 
likelihood that a suicide victim's veteran status will be captured, and 
it provides additional useful information about suicide incidents. But 
NVDRS is in operation in only 17 states. Though CDC intends it to 
become a nationwide system, expansion would depend on appropriations. 
Congress first provided funding for NVDRS in FY 2002 and has expressed 
support for the program in annual appropriations report language. The 
program has not received a specified appropriation in recent years, but 
rather is funded through CDC's budget for intentional injury prevention 
and control.
                 Suicide in the U.S. General Population
    There are risk factors that increase the likelihood that someone 
will attempt suicide, and protective factors that decrease that 
likelihood. This section provides some context for suicide among 
veterans by discussing the incidence, and risk and protective factors, 
for suicide in the U.S. general population.\10\
---------------------------------------------------------------------------
    \10\ Unless otherwise noted, information in this section is drawn 
from CDC: ``Suicide, Facts at a Glance,'' Summer 2007, and 
``Understanding Suicide, Fact Sheet,'' 2006, at http://www.cdc.gov/
ncipc/dvp/suicide/; and ``Surveillance for Violent Deaths--National 
Violent Death Reporting System, 16 States, 2005,'' MMWR, vol. 57(SS03), 
April 11, 2008, hereafter referred to as NVDRS 2005 report, at http://
www.cdc.gov/mmwr/preview/mmwrhtml/ss5703a1.htm.
---------------------------------------------------------------------------
Incidence of Suicide
    Suicide is a serious public health problem in the United States. 
According to CDC, there were more than 32,000 suicide deaths in the 
United States in 2004, making it the 11th leading cause of death that 
year. On average, there are four suicides among males for each one 
among females. Use of firearms is the most common method of suicide 
among males, while poisoning is the most common method among females. 
Suicide is the second leading cause of death among 25-34 year olds, and 
the third leading cause of death among 15-24 year olds. Although 
suicide is a leading cause of death in younger adults, the rate of 
suicide (number of suicides within the age group per 100,000 resident 
population in the age group) is actually highest in individuals aged 45 
or older. Table 1 presents suicide rates across age groups in the 
United States for 2004, as published by CDC. It is important to note 
that except in the youngest age group, these rates may, and probably 
do, include suicides among veterans, though in proportions that are not 
known.

                              Table 1.  U.S. Death Rates for Suicide, by Age, 2004
----------------------------------------------------------------------------------------------------------------
                                                    15-24        25-44        45-64       65 years     All age
             Age Group              5-14  years     years        years        years       and over     groupsa
----------------------------------------------------------------------------------------------------------------
Suicide rate                               0.7         10.3         13.9         15.4         14.3         10.9
----------------------------------------------------------------------------------------------------------------
 ASource: CDC, death rates for suicide, according to sex, race, Hispanic origin, and age: selected years, 1950-
  2004, ``Health, United States, 2007,'' Table 46, at http://www.cdc.gov/nchs/data/hus/hus07.pdf.
 ANotes: CDC does not calculate rates based on small numbers of suicides among those younger than five years of
  age, as such rates are not statistically reliable. In the source above, CDC also published rates for sub-
  intervals of the age intervals presented here (e.g., for those aged 25-34 years and 35-44 years).
 Aa. This rate is age-adjusted, calculated using the year 2000 standard population.

    There are no official national statistics on attempted suicide 
(i.e., attempts that were not fatal), but it is generally estimated 
that there are 25 attempts for each death by suicide. Also, it is 
reported that there are three suicide attempts among females for every 
one among males.
Risk and Protective Factors
    No single cause or factor leads to suicide. It is a ``final common 
outcome with multiple potential antecedents, precipitants, and 
underlying causes.'' \11\ A number of factors are known to increase or 
decrease the likelihood that an individual will attempt suicide. 
Factors that increase this likelihood are called risk factors. Risk 
factors exist at multiple levels, involving individual, family, 
community, and societal factors. Conversely, factors that decrease a 
person's inclination to attempt suicide are called protective factors, 
which also exist at multiple levels. It is important to note that none 
of these factors in isolation is known to cause or prevent suicide.
---------------------------------------------------------------------------
    \11\ Testimony of Michael Shepherd, M.D., Office of Healthcare 
Inspections, Office of Inspector General, Department of Veterans 
Affairs, in U.S. Congress, House Committee on Veterans' Affairs, 
hearing on Stopping Suicides: Mental Health Challenges Within the 
Department of Veterans Affairs, December 12, 2007.
---------------------------------------------------------------------------
    The single best predictor of an increased risk of suicide is a 
history of a prior suicide attempt. Other risk factors for suicide in 
the general population include certain mental illnesses such as 
depression, alcohol and substance abuse, history of trauma or abuse, 
family history of suicide, job or financial stress, the stigma 
associated with seeking mental healthcare, barriers to healthcare 
access, and easy access to lethal means. Protective factors include 
strong family or community connections; accessible and effective 
clinical care; skills in problem solving, conflict resolution, and 
nonviolent handling of disputes; and cultural and religious beliefs 
that discourage suicide.\12\
---------------------------------------------------------------------------
    \12\ Suicide Prevention Resource Center, ``Risk and Protective 
Factors for Suicide,'' at http://www.sprc.org/library/srisk.pdf, 
visited April 30, 2008.
---------------------------------------------------------------------------
                         Suicide Among Veterans
    In the absence of national surveillance for suicide among veterans, 
information is limited to the findings of special epidemiological 
studies and surveys. These vary considerably in their design and in the 
sub-population of veterans studied, and they often yield conflicting 
results.
    It is tempting to make comparisons between these studies, and with 
information about suicide in the general population. Such comparisons 
are often made, but they are not necessarily valid. Among other things, 
data about suicides in the general population includes suicides among 
veterans. Information about suicide in groups that exclude veterans is 
scant, as is information about the extent to which data for veterans 
may skew the data for the general population, if at all. An additional 
problem in interpreting the findings of these special studies is that 
they are often conducted on populations of veterans who are receiving 
treatment for suicide risk factors. On the one hand, this makes it 
difficult to determine whether study findings reflect the effects of 
risk factors, or the effects of interventions. On the other hand, it 
indicates that efforts to develop systematic surveillance of suicide 
among veterans may, with careful attention to design, also provide the 
means to evaluate the effectiveness of prevention and treatment 
programs. This section discusses the findings of some key studies of 
suicide among veterans.
Incidence of Suicide
    The true incidence of suicide among veterans is not known. This 
section discusses information from two recent published studies that 
yield a partial picture of the burden of suicide in this group.
    In 2005, the NVDRS identified 1,821 suicides among former or 
current military personnel, comprising 20% of all suicides, in the 16 
states in which the system was operational that year.\13\ CDC's 
published findings about these 1,821 decedents include the following:
---------------------------------------------------------------------------
    \13\ NVDRS 2005 report. The definition ``current and former 
military personnel'' is likely to include both current military 
personnel and veterans, but the publication does not provide 
information about each group separately, or about whether such separate 
information is available.

      1,765 (96.9%) were male.
      1,415 (77.7%) were 45 years of age or older.
      The most common method used was firearms (67.9%), 
followed by poisoning (12.7%), and hanging/strangulation/suffocation 
(11.5%).
      47.2% were married, 25.0% were divorced, 13.0% were 
widowed, and 14.0% were never married.\14\
---------------------------------------------------------------------------
    \14\ The remaining small number of decedents were ``married but 
separated,'' ``single, not otherwise specified,'' or their marital 
status was not known. These findings were not cross-tabulated by age.

    Researchers from the VA and the University of Michigan conducted a 
cohort study of 807,694 veterans who were diagnosed with depression in 
the VA health system, and registered in the VA's National Registry for 
Depression (NARDEP), between 1999 and 2004.\15\ During the study 
period, 1,683 (0.21%) of the veterans in this high-risk group committed 
suicide. The researchers calculated a rate of 88.25 suicides per 
100,000 person-years in this group, seven to eight times higher than 
the rate in the general population for the same time period. They noted 
that this rate was similar, though, to a more relevant comparison, 
namely, to suicides among those in the general population who were 
depressed.\16\ They also found the rate among the group of veterans 
studied to be highest among those who were younger than 45 years of 
age, in contrast with the age trend in the general population.
---------------------------------------------------------------------------
    \15\ Zivin et al., study of depression and suicide in veterans. The 
authors used CDC's National Death Index to link NARDEP registrants with 
death certificate data, in order to identify registrants who had died, 
and determine that they died of suicide, during the study period.
    \16\ The authors cited only one study on which to base this 
comparison, though, which likely reflects the limited availability of 
studies in groups that are meaningful for comparison. It is not clear 
whether the comparison group included or excluded veterans.
---------------------------------------------------------------------------
    In December 2007, VA testified that it had identified 144 known 
suicides among OIF/OEF veterans from the time the conflicts began 
through the end of 2005, and that this number translated into a rate 
that is not statistically different from the rate for age, sex, and 
race matched individuals from the general population. These data have 
not been published.\17\
---------------------------------------------------------------------------
    \17\ Testimony of Ira Katz, M.D., Ph.D., Deputy Chief Patient Care 
Services Officer, Office of Mental Health, Veterans Health 
Administration, Department of Veterans Affairs in U.S. Congress, House 
Committee on Veterans' Affairs, Stopping Suicides: Mental Health 
Challenges Within the U.S. Department of Veterans Affairs, hearings, 
110th Cong., 1st sess., December 12, 2007.
---------------------------------------------------------------------------
Risk and Protective Factors
    While there have been a number of studies to identify risk and 
protective factors for suicide in the general population, few studies 
have looked at factors specific to veterans. In the general population, 
suicide risk factors include male gender; older age; diminished psycho-
social support (e.g., homelessness or unmarried status); availability 
and knowledge of firearms; and the co-existence of medical and 
psychiatric conditions. This profile describes a large portion of the 
veteran patient population, making suicide risk management particularly 
challenging in the VA healthcare system.\18\ A study that screened 703 
patients from a general medical outpatient clinic at a VA hospital 
found that 7.3% of the patients had suicidal ideation.\19\ Younger and 
white patients were found to be at increased risk. The risk was higher 
in patients with self-described fair or poor mental health, a history 
of mental health treatment, and fair or poor perceived physical health. 
When major depression was controlled for, anxiety and substance abuse 
disorders continued to show an association with suicidal ideation.
---------------------------------------------------------------------------
    \18\ Lambert et al., ``Suicide Risk Factors among Veterans: Risk 
Management in the Changing Culture of the Department of Veterans 
Affairs,'' Journal of Mental Health Administration, Vol. 24, No. 3, pp. 
350-8, Summer 1997.
    \19\ Lish et al., ``Suicide Screening in a Primary Care Setting at 
a Veterans Affairs Medical Center,'' Psychosomatics, Vol. 37, No. 5, 
pp. 413-24, 1996.
---------------------------------------------------------------------------
    CDC's NVDRS data identified the following associated circumstances 
among a group of 1,622 former or current military personnel who died by 
suicide in 2005: \20\
---------------------------------------------------------------------------
    \20\ NVDRS 2005 report. This group is a subset of the 1,821 former 
or current military personnel whose suicides were recorded in NVDRS in 
2005, for whom these additional types of information were collected.

      Although almost half of them (47.2%) were depressed at 
the time of death, only about a fourth (26.7%) were receiving mental 
health treatment.
      17.2% had an alcohol problem, and 7.7% had a problem with 
other substances.
      24.5% had a problem with an intimate partner.
      38.4% had a physical health problem.
      28.0% had experienced an acute crisis during the prior 
two weeks.
      33.9% had left a suicide note, 13.3% had made a previous 
suicide attempt, and 29.0% had disclosed their intent to commit suicide 
with enough time for someone to have intervened.

    The VA/University of Michigan study of suicide among veterans with 
depression found that having a service-connected disability was 
associated with a lower risk of suicide in this group.\21\ The authors 
suggest that greater access to VA health facilities and regular 
compensation payments may explain the protective effect.
---------------------------------------------------------------------------
    \21\ Zivin et al., study of depression and suicide in veterans.
---------------------------------------------------------------------------
The Effects of PTSD, TBI, and Depression on Suicide Risk
    This section describes three suicide risk factors that are common 
among veterans: Post-traumatic Stress Disorder (PTSD), Traumatic Brain 
Injury (TBI), and depression. PTSD and TBI are common consequences of 
war, with distinct symptoms, treatment modalities, and long-term 
effects. PTSD has been recognized in various forms throughout military 
history. It is an anxiety disorder, with symptoms of varying severity, 
that can occur following experiences, such as military combat, in which 
grave physical injury occurred or was threatened. People who suffer 
from PTSD often relive the experience through nightmares and 
flashbacks, have difficulty sleeping, and feel detached or estranged. 
TBI occurs when a sudden physical trauma causes damage to the brain. 
Improvised explosive devices (IEDs), which have been used extensively 
in the current conflict in Iraq, can cause TBI, sometimes in the 
absence of obvious external signs of injury. Symptoms of TBI can be 
mild, moderate, or severe, depending on the extent of the brain injury. 
When symptoms of TBI or PTSD are mild, they may go undiagnosed, or be 
confused with conditions with similar symptoms, such as other mental 
illnesses, including depression, or substance use disorders. Either 
PTSD or TBI may co-occur with depression or substance abuse. Finally, 
some veterans have both a TBI and PTSD.
    In April 2008, the RAND Corporation published a study of mental 
health problems in servicemembers and veterans.\22\ From their review 
of the literature, the authors found that in the general population, 
depression, PTSD, and TBI are each independent risk factors for 
suicide. More limited information from studies of servicemembers or 
veterans generally shows the same effect of these three risk factors in 
specific groups that were studied. This information also typically 
shows trends comparable to those in the general population with respect 
to other risk factors for suicide, though the demonstrated effects of 
interactions of these factors with depression, PTSD and TBI may differ. 
For example, studies have found that while males are at greater risk of 
death from suicide than are females, the effects that depression, PTSD 
and TBI have on increasing this risk is greater in females. Among the 
general population, substance abuse, prior nonfatal suicide attempts, 
severity of PTSD symptoms, and certain types of TBI are more predictive 
for suicide, and may signal areas of greater suicide risk among 
military and veterans populations as well. Researchers also found that 
combat exposure increases the risk of suicide, as well as the 
likelihood of PTSD, which itself also increases the risk of suicide.
---------------------------------------------------------------------------
    \22\ Tanelian and Jaycox, ``Invisible Wounds of War,'' RAND, 2008, 
at http://RAND.org/pubs/monographs/2008/RAND_MG720.1.pdf, visited April 
28, 2008.
---------------------------------------------------------------------------
    The VA/University of Michigan study of suicide among veterans with 
depression found that PTSD was associated with a lower risk of suicide 
in this group.\23\ The authors suggest that this unexpected finding may 
reflect the effect of treatment for PTSD, rather than a protective 
effect of PTSD itself.
---------------------------------------------------------------------------
    \23\ Zivin et al., study of depression and suicide in veterans.
---------------------------------------------------------------------------
                          Congressional Action
    In the 109th Congress, two measures (H.R. 5771 and S. 3808) were 
introduced regarding the prevention of suicide among veterans. However, 
these bills did not see further legislative action.
    In the 110th Congress, the Joshua Omvig Veterans Suicide Prevention 
Act (H.R. 327) was introduced in the House, and a companion version (S. 
479) was introduced in the Senate.\24\ The House passed H.R. 327 on 
March 21, 2007, and the Senate passed the House measure with an 
amendment on September 27. The bill was signed into law (P.L. 110-110) 
on November 5, 2007.\25\ The act, among other things, requires the VA 
to establish a comprehensive program for suicide prevention among 
veterans. In carrying out this comprehensive program, the VA must 
designate a suicide prevention counselor at each VA medical facility. 
Each counselor is required to work with local emergency rooms, police 
departments, mental health organizations, and veterans service 
organizations to engage in outreach to veterans. The act also requires 
the VA to provide for research on best practices for suicide prevention 
among veterans, and requires the VA Secretary to provide for outreach 
and education for veterans and their families, with special emphasis on 
providing information to veterans of OIF and OEF. The act requires VA 
to provide for the availability of 24-hour mental healthcare for 
veterans and to establish a 24-hour hotline for veterans to call if 
needed.
---------------------------------------------------------------------------
    \24\ The Joshua Omvig Veterans Suicide Prevention Act is named for 
a veteran who completed suicide on December 22, 2005.
    \25\ Codified at 38 USC Sec. 1720F. For a detailed legislative 
history of PL 110-110, see H.Rept. 110-55 and S.Rept. 110-132.
---------------------------------------------------------------------------
    Also in the 110th Congress, the National Defense Authorization Act 
for Fiscal Year 2008 (P.L. 110-181) requires the Secretaries of DoD and 
VA to develop a comprehensive care and transition policy for 
servicemembers who are recovering from serious injuries or illnesses 
related to their military service, and to specifically address the risk 
of suicide among these individuals in developing the required 
policy.\26\
---------------------------------------------------------------------------
    \26\ See CRS Report RL34371, ``Wounded Warrior'' and Veterans 
Provisions in the FY 2008 National Defense Authorization Act, by Sarah 
A. Lister, Sidath Viranga Panangala, and Christine Scott.
---------------------------------------------------------------------------
    More recently, the Veterans Suicide Study Act (S. 2899) was 
introduced. This measure would require the VA to study and report to 
Congress regarding suicides that have occurred among veterans since 
1997. In carrying out this study, the VA Secretary would have to 
coordinate with the Secretary of Defense, Veterans Service 
Organizations, the CDC, and state public health offices and veterans 
agencies.
                  VA's Suicide Prevention Efforts \27\
    In response to legislation and congressional oversight, the VA has 
initiated several suicide prevention activities. Following is a summary 
of major activities.
---------------------------------------------------------------------------
    \27\ Drawn from the Department of Veterans Affairs, Report to 
Congress, P.L. 110-110, Comprehensive Program for Suicide Prevention 
Among Veterans, February 2008.
---------------------------------------------------------------------------
Mental Health Strategic Plan
    In 2004, the VA developed the Mental Health Strategic Plan (MHSP), 
which aimed to present a new approach to mental healthcare, to focus on 
recovery rather than pathology, and to integrate mental healthcare into 
overall healthcare for veteran patients. This 5-year action plan, with 
more than 200 initiatives, includes timetables and responsible offices 
identified for each action item. A number of these action items are 
specifically aimed at the prevention of suicide. In 2006, following a 
request by the House Committee on Veterans Affairs, the VA's Inspector 
General (IG) undertook an assessment of VA's progress in implementing 
the MHSP initiatives for suicide prevention, and provided 
recommendations.\28\ The IG's findings revealed that MHSP initiatives 
pertaining to 24-hour crisis availability, outreach, referral, and 
development of methods for tracking veterans at risk have been 
implemented in multiple facilities, but not yet systemwide. Initiatives 
focused on the development of methods for screening, assessment of 
veterans at risk, emerging best practice treatment interventions, 
education of VA health providers, and an electronic suicide prevention 
database have been piloted or are in the process of being piloted at 
selected facilities.
---------------------------------------------------------------------------
    \28\ Department of Veterans Affairs, Office of Inspector General, 
``Implementing VHA's Mental Health Strategic Plan Initiatives for 
Suicide Prevention,'' Report No. 06-03706-126, 2007.
---------------------------------------------------------------------------
Mental Health Research
    VA's Mental Illness Research, Education and Clinical Center 
(MIRECC) at Denver, Colorado, and the Center of Excellence in Mental 
Health and PTSD at Canandaigua, New York, have been specifically 
focusing on research related to suicide prevention. According to the 
VA, ongoing studies at these centers are studying suicide risk factors, 
validation of suicide ideation screening instruments, quality of mental 
healthcare and its relationship to suicide prevention, and risk factors 
for suicide as it relates to depression.
Suicide Awareness
    In April 2007, VA held its first Suicide Prevention Awareness Day 
at all VA medical centers (VAMCs). The program included recognizing 
risk factors for suicide, and proper protocols for responding to crisis 
situations. VA held its second Suicide Prevention Awareness Day in 
September 2007. The program consisted of required training for all 
staff on general principles of suicide prevention, and the use of the 
national VA Suicide Prevention Hotline (see below).
    VA has also appointed Suicide Prevention Coordinators who are 
located at each VA medical center. They were appointed in response to 
P.L. 110-110, which required VA to appoint suicide prevention 
counselors in each VA medical facility. The primary function of these 
coordinators is to support the identification of patients at high risk 
for suicide, and to ensure that their monitoring and care are 
intensified. Furthermore, they are involved in training and education, 
both within the VA and in the community. All the coordinators are 
licensed mental health professionals.
Screening
    A screening program aims to identify individuals who have mental or 
emotional problems that increase their risk for suicide.\29\ VA has 
implemented a policy to screen all OEF/OIF veterans for depression, 
PTSD, and alcohol abuse upon their initial visit to VA medical centers 
or clinics. Furthermore, screening for depression and alcohol abuse is 
required on an annual basis for all veterans, and screening for PTSD is 
required annually for the first five years after enrollment, and every 
five years thereafter. Veterans who screen positive for one of these 
conditions are required to receive a follow-up clinical evaluation that 
considers both the condition(s) related to the positive screen, and the 
risk of suicide. When this process confirms the presence of a mental 
disorder or suicide risk, veterans are offered mental health treatment. 
When there is a referral or request for mental health services, 
veterans must receive an initial evaluation within 24 hours. If this 
evaluation identifies an urgent need, treatment is to be provided 
immediately. Otherwise, veterans must receive a full diagnostic and 
treatment planning evaluation and the initiation of care within two 
weeks.
---------------------------------------------------------------------------
    \29\ For more information on screening tools and their 
effectiveness, see CRS Report RS22647, Screening for Youth Suicide 
Prevention, by Ramya Sundararaman.
---------------------------------------------------------------------------
    In addition, the DoD administers a post-deployment health 
reassessment (PDHRA) 90-180 days after a servicemember's return from 
deployment, to identify health concerns, with an emphasis placed on 
screening for mental health conditions that may have emerged since 
returning home. Information gathered during this assessment helps DoD 
identify servicemembers who require referrals for further 
evaluation.\30\ The Government Accountability Office (GAO) has stated 
that DoD shares information gathered through the PDHRA with the VA. 
According to GAO, ``VA officials obtain PDHRA information about 
servicemembers referred to VA and individual servicemembers' [PDHRA] 
when they access VA healthcare. Each month, VA receives a report that 
provides monthly and cumulative totals of servicemembers referred, 
including servicemembers referred to VA facilities.'' \31\ However, it 
is unclear at this time if VA uses this information to specifically 
screen those who may be potentially at risk of suicide.
---------------------------------------------------------------------------
    \30\ The PDHRA (DD Form 2900) includes questions about feeling 
down, depressed, or hopeless, the occurrence of nightmares, 
relationship issues with family and friends, and increased alcohol use.
    \31\ U.S. Government Accountability Office (GAO), DoD's Post-
Deployment Health Reassessment, GAO-08-181R, January 25, 2008, p.7.
---------------------------------------------------------------------------
Suicide Prevention Hotline
    The VA has also partnered with the Lifeline Program, a grantee of 
the Substance Abuse and Mental Health Services Administration (SAMHSA), 
of the Department of Health and Human Services (HHS), 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.\32\ 
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. The responders at the VA 
suicide prevention hotline have received American Association of 
Suicidology (AAS) credentialing and certification.
---------------------------------------------------------------------------
    \32\ VA is using the national suicide prevention hotline to provide 
this service to veterans.
---------------------------------------------------------------------------
    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 
VAMC for follow-up care.
    From October 7 to November 10, 2007, 1,636 veterans and 311 family 
members or friends called the VA suicide prevention hotline. These 
calls led to 363 referrals to suicide prevention coordinators and 93 
rescues involving emergency services.\33\
---------------------------------------------------------------------------
    \33\ Testimony of Ira Katz, M.D., Ph.D., Deputy Chief Patient Care 
Services Officer, Office of Mental Health, Veterans Health 
Administration, Department of Veterans Affairs in U.S. Congress, House 
Committee on Veterans' Affairs, Stopping Suicides: Mental Health 
Challenges Within the U.S. Department of Veterans Affairs, hearings, 
110th Cong., 1st sess., December 12, 2007.
---------------------------------------------------------------------------
Funding for Suicide Prevention
    According to VA estimates, in FY 2008, spending for the suicide 
prevention program will include $970,000 to establish the suicide 
prevention hotline; $1.97 million for the Center of Excellence in 
Canandaigua, New York; $2.20 million for the Mental Illness Research, 
Education and Clinical Center in Denver, Colorado; $90,000 for the 
Serious Mental Illness Research, Education and Clinical Center for 
monitoring of suicide rates and risk factors; and $14.32 million for 
Suicide Prevention Coordinators.\34\
---------------------------------------------------------------------------
    \34\ Department of Veterans Affairs, Report to Congress, P.L. 110-
110, Comprehensive Program for Suicide Prevention Among Veterans, p. 7, 
February 2008.
---------------------------------------------------------------------------
                               Conclusion
    There has been considerable recent interest in the burden of 
suicide among veterans, in particular those who have recently returned 
from military service in Operation Iraqi Freedom and Operation Enduring 
Freedom. This interest has thrown a spotlight on the fact that there is 
not, at this time, a system of surveillance for suicide among veterans.
    Despite recent interest in comparing suicide rates between veterans 
and the general population, this may not be the most useful comparison. 
In numerous ways that affect their suicide risk, veterans are not like 
the general population. Also, the VA has an interest in decreasing the 
burden of suicide among veterans, whether this burden exceeds that of 
the general population or not. What may be more meaningful, and more 
important to achieve, is the establishment of data systems that support 
a more robust and reliable understanding of suicide among veterans. The 
ideal systems would describe a clear baseline, and provide a means to 
track changes going forward--with respect to such things as risk and 
protective factors, and the effects of treatment--in order to know 
which interventions work, and where to target them.
[GRAPHIC] [TIFF OMITTED] 43052A.009


[GRAPHIC] [TIFF OMITTED] 43052A.010


[GRAPHIC] [TIFF OMITTED] 43052A.011


[GRAPHIC] [TIFF OMITTED] 43052A.012


                                 

                                     Department of Veterans Affairs
                                  Under Secretary for HealthAddress
                                                    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, MD, MS, 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

                                 

                                     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 non-
veteran 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/non-veterans, 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
                                                           Chairman

                                                        Steve Buyer
                                                     Ranking Member
    CW/mh

                               ----------
                                                           CBS News
                                                      New York, NY.
                                                       May 16, 2008

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 Congressmen 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 non-veteran 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/non-veterans, 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

                                 

                                     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
                                                           Chairman

                                                        Steve Buyer
                                                     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 and over                  1401     100   1734   100.0   1598   100.0   1701   100.0   1781   100.0
----------------------------------------------------------------------------------------------------------------
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 American                            2     0.1      6     0.3      3     0.2      2     0.1      7     0.4
----------------------------------------------------------------------------------------------------------------
African American                          55     3.9     80     4.6     47     2.9     62     3.6     78     4.4
----------------------------------------------------------------------------------------------------------------
Asian/Pacific Islander                     0     0.0      4     0.2      2     0.1      3     0.2     16     0.9
----------------------------------------------------------------------------------------------------------------
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               5           0.4           4           0.2           8           0.5           5           0.3          12           0.7
              exposure to non-opioid analgesics, anti-
              pyretics, and anti-rheumatics
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     X61     Intentional self-poisoning (suicide) by and              39           2.8          49           2.8          38           2.4          43           2.5          53           3.0
              exposure to antiepileptic, sedative-hypnotic
              anti-parkinsonism, and psychotropic drugs, not
              elsewhere classified
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     X62     Intentional self-poisoning (suicide) by and              26           1.9          42           2.4          30           1.9          27           1.6          48           2.7
              exposure to narcotics and psychodysleptics
              (hallucinogens), not elsewhere classified
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     X63     Intentional self-poisoning (suicide) by and               1           0.1           3           0.2           1           0.1           0           0.0           2           0.1
              exposure to other drugs acting on the autonomic
              nervous system
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     X64     Intentional self-poisoning (suicide) by and             100           7.1          97           5.6         103           6.4         112           6.6         102           5.7
              exposure to other and unspecified drugs,
              medicaments, and biological substances
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     X65     Intentional self-poisoning (suicide) by and               2           0.1           2           0.1           5           0.3           0           0.0           1           0.1
              exposure to alcohol
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     X66     Intentional self-poisoning (suicide) by and               2           0.1           3           0.2           1           0.1           6           0.4           3           0.2
              exposure to organic solvents and halogenated
              hydrocarbons and their vapors
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     X67     Intentional self-poisoning (suicide) by and              34           2.4          62           3.6          35           2.2          59           3.5          50           2.8
              exposure to other gases and vapors
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                   Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005--Continued
-----------------------------------------------------------------------------------------------------------------
                                          FY 2001        FY 2002        FY 2003        FY 2004        FY 2005
             Characteristic           --------------------------------------------------------------------------
                                         N       %      N       %      N       %      N       %      N       %
----------------------------------------------------------------------------------------------------------------
                                       DDDDD
                                       DDDDD
                                       e12,L
                                       4,b2,
                                       tp0,p
                                        1,6/
                                       7,f6,
                                       g1,t1
                                       ,4,xl
                                       s65,4
                                       ,5,4,
                                       5,4,5
                                       ,4,5,
                                         4,5
X68                                    Inten       1    0.1       1    0.1       1    0.1       0    0.0       0
                                       tiona
                                           l
                                       self-
                                       poiso
                                        ning
                                       (suic
                                        ide)
                                          by
                                         and
                                       expos
                                         ure
                                          to
                                       pesti
                                       cides
----------------------------------------------------------------------------------------------------------------
X69                                    Inten       3    0.2       6    0.3       4    0.3       3    0.2       4
                                       tiona
                                           l
                                       self-
                                       poiso
                                        ning
                                       (suic
                                        ide)
                                          by
                                         and
                                       expos
                                         ure
                                          to
                                       other
                                         and
                                       unspe
                                       cifie
                                           d
                                       chemi
                                        cals
                                         and
                                       noxio
                                          us
                                       subst
                                       ances
----------------------------------------------------------------------------------------------------------------
X70                                    Inten     163   11.6     214   12.3     189   11.8     207   12.2     189
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       hangi
                                         ng,
                                       stran
                                       gulat
                                        ion,
                                         and
                                       suffo
                                       catio
                                           n
----------------------------------------------------------------------------------------------------------------
X71                                    Inten      17    1.2      19    1.1      12    0.8      10    0.6      15
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       drown
                                         ing
                                         and
                                       subme
                                       rsion
----------------------------------------------------------------------------------------------------------------
X72                                    Inten     192   13.7     248   14.3     255   16.0     227   13.3     277
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       handg
                                          un
                                       disch
                                        arge
----------------------------------------------------------------------------------------------------------------
X73                                    Inten     145   10.3     174   10.0     150    9.4     171   10.1     170
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       rifle
                                           ,
                                       shotg
                                         un,
                                         and
                                       large
                                           r
                                       firea
                                          rm
                                       disch
                                        arge
----------------------------------------------------------------------------------------------------------------
X74                                    Inten     566   40.4     726   41.9     675   42.2     728   42.8     758
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       other
                                         and
                                       unspe
                                       cifie
                                           d
                                       firea
                                          rm
                                       disch
                                        arge
----------------------------------------------------------------------------------------------------------------
X75                                    Inten       0    0.0       0    0.0       0    0.0       0    0.0       2
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       explo
                                        sive
                                       mater
                                         ial
----------------------------------------------------------------------------------------------------------------
X76                                    Inten       6    0.4       4    0.2       6    0.4      14    0.8      12
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       smoke
                                           ,
                                       fire,
                                         and
                                       flame
                                           s
----------------------------------------------------------------------------------------------------------------
X77                                    Inten       0    0.0       0    0.0       0    0.0       0    0.0       0
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       steam
                                       , hot
                                       vapor
                                          s,
                                         and
                                         hot
                                       objec
                                          ts
----------------------------------------------------------------------------------------------------------------
X78                                    Inten      34    2.4      33    1.9      33    2.1      35    2.1      28
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       sharp
                                       objec
                                           t
----------------------------------------------------------------------------------------------------------------
X79                                    Inten       0    0.0       0    0.0       0    0.0       0    0.0       0
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       blunt
                                       objec
                                           t
----------------------------------------------------------------------------------------------------------------
X80                                    Inten      31    2.2      18    1.0      30    1.9      27    1.6      22
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       jumpi
                                          ng
                                        from
                                           a
                                        high
                                       place
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                   Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005--Continued
-----------------------------------------------------------------------------------------------------------------
                                          FY 2001        FY 2002        FY 2003        FY 2004        FY 2005
             Characteristic           --------------------------------------------------------------------------
                                         N       %      N       %      N       %      N       %      N       %
----------------------------------------------------------------------------------------------------------------
                                       DDDDD
                                       DDDDD
                                       e12,L
                                       4,b2,
                                       tp0,p
                                        1,6/
                                       7,f6,
                                       g1,t1
                                       ,4,xl
                                       s65,4
                                       ,5,4,
                                       5,4,5
                                       ,4,5,
                                         4,5
X81                                    Inten      14    1.0      10    0.6       7    0.4      12    0.7       8
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       jumpi
                                       ng or
                                       lying
                                       befor
                                           e
                                       movin
                                           g
                                       objec
                                           t
----------------------------------------------------------------------------------------------------------------
X82                                    Inten       1    0.1       4    0.2       5    0.3       4    0.2       7
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       crash
                                         ing
                                          of
                                       motor
                                       vehic
                                          le
----------------------------------------------------------------------------------------------------------------
X83                                    Inten       7    0.5       6    0.3       3    0.2       4    0.2       2
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       other
                                       speci
                                        fied
                                       means
----------------------------------------------------------------------------------------------------------------
X84                                    Inten       5    0.4       6    0.3       4    0.3       4    0.2      11
                                       tiona
                                           l
                                        self
                                        harm
                                       (suic
                                        ide)
                                          by
                                       unspe
                                       cifie
                                           d
                                       means
----------------------------------------------------------------------------------------------------------------
V87                                    Seque       7    0.5       3    0.2       3    0.2       3    0.2       5
                                         lae
                                          of
                                       inten
                                       tiona
                                           l
                                        self
                                        harm
----------------------------------------------------------------------------------------------------------------
*Includes age <20 years old
----------------------------------------------------------------------------------------------------------------


                                 
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                  December 21, 2007
Honorable Robert M. Gates
Secretary
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301

Dear Secretary Gates:

    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 Defense share their data on 
suicide among the active military population with the Committee.
    Specifically, we request the number of active duty suicides for 
each year from 1995 through 2006. We ask that this information be 
listed by military branch, year of death, age, race, gender and manner 
of suicide. Additionally, we ask for the methodology the Department 
uses to collect data on active duty suicides.
    Undoubtedly, you share our desire to ensure that every measure is 
taken to prevent those in the military 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
                                                           Chairman

                                                        Steve Buyer
                                                     Ranking Member
CW/mh
                                 *****
                                           The Secretary of Defense
                                                     Washington, DC
                                                   January 17, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    Thank you for the letter you signed with Representative Buyer 
requesting data on the number of active duty suicides from 1995 through 
2006. I have asked Dr. David Chu, Under Secretary of Defense for 
Personnel and Readiness, to address this matter. We will get back to 
you as soon as possible.
            With best wishes,
            Sincerely,
                                                    Robert M. Gates
                               ----------
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                        May 6, 2008
Honorable Robert M. Gates
Secretary
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301-1000

Dear Secretary Gates:

    I would appreciate it if you could respond to the enclosed request 
regarding assessing the programs that the Department of Veterans 
Affairs (VA) provides for veterans who are at risk for suicide. 
Previous letters were sent to you on December 21, 2007, and the 
Committee received notices on January 17, 2008, indicating that your 
office was looking into the matter.
    Because your response will be entered into the record for today's 
Full Committee hearing on ``The Truth About Veterans' Suicides,'' the 
Committee would appreciate a reply back from your office by no later 
than May 20, 2008. If you have any questions in this regard, please 
contact Mark Heyman, Professional Staff Member, at (202) 225-9756.
            Sincerely,
                                                         Bob Filner
                                                           Chairman
Enclosure
MS/jz
                               ----------
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 21, 2008
Honorable Robert M. Gates
Secretary
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301-1000

Dear Secretary Gates:

    I would appreciate it if you could respond to the enclosed request 
regarding assessing the programs that the Department of Veterans 
Affairs (VA) provides for veterans who are at risk for suicide. 
Previous letters were sent to you on December 21, 2007, and May 6, 
2008, and the Committee received notices on January 17, 2008, 
indicating that your office was looking into the matter.
    Because your response will be entered into the record for today's 
Full Committee hearing on ``The Truth About Veterans' Suicides,'' the 
Committee would appreciate a reply back from your office by no later 
than June 4, 2008.
If you have any questions in this regard, please contact Mark Heyman, 
Professional Staff Member, at (202) 225-9756.
            Sincerely,
                                                         Bob Filner
                                                           Chairman
Enclosure
MS/jz
                               ----------
                                           The Secretary of Defense
                                                     Washington, DC
                                                       June 3, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    Thank you for your letter regarding a Department of Defense 
assessment of the Department of Veterans Affairs' programs for veterans 
at risk for suicide. I have asked Dr. David Chu, Under Secretary of 
Defense for Personnel and Readiness, to address the matter. He will get 
back to you as soon as possible.
            With best wishes,
            Sincerely,
                                                    Robert M. Gates
                               ----------
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       June 5, 2008
Honorable Robert M. Gates
Secretary
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301-1000

Dear Secretary Gates:

    I would appreciate it if you could respond to the enclosed request 
regarding assessing the programs that the Department of Veterans 
Affairs (VA) provides for veterans who are at risk for suicide. 
Previous letters were sent to you on December 21, 2007; May 6, 2008; 
and May 21, 2008, and the Committee received notices on January 17, 
2008, and June 4, 2008, indicating that your office was looking into 
the matter.
    Because your response will be entered into the record for today's 
Full Committee hearing on ``The Truth About Veterans' Suicides,'' the 
Committee would appreciate a completed response to the enclosed request 
by no later than June 19, 2008. If you have any questions in this 
regard, please contact Mark Heyman, Professional Staff Member, at (202) 
225-9756.
            Sincerely,
                                                         Bob Filner
                                                           Chairman
Enclosure
MS/jz

                                 

Department of Veterans Affairs
                               MEMORANDUM
Date: May 5, 2008
From: Under Secretary for Health (10)
Subj: Blue Ribbon Work Group on Suicide Prevention in the Veteran 
Population
To: Secretary (00)
    1.  At your request, VHA has developed a draft charter and draft 
membership list for your consideration for the Blue Ribbon Work Group 
on Suicide Prevention in the Veteran Population (see attachments). We 
have also contacted prospective members to determine their willingness 
to do so and to do so without compensation.
    2.  With your approval, we will proceed with formally contacting 
the members that you have approved and setting up the one-time meeting.

    Michael J. Kussman, MD, MS, MACP

    APPROVE/DISAPPROVE                    Date 5/5/08
    James B. Peake, M.D.

    Attachments:

      Draft Charter
      Draft Membership and Staff Support List (with approval/
disapproval lines for each)
      CVs for Potential Members of The Work Group
      CVs for Potential Member of The Expert Panel
                               ----------
                     DEPARTMENT OF VETERANS AFFAIRS
                             CHARTER OF THE
          BLUE RIBBON WORK GROUP ON SUICIDE PREVENTION IN THE
                           VETERAN POPULATION
    A. OFFICIAL DESIGNATION: Blue Ribbon Work Group on Suicide 
Prevention in the Veteran Population (``Work Group'').
    B. OBJECTIVES AND SCOPE OF ACTIVITY: The Blue Ribbon Work Group on 
Suicide Prevention in the Veteran Population advises the Secretary on 
research and programs relevant to the prevention of suicide in the 
veteran population.
    C. PERIOD OF TIME NECESSARY FOR THE COMMITTEE TO CARRY OUT ITS 
PURPOSES: Established as an Executive Branch Task Force that will meet 
one time for approximately 3 days with a final report to the Secretary 
within 15 days.
    D. OFFICIAL TO WHOM THE COMMITTEE REPORTS: The Blue Ribbon Work 
Group on Suicide Prevention in the Veteran Population reports to the 
Secretary of Veterans Affairs.
    E. OFFICE RESPONSIBLE FOR PROVIDING THE NECESSARY SUPPORT FOR THE 
COMMITTEE: The Veterans Health Administration, Department of Veterans 
Affairs, is responsible for providing administrative and logistical 
support to the Blue Ribbon Work Group on Suicide Prevention in the 
Veteran Population.
    F. DUTIES OF THE COMMITTEE: The Blue Ribbon Work Group on Suicide 
Prevention in the Veteran Population provides advice and consultation 
to the Secretary on various matters relating to research, education and 
program improvements relevant to the prevention of suicide in the 
veteran population. The Blue Ribbon Work Group on Suicide Prevention in 
the Veteran Population will create a report within 15 days of the 
completion of its meeting with recommendations for improvements in VA's 
programs related to suicide prevention, research, and education. 
Recommendations will be directly related to the primary objective of 
reducing risk of suicide in the veteran population.
    G. MEMBERSHIP: Blue Ribbon Work Group on Suicide Prevention in the 
Veteran Population membership shall include only Executive Branch 
employees who are experts in public health suicide programs (including 
suicide prevention and education programs), suicide research 
(especially epidemiology and suicidiology), and clinical treatment 
programs for patients at risk for suicide. The Work Group will be 
comprised of five (5) members. The Work Group process will be informed 
by the testimony and counsel of a panel (The Expert Panel) with 
nationally recognized expertise in public health suicide programs, 
suicide research, and clinical treatment programs for patients, and 
other relevant areas. Members of The Expert Panel will have no 
significant direct relationship with the Department of Veterans 
Affairs. The role of each member of the panel is to individually 
provide: expert opinion, interpretation, and conclusions on information 
and data presented to the Work Group; expert information and data from 
other (non-VA) sources; and recommendations to the Work Group on 
opportunities for improvement in VA's programs. The Expert Panel will 
be comprised of nine (9) members. Employees of the Department of 
Veterans Affairs and other Federal Government employees may be called 
upon the Work Group to provide background briefings on any relevant 
information to better inform the Work Group decision process and The 
Expert Panel.
    H. EXPENSES: All Work Group and Expert Panel members will receive 
travel expenses and a per diem allowance in accordance with the Federal 
Travel Regulations for any travel made in connection with their duties 
as members of the Work Group or Expert Panel. No member of the Work 
Group or the Expert Panel will receive honorarium.
    I. ESTIMATED NUMBER AND FREQUENCY OF MEETING: The Group is expected 
to meet once for approximately three (3) days. Administrative support 
to the Work Group will be provided by the Veterans Health 
Administration. The Veterans Health Administration, Office of Mental 
Health Services, will support the Chair in the development of the 
schedule, operation of the meeting, general logistical requirements, 
and production of the final report. A representative of the Secretary 
will be present at the meeting, and the meeting will be conducted in 
accordance with an agenda provided by the Secretary.
    J. COMMITTEE TERMINATION DATE: The Work Group and The Expert Panel 
will be terminated upon completion and transmittal of the final report 
to the Secretary.
    K. DATE CHARTER IS FILES:

Approved: James B. Peake, M.D.
Secretary of Veterans Affairs
Date 5/5/08
                               ----------
    Membership

    Work Group

      CDR (USPHS) Alex E. Crosby, MD, MPH, Medical 
Epidemiologists, Surveillance Team/ESB/DVP/NCIPC Centers for Disease 
Control and Prevent (CDC), Atlanta, GA

    APPROVE/DISAPPROVE                    Date 5/5/08

      COL (USA) Charles W. Hoge, MD, Director, Division of 
Psychiatry And Behavior Services, Walter Reed Army Institute Of 
Research, Silver Spring, MD

    APPROVE/DISAPPROVE                    Date 5/5/08

      COL (USAF) Robert Roy Ireland, MC, Chairman, Program 
Director for Mental Health Policy, Clinical and Program Policy, Office 
of the Assistant Secretary of Defense (Health Affairs, Falls Church, VA

    APPROVE/DISAPPROVE                    Date 5/5/08

      Richard McKeon, PhD, MPH, Special Advisory Suicide 
Prevention, CMHS, Substance Abuse and Mental Health Services 
Administration (SAMHSA)

    APPROVE/DISAPPROVE                    Date 5/5/08

      Jane Pearson, MA, PhD, Associate Director for Preventive 
Interventions, Division of Services and Intervention Research, National 
Institute of Mental Health

    APPROVE/DISAPPROVE                    Date 5/5/08

    Expert Panel:

      Dan Blazer II, MD, MPH, PhD, Professor of Psychology, Co-
Director of Clinical Training, Catholic University of America

    APPROVE/DISAPPROVE                    Date 5/5/08

      Greg Brown, PhD, University of Pennsylvania

    APPROVE/DISAPPROVE                    Date 5/5/08

      Martha Livingston Bruce, PhD, MPH, Professor, Program in 
Clinical Epidemiology and Health Services Research, Graduate School of 
Medical Sciences, and Associate Vice-Chair for Research, Weill Medical 
College of Cornell University

    APPROVE/DISAPPROVE                    Date 5/5/08

      Eric D. Caine, MD, Chair of Psychiatry, John Romano 
Professor Psychiatry and Chair, Department of Psychiatry, University of 
Rochester

    APPROVE/DISAPPROVE                    Date 5/5/08

      Jan Fawcett, MD Professor of Psychiatry, School of 
Medicine, Department of Psychiatry, University of New Mexico

    APPROVE/DISAPPROVE                    Date 5/5/08

      Robert D. Gibbons, Director, Center for Health 
Statistics, University of Illinois at Chicago

    APPROVE/DISAPPROVE                    Date 5/5/08

      David Alan Jobes, PhD, ABBPP, Professor of Psychology, 
Department of Psychology, The Catholic University of America

    APPROVE/DISAPPROVE                    Date 5/5/08

      Mark S. Kaplan, PhD, Portland State University, Member, 
Suicide Prevention Action Network-USA National Scientific Advisory 
Council

    APPROVE/DISAPPROVE                    Date 5/5/08

      Thomas R. Ten Have, Director of the Biostatistics 
Analysis Center of the Center for Clinical Epidemiology and 
Biostatistics and Senior Scholar, Center for Clinical Epidemiology and 
Biostatistics, University of Pennsylvania School of Medicine; Member, 
Biomedical Graduate Studies, University of Pennsylvania School of 
Medicine

    APPROVE/DISAPPROVE                    Date 5/5/08

    Administrative Support/Planning:

      Secretary's Representative Jaewon Ryupao, JD (Secretary 
to specify)
      Seth Eisen, MD, Director, Health Services Research and 
Development (12)
      Ira Katz, MD, Deputy Chief Patient Care Services Officer 
for Mental Health (116)
      Antoinette Zeiss, Ph.D., Deputy Chief Mental Health 
Services (116)
      John O'Hara, Executive Assistant, Office of Policy and 
Planning (008)
      Technical Writer TBD

                                 


                   Rates and Risk of Suicide and other Suicidal Behaviors among U.S. Veterans
----------------------------------------------------------------------------------------------------------------
                                Population-based Studies of Vietnam-era Veterans
-----------------------------------------------------------------------------------------------------------------
 Author  Publication                          Study and  Comparison                            Limitations and
         Year          Institution,  Sponsor          Groups              Key Findings            Concerns
----------------------------------------------------------------------------------------------------------------
Cypel, 2008            WRIISC, EES, VHA       Women veterans who     Women Vietnam era      Only 12 suicide
                                               served in Vietnam      veterans had lower     deaths reported in
                                               (n=4586) or            all-cause mortality    women Vietnam
                                               elsewhere during the   (SMR=0.87). SMR for    veterans
                                               Vietnam era            suicide was 1.22 for
                                               (n=5325), compared     women veterans who
                                               with the U.S.          served in Vietnam,
                                               population.            but this was not
                                               Mortality followed     statistically
                                               through 2004 using     significant
                                               BIRLS and SSA death
                                               files
----------------------------------------------------------------------------------------------------------------
Herrell, 1999          VET registry, HSR&D,    103 male twin pairs   Homosexual             Analysis of
                        VHA                    were identified in     orientation was        discordant twin
                                               which one member of    significantly          pairs is a strong
                                               the pair reported      associated with        scientific design
                                               male sexual partners   suicidal ideation      because it adjusts
                                               but the other did      and suicide attempts   for confounding
                                               not. Suicidal          (approximately 2.5-    based on genetic
                                               ideation and suicide   fold increased risk    predisposition.
                                               attempts were          after adjusting for    Data were gathered
                                               assessed by a          substance abuse and    via interview at a
                                               structured             depression             single point in
                                               psychiatric                                   time and do not
                                               interview.                                    address risk for
                                                                                             suicide.
----------------------------------------------------------------------------------------------------------------
Bullman,1996           EES, VHA                Vietnam veterans       In comparison with    Death certificate
                                               with nonlethal         the U.S. male          data might be
                                               wounds (n=34,534)      population, veterans   inaccurate; no data
                                               were assessed for      hospitalized because   on psychological
                                               risk of suicide        of a combat wound or   and behavioral
                                               through 1991           wounded more than      characteristics
                                                                      once had increased     that might have
                                                                      suicide risk           predisposed
                                                                      (SMR=1.22 for          individuals to both
                                                                      hospitalized           injury as well as
                                                                      veterans; SMR=1.58     suicide.
                                                                      for multiple wounded
                                                                      veterans)
----------------------------------------------------------------------------------------------------------------


             Rates and Risks of Suicide and other Suicidal Behaviors among U.S. Veterans--Continued
----------------------------------------------------------------------------------------------------------------
                                Population-based Studies of Post-Vietnam Veterans
-----------------------------------------------------------------------------------------------------------------
 Author  Publication                          Study and  Comparison                            Limitations and
         Year          Institution,  Sponsor          Groups              Key Findings            Concerns
----------------------------------------------------------------------------------------------------------------
Bullman, 2005          EES, VHA               Gulf War Veterans      Relative risk for      Death certificates
                                               potentially exposed    suicide not            might not be
                                               to chemical warfare    increased (RR=1.05)    accurate; exposure
                                               agents (n=100,487)                            data might not be
                                               with those not                                accurate
                                               likely to have been
                                               exposed (n=224,980).
----------------------------------------------------------------------------------------------------------------
Kang, 2001             EES, VHA               Gulf War Veterans       Relative risk for     Death certificates
                                               (n=695,516) compared   suicide not            might not be
                                               with other military    increased (RR=0.92     accurate; ``health
                                               on active duty from    for males)             soldier effect''
                                               8/90 thru 4/91
                                               (n=746,291). Deaths
                                               through 1997
                                               obtained from BIRLS
                                               and SSA.
----------------------------------------------------------------------------------------------------------------
Kang, 1996             EES, VHA               Gulf War Veterans      Small increase in      Death certificates
                                               (n=695,516) compared   death rate from        might not be
                                               with other military    accidents (SMR=1.25)   accurate; ``health
                                               on active duty (n=     but no increase in     soldier effect''
                                               746,291). Deaths       suicide rates. There
                                               through 9/93           were 261 suicides
                                               obtained from BIRLS    among the Gulf War
                                               and SSA                veterans
----------------------------------------------------------------------------------------------------------------


              Rates and Risk of Suicide and other Suicidal Behaviors among U.S. Veterans--Continued
----------------------------------------------------------------------------------------------------------------
                                             Clinical Cohort Studies
-----------------------------------------------------------------------------------------------------------------
 Author  Publication                          Study and  Comparison                            Limitations and
         Year          Institution,  Sponsor          Groups              Key Findings            Concerns
----------------------------------------------------------------------------------------------------------------
Zivin, 2007            SMITREC, VHA           Veterans receiving     Among depressed        Lower rate of
                                               treatment in VA for    veterans, 1683         suicide among
                                               depression between     (0.21%) committed      veterans with PTSD
                                               1999 and 2004          suicide during         and depression is
                                               (n=807,694). Cause     followup. Rate of      surprising and
                                               of death determined    suicide was 90/        counter-intuitive,
                                               from state death       100,000/yr among       though it may be
                                               certificates           males, 29/100,000/yr   explained by the
                                               obtained from NDI      among females. Risk    more intensive
                                                                      was higher among       treatment received
                                                                      whites, younger        by such veterans.
                                                                      veterans, those        Important
                                                                      without service-       contributors to
                                                                      connected              suicide risk, such
                                                                      disabilities, those    as family
                                                                      with prior inpatient   structure, stress,
                                                                      hospitalizations,      and prior suicide
                                                                      veterans with          attempts, were not
                                                                      comorbid substance     assessed
                                                                      abuse, and those
                                                                      living in the
                                                                      southern or western
                                                                      United States. PTSD
                                                                      with comorbid
                                                                      depression was
                                                                      associated with a
                                                                      lower suicide rate.
----------------------------------------------------------------------------------------------------------------
Desai, 2007            NEPEC, VHA             VA mental health       Overall, a decreasing  Short follow-up
                                               outpatient users in    trend in suicide       period (1 year).
                                               three cohorts: 1995    rates over time        Did not control for
                                               (76,105), 1997         among outpatient       potential
                                               (81,512) and 2001      users (13.2/10,000/    confounders such as
                                               (102,184) followed     yr in 1995 versus      prior suicide
                                               for trends in          10.3/10,000/yr in      attempts or
                                               suicide rates during   2001) which was not    suicidal ideation.
                                               the year after their   statistically          Sicker patients may
                                               mental health visit.   significant. Greater   attend larger
                                               Study occurred         per capita mental      programs,
                                               during a period of     health expenditure     accounting for some
                                               system-wide            was associated with    of the results.
                                               reorganization         lower suicide risk.    Sample likely under-
                                               including bed          Outpatients at         represented the
                                               closures               larger programs were   more chronically
                                                                      at greater suicide     ill patients.
                                                                      risk.
----------------------------------------------------------------------------------------------------------------
Gibbons, 2007          VA CSP, NIMH           All veterans newly     Overall rate of        Data apply only to
                                               diagnosed with         suicide attempts was   suicide attempts--
                                               depression in 2003     364/100,000 among      suicides would not
                                               or 2004 (n=226,866),   those receiving        necessarily show up
                                               followed up for at     treatment with an      in VA medical
                                               least 6 months in      SSRI, versus 1057/     records.
                                               VA. Inpatient and      100,000 among the      Administrative
                                               outpatient records     untreated. Risk of     codes may not
                                               assessed for           suicide was higher     accurately reflect
                                               administrative codes   during the period      clinical status of
                                               indicating suicide     prior to initiating    veteran.
                                               attempt.               an SSRI
----------------------------------------------------------------------------------------------------------------


              Rates and Risk of Suicide and other Suicidal Behaviors among U.S. Veterans--Continued
----------------------------------------------------------------------------------------------------------------
                                        Clinical Cohort Studies_Continued
-----------------------------------------------------------------------------------------------------------------
 Author  Publication                          Study and  Comparison                            Limitations and
         Year          Institution,  Sponsor          Groups              Key Findings            Concerns
----------------------------------------------------------------------------------------------------------------
Tiet, 2006             HSR&D, VHA             Veterans aged 19 and   Veterans who had       Study examined
                                               older seeking          recently experienced   veterans only at
                                               treatment for          physical or sexual     one point in time,
                                               substance use          abuse had a 3- to 5-   so author's belief
                                               disorder or other      fold increased risk    that abuse events
                                               psychiatric            of a suicide           precipitate suicide
                                               disorders between      attempt.               attempts is still
                                               July and September,                           speculative.
                                               1997 (n=34,245).
----------------------------------------------------------------------------------------------------------------
Desai, 2005            NEPEC, VHA             All VA mental health   Suicide was higher     Facilities could not
                                               inpatients             among whites, older    be accurately
                                               discharged between     veterans, and those    ranked for quality
                                               1994 and 1998          with depression, as    based on suicide
                                               (n=121,933). Death     well as veterans       rates due to the
                                               within one year of     with lengths of        instability of
                                               discharge was          inpatient stay under   suicide estimates
                                               ascertained through    14 days and those      once adjusted for
                                               VA records and the     with higher risk for   case mix.
                                               National Death         suicide. Readmission
                                               Index. 481 suicides    with 6 months was
                                               were identified in     associated with
                                               the study sample       decreased suicide
                                                                      risk. No facility-
                                                                      level
                                                                      characteristics were
                                                                      associated with
                                                                      suicide risk.
----------------------------------------------------------------------------------------------------------------
Kausch, 2003           VHA                    Reviewed charts of     40% of patients         Retrospective chart
                                               consecutive            reported a prior       review; no
                                               admissions (n=114)     suicide attempt. 59%   denominator to
                                               to a Gambling          of those with          allow calculation
                                               Treatment Program at   history of drug        of rates; did not
                                               the St. Louis VA.      dependence had a       study completed
                                                                      history of suicide     suicides
                                                                      attempts
----------------------------------------------------------------------------------------------------------------
Desai, 2003            NEPEC, VHA             Homeless veterans      Two-thirds of          This sample was self-
                                               (n=7224)               participants           selected based on
                                               participating in a     reported suicidal      willingness to
                                               national               ideation sometime in   enter into
                                               demonstration          their life, and over   intensive case
                                               project of intensive   half had attempted     management. Whether
                                               case management.       suicide. Younger       homelessness causes
                                                                      age, substance         suicidal ideation
                                                                      abuse, and             or suicidal
                                                                      psychiatric symptoms   ideation causes
                                                                      were associated with   homelessness cannot
                                                                      risk for suicide       be determined since
                                                                      attempts.              the study examined
                                                                                             veterans at only
                                                                                             one point in time
----------------------------------------------------------------------------------------------------------------


              Rates and Risk of Suicide and other Suicidal Behaviors among U.S. Veterans--Continued
----------------------------------------------------------------------------------------------------------------
                                        Clinical Cohort Studies_Continued
-----------------------------------------------------------------------------------------------------------------
 Author  Publication                          Study and  Comparison                            Limitations and
         Year          Institution,  Sponsor          Groups              Key Findings            Concerns
----------------------------------------------------------------------------------------------------------------
Thompson, 2002         Philadelphia MIRECC,   Compared cause of      Confirmed and          Total number of
                        VHA                    death among veterans   suspected suicide      suicides as small
                                               receiving medical      accounted for 1.1%     (36). Lack of
                                               and mental             of deaths. Suicide     denominator (``at
                                               healthcare at the      was much higher        risk'' group) makes
                                               Philadelphia VA        among mental health    calculation and
                                               (4123 deaths).         than general medical   comparison of rates
                                                                      patients.              impossible.
----------------------------------------------------------------------------------------------------------------
Kausch, 2001           Case Western, VHA      Survey of all VA       Of 248 completed       Retrospective study
                                               medical centers in     suicides, most (63%)   with no control
                                               1992 identifying       were committed by      group.
                                               suicide attempts and   males with alcohol
                                               suicides in fiscal     addiction; 38% had a
                                               year 1991.             mood disorder, and
                                                                      38% a personality
                                                                      disorder. There were
                                                                      7 suicide attempts
                                                                      on inpatient units
                                                                      and 37 suicide
                                                                      attempts in
                                                                      outpatient substance
                                                                      use disorder
                                                                      treatment.
----------------------------------------------------------------------------------------------------------------
Sernyak, 2001          NEPEC, VHA             All veterans who had   Veterans receiving     Only 10 deaths due
                                               clozapine initiated    clozapine had lower    to suicide among
                                               during a VA hospital   overall death rates,   clozapine-treated
                                               stay between 1992      primarily due to       veterans makes
                                               and 1995 (n=1415)      reduced risk of        statistical
                                               were compared with a   death from             comparisons
                                               match group of         respiratory disease.   difficult.
                                               veterans with          Suicides and           Clozapine users are
                                               schizophrenia not      accidental deaths      not likely to be
                                               receiving clozapine.   did not differ         representative of
                                               VA databases and the   between the groups.    all veterans with
                                               National Death Index   Suicide rate among     serious mental
                                               were used to           clozapine users was    illness.
                                               identify all deaths    150/100,000/yr
                                               over a 3 year follow-
                                               up time.
----------------------------------------------------------------------------------------------------------------


Definitions:
    Suicidal ideation: Thoughts of harming or killing oneself. The 
severity of suicidal ideation can be determined by assessing the 
frequency, intensity, and duration of these thoughts.
    Suicide attempt: A non-fatal, self-inflicted destructive act with 
explicit or inferred intent to die.
    Suicide: Fatal self-inflicted destructive act with explicit or 
inferred intent to die.
    Self-inflicted injuries: Refers to suicidal and non-suicidal 
behaviors such as self-mutilation.
Abbreviations:
BIRLS: Beneficiary Identification and Records Locator Subsystem, 
maintained by VBA
CDC: Center for Disease Control and Prevention
DoD: Department of Defense
EES: VA Environmental Epidemiology Service
HSR&D: VA Health Services Research and Development Service
MIRECC: Mental Illness Research, Education, and Clinical Center
NEPEC: Department of Veterans Affairs Northeast Program Evaluation 
Center located in West Haven, CT
NDI: National Death Index, maintained by the National Center for Health 
Statistics
NIMH: National Institute of Mental Health
RR: Relative risk
SSA: Social Security Administration
SMITREC: Serious Mental Illness Treatment Research and Evaluation 
Center located in Ann Arbor, MI
SMR: Standardized Mortality Ratio
SSRI: Selective serotonin reuptake inhibitor (e.g. Prozac, Zoloft, 
Paxel)
VA CSP: VA Cooperative Studies Program
VET Registry: Vietnam Era Twin Registry, a population-based database of 
male-male twin pairs housed at Hines, IL
WRAMC: Walter Reed Army Medical Center
WRIISC: War-Related Illness and Injury Study Center located in 
Washington, DC
Summary prepared by:
    Joseph Francis, MD, MPH
    Acting Deputy Chief Quality and Performance Officer
    Office of Quality and Performance (10Q)
    202-266-4513
    [email protected]
    Updated April 30, 2008

                                 

           The Comprehensive VHA Mental Health Strategic Plan
       Aligned with the Recommendations of the Action Agenda (AA)
Key

    1. Completed or incorporated into ongoing operations.
    2. Goal achieved by alternate mechanisms.
    3. In planning.
    4. Requires reevaluation or further guidance.

President's New Freedom Commission Goal 1. Americans understand that 
mental health is essential to overall health.

Commission Recommendation 1.1.  Advance and implement a national 
campaign to reduce the stigma of seeking care and a national strategy 
for suicide prevention.

    Create a VA National Mental Health Campaign to increase awareness 
in veteran community that mental health is essential to overall health 
and that very effective modern treatments can promote recovery in 
mental illness. Request that Secretary Principi serve as the champion 
for this campaign and declare 2004 Veterans Mental Health Year. A. 
Initiate a campaign targeted at Iraqi Freedom and Enduring Freedom 
veterans and their families. B. Develop monthly messages on VA's 
Intranet home page focused on the theme that mental health is essential 
to overall health. The message would change monthly. C. Develop 
destigmatizing messages on VA's Internet home page for veterans, their 
families and the general public focused on the themes that mental 
health is essential to overall health and on the availability of 
effective new treatments. The monthly message would be developed with 
the help of VA Mental Health Consumer/Advocate Councils to be 
culturally competent and acceptable to veterans and their families D. 
Secretary Principi and other senior officials would include this theme 
in public addresses, speeches, and VSO convention addresses.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.1 A, B, C, D       Promote mental health     Identify a spokesperson   Ongoing                        1
Initiatives 1-4......   awareness in              to represent VA in this
                        collaboration with VA     effort. This will be a
                        Office of                 cross-cutting campaign
                        Communications, EES,      with emphasis on
                        NAMI, SMI Committee       special groups, e.g.,
                        Consumer Liaison          PTSD, women, older
                        Council, etc.             groups, returning
                                                  service personnel. This
                                                  will be accomplished by
                                                  outreach to veterans &
                                                  families; use of public
                                                  service announcements,
                                                  train VA staff in these
                                                  approaches to new vets/
                                                  families. Mental Health
                                                  Strategic Healthcare
                                                  Group (MHSHG) will
                                                  coordinate Mental
                                                  Health Awareness Day,
                                                  with educational
                                                  activities mandated at
                                                  each VAMC and kickoff
                                                  of Veterans Mental
                                                  Health Year in 2005.
                                                ----------------------------------------------------------------
                                                 MHSHG will create a       An enhanced                    3
                                                  Mental Health Workgroup   communication plan is
                                                  to identify existing      under development
                                                  resources and develop a
                                                  communications plan,
                                                  based on the Action
                                                  Agenda recommendation
                                                  1.1.1 A, B, C, D, to
                                                  inform the veteran
                                                  community, including
                                                  families, Veterans
                                                  Support Organizations,
                                                  VHA staff, Veterans
                                                  Benefits Administration
                                                  staff, and veterans
                                                  themselves as well as
                                                  the public of the
                                                  importance of mental
                                                  health care.
                      ------------------------------------------------------------------------------------------
                       Promote effective         1. Provide ``State of     Ongoing                        1
                        outreach and              the Art'' outreach,
                        reintegration of soon     screening and referral
                        to be or recently         to military personnel
                        deactivated military      transitioning from
                        personnel.                active or reserve
                                                  status to civilian
                                                  status. 2. Readjustment
                                                  Counseling Service
                                                  (RCS)/MHSHG to extend
                                                  seamless care model to
                                                  mental health service
                                                  for combat veterans. 3.
                                                  RCS/MHSHG to develop
                                                  and coordinate VHA
                                                  outreach to National
                                                  Guard, Reserve, and
                                                  soon to be or recently
                                                  discharged military
                                                  personnel and to the
                                                  families of these
                                                  groups. 4. RCS/MHSHG to
                                                  develop models of care
                                                  to address mental
                                                  health needs of
                                                  recently discharged
                                                  combat veterans.
                      ------------------------------------------------------------------------------------------
                       Promote destigmatization  Design and establish      To be reevaluated              4
                        through partnering with   Career Development
                        VBA, Department of        Centers in VHA Medical
                        Labor, state and local    Centers and Community-
                        programs to provide       based Outpatient
                        career development        Clinics (CBOCs), for
                        services.                 recently deactivated
                                                  military personnel
                                                  based on partnerships
                                                  between Psychology
                                                  Services in Mental
                                                  Health, VBA, and DoL.
----------------------------------------------------------------------------------------------------------------

    Promote a Mental Health Awareness Day, for instance in May, which 
is Mental Health Month.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.2                  Institute an annual       Mental Health Awareness   Ongoing                        1
                        Mental Health Awareness   Day annually and
                        Day.                      partner with other
                                                  national organizations
                                                  to reach broader
                                                  audience.
----------------------------------------------------------------------------------------------------------------

    Identify Mental Health an Employee Education Services (EES) focus 
area in 2005. All health care workers should understand that mental 
health is essential to overall health; reduce stigma by their 
interactions with veterans and their families; and understand the major 
suicide risk factors and the principles of suicide prevention. A. Use 
the Mental Illness Research, Educational and Clinical Centers (MIRECC) 
and National Center for PTSD (NCPTSD) Education Groups for VA staff 
education for Best Practices. B. A satellite broadcast program similar 
to the ``Face Behind the File'' series can be launched in which 
veterans; perhaps some with national stature address their mental 
health and physical problems and their interconnection. The profiles 
will illustrate veterans overcoming disability and demonstrating 
recovery and individual success. C. Develop a Mental Health Speakers 
Bureau for Continuing Medical Education (CME) credits and patient 
education.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.3 A, B, C          Educate all VHA health    MHSHG will assign a       Ongoing                        1
 Initiatives 1-2        care providers that       staff person to work
                        mental health is          with EES in the
                        essential to overall      development of
                        health and that           education programs
                        integrating mental        which will include
                        health care with          issues related to all
                        medical health care       special emphasis
                        promotes recovery in      groups, i.e., PTSD,
                        both aspects of health.   women veterans, older
                                                  adults, etc. These
                                                  programs will emphasize
                                                  the interrelationships
                                                  between mental health
                                                  and physical health and
                                                  the recovery model of
                                                  care.
                                                ----------------------------------------------------------------
                                                 Task MIRECCs and NCPTSD   Ongoing. Reassigned to         2
                                                  with development of a     OMHS PSR section
                                                  joint education plan by
                                                  12/31/2005. This plan
                                                  will include the three
                                                  tenets of recovery;
                                                  consumer self
                                                  determination,
                                                  empowering
                                                  relationships and
                                                  veteran consumer
                                                  participation in the
                                                  development and
                                                  delivery of mental
                                                  health care services.
----------------------------------------------------------------------------------------------------------------

    Endorse the National Strategy for Suicide Prevention (2001) and the 
Institute of Medicine's report, ``Reducing Suicide: A National 
Imperative'' (2003). Implement their recommendations. A. Develop a 
Suicide Prevention Program for VA patients, families, staff and the 
community. B. Develop electronic suicide prevention database using 
institutional surveillance mechanisms that support population-based 
screening.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.4 A, B             Reduce suicide among      Promote evidence based    Ongoing                        1
                        veterans.                 strategies for suicide
                                                  assessment and
                                                  prevention, including
                                                  emphasis on special
                                                  emphasis groups. MHSHG
                                                  will work with HSR&D,
                                                  NEPEC, and SMITREC to
                                                  develop and test an
                                                  electronic suicide
                                                  prevention database.
                                                  Develop a national
                                                  systematic program for
                                                  suicide prevention.
                                                  MHSHG develops a plan
                                                  to educate all staff
                                                  that interact with
                                                  veterans, including
                                                  clerks and telephone
                                                  operators, about
                                                  responding to crisis
                                                  situations involving at-
                                                  risk veterans. This
                                                  would include suicide
                                                  protocols for intake,
                                                  telephone operators,
                                                  and other first contact
                                                  personnel.
----------------------------------------------------------------------------------------------------------------

    Develop and promote support programs that: A. reinforce help 
seeking from marital and family counselors, etc B. establish crisis-
support, and C. support programs for development of more adaptive 
coping skills and resilience.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.5 A, B, C          Promote coping skills,    1. Educate and train DoD  Ongoing through                2
Initiatives 1-11.....   resiliency and            mental health care        activities of multiple
                        community support.        providers about VHA and   office
                                                  VBA programs and
                                                  eligibility
                                                  requirements equivalent
                                                  to a TAP for staff; 2.
                                                  Develop and disseminate
                                                  educational material on
                                                  VHA and VBA programs
                                                  and eligibility
                                                  requirements for mental
                                                  health patients and
                                                  families; 3. Outreach
                                                  to active duty,
                                                  especially those with
                                                  life altering injuries,
                                                  and recently
                                                  deactivated military
                                                  personnel and their
                                                  families to make them
                                                  aware of VHA and VBA
                                                  programs and
                                                  eligibility
                                                  requirements for
                                                  persons with mental
                                                  health problems.
                                                ----------------------------------------------------------------
                                                 In its National Mental    To be reevaluated              4
                                                  Health Campaign, MHSHG
                                                  will promote veterans'
                                                  seeking help from
                                                  multiple sources and
                                                  points of entry (e.g.,
                                                  marital and family
                                                  counselors, legal
                                                  counselors, financial
                                                  counselors, mental
                                                  health specialists,
                                                  clergy and other
                                                  appropriate community
                                                  leaders), and promote
                                                  to all VHA and VBA
                                                  staff a biopsychosocial/
                                                  spiritual orientation
                                                  to health care that
                                                  includes cultural
                                                  competency with
                                                  relation to unique
                                                  veterans, racial,
                                                  ethnic, sexual
                                                  orientation, and gender
                                                  sensitivities.
                                                ----------------------------------------------------------------
                                                  Medical Centers          Requires additional            4
                                                  establish contacts        guidance
                                                  through the Chaplain
                                                  Service with faith-
                                                  based organizations and
                                                  community resources to
                                                  assist with culturally
                                                  competent suicide
                                                  prevention and other
                                                  mental health issues at
                                                  local and national
                                                  levels.
                                                ----------------------------------------------------------------
                                                 MHSHG develops a plan     In planning and                3
                                                  for 24 hour mental        concurrence
                                                  health care
                                                  availability throughout
                                                  VHA.
                                                ----------------------------------------------------------------
                                                 MHSHG directs the VISNs   Ongoing                        1
                                                  to develop plans,
                                                  including peer support
                                                  programs, to assist
                                                  veterans in coping with
                                                  common problems.
                                                ----------------------------------------------------------------
                                                 Peer Support: FY-05:      A strategy for broad           3
                                                  Issue national            implementation of peer
                                                  Information Letter to     support is included in
                                                  promote paid Peer-led     the Uniform MH Services
                                                  services programming,     package
                                                  (directly or through
                                                  contract with community
                                                  providers) as an
                                                  adjunct to traditional
                                                  mental health services
                                                  at all facilities
                                                  serving veterans with
                                                  serious mental illness.
                                                  FY-06: Issue national
                                                  directive with detailed
                                                  procedural guidance.
                                                  Peer Support: FY-06:
                                                  Explore expansion of
                                                  Vet Centers to include
                                                  veterans with SMI.
                      ------------------------------------------------------------------------------------------
                       Ease Transition of        Initiate universal MST     Universal MST screening       2
                        victims of Military       screening at MTFs and     is ongoing at all VA
                        Sexual Trauma (MST)       all components of         facilities.
                        from active duty into     national guard and
                        the VA health care        reserves for separating
                        system.                   servicemembers (self-
                                                  administered with
                                                  counselors available).
                                                ----------------------------------------------------------------
                                                 TAP literature will       OMHS has established a         2
                                                  include material on       resource center for
                                                  MST.                      training and for
                                                                            monitoring MST programs
                                                ----------------------------------------------------------------
                                                 Establish EPRP MST        Required MST screening         1
                                                  screening supporting      is in place
                                                  indicator: 90% of all
                                                  veterans will be
                                                  screened for MST; 80%
                                                  of all veterans
                                                  screening positive will
                                                  be referred for
                                                  counseling within 30
                                                  days of screening.
                                                ----------------------------------------------------------------
                                                 VISN 4/5 MIRECC to        Ongoing, Reassigned to         2
                                                  expand work to focus on   MST Resource Center
                                                  female veteran
                                                  transition issues
                                                  including MST.
                      ------------------------------------------------------------------------------------------
                       Provide seamless          The outpatient and        Strategies for ensuring        3
                        transition of women       Inpatient Mental health   transitional care are
                        veterans from             providers will serve as   included in the Uniform
                        outpatient care to more   team members for both     MH Services Package
                        acute levels of mental    treatment modalities
                        health care and vice      for female veterans.
                        versa.
----------------------------------------------------------------------------------------------------------------

Commission Recommendation 1.2.  Address mental health with the same 
urgency as physical health

    Develop a modular VA-adapted mental health collaborative care model 
dissemination package as the basis for national rollout, in 
collaboration with the mental health Quality Enhancement Research 
Initiative (QUERI) Mental Health, VA Central Office and Veterans 
Integrated Service Networks (VISN) leaders.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
1.2.6 Initiatives 1-5  Develop a collaborative   MHSHG will collaborate    Ongoing. Implementation        2
                        care model for mental     with Mental Health        has been based on TIDES
                        health disorders that     QUERI to develop          and other models
                        elevates mental health    infrastructure needed
                        care to the same level    for national rollout,
                        of urgency/intervention   including an
                        as medical health care.   organizational
                                                  structure in which the
                                                  Mental Health QUERI
                                                  Depression Working
                                                  group connects to
                                                  MHSHG, Primary and
                                                  Ambulatory Care SHG,
                                                  OQP, National Clinical
                                                  Practice Guidelines
                                                  Council and the
                                                  Performance Measures
                                                  Workgroup, as well as
                                                  to the TIDES Leadership
                                                  Group. The development
                                                  will include a VA
                                                  integrated care model.
                                                ----------------------------------------------------------------
                                                 Align performance         Ongoing                        1
                                                  measures to promote
                                                  evidence-based
                                                  collaborative care for
                                                  depression.
                                                ----------------------------------------------------------------
                                                 Work with OQP to rapidly  Ongoing                        1
                                                  update depression
                                                  guidelines to include
                                                  evidence-based
                                                  collaborative care for
                                                  depression.
                                                ----------------------------------------------------------------
                                                 Develop a VA integrated   Completed                      1
                                                  care model similar to
                                                  the Four Quadrant
                                                  Clinical Integration
                                                  Model for dissemination
                                                  to VA medical centers.
                                                  This will be done in
                                                  collaboration with the
                                                  Quality Enhancement
                                                  Research Initiative
                                                  (QUERI) program and
                                                  VISN leadership.
                      ------------------------------------------------------------------------------------------
                       Assure that medical co-   Develop a tool and        Ongoing                        1
                        morbidities are           process for assessing
                        identified and            physical co-morbidities
                        addressed in the mental   in mental health
                        health care population    patients. Collect and
                        at the same rate as       monitor data at a
                        medical issues in the     national level on
                        primary care              medical co-morbidities
                        population.               in the mental health
                                                  population using
                                                  existing electronic
                                                  databases; Promote and
                                                  support epidemiological
                                                  research in the area of
                                                  medical co-morbidities
                                                  in the mental health
                                                  population; Collect and
                                                  monitor data at a
                                                  national level
                                                  regarding access to
                                                  medical care for the
                                                  mental health
                                                  population using
                                                  existing electronic
                                                  databases.
----------------------------------------------------------------------------------------------------------------

    Identify good working models of Mental Health/ Primary Care/ 
Geriatric integration (including a module on differentiating normal and 
abnormal aspects of aging) in terms of service delivery and workload/
supervision arrangements. Promote research activities on mental health/
primary care integration best practices.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
1.2.7 Initiatives 1-    Develop an accurate      Continue the MH CARES     DOMs have been                 2
 13                     mental health             Advisory Work Group to    transitioned to OMHS.
                        projection model for      further develop the       Projection models are
                        the full continuum of     projection model with     run by OPP
                        mental health care.       special emphasis on
                                                  domiciliaries and
                                                  geropsychiatry.
                      ------------------------------------------------------------------------------------------
                                                  A projection model has   Responsibility                 2
                                                  been developed by a       transferred to OMHS,
                                                  combined subgroup (SMI    who work with OPP on
                                                  Committee and GEC).       this projection model
                                                  Validation of this
                                                  model as an accurate
                                                  projection tool will
                                                  occur from now through
                                                  the end of FY07. This
                                                  will be monitored by
                                                  the continuing subgroup
                                                  which will become a
                                                  subgroup of the AASC.
                                                  This projection model
                                                  will be further
                                                  evaluated in relation
                                                  to its utility in
                                                  conjunction with the
                                                  algorithm to guide
                                                  clinical decisions for
                                                  long term psychiatric
                                                  and nursing home care
                                                  described in 1.2.8.
                                                  Expand to cover all MH.
                      ------------------------------------------------------------------------------------------
                       Develop innovative        The MHSHG will continue   Ongoing                        2
                        programs of integrated    to work closely with
                        care involving some       geriatrics and primary
                        combination of primary    care to develop
                        care, geriatrics, and     clinical models of care
                        mental health.            and guidelines that
                                                  better integrate mental
                                                  and physical health.
                      ------------------------------------------------------------------------------------------
                       Educate VHA providers on   Develop a module on      Training for some target       3
                        the normal and abnormal   differentiating normal    groups completed.
                        aspects of aging.         and abnormal aspects of   Further training is
                                                  aging. Address            being planning; was
                                                  principles of             deferred to focus on
                                                  information processing    returning veterans
                                                  and memory processes
                                                  for older adults, based
                                                  on normal age-related
                                                  changes. Provide
                                                  information on sensory
                                                  needs (e.g., use of
                                                  large font).
                                                  Differentiate normal
                                                  cognitive changes with
                                                  aging from changes
                                                  indicating dementia or
                                                  other cognitive
                                                  functional problems.
                                                  Cover evidence on
                                                  demographics of aging
                                                  and mental health,
                                                  challenging common
                                                  distortions (e.g., that
                                                  depression is normative
                                                  for older adults).
                                                  Discuss evidence that
                                                  older adults benefit at
                                                  least as much from
                                                  psychotherapy and
                                                  psychotropic medication
                                                  as do younger adults.
                                                  Discuss adaptations of
                                                  psychotherapy that
                                                  enhance its
                                                  effectiveness with
                                                  older adults. In accord
                                                  with recovery
                                                  principles, articulate
                                                  respect for the older
                                                  veteran's choices for
                                                  mental health
                                                  resources.
                      ------------------------------------------------------------------------------------------
                        Integrate primary        Expand two existing       In planning and                3
                        medical care with         pilots (VA Conn HCS &     development
                        homeless services.        West LA) to other
                                                  facilities. Incorporate
                                                  primary care into the
                                                  women's homeless
                                                  demonstration program.
                      ------------------------------------------------------------------------------------------
                       Identify outreach to      Add an indicator to the   Ongoing. Indicator             1
                        homeless recently         intake form to assess     completed and continues
                        discharged military       outreach. A draft         to be utilized.
                        servicepersons.           document has already
                                                  been sent to the field
                                                  for evaluation of
                                                  feasibility and other
                                                  comments.
                      ------------------------------------------------------------------------------------------
                       Ensure that mental        Every returning service   Ongoing--PDHRA process         2
                        health examinations are   man/woman will meet
                        a part of all physical    with a mental health
                        examinations in VHA.      professional as part of
                                                  the post-deployment and
                                                  separation medical
                                                  examinations and be
                                                  provided with a brief
                                                  pamphlet that reviews
                                                  the information
                                                  provided during the
                                                  session. He/she will be
                                                  encouraged to share
                                                  this pamphlet with his/
                                                  her family. Those found
                                                  to have significant
                                                  readjustment problems
                                                  in the course of the
                                                  examination would be
                                                  triaged to care as
                                                  appropriate. Those who
                                                  decline intervention at
                                                  time of screening, or
                                                  who are not presently
                                                  symptomatic, but deemed
                                                  at risk for future
                                                  readjustment problems
                                                  based on the exam, will
                                                  have their medical
                                                  record flagged for
                                                  repeat screening at
                                                  future medical
                                                  appointments.
                      ------------------------------------------------------------------------------------------
                       Eliminate gender          Charge a women's mental   Ongoing                        1
                        disparities and provide   health committee to
                        accessible mental         identify and design
                        health services to        evidence based optimal
                        women veterans.           women's mental health
                                                  practice models.
                                                ----------------------------------------------------------------
                                                 Expand women's HSR&D      Assigned to Women's            2
                                                  research agenda to        Mental Health Committee
                                                  evaluate women's mental
                                                  health programs
                                                  effectiveness and
                                                  patient outcomes.
                                                ----------------------------------------------------------------
                                                 Appoint a women's health  Completed.                     1
                                                  representative to the
                                                  SMI Committee.
                      ------------------------------------------------------------------------------------------
                       Women veterans will have  Women Veterans Program    Participation in               2
                        access to mental health   Manager will              planning is part of the
                        services in a milieu      participate in the MH     WVPM duties and
                        that promotes comfort     EOC planning process      responsibilities as
                        and security.             for both inpatient and    identified in the VHA
                                                  residential programs.     Handbook.
                      ------------------------------------------------------------------------------------------
                       Expand dental services    NEPEC and Dental Service  Mental Health                  2
                        for homeless veterans.    will jointly develop a    Enhancement funding has
                                                  means of monitoring       been used to expand
                                                  services delivered.       dental services for SMI
                                                                            and homeless veterans
                      ------------------------------------------------------------------------------------------
                       Realign Domiciliary       The domiciliary programs  Completed.                     1
                        Program.                  that primarily treat
                                                  substance abuse and
                                                  PTSD patients should be
                                                  placed under MH in VACO
                                                  and the field. A
                                                  subgroup of the AASC
                                                  will be formed to
                                                  explore details of how
                                                  this can be
                                                  accomplished while
                                                  maintaining domiciliary-
                                                  type services for frail
                                                  elderly veterans and
                                                  for enhancing services
                                                  for special populations
                                                  such as women veterans.
                                                  Subgroup to include
                                                  representatives of MH,
                                                  GEC and the Women's
                                                  Strategic Planning Task
                                                  Force, as well as
                                                  others selected by the
                                                  Exec Comm of the AASC.
                                                  Subgroup to be formed
                                                  and begin to explore
                                                  implementation plans by
                                                  10/1/04.
----------------------------------------------------------------------------------------------------------------

    Eliminate variability in access to mental health, substance abuse, 
long term psychiatric care and homeless services by 2008. A. Complete 
expansion of specialty mental health services in all Community Based 
Outpatient Clinics (CBOCs). B. Use tele-mental health approaches for 
smaller sites including access to specialized services such as PTSD and 
substance abuse counseling. C. Implement the Veterans' Millennium 
Health Care Act requirements for long-term psychiatric care. D. Produce 
VHA mental health strategic plan and VISN-level tactical plans to 
ensure uniform implementation.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
1.2.8 A, B, C, D       Provide a full continuum  Implement Performance     MH in CBOCs have been          3
 Initiatives 1-40       of compassionate care     Measure for FY05: 85%     expanded, and initial
                        to veterans with mental   of CBOCs serving more     performance measures
                        illness.                  than 1,500 veterans       have been met. Further
                                                  will provide on-site,     enhancement will occur
                                                  contract, or tele-        through Uniform MH
                                                  mental health services    Services package
                                                  at or above 10% of all
                                                  clinic visits by FY05.
                                                  Increase to 15% of all
                                                  clinic visits by FY07.
                                                ----------------------------------------------------------------
                                                 All Networks that are     Ongoing                        1
                                                  below the 85% standard
                                                  at COB 3rd Qtr FY04
                                                  must submit an Action
                                                  Plan to the Action
                                                  Agenda Steering
                                                  Committee Task Force
                                                  for review and
                                                  recommended approval,
                                                  and the Task Force will
                                                  monitor progress.
                                                  Appendix B of the
                                                  Secretary's Mental
                                                  Health Task Force
                                                  contains a list of over
                                                  200 CBOCs that are
                                                  below the standards as
                                                  of 6/30/04.
                                                ----------------------------------------------------------------
                                                 Establish a Point of      Directors of MH in             2
                                                  Contact for Mental        parent VAMCs have
                                                  Health in CBOCs and       responsibility for MH
                                                  notify VACO MHSHG who     in CBOCs
                                                  that individual is.
                                                ----------------------------------------------------------------
                                                 All CBOCs should provide  Ongoing                        1
                                                  access to mental health
                                                  services, either on
                                                  site or by contract
                                                  with offsite being the
                                                  option of last resort.
                                                  In remote locations
                                                  telemental health may
                                                  be used. The level care
                                                  of care and the
                                                  competencies of the
                                                  staff available at the
                                                  CBOCs must be
                                                  equivalent to the care
                                                  at the parent medical
                                                  center and not at the
                                                  expense of the parent
                                                  facility (VHA Directive
                                                  2001-060). This
                                                  workgroup recommends an
                                                  integrated model of 1.0
                                                  FTE behavioral health
                                                  clinician per 1,500
                                                  primary care patients.
                                                  Clinicians who operate
                                                  at a distance from
                                                  VAMCs in CBOCs manage a
                                                  broader and more
                                                  complex range of mental
                                                  health disorders and
                                                  require an adjusted
                                                  case load size. Develop
                                                  a national performance
                                                  measure that addresses
                                                  the mental health staff/
                                                  patient ratios in
                                                  CBOCs. All VISNs should
                                                  develop a plan of how
                                                  to deliver mental
                                                  health services in
                                                  CBOCs to patients with
                                                  primary substance use
                                                  disorder diagnoses.
                                                ----------------------------------------------------------------
                                                 Develop national          Requires additional            4
                                                  performance measure       guidance; decisions
                                                  that addresses MH staff/  will be related to
                                                  patient ratios in         mental health
                                                  CBOCs.                    productivity work group
                                                                            recommendations.
                                                ----------------------------------------------------------------
                                                 Update CBOC application   Ongoing                        1
                                                  directive and form to
                                                  include requirement to
                                                  specifically detail MH
                                                  services and staffing
                                                  to be provided at all
                                                  new CBOCs. Ask for a
                                                  focused evaluation from
                                                  the Mental Health
                                                  representative on each
                                                  CBOC application
                                                  currently under review
                                                  and secure additional
                                                  information as needed.
                                                ----------------------------------------------------------------
                                                 All medical centers and   Included in Uniform MH         3
                                                  CBOCs will develop        Services Package
                                                  service agreements
                                                  between primary care
                                                  and mental health on
                                                  bipolar disorder,
                                                  schizophrenia, PTSD, SA
                                                  defining treatment and
                                                  referral guidelines.
                      ------------------------------------------------------------------------------------------
                       Reduce geographic         Expand homeless programs  Ongoing                        1
                        variation and include     to bring all VISNs up
                        access to specialized     to the current national
                        MH and SA service         average for provision
                        delivery to homeless      of mental health
                        veterans.                 services to homeless
                                                  veterans.
----------------------------------------------------------------------------------------------------------------
                                                 Consistent with the       Projecting need is the         2
                                                  recommendation that       responsibility of OPP.
                                                  variation in service      Services have been
                                                  availability will be      enhanced in recent
                                                  reduced, the              years.
                                                  homelessness subgroup
                                                  of MHSPWG developed a
                                                  model for meeting the
                                                  needs of homeless vets
                                                  which suggests that
                                                  $11.6 M of new annual
                                                  funding over the next 5
                                                  years will bring all
                                                  VISNs up to the current
                                                  national average of
                                                  38.4 veterans served by
                                                  homeless staff in
                                                  homeless programs per
                                                  1000 veterans at risk
                                                  for homelessness. $33 M
                                                  could bring all VISNs
                                                  up to the current 85th
                                                  percentile or 49.7 for
                                                  1000 at risk. It could
                                                  cost $86 M to bring all
                                                  VISNs up to the level
                                                  of the top VISNs (73.4/
                                                  1000) in FY03. NEPEC,
                                                  in collaboration with
                                                  Performance Measures
                                                  Work Group, will
                                                  develop a performance
                                                  measure.
                      ------------------------------------------------------------------------------------------
                       Provide a full continuum  Implement Performance     Ongoing                        1
                        of care to homeless       Measure for FY05: 75%
                        veterans with mental      of homeless veterans
                        illness.                  will receive at least
                                                  one mental health or
                                                  substance abuse visit
                                                  and one primary care
                                                  visit within six months
                                                  of initial outreach
                                                  (The denominator
                                                  against which the 75%
                                                  measure is calculated
                                                  will be all veterans
                                                  for whom a Form X is
                                                  completed).
                                                ----------------------------------------------------------------
                                                 75% of veterans with SMI  MHICM programs have been       2
                                                  who meet clinical         expanded. In general,
                                                  criteria for MHICM        these programs do not
                                                  program will be           target homeless
                                                  enrolled and provided     veterans
                                                  services. The
                                                  denominator for this
                                                  measurement is the
                                                  population based need
                                                  estimate developed by
                                                  the SMI Subcommittee of
                                                  the MHSPWG. All VISNs
                                                  will submit a plan (by
                                                  9/30/04) for providing
                                                  care to meet this
                                                  measure.
                                                ----------------------------------------------------------------
                                                 VHA Directive 2000-034    Ongoing                        1
                                                  specifies the evidence
                                                  based operational
                                                  performance criteria
                                                  for MHICM in VHA and
                                                  defines the target
                                                  population. This
                                                  directive to be renewed
                                                  and facilities held
                                                  accountable for
                                                  adhering to all
                                                  performance criteria.
                                                ----------------------------------------------------------------
                                                 Require that all          Homeless veterans may be       2
                                                  homeless veterans who     entered into MHICM
                                                  meet clinical             programs when they
                                                  eligibility criteria      complete transitional
                                                  for MHICM programs be     housing programs
                                                  offered assignment to a
                                                  MHICM team and
                                                  enrollment in the MHICM
                                                  program. All MHICM
                                                  teams will adhere to
                                                  established clinical
                                                  standards and
                                                  caseloads.
----------------------------------------------------------------------------------------------------------------
                        Restore VHA's ability    Mandate that VAMCs        Ongoing planning. There        3
                        to consistently deliver   restore specialized SA    is a need to restore
                        state of the art care     treatment programs. All   specialized SA
                        for veterans with SA      networks will be ranked   treatment, AND to
                        disorders.                on their percentage of    account for SA
                                                  substance abuse           treatment in general MH
                                                  treatment capacity,       care settings and
                                                  which is defined as       primary care
                                                  follows: The numerator
                                                  is the number of
                                                  substance abuse
                                                  patients treated in
                                                  FY03 as defined in the
                                                  capacity report, and
                                                  the denominator is the
                                                  number of enrolled
                                                  veterans in the
                                                  network. The lowest
                                                  quartile of networks
                                                  (i.e., the bottom 5) on
                                                  this measure will be
                                                  required to bring their
                                                  networks up to the
                                                  national average on
                                                  this measure on the
                                                  rapid schedule laid out
                                                  by the Secretary.
                                                ----------------------------------------------------------------
                                                 Develop a National Plan   SA capacity is being           1
                                                  to meet SA capacity       expanded through the
                                                  requirements. Capacity    Mental Health
                                                  distributed by VISNs to   Enhancement Initiative
                                                  meet all dimensions of
                                                  access: geographic
                                                  distribution,
                                                  affordability,
                                                  availability,
                                                  acceptability, and
                                                  accommodation. The plan
                                                  uses VHA's clinical
                                                  practice guidelines for
                                                  substance abuse
                                                  treatment as primary
                                                  guide in reestablishing
                                                  services and show how
                                                  VISNs resources will be
                                                  reallocated to
                                                  accomplish the plan
                                                  objectives.
                                                ----------------------------------------------------------------
                                                 Ensure that primary care  Further planning is            3
                                                  at all VA facilities      needed. Many sites
                                                  has physicians trained,   remain without OAT in
                                                  accredited and            spite of ongoing
                                                  privileged in primary     support for
                                                  care provision of         buprenorphine staffing
                                                  buprenorphine and         and training.
                                                  Naltrexone or
                                                  technology to connect
                                                  to services at a larger
                                                  medical center.
                                                  Recommend that Pharmacy
                                                  and Therapeutics
                                                  Committees approve
                                                  these agents for the
                                                  facility's formulary.
                                                  Ensure that all VA
                                                  facilities have the
                                                  resources to provide 5
                                                  days of inpatient/
                                                  residential
                                                  detoxification services
                                                  either on-site, at a
                                                  nearby VA facility, or
                                                  at a contracted
                                                  facility. All
                                                  facilities will have a
                                                  specialized substance
                                                  abuse provider to
                                                  ensure linkage between
                                                  the inpatient and
                                                  outpatient follow-up
                                                  treatment programs.
                                                ----------------------------------------------------------------
                                                 Implement HEDIS for       Ongoing                        1
                                                  benchmarked performance
                                                  measures for substance
                                                  abuse in FY06.
                      ------------------------------------------------------------------------------------------
                       Establish case            Implement a special        Ongoing                       1
                        management programs for   needs grant program for
                        homeless veterans with    homeless chronically
                        mental illness and/or     ill veterans coupled
                        substance abuse.          with Critical Time
                                                  Intervention (CTI)
                                                  services at partnering
                                                  VAMCs. Current
                                                  available funding in
                                                  the Homeless Provider
                                                  Grant and Per Diem
                                                  Program can support
                                                  five collaborative
                                                  projects. Based on the
                                                  outcome of the pilots,
                                                  a plan for national
                                                  implementation will be
                                                  developed. Homeless
                                                  veterans with complex
                                                  medical problems,
                                                  serious mental
                                                  illnesses and/or
                                                  substance use disorders
                                                  will be assigned to a
                                                  targeted case
                                                  management program.
                                                ----------------------------------------------------------------
                                                 Eligible veterans who     Ongoing                        1
                                                  receive services in
                                                  grant and per diem
                                                  programs will have the
                                                  number of visits (529
                                                  stop codes) consistent
                                                  with their need, but no
                                                  less than one HCHV
                                                  visit per month, to
                                                  assure facilitated
                                                  access to VA mental
                                                  health and medical
                                                  services. Telemental
                                                  health can be used to
                                                  provide these services
                                                  in remote locations.
                                                  NEPEC to track data and
                                                  report to MHSHG.
                                                ----------------------------------------------------------------
                                                 Establish a performance   Ongoing--Four                  2
                                                  measure requiring that    performance measures
                                                  homeless veterans         have been implemented
                                                  suffering from SMI and/   focusing on timely
                                                  or SA who receive         access for homeless
                                                  residential services      veterans to VA MH/SUD
                                                  receive at least one MH   and Primary Care
                                                  or SA treatment visit     Services.
                                                  during residential care
                                                  and one follow-up visit
                                                  during discharge from
                                                  residential care.
                      ------------------------------------------------------------------------------------------
                       Develop a full range of   Provide incentives to     Ongoing.                       1
                        supportive services for   improve homeless
                        veterans in               veterans access to VA
                        collaboration with        treatment services and
                        community partners.       enhance collaboration
                                                  between VA medical
                                                  centers and Grant and
                                                  Per Diem funded
                                                  transitional housing
                                                  programs.
                                                ----------------------------------------------------------------
                                                 Establish financial       Ongoing.                       1
                                                  incentives for
                                                  providing necessary VHA
                                                  mental health services
                                                  to homeless veteran in
                                                  Grant and Per Diem
                                                  programs. A report of
                                                  options will be sent to
                                                  the Secretary from the
                                                  VHA National Leadership
                                                  Board Finance
                                                  Committee.
                                                ----------------------------------------------------------------
                                                 Enhance supported CWT      CWT programs have been        2
                                                  and employment            expanded through the
                                                  activities within VA      Mental Health
                                                  by: 1. Establish a        Enhancement Initiative
                                                  performance measure/
                                                  monitor for assessment
                                                  of occupational
                                                  dysfunction, and
                                                  referral to
                                                  transitional and
                                                  supported employment
                                                  models authorized by 38
                                                  USC 1718. Such a
                                                  measure/monitor will
                                                  establish reasonable
                                                  expectations for access
                                                  to transitional and
                                                  supported employment
                                                  separately for veterans
                                                  with homelessness and
                                                  for those with
                                                  psychosis. 2. Provide
                                                  approx $6,000,000 in
                                                  FY'04 for staffing
                                                  resources to implement
                                                  supported employments
                                                  at 107 existing
                                                  vocational programs
                                                  authorized by 38 USC
                                                  1718. Provide approx
                                                  $4,000,000 in FY'05 for
                                                  staffing resources to
                                                  operate and sustain
                                                  work restoration
                                                  services authorized
                                                  under 38 USC 1718 for
                                                  the provision of both
                                                  transitional and
                                                  supported employment
                                                  models at facilities
                                                  without existing CWT
                                                  programs. These
                                                  resources should be
                                                  provided through
                                                  recurring Specific
                                                  Purpose funding with
                                                  new permanent positions
                                                  established.
                                                ----------------------------------------------------------------
                                                 Finalize a policy         To be reevaluated              4
                                                  directive that places a
                                                  priority on making
                                                  underutilized space on
                                                  VAMC campuses available
                                                  to nonprofit community-
                                                  based organizations
                                                  that wish to develop
                                                  residential programs
                                                  for homeless veterans.
                                                  Enhance partnerships
                                                  with community partners
                                                  to provide transitional
                                                  housing.
                                                ----------------------------------------------------------------
                                                 Mandate that all VISNs    Ongoing for veterans           1
                                                  address the transition    being discharged from
                                                  needs of incarcerated     state and Federal
                                                  veterans and develop a    prisons
                                                  plan that will be
                                                  implemented in FY 2005.
                                                ----------------------------------------------------------------
                                                 Each VISN will submit a   Ongoing                        1
                                                  specific plan for pre-
                                                  release assessments of
                                                  veterans in Federal and
                                                  state correctional
                                                  facilities to determine
                                                  degree and type of need
                                                  and methods of
                                                  providing services. The
                                                  assessments to include
                                                  mental health, medical
                                                  and social service
                                                  needs.
                      ------------------------------------------------------------------------------------------
                       Meet the needs of SMI     1. Meet levels as         Requires guidance on           4
                        veterans for Community    projected by the MHSPWG   organization of CRC
                        Residential Care.         for FY07. Market level    program
                                                  plans developed for any
                                                  market with a gap that
                                                  exceeds 1,000 CRC stops
                                                  in FY07. For meeting
                                                  these gaps, a plan must
                                                  be submitted by 10/1/04
                                                  to the AASC. 2.
                                                  Increase staffing to
                                                  meet the required
                                                  minimum one case
                                                  management visit per
                                                  month. 3. Emphasize
                                                  individualized,
                                                  recovery-oriented
                                                  placements versus
                                                  placements that have an
                                                  institutionalized
                                                  atmosphere and very
                                                  little rehabilitation
                                                  services.
                      ------------------------------------------------------------------------------------------
                       Each Medical Center will  Each VISN will develop a  Ongoing, with all VAMCs        2
                        have a Mental Health      planning initiative to    have PTSD clinical
                        Clinic with adequate      address service gaps in   teams or specialists.
                        staffing to meet the      outpatient mental         Adequacy of staffing is
                        mental health needs of    health care identified    assessed through
                        veterans.                 by the MHSP model.        measures of access,
                                                  Analysis and Network      intensity, and quality
                                                  plan to address issues    of care
                                                  (with at least a 30%
                                                  gap closure by COB
                                                  FY07) must be submitted
                                                  to MHSHG and AASC by 10/
                                                  04. Markets with
                                                  positive gaps over
                                                  16,000 (actual CARES)
                                                  stops in FY07 MHSP
                                                  model need to be
                                                  addressed. This is the
                                                  same market level gap
                                                  used in the original
                                                  CARES model. Each VA
                                                  facility that currently
                                                  does not have one will
                                                  have a PTSD clinical
                                                  team or PTSD
                                                  specialists or a plan
                                                  to secure these
                                                  services. The role of
                                                  these clinicians is to
                                                  serve the facility MHC
                                                  and CBOC based OPC
                                                  services and also to
                                                  provide consultative or
                                                  clinical support to
                                                  acute inpatient units
                                                  for patients with PTSD.
----------------------------------------------------------------------------------------------------------------
                                                 Expand PTSD outpatient    Each VAMC has a PTSD           1
                                                  services in VISNs with    clinical team or
                                                  gaps as identified in     specialist
                                                  the PTSD subgroup
                                                  report. Twelve VISNs,
                                                  3, 4, 5, 8, 9, 10, 11,
                                                  12, 15, 19, 22 and 23
                                                  are identified as
                                                  having PTSD care gaps
                                                  in the P.L. 108-170
                                                  solicitation and will
                                                  be considered the first
                                                  priority for new PCT
                                                  development. In
                                                  addition, other VISNs
                                                  especially those with
                                                  significant Global War
                                                  on Terrorism troop
                                                  returnees (2, 6, 16, 17
                                                  and 21) will also
                                                  receive priority in
                                                  expanding new PCTs.
                      ------------------------------------------------------------------------------------------
                       Medical Centers will       Each VISN which has a    Planning is in progress        3
                        have adequate beds and    market(s) with a MHSP
                        staffing to meet the      projected service gap
                        needs of the local        in inpatient mental
                        veteran populations for   health both for FY'02
                        acute inpatient           and for FY'07 that
                        psychiatric services.     exceeds 7,300 bed days
                                                  of care at the market
                                                  level must submit a
                                                  plan to close that gap
                                                  by FY'07 with phased in
                                                  increments of a minimum
                                                  of 10% per year. Those
                                                  markets that exceed a
                                                  7,300 BDOC gap either
                                                  for FY'02 or for FY'07
                                                  will assess and report
                                                  if a plan is needed.
                                                  Reports should be
                                                  submitted to the AASC
                                                  no later than 10/1/04.
                      ------------------------------------------------------------------------------------------
                       Expand clinical           Explore development of a  The Uniform MH Services        3
                        monitoring systems to     Work Restoration          Package includes a
                        include Work              Information Management    strategy for broader
                        Restoration services.     System (WRIMS) for use    implementation of CWT
                                                  in each VAMC and CBOC     and SE
                                                  (using the CMIS of
                                                  VISNs 1 as a model), to
                                                  ensure that each
                                                  veteran is offered the
                                                  choice in participating
                                                  in work restoration
                                                  services; Increase Work
                                                  Restoration services
                                                  until all veterans in
                                                  VAMCs and CBOCs have
                                                  equal access to work
                                                  skills training and
                                                  development; Implement
                                                  the Evidence-Based
                                                  practice of Supported
                                                  Employment into all
                                                  Work Restoration
                                                  programs; Add work
                                                  restoration to Illness
                                                  Mgt Training of
                                                  unemployed patients who
                                                  are participating in
                                                  programs transferring
                                                  from LT custodial care
                                                  to rehabilitation in
                                                  the community; Add work
                                                  restoration training to
                                                  MHICMs and other
                                                  community support
                                                  teams.
                      ------------------------------------------------------------------------------------------
                       Meet the needs of SMI     General psychiatry PRRTP  The Uniform MH Services        3
                        veterans for              (residential care)        Package includes a
                        residential               services increase at      strategy for making
                        rehabilitation            the VISN level by FY'07   residential care
                        services.                 based on the MHSP Model   services available to
                                                  projection. VISNs that    those who need them
                                                  have a gap of 15 or
                                                  more PRRTP beds should
                                                  develop a plan to
                                                  reduce the gap by at
                                                  least 30% by FY07,
                                                  phased in annually with
                                                  a minimum of 10%
                                                  improvement each year.
                                                  The plan to be
                                                  developed by 10/1/04
                                                  and reviewed by the
                                                  Action Agenda Steering
                                                  Committee.
                      ------------------------------------------------------------------------------------------
                       Meet the needs of         SARRTP (residential       The Uniform MH Services        3
                        veterans with substance   care) services increase   Package includes a
                        abuse for residential     at the market level by    strategy for making
                        rehabilitation            FY'07 based on the MHSP   residential care
                        services.                 Model projection.         services available to
                                                  Market areas that have    those who need them
                                                  a gap of 15 or more
                                                  SARRTP beds, after
                                                  taking into account bed
                                                  section 86, DOM/SA,
                                                  develop a plan to
                                                  reduce the gap by at
                                                  least 30% by FY07. The
                                                  plan to be developed by
                                                  10/1/04 and reviewed by
                                                  the Action Agenda
                                                  Steering Committee.
                      ------------------------------------------------------------------------------------------
                       Meet the needs of         1. PRRP (residential      The Uniform MH Services        3
                        veterans with PTSD for    care) services to be      Package includes a
                        residential               increased at the VISN     strategy for making
                        rehabilitation            level by FY07 based on    residential care
                        services.                 the MHSP Model            services available to
                                                  projection. VISN areas    those who need them
                                                  that have a gap of
                                                  5,475 or more PRRP beds
                                                  (taking into account
                                                  Dom PTSD program beds
                                                  as equivalents) will
                                                  develop a plan to
                                                  correct the gap. The
                                                  plan to be developed by
                                                  10/1/04 and reviewed by
                                                  the Action Agenda
                                                  Steering Committee.
                                                  Preliminary analyses
                                                  indicates that VISNs 4,
                                                  6, 9, 16 and 22 would
                                                  develop plans.
                      ------------------------------------------------------------------------------------------
                       Allocate additional       Proposed that VHA adopt   Ongoing. Standards             1
                        resources for enhanced    the standards outlined    adopted in SA operating
                        outpatient treatment of   in the integrated         plan, FY 2005.
                        all Mental Illness        treatment of patients     Resources allocated in
                        Chemical Abuse (MICA)     contained in the MICA     FY 2005/06/07
                        patients. These           Task Force report
                        treatments must consist   (January 2004) at each
                        of appropriate            facility with a
                        integration of            substantial population
                        substance abuse and       of individuals who meet
                        mental health treatment   the definitions for
                        services.                 MICA.
                      ------------------------------------------------------------------------------------------
                       Expand Opiate Agonist     Open OAT clinics at       The Uniform MH Services        3
                        Treatment (OAT) in        Phoenix, AZ; Denver,      Package includes a
                        urban centers with high   CO; Tampa, FL; Orlando,   strategy for making
                        prevalence of heroin      FL; Salt Lake City, UT.   buprenorphine
                        use and large CARES-                                prescribing available
                        projected gaps in VA                                at all VAMCs
                        methadone treatment.
                      ------------------------------------------------------------------------------------------
                       Ensure effective          1. Authorize a joint      In planning. Programs          3
                        utilization of the        review and refinement     are being at NHCUs in
                        continuum of long term    by Mental Health,         each VISN to place
                        inpatient mental health   Geriatrics and Extended   mental health staff who
                        care.                     Care, and the SMI         can ensure that
                                                  Committee, of the 1996    recommendaton #3 is
                                                  VHA Program Guide         accomplished: educating
                                                  1103.22 ``Integrated      staff in competent care
                                                  Psychogeriatric Patient   for patients with both
                                                  Care''; by 2/2005. 2.     functional and
                                                  Promulgate throughout     behavioral health
                                                  VA the algorithm for      problems
                                                  functional decisions on
                                                  level of nursing and
                                                  mental health care for
                                                  older veterans needed
                                                  (presented in full
                                                  report of the Older
                                                  Adult subgroup) over
                                                  the next year (and then
                                                  ongoing), as a
                                                  recommendation by the
                                                  Secretary for
                                                  decisionmaking in each
                                                  VISN. This will be done
                                                  in conjunction with
                                                  ongoing efforts in
                                                  Geriatrics and Extended
                                                  Care to develop a broad
                                                  new, compassionate
                                                  model of nursing home
                                                  care for Veterans. 3.
                                                  All nursing home care
                                                  facilities will have
                                                  staff educated in and
                                                  competent to care for
                                                  patients with both
                                                  functional and
                                                  behavioral health
                                                  problems. In some
                                                  circumstances,
                                                  specialized units such
                                                  as dementia units, or
                                                  psychogeriatric units
                                                  may be necessary to
                                                  meet local needs.
                      ------------------------------------------------------------------------------------------
                       Ensure adequate day        VISNs without Day        The Uniform MH Services        3
                        treatment facilities      Treatment (or             Package includes a
                        for SMI veterans.         equivalent) capacity      strategy for making
                                                  should add it at the      psychosocial
                                                  most appropriate          rehabilitation
                                                  facility, based on size   available at all VAMCs.
                                                  and access                Day treatment with a
                                                  considerations.           PSR orientation already
                                                                            implemented in most
                                                                            VISNs
                                                ----------------------------------------------------------------
                                                 Facilities serving over   Included in the Uniform        3
                                                  1,000 veterans in the     MH Services Package
                                                  psychosis registry
                                                  without a Day Treatment
                                                  (or equivalent)
                                                  facility should add one
                                                  with appropriate
                                                  staffing and education.
                                                  Peer Specialists should
                                                  be used whenever
                                                  feasible.
                                                ----------------------------------------------------------------
                                                 Existing Day Treatment    Enhancements in day            3
                                                  programs with waiting     treatment are included
                                                  lists will provide        in the Uniform MH
                                                  resources to eliminate    Services Package
                                                  them.
----------------------------------------------------------------------------------------------------------------


    President's New Freedom Commission Goal 2. Mental health care is 
consumer and family driven.
    Commission Recommendation 2.1.  Develop an individualized plan of 
care for every adult with a serious mental illness and child with a 
serious emotional disturbance.
    Develop a performance measure based on percentage of Seriously 
Mentally Ill (SMI) patients whose family members have been contacted to 
participate in developing an individualized plan of care. A. Create 
data capture mechanism for family contacts that include implementation 
of a clinic stop code for family work and a family education/counseling 
field on encounter forms.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.1.9 A Initiatives 1- Ensure that every mental  Operationalize Family     Planning is underway to        3
 5                      health patient has an     Education clinic stop     evaluate how to capture
                        individualized            code and encounter form   family involvement in
                        treatment plan that       procedure code in FY-     care
                        includes family           05; Implement (VISN 10
                        involvement in            pilot) Family
                        treatment plan and        Involvement Performance
                        process.                  Measure nationwide in
                                                  FY-05.
                                                ----------------------------------------------------------------
                                                 The FPE/FE Task Force of  In planning                    3
                                                  MH QUERI outlined the
                                                  following in FY-05:
                                                  Develop policy
                                                  directive on Family
                                                  Involvement/Education
                                                  to include issues of
                                                  confidentiality and
                                                  expectation that the
                                                  care plan for all
                                                  patients with
                                                  schizophrenia establish
                                                  at least one family
                                                  contact or document the
                                                  reason for its absence.
                      ------------------------------------------------------------------------------------------
                       Expand seamless           1. Assign Transition      Care management programs       2
                        transition efforts to     case managers to focus    focus on seriously
                        fully cover veterans      on mental health          injured
                        with mental health        programs, based on
                        diagnoses.                caseload to WRAMC,
                                                  Brooke etc. where the
                                                  bulk of the mental
                                                  health MEBs and PEBs
                                                  are conducted; 2.
                                                  Develop case management
                                                  program for all DoD
                                                  ``complex care''
                                                  patients coming into
                                                  VHA health care system;
                                                  3. Include VHA social
                                                  worker/case manager and
                                                  patient family in
                                                  transition planning for
                                                  DoD personnel with
                                                  mental health problems
                                                  who will be
                                                  transitioning to VHA
                                                  health care system,
                                                  with a special focus on
                                                  pain management; 4.
                                                  Improve transition
                                                  planning, referral/
                                                  placement and
                                                  information exchange
                                                  for patients with
                                                  mental illness coming
                                                  into VHA health care
                                                  system; 5. Improve
                                                  outcomes for patients
                                                  eligible for VA
                                                  services and/or
                                                  benefits thru use of
                                                  recovery approach to
                                                  provision of services.
                                                ----------------------------------------------------------------
                                                 1. Assign Transition      Care management programs       2
                                                  Social Workers to focus   focus on seriously
                                                  on mental health          injured
                                                  including: 2. Survey
                                                  all MTFs to determine
                                                  the need for social
                                                  workers focused on
                                                  mental health programs;
                                                  3. Ensure that Points
                                                  of Contact at VISN and
                                                  local treatment systems
                                                  have appropriate
                                                  knowledge about mental
                                                  health programs and
                                                  capabilities; 4. Have
                                                  transition social
                                                  workers followup on
                                                  referrals at three and
                                                  six months to ensure
                                                  effective program
                                                  placement; Identify
                                                  VACO point(s) of
                                                  contact for problem
                                                  resolution.
                      ------------------------------------------------------------------------------------------
                       Mental health             1. Every military man     Ongoing. VA has worked         2
                        assessments are an        and woman meet            with DoD to support
                        integral part of all      individually with a       PDHRAs
                        exams of separating       mental health
                        military service          professional as part of
                        personnel.                the post-deployment and
                                                  separation exams. 2. An
                                                  MOU needs to be
                                                  developed with DoD to
                                                  spell out authority,
                                                  responsibility,
                                                  accountability, and
                                                  funding for the
                                                  necessary clinical
                                                  capacity to be assured.
----------------------------------------------------------------------------------------------------------------

    Commission Recommendation 2.2.  Involve consumers and families 
fully in orienting the mental health system toward recovery.
    Involve veteran consumers and families in educating staff/veterans/
family members on recovery.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.2.10 Initiatives 1-  Seek stakeholder input     For VHA staff            Ongoing                        1
 2                      into mental health        educational efforts,
                        programming related to    MHSHG will ensure that
                        recovery.                 stakeholders are
                                                  included in planning
                                                  educational programs
                                                  related to recovery.
                                                ----------------------------------------------------------------
                                                 Assess barriers and       Need further guidance on       4
                                                  explore implementation    collaborations between
                                                  of Vocational Rehab and   VBA and MH
                                                  education for DoD
                                                  patients with mental
                                                  health problems while
                                                  they await their MEBs
                                                  or PEBs.
----------------------------------------------------------------------------------------------------------------


    Implement administrative incentives that facilitate work with 
veteran's families.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
 2.2.11 / 2.2.12       Reduce barriers to        Implement (VISN 10        In planning                    3
 Initiatives 1-3        working with families.    pilot) Family
                                                  Involvement Performance
                                                  Measure, including
                                                  developing stop codes
                                                  and other incentives
                                                  for tracking workload.
                                                  MHSHG and Mental Health
                                                  QUERI will review
                                                  results of VISN 10
                                                  performance measure
                                                  pilot prior to
                                                  advocating for national
                                                  performance measure.
                                                ----------------------------------------------------------------
                                                 Implement Family          MOU is in concurrence          3
                                                  Education in every
                                                  Network through
                                                  partnership with NAMI
                                                  (Family to Family
                                                  Program).
                                                ----------------------------------------------------------------
                                                 Offer Family-to-Family    In planning                    3
                                                  Education in
                                                  partnership with NAMI
                                                  in every Network.
                                                  Partner every facility,
                                                  outpatient clinic and
                                                  CBOC with corresponding
                                                  county NAMI Affiliate,
                                                  or other comparable
                                                  Family Education
                                                  program where FFEP is
                                                  not offered and/or
                                                  there is an already
                                                  existing Family
                                                  Education program; FY-
                                                  06: Implement FPE in
                                                  pilot Networks;
                                                  Implement FPE/FE
                                                  utilizing technology in
                                                  pilot Networks; Work:
                                                  Insure Family Education
                                                  addresses issues
                                                  regarding Work
                                                  Restoration.
----------------------------------------------------------------------------------------------------------------


    Educate staff. A. Begin process of educating staff with a satellite 
broadcast introducing the current evidence base for the recovery based 
model of treatment. B. Develop programs for staff use on family psycho-
education. C. Educate staff on clinical benefits and effective 
approaches to working with families, including issues of older couples 
and intergenerational families.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.2.13 A, B, C         Educate staff on the      MHSHG will work with EES  Ongoing                        1
 Initiatives 1-3        evidence based recovery   to develop an
                        model of treatment.       educational program,
                                                  including a satellite
                                                  broadcast, for staff
                                                  regarding the recovery
                                                  model of treatment
                                                  including issues of
                                                  older veterans, female
                                                  veterans and other
                                                  special emphasis
                                                  groups.
                                                ----------------------------------------------------------------
                                                 Train staff on QUERI FPE  FPE is being                   2
                                                  via EES Broadcast and     disseminated through
                                                  develop FPE Tool Kit;     with multiple supports
                                                  Disseminate FPE Task
                                                  Force Tool Kit
                                                  (planned) which will
                                                  include working with
                                                  diverse families to
                                                  include older couples
                                                  and intergenerational
                                                  families.
                                                ----------------------------------------------------------------
                                                 Develop programs for       A number of centers are       2
                                                  staff use on family       involved in training
                                                  psycho-education at the
                                                  VA Palo Alto MIRECC and
                                                  NCPTSD (VAPAHCS is the
                                                  educational site for
                                                  the National Centers
                                                  for PTSD).
----------------------------------------------------------------------------------------------------------------

    Include veteran consumers and family members in facility mental 
health councils.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.2.14 Initiatives 1-  Establish facility        All facility Mental       Additional guidance is         4
 3                      mental health council     Health Services will      required
                        that include consumer     report to MHSHG about
                        membership.               membership composition
                                                  of the facility mental
                                                  health council.
                                                ----------------------------------------------------------------
                                                 All facility mental       Additional guidance is         4
                                                  health councils will      required
                                                  have at least one
                                                  veteran consumer and
                                                  one family member as
                                                  standing members of the
                                                  facility mental health
                                                  council.
                                                ----------------------------------------------------------------
                                                 To provide guidance to    Additional guidance is         4
                                                  the field, VACO to        required
                                                  develop and issue a
                                                  Directive promoting the
                                                  establishment of
                                                  consumer/advocate
                                                  liaison councils at
                                                  both VISN and facility
                                                  levels by 2nd Qtr
                                                  FY'05. Such a Directive
                                                  to include language
                                                  about the communication
                                                  chain to maximize the
                                                  effectiveness of the
                                                  council.
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 2.3.  Align relevant Federal programs to 
improve access and accountability for mental health services.
    Develop Peer Support Program as an adjunct to mental health 
services. A. Explore models of peer support certification (e.g. those 
developed by Georgia). B. Determine whether a directive on Peer Support 
is advisable.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.15 A, B            Partner with other        Pilot State Peer          A strategy for                 3
 Initiatives 1-5        Federal agencies to       Specialist                developing peer support
                        develop peer support      Certification projects    is included within the
                        programs.                 (such as Georgia/South    Uniform MH Services
                                                  Carolina, Hawaii, etc);   Package
                                                  Peer Support: FY-05:
                                                  Issue national
                                                  Information Letter to
                                                  promote paid Peer-led
                                                  services programming,
                                                  (directly or through
                                                  contract with community
                                                  providers) as an
                                                  adjunct to traditional
                                                  mental health services
                                                  at all facilities
                                                  serving veterans with
                                                  serious mental illness.
                                                  FY-06: Issue national
                                                  directive with detailed
                                                  procedural guidance.
                                                ----------------------------------------------------------------
                                                 Establish partnership     Requires additional            4
                                                  with SAMHSA and           guidance
                                                  continue participation
                                                  in Federal partners
                                                  workgroup at VACO
                                                  level. Establish
                                                  nationwide method for
                                                  reimbursing peer
                                                  support. Add Work
                                                  Restoration to Peer
                                                  Counseling and Vets
                                                  Helping Vets programs.
                                                  Oversight of this
                                                  effort to be conducted
                                                  by the AASC.
                                                ----------------------------------------------------------------
                                                 Develop a partnership     Requires additional            4
                                                  between the MHSHG and     guidance
                                                  RCS to develop model
                                                  systems for consumer
                                                  and family driven
                                                  services with VHA and
                                                  to create a national
                                                  Program of Excellence
                                                  in Peer Counseling
                                                  Services within VHA.
                                                ----------------------------------------------------------------
                                                 VISN 1 MIRECC will        Manuals for psychosocial       3
                                                  develop a ``How To''      rehabilitation,
                                                  manual on developing a    including peer support,
                                                  Peer Support program.     are under development
                                                ----------------------------------------------------------------
                       Transition planning and   Explore early transfer    Plans for DoD VA               3
                        referral/placement for    of patients with mental   partnerships are being
                        OEF and OIF returnees     health problems to the    developed
                                                  VA treatment system and
                                                  the use of VA health
                                                  care providers to
                                                  conduct MEBs and PEBs.
----------------------------------------------------------------------------------------------------------------

    Initiate a national Recovery and Rehabilitation Task Force to 
develop a ``How To'' manual on developing a Peer Support Program.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.16                 Provide support for the   VISN 1 MIRECC will        In planning, with              3
                        development of a Peer     facilitate the            reassignment to OMHS
                        Support Program.          following efforts: 1.
                                                  Family Support/
                                                  education--Implement
                                                  family education
                                                  program in each VISN;
                                                  educate staff; appoint
                                                  family POC within each
                                                  facility. 2. Veteran
                                                  Advisory Councils/peer
                                                  support. 3. Change VHA
                                                  culture to recovery
                                                  oriented service
                                                  delivery. Reference AA
                                                  Recommendation 5.3.61.
----------------------------------------------------------------------------------------------------------------


    Develop task oriented veteran-consumer councils in each facility. 
A. Insure consumer council has communication mechanism to facility 
leadership.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.17 A               combined with 2.3.14
----------------------------------------------------------------------------------------------------------------


    Develop paid positions for veterans) within the facility/network to 
work with Mental Health leadership in developing Peer to Peer Programs.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.18 Initiatives 1-   Utilize veterans in the  Hire or identify          In planning                    3
 3                      provision of mental       existing staff as a
                        health care. Reference    permanent veteran
                        AA Recommendation         mental health consumer
                        5.3.61.                   in the MHSHG and in
                                                  each Network to work
                                                  with Mental Health
                                                  leadership in
                                                  developing Peer
                                                  Programming and to
                                                  represent the consumer
                                                  perspective in other
                                                  mental health planning/
                                                  management initiatives
                                                  and to serve as peer/MH
                                                  para professional.
                                                ----------------------------------------------------------------
                                                 Pilot Certified Peer      A strategy for broad           3
                                                  Specialists in selected   implementation of peer
                                                  VISNs (suggest VISNs 7    support services is
                                                  and 20) Pilot Peer        included in the Uniform
                                                  Bridgers in selected      MH Services Package
                                                  VISNs (suggest VISNs 2
                                                  and 3); Modify current
                                                  State Certified Peer
                                                  Specialists training to
                                                  tailor for VHA
                                                  implementation
                                                  nationwide.
                                                ----------------------------------------------------------------
                                                 Issue national directive  A strategy for broad           3
                                                  on Peer programs;         implementation of peer
                                                  Establish Network         support services is
                                                  performance monitor to    included in the Uniform
                                                  require a formal Peer     MH Services Package
                                                  Support Program at each
                                                  facility serving
                                                  greater than 2,500
                                                  veterans with SMI; FY-
                                                  06: Establish a clinic
                                                  stop code for Peer-Led
                                                  Groups, and a Peer
                                                  Provider category on
                                                  encounter forms.
----------------------------------------------------------------------------------------------------------------


    Hire veterans as Peer / Mental Health Para Professionals.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.19                 See 2.3.18 and 5.3.61.    FY 06. Establish network  A strategy for broad           3
                                                  performance monitor to    implementation of peer
                                                  require a formal paid     support services is
                                                  peer support program at   included in the Uniform
                                                  each facility serving     MH Services Package
                                                  greater than 2,500
                                                  veterans with SMI. FY
                                                  07. Expand that monitor
                                                  to include facilities
                                                  with more than 1,200
                                                  veterans with SMI.
----------------------------------------------------------------------------------------------------------------

    Issue a national directive to facility leadership on the creation 
of local Peer Support programs. A. Identify a facility coordinator for 
the development of peer programs. B. Develop a progressive performance 
measure that addresses incremental steps to the implementation of a 
facility Peer Support program. C. Create data capture mechanisms for 
peer support and peer training that include implementation of clinic 
stop codes and modification of encounter forms to include fields for 
peer support as well as peer training.


----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.20 A, B, C         See 2.3.18 and 5.3.61
----------------------------------------------------------------------------------------------------------------


    Make housing with support more available for those veterans who are 
homeless or at risk for homelessness, particularly older veterans and 
those veterans who are new to the system.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.21 Initiatives 1-  Provide additional        Task HSR&D with creating  DOMS have been moved           2
 6                      homeless housing.         a Management              within OMHS. Projecting
                                                  Consultation Project to   need is the
                                                  develop a demand model    responsibility of OPP
                                                  for residential
                                                  services at all
                                                  facilities. The needs
                                                  of older veterans and
                                                  veterans new to the
                                                  system will addressed
                                                  in this model.
                                                ----------------------------------------------------------------
                                                 Work with HUD to          Ongoing                        1
                                                  maintain current
                                                  capacity and create new
                                                  capacity in the HUD/
                                                  VASH.
                                                ----------------------------------------------------------------
                                                 Continue support of       Ongoing                        1
                                                  joint VA/HUD/HHS
                                                  collaborative
                                                  initiative in chronic
                                                  homelessness.
                                                ----------------------------------------------------------------
                                                 Expand grant and per      Ongoing                        1
                                                  diem and domiciliary
                                                  care programs.
                                                ----------------------------------------------------------------
                                                 Develop programs focused  For planning with DoD          3
                                                  on prevention of          COE
                                                  homelessness and
                                                  unemployment for DoD
                                                  patients with mental
                                                  health problems
                                                  (Legislative authority
                                                  may be required).
                                                ----------------------------------------------------------------
                                                 Make underutilized space  For program by program         3
                                                  at VA facilities          evaluation
                                                  available for community
                                                  organizations to
                                                  provide programs.
----------------------------------------------------------------------------------------------------------------

    Work with state, local and community partners to increase 
opportunities for veterans to participate in supported employment 
programs. Support legislation to increase VA's authority to form 
partnerships to provide supported employment opportunities for 
veterans.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.22 Initiatives 1-  Increase opportunities    Partner with Department   Specific elements              4
 3                      for veterans to           of Labor (DOL) to         require reevaluation
                        participate in            develop Work
                        supportive employment.    Restoration services
                                                  that promote
                                                  entrepreneurship and
                                                  private enterprise;
                                                  Develop contract with
                                                  Department of Defense
                                                  (DoD) to expand the CWT
                                                  Veterans Construction
                                                  Team (VCT) to assist
                                                  veterans in restoring
                                                  lost construction
                                                  skills; Develop policy
                                                  and procedures for
                                                  utilization of non-
                                                  appropriated CWT
                                                  Special Therapeutics
                                                  Rehabilitation
                                                  Activities Fund (STRAF)
                                                  to contract with state,
                                                  local and community
                                                  partners to provide job
                                                  development and coaches
                                                  for Supported
                                                  Employment services;
                                                  Increase outreach by
                                                  providing CWT, IT, CWT/
                                                  TR programs in shelters
                                                  for homeless veterans.
                                                ----------------------------------------------------------------
                                                 Improve outcomes for      Additional guidance is         4
                                                  patients eligible for     required about
                                                  VA services and/or        recommendation related
                                                  benefits thru use of      to benefits
                                                  recovery approach to
                                                  provision of services.
                                                ----------------------------------------------------------------
                                                 MHSHG to create a RFP     Evaluations of CWT             3
                                                  for the development of    funding are in
                                                  new or expanded CWT/TR    progress.
                                                  programs and that they
                                                  be provided with
                                                  $500,000 annually to
                                                  support these programs.
                                                  This alternative
                                                  centralized funding
                                                  mechanism would be
                                                  established and
                                                  supported to sustain
                                                  the provision of
                                                  residential
                                                  rehabilitation in the
                                                  CWT/TR program for SMI
                                                  veterans until
                                                  authority is restored
                                                  for use of non-
                                                  appropriated dollars.
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 2.4.  Create a comprehensive State Mental 
Health Plan
    Ensure that VISNs participate in State Mental Health Plan 
development.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.4.23 Initiatives 1-  All VISNs will actively    Participate in           Ongoing                        1
 3                      participate in the        President's 10 Year
                        development of their      Plan to End Chronic
                        State mental health       Homelessness.
                        plans.
                                                ----------------------------------------------------------------
                                                 FY-05/06: Partner with    The state service              3
                                                  state-funded Consumer-    liaison program needs
                                                  run services to provide   updating.
                                                  supports for housing,
                                                  employment and other
                                                  community services to
                                                  veterans.
                                                ----------------------------------------------------------------
                                                 VISNs will work with      The state service              3
                                                  their state(s) and The    liaison program needs
                                                  National Association of   updating.
                                                  State Mental Health
                                                  Program Directors to
                                                  develop strategic plans
                                                  and processes for
                                                  collaboration of the
                                                  delivery of mental
                                                  health service. The
                                                  VISNs submit their
                                                  proposals to 10N and
                                                  the MHSHG for
                                                  consideration.
----------------------------------------------------------------------------------------------------------------


    Encourage development of state plans that provide supported 
housing, employment and other community services to veterans.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.24                 collapsed with 2.2.23
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 2.5.  Protect and enhance the rights of 
people with mental illnesses.
    Identify a family point of contact within each facility to 
coordinate services, education and liaison with National Alliance for 
the Mentally Ill.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.25                 Ensure facility           MHSHG will initiate a     AN MOU with NAMI is in         2
                        coordination with NAMI.   Task Force including      concurrence
                                                  representatives from
                                                  the Mental Health QUERI
                                                  FPE/FE Task Force, and
                                                  charge it with
                                                  developing a process
                                                  for implementing FE.
----------------------------------------------------------------------------------------------------------------


    Assist with development of an Advanced Directive for every veteran 
with serious mental illness who desires one. Advanced Directives can 
designate power of attorney at times the veteran is deemed not 
competent to make decisions for him/herself.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.26                 Across the age span,      Develop and disseminate   OMHS is collaborating          3
                        there will be no          to the VISNs a mental     with Ethics on MH
                        disparity between         health advanced           advance directives
                        mental health and         directive policy. This
                        medical health of         policy will address the
                        veterans in completing    following issues:
                        a mental health and a     Across the age span,
                        medical advanced          there will be no
                        directive.                disparity between
                                                  mental health and
                                                  physical health in
                                                  completing a medical
                                                  advance directive. When
                                                  data on advanced
                                                  directive compliance
                                                  are reviewed by
                                                  facility, rates of
                                                  completion for veterans
                                                  with and without SMI
                                                  will be compared. If
                                                  rates are not
                                                  equivalent, training
                                                  for staff described
                                                  under Goal 1 (re.
                                                  destigmatization)
                                                  should be repeated for
                                                  relevant staff, with an
                                                  emphasis on the rights
                                                  and abilities of
                                                  veterans with SMI and
                                                  veterans of all ages to
                                                  state their advanced
                                                  directive wishes.
----------------------------------------------------------------------------------------------------------------


    Partner with academic institutions that have a commitment to the 
understanding and development of psychosocial rehabilitation (e.g. 
Robert Wood Johnson Foundation).

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.27 Initiatives 1-  Provide psychosocial      Create working group to   Ongoing                        1
 3                      rehabilitation            expand partnerships by
                        expertise to VHA staff.   participating in
                                                  research and training
                                                  activities.
                                                ----------------------------------------------------------------
                                                 Identify current          Ongoing                        1
                                                  partnerships through a
                                                  survey of MIRECCs, PSR
                                                  fellowship programs,
                                                  Mental Health QUERI,
                                                  and field clinicians
                                                  and researchers.
                                                ----------------------------------------------------------------
                                                 Partner with OAA to       OAA has established 7          2
                                                  develop VHA               psychosocial
                                                  psychosocial              rehabilitation
                                                  internships in            fellowship programs
                                                  association with
                                                  universities and
                                                  foundations. Increase
                                                  linkages in Supported
                                                  Education with state
                                                  and regional colleges
                                                  and training schools.
                                                  Supported education
                                                  must increase
                                                  marketability in an
                                                  ever-changing job
                                                  market in which all
                                                  employees rapidly
                                                  become obsolete as
                                                  technology continually
                                                  transforms.
----------------------------------------------------------------------------------------------------------------


    Explore grants awarded to not for profit groups targeted at Peer 
Development and Education.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.28 Initiatives 1-  Refer to 2.3.18           Peer: FY-05: Explore      Ongoing. Technical             2
 2                                                development of a VA       Assistance for peer
                                                  Technical Assistance      support is available
                                                  Center for Peer Support   from a number of
                                                  Services and/or develop   centers
                                                  grant/contractual
                                                  arrangement with
                                                  established technical
                                                  assistance
                                                  organizations.
                                                ----------------------------------------------------------------
                                                 Part of the Special       OMHS is developing a           2
                                                  Needs Grant for           peer support program
                                                  Homeless Chronically      for homeless veterans
                                                  Mentally Ill Veterans
                                                  MHSHG is requiring non-
                                                  profit organizations
                                                  that receive funding to
                                                  develop ``Vet-to-Vet''
                                                  peer counseling model.
                                                  Ten such programs are
                                                  planned for funding.
----------------------------------------------------------------------------------------------------------------


    Charge Veterans Benefits Administration (VBA)'s Vocational 
Rehabilitation Service with identifying and developing opportunities 
for training veteran/consumers as mental health service providers.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.29                 Align VBA work            Expand the partnership    Recommendations for            4
                        restoration efforts       with VHA/CWT Program to   partnership with VBA
                        with VHA work             improve access and        should be clarified
                        restoration efforts.      services to VR&E
                                                  programs for veterans
                                                  with mental illness by
                                                  development of
                                                  supported employment
                                                  models that include
                                                  veteran/consumers as
                                                  employment specialists,
                                                  job coaches, and other
                                                  support roles. MHSHG
                                                  will prepare memo to
                                                  USB from USH with this
                                                  proposal.
----------------------------------------------------------------------------------------------------------------

    Strengthen and expand local partnerships with NAMI and with 
National Mental Health Association (NMHA) for consultation on the 
development of peer facilitated programs.


----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.30                 Refer to 2.5.25
----------------------------------------------------------------------------------------------------------------


    President's New Freedom Commission Goal 3. Disparities in mental 
health services are eliminated.
    Commission Recommendation 3.1.  Improve access to quality care that 
is culturally competent.
    Develop a culturally competent health care workforce A. Intensify 
efforts to improve the cultural diversity of health care staff and seek 
to recruit professional staff that better reflect the veteran enrollee 
population. B. Institute health professional scholarship programs 
targeted to attract minority candidates. C. Provide incentives for 
university affiliates to send undergraduate and graduate health care 
professional trainees to VA health care sites with large minority 
populations.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.31 A, B, C         Ensure that VHA           The Office of Academic    To be reevaluated. OAA         4
 Initiatives 1-2        workforce is culturally   Affiliations to develop   has been developing
                        diverse in ethnicity,     and fund health           other training
                        gender, and age.          professional              initiatives.
                                                  scholarship programs
                                                  targeted to attract
                                                  minority candidates.
                                                ----------------------------------------------------------------
                                                 The Office of Academic    Requires additional            4
                                                  Affiliations to develop   guidance
                                                  incentives for
                                                  university affiliates
                                                  to send undergraduate
                                                  and graduate health
                                                  care professional
                                                  trainees to VA health
                                                  care sites with large
                                                  minority populations.
----------------------------------------------------------------------------------------------------------------

    Request that the Office of Research and Development (ORD) support 
research on minority mental health treatment. A. Identify areas of 
research specifically needed to close the gap in providing mental 
health care for minority veterans.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.32A                Conduct research to       SOTA conference with      VISN 4 HSR&D COE focuses       2
                        assess and remedy         HSR&D and HSR&D COE on    on health disparities
                        potential disparities     minorities will review    including MH
                        in treatment for          existing portfolio and    disparities
                        minorities, including     develop solicitations
                        ethnicity, gender, age.   as appropriate for
                                                  research on minority
                                                  mental health
                                                  treatment. The research
                                                  will cover
                                                  psychobiology of
                                                  ethnicity, service/
                                                  treatment disparities,
                                                  and health related
                                                  characteristics of
                                                  other special emphasis
                                                  groups.
----------------------------------------------------------------------------------------------------------------

    28Collaborate in national interagency efforts to address minority 
issues, staff training needs, and assessment instruments, etc

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.33 Initiatives 1-  Ensure that there are     MHSHG will designate a    Ongoing. Federal               1
 3                      effective interagency     liaison to other          Partners on MH focuses
                        relationships to          Federal agencies to       on a broad array of
                        address minority          collaborate with their    issues
                        issues, staff training    efforts in this area.
                        needs, and assessment
                        instruments, etc.
                                                ----------------------------------------------------------------
                                                 MHSHG will explore        Ongoing. Topic covered         2
                                                  options to collaborate    as part of Federal
                                                  with HHS minority         Partners work group
                                                  offices in this area.
                                                ----------------------------------------------------------------
                                                 VA will initiate          Ongoing. Topic covered         1
                                                  collaboration with        as part of Federal
                                                  National Federal          Partners work group
                                                  Partners' work group in
                                                  this area.
----------------------------------------------------------------------------------------------------------------


    Incorporate a cultural competence strategy in the VHA Strategic 
Plan.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.34 Initiatives 1-  Ensure that all VHA       By January of 2005, the   Task Force developed and       3
 2                      staff are culturally      MHSHG to establish a      has produced an
                        competent                 Cultural Competency       implementation plan
                                                  Task Force to focus on    that has been approved
                                                  clinician education and   in PCS. It will be
                                                  health care services.     implemented as part of
                                                  Representation to be      the Universal MH
                                                  from VACO and the field   Services
                                                  as well as MIRECCs,
                                                  QUERI and EES. This
                                                  Task Force to provide
                                                  an action plan to be
                                                  implemented by end of
                                                  FY2006 and to include
                                                  an evaluation component
                                                  to assess effectiveness
                                                  of the implementation
                                                  in improving cultural
                                                  competency. Refer to
                                                  3.1.31 and 3.1.37.
                                                ----------------------------------------------------------------
                                                 Convene a work group to   To be evaluated as part        3
                                                  review literature and     of the implementation
                                                  track the                 of the Uniform MH
                                                  implementation of the     Services Package
                                                  recommendations of the
                                                  Commission's Cultural
                                                  Competence
                                                  Subcommittee, the
                                                  Surgeon General's
                                                  Report on Mental
                                                  Health, Minority
                                                  Supplement, and
                                                  evaluate the
                                                  effectiveness of VA's
                                                  cultural competence
                                                  training program.
----------------------------------------------------------------------------------------------------------------


    Fund EES to develop and implement comprehensive, cultural 
competence training, including a module on aging, for all VA employees.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.35                 Refer to 1.2.7
----------------------------------------------------------------------------------------------------------------


    Develop a knowledge management system to disseminate timely, 
program specific education that will keep staff continuously apprised 
of new information on best practices and research related to racial and 
ethnic differences in care needs and interventions.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.36 Initiatives 1-  Enhance the current       MHSHG to urge VHA to      Planning and preparation       3
 3                      information               develop information
                        dissemination system to   systems such as data
                        speed the dissemination   warehouses and
                        of information on         associated tools that
                        research findings and     allow real-time access
                        best clinical and         to clinical data, and
                        management practices      to encourage training
                        throughout the VHA        of managers and
                        mental health             providers in use of
                        community.                these tools as well as
                                                  sharing of best
                                                  practices.
                                                ----------------------------------------------------------------
                                                 Develop web-based         ORD is developing a            2
                                                  educational programs on   major program on
                                                  best practices and        personalized medicine
                                                  research related to
                                                  racial and ethnic
                                                  differences in care
                                                  needs and
                                                  interventions.
                                                ----------------------------------------------------------------
                                                 Develop a registry of     Ongoing MH enhancements        2
                                                  best practices similar    and the evolving
                                                  to SAMHSA's National      Uniform MH Services
                                                  Registry of Effective     Package disseminate
                                                  Programs.                 evidence-based
                                                                            practices
----------------------------------------------------------------------------------------------------------------


    Partner with Indian Health Service (IHS) to improve access to 
culturally competent mental health and substance abuse care for 
American Indian and Native Alaskan veterans.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.37 Initiatives 1-  Partner with IHS to       VHA will designate a VA   Ongoing operations             1
 2                      improve access to the     liaison to work with
                        full continuum of MH      IHS to promote this
                        care for Native           collaboration;
                        Americans and Alaskan     specialty groups will
                        Indians.                  be included in the
                                                  planning.
                                                ----------------------------------------------------------------
                                                 OAA will review and       Requires reevaluation          4
                                                  disseminate the
                                                  cultural competence
                                                  education pilot in VISN
                                                  1 MIRECC. Refer to
                                                  3.1.31 and 3.1.34.
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 3.2.  Improve access to quality care in 
rural and geographically remote areas.

    Identify national, state and local partners who are focused on 
improving health care in rural America. VHA is a stakeholder in any 
process involving rural health care and should request to participate 
in national initiatives and activities. This should include any actions 
taken on the part of the Department of Health and Human Services (HHS) 
to establish a State rural health initiative, especially those 
involving National Institute of Mental Health (NIMH), Health Resources 
and Services Administration (HRSA), IHS or the Substance Abuse and 
Mental Health Services Administration (SAMHSA).

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.2.38 Initiatives 1-  Collaborate with other    VHA to have a designated  Rural issues are being         3
 2                      agencies in delivering    liaison from the MHSHG    addressed through
                        quality health care to    to focus on rural         multiple mechanisms
                        veterans in rural         mental health care        within VHA
                        areas.                    issues and participate
                                                  in the activities of
                                                  HHS, NIMH, IHS, HRSA,
                                                  SAMHSA.
                                                ----------------------------------------------------------------
                                                 VA liaisons will           Liaison between VA and        3
                                                  advocate inclusion of     state MH systems is
                                                  veterans located in       being strengthened
                                                  rural areas in all
                                                  state MH plans.
----------------------------------------------------------------------------------------------------------------


    VHA should pursue a wide range of options for providing rural 
mental health care; particular attention should be paid to the needs of 
older veterans living in rural areas. VHA should examine existing and 
planned community access sites to ensure that they have mental health 
access that meet veteran's needs. Options for providing mental health 
services include but are not limited to on site staffing, tele-mental 
health, use of mid level providers, partnerships with State agencies, 
and fee for services with local private providers.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.2.39 Initiatives 1-  Ensure that veterans in   Develop internet-based    Requires reevaluation          4
 5                      rural areas have access   services to facilitate
                        to quality mental         Peer Support services
                        health care.              for veterans.
                                                ----------------------------------------------------------------
                                                 Case management models    Ongoing operations             1
                                                  in rural areas where
                                                  MHICM is not feasible/
                                                  practical will be
                                                  developed by NEPEC.
                                                ----------------------------------------------------------------
                                                 Design and launch a       Telemental health is           3
                                                  major demonstration       being expanded and
                                                  project on telehealth     enhanced
                                                  addiction and mental
                                                  health services for
                                                  veterans, including
                                                  recently separated
                                                  military personnel,
                                                  living in remote and
                                                  rural areas.
                                                ----------------------------------------------------------------
                                                  VHA to examine existing  A strategy for                 3
                                                  and planned community     delivering MH in rural
                                                  access sites to ensure    areas is included in
                                                  that they have mental     the Uniform MH Services
                                                  health access that        Package
                                                  meets the veteran needs
                                                  in those areas. Mental
                                                  health providers to be
                                                  available in all CBOCs,
                                                  and they will provide
                                                  training using the
                                                  psychoeducational
                                                  modules described in
                                                  the various
                                                  recommendations above.
                                                  Tele-mental health
                                                  options, as described
                                                  in later
                                                  recommendations, will
                                                  be widely available for
                                                  use of older adults,
                                                  PTSD, women, SA, etc.
                                                ----------------------------------------------------------------
                                                 MHSHG will collaborate    VA is in ongoing               2
                                                  with SAMHSA's Registry    dialogue with SAMHSA
                                                  of Effective Programs     about providing MH
                                                  to establish a parallel   services in rural areas
                                                  mechanism to have a VHA
                                                  registry of best
                                                  practices/demonstration
                                                  programs including, for
                                                  example, telemedicine
                                                  programs and practices
                                                  in remote areas and
                                                  best practices for
                                                  rural communities.
----------------------------------------------------------------------------------------------------------------


    VHA should request participation in SAMHSA efforts to identify and 
disseminate best practices to the rural community.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
3.2.40                 collapsed 3.2.39
----------------------------------------------------------------------------------------------------------------


    There are no items for Commission recommendations 4.1 and 4.2, as 
these deal with children & schools.
    President's New Freedom Commission Goal 4. Early mental health 
screening, assessment, and referral to services are common practice.
    Commission Recommendation 4.3.  Screen for co-occurring mental and 
substance use disorders and link with integrated treatment strategies.
    Ensure that every clinician knows that mental health and substance 
use disorders can and do co-occur with other disorders that they assess 
and treat.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
4.3.41 Initiatives 1-  Implement a broad range,  HSR&D will evaluate       Processes for screening,       2
 3                      self-administered         current instruments and   followup, and
                        screening for mental      pilot a proposed mental   monitoring of outcomes
                        health disorders. The     health screening          for MH conditions are
                        screening will be         instrument.               being developed
                        conducted annually
                        throughout the
                        veteran's lifespan by
                        the veteran's primary
                        care team or identified
                        care manager.
                      ------------------------------------------------------------------------------------------
                       Provide education to      Require 8 hours annually  MH training for primary        2
                        primary care providers    of CMEs on mental         care providers is being
                        regarding mental health   health for primary care   provided through the
                        disease management and    providers and on          Integrated Care
                        to mental health          medical health for        programs
                        providers regarding       mental health
                        common medical            providers. Recommend
                        conditions found in       increasing medicine
                        psychiatric patients.     residency training
                                                  program requirements
                                                  for mental health
                                                  electives and/or
                                                  training.
                      ------------------------------------------------------------------------------------------
                       Improve diagnosis and     Provide outreach to       Programs for seamless          1
                        treatment of mental       active duty, especially   transition and outreach
                        health disorders among    those with life           are operational
                        returning service         altering injuries, and
                        personnel with serious    recently deactivated
                        physical injuries.        military personnel and
                                                  their families to make
                                                  them aware of VHA and
                                                  VBA programs and
                                                  eligibility
                                                  requirements for
                                                  persons with mental
                                                  health problems.
                                                  Develop partnership
                                                  between the MHSHG and
                                                  RCS to lead VHA
                                                  outreach to special
                                                  populations; 1. Partner
                                                  with DoD MTFs to screen
                                                  all patients for mental
                                                  health and substance
                                                  abuse problems; 2.
                                                  Expand use of clinical
                                                  reminder currently used
                                                  to screen for mental
                                                  health and substance
                                                  abuse in OIF and OEF
                                                  veterans to all new
                                                  patients coming into
                                                  the VA health care
                                                  system.
----------------------------------------------------------------------------------------------------------------


    Ensure that screening and evaluation for these disorders are part 
of accepted clinical practice for every health care provider.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
4.3.42                 collapsed with 4.3.41
----------------------------------------------------------------------------------------------------------------


    Ensure that diagnosis of a mental health or substance abuse 
disorder results in an automatic screen for the other disorder as a 
routine clinical practice.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
4.3.43                 See above 4.3.41
----------------------------------------------------------------------------------------------------------------


    Require cross training in the two areas including the acquisition 
of a minimum number of CME/CEU credits in the assessment and treatment 
of the two disorders for mental health and substance abuse service 
providers and non-specialists in these areas.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
4.3.44 Initiatives 1-  Mental health and         MICA Task Force is        Plans for meeting the          2
 2                      substance abuse           working on specific       needs of patients with
                        providers will be         recommendations on        Dual Diagnoses are
                        competent in assessment   mandatory CMEs.           included in the Uniform
                        and treatment for both                              MH Services Package
                        mental health and
                        substance abuse
                        disorders and these
                        competencies will be
                        documented.
                                                ----------------------------------------------------------------
                                                 Link with SAMHSA Co-      Resource enhancements,         2
                                                  occurring Disorders       education, and
                                                  Project to develop        strategic planning are
                                                  educational program.      in progress. VA is in
                                                                            dialogue with SAMHSA
                                                                            over many issues
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 4.4.  Screen for mental disorders in 
primary health care, across the lifespan, and connect to treatment and 
supports.
    Require annual screening for mental health and substance abuse 
disorders across the life span by the veteran's primary care team or 
other providers responsible for the veteran's VA health care. A. Pilot 
test the clinical reminder developed for veterans from Operation Iraqi 
Freedom for use as a screen in primary care and specialty care clinics 
for all recently deployed individuals. B. Evaluate whether early 
screening and treatment can prevent chronic mental and multi-system 
illnesses.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.45 A, B            Require annual screening  Work with MHSHG and       Annual screening for MH        1
                        for Mental Health and     MIRECCs to develop and    conditions is in place
                        Substance Abuse           test a comprehensive
                        Disorders across the      tool for annual
                        lifespan by the           screening.
                        veterans' primary care
                        provider.
----------------------------------------------------------------------------------------------------------------


    Evaluate the dual diagnosis/co-occurring VA programs to identify 
best practices and to determine which programs were most effective. 
Fund research to develop a valid screen for suicide risk and 
prevention.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.46 Initiatives 1-  Suicide prevention.       Endorsement and           Ongoing                        1
 4                                                implementation of the
                                                  National Strategy for
                                                  Suicide Prevention
                                                  (2001) and the
                                                  Institute of Medicine's
                                                  report, Reducing
                                                  Suicide: A National
                                                  Imperative (2002).
                                                ----------------------------------------------------------------
                                                 Develop methods for       Ongoing                        1
                                                  tracking veterans with
                                                  risk factors for
                                                  suicide and systems for
                                                  appropriate referral of
                                                  such patients to
                                                  specialty mental health
                                                  care.
                                                ----------------------------------------------------------------
                                                 EES in conjunction with   Mechanisms to document         3
                                                  MHSHG develop mandatory   mandatory training are
                                                  education programs for    being developed
                                                  VA health care
                                                  providers about suicide
                                                  risks and ways to
                                                  address these risks.
                                                  Incorporate best
                                                  practices for suicide
                                                  prevention.
                                                ----------------------------------------------------------------
                                                 Recommend support for     VISN 19 MIRECC and             1
                                                  new MIRECC with focus     Canandaigua COE are
                                                  on suicide prevention,    operational
                                                  in collaboration in
                                                  other MIRECCs working
                                                  in this area.
----------------------------------------------------------------------------------------------------------------


    Increase collaboration with VBA to provide the full range of 
supports and services that are needed by patients with mental health, 
substance abuse and co-occurring disorders.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.47 Initiatives 1-  Eliminate the             MHSHG will evaluate and   There have been a legal        1
 2                      disincentives in the      address these             opinion that comp and
                        work restoration          disincentives. Link VA    pension are fully
                        program for veterans.     work restoration          protected while
                                                  program to Supported      veterans participate in
                                                  Employment in the         CWT for voc rehab.
                                                  Veterans Benefits
                                                  Administration (VBA)
                                                  that focuses on
                                                  competitive work, rapid
                                                  job search, coupled
                                                  with job coaching, and
                                                  training veteran/
                                                  consumers as mental
                                                  health service
                                                  providers. MHSHG will
                                                  prepare memo to USB
                                                  from USH with this
                                                  proposal.
                      ------------------------------------------------------------------------------------------
                       Increase collaboration    Recommend that VARO       G&PD liaisons evaluate         2
                        with VBA.                 Benefits Counselors       veterans clinically to
                                                  annually assess all       identify those who may
                                                  veterans in the G&PD      be eligible for
                                                  programs to determine     additional benefits.
                                                  eligibility for
                                                  benefits. MHSHG will
                                                  prepare memo to USB
                                                  from USH with this
                                                  proposal.
----------------------------------------------------------------------------------------------------------------


    Work with Residency Review Committees to encourage incorporation of 
mental health modules into all residency programs.

----------------------------------------------------------------------------------------------------------------
                       Mental Health Strategies
       AA Rec.#                                         Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.48                 Incorporate mental        The Coordination Council  Integration of MH and          3
                        health education and      for education program,    Primary Care, and
                        training into residency   ``Mental Health for       introduction of MH into
                        programs.                 Primary Care              other medical care
                                                  Providers,'' described    settings lay the
                                                  in Action Agenda          groundwork for
                                                  recommendation 5.3.65,    residency training.
                                                  will work through VHA
                                                  clinical services & OAA
                                                  to promote inclusion of
                                                  a mental health module
                                                  in all residency
                                                  training programs. The
                                                  Council will also work
                                                  with professional
                                                  organizations to
                                                  include such a module
                                                  as a requirement by
                                                  Residency Review
                                                  Committees.
----------------------------------------------------------------------------------------------------------------


    Contract with the Institute of Medicine for a literature review to 
determine effective prevention strategies for mental illness in combat 
veterans, with and without physical injury. Recommendations should also 
include an agenda for needed research.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.49                 Determine effective       VHA will contract with    Research on early              3
                        prevention strategies     IOM, and other            intervention or
                        for mental illness in     pertinent agencies, for   prevention of PTSD is
                        combat veterans with/     literature review after   included within the
                        without physical          consultation with         activities of NCPTSD,
                        injuries.                 specialty groups.         MIRECC, other VA COEs
                                                                            and the DoD COE.
                                                                            Contracting with IOM
                                                                            may not be necessary
----------------------------------------------------------------------------------------------------------------


    President's New Freedom Commission Goal 5. Excellent mental health 
care is delivered and research is accelerated.
    Commission Recommendation 5.1.  Accelerate research to promote 
recovery and resilience, and ultimately to cure and prevent mental 
illnesses.
    Convene an Evidence Based Practices (EBP) Steering Committee to 
focus on recovery and rehabilitation. Representatives from NIMH and 
SAMHSA should be invited to participate as committee members. The 
Mental Health Strategic Health Care Group (MHSHG) should be staffed to 
coordinate and manage this activity. This steering Committee 
continuously review advances published in the scientific literature and 
A. Identify new research that is needed; B. Identify research results 
that are ready for demonstration projects or pilot testing, and C. 
Identify models that can be disseminated as EBP or best practices.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.1.50 A, B, C         Emphasize recovery and    MHSHG will propose a      Ongoing. Recovery              2
Initiatives 1-5......   rehabilitation in         structure and resources   coordinators have been
                        mental health care.       to facilitate recovery,   appointed in each VAMHC
                                                  including supporting
                                                  the work of the EBP
                                                  Steering Committee.
                                                ----------------------------------------------------------------
                                                 1. Establish a joint DoD/ Ongoing                        1
                                                  VA ``Center of
                                                  Excellence'' focused on
                                                  traumatic brain injury
                                                  and other life altering
                                                  injuries; 2. Develop
                                                  longitudinal tracking
                                                  system for veterans
                                                  from OIF and OEF; 3.
                                                  Evaluate the
                                                  effectiveness of the
                                                  mental health
                                                  transition program.
                                                ----------------------------------------------------------------
                                                 Pilot and research State  Peer support programs          2
                                                  Peer Specialist           are in place and will
                                                  certification programs;   be supported through
                                                  Pilot partnership with    the Uniform MH Services
                                                  NY Assoc of Psych Rehab   Package
                                                  Services to develop
                                                  Peer Bridgers in VISNs
                                                  2 and/or 3.
                                                ----------------------------------------------------------------
                                                 Task the MIRECCs to       Psychosocial                   2
                                                  review the role and       Rehabilitation Centers
                                                  function of Day           have been developed,
                                                  Hospitals and Day         and will be
                                                  Treatment Center to       disseminated throughout
                                                  ensure adequate           VAMCs
                                                  dissemination of
                                                  recovery based care in
                                                  the centers.
                                                ----------------------------------------------------------------
                                                 Identify recovery-        Ongoing. All RFPs have         1
                                                  oriented research         emphasized use of PSR
                                                  across the age span       evidence-base as source
                                                  that is ready to be       of program proposals
                                                  tested for
                                                  generalizability or
                                                  developed into best
                                                  practice models;
                                                  Develop demonstration
                                                  pilots to test
                                                  implementation
                                                  strategies prior to
                                                  national program
                                                  dissemination.
----------------------------------------------------------------------------------------------------------------


    Facilitate the work of the Steering Committee by tasking the 
MIRECCs to: A. Identify recovery-oriented research across the age span 
that is ready to be tested for generalizability or developed into best 
practice models. B. Develop demonstration pilots to test implementation 
strategies prior to national program dissemination.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
 5.1.51 A, B           Refer to 5.1.50
----------------------------------------------------------------------------------------------------------------


    Task the National Center for PTSD to develop a research agenda to 
close the gap in developing prevention and evidence based early 
interventions for acutely traumatized veterans. Research should have 
sufficient analytic power to identify racial and ethnic differences in 
response.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.1.52                 Develop a research        Present suggestions to    Ongoing activities of          1
                        agenda to close the gap   NCPTSD Scientific         NCPTSD, MIRECC, other
                        in developing             Advisory Board & ORD      VA COEs and DoD COE
                        prevention and evidence   and jointly develop a
                        based early               plan to conduct
                        interventions for         targeted research.
                        acutely traumatized
                        veterans.
----------------------------------------------------------------------------------------------------------------


    Emphasize and strengthen the VA mental health research portfolio 
focused on rehabilitation/recovery; A. Establish a Cooperative Study 
Program Center of Excellence in Mental Health. The Center(s) will issue 
Request for Proposals to conduct clinical trials and large-scale 
demonstration programs. B. Initiate an educational study to evaluate 
the impact of the Office of Academic Affiliations (OAA) 
Interdisciplinary Fellowship Program in Psychosocial Rehabilitation 
training program on shifting the emphasis of care from a traditional 
medical model to a recovery oriented model. C. Create a Mental Health 
Liaison position in ORD to develop the behavioral health research 
agenda and to assist with implementation.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.1.53 A, B, C         Promote research related  Convene a MHSHG/ORD       ORD successfully manages       2
Initiatives 1-6......   to rehabilitation and     workgroup to analyze      mental health--and
                        recovery.                 the ORD mental health     substance abuse--
                                                  research portfolio and    related projects within
                                                  develop solicitations     its current structures
                                                  for clinical trials and
                                                  large-scale
                                                  demonstration projects
                                                  in the area of
                                                  rehabilitation and
                                                  recovery.
                                                ----------------------------------------------------------------
                                                 Establish a Cooperative   To be reevaluated              4
                                                  Study Program Center of
                                                  Excellence in Mental
                                                  Health.
                                                ----------------------------------------------------------------
                                                 Create a Mental Health    Ongoing                        1
                                                  Liaison position in ORD
                                                  to monitor the mental
                                                  health portfolio across
                                                  research services, to
                                                  coordinate development
                                                  of solicitations for
                                                  new research, and to
                                                  coordinate mental
                                                  health research
                                                  initiatives across
                                                  services.
                                                ----------------------------------------------------------------
                                                 Develop position          To be reevaluated              4
                                                  description and hire a
                                                  high-level scientific
                                                  program manager to
                                                  facilitate strategic
                                                  planning for ORD mental
                                                  health research, to
                                                  monitor mental health
                                                  portfolios in
                                                  consultation with
                                                  research leadership and
                                                  investigators in the
                                                  field, and to serve as
                                                  a liaison to mental
                                                  health leadership and
                                                  the mental health
                                                  community.
                                                ----------------------------------------------------------------
                                                 Establish a steering      To be reevaluated              4
                                                  Committee of
                                                  researchers and chief
                                                  officers to advise on
                                                  research efforts in
                                                  this area.
                      ------------------------------------------------------------------------------------------
                       Evaluate the              Commission an evaluation  The PSR program has            3
                        interdisciplinary         of PSR fellowship         recently been expanded
                        fellowship program in     programs to determine     to 7 sites and a Hub
                        PSR to determine its      program impact on         site has been created
                        impact in disseminating   career trajectory, job    to ensure national
                        the rehabilitation/       duties (extent to which   training consistency
                        recovery model.           current position          and evaluation.
                                                  involves PSR),            Evaluation of its
                                                  attitudes toward PSR      impact is being planned
                                                  and recovery,
                                                  dissemination of PSR
                                                  and recovery principles
                                                  to other staff, and
                                                  perceived barriers and
                                                  facilitators to
                                                  implementing PSR and
                                                  recovery-oriented
                                                  programs.
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 5.2.  Advance evidence-based practices 
using dissemination and demonstration projects and create a public-
private partnership to guide their implementation.
    Develop a knowledge management system to disseminate almost real-
time, program specific education that will keep staff continuously 
apprised of new information on best practices and research.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.2.54                 Develop a knowledge       See also 3.1.36           Prioritization from            4
                        management system to                                senior leadership will
                        link research,                                      be needed to prioritize
                        guideline development                               development of a MH
                        and implementation,                                 real-time data analysis
                        clinical tools, sharing                             capability
                        of best practices, and
                        real-time data analysis
                        related to racial and
                        ethnic differences in
                        care needs and
                        interventions in order
                        to create continuous
                        expansion of the
                        evidence base and
                        increased knowledge
                        generated by a spirit
                        of inquiry.
----------------------------------------------------------------------------------------------------------------


    Implement an improved Clinical Practice Guideline (CPG) process to 
reduce the time between initiation of development and release of a CPG 
and ensure timely, periodic updates. Invite additional Federal partners 
to join the CPG effort.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.2.55 Initiatives 1-  Ensure regular and        Establish a working       Ongoing                        1
 4                      timely updates of         group to monitor the
                        mental health CPGs.       literature and provide
                                                  focused additions and
                                                  revisions for expedited
                                                  approval. Renew CPGs
                                                  every 3 years or sooner
                                                  as indicated by the
                                                  development of new
                                                  treatment
                                                  methodologies.
                                                ----------------------------------------------------------------
                                                 The National Clinical     Ongoing                        1
                                                  Practice Guidelines
                                                  Council will have a
                                                  member with expertise
                                                  in evidence-based
                                                  mental health care.
                      ------------------------------------------------------------------------------------------
                       Expedite the approval of  Once approved by MHSHG    First CPG in MH since          3
                        mental health CPGs,       and the National          approval of the MHSP,
                        including updates.        Clinical Practice         on Major Depressive
                                                  Guidelines Council,       Disorder, is being
                                                  final approvals must be   developed. This item
                                                  completed within 60       should be addressed
                                                  days.                     upon approval of this
                                                                            CPG when completed.
                                                ----------------------------------------------------------------
                                                 Ensure that draft         Ongoing                        1
                                                  recommendations from
                                                  the Medication Advisory
                                                  Panel (MAP) are
                                                  approved by the
                                                  National Clinical
                                                  Practice Guidelines
                                                  Council to be
                                                  consistent with CPGs.
----------------------------------------------------------------------------------------------------------------


    Implement QUERI-MH current priorities & major projects including: 
A. Measure care gaps in depression & schizophrenia B. Develop 
Nat.Clin.Reminders key care processes for depression, schizophrenia, 
SA, & co-occurring disorders. C. Develop/implement evidence-based 
guidelines & perf measures across age span. D. Implement evidence-based 
antipsychotic practices in schizophrenia, promoting use of appropriate 
antipsychotic doses & newer atypical antipsychotics, and monitor 
important side effects. E. Implement evidence-based depression 
collaborative care model in primary care with particular attention to 
elderly; evaluate impact on quality/outcomes/cost effectiveness. F. 
Convene group to review literature/track implementation of 
recommendations (Commission's Cultural Competence Sub., Surgeon 
General's Report on MH-Minority Supplement, & evaluate effectiveness of 
VA's cultural competence trng. program. G. Prioritize interventions 
that assess applicability of existing family psychoeducation models to 
vets/families, & studies of interventions including advance directives, 
behavioral family management, intensive case management or assertive 
community treatment, and work restoration programs.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.2.56 A--G            Promote implementation    Put treatment             Ongoing                        1
 Initiatives 1-11       of research on evidence   initiation, engagement
                        based practices.          and continuation
                                                  measures in official VA
                                                  performance system.
                                                  Implement benchmarked
                                                  performance measures.
                                                ----------------------------------------------------------------
                                                 Appoint a representative  Ongoing                        1
                                                  from the MHSHG to the
                                                  national CPG work
                                                  group.
                                                ----------------------------------------------------------------
                                                 Collaborate with Mental   Multiple centers are           2
                                                  Health QUERI to           contributing to the
                                                  continue development of   development of clinical
                                                  clinical tools and        tools
                                                  implementation
                                                  strategies to improve
                                                  medication management
                                                  for schizophrenia and
                                                  to implement a
                                                  collaborative care
                                                  approach.
                                                ----------------------------------------------------------------
                                                 Support Mental Health     Multiple centers are           2
                                                  QUERI, Substance Use      contributing to the
                                                  Disorders QUERI, and      development of clinical
                                                  MHSHG Informatics         tools
                                                  Section to develop and
                                                  implement clinical
                                                  practice tools.
                                                ----------------------------------------------------------------
                                                  Support Mental Health    Ongoing                        1
                                                  QUERI initiatives to
                                                  measure gaps in
                                                  depression and
                                                  schizophrenia care.
                                                ----------------------------------------------------------------
                                                 Support Mental Health     Ongoing                        1
                                                  QUERI and SMITREC in
                                                  creating and analyzing
                                                  national registries for
                                                  psychosis and
                                                  schizophrenia.
                                                  Collaborate with Mental
                                                  Health QUERI on
                                                  development, testing,
                                                  and implementation of
                                                  outcomes monitoring.
                                                ----------------------------------------------------------------
                                                 Solicit new research and  Ongoing                        1
                                                  promote Mental Health
                                                  QUERI implementation
                                                  research efforts in
                                                  management of
                                                  individuals with
                                                  depression or
                                                  schizophrenia who have
                                                  comorbid substance use
                                                  disorders or medical
                                                  disorders.
                                                ----------------------------------------------------------------
                                                 Prioritize the study and  Ongoing                        1
                                                  implementation of
                                                  psychosocial and
                                                  recovery-oriented
                                                  interventions,
                                                  including family
                                                  psychoeducation,
                                                  behavioral family
                                                  management, intensive
                                                  case management or
                                                  assertive community
                                                  treatment, work
                                                  restoration programs,
                                                  and peer support.
                                                ----------------------------------------------------------------
                                                 Collaborate with the      Ongoing. Integrated care       2
                                                  Office of Quality and     programs have been
                                                  Performance in            implemented in more
                                                  developing and            than 100 facilities
                                                  implementing evidence-
                                                  based guidelines and
                                                  performance measures
                                                  across the adult age
                                                  span; Implement an
                                                  evidence-based
                                                  collaborative care
                                                  model for depression in
                                                  primary care settings
                                                  with particular
                                                  attention to the
                                                  elderly, evaluating its
                                                  impacts on quality and
                                                  outcomes and measuring
                                                  its cost effectiveness.
                                                ----------------------------------------------------------------
                                                 Solicit new research and  Ongoing.                       1
                                                  promote Mental Health
                                                  QUERI implementation
                                                  research efforts in
                                                  psychosocial
                                                  rehabilitation and
                                                  recovery.
                                                ----------------------------------------------------------------
                                                 Implement the QUERI-      Evidence based practices       2
                                                  Mental Health current     from multiple sources
                                                  priorities and major      have been incorporated
                                                  projects in EBPs.         in MH enhancements
----------------------------------------------------------------------------------------------------------------


    Investigate strategies for sustaining treatment adherence and 
retention for individuals with major depressive disorder and 
schizophrenia; and strategies for increasing treatment engagement for 
patients who are not currently in treatment.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.2.57                 Promote treatment         Continue to solicit new   Ongoing. Involving             2
                        adherence and retention   research in this area     MIRECCs and other
                        for veterans with Major   through Mental Health     centers as well as
                        Depression and            QUERI solicitation.       QUERI
                        Schizophrenia.
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 5.3.  Improve and expand the workforce 
providing evidence-based mental health services and supports.
    Work with the Senate and House Veterans Affairs Committees to enact 
the physician salary reform legislation to maintain our ability to 
recruit and retain a high quality psychiatrist workforce.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.58                 VHA must have competent   A market survey of MD     MD pay has been                1
                        MDs, who are adequately   salaries to be            increased
                        reimbursed.               performed in all
                                                  markets, and the
                                                  physician pay bill
                                                  amended to reflect the
                                                  results of the survey.
----------------------------------------------------------------------------------------------------------------


    Implement legislation designating psychologists and social workers 
as Title 38 hybrid employees.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.59                 Done
----------------------------------------------------------------------------------------------------------------


    Collaborate and affiliate with Historically Black Colleges and 
Universities (HBCUs) and Hispanic Association of Colleges and 
Universities (HACUs) to help us in developing diversity in our 
workforce and cultural competence among the providers.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.60                 Expand diversity in the   Collaborate and           There are multiple             2
                        VHA workforce.            affiliate with            ongoing initiatives to
                                                  Historically Black        increase diversity in
                                                  Colleges and              the MH workforce
                                                  Universities (HBCUs)
                                                  and Hispanic
                                                  Association of Colleges
                                                  and Universities
                                                  (HACUs) to help us in
                                                  developing diversity in
                                                  our workforce and
                                                  cultural competence
                                                  among the providers.
                                                  The previously (3.1.34)
                                                  recommended Cultural
                                                  Competency Task Force
                                                  will be responsible for
                                                  accomplishing this
                                                  collaboration.
----------------------------------------------------------------------------------------------------------------


    Train veterans who have recovered from mental illness in peer 
support, to develop a cadre of peer counselors.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.61 Initiatives 1-  VHA will have veterans    1. MH QUERI to develop    Peer support programs          2
 5                      trained and competent     an RFP in 2005 for the    have been expanded.
                        as peer counselors.       assessment of the         Evaluations are being
                        Reference AA              effectiveness of peer     planned
                        Recommendations 2.3.16,   support. 2. MHSHG
                        2.3.18, 2.3.19 and        recommends the
                        2.3.20.                   development of peer
                                                  support programs
                                                  consistent with the
                                                  recovery model and
                                                  would become Centers of
                                                  Excellence to
                                                  disseminate best
                                                  practices.
                                                ----------------------------------------------------------------
                                                 Pilot Peer Specialists    Peer support programs          2
                                                  and Peer Bridgers         have been expanded. A
                                                  models in selected        strategy for further
                                                  VISNs; FY-07: Develop     expansion is included
                                                  VHA Peer Certification    in the Uniform MH
                                                  process and implement     Services Package
                                                  nationwide.
                                                ----------------------------------------------------------------
                                                 Identify additional       The need for additional        3
                                                  formal Peer-Specialist    resources to support
                                                  training programs         recruitment of
                                                  (colleges, foundations,   certified peer
                                                  etc.) for targeted        specialists will be
                                                  recruitment into paid     evaluated during the
                                                  Peer-Provider/            implementation of the
                                                  Specialist positions      Uniform MH Services
                                                  and for additional peer   Package
                                                  specialist training
                                                  venues FY 07.
                                                ----------------------------------------------------------------
                                                 Work with SAMHSA's        To be reevaluated              4
                                                  Center for Mental
                                                  Health Services and
                                                  National Association of
                                                  State Mental Health
                                                  Directors to develop
                                                  strategy for
                                                  collaborative
                                                  initiatives to improve
                                                  veteran access to
                                                  premier community-
                                                  based, consumer-run
                                                  services.
                                                ----------------------------------------------------------------
                                                 Issue national            Included in the Uniform        2
                                                  Information Letter        MH Services Package
                                                  promoting and providing
                                                  broad guidance on the
                                                  recruitment of peer
                                                  professionals/para-
                                                  professionals, and the
                                                  development of paid
                                                  Peer-led support
                                                  services (directly or
                                                  through contract with
                                                  community providers) as
                                                  an adjunct to
                                                  traditional mental
                                                  health services at all
                                                  facilities serving
                                                  veterans with serious
                                                  mental illness.
----------------------------------------------------------------------------------------------------------------


    Enhance clinical pastoral programs to connect to faith-based 
initiatives, and to add a spiritual dimension to the biopsychosocial 
framework, and thus reach the majority of veterans who are religiously 
committed.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.62 Initiatives 1-  Spiritual assessment      Establish MHSHG liaison   Requires additional            4
 2                      will be a routine part    to the National           guidance
                        of mental health          Chaplain Center to
                        evaluation, and           provide input into the
                        treatment provided        Clinical Pastoral
                        according to the          Education Program and
                        veteran's preference.     other training
                                                  programs. Include
                                                  education about initial
                                                  presentation and
                                                  referral to enhance
                                                  mental health outreach
                                                  to veterans. MHSHG
                                                  Liaison will also
                                                  participate in
                                                  activities of the
                                                  National Chaplain
                                                  Center Faith Based
                                                  Initiative.
                                                ----------------------------------------------------------------
                                                 Link the registry of      Requires additional            4
                                                  mental health best        guidance
                                                  practices to the Best
                                                  Practices in Chaplaincy
                                                  program.
----------------------------------------------------------------------------------------------------------------


    Extend Mental Health Liaison/Consultation to primary and specialty 
care to support and educate that workforce.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.63 Initiatives 1-  Implement collaborative   Implement collaborative   Ongoing                        1
 2                      care models for MH        care models for
                        care.                     depression care, etc.
                                                  to promote the mental
                                                  health liaison role and
                                                  provide multi-modal
                                                  education on mental
                                                  health for non-mental
                                                  health clinicians and
                                                  staff.
                                                ----------------------------------------------------------------
                                                 Develop a mechanism to    Productivity workgroup         3
                                                  account for liaison and   has been empanelled
                                                  teaching time of mental
                                                  health providers.
----------------------------------------------------------------------------------------------------------------


    The MHSHG should enhance the Mental Health Leaders' training and 
support the annual meetings of the VISN Mental Health Liaisons.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.64 Initiatives 1-   Ensure highly competent  Reestablish and enhance   Ongoing                        1
 8                      Mental Health             the Behavioral Health
                        Leadership.               Leadership Training
                                                  program.
                      ------------------------------------------------------------------------------------------
                       Ensure effective          Develop options for       Requires additional            4
                        organizational            effective mental health   guidance
                        leadership in             leadership that will
                        addressing the            further the goals of
                        treatment of mental       the PNFC on mental
                        disorders.                health incorporate this
                                                  process into the
                                                  ongoing patient care
                                                  services review and add
                                                  a mental health task
                                                  force member to that
                                                  committee for
                                                  continuity. The Mental
                                                  Health Chief Consultant
                                                  will become a member of
                                                  the NLB and Executive
                                                  Committee by July/
                                                  August 2004.
                                                ----------------------------------------------------------------
                                                 Require that a mental     Ongoing                        1
                                                  health leader,
                                                  representing care of
                                                  veterans with mental
                                                  disorders, be a member
                                                  of the highest level
                                                  decisionmaking body in
                                                  every VISN.
                                                ----------------------------------------------------------------
                                                 Extend the mission of     Completed.                     1
                                                  the Secretary's Task
                                                  Force for three years;
                                                  request this task force
                                                  submit a progress
                                                  report to the Secretary
                                                  by 9/30/04.
                                                ----------------------------------------------------------------
                                                 The PCS will provide      Completed. Such reports        1
                                                  quarterly reports to      were sent during the
                                                  the task force on         time the Task Force was
                                                  implementation of the     meeting.
                                                  recommendations.
                                                  Resource needs and
                                                  budget implications
                                                  will be addressed in
                                                  these reports. This
                                                  information will be
                                                  utilized in the
                                                  preparation of the ELDA
                                                  and FY 2006 budget.
                      ------------------------------------------------------------------------------------------
                       Promote, expand, and      Expand the size of the    Meeting structure was          2
                        support the annual        meeting to allow          revised to be more
                        ``Best Practices in       attendance of all VISN    inclusive
                        Network Mental            mental health leaders
                        Healthcare Systems''      and at least one
                        conference.               representative from
                                                  each facility.
                                                ----------------------------------------------------------------
                                                 Each VISN must support    Meeting structure was          2
                                                  the annual attendance     revised to be more
                                                  of at least one VISN      inclusive
                                                  mental health leader or
                                                  representative. VISN
                                                  Directors, CMOs and
                                                  QMOs will be invited.
                                                ----------------------------------------------------------------
                                                  Link ECF program and     Ongoing                        1
                                                  HPDM for preparation of
                                                  future MH leaders.
----------------------------------------------------------------------------------------------------------------


    EES should develop a CME/CEU training program: ``Mental Health for 
Primary Care Providers;'' in coordination with the Mental Health, 
Geriatrics and Extended Care, and Acute Care Strategic Health Care 
Groups. These groups could be convened as Coordination Council to 
oversee development in this area.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.65 Initiatives 1-  Develop CME/CEU training  Form a Coordination       The Integrated Care            2
 2                      program on mental         Council involving EES,    program is ongoing
                        health care in the        MHSHG, Acute Care SHG,
                        primary care setting.     Geriatrics and Extended
                                                  Care SHG, and Mental
                                                  Health QUERI to oversee
                                                  education program and
                                                  plan implementation of
                                                  collaborative care for
                                                  depression.
                                                ----------------------------------------------------------------
                                                 MHSHG and EES will        The Integrated Care            1
                                                  develop training          program is ongoing
                                                  programs for mental
                                                  health managers,
                                                  providers, and staff.
                                                  Programs will emphasize
                                                  evidence base for
                                                  collaborative care and
                                                  recovery programs.
----------------------------------------------------------------------------------------------------------------


    Expand Office of Academic Affairs and the Mental Health Strategic 
Healthcare Group's programs for training of interdisciplinary teams and 
collaborative care. The recovery orientation in these programs should 
be enhanced and expanded.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.66                 Build on the model        Work with OAA to expand   PSR fellowship has been        1
                        Psychosocial              the PSR Fellowship        expanded to 7 sites.
                        Rehabilitation Special    Program to provide        Other forms of training
                        (PSR) Fellowship          training in life span     and career development
                        program, expanding it     issues in recovery. The   are being evaluated
                        to training at more       program will fund
                        than the fellowship       stipends for a wide
                        level.                    variety of mental and
                                                  physical health
                                                  disciplines, provide
                                                  training in sites with
                                                  interprofessional
                                                  recovery-oriented care,
                                                  and include a didactic
                                                  component on the
                                                  recovery model and
                                                  interprofessional
                                                  collaboration in
                                                  implementing the model.
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 5.4.  Develop the knowledge base in four 
understudied areas: mental health disparities, long-term effects of 
medications, trauma and acute care.
    Enhance research programs and EBP related to treatment of minority 
veteran populations and cultural competence.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.4.67                 Increase research that     Solicit research on      ORD is implementing a          3
                        expands the evidence      variation in treatment    major program in
                        base related to ethnic    response among ethnic     personalized medicine
                        variability in disease    groups to inform
                        manifestations and        evidence-based
                        treatment response; to    guidelines; solicit
                        inequities in access;     research on disparities
                        and to disparities in     in access and
                        evaluation and            availability of
                        treatment. Conduct        services, treatment
                        research on gaps in       practices, and
                        cultural competency and   outcomes. Solicit
                        strategies to close       research on cultural
                        gaps.                     competency, including
                                                  descriptive studies and
                                                  intervention research.
----------------------------------------------------------------------------------------------------------------

    Enhance trauma research related to combat trauma, terrorism, and 
prevention of chronic PTSD after exposure to traumatic events. 
Screening, prevention, neurobiology, treatment and recovery should be 
priorities.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.4.68 Initiatives 1-  Enhance trauma research.  Engage NCPTSD, MIRECCs,   Ongoing                        1
 2                                                ORD, DoD/ USUHS in
                                                  these projects. Include
                                                  minority &
                                                  collaborative care
                                                  issues.
                                                ----------------------------------------------------------------
                                                 Establish a joint DoD/VA  Ongoing                        1
                                                  ``Center of
                                                  Excellence'' focused on
                                                  traumatic brain injury
                                                  and other life altering
                                                  injuries; Develop
                                                  longitudinal tracking
                                                  system for veterans
                                                  from OIF and OEF.
                                                  Trauma research agenda
                                                  to also include trauma
                                                  related to MST.
----------------------------------------------------------------------------------------------------------------


    Assess the effects of long-term medications: A. Task a Work Group 
consisting of the Pharmacy Benefits Management (PBM), Mental Health 
QUERI, Clozapine Center, and Serious Mental Illness Treatment Research 
and Evaluation Center (SMITREC) to perform a literature review, analyze 
the Clozapine and Psychosis Registries, and report their findings and 
recommended actions to the Office of Patient Care Services.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.4.69                 Develop algorithm for      MHSHG will take          A work group has               3
                        use of atypical           responsibility for        recently been formed
                        antipsychotics.           organizing a work group
                                                  that will utilize the
                                                  National Consensus
                                                  Guidelines to develop
                                                  an algorithm for: use
                                                  of atypical
                                                  antipsychotics with
                                                  consideration of
                                                  medical complications
                                                  and cost, including
                                                  recommendations for
                                                  changing therapy when
                                                  medical complications
                                                  develop; develop
                                                  monitors for medical
                                                  complications related
                                                  to the use of the
                                                  atypical
                                                  antipsychotics; and
                                                  education of primary
                                                  care and mental health
                                                  providers on the
                                                  complications of
                                                  atypical
                                                  antipsychotics.
----------------------------------------------------------------------------------------------------------------


    Assess the VHA's provision of Acute Mental Health Care: A. Develop 
and test a valid VA demand model for acute inpatient and outpatient 
mental health care. B. Develop a national electronic database to track 
veterans who request admission or transfer to a VA acute inpatient 
mental health facility but are denied admission because of 
unavailability of a hospital bed or inadequate staffing.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
5.4.70 A, B            See recommendation 1.2.8
----------------------------------------------------------------------------------------------------------------


    President's New Freedom Commission Goal 6. Technology is used to 
access mental health care and information.
    Commission Recommendation 6.1.  Use health technology and 
telehealth to improve access and coordination of mental health care, 
especially for Americans in remote areas or in underserved populations.
    Expand the charge to the VHA Telemental Health Field Work Group to 
coordinate the implementation of the 6.1 action agenda items, in 
conjunction with VISN leadership, VISN mental health clinicians, and 
VISN telemental health coordinators.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.71 Initiatives 1-  Expand the charge to the  The Telemental Health     Ongoing.                       1
 2                      VHA Telemental Health     Field Work Group to
                        Field Work Group.         continue to meet
                                                  virtually or in person
                                                  to coordinate the
                                                  implementation of 6.1
                                                  action agenda items, in
                                                  conjunction with VISN
                                                  leadership, VISN mental
                                                  health clinicians, and
                                                  VISN telemental health
                                                  coordinators.
                                                ----------------------------------------------------------------
                                                 Expand telemental health  Homeless programs              2
                                                  to target homeless        continue to be expanded
                                                  veterans.                 through other
                                                                            mechanisms
----------------------------------------------------------------------------------------------------------------


    Commission the VHA Telemental Health Work Group to perform a needs 
assessment for telemental health services. The needs assessment should 
focus on identification of underserved veteran populations, access to 
mental health services in CBOCs and Vet Centers, and provision of 
specialty mental health and substance abuse consultations in rural and 
remote areas.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.72 Initiatives 1-  Improve access through    Together, the Office of   Ongoing                        1
 5                      use of technology.        Care Coordination, the
                                                  Mental Health Strategic
                                                  Healthcare Group, VISN
                                                  Leadership, and each
                                                  VHA Telemental Health
                                                  Field Work Group VISN
                                                  representative will
                                                  assure that the need
                                                  for telemental health
                                                  services are clearly
                                                  determined, in
                                                  conjunction with other
                                                  mental health needs
                                                  assessments already
                                                  being undertaken by
                                                  VISN mental health
                                                  clinicians, VISN CBOC
                                                  administrators, and
                                                  VISN telemedicine
                                                  coordinators.
                                                ----------------------------------------------------------------
                                                 Improve transition        Ongoing                        1
                                                  planning, referral/
                                                  placement and
                                                  information exchange
                                                  for patients with
                                                  mental illness coming
                                                  into VHA health care
                                                  system.
                                                ----------------------------------------------------------------
                                                 1. Ensure that all        Ongoing                        1
                                                  mental health programs
                                                  within VHA, including
                                                  RCS, have standardized
                                                  systems of electronic
                                                  technology to access
                                                  information while
                                                  maintaining
                                                  confidentiality and
                                                  informed consent; 2.
                                                  Explore ``at home''
                                                  mental health care
                                                  coordination for
                                                  recently discharged
                                                  veterans, especially
                                                  those in rural areas or
                                                  in areas where
                                                  specialty care is
                                                  limited.
                                                ----------------------------------------------------------------
                                                 Improve the electronic    Ongoing                        1
                                                  exchange of information
                                                  from DoD to VA on
                                                  patients awaiting MEBs
                                                  and PEBs.
                                                ----------------------------------------------------------------
                                                 Include questions on      Current planning               3
                                                  screening tools for
                                                  older veterans to
                                                  determine difficulties
                                                  with transportation or
                                                  other resources that
                                                  restrict ability to
                                                  attend outpatient
                                                  appointments; and to
                                                  identify needs of
                                                  caregivers for older
                                                  veterans who are home
                                                  bound due to medical
                                                  problems and/or who
                                                  have a dementing
                                                  illness.
----------------------------------------------------------------------------------------------------------------


    Based on the results of the needs assessment, each VISN should be 
tasked with the development of a telemental health implementation plan 
designed to improve access to mental health care within the VISN. A. 
Each VISN Telemental Health Plan should identify adequate equipment and 
staffing resources to assure that it can be successfully implemented. 
B. Implementation of VISN Telemental Health Plans should be assessed 
through such strategies as VHA performance measures/monitors and 
official reports to VACO leadership on a regular basis. C. Formalize 
the registration of telemental health programs throughout VHA.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.73 A, B, C         Expand mental health      Each VISN will: submit a  Ongoing                        1
Initiatives 1-5......   telehealth care to all    Telemental Health plan
                        facilities, CBOCs, and    to Office of Care
                        Vet Centers.              Coordination (OCC) by 6/
                                                  30/05; Outcomes
                                                  approved on National
                                                  Performance Measures
                                                  will be developed to
                                                  assure implementation
                                                  is successful; All
                                                  Telemental Programs
                                                  will be approved by
                                                  OCC.
                                                ----------------------------------------------------------------
                                                 Action Agenda Steering    Completed                      1
                                                  Committee to appoint a
                                                  group to review the
                                                  data on pilot
                                                  telemental health use
                                                  and make
                                                  recommendations on an
                                                  outcomes monitoring
                                                  system and feedback
                                                  mechanism.
                                                ----------------------------------------------------------------
                                                 Together with the Office  Ongoing                        1
                                                  of Care Coordination,
                                                  the Mental Health
                                                  Strategic Healthcare
                                                  Group and VISN
                                                  Leadership, each VHA
                                                  Telemental Health Field
                                                  Work Group VISN
                                                  representative will
                                                  assure that their VISN
                                                  Telemental Health Plans
                                                  are viable, and that
                                                  they identify adequate
                                                  equipment and staffing
                                                  resources to assure
                                                  that it can be
                                                  successfully
                                                  implemented.
                                                ----------------------------------------------------------------
                                                 Together with the Office  Mechanisms for                 3
                                                  of Care Coordination,     accountability are
                                                  the Mental Health         being developed
                                                  Strategic Healthcare
                                                  Group and VISN
                                                  Leadership the VHA
                                                  Telemental Health Field
                                                  Work Group will work to
                                                  assure that
                                                  implementation of the
                                                  VISN Telemental Health
                                                  Plans be assessed
                                                  through accountability
                                                  strategies such as
                                                  official reports to
                                                  VACO on a regular
                                                  basis, and the
                                                  establishment of
                                                  applicable VHA
                                                  performance measures/
                                                  monitors.
                                                ----------------------------------------------------------------
                                                 Together with the Office  Ongoing                        1
                                                  of Care Coordination,
                                                  the Mental Health
                                                  Strategic health care
                                                  Group and VISN
                                                  Leadership, the VHA
                                                  Telemental Health Field
                                                  Work Group will extend
                                                  its annual telemental
                                                  health service
                                                  inventory by
                                                  formalizing the
                                                  registration of
                                                  telemental health
                                                  programs throughout
                                                  VHA.
----------------------------------------------------------------------------------------------------------------


    Expand use of existing telemental health and telehome care 
technologies as well as develop new technologies, including : A. 
Identify mental health care coordination opportunities using in-home 
messaging devices, etc. B. Expand on the existing telemental health 
collaborations with VHA and the Readjustment Counseling Services. C. 
Identify existing sharing programs and evaluate telemental health 
opportunities with the DHHS, IHS, DoD. D. Develop and implement family 
psychoeducational video programs and telehome care family therapy 
programs. E. Increase telemental health consultation between mental 
health specialists at the medical centers and CBOC staff. F. Utilize 
telemental health technologies that make telemental health and telehome 
care accessible to the visually and hearing impaired.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.74 A-F             Combine with 6.1.73       A. Together with the      Home telemental health         1
 Initiatives 1-6                                  Office of Care            is currently being
                                                  Coordination (OCC), the   developed
                                                  Mental Health Strategic
                                                  Healthcare Group
                                                  (MHSHG) and VISN
                                                  Leadership, the VHA
                                                  Telemental Health Field
                                                  Work Group will
                                                  identify mental health
                                                  care coordination
                                                  opportunities using in-
                                                  home messaging devices,
                                                  mental illness
                                                  management dialogues,
                                                  interactive voice
                                                  response programs, and
                                                  other new technologies
                                                  to bring mental health
                                                  services to the
                                                  patients' homes, to
                                                  half-way houses, to
                                                  homeless shelters, and
                                                  the state veterans
                                                  homes.
                                                ----------------------------------------------------------------
                                                 Together with the Office  To be reevaluated              4
                                                  of CC, the MHSHG and
                                                  VISN Leadership, the
                                                  VHA Telemental Health
                                                  Field Work Group will
                                                  expand on the existing
                                                  telemental health
                                                  collaborations with VHA
                                                  and the Readjustment
                                                  Counseling Services.
                                                ----------------------------------------------------------------
                                                 Together with the Office  Included in the                3
                                                  of CC, the MHSHG and      activities of DoD COE
                                                  VISN Leadership, the
                                                  VHA Telemental Health
                                                  Field Work Group will
                                                  identify existing
                                                  sharing programs and
                                                  evaluate telemental
                                                  health opportunities
                                                  with the DHHS, IHS,
                                                  DoD.
                                                ----------------------------------------------------------------
                                                 Together with the Office  Requires additional            4
                                                  of CC, the MHSHG and      guidance
                                                  VISN Leadership, the
                                                  VHA Telemental Health
                                                  Field Work Group will
                                                  develop and implement
                                                  family
                                                  psychoeducational video
                                                  programs and telehome
                                                  care family therapy
                                                  programs.
                                                ----------------------------------------------------------------
                                                 Together with the Office  Ongoing.                       1
                                                  of CC, the MHSHG and
                                                  VISN Leadership, the
                                                  VHA Telemental Health
                                                  Field Work Group will
                                                  increase telemental
                                                  health consultation
                                                  between mental health
                                                  specialists at the
                                                  medical centers and
                                                  CBOC staff.
                                                ----------------------------------------------------------------
                                                 Together with the Office  Ongoing. Attention             1
                                                  of CC, the MHSHG and      continuously paid to
                                                  VISN Leadership and       ADA requirements.
                                                  Office of Geriatrics
                                                  and Extended Care, the
                                                  VHA Telemental Health
                                                  Field Work Group will
                                                  utilize telemental
                                                  health technologies
                                                  that make telemental
                                                  health and telehome
                                                  care compliant with
                                                  ADA.
----------------------------------------------------------------------------------------------------------------


    Charge Northeast Program Evaluation Center (NEPEC), the MIRECCs, 
SMITREC and Health Services Research and Development (HSR&D) with 
providing outcomes monitoring and feedback regarding national, VISN, 
and individual facility telemental health and care coordination 
programs.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.75 Initiatives 1-  Develop outcomes          Together, the Office of   In planning                    3
 2                      monitoring and feedback   CC, the MHSHG and VISN
                        system.                   Leadership and the VHA
                                                  Telemental Health Field
                                                  Work Group to establish
                                                  a plan to monitor
                                                  outcomes of telemental
                                                  health activities,
                                                  utilizing existing
                                                  mental health and VHA
                                                  venues.
                                                ----------------------------------------------------------------
                                                 Charge workgroup with     In planning                    3
                                                  exploring outcome
                                                  measures specifically
                                                  related to older
                                                  adults' access and
                                                  utilization.
----------------------------------------------------------------------------------------------------------------


    Establish a full-time position for a VHA Telemental Health 
Coordinator. Provide adequate administrative staff and resources for 
necessary meetings and collaborations.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.76                 Provide full time          The Office of CC and     Ongoing                        1
                        coordination of           the MHSHG to facilitate
                        telemental health care.   adequate leadership and
                                                  administrative staff
                                                  resources necessary to
                                                  successfully implement
                                                  these action items.
----------------------------------------------------------------------------------------------------------------


    Work with the HHS in the review recommended by the Commission of 
how best to deliver and finance telehealth services.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.77 Initiatives 1-  Optimize telehealth        Work with HHS in the     Requires additional            4
 2                      mental health delivery    review recommended by     guidance
                        both in VA and the        the Commission of how
                        private sector.           best to deliver and
                                                  finance telehealth
                                                  services.
                                                ----------------------------------------------------------------
                                                 Explore financial and     Ongoing.                       1
                                                  other incentives to
                                                  increase the use of
                                                  telemental health.
----------------------------------------------------------------------------------------------------------------

    Develop and implement adequate means to accurately capture and 
reflect workload generated by telemental health and telehome care (stop 
codes, encounter forms, etc.).


----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.78                 Capture workload          Develop and implement     Ongoing                        1
                        generated by telemental   adequate means to
                        health services.          accurately capture and
                                                  reflect workload
                                                  generated by telemental
                                                  health providers.
                                                  Charge Office of Care
                                                  Coordination with
                                                  developing a system of
                                                  secondary stop codes
                                                  and guidelines for
                                                  using correctly to
                                                  capture data
                                                  accurately. Ensure
                                                  mental health review of
                                                  plans to finalize and
                                                  implement telemental
                                                  health stop codes.
----------------------------------------------------------------------------------------------------------------


    Commission Recommendation 6.2.  Develop and implement integrated 
electronic health record and personal health information systems.
    Establish a Mental Health IT Work Group to enhance VHA's electronic 
health record (VistA/CPRS and MHP/MHA) and personal health information 
systems (MyHealtheVet). This group should be charged with the 
responsibility of developing in more detail the other recommendations 
included under Action Agenda items 6.2.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.2.79 Initiatives 1-  Establish a MH IT Work    Charge this group with    Requires additional            4
 2                      Group to work with IDMC   developing in more        guidance
                        and MHSHG.                detail the other
                                                  recommendations
                                                  included under Action
                                                  Agenda items 6.2.
                                                ----------------------------------------------------------------
                                                  Develop electronic       Ongoing                        1
                                                  method to monitor
                                                  community employment in
                                                  the CWT supported
                                                  employment program.
                                                  Include NEPEC
                                                  monitoring of Supported
                                                  Employment.
----------------------------------------------------------------------------------------------------------------

    VISTA/CPRS should be modified to provide optimal functionality for 
the care of veterans with serious mental illness.


----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.2.80 Initiatives 1-  Ensure that all mental    Improve Transition        Ongoing                        1
 2                      health programs within    planning, referral/
                        VHA, including RCS,       placement and
                        have standardized         information exchange
                        systems of electronic     for patients with
                        technology to access      mental illness coming
                        information while         into VHA health care
                        maintaining               system.
                        confidentiality and
                        informed consent.
                                                ----------------------------------------------------------------
                                                 Modify CPRS to include    Requires additional            4
                                                  the identification of a   guidance
                                                  Primary Mental Health
                                                  Provider as well as
                                                  Primary Care Provider.
----------------------------------------------------------------------------------------------------------------


    Develop a mental health treatment planning tool. VHA should 
consider build/buy options including the Commercial Off the Shelf 
(COTS) product currently being used at several facilities. The 
treatment planner should facilitate the participation of the patient 
and his/her family in the treatment planning process. The Mental Health 
IT Work Group should submit a formal request to the Informatics & Data 
Management Committee (IDMC) for the development of a treatment planner.

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.2.81                 Develop a MH treatment    Mental Health IT Work     To be reevaluated              4
                        planning tool.            Group will review
                                                  treatment planner
                                                  options including
                                                  review of the planner
                                                  developed in VISN 3.
                                                  The treatment planner
                                                  will facilitate the
                                                  participation of the
                                                  patient and his/her
                                                  family in the treatment
                                                  planning process. The
                                                  Mental Health IT Work
                                                  Group to submit a
                                                  formal request to the
                                                  Informatics & Data
                                                  Management Committee
                                                  (IDMC) for the
                                                  development of a
                                                  treatment planner.
----------------------------------------------------------------------------------------------------------------


    Develop MyHealtheVet to better serve the needs of veterans with 
mental illnesses. A. Provide adequate resources to the Office of 
Information to ensure continuity and availability of the MyHealtheVet 
platform. B. Conduct a pilot test or a functional test of the use of 
mental health patient's use of to assess possible implementation issues 
unique to this patient population. C. Fund development of a mental 
health portal as an addition to MyHealtheVet to better serve the needs 
of veterans with mental illness and their families. D. Develop criteria 
that veterans and their families could use to evaluate non-VHA mental 
health information sites (see http://helping.apa.org/dotcomsense/ for 
an example developed by the American Psychological Association).

----------------------------------------------------------------------------------------------------------------
                             Mental Health
       AA Rec.#               Strategies                Initiatives
----------------------------------------------------------------------------------------------------------------
6.2.82 A, B, C, D      Develop a MH component    The MH IT Work Group      Some initial MH                3
                        within MyHealtheVet.      will implement this       components for
                                                  Action Agenda             MyHealtheVet have been
                                                  recommendation.           developed and are
                                                                            online. Additional MH
                                                                            components for
                                                                            MyHealtheVet are under
                                                                            development
----------------------------------------------------------------------------------------------------------------


    A Comprehensive VHA Strategic Plan of Mental Health Services July 
2004

                                 


 Crosswalking between the U.S. National Strategy for Suicide Prevention,
  the VHA Comprehensive Mental Health Strategic Plan, and VHA's Suicide
                           Prevention Actions
------------------------------------------------------------------------
                                                         VHA Suicide
  U.S. National Strategy for   VHA Comprehensive MH   Prevention Actions
      Suicide Prevention           Strategic Plan         and Plans
------------------------------------------------------------------------
                               Endorse the National
                                Strategy for
                                Suicide Prevention
                                (2001) and the
                                Institute of
                                Medicine's report,
                                ``Reducing Suicide:
                                A National
                                Imperative''
                                (2003). Implement
                                their
                                recommendations..
------------------------------------------------------------------------
Promote awareness that
 suicide is a public health
 problem that is preventable
------------------------------
Develop broad-based support
 for suicide prevention
------------------------------
Develop and implement
 strategies to reduce the
 stigma associated with being
 a consumer of mental health,
 substance abuse and suicide
 prevention services
                               Identify Mental
                                Health an Employee
                                Education Services
                                (EES) focus area in
                                2005. All health
                                care workers should
                                understand that
                                mental health is
                                essential to
                                overall health;
                                reduce stigma by
                                their interactions
                                with veterans and
                                their families; and
                                understand the
                                major suicide risk
                                factors and the
                                principles of
                                suicide prevention
                                                     Education and
------------------------------------------------------------------------
Develop and implement suicide
 prevention programs
------------------------------
Increase access to and
 community linkages with
 mental health and substance
 abuse services
----------------------------------------------------
Develop and promote effective
 clinical and professional
 practices
                               Develop a Suicide     VHA has created a
                                Prevention Program    national system
                                for VA patients,      that includes: 1)
                                families, staff and   Overall
                                the community.        enhancement of
                                                      mental health
                                                      services; a)
                                                      Enhanced access to
                                                      care; b)
                                                      Integration of
                                                      mental health and
                                                      primary care; c)
                                                      transformation of
                                                      the specialty
                                                      mental health care
                                                      system to focus on
                                                      rehabilitation and
                                                      recovery; d) Broad-
                                                      based training in
                                                      evidence-based
                                                      Psychotherapy and
                                                      pharmacotherapy;
                                                      e) Outreach and
                                                      clinical programs
                                                      to support the
                                                      engagement of OEF/
                                                      OIF veterans; 2)
                                                      Programs
                                                      specifically
                                                      addressing suicide
                                                      prevention; a)
                                                      Suicide Prevention
                                                      Hotline; b)
                                                      Suicide Prevention
                                                      Coordinators in
                                                      each Medical
                                                      Center; c)
                                                      Programs to
                                                      identify high-risk
                                                      patients and
                                                      enhance their
                                                      care; d) Training
                                                      for all staff; e)
                                                      Community
                                                      outreach; and 3)
                                                      Inclusion of
                                                      suicide prevention
                                                      activities in the
                                                      uniform mental
                                                      health services
                                                      package that is
                                                      under development;
------------------------------------------------------------------------
                               Promote evidence
                                based strategies
                                for suicide
                                assessment and
                                prevention,
                                including emphasis
                                on special emphasis
                                groups. MHSHG will
                                work with HSR&D,
                                NEPEC, and SMITREC
                                to develop and test
                                an electronic
                                suicide prevention
                                database. Develop a
                                national systematic
                                program for suicide
                                prevention. MHSHG
                                develops a plan to
                                educate all staff
                                that interact with
                                veterans, including
                                clerks and
                                telephone
                                operators, about
                                responding to
                                crisis situations
                                involving at-risk
                                veterans. This
                                would include
                                suicide protocols
                                for intake,
                                telephone
                                operators, and
                                other first contact
                                personnel

Improve and expand             Develop electronic    SMITREC initiative
 surveillance systems           suicide prevention    based on
                                database using        information from
                                institutional         the National Death
                                surveillance          Index; Evolving
                                mechanisms that       interactions with
                                support population-   the CDC's National
                                based screening.      Violent Death
                                                      Reporting System;
                                                      Validation and
                                                      utilization of
                                                      attempt reporting
                                                      by the Suicide
                                                      Prevention
                                                      Coordinators;
                                                      Exploration of
                                                      interactions with
                                                      state or county
                                                      medical examiners
------------------------------------------------------------------------
                               Develop methods for   A Category 2 flag,
                                tracking veterans     to be managed by
                                with risk factors     the Suicide
                                for suicide and       Prevention
                                systems for           Coordinators is
                                appropriate           under development.
                                referral of such      It would serve to
                                patients to           facilitate
                                specialty mental      tracking and
                                health care.          follow-up.
------------------------------------------------------------------------
                               Medical Centers       Deferred by VHA
                                establish contacts    senior leadership
                                through the
                                Chaplain Service
                                with faith-based
                                organizations and
                                community resources
                                to assist with
                                culturally
                                competent suicide
                                prevention and
                                other mental health
                                issues at local and
                                national levels.
------------------------------------------------------------------------
Promote and support research   Fund research to      ORD has been
 on suicide and suicide         develop a valid       meeting with
 prevention                     screen for suicide    Federal partners
                                risk and              to develop a
                                prevention.           research agenda;
                                                      research at the
                                                      VISN 19 MIRECC and
                                                      the Canandaigua
                                                      COE is
                                                      accelerating;
                                                      nevertheless,
                                                      developing a valid
                                                      screen for suicide
                                                      risk and
                                                      prevention may
                                                      prove elusive-
                                                      instead, VA is
                                                      pursuing a two
                                                      stage process,
                                                      screening for MH
                                                      conditions and
                                                      providing clinical
                                                      evaluations for
                                                      those identified
                                                      as having these
                                                      conditions.
------------------------------------------------------------------------
Implement training for         EES in conjunction    Ongoing training
 recognition of at-risk         with MHSHG develop    including Suicide
 behavior and delivery of       mandatory education   Prevention
 effective treatment            programs for V A      Awareness Day,
                                health care           Operation Save,
                                providers about       Facility-based
                                suicide risks and     activities
                                ways to address       organized by the
                                these risks.          suicide prevention
                                Incorporate best      coordinators; and
                                practices for         other EES
                                suicide prevention.   activities
------------------------------------------------------------------------
                               Recommend support     Implementation of
                                for new MIRECC with   the VISN 19 MIRECC
                                focus on suicide      and Canandaigua
                                prevention, in        Center of
                                collaboration in      Excellence as
                                other MIRECCs         centers for
                                working in this       research,
                                area.                 demonstrations,
                                                      training, and
                                                      technical,
                                                      assistance for the
                                                      system as a whole
------------------------------------------------------------------------
Promote efforts to reduce                            Individualized
 access to lethal means and                           interventions
 methods of self-harm                                 between providers
                                                      and/or suicide
                                                      prevention
                                                      coordinators with
                                                      high-risk patients
                                                      and/or their
                                                      families; VA
                                                      policy for gun
                                                      safety programs is
                                                      under
                                                      consideration
------------------------------------------------------------------------
Improve reporting and                                Addressed through
 portrayals of suicidal                               ongoing
 behavior, mental illness,                            collaborations in
 and substance abuse in the                           the Federal
 entertainment and news media.                        partnership on
                                                      suicide
                                                      preventions
------------------------------------------------------------------------


                                 

Information Provided by VA From Discussion with Secretary Peake during 
                          Post-Hearing Meeting
  In response to Dr. Rudd testimony of increased risk of suicide for 
                           wounded warriors.

Discharge Plan, both mental health and wounded warriors (increased risk 
        of suicide) need one. What do we do to ensure followup after 
        discharge of both mental health patients as well as wounded 
        warriors?
    Response: The Federal Recovery Coordinators (FRC) actively started 
working with discharge for patients January 28, 2008. FRCs develop 
Federal Individualized Recovery Plans (FIRPs) for servicemembers or 
veterans who have catastrophic wounds, illness and injuries, including 
mental health issues, which will require longitudinal care, 
coordination and oversight. Using the Federal Individual Recovery Plan, 
based on the input of clinical and non-clinical case managers as well 
as the patient and the family, the Federal Recovery Coordinator (FRC) 
will ensure that the servicemember, veteran and family have access to 
and delivery of support programs and resources for family members and 
caregivers.
    Phase One of the FRC Program, scheduled to be completed in May 
2008, targeted those catastrophically wounded, ill or injured arriving 
from theatre to the military treatment facility (MTF). Phase Two, which 
will begin immediately after Phase One, is complete, will expand the 
program's scope to include those servicemembers and veterans who were 
discharged from an MTF prior to January 2008.
    At this time, FRCs are accepting servicemembers/veterans injured 
prior to January 2008 into the FRCP on a referral basis. As mentioned 
above, Phase Two will start in June 2008, and will expand the program's 
scope to include those servicemembers and veterans who were discharged 
from an MTF prior to January 2008. Identification of this population 
will be conducted through a review of VA rehabilitation databases, to 
include spinal cord and blind rehabilitation, along with the polytrauma 
centers. In tandem, DoD will work through TRICARE in an effort to 
identify the same population for potential inclusion into the FRCP. 
Staffing support has been initiated to support this expansion effort. 
An additional registered nurse is being actively recruited to champion 
this effort along with additional FRCs whose geographic placement will 
be based on identified patient needs.
    Federal Recovery Coordinators are nurses and masters prepared 
social workers with experience in Mental Health issues and receive 
ongoing training which improves their ability to both identify and 
prioritize those servicemembers and veterans in need of mental health 
services and programs. Thus they will ensure that the clinical case 
manager addressed any mental health issues that the patient or family 
may have.
    As of May 13, the Combat Veteran Call Center has made 8,598 calls 
and has spoken to 2,953 veterans. The percentage of unique veterans 
spoken with on this initiative is 34.3%.

                               ----------
Information Provided by VA From Discussion with Secretary Peake during 
                          Post-Hearing Meeting
                    In response to Maris testimony.

Reanalysis of data; pulling out base population, including veterans.
    Response: The National Violent Death Reporting System (NVDRS) 
database is owned by CDC. VA uses the information, however, we feel 
outreach efforts to make its use more prevalent should be initiated by 
CDC.
    To compare information of veterans using VHA health care services 
with all veterans and all Americans, VA uses information on all 
veterans' suicides from the NVDRS. The NVDRS has been tracking suicides 
among veterans and others in an increasing number of States since 2003, 
in six States since 2003, in 13 since 2004, and in 16 since 2005. Only 
preliminary information is available for 2006. It is likely that the 
counts and rates presented for this year will increase as additional 
case reports are received.
    To give a view of suicide rates over time, the NVDRS document 
attached dated 5-15-08 looks at NVDRS data for all veterans and 
compares it to information on VMA health care users and all Americans 
in separate tables for each grouping of NVDRS States.
    Calculations for VHA patients were based on causes of death from 
the National Death Index for veterans from the relevant States 
identified from clinical and administrative records. Figures for the 
general populations were derived from the CDC's Web-based Injury 
Statistics Query and Reporting System (WISQARS) site, again, for the 
relevant States.

                                                                                                                        The National Violent Death Reporting System (NVDRS) Update, 5-15-08 11am
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                       For VHA Patients in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                                                       FY03                                         FY04                                         FY05
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                                                       Suicide     Suicides /                       Suicide     Suicides /                       Suicide     Suicides /
                                                                                                                                                                                         Pop.          Deaths        100,000          Pop.          Deaths        100,000          Pop.          Deaths        100,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29                                                                                                                                                                               10,342             5          48.3           11,453             6          52.4           12,847             7          54.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64                                                                                                                                                                              232,427            88          37.9          236,043            89          37.7          240,439            83          34.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+                                                                                                                                                                                255,853            76          29.7          239,609            75          31.3          235,410            66          28.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males                                                                                                                                                                                 498,622           169          33.9          487,105           170          34.9          488,696           156          31.9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                                                                                                                                                              4,818             1          20.8            5,431             1          18.4            5,945             2          33.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64                                                                                                                                                                             33,030             8          24.2           34,404             6          17.4           35,641             6          16.8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+                                                                                                                                                                                6,985             0           0.0            6,471             0           0.0            6,388             0           0.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females                                                                                                                                                                                44,834             9          20.1           46,306             7          15.1           47,974             8          16.7
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                For General U.S. Population in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)--Continued
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                               CY03                                         CY04                                         CY05
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                               Suicide     Suicides /                       Suicide     Suicides /                       Suicide     Suicides /
                                                                 Pop.          Deaths        100,000          Pop.          Deaths        100,000          Pop.          Deaths        100,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29                                                    2,882,507           520          18.0        2,940,762           498          16.9        2,979,291           524          17.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64                                                    8,478,693         1,676          19.8        8,554,240         1,730          20.2        8,626,030         1,697          19.7
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+                                                      1,829,120           512          28.0        1,853,752           491          26.5        1,885,066           489          25.9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males                                                      13,190,320         2,708          20.5       13,348,754         2,719          20.4       13,490,387         2,710          20.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                                  2,811,814            91           3.2        2,846,934           109           3.8        2,878,825            98           3.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64                                                  8,868,182           515           5.8        8,937,771           510           5.7        9,008,792           544           6.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+                                                    2,617,145           111           4.2        2,632,363            87           3.3        2,657,046            95           3.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females                                                    14,297,141           717           5.0       14,417,068           706           4.9       14,544,663           737           5.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                           For All Veterans in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                 CY03                                CY04                                CY05                            CY06 Partial
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                Suicide   Suicides /                Suicide   Suicides /                Suicide   Suicides /                Suicide   Suicides /
                                                     Pop.       Deaths      100,000      Pop.       Deaths      100,000      Pop.       Deaths      100,000      Pop.       Deaths      100,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29                                         97,430          51        52.3      97,761          48        49.1     101,622          40        39.4     105,108          40        38.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64                                      1,728,183         423        24.5   1,695,677         412        24.3   1,664,851         374        22.5   1,631,152         306        18.8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+                                        1,171,401         326        27.8   1,157,448         314        27.1   1,139,862         319        28.0   1,125,567         251        22.3
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males                                         2,997,014         800        26.7   2,950,886         774        26.2   2,906,335         733        25.2   2,861,826         597        20.9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                       26,503           3        11.3      26,891           4        14.9      27,728           3        10.8      28,104           7        24.9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64                                      167,872          11         6.6     173,324          18        10.4     177,874          18        10.1     182,547          13         7.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+                                         44,773           1         2.2      43,732           2         4.6      42,828           2         4.7      41,667           3         7.2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females                                         239,147          15         6.3     243,947          24         9.8     248,430          23         9.3     252,318          23         9.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
       For VHA Patients in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland,
 Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, Wisconsin)
-----------------------------------------------------------------------------------------------------------------
                                                         FY04                                FY05
----------------------------------------------------------------------------------------------------------------
                                                        Suicide   Suicides /                Suicide   Suicides /
                                             Pop.       Deaths      100,000      Pop.       Deaths      100,000
----------------------------------------------------------------------------------------------------------------
Males, 18-29                                 22,130           8        36.2      25,353          15        59.2
----------------------------------------------------------------------------------------------------------------
Males, 30-64                                494,213         202        40.9     510,042         180        35.3
----------------------------------------------------------------------------------------------------------------
Males, 65+                                  460,764         156        33.9     454,915         159        35.0
----------------------------------------------------------------------------------------------------------------
All Males                                   977,106         366        37.5     990,311         354        35.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                               11,189           1         8.9      12,381           3        24.2
----------------------------------------------------------------------------------------------------------------
Females, 30-64                               70,609           9        12.7      73,261          12        16.4
----------------------------------------------------------------------------------------------------------------
Females, 65+                                 13,615           0         0.0      12,350           0         0.0
----------------------------------------------------------------------------------------------------------------
All Females                                  95,414          10        10.5      97,991          15        15.3
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
     For the General U.S. Population in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia,
 Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia,
                                                   Wisconsin)
-----------------------------------------------------------------------------------------------------------------
                                                        CY04                                 CY05
----------------------------------------------------------------------------------------------------------------
                                                       Suicide   Suicides /                 Suicide   Suicides /
                                            Pop.       Deaths      100,000       Pop.       Deaths      100,000
----------------------------------------------------------------------------------------------------------------
Males, 18-29                             5,759,748        1154        20.0    5,825,312        1117        19.2
----------------------------------------------------------------------------------------------------------------
Males, 30-64                            15,981,610        3647        22.8   16,172,388        3593        22.2
----------------------------------------------------------------------------------------------------------------
Males, 65+                               3,371,832         971        28.8    3,439,314        1029        29.9
----------------------------------------------------------------------------------------------------------------
All Males                               25,113,190       5,772        23.0   25,437,014       5,739        22.6
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                           5,487,877         235         4.3    5,549,163         236         4.3
----------------------------------------------------------------------------------------------------------------
Females, 30-64                          16,507,912        1160         7.0   16,702,515        1133         6.8
----------------------------------------------------------------------------------------------------------------
Females, 65+                             4,783,669         181         3.8    4,843,413         180         3.7
----------------------------------------------------------------------------------------------------------------
All Females                             26,779,458       1,576         5.9   27,095,091       1,549         5.7
----------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  For All Veterans in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
                                                                                      Virginia, Wisconsin)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                               CY04                                         CY05                                     CY06 Partial
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                               Suicide     Suicides /                       Suicide     Suicides /                       Suicide     Suicides /
                                                                 Pop.          Deaths        100,000          Pop.          Deaths        100,000          Pop.          Deaths        100,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29                                                      190,949           100          52.4          198,183            88          44.4          204,917            89          43.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64                                                    3,311,746           889          26.8        3,261,900           833          25.5        3,206,111           750          23.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+                                                      2,111,452           592          28.0        2,086,273           674          32.3        2,066,921           491          23.8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males                                                       5,614,146         1,581          28.2        5,546,357         1,595          28.8        5,477,950         1,330          24.3
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                                     51,664             9          17.4           53,454             9          16.8           54,207             9          16.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64                                                    333,660            39          11.7          342,846            37          10.8          352,071            30           8.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+                                                       75,115             2           2.7           73,945             3           4.1           72,625             4           5.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females                                                       460,438            50          10.9          470,245            49          10.4          478,902            43           9.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------
  For VHA Patients in the 16 States with NVDRS data for CY2005 (Alaska,
  Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New
 Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
                       Utah, Virginia, Wisconsin)
-------------------------------------------------------------------------
                                                     FY05
------------------------------------------------------------------------
                                                    Suicide   Suicides /
                                         Pop.       Deaths      100,000
------------------------------------------------------------------------
Males, 18-29                             31,966          17        53.2
------------------------------------------------------------------------
Males, 30-64                            594,346         217        36.5
------------------------------------------------------------------------
Males, 65+                              524,948         189        36.0
------------------------------------------------------------------------
All Males                             1,151,261         423        36.7
------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                           15,988           4        25.0
------------------------------------------------------------------------
Females, 30-64                           88,531          14        15.8
------------------------------------------------------------------------
Females, 65+                             14,293           0         0.0
------------------------------------------------------------------------
All Females                             118,811          18        15.2
------------------------------------------------------------------------


------------------------------------------------------------------------
  For the General U.S. Population in the 16 States with NVDRS data for
  CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts,
 New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island,
               South Carolina, Utah, Virginia, Wisconsin)
-------------------------------------------------------------------------
                                                     CY05
------------------------------------------------------------------------
                                                    Suicide   Suicides /
                                         Pop.       Deaths      100,000
------------------------------------------------------------------------
Males, 18-29                          6,630,344       1,350        20.4
------------------------------------------------------------------------
Males, 30-64                         18,026,867       4,196        23.3
------------------------------------------------------------------------
Males, 65+                            3,858,225       1,177        30.5
------------------------------------------------------------------------
All Males                            28,515,436       6,723        23.6
------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                        6,318,615         275         4.4
------------------------------------------------------------------------
Females, 30-64                       18,602,682       1,309         7.0
------------------------------------------------------------------------
Females, 65+                          5,406,681         196         3.6
------------------------------------------------------------------------
All Females                          30,327,978       1,780         5.9
------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
  For All Veterans in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland,
  Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah,
                                              Virginia, Wisconsin)
-----------------------------------------------------------------------------------------------------------------
                                                        CY05                             CY06 Partial
----------------------------------------------------------------------------------------------------------------
                                                       Suicide   Suicides /                 Suicide   Suicides /
                                            Pop.       Deaths      100,000       Pop.       Deaths      100,000
----------------------------------------------------------------------------------------------------------------
Males, 18-29                               222,255         100        45.0      229,855          98        42.6
----------------------------------------------------------------------------------------------------------------
Males, 30-64                             3,636,370         931        25.6    3,575,055         842        23.6
----------------------------------------------------------------------------------------------------------------
Males, 65+                               2,334,819         736        31.5    2,313,321         558        24.1
----------------------------------------------------------------------------------------------------------------
All Males                                6,193,443       1,767        28.5    6,118,231       1,498        24.5
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                              58,614           9        15.4       59,514          10        16.8
----------------------------------------------------------------------------------------------------------------
Females, 30-64                             376,875          43        11.4      387,015          34         8.8
----------------------------------------------------------------------------------------------------------------
Females, 65+                                82,077           3         3.7       80,703           4         5.0
----------------------------------------------------------------------------------------------------------------
All Females                                517,566          55        10.6      527,232          48         9.1
----------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
       For VHA Patients in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                 FY03                                     FY04                                     FY05
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        95% CI                                   95% CI                                   95% CI
                                  Suicides /   ------------------------    Suicides /   ------------------------    Suicides /   -----------------------
                                   100,000         Lower       Upper        100,000         Lower       Upper        100,000         Lower       Upper
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29                             48.3        15.7       112.8             52.4        19.2       114.0             54.5        21.9       112.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64                             37.9        30.4        46.6             37.7        30.3        46.4             34.5        27.5        42.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+                               29.7        23.4        37.2             31.3        24.6        39.2             28.0        21.7        35.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Males                                33.9        29.0        39.4             34.9        29.9        40.6             31.9        27.1        37.3
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                           20.8         0.5       115.6             18.4         0.5       102.6             33.6         4.1       121.5
--------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64                           24.2        10.5        47.7             17.4         6.4        38.0             16.8         6.2        36.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+                              0.0         0.0        52.8              0.0         0.0        57.0              0.0         0.0        57.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Females                              20.1         9.2        38.1             15.1         6.1        31.1             16.7         7.2        32.9
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
 For General U.S. Population in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                 CY03                                     CY04                                     CY05
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        95% CI                                   95% CI                                   95% CI
                                  Suicides /   ------------------------    Suicides /   ------------------------    Suicides /   -----------------------
                                   100,000         Lower       Upper        100,000         Lower       Upper        100,000         Lower       Upper
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29                             18.0        16.5        20.3             16.9        15.5        18.5             17.6        15.9        19.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64                             19.8        18.8        20.7             20.2        19.3        21.2             19.7        18.7        20.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+                               28.0        25.6        30.5             26.5        24.2        28.9             25.9        23.7        28.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Males                                20.5        19.8        21.3             20.4        19.6        21.1             20.1        19.3        20.8
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                            3.2         2.6         4.0              3.8         3.1         4.6              3.4         2.8         4.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64                            5.8         5.3         6.3              5.7         5.2         6.2              6.0         5.5         6.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+                              4.2         3.5         5.1              3.3         2.6         4.1              3.6         2.9         4.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Females                               5.0         4.6         5.4              4.9         4.5         5.3              5.1         4.7         5.4
--------------------------------------------------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                           For All Veterans in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                 CY03                                CY04                                CY05                                CY06
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                        95% CI                              95% CI                              95% CI                              95% CI
                                                    Suicides /   --------------------   Suicides /   --------------------   Suicides /   --------------------   Suicides /   -------------------
                                                      100,000       Lower     Upper       100,000       Lower     Upper       100,000       Lower     Upper       100,000       Lower     Upper
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29                                               52.3      39.0      68.8            49.1      36.2      65.1            39.4      28.1      53.6            38.1      27.2      51.8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64                                               24.5      22.2      26.9            24.3      22.0      26.8            22.5      20.2      24.9            18.8      16.7      21.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+                                                 27.8      24.9      31.0            27.1      24.2      30.3            28.0      25.0      31.2            22.3      19.6      25.2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males                                                  26.7      24.8      28.5            26.2      24.4      28.1            25.2      23.4      27.0            20.9      19.2      24.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                             11.3       2.3      33.1            14.9       4.1      38.1            10.8       2.2      31.6            24.9      10.0      51.3
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64                                              6.6       3.3      11.7            10.4       6.2      16.4            10.1       6.0      16.0             7.1       3.8      12.2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+                                                2.2       0.1      12.4             4.6       0.6      16.5             4.7       0.6      16.9             7.2       1.5      21.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females                                                 6.3       3.5      10.3             9.8       6.3      14.6             9.3       5.9      13.9             9.1       5.8      13.7
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
       For VHA Patients in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland,
 Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, Wisconsin)
-----------------------------------------------------------------------------------------------------------------
                                                        FY04                                 FY05
----------------------------------------------------------------------------------------------------------------
                                                             95% CI                               95% CI
                                         Suicides / ------------------------  Suicides / -----------------------
                                          100,000       Lower       Upper      100,000       Lower       Upper
----------------------------------------------------------------------------------------------------------------
Males, 18-29                                  36.2        15.6        71.2         59.2        33.1        97.6
----------------------------------------------------------------------------------------------------------------
Males, 30-64                                  40.9        35.4        46.9         35.3        30.3        40.8
----------------------------------------------------------------------------------------------------------------
Males, 65+                                    33.9        28.8        39.6         35.0        29.7        40.8
----------------------------------------------------------------------------------------------------------------
All Males                                     37.5        33.7        41.5         35.7        32.1        39.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                 8.9         0.2        49.8         24.2         5.0        70.8
----------------------------------------------------------------------------------------------------------------
Females, 30-64                                12.7         5.8        24.2         16.4         8.5        28.6
----------------------------------------------------------------------------------------------------------------
Females, 65+                                   0.0         0.0        27.1          0.0         0.0        29.9
----------------------------------------------------------------------------------------------------------------
All Females                                   10.5         5.0        19.3         15.3         8.6        25.2
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
     For the General U.S. Population in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia,
 Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia,
                                                   Wisconsin)
-----------------------------------------------------------------------------------------------------------------
                                                        CY04                                 CY05
----------------------------------------------------------------------------------------------------------------
                                                             95% CI                               95% CI
                                         Suicides / ------------------------  Suicides / -----------------------
                                          100,000       Lower       Upper      100,000       Lower       Upper
----------------------------------------------------------------------------------------------------------------
Males, 18-29                                  20.0        18.9        21.2         19.2        18.1        20.3
----------------------------------------------------------------------------------------------------------------
Males, 30-64                                  22.8        22.1        23.6         22.2        21.5        22.9
----------------------------------------------------------------------------------------------------------------
Males, 65+                                    28.8        27.0        30.6         29.9        28.1        31.7
----------------------------------------------------------------------------------------------------------------
All Males                                     23.0        22.4        23.6         22.6        22.0        23.1
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                 4.3         3.8         4.9          4.3         3.7         4.8
----------------------------------------------------------------------------------------------------------------
Females, 30-64                                 7.0         6.6         7.4          6.8         6.4         7.2
----------------------------------------------------------------------------------------------------------------
Females, 65+                                   3.8         3.3         4.4          3.7         3.2         4.3
----------------------------------------------------------------------------------------------------------------
All Females                                    5.9         5.6         6.2          5.7         5.4         6.0
----------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  For All Veterans in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
                                                                                      Virginia, Wisconsin)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                    CY04                                       CY05                                  CY06 (Partial)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                            95% CI                                     95% CI                                     95% CI
                                                                 Suicides /100,000 ------------------------ Suicides /100,000 ------------------------ Suicides /100,000 -----------------------
                                                                                       Lower       Upper                          Lower       Upper                          Lower       Upper
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29                                                                 52.4        42.6        63.7               44.4        35.6        54.7               43.4        34.9        53.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64                                                                 26.8        25.1        28.6               25.5        23.8        27.3               23.4        21.7        25.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+                                                                   28.0        25.8        32.5               32.3        29.9        34.7               23.8        21.7        26.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males                                                                    28.2        26.8        29.5               28.8        27.3        30.2               24.3        23.0        25.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                                               17.4         8.0        33.1               16.8         7.7        32.0               16.6         7.6        31.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64                                                               11.7         8.3        16.0               10.8         7.6        14.9                8.5         5.7        12.2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+                                                                  2.7         0.3         9.6                4.1         0.8        11.9                5.5         1.5        14.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females                                                                  10.9         8.1        14.3               10.4         7.7        13.8                9.0         6.5        12.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------
  For VHA Patients in the 16 States with NVDRS data for CY2005 (Alaska,
  Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New
 Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
                       Utah, Virginia, Wisconsin)
-------------------------------------------------------------------------
                                                      FY05
------------------------------------------------------------------------
                                                          95% CI
                                        Suicides -----------------------
                                        /100,000     Lower       Upper
------------------------------------------------------------------------
Males, 18-29                              53.2         31.0        85.1
------------------------------------------------------------------------
Males, 30-64                              36.5         31.8        41.7
------------------------------------------------------------------------
Males, 65+                                36.0         31.1        41.5
------------------------------------------------------------------------
All Males                                 36.7         33.3        40.4
------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                            25.0          6.8        64.1
------------------------------------------------------------------------
Females, 30-64                            15.8          8.6        26.5
------------------------------------------------------------------------
Females, 65+                               0.0          0.0        25.8
------------------------------------------------------------------------
All Females                               15.2          9.0        23.9
------------------------------------------------------------------------


------------------------------------------------------------------------
  For the General U.S. Population in the 16 States with NVDRS data for
  CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts,
 New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island,
               South Carolina, Utah, Virginia, Wisconsin)
-------------------------------------------------------------------------
                                                      CY05
------------------------------------------------------------------------
                                                          95% CI
                                        Suicides -----------------------
                                        /100,000     Lower       Upper
------------------------------------------------------------------------
Males, 18-29                              20.4         19.3        21.4
------------------------------------------------------------------------
Males, 30-64                              23.3         22.6        24.0
------------------------------------------------------------------------
Males, 65+                                30.5         28.8        32.2
------------------------------------------------------------------------
All Males                                 23.6         23.0        24.1
------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                             4.4          3.9         4.9
------------------------------------------------------------------------
Females, 30-64                             7.0          6.7         7.4
------------------------------------------------------------------------
Females, 65+                               3.6          3.1         4.2
------------------------------------------------------------------------
All Females                                5.9          5.6         6.1
------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
  For All Veterans in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland,
  Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah,
                                              Virginia, Wisconsin)
-----------------------------------------------------------------------------------------------------------------
                                                            CY05                         CY06 (Partial)
----------------------------------------------------------------------------------------------------------------
                                                                  95% CI                            95% CI
                                               Suicides /  --------------------  Suicides /  -------------------
                                                 100,000      Lower     Upper      100,000      Lower     Upper
----------------------------------------------------------------------------------------------------------------
Males, 18-29                                         45.0      36.6      54.7          42.6      34.6      52.0
----------------------------------------------------------------------------------------------------------------
Males, 30-64                                         25.6      24.0      27.2          23.6      22.0      25.1
----------------------------------------------------------------------------------------------------------------
Males, 65+                                           31.5      29.2      33.8          24.1      22.2      26.2
----------------------------------------------------------------------------------------------------------------
All Males                                            28.5      27.2      29.9          24.5      23.2      25.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29                                       15.4       7.0      29.1          16.8       8.1      30.9
----------------------------------------------------------------------------------------------------------------
Females, 30-64                                       11.4       8.3      15.4           8.8       6.1      12.3
----------------------------------------------------------------------------------------------------------------
Females, 65+                                          3.7       0.8      10.7           5.0       1.4      12.7
----------------------------------------------------------------------------------------------------------------
10All Females                                        10.6       8.0      13.8           9.1       6.7      12.1
----------------------------------------------------------------------------------------------------------------


                                 

Information Provided by VA From Discussion with Secretary Peake during 
                          Post-Hearing Meeting
Cost of Call Center
Response: Currently, the cost for the suicide hotline in FY 2008 is 
projected to be $2.6 million. However, the funding will increase if and 
when the calls require additional lines.

                                           Detail of Program Expenses
                                    Specific Purpose Program: Suicide Hotline
----------------------------------------------------------------------------------------------------------------
      Estimated Expenses:         FTEE     Qtr 1      Qtr 2      Qtr 3      Qtr 4       Total        Comments
----------------------------------------------------------------------------------------------------------------
VA Personnel                      37.50   $517,805   $647,760   $642,521   $652,384   $2,460,469
----------------------------------------------------------------------------------------------------------------
Contract Personnel (IPA, etc.)
----------------------------------------------------------------------------------------------------------------
Contract Services & Misc.
------------------------------------------$118,456--------------------------------------$118,456----------------
----------------------------------------------------------------------------------------------------------------
Supplies                                    $1,050     $1,050     $1,050     $1,050       $4,200
----------------------------------------------------------------------------------------------------------------
Other                                       $4,688     $4,688     $4,688     $4,688      $18,752
----------------------------------------------------------------------------------------------------------------
Travel                                      $9,375     $9,375     $9,375     $9,375      $37,500
----------------------------------------------------------------------------------------------------------------
Equipment                                   $5,463                                        $5,463
----------------------------------------------------------------------------------------------------------------
Total Expenditures:               37.50   $656,837   $662,873   $657,634   $667,497   $2,644,840
----------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                            Function     Station To
               VA Personnel  (Name)                Grade  /    Position (Title)      FTEE       Qtr 1       Qtr 2       Qtr 3       Qtr 4       Total         (Job         Receive      Station
                                                     Step                                                                                                    Duties)       Funding      Number
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $16,833     $16,889     $16,909     $17,170      $67,801                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        09      Other Therapists      1.00     $19,403     $19,468     $19,492     $19,792      $78,155                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        06    Other Health Aides      1.00     $12,443     $12,484     $12,499     $12,692      $50,118                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        01                    RN      1.00     $21,528     $21,600     $21,626     $21,959      $86,713                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        05    Other Health Aides      1.00      $7,803      $7,829      $7,838      $7,959      $31,429                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $18,696     $18,759     $18,781     $19,070      $75,306                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        06    Other Health Aides      1.00     $12,918     $12,961     $12,977     $13,177      $52,033                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        09      Other Therapists      1.00     $14,954     $15,004     $15,022     $15,253      $60,233                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $16,635     $16,690     $16,710     $16,967      $67,002                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $15,935     $15,988     $16,008     $16,254      $64,185                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $17,917     $17,977     $17,999     $18,276      $72,169                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        02                    RN      1.00      $7,386      $7,411      $7,420      $7,534      $29,751                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        06    Other Health Aides      1.00     $10,468     $10,503     $10,516     $10,678      $42,165                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $19,156     $19,234     $19,243     $19,539      $77,172                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        01                    RN      1.00     $19,749     $19,815     $19,839     $20,144      $79,547                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $18,594     $18,656     $18,679     $18,966      $74,895                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        05         Nursing Aides      1.00      $9,376      $9,407      $9,419      $9,564      $37,766                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $17,109     $17,166     $17,186     $17,451      $68,912                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11         Social Worker      1.00     $17,268     $17,325     $17,346     $17,613      $69,552                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        09      Other Therapists      1.00     $15,826     $15,878     $15,898     $16,142      $63,744                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                         3                    RN      1.00     $23,026     $23,103     $23,131     $23,486      $92,746                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                         3                    RN      1.00     $20,593     $20,662     $20,687     $21,005      $82,947                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                         2                    RN      1.00     $21,038     $21,108     $21,134     $21,459      $84,739                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                         2                    RN      1.00     $20,867     $20,936     $20,962     $21,284      $84,049                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11      Other Therapists      1.00     $15,510     $15,562     $15,581     $15,820      $62,473                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        11      Other Therapists      1.00     $15,164     $15,215     $15,233     $15,467      $61,079                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      1.00     $10,361     $19,058     $19,081     $19,375      $67,875                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      1.00     $10,361     $19,058     $19,081     $19,375      $67,875                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      1.00     $10,361     $19,058     $19,081     $19,375      $67,875                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      1.00     $10,361     $19,058     $19,081     $19,375      $67,875                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      1.00                 $19,058     $19,081     $19,375      $57,514                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
 RECRUITMENT                                         02/11              RN or SW      1.00                 $19,058     $19,081     $19,375      $57,514                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      1.00                 $19,058     $19,081     $19,375      $57,514                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      1.00                 $19,058     $19,081     $19,375      $57,514                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      1.00                 $19,058     $19,081     $19,375      $57,514                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                          02/11              RN or SW      0.50                  $9,529      $9,541      $9,688      $28,757                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                             11       Program Analyst      1.00     $10,591     $19,482     $19,505     $19,806      $69,384                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT                                              6       Program Support      1.00      $6,440     $11,847     $11,861     $12,044      $42,192                         528         528
                                                                           Asst.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
OT                                                                                             $23,135      $1,750      $1,750      $1,750      $28,385                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Awards                                                                                         $10,000      $6,000                              $16,000                         528         528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                      Sub Total:     37.50    $517,805    $647,760    $642,521    $652,384   $2,460,469
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                 Contract Personnel (IPA, etc.)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                       Station To
                        Personnel                            Position            FTEE            Qtr 1      Qtr 2       Qtr 3       Qtr 4       Total      Function      Receive       Station
                                                                                                                                                                         Funding       Number
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                            Sub Total:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


                                                                                   Detail of Program Expenses
                                                                      Specific Purpose Program: Suicide Hotline--Continued
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                    Contract Services & Misc.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                       Reason for      Station To
              Contract (Service  provided)                  Contractor        Needed       Qtr 1       Qtr 2       Qtr 3       Qtr 4       Total         Service         Receive       Station
                                                                                                                                                       (Contract)        Funding       Number
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Accreditation                                                                              $5,000                                          $5,000                             528           528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Lifeline                                                                                 $111,456                                        $111,456                             528           528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Advertising                                                                                $2,000                                          $2,000                             528           528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              Sub Total:                 $118,456                                        $118,456
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Actual Services which are under a contract (copier maintenance, phone service, etc.). Any service provided by the local facility and charged to the program are listed under Supplies or
 Other. Also List in order of priority to your program.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                       Station To
                        Supplies                              Purpose         Needed       Qtr 1       Qtr 2       Qtr 3       Qtr 4       Total        Comments         Receive       Station
                                                                                                                                                                         Funding       Number
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Office supplies                                                                            $1,050      $1,050      $1,050      $1,050      $4,200                             528           528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              Sub Total:                   $1,050      $1,050      $1,050      $1,050      $4,200
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Includes paper, pens, toner, etc. along with any additional supplies which are consumable and need to be replaced. Also List supplies in order of priority to your program.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                              Station To
                             Other                                   Purpose         Needed       Qtr 1       Qtr 2       Qtr 3       Qtr 4       Total       Reason for        Receive    Station
                                                                                                                                                                expense         Funding     Number
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------
Education/tuition/registration                                                        $4,688      $4,688      $4,688      $4,688     $18,752                           528           528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                     Sub Total:       $4,688      $4,688      $4,688      $4,688     $18,752
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Any item not covered under contracts or supplies (not to include equipment which is covered below). Also List in order of priority to your program.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


                                                               Detail of Program Expenses
                                                  Specific Purpose Program: Suicide Hot Line--Continued
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                         Travel
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                Reason       Station To        Station
       Personnel (Name)          Traveling to       Qtr 1        Qtr 2       Qtr 3       Qtr 4       Total     for Trip   Receive  Funding     Number
--------------------------------------------------------------------------------------------------------------------------------------------------------
Employee travel                                      $9,375      $9,375      $9,375      $9,375     $37,500                           528           528
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                    Sub Total:       $9,375      $9,375      $9,375      $9,375     $37,500
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Please include as much detail on each separate trip and the personnel taking the trips as possible. Also List Travel in order of priority to your
 program.
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                Reason
          Equipment                 Purpose         Qtr 1        Qtr 2       Qtr 3       Qtr 4       Total     Equipment     Station To        Station
                                                                                                               is needed  Receive  Funding     Number
--------------------------------------------------------------------------------------------------------------------------------------------------------
Filing cabinet                                       $1,100                                          $1,100                           528           528
--------------------------------------------------------------------------------------------------------------------------------------------------------
Security System                                      $4,363                                          $4,363                           528           528
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                    Sub Total:       $5,463                                          $5,463
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Equipment consist of items which bear an actual VA property tag all other items go under ``Supplies'' or ``Other''. Also List Equipment in order
 of priority to your program.
--------------------------------------------------------------------------------------------------------------------------------------------------------

          POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 21, 2008

The Honorable James B. Peake, M.D.
The Secretary Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Mr. Secretary:

    In reference to our Full Committee hearing on ``The Truth About 
Veterans' Suicides'' on May 6, 2008, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on July 
7, 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 your responses at 202-225-2034. If you have any 
questions, please call 202-225-9756.

            Sincerely,

                                                         BOB FILNER
                                                           Chairman

CW:ds
                               __________
                        Questions for the Record
                   The Honorable Bob Filner, Chairman
                  House Committee on Veterans' Affairs
                              May 6, 2008
                    The Truth about Veteran Suicides
    Question 1(a): In testimony before the Committee, the VA presented 
data regarding suicide rates for the general population and veteran 
users grouped into three cohorts: 18-29; 30-64; and, 65+. Please 
provide a detailed explanation to the Committee to explain why these 
particular age cohorts were chosen.

    Response: To ensure consistency with other Veterans Health 
Administration (VHA) data on suicides, age groups selected by the 
National Serious Mental Illness Treatment Research and Evaluation 
Center (SMITREC) were used.

    Question 1(b): Please provide the Committee with the data presented 
at the May 6, 2008 hearing grouped by the following age cohorts: 20-24; 
25-29; 30-34; 35-39; 40-44; 45-49; 50-54; 55-59; 60-64; 65-69; 70-74; 
and, 75+.

    Response: The table below provides: Number of Suicides by Age Group 
Among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 
Veterans Compared to U.S. General Population \1\
---------------------------------------------------------------------------
    \1\ Age based on age in 2005. Suicides, n=144, were identified 
among a cohort of 490,346 OEF/OIF selected for mortality follow-up 
through 2005.

----------------------------------------------------------------------------------------------------------------
                                                                               Standardized
                Age Groups                    Observed #     Expected # Of    Mortality Rate    95% confidence
                                               Suicides       Suicides \2\         \3\           interval \4\
----------------------------------------------------------------------------------------------------------------
20-24                                                  38             23.6             1.61           1.14-2.21
----------------------------------------------------------------------------------------------------------------
25-29                                                  37             32.7             1.13           0.80-1.56
----------------------------------------------------------------------------------------------------------------
30-34                                                  19             15.1             1.26           0.76-1.97
----------------------------------------------------------------------------------------------------------------
35-39                                                  18             14.8             1.21           0.72-1.92
----------------------------------------------------------------------------------------------------------------
40-44                                                  14             18.7             0.75           0.41-1.26
----------------------------------------------------------------------------------------------------------------
45-49                                                   5             10.6             0.47           0.15-1.10
----------------------------------------------------------------------------------------------------------------
50-54                                                   7              5.2             1.34           0.54-2.75
----------------------------------------------------------------------------------------------------------------
55-59                                                   6              3.5             1.72           0.63-3.74
----------------------------------------------------------------------------------------------------------------
60-64                                                   0               --               --                  --
----------------------------------------------------------------------------------------------------------------
65-69                                                   0               --               --                  --
----------------------------------------------------------------------------------------------------------------
70-74                                                   0               --               --                  --
----------------------------------------------------------------------------------------------------------------
75-+                                                    0               --               --                  --
----------------------------------------------------------------------------------------------------------------
 A2 Expected based on U.S. general population.
 A3 Standardized Mortality Ratio (SMR) is the ratio of observed to expected with adjustment for race, sex, age,
  and calendar year period.
 A4 95 percent confidence interval (C.I.).
There were no OEF/OIF veteran suicides in the age groups older than 55-59, therefore expected numbers and SMRs
  were not presented.

    Question 2: On December 12, 2007, the Committee held a hearing 
entitled ``Stopping Suicides: Mental Health Challenges within the U.S. 
Department of Veterans Affairs.'' Please provide to the Committee a 
detailed explanation of the specific steps and actions undertaken by 
the VA to improve mental health care and services since December 13, 
2007. Please exclude any steps and actions that the VA had planned to 
undertake prior to December 12, 2007.

    Response: Since December 13, 2007, the following actions were 
initiated to improve mental health care:

      Expansion of the suicide prevention coordinator staffing 
into teams is underway, with increased access in community based 
outpatient clinics (CBOC)
      Expansion of mental health staff
      Expansion of sites of care--CBOCs
      Expansion of veteran centers
      Collaborating with the Defense Center of Excellence 
(DCoE) on mental health and traumatic brain injury (TBI) by providing a 
Deputy Center Director and a mental health subject matter expert
      Funding to expand VA's substance use disorder outpatient 
intensive care programs by adding 28 new sites and a substance use 
disorder care specialist to every post traumatic stress disorder (PTSD) 
team or specialty program if one doesn't already exist

    Question 3(a): An Associated Press article dated April 15, 2008, 
entitled ``Dallas Veterans' Hospital Shutters Psych Ward after Fourth 
Patient Suicide of Year'' states that ``[t]he fourth suicide this year 
among mentally ill patients treated at the Dallas VA Medical Center has 
led the hospital to close its psychiatric ward to new patients, and 
investigators from the national Veterans Affairs office are expected to 
arrive next week to assess safety.'' Please provide the Committee with 
the results of this investigation to date. If the results of this 
investigation have not been finalized, please provide the preliminary 
findings and recommendations of these investigators.

    Response: The Medical Inspector Final Report #2008-D-654 dated May 
20, 2008 (Quality of Care Review, Veterans Affairs Medical Center 
(VAMC) Dallas, Texas, Veterans Integrated Service Network 17) is 
attached.
    [The Medical Inspector Final Report #2008-D-654 dated May 20, 2008, 
entitled ``Quality of Care Review, Veterans Affairs Medical Center 
(VAMC) Dallas, Texas, Veterans Integrated Service Network 17,'' will be 
retained in the Committee files.]

    Question 3(b): Please provide the Committee with a detailed 
explanation regarding the VA's plans to address this situation.

    Response: On April 5, 2008, the Dallas VAMC, formally known as the 
Department of Veterans Affairs (VA) North Texas Health Care System 
(VANTHCS), temporarily stopped admitting new patients to the two 
inpatient psychiatry units (a 22-bed unit located on 3 South and a 29-
bed unit located on 3 North) following two previous inpatient suicides 
on February 5, 2008 and April 4, 2008. Patients remained on the units 
until completion of their course of treatment to ensure continuity of 
care. The temporary stand down was put in place to allow adequate time 
for a thorough review of mental health staffing and environment of care 
issues.
    On April 16-17, and April 22-23, 2008, the Office of Medical 
Inspector (OMI) and the Office of Mental Health, respectively, visited 
the Dallas VAMC to evaluate the mental health program. The OMI and 
Office of Mental Health teams made several recommendations for safety 
improvements, including environment of care enhancements, staffing/
program enhancements, and organizational/cultural changes needed to 
enhance patient safety. The Dallas VAMC leadership embraced these 
recommendations and has implemented an action plan successfully 
correcting all deficiencies.
    On May 8, 2008, Veterans Integrated Service Network (VISN) 17 
responded to Office of Mental Health's recommendations with a detailed 
action plan. All items on the list were either completed or closed out 
in compliance and confirmed with the Deputy Chief of Mental Health 
prior to re-opening the inpatient units. VISN 17 also consulted with 
the National Center for Patient Safety (NCPS). NCPS determined that the 
Dallas VAMC's plan for enhanced safety checks and increased staffing on 
the units should mitigate the risk of suicide.
    On May 19, 2008, following renovations, the 3 South inpatient unit 
was re-opened. New admissions were capped to two per day, with 
exceptions for patients hospitalized under the order of protected 
custody. While the unit was closed to new admission, patients were 
assessed in the emergency department and outpatient clinics and 
transferred for inpatient hospitalization as needed to the Waco VAMC 
and local psychiatric hospitals. A social worker coordinated admissions 
and discharges to ensure continuity of care. Mental health staff was 
proactive in providing information to the receiving facilities and 
remained in communication with the facilities throughout the 
hospitalization.
    Over the past 6 months, Dallas VAMC has invested $250,000 in the 
inpatient units to provide upgrades to the environment of care to 
decrease suicide risks. An additional $250,000 has been spent on 
furniture to also reduce suicide risk. These improvements included the 
following: replacing windows and door hardware, clipping ceiling tiles 
in bedrooms, installing camera systems in hallway, changing bathrooms 
fixtures, enclosing plumbing and electrical wiring, and removing tall 
furniture and nightstands. Continuous improvements and modifications 
are being made to the environment of care.
    The Dallas VAMC is actively recruiting permanent additional staff 
and reorganizing the Mental Health Department. Education for all 
existing and new staff hired on integrating principles of psychosocial 
recovery and suicide prevention is being conducted and will continue. 
The Dallas VAMC regularly consults the Office of Mental Health in 
preparation for the reopening of 3 North. The tentative opening date 
for 3 North is fiscal year (FY) 2009. Outsourcing of services will 
discontinue once the unit is re-opened and fully staffed.

    Question 3(c): Please provide the current level of mental health 
care services at the Dallas facility

    Response: The chart below provides the current level of mental 
health services at the Dallas facility.

    Question 3(d): What is the expected level of services at the Dallas 
facility in one year?

------------------------------------------------------------------------------------------------------------------------------------------------
VA North Texas Health Care System (Dallas) Mental Health Services
------------------------------------------------------------------------
 Inpatient acute care        Health care for homeless
 Intensive outpatient        veterans
 group therapies.                    Outreach for homeless
 Alcohol/drug recovery       veterans
 counseling.                         Special programs for women
 Anger management.........   veterans suffering from trauma
 Evaluation and treatment    Support groups for wives of
 of PTSD.                            veterans with PTSD
 Geriatric psychiatry.....   Day treatment
 Memory problems..........   Suicide prevention
 Homeless domiciliary.....   coordinators (Dallas/Bonham/Fort
 Compensated work therapy    Worth)
 (CWT).                              Recovery services that help
 Community residential       promote veteran empowerment,
 care program (CRCP).                development of life and work
 Programs to help ex-        skills, supportive family and
 offenders reintegrate back into     social networks and improved
 society.                            problem solving
 Assisted housing veterans   Trauma team (military
                                     sexual trauma, PTSD)
------------------------------------------------------------------------

    Response: In FY 2009, the Dallas VAMC will provide the full 
spectrum of mental health services as indicated in the chart above 
including the reopening of 3 North.

    Question 3(e): What is the length of time the VA plans to outsource 
these services to other VA facilities in North Texas, Waco, and Temple?

    Response: The inpatient mental health services will continue to be 
outsourced in FY 2009 until the renovations of the 29-bed unit is on 3 
North and the 22-bed unit on 3 South are complete and the facilities 
are in full compliance with national patient safety measures.

    Question 4(a): A Dallas Morning News article dated January 18, 
2005, entitled ``Dallas VA Hospital is Nation's Worst'' states that the 
``Dallas veterans hospital is so dirty, dangerous, and poorly managed, 
Federal investigators have found that it ranks as the worst such 
medical center in the country.'' Please provide the Committee with 
information regarding the current ranking of the Dallas facility.

    Response: In May 2008, VA Office of Quality and Performance issued 
a second quarter FY 2008 Facility Aggregated Report ranking Dallas 123 
out of 139.

    Question 4(b): Please provide the Committee with a detailed 
explanation of the specific steps undertaken by the VA since 2005 to 
improve the Dallas VA Medical Center.

    Response: Since 2005, the Dallas VAMC has taken steps to improve 
the organization. The graph below shows the total budget, staffing and 
equipment purchases from 2005 through 2008. Since 2005, the total 
budget increased by 21 percent, staffing increased by 10 percent and 
equipment purchase expenditures were 145 percent.

----------------------------------------------------------------------------------------------------------------
 VANTHCS  Operational Budget**        FY 2005           FY 2006           FY 2007           FY 2008      Projected
------------------------------------------------------------------------------------------------------- -----------
Medical                           $408,470,538.30   $461,669,051.57   $484,666,641.06   $530,439,213.09
----------------------------------------------------------------------------------------------------------------
Administration                    $ 54,860,479.67   $ 50,051,586.51   $ 57,226,061.12   $ 42,143,425.62
----------------------------------------------------------------------------------------------------------------
Facility                          $ 50,477,600.71   $ 56,877,468.86   $ 64,230,384.76   $ 49,410,582.70
----------------------------------------------------------------------------------------------------------------
Total                             $513,808,618.68   $568,598,106.94   $606,123,086.94   $621,993,221.41
----------------------------------------------------------------------------------------------------------------
**Includes general purpose/specific purpose/Consolidated Mail Out Pharmacy
----------------------------------------------------------------------------------------------------------------

[GRAPHIC] [TIFF OMITTED] 43052A.013


[GRAPHIC] [TIFF OMITTED] 43052A.014


    Since 2005, the Dallas VAMC has improved its infrastructure and its 
ability to provide high quality of care. Its capital budget has 
increased by 30 percent since 2005. Below is a detailed list of its 
minor and non-recurring Maintenance (NRM) projects and capital funding 
for VA North Texas Health Care System.

                                        FY 2005--FY 2008 Minor Projects:
----------------------------------------------------------------------------------------------------------------
                                                                                                  Total Project
                     FY Approved                       Facility           Project Title                Cost
----------------------------------------------------------------------------------------------------------------
2005                                                     Dallas           Patient Privacy/UFAS       $2,200,000
                                                                            Deficiencies, Ph 8
----------------------------------------------------------------------------------------------------------------
2005                                                     Dallas        Relocate Geropsychiatry       $6,050,000
----------------------------------------------------------------------------------------------------------------
2006                                                     Dallas         Transitional Care Unit       $3,630,000
----------------------------------------------------------------------------------------------------------------
2007                                                     Dallas      MRI Addition for Research       $6,299,000
----------------------------------------------------------------------------------------------------------------
2008                                                     Dallas     Upgrade Mental Health Ph 2       $6,984,475
----------------------------------------------------------------------------------------------------------------


       FY 2005--FY 2008 Non-Recurring Maintenance (NRM) Projects:
                                 FY 2005
------------------------------------------------------------------------
                                                             Total $
  Facility                  Project Title                   Obligated
------------------------------------------------------------------------
Dallas                                                Cor$   219,565.00l Panel Deficiencies
------------------------------------------------------------------------
Dallas                                               SCI $    69,000.00ab
------------------------------------------------------------------------
Dallas                                Dallas Pharmacy Cle$    33,000.00tion
------------------------------------------------------------------------
Dallas                                  Bldg. #1 & #2 Con$    60,000.00or
                                            Renovation
------------------------------------------------------------------------
Dallas                                                Cli$    44,610.00n Renovation
------------------------------------------------------------------------
Dallas                           Mental Health Offices   $    35,000.00
------------------------------------------------------------------------
Dallas                 Modular Bldgs. 5/6 Installation   $   325,000.00
------------------------------------------------------------------------
Dallas                      Increase Provider/Patient Car$   125,000.00
------------------------------------------------------------------------
Dallas                                   GU Renovation   $    65,000.00
------------------------------------------------------------------------
Dallas                                                CWT$   187,603.00
------------------------------------------------------------------------
Dallas                            Replace PRV Stations   $   261,784.00
------------------------------------------------------------------------
Dallas                           Sump Pump Replacement   $   170,000.00
------------------------------------------------------------------------
Dallas              Install Elevator Monitoring System   $   168,083.00
------------------------------------------------------------------------
Dallas                                             EP/Cat$   150,000.00
------------------------------------------------------------------------
Dallas                             Dallas Roof Repairs   $   164,850.00
------------------------------------------------------------------------
Dallas                                             HVAC C$    81,180.00
------------------------------------------------------------------------
Dallas                              Asbestos Abatement   $   174,938.00
------------------------------------------------------------------------
Dallas                                       Renovate Can$    50,000.00
------------------------------------------------------------------------
Dallas                      Plan For Improvement (PFI)    $  168,196.00
------------------------------------------------------------------------
Dallas                                                Cor$   571,113.00m/Sprinkler Def.
------------------------------------------------------------------------
Dallas                               ER Nursing Triage    $   15,000.00
------------------------------------------------------------------------
Dallas                                           Duct Cle$   423,300.00
------------------------------------------------------------------------
Dallas                                             HVAC C$    81,180.00
------------------------------------------------------------------------
Dallas                          FY05 Facility Lump Sum   $   293,364.00
------------------------------------------------------------------------
Total                                                    $ 3,936,766.00
------------------------------------------------------------------------


                                 FY 2006
------------------------------------------------------------------------
                                                             Total $
  Facility                  Project Title                   Obligated
------------------------------------------------------------------------
Dallas                                             HVAC C$ 2,037,620.00
------------------------------------------------------------------------
Dallas                     Pneumatic Tube Installation   $    74,149.00
------------------------------------------------------------------------
Dallas                B-1/B-12 Electrical Deficiencies   $   242,062.00
------------------------------------------------------------------------
Dallas                                         Mental Cli$   439,400.00
------------------------------------------------------------------------
Dallas                               Diabetes/Women's Cli$   236,330.00
------------------------------------------------------------------------
Dallas                                    5A Telemetry   $    65,049.00
------------------------------------------------------------------------
Dallas                                       Bldg. 2, Cha$    86,652.00
------------------------------------------------------------------------
Dallas                               Dental Renovation   $    61,199.00
------------------------------------------------------------------------
Dallas                                   QM Renovation   $    70,866.00
------------------------------------------------------------------------
Dallas                                                Cor$    82,873.00densate
------------------------------------------------------------------------
Dallas                             Dallas Roof Repairs   $    29,506.00
------------------------------------------------------------------------
Dallas                                             HVAC C$ 2,057,620.00
------------------------------------------------------------------------
Dallas                             Replace Dallas UGST   $   146,000.00
------------------------------------------------------------------------
Dallas                                                Cor$   172,043.00
------------------------------------------------------------------------
Dallas                              Asbestos Abatement   $   140,221.00
------------------------------------------------------------------------
Dallas                                       Renovate Can$    85,769.00
------------------------------------------------------------------------
Dallas                        USP 797 Dallas Pharmacy Cle$    29,207.00
------------------------------------------------------------------------
Dallas                      Plan For Improvement (PFI)   $    79,000.00
------------------------------------------------------------------------
Dallas                                                Cor$    47,609.00m/Sprinkler Def.
------------------------------------------------------------------------
Dallas                               ER Nursing Triage   $    54,247.00
------------------------------------------------------------------------
Dallas                                        Replace CPV$    49,623.00
------------------------------------------------------------------------
Dallas                                                Cor$    64,059.00densate
------------------------------------------------------------------------
Dallas                                        Replace CPV$    29,000.00
------------------------------------------------------------------------
Dallas                          FY06 Facility Lump Sum   $   335,273.00
------------------------------------------------------------------------
Total                                                    $ 6,715,377.00
------------------------------------------------------------------------


                                 FY 2007
------------------------------------------------------------------------
                                                             Total $
  Facility                  Project Title                   Obligated
------------------------------------------------------------------------
Dallas                   Bonham Electrical Deficiency Cor$     43,475.00
------------------------------------------------------------------------
Dallas                           Bonham Fire Sprinkler   $    235,332.00
------------------------------------------------------------------------
Dallas              Replace/Repair Ductwork Insulation   $     99,897.00
------------------------------------------------------------------------
Dallas                 Bonham Roof/Repair Replacements   $    219,979.00
------------------------------------------------------------------------
Dallas                                         Repair Cam$    161,339.00dway and
                                             Sidewalks
------------------------------------------------------------------------
Dallas                                                Cor$     68,932.00wer Deficiencies
------------------------------------------------------------------------
Dallas                        USP 797 Dallas Pharmacy Cle$    218,000.00
------------------------------------------------------------------------
Dallas                   Polytrauma Program Renovation   $    218,824.00
------------------------------------------------------------------------
Dallas                                   Brachytherapy   $     30,148.00
------------------------------------------------------------------------
Dallas                          9th Floor Building #2 Cal$     83,504.00
------------------------------------------------------------------------
Dallas                           QM/PP #8 Domino Moves   $    124,070.00
------------------------------------------------------------------------
Dallas                   Remove Lithotripter Equipment   $     50,066.00
------------------------------------------------------------------------
Dallas                                                Cor$    495,533.00ensate
------------------------------------------------------------------------
Dallas                             Dallas Roof Repairs   $    229,462.00
------------------------------------------------------------------------
Dallas                                                Cor$     68,578.00iencies, Bldg 2
------------------------------------------------------------------------
Dallas                              Asbestos Abatement   $     85,513.00
------------------------------------------------------------------------
Dallas                            Plan For Improvement   $    200,894.00
------------------------------------------------------------------------
Dallas                                               TCU $  1,638,711.00structure
------------------------------------------------------------------------
Dallas                              Relocate Pharmacy Cac$     30,500.00
------------------------------------------------------------------------
Dallas                                  B.2 Steam and Con$    335,092.00Upgrade
------------------------------------------------------------------------
Dallas         Fuel Oil Tank Replacement Dallas/Bonham   $    114,848.00
------------------------------------------------------------------------
Dallas                                  B.2 IT Upgrade   $    335,093.00
------------------------------------------------------------------------
Dallas                                            B.2 Chi$    346,598.00e
------------------------------------------------------------------------
Dallas                              1.5T MRI SITE PREP   $    253,486.00
------------------------------------------------------------------------
Dallas                                 Repair/Replace Cam$    343,104.00
------------------------------------------------------------------------
Dallas                   Fisher House Site Preparation   $    397,407.00
------------------------------------------------------------------------
Dallas                           GI Recovery Expansion   $    143,303.00
------------------------------------------------------------------------
Dallas                    Radiology Renovation Phase I   $      3,000.00
------------------------------------------------------------------------
Dallas                    Human Resources (HR) Modular   $    471,651.00
------------------------------------------------------------------------
Dallas                            MAS Modular Building   $    471,651.00
------------------------------------------------------------------------
Dallas                           Mental Health Modular   $    383,124.00
------------------------------------------------------------------------
Dallas                                              ASCO $    272,181.00
------------------------------------------------------------------------
Dallas        Additional NRM Mental Health Modular Bldg  $    448,608.00
------------------------------------------------------------------------
Dallas                                                Cor$     70,513.00C Deficiencies Phase 1
------------------------------------------------------------------------
Dallas                                                Cor$     47,131.00ctrical Deficiencies
------------------------------------------------------------------------
Dallas                OR Vascular Equipment Site Prep.   $     49,790.00
------------------------------------------------------------------------
Dallas                     Dallas Roof Repairs, Bldg 2   $    229,462.00
------------------------------------------------------------------------
Dallas                                        Replace Chi$  1,710,823.00
------------------------------------------------------------------------
Dallas            Install Steam trap Monitoring System   $     46,418.00
------------------------------------------------------------------------
Dallas                                   Power Factor Cor$     16,300.00
------------------------------------------------------------------------
Dallas          Building 1 Exterior Renovation Phase 1   $     20,381.00
------------------------------------------------------------------------
Dallas          Building 2 Exterior Renovation Phase 2   $     67,734.00
------------------------------------------------------------------------
Dallas                          FY07 Facility Lump Sum   $  2,834,226.00
------------------------------------------------------------------------
Total                                                    $ 13,714,681.00
------------------------------------------------------------------------


                                                     FY 2008
----------------------------------------------------------------------------------------------------------------
                                                                                                       Planned
               Facility                                 Project Title                    Planned    Construction
                                                                                       Design Cost       Cost
----------------------------------------------------------------------------------------------------------------
Dallas                                         Install steam trap monitoring system     $  50,000   $   200,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                          East Site Utilities                 $   400,000
----------------------------------------------------------------------------------------------------------------
Dallas                                          Building 2 Exterior Renovation Ph.1     $  45,000   $   250,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                        Lot 27 Site Utilities                 $   400,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                                             Corre$       0Con$   500,0002
----------------------------------------------------------------------------------------------------------------
Dallas                                                 Replace deteriorated Bldg. 2     $  60,000   $   706,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                                            SCI Pool Lift Upgr$   356,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                                     Replace CPVC $ 100,000al $   800,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                        Polytrauma Renovation     $ 150,000   $ 1,350,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                    Window Repair/Replacement     $  70,000   $   753,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                                             Corre$  65,000efi$   536,201ldg 2
----------------------------------------------------------------------------------------------------------------
Dallas                                                                             Corre$  50,0001 H$   450,000ncies Ph1
----------------------------------------------------------------------------------------------------------------
Dallas                                                                             Corre$  50,0001 E$   412,500eficiencies
----------------------------------------------------------------------------------------------------------------
Dallas                                                    Replace Elevators Bldg. 1     $  90,000   $   900,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                                             Chi$    60,000placement Upgrade*
----------------------------------------------------------------------------------------------------------------
Dallas                                         Bldg 43 Sprinkler Pipe Installation*   $    40,000
----------------------------------------------------------------------------------------------------------------
Dallas                                             Pharmacy Prescription Disp Area*   $    20,000
----------------------------------------------------------------------------------------------------------------
Dallas                                                              Upgrade Dallas Cam$    90,000rk Phl*
----------------------------------------------------------------------------------------------------------------
Dallas                                                                     Replace Cam$   100,000arm System*
----------------------------------------------------------------------------------------------------------------
Dallas                                                             Bldg 1 Replace FCU $    42,000s Ph.1 *
----------------------------------------------------------------------------------------------------------------
Dallas                                                           Boiler Plant Repl*   $   200,000
----------------------------------------------------------------------------------------------------------------
10Total                                                                                $1,282,000   $ 8,013,701
----------------------------------------------------------------------------------------------------------------
* Only planned designed costs for FY 2008
----------------------------------------------------------------------------------------------------------------

FY 2007 and FY 2008 Emergency Supplemental:

------------------------------------------------------------------------
             FY 2007 and FY 2008 Emergency Supplemental NRM
-------------------------------------------------------------------------
   Station            Project Title/Description             Total Cost
------------------------------------------------------------------------
Dallas                             Dallas Roof Repairs   $   816,000.00
------------------------------------------------------------------------
Dallas                                                Cor$   604,780.00Def
------------------------------------------------------------------------
Dallas                                 Repair/Replace Cam$   400,000.00
------------------------------------------------------------------------
Dallas                                                Cor$   520,514.00Def (Ph1)
------------------------------------------------------------------------
Dallas                                                Cor$   462,500.00rical Deficiencies
------------------------------------------------------------------------
Dallas                                        Replace Chi$ 1,800,000.00
------------------------------------------------------------------------
Dallas                           Window Repair/Replace   $   753,000.00
------------------------------------------------------------------------
Dallas                    B.1 Exterior Renovation Ph.2   $   450,000.00
------------------------------------------------------------------------
Dallas                           Replace Elevators B.1   $   900,000.00
------------------------------------------------------------------------
Dallas                           Polytrauma Renovation   $ 1,500,000.00
------------------------------------------------------------------------
Total                                                    $ 8,206,794.00
------------------------------------------------------------------------


VA North Texas Capital Budget for FY 2005-2008:

------------------------------------------------------------------------------------------------------------------------------------------------
VA North Texas Capital Budget
------------------------------------------------------------------------
FY 2005 Dallas VERA NRM Allocation                      $  5,945,530.00
------------------------------------------------------------------------
FY 2005 Dallas Supplemental Appropriation for NRM       $  2,200,000.00
------------------------------------------------------------------------
Total                                                   $  8,145,530.00
------------------------------------------------------------------------------------------------------------------------------------------------
FY 2006 Dallas VERA NRM Allocation                      $  6,450,000.00
------------------------------------------------------------------------------------------------------------------------------------------------
FY 2007 Dallas VERA NRM Allocation                      $  5,663,301.00
------------------------------------------------------------------------
FY 2007 Dallas Emergency Supplemental Allocation        $  2,581,985.71
------------------------------------------------------------------------
FY 2007 Dallas Energy Funds                             $    700,000.00
------------------------------------------------------------------------
FY 2007 Dallas Mental Health (Modular Building)         $    831,732.00
------------------------------------------------------------------------
Total                                                   $  9,777,018.71
------------------------------------------------------------------------------------------------------------------------------------------------
FY 2008 Dallas VERA NRM Allocation                      $  3,137,240.00
------------------------------------------------------------------------
FY 2008 Dallas Supplemental Add-on Allocation           $  2,400,000.00
------------------------------------------------------------------------


------------------------------------------------------------------------------------------------------------------------------------------------
VA North Texas Capital Budget--Continued
------------------------------------------------------------------------
FY 2008 Dallas Mental Health Allocation                 $     10,000.00
------------------------------------------------------------------------
FY 2007/2008 Dallas Emergency Supplemental              $  5,001,701.00
 Allocation
------------------------------------------------------------------------
Total                                                   $ 10,548,941.00
------------------------------------------------------------------------
Total Capital Funding                                   $ 34,921,489.71
------------------------------------------------------------------------

    The Dallas VAMC is a complexity Level I facility, providing 
tertiary care services to over 102,000 unique patients, which makes it 
VA's 3rd largest health care system in terms of number of unique 
patients treated. The Dallas VAMC is a teaching hospital, providing a 
full range of patient care services with state-of-the-art technology as 
well as advanced education and research. Through its strategic 
partnership with University of Texas Southwestern Medical Center and 
Baylor College of Dentistry, Dallas VAMC helped train more than 740 
medical residents and eight dental residents in FY 2007. The Dallas 
VAMC has affiliation agreements with over 100 agencies and 
institutions, providing training to approximately 2,000 students.

    Question 4(c): Please provide the Committee with a list including 
the names of the director and the senior leadership of the Dallas VA 
Medical Center during 2004 and 2005, and if still employed by the VA, 
their current titles and responsibilities.

    Response: In 2004, Dallas VAMC leadership consisted of the 
following:

    Medical Center Director: Alan G. Harper, retired March 2005.
    Associate Director: William E. Cox, transferred to Clarksburg VAMC 
as Director, January 2005. He currently has full delegated line 
authority and responsibility for executive level management of the 
Clarksburg VAMC and its community outpatient clinics.
    Assistant Director: Daniel K. Heers, retired April 2005.
    Chief of Staff: Robert Cronin, reassigned to staff physician, 
Medical Services in March 2005. He currently treats patients in the 
Nephrology Clinic and on the inpatient wards for kidney diseases.
    Chief Nurse: Burlean Huff was the Acting Executive Nurse for Dallas 
from January 2005 to September 2005 until recruitment of Associate 
Director of Nursing. He retired December 2007. This position converted 
into the Associate Director of Nursing.

    In 2005, Dallas VAMC leadership consisted of the following:

    Medical Center Director: Betty Bolin Brown transferred to Employee 
Education System in Shreveport, LA on April 2007. She is the Executive 
Scholar for the Employee Education System.
    Current Medical Center Director: Joseph M. Dalpiaz, effective May 
2007 has full delegated line authority and responsibility for executive 
level management of the VA North Texas Health Care System (VANTHCS).
    Associate Director: Jeff Milligan, Associate Director, effective 
September 2005, has the responsibility for the direction, evaluation 
and control of all administrative activities in the medical center.
    Assistant Director: Daniel K. Heers, retired April 2005. Eric D. 
Jacobsen, Assistant Director effective December 2005 his 
responsibilities include direction of human resources and information 
resources management, logistics, facilities and health care environment 
management and health services administration.
    Chief of Staff: Robert Cronin, Chief of Staff since January 2005, 
and reassigned in March 2005 to Staff Physician, Medical Service where 
he is responsible for treating patients in the Nephrology Clinic and on 
the inpatient wards for kidney diseases. John Sum-Ping, MD, Acting 
Chief of Staff effective 2005 through November 2006. Dr. Sum-Ping is 
currently Chief, Anesthesiology and Pain Management Service at VANTHCS 
and manages all of the anesthesiology and pain management operations at 
VANTHCS. Clark R. Gregg effective November 2006 is the current Chief of 
Staff responsible for managing clinical operations.
    Associate Director of Patient Care Services: Sandra Y. Griffin, 
effective September 2005 is the current Associate Director for Nursing 
Service having oversight for the daily clinical and administrative 
operations of the Nursing Service.

    Question 5: The email sent on March 20, 2008, by a VA employee at 
the Temple Texas VAMC, suggested that diagnoses of ``adjustment 
disorder'' be given instead of diagnoses of PTSD. Please provide the 
Committee with the number of adjustment disorder diagnoses and PTSD 
diagnoses by facility since 2001.

    Response: The attached spread sheet provides data related to 
adjustment disorder diagnoses and PTSD diagnosis by facility, 
separately for each year from 2001 through 2008.

    Question 6(a): Recently, CBS News reported that a VA team leader in 
Texas suggested mental health professionals should diagnose patients 
with ``adjustment disorder'' rather than post-traumatic stress disorder 
in order to save time and money treating veterans. Secretary Peake has 
characterized this email as ``inappropriate.'' An email by Dr. Katz 
dated February 13, 2008, entitled ``Not for the CBS News Interview 
Request'' has also been characterized as inappropriate. Please provide 
to the Committee the training materials provided to VA employees 
regarding proper electronic mail behavior.

    Response: Email training is provided annually to VA employees and 
contractors through the VA cyber security awareness training program. 
VA annual cyber security awareness training is mandatory for all VA 
employees, contractors, students, and volunteers. This requirement is 
specified in law through the Federal Information Security Management 
Act (FISMA) of 2002 and the Office of Management and Budget (OMB) 
Circular A-130, Appendix III. VA-wide compliance statistics are 
reported each year in accordance FISMA and to OMB. VA employees can 
access the Cyber Security Awareness Course on the VA Intranet. Attached 
is the course script for the VA National Rules of Behavior.
    [The Course Script entitled, ``VA National Rules of Behavior,'' 
Developed by the U.S. Department of Veterans Affairs, Office of 
Information and Technology, Cyber Security Service, and the 
Presentation entitled, ``VHA Privacy Policy Training, FY 2008,'' will 
be retained in the Committee files.]

    Question 6(b): Please provide the Committee with the training 
materials provided to VA employees regarding what constitutes 
appropriate behavior and accountability or individual actions, 
especially with regards to electronic mail.

    Response: The VA Rules of Behavior document that each VA employee 
is required to sign prior to gaining access to VA IT systems outlines 
the proper use of VA email. Attached is a copy of the Rules of Behavior 
document.

    Question 6(c): Please provide the Committee with the number of 
disciplinary actions, including the reason for the disciplinary action, 
undertaken by the VA since 2002 involving electronic mail or in 
response to individual actions that the VA has determined to be 
inappropriate.

    Response: The Department does not track reasons for disciplinary 
actions.

    Question 7(a): It has been clearly demonstrated that the Department 
of Defense and VA must work together to address issues that face 
departments, such as suicide, mental health and substance abuse 
treatment. Given such demonstrated need: Please provide the Committee 
with a detailed list of specific programs being developed by both 
departments to jointly address these issues.

    Response: VA and the Department of Defense (DoD) have 
collaborations on the following:

      VA and DoD produced joint Clinical Practice Guidelines 
(CPG) on major depressive disorder (MDD), PTSD, and substance use 
disorders since the first MDD CPG in 1996.
      VA and DoD collaborated on the creation of the mental 
health questions in the post deployment health re-assessment (PDHRA). 
The questions on PTSD, for example, are identical to those used as the 
standard PTSD screen administered to all veterans and are part of VA's 
OEF/OIF automated screening tool.
      DoD participated with VA and other entities in developing 
a plan for improving PTSD clinical research methodology subsequent to 
the recent Institute of Medicine (IOM) report on PTSD treatments.
      VA and DoD are collaborating on the activities of the 
Defense Center of Excellence (DCoE) for psychological health and TBI. A 
VA clinician is the new Deputy Director of the DCoE. VA will 
collaborate on future DCoE research.

    Question 7(b): Please provide the Committee with a detailed 
explanation of the individual or joint efforts by both departments to 
collect data on suicides or to do a comprehensive study on suicides. If 
there have not been any efforts, please explain the lack of such 
efforts.

    Response: There is an effort underway across Federal agencies, 
including VA, DoD, Substance Abuse and Mental Health Services 
Administration, Center for Disease Control, and the National Institutes 
of Health to examine suicide prevention efforts across systems. A panel 
of experts has been assembled to advise a Blue Ribbon Work Group on 
Suicide Prevention in the Veteran Population (Work Group) who will 
examine current knowledge as well as gaps in knowledge regarding 
suicide prevention. The Work Group is meeting in mid-June with a final 
report due 15 days following the meeting. New joint efforts to collect 
data on suicides based on the recommendations of the Work Group will be 
developed from these deliberations.
    Another joint effort between VA and DoD is collaboration on the 
development of a joint Web site for suicide prevention. The goal of 
building such a site is to provide linkage with multiple resources 
appropriate for servicemembers, veterans, and their families.
    In addition, the Center of Excellence at Canandaigua and the 
Serious Mental Illness Treatment Research and Evaluation Center 
(SMITREC) at Ann Arbor are planning a study to use population based 
data on suicide and suicide attempts to develop real time tracking 
systems of suicidal behavior for veterans in VA.
    The Center of Excellence at Canandaigua is planning a study of the 
reliability of the suicide behavior template data, which includes data 
on suicide attempts and completions reported by the suicide prevention 
coordinators. Reliability will be established through the use of 
vignettes that present a series of diverse scenarios of veterans in 
psychological or emotional distress. A rating scale based on consensus 
from a consortium of Center of Excellence experts will be developed in 
order to define an appropriate assessment of the veteran depicted in 
each scenario. These vignettes will be rated by the suicide prevention 
coordinators. This will allow us to examine both the inter-rater 
reliability and reliability with the expert consensus response.
    The Center of Excellence at Canandaigua, in collaboration with 
SMITREC at Ann Arbor, will also conduct a study to establish concurrent 
validity of the Suicide Behavior Template using administrative and 
clinical data. This collaborative study will include establishing the 
predictive validity of the reported measures of suicidal behavior using 
repeat attempts or death from suicide.
    The Center of Excellence at Canandaigua and the SMITREC at Ann 
Arbor, Michigan are planning a study of the data from VA's 24-hour 
suicide crisis line to determine if there are new, emergent veteran 
populations at risk for suicidal behaviors. Both younger veterans and 
veterans in rural or underserved areas will be evaluated as part of 
this study as to mental health care needs of both groups that VA should 
address.

    Question 8(a): VHA testified before the Subcommittee on Health on 
January 17, 2008, regarding Mr. Boswell's bill H.R. 4204, the 
``Veterans Suicide Study Act.'' The testimony given was very critical 
of the bill as far as what the bill would accomplish as written. 
Specifically, VHA stated that ``[w]e do not believe the study required 
by this bill would generate information that would further our 
understanding of how to effectively screen and treat veterans who may 
be at risk of suicide. It would merely provide us with the rates for 
this cohort of veterans. VA has studied suicide rates for multiple 
cohorts of veterans and, through such efforts, has already identified 
the major clinical risk factors for suicide''. VHA also stated that 
this bill, as drafted, would not afford VA the flexibility needed to 
develop a thorough and useful study. Is this still the position of the 
VA?

    Response: We do not believe the study required by this bill would 
generate information that would further our understanding of how to 
effectively screen and treat veterans who may be at risk of suicide. It 
would merely provide us with the rates for this cohort of veterans. VA 
has studied suicide rates for multiple cohorts of veterans and has 
already identified the major clinical risk factors for suicide. In 
fact, we recently completed such a study for OEF/OIF veterans. Using 
the data generated from those studies, we have developed protocols and 
processes to mitigate those risk-factors. For these reasons, we do not 
support section 103.
    Further, certain requirements mandated by the bill make its 
implementation not feasible. As now drafted, it would not afford VA the 
flexibility needed to develop a thorough and useful study. To design 
and carry out a study that is best designed to provide usable 
information to address the issue of veteran suicide rates, we believe 
the Secretary should determine the organization(s) with which the 
Department should coordinate the study. For instance, the Center for 
Disease Control (CDC) studies suicide rates among the general 
population, while VA's role has been to validate the information 
compiled by CDC.
    Additionally the 180-day timeframe is not realistic, as there is 
currently a 2-year time lag in the information released by CDC on 
suicide rates. We estimate the cost of this bill to be $1,580,006 in FY 
2008 and $2,078,667 over a 10-year period.

    Question 8(b): Is VA developing a large scale study on the OEF/OIF 
veteran population to track suicides?

    Response: VHA's Environmental Epidemiology Service is conducting a 
large scale study of suicides among OEF/OIF veterans. Study results are 
expected within the next 6 months.

    Question 8(c): Does VA believe this needs to be done? If not, why 
not?

    Response: VA believes this study should be conducted.

    Question 9(a): In a July 2005 briefing by the Veterans Health 
Administration on ``Modeling and Strategic Planning for Mental Health 
and Substance Abuse Services'' slide 14, entitled ``Negative Gaps,'' 
states that: VISNs will not address gaps where the FY 2013 or 2013 
forecast demand is less than the FY 2003 actual demand with one 
exception

      --In those markets in which enrollment is projected to decline 
for the FY 2003 actual demand by more than 10% in FY 2013 and/or by 
more than 20% in FY 2023, the VISN should develop plans to reduce 
services in line with the projected declines in demand.

    Does this accurately reflect the current policy of the VHA? If not, 
when was this policy changed and for what reasons?

    Response: Since the 2005 presentation, our planning process for 
mental health and substance abuse services has significantly evolved 
with the creation of the VHA Comprehensive Mental Health Strategic Plan 
(MHSP), which was signed as policy by the Secretary in November 2005. 
The plan calls for expansion and enhancement of mental health services 
to fill gaps in mental health care, and to use the best practices in 
care that will offer the greatest likelihood of decreasing mental 
health symptoms and improving overall functioning and well-being of 
veterans with mental health problems. There is no current policy that 
would fit the information as described in this query.

    Question 9(b): What is the current strategic plan of the VHA 
regarding mental health and substance abuse, especially with regards to 
planning for future infrastructure and employment needs? Has this 
planning changed since 2005?

    Response: The MHSP of 2005 is the current strategic plan of VA 
regarding mental health and substance abuse services. It provides 
guidance for infrastructure and employment needs, along with many other 
elements of enhanced mental health care. The MHSP continues to be 
implemented aggressively, with collaboration across many offices in VHA 
to guide that process, including the Office of Mental Health Services, 
working within Patient Care Services (PCS) and involving many other 
offices within PCS; the Office of the Assistant Deputy Under Secretary 
for Health for Policy and Planning; and the Office of the Deputy Under 
Secretary for Health for Operations and Management.
    Additional guidance for implementation of the MHSP is under 
development. A VA handbook on Uniform Mental Health Services outlines 
services available to all veterans seeking or identified as needing 
mental health care. This handbook is an outgrowth of our extensive 
experience in implementing enhanced mental health services and reflects 
the MHSP. The handbook delineates the essential components of the 
mental health program that are to be implemented nationally, to ensure 
that all enrolled veterans, wherever they obtain care, have access to 
needed mental health services. It also specifies those services that 
must be accessible through each VAMC and each CBOC, and delineates that 
services must be made available through collaborative fee basis and 
contract relationships for veterans who are not close enough to receive 
care directly from VA facilities. By establishing the requirements of 
what services must be available to each veteran, no matter where in VHA 
they receive care VHA is ensuring a patient-centric uniform mental 
health services package to meet the care needs for each veteran.

    Question 10(a): The recent RAND report, ``Invisible Wounds of 
War,'' defined ``minimally adequate exposure to psychotherapy'' (as 
part of the definition for minimally adequate care) in the following 
manner:

      Minimally adequate exposure to psychotherapy. was defined as 
having had at least 8 visits with a ``mental health professional such 
as a psychiatrist, psychologist or counselor'' in the past 12 months, 
with visits averaging at least 30 minutes. Criteria for minimally 
adequate courses of treatment were adapted from the National 
Comorbidity Study Replication (Wang et al., 2005). Does the VA agree 
with this definition? Why or why not?

    Response: This definition is not a sufficient representation of 
adequate treatment and is limited in a number of significant respects, 
as follows:

      This definition is very broad and could include a wide 
variety of psychotherapies that have not been empirically established 
or shown to be effective, such as supportive counseling or other talk 
therapies that do not focus on promoting changes in thinking, behavior, 
or emotional functioning in a sustained way, as other psychotherapies 
have been demonstrated to do. Significantly, the above definition was 
initially developed by Wang et al. (2005) for measuring patterns of 
services, not for evaluating or establishing standards of care. 
Moreover, the references cited for the authors' definition were to 
practice guidelines that specifically recommend established evidence-
based psychotherapies, such as cognitive-behavioral therapy (CBT).
      In addition to including psychotherapeutic interventions 
that have not been scientifically established, the definition could 
also include case management, counseling, and other similar 
interventions that are not standard treatments for the core symptoms of 
PTSD, depression, and other mental health conditions.
      The definition of what may be considered adequate 
psychotherapeutic treatment is inconsistent with widely accepted 
practice guidelines for psychotherapy. This includes guidelines 
established by the American Psychiatric Association and the Agency for 
Health Care Policy and Research, as well as the VA/ DoD Clinical 
Practice Guidelines for PTSD and depression. These guidelines recommend 
the delivery of evidence-based psychotherapies, such as CBT for 
depressive and anxiety disorders, and cognitive processing therapy 
(CPT) and prolonged exposure (PE) therapy for PTSD. Both CPT and PE are 
highly recommended in the VA/DoD Clinical Practice Guidelines, 
indicating that the intervention is always indicated and acceptable. 
This was affirmed by a recent report on evidence-based treatments for 
PTSD by the Institute of Medicine. These practice guidelines also 
generally recommend 12-16 sessions of 50-90 minutes each, as opposed to 
the standard of eight 30-minute sessions included in the definition in 
the RAND report.

    Psychotherapies identified as ``evidence-based,'' including CBT, 
CPT, and PE, are psychotherapies that have been shown in randomized 
clinical trials to be more effective than other forms of psychotherapy, 
such as supportive counseling. Evidence-based psychotherapies are 
structured with established protocols and have manuals to help guide 
the treatment process. They also have the benefit of being time-
limited. Moreover, evidence-based psychotherapies typically provide 
long-term benefits and have thus been found to be cost-effective.
    Data on mental health care delivery in VA indicate that 
psychotherapy, particularly individual psychotherapy, is provided at 
levels of frequency and intensity well below those recommended in 
practice guidelines. Evidence-based psychotherapy appears to be 
especially under-used. Unfortunately, psychotherapy codes in medical 
records do not indicate the specific type of psychotherapy provided, so 
precise data on the delivery of evidence-based psychotherapies in VA is 
unknown. However, a recent survey of VA program leaders found that lack 
of implementation of evidence-based psychological treatments was due, 
in large part, to limited knowledge and skills and lack of 
administrative support (Willenbring et al., 2004).
    VA has recently developed several national initiatives to train VA 
mental health providers in the delivery of a number of evidence-based 
psychotherapies for a variety of mental health conditions, including 
CPT and PE for PTSD, CBT for depression and anxiety, and social skills 
training for serious mental illnesses. CPT was the first funded 
initiative, initially funded in early FY 2007. In May 2008, VA began 
the training rollout for all mental health professionals.

    Question 10(b): On average, over the last 5 years, how many visits 
with a psychiatrist, psychologist or counselor could a veteran expect 
over the course of one year, and what is the average length of each 
visit?
    Response: The following table provides summary data of veterans who 
received mental health services in an outpatient mental health program 
from FY 2003 through FY 2007:

----------------------------------------------------------------------------------------------------------------
                           Veterans with a MH Dx* seen as an Outpatient by Fiscal Year
-----------------------------------------------------------------------------------------------------------------
                                                                                                 Avg Number of
                                                                          Total Outpatient        Outpatient
                                               Veterans with a MH Dx     Encounters with MH   Encounters with MH
                     FY                        Seen by  MH Provider         Provider for         Provider for
                                                                        Veterans with  MH Dx   Veterans Seen by
                                                                                                  MH Provider
----------------------------------------------------------------------------------------------------------------
FY03                                                         708,882              7,345,328                10.4
----------------------------------------------------------------------------------------------------------------
FY04                                                         771,235              7,514,644                 9.7
----------------------------------------------------------------------------------------------------------------
FY05                                                         831,890              7,914,211                 9.5
----------------------------------------------------------------------------------------------------------------
FY06                                                         878,246              8,489,263                 9.7
----------------------------------------------------------------------------------------------------------------
FY07                                                         944,969              9,387,070                 9.9
----------------------------------------------------------------------------------------------------------------
*Outpatient Diagnoses 290.x-319.x excluding Tobacco Use 305.1xData provided by VSSC on June 23, 2008 using VA Outpatient Workload and Enrollment Data. Fee data not included.
 Veterans Only.
----------------------------------------------------------------------------------------------------------------

    The duration and intensity of treatment varies depending on the 
acuity level of the veteran. Typically in the early stages of recovery 
veterans are seen more frequently for both medication management and 
psychotherapy. As the veteran progresses and becomes more stable, the 
frequency and duration of treatment decreases. The duration of 
medication management sessions range from 15--60 minutes. Most 
psychotherapy sessions are 60 minutes but they also can be 30 minute 
brief treatment sessions, or they may be up to 90 minutes for some 
sessions of PE therapy for PTSD. Group therapy sessions tend to be 60 
minutes.

                               __________

                                                                                    ATTACHMENT TO QUESTION 5
                                                          VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01
                                              (includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Uniques with   Uniques with  PTSD  Dx   Uniques with PTSD Dx      Uniques with  Adj       Uniques with Adj      Uniques with PTSD Dx
-------------------------------------------------------- PTSD and/or Adj ------------------------ Only (w/o Adj Disorder       Disorders  Dx      Disorders Dx Only (w/o   and Adj  Disorder Dx
                                                             Disorder                                       Dx)          ------------------------        PTSD Dx)        -----------------------
                                                        -----------------      N      % of Total ------------------------                        ------------------------
                                                                                                       N      % of Total       N      % of Total       N      % of Total       N      % of Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
VHA                                                             257,332     193,954       75.4%     180,006       70.0%      77,326       30.0%      63,378       24.6%      13,948        5.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (402) Togus, ME                                             2,494       2,132       85.5%       1,978       79.3%         516       20.7%         362       14.5%         154        6.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (405) White River Junction, VT                              1,426       1,114       78.1%       1,055       74.0%         371       26.0%         312       21.9%          59        4.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (518) Bedford, MA                                           1,155         917       79.4%         829       71.8%         326       28.2%         238       20.6%          88        7.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (523) VA Boston HCS, MA                                     6,655       4,435       66.6%       3,957       59.5%       2,698       40.5%       2,220       33.4%         478        7.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (608) Manchester, NH                                        1,206       1,013       84.0%         964       79.9%         242       20.1%         193       16.0%          49        4.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (631) Northampton, MA                                       1,442       1,236       85.7%       1,183       82.0%         259       18.0%         206       14.3%          53        3.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (650) Providence, RI                                        1,952       1,729       88.6%       1,687       86.4%         265       13.6%         223       11.4%          42        2.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (689) VA Connecticut HCS, CT                                2,444       2,062       84.4%       1,983       81.1%         461       18.9%         382       15.6%          79        3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Albany, NY                                            2,535       1,951       77.0%       1,730       68.2%         805       31.8%         584       23.0%         221        8.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Bath, NY                                                852         648       76.1%         595       69.8%         257       30.2%         204       23.9%          53        6.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Buffalo, NY                                           2,396       1,648       68.8%       1,532       63.9%         864       36.1%         748       31.2%         116        4.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Canandaigua, NY                                       1,227         995       81.1%         946       77.1%         281       22.9%         232       18.9%          49        4.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Syracuse, NY                                          1,698       1,209       71.2%       1,112       65.5%         586       34.5%         489       28.8%          97        5.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (526) Bronx, NY                                             1,090         850       78.0%         812       74.5%         278       25.5%         240       22.0%          38        3.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (561) New Jersey HCS, NJ                                    3,344       2,848       85.2%       2,739       81.9%         605       18.1%         496       14.8%         109        3.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (620) VA Hudson Valley HCS, NY                              1,536       1,369       89.1%       1,213       79.0%         323       21.0%         167       10.9%         156       10.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (630) New York Harbor HCS, NY                               4,879       3,327       68.2%       2,959       60.6%       1,920       39.4%       1,552       31.8%         368        7.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (632) Northport, NY                                         1,794       1,375       76.6%       1,281       71.4%         513       28.6%         419       23.4%          94        5.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (460) Wilmington, DE                                          988         717       72.6%         664       67.2%         324       32.8%         271       27.4%          53        5.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (503) Altoona, PA                                             503         329       65.4%         313       62.2%         190       37.8%         174       34.6%          16        3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (529) Butler, PA                                              407         249       61.2%         236       58.0%         171       42.0%         158       38.8%          13        3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (540) Clarksburg, WV                                        1,652       1,452       87.9%       1,342       81.2%         310       18.8%         200       12.1%         110        6.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (542) Coatesville, PA                                       2,735       1,655       60.5%       1,444       52.8%       1,291       47.2%       1,080       39.5%         211        7.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (562) Erie, PA                                                513         354       69.0%         324       63.2%         189       36.8%         159       31.0%          30        5.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (595) Lebanon, PA                                           1,540       1,000       64.9%         891       57.9%         649       42.1%         540       35.1%         109        7.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (642) Philadelphia, PA                                      2,996       2,711       90.5%       2,604       86.9%         392       13.1%         285        9.5%         107        3.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (646) Pittsburgh, PA                                        2,337       1,985       84.9%       1,863       79.7%         474       20.3%         352       15.1%         122        5.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (693) Wilkes-Barre, PA                                      1,628       1,120       68.8%       1,063       65.3%         565       34.7%         508       31.2%          57        3.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V05) (512) Baltimore HCS, MD                                     2,925       1,651       56.4%       1,436       49.1%       1,489       50.9%       1,274       43.6%         215        7.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V05) (613) Martinsburg, WV                                       1,972       1,476       74.8%       1,320       66.9%         652       33.1%         496       25.2%         156        7.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V05) (688) Washington, DC                                        2,226       1,905       85.6%       1,765       79.3%         461       20.7%         321       14.4%         140        6.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (517) Beckley, WV                                             961         765       79.6%         733       76.3%         228       23.7%         196       20.4%          32        3.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (558) Durham, NC                                            2,411       2,105       87.3%       2,027       84.1%         384       15.9%         306       12.7%          78        3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (565) Fayetteville, NC                                      1,246       1,041       83.5%       1,011       81.1%         235       18.9%         205       16.5%          30        2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (590) Hampton, VA                                           1,703       1,500       88.1%       1,441       84.6%         262       15.4%         203       11.9%          59        3.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (637) Asheville, NC                                         1,680       1,482       88.2%       1,397       83.2%         283       16.8%         198       11.8%          85        5.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (652) Richmond, VA                                          1,321         948       71.8%         890       67.4%         431       32.6%         373       28.2%          58        4.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (658) Salem, VA                                             1,521       1,282       84.3%       1,210       79.6%         311       20.4%         239       15.7%          72        4.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


                                                    VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01--Continued
                                              (includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Uniques with   Uniques with  PTSD  Dx   Uniques with PTSD Dx      Uniques with  Adj       Uniques with Adj      Uniques with PTSD Dx
-------------------------------------------------------- PTSD and/or Adj ------------------------ Only (w/o Adj Disorder       Disorders  Dx      Disorders Dx Only (w/o   and Adj  Disorder Dx
                                                             Disorder                                       Dx)          ------------------------        PTSD Dx)        -----------------------
                                                        -----------------      N      % of Total ------------------------                        ------------------------
                                                                                                       N      % of Total       N      % of Total       N      % of Total       N      % of Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (659) Salisbury, NC                                         2,696       2,090       77.5%       1,964       72.8%         732       27.2%         606       22.5%         126        4.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (508) Decatur, GA                                           2,895       2,700       93.3%       2,616       90.4%         279        9.6%         195        6.7%          84        2.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (509) Augusta, GA                                           1,856       1,606       86.5%       1,562       84.2%         294       15.8%         250       13.5%          44        2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (521) Birmingham, AL                                        2,310       2,001       86.6%       1,864       80.7%         446       19.3%         309       13.4%         137        5.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (534) Charleston, SC                                        1,403       1,166       83.1%       1,131       80.6%         272       19.4%         237       16.9%          35        2.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (544) Columbia, SC                                          3,707       2,611       70.4%       2,302       62.1%       1,405       37.9%       1,096       29.6%         309        8.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (557) Dublin, GA                                            1,456       1,276       87.6%       1,163       79.9%         293       20.1%         180       12.4%         113        7.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (619) Montgomery-West, AL                                   2,046       1,773       86.7%       1,695       82.8%         351       17.2%         273       13.3%          78        3.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (679) Tuscaloosa, AL                                        1,814       1,718       94.7%       1,676       92.4%         138        7.6%          96        5.3%          42        2.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (516) Bay Pines, FL                                         4,285       2,950       68.8%       2,775       64.8%       1,510       35.2%       1,335       31.2%         175        4.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (546) Miami, FL                                             3,024       2,051       67.8%       1,937       64.1%       1,087       35.9%         973       32.2%         114        3.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (548) West Palm Beach, FL                                   2,191       1,652       75.4%       1,558       71.1%         633       28.9%         539       24.6%          94        4.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (573) Gainesville, FL                                       4,897       3,470       70.9%       3,181       65.0%       1,716       35.0%       1,427       29.1%         289        5.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (672) San Juan, PR                                          1,969         976       49.6%         929       47.2%       1,040       52.8%         993       50.4%          47        2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (673) Tampa, FL                                             6,006       3,791       63.1%       3,398       56.6%       2,608       43.4%       2,215       36.9%         393        6.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (581) Huntington, WV                                        1,806       1,623       89.9%       1,594       88.3%         212       11.7%         183       10.1%          29        1.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (596) Lexington, KY                                         1,788       1,482       82.9%       1,382       77.3%         406       22.7%         306       17.1%         100        5.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (603) Louisville, KY                                        1,857       1,017       54.8%         866       46.6%         991       53.4%         840       45.2%         151        8.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (614) Memphis, TN                                           1,588       1,073       67.6%         935       58.9%         653       41.1%         515       32.4%         138        8.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (621) Mountain Home, TN                                     2,154       1,658       77.0%       1,580       73.4%         574       26.6%         496       23.0%          78        3.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (626) Middle Tennessee HCS, TN                              3,466       2,656       76.6%       2,502       72.2%         964       27.8%         810       23.4%         154        4.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (538) Chillicothe, OH                                       1,612       1,173       72.8%       1,031       64.0%         581       36.0%         439       27.2%         142        8.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (539) Cincinnati, OH                                        2,006       1,586       79.1%       1,422       70.9%         584       29.1%         420       20.9%         164        8.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (541) Cleveland--Wade Park, OH                              4,347       2,752       63.3%       2,452       56.4%       1,895       43.6%       1,595       36.7%         300        6.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (552) Dayton, OH                                            1,776       1,206       67.9%       1,087       61.2%         689       38.8%         570       32.1%         119        6.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (757) Columbus, OH                                            937         601       64.1%         565       60.3%         372       39.7%         336       35.9%          36        3.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (506) Ann Arbor, MI                                           885         689       77.9%         659       74.5%         226       25.5%         196       22.1%          30        3.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (515) Battle Creek, MI                                      1,983       1,506       75.9%       1,371       69.1%         612       30.9%         477       24.1%         135        6.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (550) Danville, IL                                          2,108         960       45.5%         837       39.7%       1,271       60.3%       1,148       54.5%         123        5.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (553) Detroit, MI                                           1,225         738       60.2%         661       54.0%         564       46.0%         487       39.8%          77        6.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (583) Indianapolis, IN                                      1,247         751       60.2%         667       53.5%         580       46.5%         496       39.8%          84        6.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (610) Northern Indiana HCS, IN                                981         675       68.8%         651       66.4%         330       33.6%         306       31.2%          24        2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (655) Saginaw, MI                                             723         526       72.8%         491       67.9%         232       32.1%         197       27.2%          35        4.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (537) Jesse Brown VAMC (Chicago), IL                        2,938       1,750       59.6%       1,589       54.1%       1,349       45.9%       1,188       40.4%         161        5.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (556) North Chicago, IL                                     1,300         872       67.1%         759       58.4%         541       41.6%         428       32.9%         113        8.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (578) Hines, IL                                             1,219         858       70.4%         807       66.2%         412       33.8%         361       29.6%          51        4.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (585) Iron Mountain, MI                                       388         350       90.2%         344       88.7%          44       11.3%          38        9.8%           6        1.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (607) Madison, VVI                                            863         702       81.3%         668       77.4%         195       22.6%         161       18.7%          34        3.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (676) Tomah, VVI                                              917         815       88.9%         786       85.7%         131       14.3%         102       11.1%          29        3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


                                                    VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01--Continued
                                              (includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Uniques with   Uniques with  PTSD  Dx   Uniques with PTSD Dx      Uniques with  Adj       Uniques with Adj      Uniques with PTSD Dx
-------------------------------------------------------- PTSD and/or Adj ------------------------ Only (w/o Adj Disorder       Disorders  Dx      Disorders Dx Only (w/o   and Adj  Disorder Dx
                                                             Disorder                                       Dx)          ------------------------        PTSD Dx)        -----------------------
                                                        -----------------      N      % of Total ------------------------                        ------------------------
                                                                                                       N      % of Total       N      % of Total       N      % of Total       N      % of Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (695) Milwaukee, WI                                         1,756       1,267       72.2%       1,121       63.8%         635       36.2%         489       27.8%         146        8.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (589) Columbia, MO                                          1,025         805       78.5%         755       73.7%         270       26.3%         220       21.5%          50        4.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (589) Eastern KS HCS, KS                                    2,510       1,795       71.5%       1,473       58.7%       1,037       41.3%         715       28.5%         322       12.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (589) Kansas City, MO                                       1,804       1,161       64.4%       1,026       56.9%         778       43.1%         643       35.6%         135        7.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (589) Wichita, KS                                             880         752       85.5%         730       83.0%         150       17.0%         128       14.5%          22        2.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (657) Marion, IL                                            1,254       1,075       85.7%       1,047       83.5%         207       16.5%         179       14.3%          28        2.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (657) Poplar Bluff, MO                                      1,074         858       79.9%         825       76.8%         249       23.2%         216       20.1%          33        3.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (657) SI. Louis, MO                                         2,074       1,374       66.2%       1,307       63.0%         767       37.0%         700       33.8%          67        3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (502) Alexandria, LA                                          775         628       81.0%         592       76.4%         183       23.6%         147       19.0%          36        4.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (520) Biloxi, MS                                            3,776       2,812       74.5%       2,599       68.8%       1,177       31.2%         964       25.5%         213        5.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (564) Fayetteville, AR                                      1,693       1,474       87.1%       1,384       81.7%         309       18.3%         219       12.9%          90        5.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (580) Houston, TX                                           2,524       2,187       86.6%       2,114       83.8%         410       16.2%         337       13.4%          73        2.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (586) Jackson, MS                                           1,120         810       72.3%         786       70.2%         334       29.8%         310       27.7%          24        2.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (598) Little Rock, AR                                       3,549       2,279       64.2%       2,032       57.3%       1,517       42.7%       1,270       35.8%         247        7.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (623) Muskogee, OK                                          1,784       1,547       86.7%       1,515       84.9%         269       15.1%         237       13.3%          32        1.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (629) New Orleans, LA                                       2,961       2,774       93.7%       2,743       92.6%         218        7.4%         187        6.3%          31        1.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (635) Oklahoma City, OK                                     2,619       2,055       78.5%       1,904       72.7%         715       27.3%         564       21.5%         151        5.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (667) Shreveport, LA                                        2,205       1,294       58.7%       1,108       50.2%       1,097       49.8%         911       41.3%         186        8.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V17) (549) Dallas, TX                                            4,653       3,197       68.7%       2,953       63.5%       1,700       36.5%       1,456       31.3%         244        5.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V17) (671) San Antonio, TX                                       4,448       3,612       81.2%       3,383       76.1%       1,065       23.9%         836       18.8%         229        5.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V17) (674) Temple, TX                                            2,885       2,433       84.3%       2,356       81.7%         529       18.3%         452       15.7%          77        2.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (501) Albuquerque, NM                                       4,263       3,169       74.3%       2,909       68.2%       1,354       31.8%       1,094       25.7%         260        6.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (504) Amarillo, TX                                            832         707       85.0%         696       83.7%         136       16.3%         125       15.0%          11        1.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (519) Big Spring, TX                                          527         486       92.2%         479       90.9%          48        9.1%          41        7.8%           7        1.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (644) Phoenix, AZ                                           3,789       2,552       67.4%       2,302       60.8%       1,487       39.2%       1,237       32.6%         250        6.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (649) Northern Arizona HCS                                  1,220         716       58.7%         601       49.3%         619       50.7%         504       41.3%         115        9.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (678) Tucson, AZ                                            1,825       1,282       70.2%       1,233       67.6%         592       32.4%         543       29.8%          49        2.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (756) EI Paso, TX                                           1,179         953       80.8%         898       76.2%         281       23.8%         226       19.2%          55        4.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (436) Fort Harrison, MT                                     1,085         921       84.9%         895       82.5%         190       17.5%         164       15.1%          26        2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (442) Cheyenne, WY                                            688         561       81.5%         546       79.4%         142       20.6%         127       18.5%          15        2.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (554) Denver, CO                                            3,536       3,076       87.0%       2,919       82.6%         617       17.4%         460       13.0%         157        4.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (575) Grand Junction, CO                                      773         421       54.5%         347       44.9%         426       55.1%         352       45.5%          74        9.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (660) Salt Lake City, UT                                    1,621       1,424       87.8%       1,365       84.2%         256       15.8%         197       12.2%          59        3.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (666) Sheridan, WY                                            543         447       82.3%         414       76.2%         129       23.8%          96       17.7%          33        6.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (463) Anchorage, AK                                           684         538       78.7%         522       76.3%         162       23.7%         146       21.3%          16        2.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (531) Boise, ID                                             1,065       1,027       96.4%       1,022       96.0%          43        4.0%          38        3.6%           5        0.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (648) Portland, OR                                          4,225       3,604       85.3%       3,357       79.5%         868       20.5%         621       14.7%         247        5.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (653) Roseburg, OR                                          1,851       1,592       86.0%       1,525       82.4%         326       17.6%         259       14.0%          67        3.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (663) VA Puget Sound, WA                                    6,081       5,465       89.9%       5,221       85.9%         860       14.1%         616       10.1%         244        4.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


                                                    VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01--Continued
                                              (includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Uniques with   Uniques with  PTSD  Dx   Uniques with PTSD Dx      Uniques with  Adj       Uniques with Adj      Uniques with PTSD Dx
-------------------------------------------------------- PTSD and/or Adj ------------------------ Only (w/o Adj Disorder       Disorders  Dx      Disorders Dx Only (w/o   and Adj  Disorder Dx
                                                             Disorder                                       Dx)          ------------------------        PTSD Dx)        -----------------------
                                                        -----------------      N      % of Total ------------------------                        ------------------------
                                                                                                       N      % of Total       N      % of Total       N      % of Total       N      % of Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (668) Spokane, WA                                           1,281       1,132       88.4%       1,099       85.8%         182       14.2%         149       11.6%          33        2.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (687) Walla Walla, WA                                         903         698       77.3%         631       69.9%         272       30.1%         205       22.7%          67        7.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (692) White City, OR                                          812         749       92.2%         730       89.9%          82       10.1%          63        7.8%          19        2.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (358) Manila, PI                                              192         189       98.4%         187       97.4%           5        2.6%           3        1.6%           2        1.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (459) Honolulu, HI                                          1,515       1,331       87.9%       1,221       80.6%         294       19.4%         184       12.1%         110        7.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (570) Fresno, CA                                            1,366         894       65.4%         812       59.4%         554       40.6%         472       34.6%          82        6.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (612) N. California, CA                                     4,272       3,706       86.8%       3,481       81.5%         791       18.5%         566       13.2%         225        5.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (640) Palo Alto, CA                                         3,247       2,580       79.5%       2,319       71.4%         928       28.6%         667       20.5%         261        8.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (654) Reno, NV                                              1,114         728       65.4%         670       60.1%         444       39.9%         386       34.6%          58        5.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (662) San Francisco, CA                                     2,592       2,014       77.7%       1,874       72.3%         718       27.7%         578       22.3%         140        5.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (593) Las Vegas, NV                                         2,206       1,504       68.2%       1,350       61.2%         856       38.8%         702       31.8%         154        7.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (600) Long Beach, CA                                        1,599         857       53.6%         762       47.7%         837       52.3%         742       46.4%          95        5.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (605) Lorna Linda, CA                                       2,146       1,912       89.1%       1,837       85.6%         309       14.4%         234       10.9%          75        3.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (664) San Diego, CA                                         2,050       1,846       90.0%       1,815       88.5%         235       11.5%         204       10.0%          31        1.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (691) West Los Angeles, CA                                  5,877       3,940       67.0%       3,407       58.0%       2,470       42.0%       1,937       33.0%         533        9.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (437) Fargo, ND                                               434         341       78.6%         332       76.5%         102       23.5%          93       21.4%           9        2.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (438) Sioux Falls, SD                                         632         462       73.1%         445       70.4%         187       29.6%         170       26.9%          17        2.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (568) Black Hills HCS, SD                                   1,007         718       71.3%         650       64.5%         357       35.5%         289       28.7%          68        6.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (618) Minneapolis, MN                                       2,415       1,806       74.8%       1,727       71.5%         688       28.5%         609       25.2%          79        3.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (636) Central Iowa, IA                                      1,026         551       53.7%         468       45.6%         558       54.4%         475       46.3%          83        8.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (636) Iowa City, IA                                         1,057         662       62.6%         629       59.5%         428       40.5%         395       37.4%          33        3.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (636) Nebraska-W Iowa, NE                                   1,322         979       74.1%         949       71.8%         373       28.2%         343       25.9%          30        2.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (656) St. Cloud, MN                                         1,616       1,339       82.9%       1,213       75.1%         403       24.9%         277       17.1%         126        7.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------                                                                                ----------------


                      ATTACHMENT TO QUESTION 6(B)

September 18, 2007
                                                   VA Handbook 6500
                                                         Appendix G
     Department of Veterans Affairs (VA) National Rules of Behavior
1. Background

a.

Section 5723(b)(12) of title 38, United States Code, requires the Assistant 
Secretary for Information and Technology to establish ``VA National Rules 
of Behavior for appropriate use and protection of the information which is 
used to support Department's missions and functions.'' The Office of 
Management and Budget (OMB) Circular A-130, Appendix III, paragraph 
3(a(2)(a) requires that all Federal agencies promulgate rules of behavior 
that ``clearly delineate responsibilities and expected behavior of all 
individuals with access'' to the agencies' information and information 
systems, as well as state clearly the ``consequences of behavior not 
consistent'' with the rules of behavior. The National Rules of Behavior 
that begin on page G-3, are required to be used throughout the VA.

b.

Congress and OMB require the promulgation of national rules of behavior for 
two reasons. First, Congress and OMB recognize that knowledgeable users are 
the foundation of a successful security program. Users must understand that 
taking personal responsibility for the security of their computer and the 
VA data that it contains or that may be accessed through it, as well as the 
security and protection of VA information in any form (e.g. digital, 
paper), are essential aspects of their job. Second, individuals must be 
held accountable for their use of VA information and information systems.

c.

VA must achieve the Gold Standard in data security which requires that VA 
information and information system users protect VA information and 
information systems, especially the personal data of veterans, their family 
members, and employees. Users must maintain a heightened and constant 
awareness of their responsibilities regarding the protection of VA 
information. The Golden Rule with respect to this aspect of an employee's 
job is to treat the personal information of others the same as they would 
their own.

d.

Since written guidance cannot cover every contingency, personnel are asked 
to go beyond the stated rules, using ``due diligence'' and highest ethical 
standards to guide their actions. Personnel must understand that these 
rules are based on Federal laws, regulations, and VA Directives.

2. Coverage

a.

The attached VA National Rules of Behavior must be signed annually by all 
VA employees who are provided access to VA information or VA information 
systems. The term VA employees includes all individuals who are employees 
under title 5 or title 38, United States Code, as well as individuals whom 
the Department considers employees such as volunteers, without compensation 
employees, and students and other trainees. Directions for signing the 
rules of behavior by other individuals who have access to VA information or 
information systems, such as contractor employees, will be addressed in 
subsequent policy. VA employees must initial and date each page of the copy 
of the VA National Rules of Behavior; they must also provide the 
information requested on the last page, sign and date it.

b.

The VA National Rules of Behavior address notice and consent issues 
identified by the Department of Justice and other sources. It also serves 
to clarify the roles of management and system administrators, and serves to 
provide notice of what is considered acceptable use of all VA information 
and information systems, VA sensitive information, and behavior of VA 
users.

c.

The VA National Rules of Behavior use the phrase ``VA sensitive 
information''. This phrase is defined in VA Directive 6500, paragraph 5q. 
This definition covers all information as defined in 38 USC 5727(19), and 
in 38 USC 5727(23). The phrase ``VA sensitive information'' as used in the 
attached VA National Rules of Behavior means:

    L  All Department data, on any storage media or in any form or format, 
which requires protection due to the risk of harm that could result from 
inadvertent or deliberate disclosure, alteration, or destruction of the 
information. The term includes information whose improper use or disclosure 
could adversely affect the ability of an agency to accomplish its mission, 
proprietary information, records about individuals requiring protection 
under various confidentiality provisions such as the Privacy Act and the 
HIPAA Privacy Rule, and information that can be withheld under the Freedom 
of Information Act. Examples of VA sensitive information include the 
following: individually identifiable medical, benefits, and personnel 
information, financial, budgetary, research, quality assurance, 
confidential commercial, critical infrastructure, investigatory, and law 
enforcement information, information that is confidential and privileged in 
litigation such as information protected by the deliberative process 
privilege, attorney work-product privilege, and the attorney-client 
privilege, and other information which, if released, could result in 
violation of law or harm or unfairness to any individual or group, or could 
adversely affect the national interest or the conduct of Federal programs.

d.

The phrase ``VA sensitive information'' includes information entrusted to 
the Department.

3. Rules of Behavior

a.

Immediately following this section is the VA approved National Rules of 
Behavior that all employees (as discussed in paragraph 2a of Appendix G) 
who are provided access to VA information and VA information systems are 
required to sign in order to obtain access to VA information and 
information systems.

                               __________
     Department of Veterans Affairs (VA) National Rules of Behavior
    I understand, accept, and agree to the following terms and 
conditions that apply to my access to, and use of, information, 
including VA sensitive information, or information systems of the U.S. 
Department of Veterans Affairs.
1. GENERAL RULES OF BEHAVIOR

a.

I understand that when I use any government information system, I have NO 
expectation of Privacy in VA records that I create or in my activities 
while accessing or using such information system.

b.

I understand that authorized VA personnel may review my conduct or actions 
concerning VA information and information systems, and take appropriate 
action. Authorized VA personnel include my supervisory chain of command as 
well as VA system administrators and Information Security Officers (ISOs). 
Appropriate action may include monitoring, recording, copying, inspecting, 
restricting access, blocking, tracking, and disclosing information to 
authorized Office of Inspector General (OIG), VA, and law enforcement 
personnel.

c.

I understand that the following actions are prohibited: unauthorized 
access, unauthorized uploading, unauthorized downloading, unauthorized 
changing, unauthorized circumventing, or unauthorized deleting information 
on VA systems, modifying VA systems, unauthorized denying or granting 
access to VA systems, using VA resources for unauthorized use on VA 
systems, or otherwise misusing VA systems or resources. I also understand 
that attempting to engage in any of these unauthorized actions is also 
prohibited.

d.

I understand that such unauthorized attempts or acts may result in 
disciplinary or other adverse action, as well as criminal, civil, and/or 
administrative penalties. Depending on the severity of the violation, 
disciplinary or adverse action consequences may include: suspension of 
access privileges, reprimand, suspension from work, demotion, or removal. 
Theft, conversion, or unauthorized disposal or destruction of Federal 
property or information may also result in criminal sanctions.

e.

I understand that I have a responsibility to report suspected or identified 
information security incidents (security and privacy) to my Operating 
Unit's Information Security Officer (ISO), Privacy Officer (PO), and my 
supervisor as appropriate.

f.

I understand that I have a duty to report information about actual or 
possible criminal violations involving VA programs, operations, facilities, 
contracts or information systems to my supervisor, any management official 
or directly to the OIG, including reporting to the OIG Hotline. I also 
understand that I have a duty to immediately report to the OIG any possible 
criminal matters involving felonies, including crimes involving information 
systems.

g.

I understand that the VA National Rules of Behavior do not and should not 
be relied upon to create any other right or benefit, substantive or 
procedural, enforceable by law, by a party to litigation with the United 
States Government.

h.

I understand that the VA National Rules of Behavior do not supersede any 
local policies that provide higher levels of protection to VA's information 
or information systems. The VA National Rules of Behavior provide the 
minimal rules with which individual users must comply.

i.

I understand that if I refuse to sign this VA National Rules of Behavior as 
required by VA policy, I will be denied access to VA information and 
information systems. Any refusal to sign the VA National Rules of Behavior 
may have an adverse impact on my employment with the Department.

2. SPECIFIC RULES OF BEHAVIOR

a.

I will follow established procedures for requesting access to any VA 
computer system and for notification to the VA supervisor and the ISO when 
the access is no longer needed.

b.

I will follow established VA information security and privacy policies and 
procedures.

c.

I will use only devices, systems, software, and data which I am authorized 
to use, including complying with any software licensing or copyright 
restrictions. This includes downloads of software offered as free trials, 
shareware or public domain.

d.

I will only use my access for authorized and official duties, and to only 
access data that is needed in the fulfillment of my duties except as 
provided for in VA Directive 6001, Limited Personal Use of Government 
Office Equipment Including Information Technology. I also agree that I will 
not engage in any activities prohibited as stated in section 2c of VA 
Directive 6001.

e.

I will secure VA sensitive information in all areas (at work and remotely) 
and in any form (e.g. digital, paper etc.), to include mobile media and 
devices that contain sensitive information, and I will follow the mandate 
that all VA sensitive information must be in a protected environment at all 
times or it must be encrypted (using FIPS 140-2 approved encryption). If 
clarification is needed whether or not an environment is adequately 
protected, I will follow the guidance of the local Chief Information 
Officer (CIO).

f.

I will properly dispose of VA sensitive information, either in hardcopy, 
softcopy or electronic format, in accordance with VA policy and procedures.

g.

I will not attempt to override, circumvent or disable operational, 
technical, or management security controls unless expressly directed to do 
so in writing by authorized VA staff.

h.

I will not attempt to alter the security configuration of government 
equipment unless authorized. This includes operational, technical, or 
management security controls.

i.

I will protect my verify codes and passwords from unauthorized use and 
disclosure and ensure I utilize only passwords that meet the VA minimum 
requirements for the systems that I am authorized to use and are contained 
in Appendix F of VA Handbook 6500.

j.

I will not store any passwords/verify codes in any type of script file or 
cache on VA systems.

k.

I will ensure that I log off or lock any computer or console before walking 
away and will not allow another user to access that computer or console 
while I am logged on to it.

l.

I will not misrepresent, obscure, suppress, or replace a user's identity on 
the Internet or any VA electronic communication system.

m.

I will not auto-forward e-mail messages to addresses outside the VA 
network.

n.

I will comply with any directions from my supervisors, VA system 
administrators and information security officers concerning my access to, 
and use of, VA information and information systems or matters covered by 
these Rules.

o.

I will ensure that any devices that I use to transmit, access, and store VA 
sensitive information outside of a VA protected environment will use FIPS 
140-2 approved encryption (the translation of data into a form that is 
unintelligible without a deciphering mechanism). This includes laptops, 
thumb drives, and other removable storage devices and storage media (CDs, 
DVDs, etc.).

p.

I will obtain the approval of appropriate management officials before 
releasing VA information for public dissemination.

q.

I will not host, set up, administer, or operate any type of Internet server 
on any VA network or attempt to connect any personal equipment to a VA 
network unless explicitly authorized in writing by my local CIO and I will 
ensure that all such activity is in compliance with Federal and VA 
policies.

r.

I will not attempt to probe computer systems to exploit system controls or 
access VA sensitive data for any reason other than in the performance of 
official duties. Authorized penetration testing must be approved in writing 
by the VA CIO.

s.

I will protect Government property from theft, loss, destruction, or 
misuse. I will follow VA policies and procedures for handling Federal 
Government IT equipment and will sign for items provided to me for my 
exclusive use and return them when no longer required for VA activities.

t.

I will only use virus protection software, anti-spyware, and firewall/
intrusion detection software authorized by the VA on VA equipment or on 
computer systems that are connected to any VA network.

u.

If authorized, by waiver, to use my own personal equipment, I must use VA 
approved virus protection software, anti-spyware, and firewall/intrusion 
detection software and ensure the software is configured to meet VA 
configuration requirements. My local CIO will confirm that the system meets 
VA configuration requirements prior to connection to VA's network.

v.

I will never swap or surrender VA hard drives or other storage devices to 
anyone other than an authorized OI&T employee at the time of system 
problems.

w.

I will not disable or degrade software programs used by the VA that install 
security software updates to VA computer equipment, to computer equipment 
used to connect to VA information systems, or to create, store or use VA 
information.

x.

I agree to allow examination by authorized OI&T personnel of any personal 
IT device [Other Equipment (OE)] that I have been granted permission to 
use, whether remotely or in any setting to access VA information or 
information systems or to create, store or use VA information.

y.

I agree to have all equipment scanned by the appropriate facility IT 
Operations Service prior to connecting to the VA network if the equipment 
has not been connected to the VA network for a period of more than three 
weeks.

z.

I will complete mandatory periodic security and privacy awareness training 
within designated timeframes, and complete any additional required training 
for the particular systems to which I require access.

aa.

I understand that if I must sign a non-VA entity's Rules of Behavior to 
obtain access to information or information systems controlled by that non-
VA entity, I still must comply with my responsibilities under the VA 
National Rules of Behavior when accessing or using VA information or 
information systems. However, those Rules of Behavior apply to my access to 
or use of the non-VA entity's information and information systems as a VA 
user.

bb.

I understand that remote access is allowed from other Federal government 
computers and systems to VA information systems, subject to the terms of VA 
and the host Federal agency's policies.

cc.

I agree that I will directly connect to the VA network whenever possible. 
If a direct connection to the VA network is not possible, then I will use 
VA-approved remote access software and services. I must use VA-provided IT 
equipment for remote access when possible. I may be permitted to use non-VA 
IT equipment [Other Equipment (OE)] only if a VA-CIO-approved waiver has 
been issued and the equipment is configured to follow all VA security 
policies and requirements. I agree that VA OI&T officials may examine such 
devices, including an OE device operating under an approved waiver, at any 
time for proper configuration and unauthorized storage of VA sensitive 
information.

dd.

I agree that I will not have both a VA network connection and any kind of 
non-VA network connection (including a modem or phone line or wireless 
network card, etc.) physically connected to any computer at the same time 
unless the dual connection is explicitly authorized in writing by my local 
CIO.

ee.

I agree that I will not allow VA sensitive information to reside on non-VA 
systems or devices unless specifically designated and approved in advance 
by the appropriate VA official (supervisor), and a waiver has been issued 
by the VA's CIO. I agree that I will not access, transmit or store remotely 
anyP

VA sensitive information that is not encrypted using VA approved 
encryption.

ff.

I will obtain my VA supervisor's authorization, in writing, prior to 
transporting, transmitting, accessing, and using VA sensitive information 
outside of VA's protected environment.

gg.

I will ensure that VA sensitive information, in any format, and devices, 
systems and/or software that contain such information or that I use to 
access VA sensitive information or information systems are adequately 
secured in remote locations, e.g., at home and during travel, and agree to 
periodic VA inspections of the devices, systems or software from which I 
conduct access from remote locations. I agree that if I work from a remote 
location pursuant to an approved telework agreement with VA sensitive 
information that authorized OI&T personnel may periodically inspect the 
remote location for compliance with required security requirements.

hh.

I will protect sensitive information from unauthorized disclosure, use, 
modification, or destruction, including using encryption products approved 
and provided by the VA to protect sensitive data.

ii.

I will not store or transport any VA sensitive information on any portable 
storage media or device unless it is encrypted using VA approved 
encryption.

jj.

I will use VA-provided encryption to encrypt any e-mail, including 
attachments to the e-mail, that contains VA sensitive information before 
sending the e-mail. I will not send any e-mail that contains VA sensitive 
information in an unencrypted form. VA sensitive information includes 
personally identifiable information and protected health information.

kk.

I may be required to acknowledge or sign additional specific or unique 
rules of behavior in order to access or use specific VA systems. I 
understand that those specific rules of behavior may include, but are not 
limited to, restrictions or prohibitions on limited personal use, special 
requirements for access or use of the data in that system, special 
requirements for the devices used to access that specific system, or 
special restrictions on interconnections between that system and other IT 
resources or systems.

3. Acknowledgement and Acceptance

a.

I acknowledge that I have received a copy of these Rules of Behavior.

b.

I understand, accept and agree to comply with all terms and conditions of 
these Rules of Behavior.

     ------------------------------------
    [Print or type your full name]
                               ------------------------------------
                               Signature                           

    ------------------------------------
    Date

     ------------------------------------
    Office Phone
                               ------------------------------------
                              Position Title                       
                               ----------
                        Questions for the Record
                The Honorable Stephanie Herseth Sandlin
    Question 1: What can the VA do to address the health care needs of 
Guard and Reserve members, who account for more than half of all 
veterans who took their own lives after returning from Iraq or 
Afghanistan?
    Response: In order to ensure that Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) combat veterans receive high quality 
health care and coordinated Department of Veterans Affairs (VA) 
services and benefits as they transition from the Department of Defense 
(DoD) to VA, VA and the National Guard developed a creative 
partnership. Late in 2005, following the signing of a memorandum of un-

derstanding (MOU) between the National Guard and VA, the National Guard 
hired 54 (now 60) National Guard transition assistance advisors (TAA) 
to serve as VA/National Guard liaisons in the field at the State level, 
assisting National Guard service members and their families in 
accessing VA benefits and services. In February 2006, the newly hired 
National Guard/VA TAAs were trained by VA staff about VA benefits and 
services at the Veterans Benefit Administration (VBA) Academy in 
Baltimore. The purpose of the training was to enhance the outreach 
skills of the TAAs by learning about VA benefits and services and to 
connect them with VA resources and staff members in the field at the VA 
medical centers (VAMC) and the regional offices (RO). This knowledge 
will assist them in helping Guard/Reserve members in obtaining VA 
benefits and services and address access issues in the 50 States and 4 
territories. Annual refresher training was held in January 2007 and 
2008 in conjunction with the National Guard Family Program Conference. 
The TAAs have been the critical link in facilitating access to VA by 
National Guard/Reserves in each of the 50 States and 4 territories 
(Puerto Rico, Virgin Islands, Guam and District of Columbia) and 
providing VA with critical information on numbers of returning troops, 
location, homecoming and reintegration events. TAAs also facilitate 
enrollment of returning troops into the Veterans Health Administration 
(VHA).
    The National Guard is presently expanding the TAA program with a 
goal of two TAAs for States with large number of deployed troops. The 
VHA OEF/OIF Outreach Office continues to collaboration with the 60 TAAs 
at monthly teleconferences, through quarterly newsletters, and monthly 
identification of success stories and best practices in the States. 
Outreach staff work with VA experts at annual training events to ensure 
they are updated on changes in VA services/benefits. TAAs facilitate 
the development and maintenance of State coalitions using the State 
Triad Leadership of the Adjutant General, State Director of Veterans 
Affairs (DVA) and VA to integrate and coordinate the delivery of VA 
services and benefits to Guard and Reservists in each State. Over 47 
States have developed State MOUs through the Leadership Triad of the 
State Director DVA, Adjutant General and VA. These State partnerships 
are the foundation for State coalitions with participation by community 
and State organizations to address the coming home needs of the Guard 
and the Reserve members.
    In addition VA operates a system of over 200 community based 
counseling centers, known as Vet Centers, located near where veterans 
and their families reside. Vet Centers are staffed by small multi-
disciplinary teams of dedicated providers, many of which are combat 
veterans themselves, providing a broad range of counseling, outreach, 
and referral services to OEF/OIF veterans in order to help them 
readjustment to civilian life. Services include individual counseling, 
group counseling, marital and family counseling, bereavement 
counseling, medical referrals, assistance in applying for VA benefits, 
employment counseling, guidance and referral. alcohol/drug assessments, 
information and referral to community resources, military sexual trauma 
counseling and referral, outreach and community education.
    On May 2, 2008 VA began contacting nearly 570,000 OEF/OIF combat 
veterans to ensure they know about VA medical services and other 
benefits. The Department will reach out and touch every veteran of the 
war to let them know it is here for them. The first of those calls are 
going to an estimated 17,000 veterans who were sick or injured while 
serving in Iraq or Afghanistan. If any of these 17,000 veterans do not 
now have a care manager to work with them to ensure they get 
appropriate health care, VA will offer to appoint one for them.

    Question 2: What is the VA doing, and what should the VA be doing 
to address the unique mental health care needs of younger veterans?

    Response: VA has several resources to train staff to better 
understand the needs of younger veterans and their families. These 
resources include:

      My HealtheVet. Younger veterans use the Internet to 
obtain information and communicate. We have developed mental health 
content for My HealtheVet and continue to expand that content.
      VA also has clinical programs geared to returning 
veterans, many of whom are younger, such as:
            Serving returning veterans mental health needs 
        teams (SeRV-MH teams) to address issues of younger veterans and 
        families in clinical care. Monthly conference calls are held 
        for the SeRV-MH team and include discussion of various issues, 
        such as non-traditional scheduling to meet the needs of working 
        or school engaged patients, and care needs of younger families.
            Additionally, as many younger veterans are married 
        and may have young children. The new Housing and Urban 
        Development/VA supported housing (HUD/VASH) voucher program 
        offers opportunities for housing of homeless veterans with 
        families.

      The Iraq Clinician War Guide, developed by the National 
Center for Post Traumatic Stress Disorder (NCPTSD) in collaboration 
with DoD in 2004, is posted on the NCPTSD Web site, as well as being 
used in VA training sessions across the country.
      A national conference, Evolving Paradigms in Treating 
Combat Veterans. Was developed as a joint VA/ DoD training effort in 
2007.
      Conferences for Veterans Integrated Service Networks 
(VISN) 5 and 6 staff were held in 2006/2007 with a focus on Family 
Transition Meetings. Training to other VISNs is being planned.
      Many younger veterans have families with young children, 
and reintegration into the family after deployment to a combat zone can 
be stressful for the veteran's family. We have used the Sesame Street 
project, ``Talk, Listen, Connect'', to help families of servicemembers 
and veterans guide their children's adjustment to a parent who returns 
form Iraq or Afghanistan. Copies of the video and accompanying 
materials are currently available at all VA facilities and we will be 
disseminating additional copies to staff system-wide to train them to 
use this valuable tool.

    Question 3: What should the VA be doing to address the mental 
health care needs of veterans, especially veterans in rural or 
underserved areas?

    Response: The Center of Excellence at Canandaigua and the Serious 
Mental Illness Treatment Research and Evaluation Center (SMITREC) at 
Ann Arbor, Michigan are planning a study of the data from VA's 24-hour 
Suicide Crisis Line to determine if there are new, emergent veteran 
populations at risk for suicidal behaviors. Both younger veterans and 
veterans in rural or underserved areas will be evaluated as part of 
this study as to mental health care needs of both groups VA should 
address.
    VA also has increased availability of mental health services in 
community based outpatient clinics (CBOC) designed to bring care closer 
to the veterans. As of the end of the first quarter of fiscal 2008, 93 
percent of CBOCs reported mental health visits. All 21 VISNS have some 
form of VA/State-community collaborations including telemental health 
or VA staff placements in community health or mental health centers; 
Tribal or Indian Health Service clinical sites. VA's Office of Mental 
Health Services and Office of Rural Health are collaborating to improve 
access to services for veterans in remote areas, including an increased 
effort at telemental health capabilities. VA has authorized facilities 
to arrange for fee basis and contract services in situations where 
timely services cannot be provided by existing VA facilities.
                               __________
                        Questions for the Record
                       The Honorable John J. Hall
    Question: When a veteran gets a prescription or has to order a 
refill there is no way for a doctor to expedite the delivery of the 
medication which can take 10 days. Someone needing an anti-depressant 
should be able to get that sent quickly by allowing the doctor to 
overnight the delivery. Why can't his be done?
    Response: At the request of a Department of Veterans Affairs (VA) 
prescriber, VA medical center pharmacy staff will make urgently needed 
prescription medications available to patients within 24 hours of 
notification, using the most appropriate means available. This 
requirement applies to all points of service including community based 
outpatient clinics (CBOC).
    Current practice within VA system: Newly prescribed medications are 
available immediately through VA pharmacies or through non-VA contract 
pharmacies serving VA CBOCs. Refills for previously filled 
prescriptions are primarily available through VA's consolidated mail 
outpatient pharmacies (CMOP), or alternately through VA medical center 
pharmacies. Current CMOP prescription refill processing times average 5 
days after the refill is requested (1 day to send data to CMOP; 1.5 
days to fill the prescription; and 2.5 days to mail/ship the package to 
the patient).
    Current practice outside the VA system: VA has contracts with 
community pharmacies to provide urgently needed outpatient CBOC 
prescriptions, or to provide medications when the VA medical center 
does not offer 24/7 outpatient pharmacy services. VA's current contract 
pharmacy prescription volume is approximately 300,000 per year.
    Ongoing Emphasis: A VHA policy Directive intended to reemphasize 
VA's practice of providing urgently needed outpatient medications in a 
timely manner has been approved. The new Directive was distributed to 
the field in May 2008. Enclosed is a copy of Directive 2008-028, Access 
to Urgently Needed Outpatient Prescription Medications.
    VA/DoD Partnering: VA's requirements have been included in the 
Department of Defense's (DoD) TRICARE retail pharmacy network (TRx) 
which will allow VA to use DoD's 50,000 retail pharmacies to fill 
urgently needed outpatient prescriptions if a VA pharmacy is not 
available. It is expected that VA will be able to begin using the TRx 
retail contract sometime in late 2009.
    Vet centers refer veterans to the local VA medical centers for 
medical care and follow up of prescriptions if needed. In the mental 
health mental status evaluation, any indicators of need for medical 
psychiatric or primary care are automatically referred to the medical 
center. If the veteran is on medications and have challenges in getting 
prescriptions filled, they are referred to the local VA medical center 
or CBOC.
                               __________
Department of Veterans Affairs
                                             VHA DIRECTIVE 2008-028
Veterans Health Administration
Washington, DC 20420
                                                       May 16, 2008

     ACCESS TO URGENTLY NEEDED OUTPATIENT PRESCRIPTION MEDICATIONS
    1. PURPOSE: This Veterans Health Administration (VHA) Directive 
defines expectations for access to urgently needed outpatient 
prescription medications.

    2. BACKGROUND:

    a.  Urgently needed outpatient medications are medications that, in 
the clinical judgment of the prescriber, if not taken within 24 hours 
of determining the need of those medications have the potential to 
result in serious patient harm.
    b.  Local restrictions on the use of overnight mail or package 
delivery service to deliver urgently needed outpatient prescription 
medications have the potential to cause unnecessary hospital visits, 
hospitalizations and patient harm.

    3. POLICY: It is VHA policy that at the request of a VA prescriber, 
VA medical center pharmacy staff will make urgently needed outpatient 
prescription medications available to patients within 24 hours of 
notification, using the most appropriate means available. This 
requirement applies to all points of service including Community Based 
Outpatient Clinics.

    4. ACTION:

    a.  Facility Director. The facility Director, or designee, is 
responsible for ensuring written policies are established to address 
the timely delivery of urgently needed outpatient prescription 
medications.
    b.  VA Prescriber. The VA prescriber must notify the pharmacy when 
a new prescription or refill is urgently needed due to a change in the 
patient's clinical condition. NOTE: If the prescriber determines that 
medication is needed sooner than 24 hours, the prescriber needs to make 
arrangements for the patient to receive urgent medical care or instruct 
the patient to contact the local emergency medical care system.
    c.  Chief of Pharmacy. The Chief of Pharmacy must contact the 
patient or the patient's representative to determine the most 
appropriate means to make the prescription available and must take all 
necessary steps to make the prescription available. This may include:
          1.  Making the prescription available at a VA pharmacy for 
        pick up.
          2.  Providing the prescription through a non-VA pharmacy 
        under contract to VA.
          3.  Mailing or shipping the medication overnight via 
        commercial or government carrier.

              THIS VHA DIRECTIVE WILL EXPIRE MAY 31, 2013

    5. REFERENCES: None.

    6. FOLLOW-UP RESPONSIBILITY: The Pharmacy Benefits Management 
Services office (119) is responsible for the content of this Directive. 
Questions may be referred to (202) 4617326.

    7. RESCISSIONS: None

                                   Michael J. Kussman, MD, MS, MACP
                                         Under Secretary for Health
    DISTRIBUTION: CO: E-mailed 5/19/08
    FLD: VISN, MA, DO, OC, OCRO, and 200--E-mailed 5/19/08
                               __________
                        Questions for the Record
                     The Honorable Shelley Berkley
    Question 1: What are we doing to follow through with a veteran 
after it has been identified that they have a mental health issue to 
decrease their risk of committing suicide?
    Response: For veterans found to be at risk for suicide, the 
Veterans Health Administration (VHA) supplements basic mental health 
services with increased monitoring and intense treatment directed 
toward reducing suicidality, as well as the underlying mental health 
problem. For a veteran identified as having a mental health problem, 
the most basic approach to decreasing the risk of suicide is to provide 
appropriate, evidence-based treatment for the mental health problem. To 
ensure veterans' mental health needs are addressed, VHA has been 
enhancing the mental health services it provides through substantial 
increases in the allocation of funds, and has hired almost 4,000 new 
mental health staff members over the past 3 years. Between 2005 and 
2007, there was a 10.3-percent increase in uniques, and a 7.6-percent 
increase in encounters.
    Question 2: How much of the Joshua Omvig Suicide Prevention Act 
(aside from the establishment of the suicide hotline) has been 
initiated since its enactment in November 2007?
    Response: The Comprehensive Program for Suicide Prevention Among 
Veterans Report (Public Law 110-110) was submitted to Congress in 
February 2008 and is attached for your review. In the report we stated 
that we are able to monitor risk and needs and respond to them under 
existing legal authority. Since the report was released the Department 
of Veterans Affairs (VA) has the following updated information:
    Requirement: Designation of Suicide Prevention Counselors--To 
support the identification of patients at high risk, the suicide 
prevention coordinators have been collecting information from 
providers, other staff, and community contacts about veterans who have 
survived suicide attempts. In preliminary findings, we have identified 
approximately 1,000 attempts per month. To address the increased needs 
for these vulnerable veterans, VA has implemented standardized 
approaches to enhancing care while, at the same time, encouraging 
innovation and creativity.
    Further developments in process at this time include tests of the 
coordinators inter-rater reliability and its sensitivity in the 
identification of suicide attempts. Both will be necessary before the 
number of attempts (or reattempts) in a facility can be used as a 
measure for epidemiological or quality improvement purposes.
    Requirement: Hotline--From the time the veterans' Hotline was 
established in July, 2007 until the end of May, 2008, we received 
49,544 calls. From the start of 2008 until the end of May we received 
40,165 calls, with 16,436 confirmed as coming from veterans and 2,543 
from family members or friends. These led to 3,240 referrals to the 
suicide prevention coordinators at VA facilities and 909 ``rescues'' 
requiring emergency services.
    Attached: Report to Congress on Comprehensive Program for Suicide 
Prevention Among Veterans

                               ----------
      
                           REPORT TO CONGRESS
                           PUBLIC LAW 110-110
                       COMPREHENSIVE PROGRAM FOR
                   SUICIDE PREVENTION AMONG VETERANS
                     Department of Veterans Affairs
                             February 2008
  Report to Congress on VA's Implementation of 38 U.S.C. Sec. 1720F, 
            ``Joshua Omvig Veterans Suicide Prevention Act''
    Issue: Implementation of section 3(b)(1) of Public Law 110-110, the 
``Joshua Omvig Veterans Suicide Prevention Act,'' requires the 
Department of Veterans Affairs (VA) to submit a report to Congress not 
later than 90 days after November 5, 2007, on the Department's 
implementation of its comprehensive suicide prevention program, as 
established by 38 U.S.C. Sec. 1720F.
Information on the status of the implementation of the VA comprehensive 
        program for suicide prevention
    Requirement: Establishment--The Secretary shall develop and carry 
out a comprehensive program designed to reduce the incidence of suicide 
among veterans incorporating the components described in this section.
    VA Response: Recommendations for suicide prevention programs within 
VA were included in the 2004 VA Comprehensive Mental Health Strategic 
Plan. Implementation began shortly after the plan was approved and 
suicide prevention programs in VA medical centers were accelerated in 
spring 2006. Ongoing activities have been monitored by Office of 
Inspector General as documented in report number 06-03706-126 from May 
10, 2007.
    Requirement: Staff Education--In carrying out the comprehensive 
program under this section, the Secretary shall provide for mandatory 
training for appropriate staff and contractors (including all medical 
personnel) of the Department who interact with veterans. This training 
shall cover information appropriate to the duties being performed by 
such staff and contractors. The training shall include information on--
(1) recognizing risk factors for suicide; (2) proper protocols for 
responding to crisis situations involving veterans who may be at high 
risk for suicide; and (3) best practices for suicide prevention.
    VA Response: VA held its first Suicide Prevention Awareness Day for 
all VA medical centers in April 2007, which included a program that 
focused on recognizing risk factors for suicide, proper protocols for 
responding to crisis situations involving veterans who may be at high 
risk for suicide, and best practices for suicide prevention. It held 
its second Suicide Prevention Awareness Day in September 2007, and 
scheduled the event during National Suicide Prevention Week. The 
program consisted of required training for all staff on general 
principles of suicide prevention, and the use of specific new VA 
resources: the national VA Suicide Prevention Hotline and the Suicide 
Prevention Coordinators who are located at each VA medical center. VA 
Suicide Prevention Awareness Day is now an annual event held during 
Suicide Prevention Week each September. VA has also held several 
regional conferences on suicide prevention attended by mental health 
providers, primary care clinicians, administrators, and a wide range of 
other medical center staff members. Additional mandatory training 
initiatives are being developed for fiscal year (FY) 2008, including a 
Web-based curriculum with associated written materials for all staff 
with patient contact.
    A major responsibility of Suicide Prevention Coordinators is 
coordination of local training in suicide prevention. This includes 
providing training for both providers and non-clinical staff with 
patient contact. Suicide Prevention Coordinators also provide special 
training to staff members who respond to telephone calls. Additional 
education and training includes outreach to the community, with a focus 
on ``guide'' training, designed for non-clinical staff who interact 
with veterans to help them better understand suicide risk and to assist 
veterans in accessing needed services.
    Requirement: Health Assessments of Veterans--In carrying out the 
comprehensive program, the Secretary shall direct that medical staff 
offer mental health in their overall health assessment when veterans 
seek medical care at a Department medical facility (including a center 
established under section 1712A of this title) and make referrals, at 
the request of the veteran concerned, to appropriate counseling and 
treatment programs for veterans who show signs or symptoms of mental 
health problems.
    VA Response: VA policy for all new Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) veterans upon their initial visit to 
VA medical centers or clinics is to screen them for depression, Post-
Traumatic Stress Disorder (PTSD), and problem drinking. Screening for 
depression and problem drinking is required on an annual basis for all 
veterans, and screening for PTSD is required annually for the first 5 
years after enrollment, and every 5 years afterward. Whenever veterans 
screen positive for one of these conditions, they must receive a 
followup clinical evaluation that considers both the condition(s) 
related to the positive screen, and the risk of suicide. When this 
process confirms the presence of a mental disorder or suicide risk, 
veterans must be offered mental health treatment. Whenever there is a 
referral or request for mental health services, veterans must receive 
an initial evaluation within 24 hours. When this evaluation identifies 
urgent need, treatment must be provided immediately; otherwise, 
veterans must receive a full diagnostic and treatment planning 
evaluation and the initiation of care within 2 weeks.
    Requirement: Designation of Suicide Prevention Counselors--In 
carrying out the comprehensive program, the Secretary shall designate a 
suicide prevention counselor at each Department medical facility other 
than centers established under section 1712A of this title. Each 
counselor shall work with local emergency rooms, police departments, 
mental health organizations, and veterans service organizations to 
engage in outreach to veterans and improve the coordination of mental 
health care to veterans.
    VA Response: Each VA medical center is required to appoint a full-
time Suicide Prevention Coordinator. The primary responsibility of the 
Suicide Prevention Coordinator is to support the identification of 
patients at high risk for suicide, and to ensure that their monitoring 
and care are intensified. Other responsibilities include training and 
education, both within VA and in the community.
    Requirement: Best Practices Research--In carrying out the 
comprehensive program, the Secretary shall provide for research on best 
practices for suicide prevention among veterans. Research shall be 
conducted under this subsection in consultation with the heads of the 
following entities: (1) The Department of Health and Human Services. 
(2) The National Institute of Mental Health. (3) The Substance Abuse 
and Mental Health Services Administration. (4) The Centers for Disease 
Control and Prevention.
    VA Response: The Mental Illness Research, Education and Clinical 
Center (MIRECC) at Denver, Colorado, 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 health care 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 (HVAC) hearing on December 12, 2007. One, conducted 
by VA's Office of Environmental Epidemiology, investigated the 
mortality and causes of death in returning OEF/OIF veterans. Another, 
conducted by VA's Serious Mental Illness Research Education and 
Clinical Center, studied rates of suicide, risk factors, and their 
local variability in all of those receiving health care from VA. 
Research under development by the Center of Excellence at Canandaigua, 
includes 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. In January 2008, a new 
research solicitation was initiated seeking studies to validate 
screening instruments and to identify successful strategies and 
interventions for suicide prevention.
    VA has convened a new targeted working group, the Interagency 
Working Group to Inform Research on Suicide Prevention, comprised of 
experts from the Department of Health and Human Services, National 
Institute on Mental Health, Substance Abuse and Mental Health Services 
Administration, Centers for Disease Control and Prevention, and the 
Department of Defense to assess the current state of knowledge and 
their respective relevant portfolios of research in order to provide 
recommendations on specific efforts that should be undertaken by VA.
    Requirement: Sexual Trauma Research--In carrying out the 
comprehensive program, the Secretary shall provide for research on 
mental health care for veterans who have experienced sexual trauma 
while in military service. The research design shall include 
consideration of veterans of a reserve component.
    VA Response: Ongoing research supported by the Office of Research 
and Development that is specific to sexual trauma includes studies 
examining sexual violence and gynecologic health; screening and 
treatment responses; risks, outcomes, and services for women; and a 
longitudinal study of Military Sexual Trauma; and effects on PTSD and 
Health Behavior. These studies include a wide range of subjects, 
including National Guard and Reserve component veterans. Male veterans 
are also targeted in a study addressing sexual assault prevalence among 
Gulf War veterans suffering from PTSD.
    Requirement: 24-Hour Mental Health Care--In carrying out the 
comprehensive program, the Secretary shall provide for mental health 
care availability to veterans on a 24-hour basis.
    VA Response: VA policy requires 24/7 mental health coverage in all 
VA emergency departments and 24-hour urgent care centers. Twenty-four 
hour coverage for veterans who do not have ready access to these 
services is facility based and may include access to local or regional 
call centers, or to providers covering inpatient units. National 
coverage is available for all veterans through the Suicide Prevention 
Hotline.
    The Veterans Health Administration is developing a uniform policy 
that will require each medical center or clinic that does not have an 
emergency department or 24/7 urgent care center to designate one or 
more nearby VA or community-based facilities to provide 24/7 emergency 
mental health coverage. Elements of the policy already approved ensure 
that: (1) providers and responders to telephone calls to the facility 
make veterans aware of coverage; (2) facilities develop contracts or 
memoranda of understanding with the designated emergency departments to 
facilitate bidirectional communication; and (3) contracts or memoranda 
of understanding to ensure that veterans receiving care in the 
designated facilities are transferred back to VA as soon as it is 
medically appropriate. Elements still under development include issues 
related to payment for emergency services and hospitalizations.
    Requirement: Hotline--In carrying out the comprehensive program, 
the Secretary may provide for a toll-free hotline for veterans to be 
staffed by appropriately trained mental health personnel and available 
at all times.
    VA Response: VA has partnered with the Substance Abuse and Mental 
Health Service Administration to include services for veterans in its 
Suicide Prevention Hotline program. When calls are made to the national 
toll-free Suicide Prevention Hotline, a message states that if the 
caller is a United States military veteran, or if the call pertains to 
a veteran, the caller should press ``1.'' With this action, the veteran 
or person calling is immediately connected to VA's suicide prevention 
call center at Canandaigua, which is staffed by VA mental health 
professionals who have real-time access to veterans' electronic medical 
records.
    Additionally, staff members at the Veterans Benefits Administration 
Call Center have received training on managing callers with warning 
signs of suicide. They immediately transfer these calls to the hotline 
call center.
    Requirement: Outreach and Education for Veterans and Families--In 
carrying out the comprehensive program, the Secretary shall provide for 
outreach to and education for veterans and the families of veterans, 
with special emphasis on providing information to veterans of Operation 
Iraqi Freedom and Operation Enduring Freedom and the families of such 
veterans. Education to promote mental health shall include information 
designed to--(1) remove the stigma associated with mental illness; (2) 
encourage veterans to seek treatment and assistance for mental illness; 
(3) promote skills for coping with mental illness; and (4) help 
families of veterans with--(A) understanding issues arising from the 
readjustment of veterans to civilian life; (B) identifying signs and 
symptoms of mental illness; and (C) encouraging veterans to seek 
assistance for mental illness.
    VA Response: Through its Readjustment Counseling Service (Vet 
Centers), VA has hired 100 OEF/OIF peer specialists to complement its 
existing peer outreach program to provide education and outreach to 
returning veterans. Staffs from Vet Centers attend each post-deployment 
health reassessment to provide information about the availability and 
effectiveness of VA services. This allows Vet Centers to facilitate 
counseling services. Vet Centers also provide extensive outreach 
services to National Guard and Reserve units, and to the community to 
provide education about readjustment and related mental health issues, 
and the availability of care.
    VA has funded over 90 OEF/OIF teams in mental health to provide 
further outreach and education in VA facilities, in National Guard and 
Reserve units, and in the communities. The messages they deliver are 
related to destigmatizing mental illness, increasing knowledge of the 
symptoms and warning signs of mental disorders, and ensuring that 
veterans and families are aware that effective, high-quality mental 
health treatment is readily available in VA facilities.
    Other sources of information for veterans and families include the 
Internet (e.g., www.ncptsd.va.gov, the National Center for PTSD's Web 
site), and numerous media reports.
    Requirement: Peer Support Counseling Program--(1) In carrying out 
the comprehensive program, the Secretary may establish and carry out a 
peer support counseling program, under which veterans shall be 
permitted to volunteer as peer counselors--(A) to assist other veterans 
with issues related to mental health and readjustment; and (B) to 
conduct outreach to veterans and the families of veterans. (2) In 
carrying out the peer support counseling program under this subsection, 
the Secretary shall provide adequate training for peer counselors.
    VA Response: VA provides a number of distinct types of peer 
counseling in a number of different contexts.
    Vet Centers have recently hired 100 returning veterans as OEF/OIF 
peer specialists to provide outreach, education, and counseling to 
returning veterans and their families. These OEF/OIF veterans 
complement the counseling and outreach services provided by an even 
larger number of ex-veterans who serve as staff members in Vet Centers. 
The services provided by Vet Centers are based on problem-focused, not 
diagnosis-focused, care for readjustment problems. Peer counseling is a 
key component of the overall program. Training for the OEF/OIF peers 
specialists is provided through the Vet Center program.
    VA's homeless program established the Peer Housing Location 
Assistance Group (PHLAG) program as a 2-year pilot program started in 
late 2006, and is located at six VA medical centers. The program 
utilizes formerly homeless veterans trained as peer specialists to 
provide assistance to homeless veterans completing residential 
treatment programs. They also assist homeless veterans to locate 
community housing and make a successful transition to independent 
living. Veterans Integrated Service Network 5's (VISN) MIRECC trained 
the peer specialists and is evaluating the outcome of the pilot 
program.
    VA's specialty care programs include peer support services for 
patients with serious mental illness. Beginning in FY 2005, 123.5 Full-
time Equivalent (FTE) peer support technicians have been funded from 
mental health enhancement funds in 47 mental health programs across 27 
states. Peer Support Technicians provide a variety of peer support 
services under the supervision of a mental health provider in homeless 
programs, therapeutic employment programs, residential programs, and 
day programs. Peer Support Technicians assist veterans in identifying 
personal recovery goals and in determining necessary steps to achieve 
their goals; teach problem solving techniques; assist and support 
skills training; and help veterans locate VA and community resources. 
Having availed themselves of mental health services, Peer Support 
Technicians share their own experiences and the skills, strengths, by 
serving as positive role models to other veterans working on their own 
recovery from serious mental illness. Several states offer 
certification as peer support specialists. VA facilities have developed 
training and continuing education for Peer Support Technicians 
utilizing both internal VA resources, as well as non-VA training 
entities. Peer support technicians and their supervisors obtain 
additional information and support from monthly conference calls. Two 
national face-to-face training meetings have been conducted on peer 
support and a third conference is planned for later in FY 2008.
    Requirement: Other Components--In carrying out the comprehensive 
program, the Secretary may provide for other actions to reduce the 
incidence of suicide among veterans that the Secretary considers 
appropriate.
    VA Response: VA's comprehensive program for suicide prevention must 
be viewed as a dynamic activity that will evolve over time as new 
information becomes available on needs, opportunities, and best 
practices. The two Centers of Excellence with their capacity for 
research and technical assistance (Denver and Canandaigua), the ongoing 
studies on rates and risk factors being conducted by the Office of 
Environmental Epidemiology and the Serious Mental Illness Research 
Education and Clinical Center, the hotline call center, and the Suicide 
Prevention Coordinators at each medical center, constitute a core 
infrastructure to support the identification of needs, and the 
development of opportunities to allow enhancement of the program over 
time.
    To allow ongoing scanning of the clinical and scientific 
literature, as well as activities in the field, both within VA and in 
community-based programs, VA has appointed a Suicide Prevention 
Steering Committee cochaired by the Deputy Chief Patient Care Services 
Officer for Mental Health and the Director of the Center of Excellence 
at Canandaigua and with multidisciplinary staffing from relevant VA 
program offices. The steering committee has been charged with 
identifying opportunities for program development. Additional input 
from outside agencies comes from the Interagency Working Group to 
Inform Research on Suicide Prevention convened by VA's Office of 
Research and Development, and from VA's active participation in the 
workgroup on suicide prevention of the Federal Partnership on Mental 
Health.
    Information on the time line and costs for complete implementation 
of the program within 2 years.
    VA's comprehensive program on suicide prevention, as specified in 
the Joshua Omvig Veterans Suicide Prevention Act has been completely 
implemented. It is a dynamic program that will evolve over time in 
response to needs and opportunities. The basic structures and processes 
required by the Act have already been established and implemented.
    Expenditures for the suicide prevention program include $.97 
million for the Hotline; $1.97 million for the Center of Excellence in 
Canandaigua; $2.20 million for the Mental Illness Research, Education 
and Clinical Center in Denver; $90,000 for the Serious Mental Illness 
Research, Education and Clinical Center for monitoring of suicide rates 
and risk factors; and $14.32 million for Suicide Prevention 
Coordinators. The expenditures for suicide prevention for FY 2008 will 
be more than $19.55 million.
    A plan for additional programs and activities designed to reduce 
the occurrence of suicide among veterans.
    VA's comprehensive program for suicide prevention must be viewed as 
a dynamic activity that will evolve over time as new information 
becomes available on needs, opportunities, and best practices. The two 
Centers of Excellence with their capacity for research and technical 
assistance (Denver and Canandaigua), the ongoing studies on rates and 
risk factors being conducted by the Office of Environmental 
Epidemiology and the Serious Mental Illness Research Education and 
Clinical Center, the hotline call center, and the suicide prevention 
coordinators at each medical center, constitute a core infrastructure 
to support the identification of needs, and the development of 
opportunities to allow enhancement of the program over time.
    VA also established a Suicide Prevention Steering Committee, 
convened the Interagency Working Group to Inform Research on Suicide 
Prevention, and participates in the workgroup on suicide prevention of 
the Federal Partnership on Mental Health, all to support the ongoing 
enhancement of its comprehensive program for suicide prevention.
    Recommendations for further legislation or administrative action 
that the Secretary considers appropriate to improve suicide prevention 
programs within the Department of Veterans Affairs.
    VA is able to monitor risk and needs and respond to them under 
existing legal authority. VA does not recommend further legislative 
action.

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC,
                                                       May 21, 2008
Michael Shepherd, M.D.
Physician, Office of Healthcare Inspections
Office of Inspector General
U.S. Department of Veterans Affairs
Washington, DC 20420

Dear Michael:

    In reference to our Full Committee hearing on ``The Truth About 
Veterans' Suicides'' on May 6, 2008, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on July 
7, 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 your responses at 202-225-2034. If you have any 
questions, please call 202-225-9756.
            Sincerely,
                                                         BOB FILNER
                                                           Chairman
    CW:ds
                               ----------
      
                                U.S. Department of Veterans Affairs
                                                     Washington, DC
                                                       July 2, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
United States House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    This is in response to your May 21, 2008, letter to Dr. Michael 
Shepherd, Senior Physician, Office of Healthcare Inspections, Office of 
Inspector General, following the May 6, 2008, hearing on ``The Truth 
About Veterans' Suicides.'' Enclosed is Dr. Shepherd's answer to the 
additional hearing question.
    Thank you for your interest in the Department of Veterans Affairs.
            Sincerely,
                                            GEORGE J. OPFER
                                                  Inspector General
    Enclosure
                               ----------
         Question from the Honorable Stephanie Herseth Sandlin
                       For Michael Shepherd, M.D.
           Senior Physician, Office of Healthcare Inspections
    Office of Inspector General, U.S. Department of Veterans Affairs

               Before the Committee on Veterans' Affairs
             United States House of Representatives Hearing
                 ``The Truth about Veterans' Suicides''
                              May 6, 2008
    Question: In your written statement, you indicated that there are 
ongoing enhancements in the availability of mental health services at 
community-based outpatient clinics (CBOCs) that may help mitigate 
vocational and logistical challenges facing some veterans residing in 
more rural areas. What are the ``ongoing enhancements'' that are taking 
place at CBOCs?
    Answer: Because mental health conditions may require multiple modes 
of therapy and in some cases multiple weekly visits, treatment for 
veterans residing in rural areas is especially challenging. Traveling 
long distances to appointments can interfere with work and academic 
obligations which can diminish the ability and incentive for veterans 
to seek or stay involved in treatment programs. VA reports having taken 
the following steps to expand access to mental health care, which 
includes rural areas:

      Increasing CBOC and Outreach Clinic Program sites over 
the past few years. Outreach clinics are ``part-time'' VA clinic or 
contract sites that do not have enough patient volume to sustain full-
time hours. Mental health services are also available at outreach 
sites.
      Planning to open 44 new CBOCs and 23 new Vet Centers over 
the next 2 years.
      Expanding telemental health from use in 259 CBOCs in 
fiscal year 2007 to 295 CBOCs in fiscal year 2008.
      Changing the mission of the Veterans Integrated Service 
Network 16 Mental Illness, Research, Education, and Clinical Center to 
focus on improving access to evidenced-based mental health practices in 
rural and other underserved populations.
    While this indicates some increase in rural VHA mental health 
presence, the intent of my statement was to point out the need for 
continued progress in this important area.

                                 
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